NATIONAL HEALTH SERVICE

HC Deb 10 May 1954 vol 527 cc855-970

3.31 p.m.

Mr. A. Blenkinsop (Newcastle-upon-Tyne, East)

When my right hon. Friend the Member for Ebbw Vale (Mr. Bevan) introduced a rather similar debate a year ago, we on this side were all concerned about the information we had been given just a short time before about the setting up of a special Committee to investigate the financial background of the National Health Service. Many of the anxieties that were expressed at that time are very much still with us in regard to that Committee, but at least it can be said that the Guillebaud Committee is clearly being given the opportunity of time for studying this matter with care and apparently fairly fully, which we welcome. Therefore, some of our anxieties of a year ago need not worry us so much today.

We were anxious then lest that Committee should be used, as other Committees had been used in the past, for making spot interim recommendations that might have a serious detrimental effect on the working of the National Health Service. We feel certain that the more fully the Guillebaud Committee investigates the whole set-up of the National Health Service, the more it will be convinced that true economy in many fields of the Service will demand increased rather than reduced expenditure. We, with others, will await with great interest the report that the Committee will be presenting in due course.

But we would all agree that it would be quite wrong for us in the House of Commons to assume that we have no responsibility for National Health Service expenditure in this interim period before the Guillebaud Committee reports, I make no apology for raising many matters which certainly will be considered by the Guillebaud Committee but the responsibility for which nevertheless falls upon the Minister and, indeed, falls properly upon the House as a whole.

We on this side want to use the debate today not only to raise certain immediate vital issues, on which a good deal of concern has been expressed many times by hon. Members, on both sides, in Questions that have been put to the Minister, we want also to use this opportunity to raise wider questions about the whole future policy with regard to the National Health Service which, we think, it is vital to consider at this time.

I need not emphasise that we on this side are immensely proud of what the National Health Service has achieved. All of us realise what great relief it has brought to thousands of families all over the country. It has relieved a great number of them from very real anxiety. It has brought great new possibilities of treatment. It has unquestionably improved the general standard of hospital provision, although I am rather worried that recently several medical officers of health, in speaking at various congresses in various watering places, have been giving a misleading account of the situation with regard to hospitals.

I am particularly anxious when I see that one very well-known medical officer of health has been saying that no progress whatever has been made in our hospital provision since 1948. We know that that is demonstrably false. We know that throughout the country great advances have been made. While in some cities which were particularly fortunate in the past the same rate of progress may not have been maintained, in order to press forward more rapidly in other areas, it is quite misleading for men in responsible public positions, as many of these medical officers of health have been, to attempt to give the impression to the general public that because they have lost some contact with hospital development themselves, that has meant a complete setback to hospital development as a whole.

This is all the more a matter of anxiety to many of us when we are anxious today to consider ways in which we can secure a more adequate link between hospitals and other services of the local authority. It makes us all the more anxious when particular medical officers of health are making these statements, which are based upon a very narrow appreciation of the situation.

To most of us, certainly on this side and probably on both sides of the Committee, it is vital that we should conceive of the Health Service as whole, as a unity. Even though the Service has been developed administratively with three administrative arms, nevertheless none of our health problems can be solved by any one of those arms alone. We want to emphasise the need for co-operation within all parts of the Service if we are to make effective progress. It must be accepted by everyone that a common responsibility rests not only upon the medical profession, but upon all of us, with regard to the development of this Service.

All of us in this country stand to gain from the National Health Service, whether as individuals we need to make a claim upon it or not. We gain enormously from the general improvement of the standard of health that we seek to ensure. Therefore, it is wrong to argue that this Service —or, indeed, other services—is making us, as it were, dependants of the State. Rather I would urge that this great Service is emphasising our inter-dependence upon one another. It is that aspect of the Service that we want to emphasise as much as we can.

That means that a joint effort is required. If we have a criticism, it may well be that we have failed to make this common purpose as much understood as we need to do. In the medical profession itself there is far too much isolation, both from the world outside and, within the profession, between one section of it and another. So far as the general public is concerned, there is a great lack of knowledge of what is happening in the National Health Service.

Unfortunately, a good deal of what the public learn about the National Health Service comes from rather flamboyant articles about the rare cases that occur within the Service, where something goes wrong. By those accounts many amongst the general public are given a wholly wrong impression of the excellent work and high standard that is maintained generally in our hospitals and elsewhere in the Service. There is, therefore, a very great need for us to attempt to break down in the Service the barriers which at present isolate one section of the profession from another and which also tend to isolate the Service from the general public. I hope to put before the Committee some ideas which may be helpful in trying to meet those problems.

Before turning to that, I want to mention one major issue which, inevitably and very properly is raised year by year in these debates on the Estimates of the National Health Service. I refer to the great anxiety which we feel with regard to the whole financial treatment of this Service. The Minister can quite truly say that his Estimates this year provide for an increased capital allocation to hospitals of some 25 per cent, over the capital allocation last year; but what a miserable total is disguised by that percentage. It means that on the £8 million allocation last year there is an increase of some £2 million.

This increase brings us not wholly but only nearly back to the allocation provided in the Estimates for 1951–52. I do not think that anyone could possibly claim that this very modest increase in total is doing more than partially redressing the severe cuts made a year ago. It goes no way to meet the real needs of the Service. With that, to give him credit, I should imagine that the Minister himself would agree.

There is a serious lack of sufficient capital to embark upon even the modest schemes. We understand that, within the capital allocation, the Minister has been making special provision for mental hospitals and mental deficiency. We were glad to hear that only this weekend he was laying the foundation stone of such a hospital. But that has to come out of this very small increase in capital provision.

Provision for revenue may be regarded as even worse. I do not know what last year's figure amounted to, but the increase over last year is only about 3 per cent. The extra provision in the Estimates—which is all I can go on at the present time—for the general running expenses of the hospitals is some £7½million. The greater part of that must surely be swallowed up by salary and wage increases that have either already been agreed or are about to be agreed and will be current during this period.

The right hon. Gentleman, in answer to a Question which I put to him some little time ago, said that some £6 million was provided in the Estimates as a whole for salary and wage increases that had either been agreed or which it was anticipated would fall upon the Estimates this year. I agree that probably not the whole of that amount will fall upon the hospitals, but a very large part of it certainly will. Therefore, the increase, if increase at all it be, is of a very modest character indeed.

When one looks at the details of the provision for hospitals, one finds that, for example, there is little betterment provided for their repair and maintenance. That is a matter about which, as we all know, there is great anxiety. There comes a point beyond which one cannot further cut down repairs and maintenance except at very serious future capital cost. Many of us believe that that is happening today. Over a series of years we have been putting the screw on this sort of expenditure. If a proper standard of service is to be maintained, that cannot go on, unless one wishes to build up for oneself even higher future costs.

On many occasions I have pressed upon the Minister the urgent need for both capital and maintenance expenditure on such vital work as heating schemes, sanitation and laundry work. Expenditure on a very big scale in that sphere can bring enormous economies in the National Health Service and, apart from its very great importance in the care of the hospital patients, can be of very great value indeed. It is astonishing how many of our most famous London teaching hospitals still work in the most inadequate and out-dated sanitary conditions—conditions which I am sure would be regarded as quite impossible for present-day operation.

The Newcastle Regional Hospital Board, about whose operations I know a good deal, in its report for the year ended 31st March, 1953, made a good deal of comment on this very matter. It has been able to carry out small schemes of concentration of laundry work. It has had a great deal of very valuable advice in this regard. The small schemes it has carried out in relation to two hospital groups in the region have already secured savings, in one hospital group of about £4,500 and in the other of about £10,000 a year. From its experience it is satisfied that in this field in very many cases for £1 of capital expenditure a saving of £1 a year can be obtained. It urges that what is true in the north-east of England is also true of the generality of hospitals throughout the country.

To deny hospitals the opportunity of spending this capital money which can be of such great value is, therefore, just crazy. We must find a way—and I think that the Minister is anxious to do this—to secure the necessary capital grants to carry out this work. It is just as true of heating as it is of laundry work. We all know how many hospitals still have the most out-dated and extravagant heating appliances which are both a nuisance and wasteful in every possible way. The trouble is that today we very often have to wait for a boiler to burst or something of that sort to happen before we can tackle the job of putting in modern equipment. Even then, instead of doing the job properly, we may have to try to patch up.

I suggest that this shows the need for examining in some special way the capital provision for our hospitals. We must be prepared, as we are prepared in general housing provisions, to write off annual depreciation or amortisation of capital expenditure, in the Health Service and to regard it in the same way as we regard it in housing. If that is objectionable to the Treasury, as it may be, can we not at least try to secure some distinction between the types of capital expenditure so as to ensure that expenditure bringing such immediate returns as those which I have mentioned shall be given special and immediate consideration? As I say, I have raised this matter before with the Minister. I think that he is sympathetic towards it, and I hope that he will be able to say something further about it this afternoon.

Owing to the natural development of this country and as a result of factors over which the hospital boards have absolutely no control, there is today probably a need for more hospital beds and more expenditure, and not less. At least, there is a need for the better use of existing beds, and there is a limit to which we can go in this respect. Certainly a great strain is put on hospital staffs.

First, there is the fact of the growth in the general population, and secondly there is the fact of the added population at risk, if I may put it in that way. That is to say, there has been a great increase in the number of old people over retirement age and in the number of children today compared with before the war. I understand that there are over two million more old people and children in our population today, and obviously those are the very people who make the greater call upon our hospitals and, indeed, general medical provisions.

Various small surveys have been made of this matter. I very much hope that the Minister can say that he will be prepared to examine this matter more thoroughly and that there will be an adequate survey of the effect of the change in our population on the requirements of our hospital and other services. Since, because of these natural factors, the demands upon our hospitals must inevitably increase, that makes it all the more necessary to look logically and properly at the total figures of expenditure which are being incurred today.

Another factor which we cannot leave out of account is the serious increase in accidents, both on the road and in the home, which are again occupying a great deal of the work of the average outpatient department in the hospitals today. I learned the other day that, according to an estimate, something like £200 million a year is the cost to the country as a whole of accidents on the road and in the home. A good deal of that cost —I cannot tell how much—must be falling upon the Service as a whole, and a good deal upon the hospitals.

Again, it is utterly illogical to condemn the rising tide of hospital expenditure, as is often done, without regard to these factors with which we all have to deal, whether we like it or not. I think that the continuous pressure upon the hospital management committees and regional hospital boards for economy is beginning to produce a sense of general frustration among the members of those committees themselves. They know perfectly well— no one better—the kind of expenditure that can bring so much vital reward in the form of improved treatment—things that they want to do to improve the standard of provision—and they also know what can be done to produce greater efficiency in the hospital organisation, and economy as well. But they are precluded from doing those very things. Year after year this has happened. It is not just what has happened during the last year. This is piling up upon them, and the sense of frustration is growing.

While mentioning hospital management committees and regional boards, I should like, in view of some comments which the Minister made the other day in answer to a supplementary question, to pay a tribute to hon. Members on both sides of the Committee who have contributed a great deal to hospital management committees and regional boards. Many of them who are well known to us have played a great part in the development of our hospital services both before and since the National Health Service was introduced. One, of whom we are very proud, has been serving as Chairman of the Central Health Services Council since its formation, and he has a very wide experience of the National Health Service. In addition, there are many hon. Members on both sides of the Committee, as well as members of another place, who have contributed a great deal.

I think that it is a little unfortunate that the right hon. Gentleman should have tried to get his little bit of fun out of a supplementary question the other day by suggesting that there had been some political wangling in appointments of that sort, when the names of those concerned bear such a very high reputation throughout the country and, indeed, in some cases abroad as well.

If we are to get on to our management committees and hospital boards people of this calibre, then it seems to me that we must find some way of breaking this sense of frustration—all the more so today when people can see for themselves all manner of other capital expenditure going forward on relative luxuries, and when they know how much they themselves are being cabined, cribbed and confined, and prevented from doing work which they know will inure to the benefit of the country as a whole.

This is not to say that we on these benches do not believe in economy. Of course, we do. We are all fully seized of that and of the need for effective control. What we all want to strive after— and I do not think there is any difference of opinion here—is greater self-regulation in the hospital field as elsewhere. That means, surely, some improvement, if we can achieve it, in our system of costing. Here there have been different proposals put forward by the King Edward Fund and by the Nuffield Trust, and at this very moment the right hon. Gentleman has set up a committee to examine the different proposals and to see what can be worked out from them and what can be applied.

What we clearly need is some way of letting the staff of the department of a hospital know what is happening in relation to the general cost of the hospital, and, even though it may be difficult, if not impossible, to give a really accurate figure that would satisfy the average cost accountant in this field, some sort of rough-and-ready figures would be of immense value and would be helpful within the departments of hospitals themselves. Perhaps the Minister can say something about the committee that he has set up, or it may be that some further time is required before any recommendations can be made. We certainly would be interested to hear as soon as possible. We feel it is important that we should get some self-regulating machinery that will avoid the necessity of as much central control, because it would obviously be a great help to hospital committees throughout the country.

On the question of economy, I come back again to a matter that I have raised on several occasions in the House, the question of the employment and the extent of employment of the part-time specialists in hospitals. We are well aware that provision was made in the Act itself for the employment of part-time specialists. We make no complaint about that and about its continuance, although it raises very difficult issues on many occasions. But what concerns us is the feeling that, in some regions in the country, full-time specialists are being offered the choice of accepting the maximum number of part-time sessions, which cannot but be costly to the hospitals and also tends to cause very great difficulties within the hospitals themselves between full-time and part-time specialists.

There is a further matter; it is not merely a question of expenditure. I think it is a bad thing that full-time specialists at present are, in effect, debarred from domiciliary work. I know that there is no statutory provision to this effect, but in practice general practitioners do not call out full-time specialists for domiciliary work, and yet surely it should be the full-time specialist who, more than any one else, needs the contact outside and should be encouraged to have it.

We ought to bring about a moving around of these specialists in this way. It is a matter of concern that the domiciliary work should have been retained in effect entirely in the hands of part-time specialists. One hears continually accounts of the number of full-time men in the north who are transferring to part-time work. There is also the problem, which we know very well, of the attendance of part-time specialists at the hospitals. Some, we know, are very conscientious indeed; some are not so conscientious, and the hospital staff have to wait on their pleasure in some cases. I suggest that this is a matter of very great concern.

A link with it is the question of pay beds. We are conscious of the fact that we made provision for the maintenance of a certain number of private pay beds in hospitals and also of the fact that the matter has been under consideration, and amenity beds have been developed in many hospitals. But it must be a matter of real concern when we learn, as we do from the answer recently given to a Question put by one of my hon. Friends, that something like one-third of the private pay beds are not being used at the present time. Although I am fully aware of the fact that the total number of pay beds is very small in relation to the total bed provision of a hospital, nevertheless this is a matter which causes an amount of anxiety and worry, far out of proportion perhaps to the number of cases which are involved. I suggest that this is a matter which must be re-examined to see whether we cannot ensure that a higher proportion of these beds which are not being used for paying patients should be made available for the many who want them.

I have said that inevitably, because of the increase of population at risk, the total expenditure on our services tends to rise. There is another reason why our hospital expenditure tends to rise which we should surely welcome, and that is that we are able to treat many diseases which were previously not capable of active treatment, and it becomes more necessary to turn wards which were available for general welfare cases into active treatment units. Each time that is done the cost goes up,

I will take an extreme example. We know that mental hospitals, by and large, have a very low unit cost. There is nothing very much to be proud of in that. The more active treatment we manage to introduce into our mental hospitals, the more that cost will rise—and so it should. I was looking over a large mental hospital near where I live where there has been, as in most mental hospitals, a frightful amount of overcrowding, which still exists; but they have been able to start a certain amount of very progressive new treatment there, and costs are rising nearer to the average cost of the general hospital, which is as it should be. I am sure that in this field, during the next few years, there will be great developments. This will become much more general, and therefore we have to face the fact that it will not mean any reduction in the initial expenditure, but must result in an increase, which we should welcome because of the economies which will shortly be found in several fields in the ordinary general life in the country as a whole.

Surely, no one can say that, if we are able to achieve some improvement in our treatment of a section of mental cases, so that they are able to return home after a relatively short period of time and play some part in the general economy of the country, that is extravagant or wasted expenditure. This expenditure is surely of great importance to the economy as a whole. For all these reasons, there can be no justification for a general charge of extravagance against the National Health Service.

There may be many ways in which some saving can be made, but the general charge of extravagance is one which, we must understand, is quite false. Actually, when we think in terms of our national income and the small proportion of the expenditure on the National Health Service—if anything, a declining proportion—and compare it fairly with the expenditure on health generally in the days before the war, taking into account the change in the make-up of our population, we shall find that the expenditure per head of population has tended to fall rather than to rise.

There are points about the allocation of these funds which I must put. First, we welcome the improvement in the timetable arrangements for estimates which the Minister introduced a year or so ago. With regard to the capital, is it not possible to get the Treasury to agree to an allocation for capital resources at least over a period of some three or four years? I am not suggesting that this can be done over the very large general field of revenue expenditure of hospitals, with all the difficulties involved in that, but I think that with regard to capital expenditure it would be a reasonable proposal, and no doubt the Guillebaud Committee will be making some recommendation about it.

I want to turn to the question of health charges. This is a matter which we have raised from this side of the Committee on many occasions in the past. As we have made clear, we object to the way in which these charges have, in our view, infringed the general principle of a service which is equally available to everyone. I regret the fact that no effective means have been found of checking the detailed effect of these charges upon different sections of the community.

I regret particularly that the social surveys have been stopped which were providing us with some information about those who went to see their doctors and in particular the age composition of those who went. We want that information badly today. I should have thought that the Minister himself would have wanted it. I hope that he is prepared to see what further information can be obtained as to the full effect of these charges. I should have thought that this was the proper time to review the whole of the charging position. We learn that last year assistance of £1 million was paid out in refund of charges. Although I am not suggesting that this outweighs the financial return of the charges being made, it seems an extraordinary thing that so large a figure as that should have to be incurred.

I want to take three examples. First, the prescription charges. Do we really need now to maintain what is nothing more than a niggling tax on the general community? It has been condemned by such great authorities as the B.M.A. and the T.U.C., and when we get a combination of the two agreeing, who can possibly say that there is any case for maintaining those charges?

What is perhaps of greater importance is that we are now achieving a greater effective control over the issue of prescriptions than we had before, partly because of the proposals which were initiated some years ago. On the general question of getting the doctors themselves better informed as to the cost of prescriptions, good work has been done in that direction. I understand that fairly shortly area averages are to be instituted by which doctors can check how expensive their prescriptions have been. In these ways, as well as in drug costing, which the right hon. Gentleman has introduced, we should be able to make valuable progress towards getting really effective control of the amount of our drug bill, which we all want to do. Therefore, the need for any charge, if ever there was one, should now have gone.

I should like to know what progress has been made—and I hope that the Minister will be able to say something about it—on the question of costing. It is a matter which has been referred to by the Public Accounts Committee on more than one occasion, and it is a matter which arouses a great deal of feeling. It seems to me wrong that, where the State itself is paying the bill, the charge in respect of an individual for a certain item of medicine can be almost unlimited. It seems to be fair on the whole that, if the State is to pay the bill in this way, as we believe it should, the State should also have the right of investigation of the make-up of the cost of the articles which it is prepared to supply. I think that the Minister is moving some way towards this in the investigations which he is carrying out now. We shall be glad to hear what progress has been made, and whether some consideration can be given to the wider proposal which I have made.

With regard to dental charges, and especially with regard to charges for treatment, while we welcome the fact that more children are receiving treatment, a good deal of the value of increasing the amount of treatment for children is lost is there is a fall-away in the number of adults receiving treatment. I quite agree that it is very difficult to get any detailed information on this subject. Unless the Minister has made some special arrangements to obtain the figures in this field, a large part of the data is not covered by the ordinary returns, because a good deal of the simple treatment is now being paid for by the patient directly to the dentist, and so we hear nothing about it.

It is now quite commonly being argued by dentists and others that many adults and adolescents who should be persuaded to go to them for a regular checkup on their teeth are no longer going but are waiting until they get a mouthful of trouble, on the natural basis that they have anyhow to pay £1 and might as well get then-money's worth. I believe that that is occurring to a very large extent. If that is true, it is bound to be having a very bad effect upon general health.

Another point which I wish to raise relates to an alteration which was made by the Labour Government and for which I cannot charge the Minister with responsibility. It is the matter of travelling expenses. There is no doubt that this is causing a good deal of difficulty. We always understood that, especially in mining areas, but it is happening elsewhere too. Sometimes patients visiting specialists have to travel a long distance, and on many occasions they have to travel certain distances to attend outpatient departments. It seems wrong that in many of these cases the only way in which they can get a refund of their travelling expenses is by application to the National Assistance Board.

I make no charge against the present Minister on this score; we ourselves accept responsibility for its introduction. We know the abuses which may be possible. The problem is how to avoid abuses and yet deal fairly with the many hard and borderline cases which emerge. If the Minister has any suggestions to put forward, it will be a matter of very great interest to all of us, especially the members of the T.U.C. who have been pressing the subject very strongly.

I have said that it seems to me that if we are to make progress in the development of the National Health Service, we need to have much more effective cooperation within the Service. If we look at any of the major problems, whether they relate to the care of old people, mental illness or the great growing modern problem of cancer, it is surely clear to everyone that no one element of our Health Service can hope to treat it by itself. We must ensure the effective cooperation of all parts of the Service. Indeed, we might well ask whether the preventive part of our Service is getting sufficient attention.

I do not want to exaggerate the effect of dividing the Service into its present three parts. There were previously more than three parts, and so to that extent, what we have at present seems to be a great advance. But it is true that it has had the effect, to some extent anyhow, of holding back some of the co-operation which we might otherwise have had. We must get the medical officer of health, the general practitioner and the hospital specialist working together on the great range of the problems that we face today.

With very great respect to the Central Health Services Advisory Council, I do not believe that co-ordinating committees will get us very far. The danger is that we meet ourselves round the corner, for it is the same group of people, divided into twos, threes, fours or fives, which keeps meeting.

Ideally, we want a single health authority. I was very much struck by an article in the "Municipal Journal" by my right hon. Friend the Member for Ebbw Vale urging that we must now consider the possibility of a single health authority after, and only after, the reform of local government. Large areas of local government would be practicable for hospital planning purposes, but do we need to wait as long as I fear that might be?

I believe that we can make some start on the problem of administrative changes fairly soon. For example, it should be possible within a reasonable period of time to get a linking up to begin with between the health executive councils and the local health authorities. Already we have a good deal of common membership between the two. They cover the same areas.

I know very well the difficulties, which will be more professional than anything else, difficulties between medical officers of health and general practitioners in some cases, but if we could get that combination it would cut out one of the elements of division which we do not want and would enable us to look at part of the problem anyhow rather more sensibly and rather more connectedly.

More important than that is the actual physical contacts which we want to achieve between the doctors themselves and those working under the local health authority, between doctors and the hospital staffs. I certainly believe that group practices can help a good deal. Provision was made in the Danckwerts award to general practitioners for the setting aside of £100,000—a ridiculously small amount —to assist in the development of group practices.

Group practices may constitute merely a working together of anything up to six doctors in one set of premises. The doctors may or may not be partners, but at any rate they are working together from the same premises. Clearly, there is real advantage to be gained from this arrangement. There will be some discussion between doctors, which will be valuable. There will be a better organisation of work to enable the doctors to employ some staff which many doctors on their own cannot afford. There will probably be time available to enable some doctors to do work at some of our hospitals as clinical assistants which they might not be able to arrange on their own. It is a matter of concern that doctors should have direct access to diagnostic facilities in hospitals. Something on those lines has been happening, but we need to encourage it a great deal more.

These are great advantages, but they must be encouraged because we want more use made of them. I want to see a linking together between the general practitioners and those working on the staffs of local health authorities. We do not necessarily want very formal arrange- meats. We want the general practitioner to see more of the health authority staff, more of the medical officer of health and more of the health visitors and district nurses, who are working on the same problem as the general practitioner.

Therefore, I have a suggestion to submit to the Minister. Would it be wise, or possible, to suggest that, where funds are made available for the encouragement of group practices, it should, wherever conceivable, be arranged that there should be some facilities for local health authoity clinics to be held in the same premises or at least that there should be some accommodation for health visitors or district nurses on the same premises? It would not make any very large demand on accommodation and it would in many cases be very simply arranged.

On the other hand, we would also welcome further development of health centres themselves, perhaps on a more modest scale that that of Woodberry Down, which was a vital experiment to carry out, but perhaps more on the lines of the Bristol health centre, where essentially there is obtained a linking up of the general practitioners with the local health authority's staffs.

We cannot afford to wait any longer to get an improvement in general practice. I do not pretend, of course, that the general standard all round of general practice is bad—far from it. The various reports which have been made make it clear that the majority of it is very good, but there is certainly a proportion, possibly a small one but a very serious proportion, which is very bad. We ought to face that fact.

I have been reading, as I am sure many other Members have been, an excellent book by one of our former colleagues in the House, Dr. Stephen Taylor, who has made a most interesting and valuable report which brings out the fact that, from the experience he has gained in going round covering good practices, he estimates that there are something like 10 per cent, of general practices that are really bad—there may be as many as 25 per cent, altogether below standard but 10 per cent, that are really bad, and about which some action really should be taken.

I suggest that the great majority of these bad practices are in industrial areas —we all know that the vast proportion of them are. It is a great tragedy that those doctors are getting the advantage of payments in a way in which they have no right to do. The new award, and the payment to general practice, is based on the assumption of a percentage of expenses of about 38.7. No one will make me believe that in these shocking practices in many of our industrial areas anything like that percentage is being spent on expenses. Therefore, in fact, they are swindling the National Health Service. What is more, they are bringing contumely on the other doctors who maintain, sometimes at great expense to themselves, a good standard of provision generally.

I suggest that we cannot wait any longer before taking action about these bad practices, which are well known. I am sure that the health executive councils know who those concerned are, and I believe that the councils should be encouraged, without waiting any longer, to take action about them. They should now inspect these premises and warn some of the worst offenders at all events that unless some immediate improvement is made they cannot be any longer regarded as practising within the National Health Service. The time has come for really strong action of that kind, and I very much hope that the Minister will consider it.

It is true, unhappily, that many of these bad practices have long lists of patients; it is not a question, unhappily, that the patients are objecting; it may be that they know no better, that they have been used to this very low standard. It is our duty, however, to take action now about such practices and really to raise the standard, because upon this standard of general practice depends the whole of the rest of the working of the Health Service. That is in many cases the only contact which the general public has with the Service. For the sake of our good name in the world, we should do something about it. I apologise for spending so much time on that issue.

It seems to me that we need a new climate of co-operation within the National Health Service. How can we obtain it? I suggest that we must look at the content of medical teaching to some degree; we must have more regard for general practice in the teaching of medicine instead of regarding it as the son of field that the doctor goes into if he cannot go into anything better. The medical student should be encouraged, and I am glad that in some ways he is being encouraged, to regard it in many cases as one of the most important fields for the use of his skill and ability.

We wish to ensure, if we can, that the newly-qualified medical practitioner, having gone out into individual practice, shall retain his contact with his teaching hospital and with hospitals in general. I wish to pay a tribute here to Sir James Spence, whom I know very well, who in the north has done a good deal of valuable work in this field. He has gone out of his way to ensure an informal maintenance of contact with newly-qualified practitioners and has done very well in that way and help to raise the general standard of general practice by encouraging continuous contacts between the hospital and the general practitioner.

I think we can also do something in the sphere of administration. We badly need today a better standard of hospital administration. I make no charge against existing hospital administrators, but they would themselves agree that they would profit by a great deal of further training. Many of them are now taking advantage of some schemes of training that are being provided on a limited scale by the College of Hospital Administrators in collaboration with the King Edward Fund. Can we not regularise that position rather more by conceiving of the linking of the training for hospital administration with one of our existing medical colleges, possibly, for example, with the School of Hygiene? If not that, it ought to be linked, somebody has suggested, with the London School of Economics or social welfare. It needs to be brought within a definite scheme. Everyone who is concerned with this experiment of the College of Hospital Administrators—

Mr. Arthur Moyle (Oldbury and Hales owen)

Would my hon. Friend go so far as to suggest the substitution of fully-qualified and experienced lay administrators for medical superintendents?

Mr. Blenkinsop

My hon. Friend must not lead me into that argument, which I find rather sterile, between medical and lay administrators. The thing that matters most is to have a good quality of adminis- tration, whether medical or lay. There are some limited fields, in mental health, for example, in which there is a special call for medical qualifications, but I think that in general that problem does not really arise. The experience of America, which in this sphere is useful, suggests that the thing that matters most is to have a man, whether he be medical or lay, of real standing and of administrative quality.

I wish finally to suggest that in working to achieve a new climate of co-operation within the National Health Service we also need to think of the link between the Health Service itself and the general public. The Ministry of Health has a duty to give far more information to the general public about what is happening than I think it does today. I hope that the Minister will regard this as a suitable occasion to give as much information as he can, but we need regular information. It would be reasonable to suggest that we should try to have some form of quarterly statistics presented to the House, to be available both to those who have a special interest in the subject and to the general public.

We need to encourage more of the meetings that some hospital management committees have been very successful in arranging with delegates of all kinds of different organisations in their own localities, where the problems and difficulties of the hospitals are discussed and some account is given of what has been happening. We wish to encourage more and more people to understand the work which is being done in hospitals, in general practice and in other parts of the great medical field. So far we have not succeeded so much as we could have done in doing that, or perhaps we have not succeeded as much as we should have done in encouraging greater actual participation by the public in the Service.

As I said at the start, we are proud of what this Health Service has done. We believe strongly that it is capable of much more, not only of benefiting the health of the public but also of encouraging a far greater understanding among the general public of how much we depend upon one another. That is a good moral precept. It is, I believe, the basis of the National Health Service, and it is also the basis of my Socialism.

4.30 p.m.

The Minister of Health (Mr. Iain Macleod)

The hon. Member for Newcastle-upon-Tyne, East (Mr. Blenkinsop) is no stranger to the Dispatch Box on either side of the Committee during health debates, but I am bound to say that I have never heard him make a more interesting nor, I think, a better speech than the wide survey to which we have just listened. I shall be very glad to do what I can to follow his interesting observations, particularly on such matters as general practice, the question of the position of the various costing investigations, the position of the Guillebaud Committee and, perhaps above all, an interpretation of the Health Estimates.

If I differ from the hon. Gentleman a little in his calculations about the interpretation of the hospital services, I am very conscious of the fact that it is almost impossible to read these Estimates aright unless one knows what was the out-turn of the last year and what assumptions the Minister had in mind in agreeing his Estimates with the Chancellor of the Exchequer and subsequently presenting them to this House.

I should like to sketch the position as a background, using the figures to include England and Wales, and Scotland as well. But, when I come to detailed summaries, it would be easier if I took the figures for England and Wales; not only because I am more closely in touch with them, but because there are so many reservations which I should have to make every time I included Scotland, and I do not wish to weary the House with footnotes.

For the first time the true gross cost of the Health Service exceeds £500 million, at a total of £505 million. I use the word "true," because in 1952–53 the figures were rather the same, but they were distorted by the arrears of the Danckwerts award. The net cost is £433 million. These figures show a steady climb since the first full year, which was 1949–50, from a gross figure of £436 million and a net figure of £345 million.

The first important figure I should like to give to the Committee is that last year's Estimates were, in fact, under-spent by some £5 million, of which nearly £4½ million is attributable to England and Wales. Reserving hospital maintenance and capital for a rather more detailed study, perhaps I may glance at some of the main subheads which take the weight of the expenditure.

There is an increase of £1¼ million in the general medical service in England and Wales, which reflects, as the hon. Gentleman has said, the increasing number of principals engaged. As a result of the Danckwerts award, the increase in the number of principals automatically increases the amount in the central pool. The Danckwerts award of March, 1952, led to the working party which reported a month or so later. The proposals of the working party came into effect on 1st April, 1953. I should like to give the figures a little later, because they are interesting to show how the working party proposals affected the distribution of general practitioners and led to an increase in partnerships. But I think it would be more appropriate if I dealt with that under my remarks about general practice.

The pharmaceutical service remains more or less where it was, and a very small increase over the probable out-turn for last year is attributable to the fact that we shall overtake all pricing arrears entirely this year. So far as the general dental services are concerned, there is for Great Britain an increase of £2½ million over the Estimate for last year, but not more than £750,000 over the out-turn. Increased demand was here responsible, and the same is true for the supplementary ophthalmic services.

The Committee will notice an increase in the grants to local health authorities of some £1½ million over last year's Estimates. Some of that increase, as it often is, is due to increased wages, but a good deal of it is due to something which I am sure we are all glad to see, a genuine increase in the domiciliary services, particularly home helps and home nurses; and it is possible by an extension of this service to do a good deal to take the weight off the hospitals. Perhaps I should also say—because if I do not say it I am certain that an hon. Member opposite will point it out to me—that no doubt the figure is also affected, and would be higher still, but for the fact that a number of local health authorities have closed some day nurseries in their areas.

I wish to say a word about the large drop in expenditure on Civil Defence services, although I doubt if it will come very much into our debate today. The reduction there is a reduction of the rate at which reserves of equipment of various kinds, canvas, mattresses, and so on, were being built up. It does not represent a reduction in stocks. Lastly, there is little change in the estimate of central purchases at a sum of nearly £7 million for Great Britain. There are changes, of course, which reflect different needs. For example, in England and Wales we are spending £170,000 more on X-ray equipment for the hospitals, but of course we have caught up practically with the hearing aid position. The total there is down again by £230,000.

I should like to turn to what must be, and rightly so, the main issue of the Estimates themselves, whether we are giving enough money to the hospitals and whether the hospitals will be able to meet the main needs in the coming year as a result of the allocations we make. I remember two years ago observing that our financial debates on health were to some extent dominated by the conception of the ceiling with which hon. Members will be familiar. But expenditure has now gone far beyond the ceiling, and I notice that in a leading article on 29th March, "The Times" came to the conclusion that A limit fixed in terms of money and maintained regardless of increasing costs seems now to have given way to a limit fixed as a proportion of the national output. I think the "Economist" expressed a similar view. It is not as precise as "The Times" suggests. Indeed, the Estimates now— whatever may have been the position when the ceiling was in ordinary operation—are determined by, as I understand it, the ordinary process of Departmental agreement with the Chancellor of the Exchequer.

They are built up as follows: First of all, one looks at the out-turn for the previous year which, of course, entails a good deal of guesswork, because this process has to be gone through during the autumn when there is half a year unfinished. Then one adds sums to cover known increases. Usually these are increases negotiated through the Whitley Councils and also amounts that are necessary to bring into use developments that were effective for only part of the previous year. Whatever extra sum that the government decide they can make available for further development is added, and any adjust- ments to stocks and cash, if any, are then made.

I should like to make clear that it is possible to inflate these figures very substantially without any true benefit to the hospital service if one includes substantial amounts for Whitley reserves or for an anticipated rise in the cost of living. In the year 1951–52, a year in which the index went up by 11 per cent., the figure which I am told would have had to be added if it was in fact applicable to hospitals, was about £9½ million. When we took power in the late autumn of 1951, and the figures had already been prepared to some extent for 1952–3, we included a sum of £54 million to cover an anticipated rise in the cost of living, although in fact it was not fully needed. Last year, 1953–54, I asked for a sum of only £1 million, and this year I have included nothing at all.

One could not have a better example of the steadying of the cost of living in that period, or a better illustration of the benefit which accrues to a large spending Minister from stability in this field. And, because they are closely linked, a very similar argument applies to the Whitley reserves, for which this year I have only included a little more than a token amount of £1 million in addition to the requirement for certain pending awards.

Mr. Hector McNeil (Greenock)

Will the right hon. Gentleman make a correction in respect of butter?

Mr. Macleod

I am sure that the right hon. Gentleman is familiar with the stability of the cost of living index in the past year. It is a very genuine point, whether one thinks the argument is sound or not, that we are taking into these figures far less than was taken a few years ago in that respect. If one took in a large figure here, it would look as if one was giving more to the hospitals, whereas that would not be the case.

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

Before the right hon. Gentleman leaves the general case of expenditure on the Health Service as compared with other expenditure in the community, has he calculated what relation it bears to the total national income now? The right hon. Gentleman was talking about the movement in gross expenditure. Can he indicate what the movement has been in terms of percentage of national expenditure?

Mr. Macleod

I cannot do that mental arithmetic, but I do not dissent very greatly from what "The Times" said. I am saying that although the figures look as if they support that argument, in fact the Estimates are not calculated by any such formula but by the ordinary process of negotiation. It may well be true that in relation to the national output the figures this year are, if anything, a little above the figures for previous years.

To summarise the position in relation to maintenance costs, if we take an outturn of just under £251 million for England and Wales, with added sums coming to £6 million, an extra amount of £2 million allocated by the Government for new developments in this field, a reduction in stocks which, after careful examination, I feel I can make again this year of a further £2 million and the Whitley reserve of £1 million, and we then estimate as a result of continued pressure for economy, which will certainly go on, a saving of £1 million, that is as good a summary as I can give the Committee of the amounts available next year. It will be seen that the Estimate in the Votes comes to £263½ million and that there is therefore available for allocation £265J million, taking the position of stocks into account. The Estimate alone, therefore, is £12½ million above the out-turn for last year.

I should like to make one point about the allocation of these sums. I have deliberately allocated less in proportion to the teaching hospitals than to the regional hospital boards. I am not disguising for a minute that this may well be a very difficult year for many boards in the matter of hospital maintenance, but I felt that on the whole there was more scope for economy in the teaching hospitals and that, within the limits of what was available to me, it was right to be more generous to the regional hospital boards.

The great question is whether this amount of money will enable the hospitals to meet the most urgent needs. I have no doubt that many hon. Members will have differing views on that. I should like to give one illustration of a matter which is of great importance and which is very close to all our hearts. Will it, for example, slow up recruitment into the field of mental nursing, assuming that we can obtain the recruits?

The figures for the last few years of recruitment of nurses for mental and mentally deficient cases show that there was a small decrease in 1951, a small increase of 253 full-timers in 1952 and, in the first nine months of 1953, a much more substantial increase of 925, still leaving us, as hon. Members know perfectly well, with very substantial under-staffing. Assuming that we put the figure of recruits attracted to this field as high as 2,000, and that they were used to relieve existing shortages, the additional annual cost should not exceed about £500,000. I feel that that, and other forms of development in which we are most interested, can and should be met.

On the subject of capital, I pick up one point which the hon. Member for Newcastle-upon-Tyne, East made, which illustrates the difference between estimates and out-turn. He said that the amount available this year in England and Wales of £10 million was less than the allocation in previous years, and particularly in 1951–52. It is quite substantially more than the amount of money that was spent, and that must always be the figure with which we should be concerned.

Mr. Blenkinsop

Would not the right hon. Gentleman agree that inevitably the allocation made is bound to determine to a very large extent the kind of schemes which the regional hospital boards feel that they can inaugurate? There is bound to be a great deal of carry-over.

Mr. Macleod

I do not dispute that, but the point is that so far we have not spent £10 million in any year since the National Health Service came into being. There have been a number of under-spendings of rather larger allocations, but last year my estimate of £8 million in this field was over-spent by £100,000.

If I may give an illustration of how anxious I am to spend fully everything allocated to me, perhaps I may mention that, having made a preliminary allocation of the £10 million I saw later that there seemed to be very little leeway. The amount was normally what one would have left as an insurance against inaccurate estimating. But I did take into the large schemes for next year as a whole the third phase of the Coventry scheme. I shall certainly do everything I can to see that we get full value for the £10 million which, I hope, will prove to be the largest amount of money spent in any year since the Service began.

The outlook, in the capital Held at least, is a great deal more encouraging than it has been for sometime. It is true, as the hon. Member mentioned, that last Saturday I laid the foundation stone, near Southport, of the first completely new hospital to be started in England and Wales since before the war. As everyone knows, we have a great distance to go and everyone wants to see us get ahead as quickly as possible. That is why most of the extra £2 million has been reserved for central allocation for schemes so big that no region could reasonably be expected to cope with them within its ordinary budget.

The figures I wish to give the House show the tendency ever since the beginning of the Scheme. This is very relevant to what the hon. Member was saying. On schemes up to the end of last year from the beginning of the Health Service, 20 per cent, of all moneys to be spent in the capital field were on ward accommodation; 17 per cent, on staff accommodation; 21 per cent, on special departments; 6 per cent, on out-patient departments; 4 per cent, on laundry and kitchens; 19 per cent, on engineering services; and 13 per cent, on others.

One thing to which I should like to draw attention and which has been consistently the policy of successive Ministers of Health, is that we are all right, I am sure, to give a high priority to special departments. The fact that we have been able to do so much work relative to the total in this field has led to the greatly increased turnover of patients and the improvement in the rate. For example, in 1952 155,000 more patients were treated, which was a rise of 4–8 per cent., although the number of beds available increased by no more than 14 per cent.

I think, also, we will find something of a switch in emphasis from staff accommodation, which, at 17 per cent., to some extent reflected the urgency of the position in the first years of the Health Service, but has now improved, and the standing nursing advisory committee has advised me that it is desirable that nurses should be non-resident wherever possible. It may well be that that percentage will decline and more perhaps become avail- able for some of the engineering services to which the hon. Member referred.

In response to the invitation of the hon. Member, I should say that I am very conscious of the fact that it would be possible to hold maintenance costs and, in many cases, to reduce maintenance costs by some expenditure in this field. That is certainly a matter which is within the purview of the Guillebaud Committee. Without waiting for their Report, as I indicated to the hon. Member in answer to a Question, we are discussing whether a particular allocation should be made to that field. There are two points I made then and I wish to make again. If we are to go on making central allocations of capital expenditure as we are doing in the mental health field and as we are urged to do for engineering, that will take away a great deal of the autonomy of the regional hospital boards and their discretion in the matter. The second point is that if we are to give the impression that a fund is to be made available for a particular service, such as for the replacement of out-of-date and dangerous boilers, we shall tend to make regional hospital authorities think that, as this is being taken care of centrally, they need not bother about financing any part of it out of their own budgets.

The last point I wish to make on the question of capital is to say, largely for the record, that there has been a notable development, in that it is no longer necessary for capital works financed from non-Exchequer funds to be counted as they used to be against capital allocations made to hospital boards. I should like to make quite clear that there is no question of raiding the Hospital Endowments Fund of £17 million which provides a small but steady income for the non-teaching hospitals. The moneys to which I refer are those which are available as other free moneys largely from the endowments of the teaching hospitals but in part from gifts and other sources which have accrued to hospitals since 1948.

Although the amount need not count within the hospital budget, clearly the Minister of Health has to have full regard to the burden of maintenance which may fall to him to meet in subsequent years from capital development if he approves it. It therefore follows that I should have to look a great deal more narrowly at that sort of project than if the capital expenditure were directly related to revenue saving projects, particularly when linked to the engineering services to which the hon. Member referred.

Mr. Blenkinsop

Could the right hon. Gentleman give any impression of the amount of this sort of work which is likely to go forward within the next 12 months, or any period he likes to name?

Mr. Macleod

I was thinking this morning whether I could find a phrase to cover that, because I rather expected to be asked such a question, but I am afraid I cannot. The amount of free money available is £32 million, but in no way is it in my hands. It depends entirely on the rate at which hospitals come forward with offers of money and how many of these schemes are accepted. I would be disappointed if it did not run into millions of pounds.

I turn to what has been said about charges. As a result of a series of views on charges I have put before the House over a number of years, I have come to be regarded—to some extent at least—as the apostle of charges in the Health Scheme. Therefore, I think I am entitled at least to make the point that I am the only one of four Health Ministers since 1948 who has not introduced a Bill to put charges upon the Health Service. The right hon. Member for Bbbw Vale (Mr. Bevan), for good measure, introduced two such Bills. I readily respond to the suggestion of the hon. Member for Newcastle-upon-Tyne, East and I shall say something about charges.

I did make a very full report last year, and perhaps I need do no more than carry the story forward now. In the general dental service, the provision of dentures was running at about 2¾ million cases a year before the charges came in under the 1951 Act. They dropped almost at once to under 1¾ million, which was about 50 per cent., and the figure has remained fairly constant at that level since. There is a much more interesting story to be told about what has happened to conservative treatment and the effect of the 1952 Act.

In 1950–51 the number of applications which came under this heading was less than 4½ million; in 1951– 52 it rose to nearly 5 million, helped no doubt by the switch of some work from dentures as a result of the 1951 Measure. In 1952– 53, despite the introduction of charges for dental treatment for which we on this side of the Committee were responsible, the number rose to just over 5 million; in 1953– 54 to about 5J million; and the figure for the first quarter of 1954 which I have was higher than in any previous quarter. As far as I can judge trends, that is going on in 1954–55.

Within that increase, which is very gratifying, the number of children's courses, which was 170,000 in the last quarter of 1950, went up by 40 per cent, in the last quarter of 1951, 100 per cent, in the last quarter of 1952 and 150 per cent, in the last quarter of 1953. Those are indeed very remarkable figures, and even if one takes into account the increase in children's courses on the one side and what is undeniable, and to which the hon. Member referred, that many contracts now are being done privately because of the charge of £1 or less that is being made, I am quite certain that, although there has been a very considerable increase indeed in children's courses, there has been no fall at all in the conservative treatment for adults. Whatever we may feel about charges, I do not see how the Opposition can go on denying that a charge on the Health Service can, under certain circumstances, have a social and beneficial result as a consequence of the switch which it encouraged.

Mr. Joseph Slater (Sedgefield)

rose—

Mr. Macleod

Let me give one more figure in this field. The last figures that we get here to complete the picture are those of recruitment to the school dental services. On the 31st December, 1947, 921 full-time dentists were employed. Year by year that figure dropped until the end of 1951, when it was 713, but at the end of 1952 it was 850, and by the end of 1953 it was 945. We have more than restored the position to the peak that it reached when the Health Service came into operation. I hope hon. Members opposite will reflect that, if they decide to remove these particular charges, I have no doubt at all they will at the same time be threatening the future of the school dental service.

Mr. Slater

If we accept the Minister's figures, which we do, do they not refute the number of statements that were made when we had a free Health Service under the Labour Government, that it was being abused?

Mr. Macleod

I personally have never been one who has lent his name to the suggestion that there has been any substantial abuse in this particular field. If there has been any, presumably it is linked with dentures, and there has been a substantial fall, as is seen in the figures that I have given.

In the pharmaceutical field, it is immensely difficult to make a reasonable comparison for obvious reasons, because we cannot compare the number of prescriptions issued in one year with another unless we take into account the amount of sickness that there was in the year. For example, the first year of the Health Service charge of Is. on prescriptions was completely distorted by the effects, first of all, of the London fog, secondly, of the East Coast floods and, thirdly, of the flu epidemic of that year. All these things have to be taken into account.

Remembering that, the main figures are these. Prescriptions dispensed are now 213 million a year as against a peak of 225 million. The cost per prescription is down from the peak of 49d. to an estimated level of about 47¾d. The cost to the Exchequer is £40 million as against a peak of £45½ million, and the patients are paying about £6½ million. Those are the figures, and, as I say, one can interpret them in many different ways. The only caveat I would enter is the level of sickness should be very much in people's minds when this is considered.

I do not want to go into the extremely controversial problem of the future of the charges and the recent declaration that the Labour Party has thought it right to make. But I think I can say this, that I hope if it should happen that a Socialist Government returned to power they will think very carefully indeed and ponder upon some of the figures I have put forward, reflecting at least that there may well be higher priorities on which we can spend money in the Health Service than free laxatives and free vitamin pills.

One small point I want to make is related to the Ministry of Pensions hospitals which I have been very proud indeed to take over. Shortly after the merger a Question was put to me about delivery dates based on one particular case, and the suggestion was made that the slowness of delivery dates, which was marked with one particular firm at the time for a variety of reasons, was the result of the administrative change. I thought I would obtain later figures for delivery dates of artificial limbs, and for the record these are they.

For new legs before the merger the time taken was 120 days, now it is 100 days; for new arms before the merger 135 days, now 90 days; for the repair of legs before the merger 35 days, now 30 days; and for the repair of arms before the merger 50 days, now 45 days. In each case there is a reduction. I should perhaps make it quite clear that I do not suggest in any way "that the reduction is the result of the merger. I am certain it is not. But equally I think it is right that I should refute the suggestion that any local difficulties in deliveries may have been a result of the merger. We can all feel that, whatever doubts we may have had at the time about the wisdom of the merger, at least the worst fears that many people expressed have not been realised.

A year ago almost exactly in this debate the discussion centred round the appointment of the Guillebaud Committee, and perhaps I can say a word about what the position is. I understand that the Committee met first in May, 1953, and has been meeting regularly since then, including meetings in Scotland, where it met for four days in Edinburgh in March. It has an immense weight of material to study, and it has announced that the closing date for written evidence is to be 30th June. There is a great deal of oral evidence to be taken after that, and I understand that the Guillebaud Committee will probably begin preparation of its Report towards the end of the year. We all await eagerly the opportunity to study its conclusions.

The last two points which the hon. Member asked me to refer to and also on which I should like to say a word are, cost investigations and the general practitioner service. The hon. Member has a particular interest in what has been happening in cost investigations on the pharmaceutical side, although I should say that many other investigations, such as those into the price of spectacle lenses, of ophthalmic prescriptions, of surgical dressings and other items have been or are being completed. Many of these were completed before action in the pharmaceutical field because claims for higher prices were pending.

In the pharmaceutical field we had two main lines of investigation, first into the basic drugs and, secondly, into the proprietaries. As far as the basic drugs are concerned, we have selected the following four groups for investigation: the antibiotics, which are responsible for 20 per cent, of the total drugs and dressings bill; vitamins, which represent 5 per cent.; hormones, which represent 2 per cent.; insulin, which represents a similar figure.

We have had a number of reports. This has to be a long and complicated affair of negotiation and investigation but, as far as these basic drugs are concerned, it is perhaps worth observing that the prices of penicillin and hormones have been reduced by the manufacturers themselves. I do not suggest that this is as a result of investigation, although it may well be linked to it. The cut in hormones is as much as 10 per cent., which saves the Exchequer £50,000 out of the £500,000 ingredient cost plus another quarter of that, £12,500, which would have to be paid as an on-cost contribution.

I want to make clear what I said over a year ago, but which was rather obscured in some of the reports, namely, that in this field of the basic drugs I am very conscious of the dangers of interfering with valuable research, of the importance of the export trade, and even of the possibility that we might damage the structure of the industry itself. I am sure there is no question that in this field there are risks taken by manufacturers which are probably different from the corresponding position in other fields.

Dr. Barnett Stress (Stoke-on-Trent, Central)

Before the Minister leaves that point, has he considered that about one-third of the proprietary drugs which are listed as an equivalent formula in the Pharmacopoeia to be used by medical men are cheaper as proprietary drugs than those listed in the formula? Will he look at that, because it is a mystery to me, I cannot understand why it should be so, and I suspect that we are being overcharged.

Mr. Macleod

I am coming on to the proprietaries, I was dealing with basic drugs. As a result of action taken in this field, originally, I think, by the right hon. Gentleman the Member for Ebbw Vale, we are investigating the most expensive and the most widely prescribed proprietaries in the middle categories, ii, iii and iv, into which all these were classified by Sir Henry Cohen's Committee, that is, those which have an official therapeutic equivalent. Different Ministers of Health all over the world are taking different ways of tackling this problem. In Sweden they have a list which is linked to the disease from which the patient may suffer. In Australia they have a kind of white list system, by which the State will provide all drugs on a specified list but nothing that does not fall within it.

It would be possible to put various restrictions on doctors or patients, either on the right to prescribe or the right to receive, and it would be possible to limit prices or to say that we would not consent to prices higher than the standard equivalents. The hon. gentleman said that a surprisingly high number of proprietaries are cheaper than the standard equivalents. I do not find that surprising. I should have thought the main reason clearly was that we have to pay the chemist in many cases for the standard equivalent to make up the final preparation, whereas the proprietary can in that field obtain the advantages of bulk preparation, bulk manufacture and, above all, bulk packaging. So it may well be that in some of these circumstances the proprietary drug comes to the chemist cheaper than I, as Minister, can buy, not the basic ingredients, but the completed standard equivalent.

Whatever the merit of these various methods may be, and without prejudice to final action in this field, as I told the Committee a year ago, we decided to undertake: … 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." —[OFFICIAL REPORT. 18th May, 1953; Vol. 515. c. 1726.] There are 6,000 preparations in categories ii, iii and iv, and we are investigating 91, which is as many as we can take on at present. Although 91 is a small percentage of 6,000, those 91 preparations account for no less than 30 per cent, of the total cost of proprietaries to the National Health Service, and 18 per cent, of the total drug bill. So that if we can get results, limited as we are by the number of cost accountants and the time that these investigations must take, even with what looks like a narrow sample, we may perhaps get dramatic savings on the total bill.

For each preparation, we are examining the profit margin and also the costs of production and sale. In one important group our investigations are now complete. We have not been able to reach agreement with the manufacturers on what we consider a reasonable level of profit, and we propose shortly to advise the doctors that satisfactory price arrangements have not been made and to ask them not to prescribe these preparations. I am certain that in this we shall have the full co-operation of the doctors and of the House as well.

My last main subject concerns the interesting remarks of the hon. Gentleman about the general practitioner service. We have 18,000 doctors in the general practitioner service of different ages, different outlooks, in different communities, with different backgrounds. Therefore it is impossible, and anyway wholly undesirable, to have uniformity in this field. The House will be familiar with the new arrangements which came into force at the beginning of the last financial year. These were designed to help to raise the standards of treatment, first by reducing the size of the maximum permitted list from 4,000 to 3,500, secondly by deliberately loading the maximum rate of remuneration to the doctors with the middle lists and, thirdly, by encouraging the formation and growth of partnerships, to see whether we could provide additional inducements to doctors to practice in the under-doctored areas.

The figures which we have are of some interest here. From 1st July, 1952 to 1st July, 1953, which was the period within which we would expect the partnerships to be formed with the knowledge of the proposals of the working party, and in anticipation of the financial arrangements coming into force on 1st April, 1953, we find that the number of doctors in partnership went up by over 1,000. This was an increase of 3.6 per cent, and seems to show that at least in this field the recommendations of the working party are bearing fruit in an increase in the numbers of those taken into partnership.

Of the doctors I have mentioned, newly admitted to established partnerships, 555 were known to have been previously assistants in the practice in which they became partners. That is a most welcome development. Another development of even more importance is that a substantial share of the large number of doctors entering the service in 1952–53 went into the urban, under-doctored, designated areas, with the result that the proportion of the urban population who live in under-doctored areas fell from 60 per cent, in October, 1952, to 46 per cent, in July, 1953. That is really an enormous improvement in the service that has been, and will now be, given to the under-doctored areas.

The hon. Member referred to accommodation and surgeries. As part of a doctor's terms of service he is required to provide proper and sufficient surgery and waiting room accommodation for his patients at his own expense. There can be no justification whatever, now that the Danckwerts award has been promulgated, for that not being done up to a reasonable standard. Last October the chairman of the General Medical Services Committee of the B.M.A. drew the attention of all general practitioners to this matter in a letter, and urged the highest possible standard, which I very much hope that we shall see.

I should like to say a few words about the position in regard to health centres and group practices. There is a Report about to be published from Sir Henry Cohen's Committee on General Practice which is a sub-committee of the Central Health Services Council. The Re-port is in my hands and it will be published shortly. People hold very different views on the future of the health centres. Many people perhaps see their major development on housing estates. I was looking, with Sir Henry Cohen, at a very large housing estate at Kirkby, just outside Liverpool, where it may be that some provision of that sort should be examined.

I very much agree with what was said, that these local health authorities and others who have difficulties in this field should consider a study of the Bristol centre which provides both suites for the general practitioners and at the same time accommodation for local health authority clinics when the general practitioners are not using it. It may be that some of our problems can be solved along those lines.

Another matter which we must seek to develop in the general practitioner service is that we should see that they have as much help as they can have for X-ray and "path" examinations in the hospitals. A good deal of opportunity is being given. I am certain that it provides a very genuine incentive to the really keen practitioner. Despite the difficulties in the way of providing such a direct service, I am told that about half the hospitals with these facilities have made them directly available to the general practitioners.

To sum up on the general practitioner point, it is not right that we should look for spectacular changes in the structure of general practice, but we can draw encouragement from the figures I have given and the beginnings, anyway, of the implementation of the Report of the working party. It is true that there is a great interest in this field. Many most interesting studies, including that by Dr. Hatfield, by the B.M.A., and the one by Dr. Stephen Taylor to which reference has been made, help to encourage interest.

I have read Dr. Stephen Taylor's book with great interest. Perhaps a quotation from it can sum up what I want to say about general practitioners and the provision of accommodation. He says: … there is no impossibility about raising the standards of practice of the less good general practitioner to those of the best, providing that what happens in the best practices is made known to all. I am sure that that is an accurate reflection of the position.

Mr. Blenkinsop

Before the right hon. Gentleman leaves that subject, can he say something about the position of this estimated 10 per cent, of practices that are well below any sort of decent standard? Would not the Minister agree that he should take further action in addition to what he has done with the executive councils, and invite them to keep an eye on the matter?

Mr. Macleod

I will not lose sight ot that, but it is a little early for special action in this field, remembering that the chairman of the General Medical Services Committee sent out in October this special appeal to all general practitioners. It is too early to assess the effect of that. It is later than Dr. Taylor's survey. I should like to leave the matter to the profession itself, as I am sure we can. I look for a generous response to the letter.

Mr. Marquand

Can the Minister say how the £100,000 set aside for the encouragement of group practices will be spent?

Mr. Macleod

Rather than give an impromptu summary of the scheme which has already been reported and which was released in January—1 remember reading of it last in the British Medical Journal fairly recently—perhaps I might ask my right hon. and gallant Friend the Joint Under-Secretary of State for Scotland to summarise it when he winds up the debate tonight.

I am conscious that I have spoken for a long time, and I am grateful for the courtesy and patience which has been shown. This Estimate really raises two questions: first, is the sum too large or too little; second, given the sum, is it being spent wisely?

I think that criticism will centre mainly on the first of those points. It is certainly true that the amount available is more than ever before. It is equally certain that if one took medical need alone as the criterion, we could justify expenditure vastly in excess of this Estimate, vastly in excess of anything that any Chancellor could sanction or indeed that the country could bear.

To the charge that the amount made available is not enough, I would reply that in my judgment it is. I know perfectly well that for maintenance this will be a very difficult year for many hospitals. I have not tried to hide that, but the sum being spent is about £12½ million more than the out-turn for last year. With that amount of money we ought to be able to hold the line, to meet major needs and to make some modest improvement, development and advance.

It is certainly true that the outlook in the capital field is a good deal more encouraging than it has been for some time. In short, although—and I am no exception—Departmental Ministers want more for their Departments, in the wider setting of Government expenditure I am satisfied with the Estimate this year. I am very proud indeed to be the head of the National Health Service in England and Wales, and I am sure that my colleague the Secretary of State for Scotland has a similar feeling of pride.

There are an immense number of people to whom one owes gratitude for the help they give in carrying out tasks put upon them. Although it will be difficult for hospitals to manage this year, I think that we shall be able to meet the main needs and to go forward a little. The capital position points the way to a much brighter future, and I invite the Committee to approve the Estimate and to say that these are the right sort of figures for the National Health Service.

5.30 p.m.

Mr. Somerville Hastings (Barking)

We have listened to an exceedingly interesting survey by the Minister of the National Health Service, but an opportunity such as this is one for the ordinary Member of the House to give suggestions to the Minister for the improvement of this Service and, in the short time for which I shall speak, I want to take full advantage of this privilege.

I can speak, perhaps as some others cannot, as a consumer in respect of the hospitals, for I have been an in-patient within the last few years in one of the National Health Service hospitals. I was also in one of these hospitals before they were taken over, and in my opinion the improvement has been very great. The improvement in medical treatment has been especially marked in the small ex-Poor Law hospitals in country districts, where the standard of medical treatment before the appointed day was very low. I wish I could say that the improvement in nursing in these ex-Poor Law hospitals was as great. Although it is 14 years since many of these hospitals left the Poor Law system, the Poor Law spirit still animates some of the nursing work carried out by nurses and sisters in them.

There can be no doubt that many people, notably the wives and children of the employed, are getting a much better general practitioner service than they ever had before. There are complaints; certain people who were accustomed to send for the doctor for almost anything, very much as they send for the plumber and the chimney sweep, find that they do not get quite tie same attention as they did before, for the very good reason that the practitioner is busy dealing with more important matters in other patients.

Probably the best example of the advantage of the unity of control which the National Health Service has brought can be found in the treatment of tuberculosis. A few years ago, as a result of X-ray examinations, many cases of tuberculosis came to light which previously had not even been suspected. Such people were infecting others working with them in factories and offices. Mothers were infecting their children. What was to be done? There was no room for them in sanitoria and tuberculosis hospitals. Very rightly, the Minister said that as the infectious disease hospitals were not as full as they had been, many cases of pulmonary tuberculosis should be taken there.

But that did not deal with the question. Again very justly, the Minister applied to the general hospitals and asked that a percentage of beds in these hospitals should be reserved for tuberculosis. As a result, the waiting lists have become much smaller, and in some regions they hardly exist at all. This indicates that when any disease comes into prominence and seems to need extra treatment, the provisions of the National Health Service Act, which gives unity of control, can be used to very great advantage.

We must not forget that what the National Health Service has done has been to open wide the gates of curative medicine to all the people of this country. I want to ask the Minister whether he is satisfied that preventive medicine has improved in the same proportion, whether he is certain that the preventive services today are one wit better than they were before the appointed day. I am not sure that the Minister is entirely to blame, or is to blame at all; or whether the blame is not on the doctors. Are we not, as doctors, much more concerned with keeping people alive than with keeping them healthy?

Very often the figures of the Peckham Health Centre have been quoted in the House. Two doctors there started a social club in order that people should be examined regularly, once a year. They found that 90.8 per cent, were suffering from some disease, disorder or disability. I know that we can find what we look for; and indeed that is partly the explanation; but I want to ask the Minister whether more cannot be done to deal with the vast amount of preventable disease which still exists, whether some direct teaching of the laws of health would not be desirable, or whether we might think fit to ask for some inquiry on these lines.

Then again, I wonder whether we have not been developing the in-patient section of our hospitals during the last six years out of proportion to the development of out-patient facilities and home treatment. I know that it is easy for doctors to have patients taken into hospital, but I feel that out-patient and in-patient treatment should be much more of a continuous process. The Westminster Hospital has stressed that fact by having an out-patient department to each ward block.

I believe we should stress the essential unity of treatment, whether it is in the out-patient or in-patient departments. No doubt part of the reason for the present situation is historical because, until a few years ago, many of the Minister's hospitals were Poor Law infirmaries and many of the patients who entered Poor Law infirmaries never expected to come out alive. There was therefore not much need for an outpatient department. In any event, the out-patient departments of the old Poor Law hospitals had not been developed very far.

Many more people could be treated at home if there were better liaison between the general practitioner and the hospital, with advantage to everybody concerned. I particularly stress that this is the case with old people and children. It is an extraordinary thing—and I know no reason for it—that when an old, sick patient is moved out of his normal setting, the case very often turns out to be fatal. Some years ago when I was chairman of the Committee in charge of the municipal hospitals of the London County Council, 12 old people were admitted to one of our hospitals within a few days and all died within a fortnight. We were very much concerned. We instituted an inquiry and looked carefully into the question of whether there had been any neglect or mistaken treatment of these old patients, or whether anything had been done wrongly for them. We could find nothing. Old people do much better if they can be treated at home.

The same thing applies to young children. Infection in a children's hospital is a constant danger, and wards are always being closed for different infections. There are also psychological difficulties in removing a child from its normal setting in its own home. I know quite well that, in certain cases, removal to hospital is essential, but in many cases where experiments in home treatment have been tried, very excellent results have been obtained. In Rotherham, the medical officer of health has arranged a children's home nursing department which is dealing with 600 or 700 separate cases per year. It has been running for 3^ years, and it has been found that the infantile death-rate has been halved, and that there have been no deaths in the home among children who have been so treated.

The trouble is that it is to the advantage of both the local authority and the general practitioner to get the patient removed to hospital as soon as possible. The local authority has to pay half the cost of home helps and home nursing, and, very often, all the impedimenta of nursing is lent. There are many other expenses, such as meals on wheels; washing of foul linen has to be done, and half the cost has to be borne by them. Therefore, the tendency is to get the patient into hospital. The general practitioner who is in charge of the case may be a busy man who is only too ready to agree to the suggestion that the patient might better treated in hospital.

This is a matter with which we are now beginning to deal, but, short of a unification of all three services, financially under the same control, which seems to me the only practical solution to the problem, it would be a very good thing if all doctors became more closely associated with the hospital in whose catchment area they practise. They could be made clinical assistants and so put upon the staff of the hospital. A great advantage would accrue if they could be associated, as they would be able to assess the relative value of moving the patient into hospital and using the facilities in the home, and would also be able to estimate the relative urgency of their own cases with other cases awaiting admission to hospital. I think most general practitioners would agree to this, and would welcome it.

The Minister has quoted from that valuable report of Dr. Hadfield's "Field Survey of General Practise." May I just read these few words from that report: Most practitioners are anxious to keep in as close touch as possible with the progress of the patient, even though the responsibility for his treatment has passed temporarily out of their hands into those of the hospital outpatient and in-patient department. They like to be ready to take over the treatment, convalescence, and rehabilitation after the patient's discharge from specialist treatment. A smooth transference of responsibility is more likely when general practitioners are working with the hospital and where the liaison with the hospital staff is good. Finally, may I, in all humility, make one or two suggestions to the Minister as to how, without increasing the cost, a better service could be provided for the patients? It has already been pointed out that money could be saved by improving the facilities of hospitals. I suggest to the Minister that it might be worthy of consideration that a special fund should be provided for money-saving schemes, and that its distribution should be entirely in control of the Ministry? In a hospital which I know very well, a few months ago we improved the stoking facilities for our boilers, and, to our intense surprise, we found that we were saving over £100 per month in fuel, and that, in two years, the whole cost of that installation would be repaid. That seems to me to be a very important thing.

Then, I want to suggest that consultants should no longer be paid travelling time and expenses. At one small teaching hospital which I know very well, it was calculated that 18 per cent, of the consultants' fees were in respect of travelling time and travelling expenses. The payment of travelling time and expenses tends to induce consultants to dissipate their energies by going to too many hospitals. They are inclined to do so in any case, because the more hospitals they cover the more likely is it that they will get cases for consultation visits from the practitioners who use the hospital and also private practice.

The term consultant of a hospital is a misnomer. A consultant is in clinical charge of cases, and does not only consult, and it is important that the consultant should concentrate his efforts, and that he should live as near as he reasonably can to his patients so that, when the latter needs his services, he can get them. I know that this applies mainly to surgical cases, but it applies also in all cases of acute illness.

When I was appointed, many years ago, to the consultant staff of the Middlesex Hospital, I was told that I had to live within three miles of that hospital, and if the Minister would insist on the same restriction for all consultants today, it would be greatly to the advantage of the service.

Another point concerns the main tenance estimates of hospitals. Most people in charge of hospitals have a shrewd idea that the money they will get for one year depends largely upon the money they spent in the previous year. Very few hospitals are able to spend all their estimates. That arises from a variety of causes. There may have been a warmer winter than was expected, or the hospital may not have been able to secure all the staff they had hoped for. The result in either case is under-spending in all but some 3 per cent, or 4 per cent, of hospitals. This position accounts at the end of the financial year for the mad March rush to spend up to the estimate, so that the amount allocated next year may not be substantially reduced. Some better method should be devised for assessing the maintenance needs of hospitals.

I know there is a need for economy, but I warn the Minister that he will not get the best type of people to run his hospitals if the main attention of the committees and their staffs is concentrated upon saving ha'pence and not upon improving the service. The most favoured financially of the hospitals in England and Wales have been the 36 teaching hospitals. I do not complain of this, because they have most important teaching functions and they must keep their buildings and equipment up to date as far as possible. These teaching hospitals are associated together in the Teaching Hospitals' Association, which has prepared a memorandum for the Guillebaud Committee. The memorandum was not marked "Private," so I do not think there can be any harm in reading a paragraph from it. This is what the Teaching Hospitals' Association says: Yet the unattractive word 'frustration' is all too current and it is undeniable that a number of members of Hospital Boards—not least those whose services on account of age, character and ability are most in demand: elsewhere—are anxiously wondering whether they are justified in giving so much time and labour to public work where the possibility of accomplishment is so restricted. I ask the Minister to give his careful attention to those words. The hospitals are run by a devoted body of voluntary workers, and if the hospitals are to maintain their present high level of attainment, we must not allow the standard of the committees of management to deteriorate.

5.55 p.m.

Sir Hugh I instead (Putney)

All of us must have listened with very great attention to the very human speech just made by the hon. Member for Barking (Mr. Hastings), based upon a long experience of medical and hospital affairs. I found myself in agreement with a very great deal of what he said, with only minor exceptions.

I would quarrel with the phrase— which may pass into hospital history— "the mad March rush," which he used, or which he coined, to describe the way in which hospital staffs tend to use up the last of their money before the financial year comes to an end. I do not think there is a mad March rush nowadays, because the tail-end expenditure is very carefully worked out. It may happen on occasions that some things get second priority instead of first priority, but I do not think that there is very much left in the kitty at the end of the year.

I would quarrel with him in his rather startling suggestion that part-time consultants should not be paid travelling time. That is merely a drastic way of attacking a problem which, I agree, needs to be looked at, namely, the relationship of the part-time consultant to the hospital service. The hon. Member for Newcastle-upon-Tyne, East (Mr. Blenkinsop) had some wise remarks to make on that subject. We are inclined to overlook the so-called part-time specialist, who is really full-time in the hospital service but is allowed to take private work.

He takes a part-tune contract, and, in theory, is giving nine-elevenths of his sessions to the hospital. In actual fact, he is giving eleven-elevenths, or probably more— [An HON. MEMBER: "More?"] —as much time as the hospital requires, and sometimes more than full-time, to deal with hospital work when he takes a part-time contract in order to be able to take private patients.

I was very glad to hear the references made by the hon. Member for Newcastle-upon-Tyne, East to the necessity for developing hospital administration as an art and a science of its own and to hear Ms commendation of the Hospital Administration Staff College, which I have visited from time to time and at which I have spoken, and where they are trying to develop hospital administration as a profession. I hope that that profession will not become too much of a closed shop. I hope that it will always be possible for recruits to go into hospital administration, not solely by growing up in it, and that at higher levels from time to time people can be recruited at older ages. In that way, experience, and it may be university education, can be brought in to refresh the administration service, as well as recruitment from the people who take it up from the time they leave school.

The Minister devoted some time to discussing the present position of the pharmaceutical service and the inquiries Which he was putting on foot in regard to the price he is paying for drugs. I was very glad to hear him say that he hopes, by the end of this year, that his Department will have overtaken all the arrears in pricing. Once that has been done he will have a weapon in his hand which is very necessary for the checking of excessive prescribing. Until he has caught up with the arrears of pricing he cannot identify the doctor who is careless in prescribing. Apparently, by the end of the year he will be in that position. I congratulate him that he has found it possible to catch up with those very substantial arrears, and is now nearly in a position to use the information.

I was glad that when discussing his present negotiations with the manufacturing pharmaceutical industry, my right hon. Friend referred to the dangers of damaging one of our large export industries by forcing the price of its goods down too far. He is, after all, not their sole customer, but he is their largest customer, and he is in a position either to encourage that industry to develop and expand or to deal it almost a mortal blow.

I am pleased to know that my right hon. Friend is conscious of the dangers of interfering with the research work which comes from the pharmaceutical industry. It is worth remembering that the medical schools and university departments and the pharmaceutical industry are practically the only two sources of medical research in this country, and that the first of these—the universities and medical schools—are mainly interested in research as an academic subject and that the development from the laboratory to the production stage is largely a matter for the industry itself.

I speak as one who has been a considerable critic of the pharmaceutical industry from time to time when I say that f was delighted to hear my right hon. Friend say that he was conscious of these dangers in pressing his negotiations too far. After all, the only time when the pharmaceutical industry came before the Monopolies Commission was when the price of insulin was examined, and the industry came triumphantly out of a very detailed inquiry. I hope that the Minister or his civil servants will not, in their zeal, try to buy cheapness too dearly, which, in this field, can easily be done.

Both the hon. Member for Newcastle-upon-Tyne, East and my right hon. Friend referred to the organisation of the hospitals system. The hon. Member for Newcastle-upon-Tyne, East opened up the question, which we have all from time to time thought about and discussed, of the possibility of the return of the hospitals to local authority control. He qualified it as we all do, by saying that one could not contemplate doing it with the present local authority set-up and that only after a redistribution of local authority powers and areas could it be contemplated. But before we lend ourselves too easily to that proposal, attractive though it is, we need to remember one or two historical facts.

First, it might be regarded as a betrayal of the old voluntary hospitals. If those who worked for them in the past found those hospitals first of all taken into a scheme that was not subordinate to the local authorities, and then from there, at a second stage, are moved under local authority control, it might well be regarded as a betrayal of the negotiations that took place before the passing of the Act.

I think, also, that if we wait until local authority areas have been redesigned and if they are, as they probably will have to be in many cases, made larger than the old local authority hospital areas, we would be in danger of getting away from real local control and interest in the local hospital. It may be that even under the present rather anomalous system of hospital management committees, there is closer liaison between the user and the member of the management committee than there would be under local authority control.

The hon. Member for Newcastle-upon-Tyne, East suggested that a first step in co-ordination might be some type of liaison between the executive councils and the local authorities. If my memory serves me aright, that was recommended many years ago, as far back as 1926, by a Royal Commission, of which Sir Humphry Rolleston was chairman, but was never acted upon. I do not think that this step should be taken until the whole pattern of reorganisation could be seen clearly.

If now we link executive councils with the existing local authorities, we are to that extent making it more difficult to work out a new health area for the future. It would be far better to let the present system grow its roots and settle down than to make one change now and then to find, if it so came about, that we were making a further change in 5 or 10 years' time.

Mr. Ellis Smith (Stoke-on-Trent, South)

Who is advocating that?

Sir H. Linstead

Nobody is advocating it in relation to the present local authority areas, but the hon. Member for Newcastle-upon-Tyne, East was advocating that the executive councils should be linked up with the present local authorities. I am only saying that we should not do that until we have decided on the future of the hospital service, so that we do not make a false step and have to retrace later.

Dr. Stress

If, however, it was thought right by the Ministry to consider special regions or regional groupings which would co-ordinate the present tripartite arrangements, so that both the local authority services, the special services and the general practitioner services would work together, would the hon. Member not agree that that might be a progressive step?

Sir H. Linstead

I am more in accord with what the hon. Member for New-castle-upon Tyne, East said about that. I do not believe that we would get effective co-ordination between the hospitals, the executive councils and the local authorities by means of regional organisations, committees or anything of that kind. It has to be broken down to much smaller units, and this co-ordination is a local matter, which must be decided at a local level in accordance with local circumstances.

It is much more likely to come about effectively if the medical officer of health is a member of his local hospital management committee and if the secretary of the hospital management committee is on good personal terms with the secretary of the executive council, rather than by any scheme of large areas being brought together under committees or in some such way.

I should like to deal briefly with the relationship of the hospital management committees and the regional hospital boards. Very largely for financial reasons, the regional boards are having to take a detailed interest in what hospital management committees are doing. I do not think that that was ever intended. Indeed, if one refers to the original circular H.M.C. 48/2, issued in the early days, one sees that hospital management committees were encouraged to take their own decisions and to run their own hospitals in their own way. This has tended to disappear. I should hope that regional hospital boards would find it more and more possible to withdraw from the day-to-day concern with the running of the hospitals in their regions as far as they can and by convention leave the man- agement committees with the greatest possible freedom to conduct their affairs.

I had not previously heard the passage which was read by the hon. Member for Barking, but I was interested to hear it. There was a complaint from the teaching hospitals—who are the most favoured group of hospitals in the Service—that if their existing state of affairs continued much longer it would be difficult to find people of the right experience and calibre to serve there.

If that be true of these great institutions which have a considerable amount of freedom and a great deal of finance at their own disposal, how much more true is it of the hospital management committee, which is surrounded by frustration and is finding it extremely difficult to serve its own area as it would like? I would, therefore, make a special plea to my right hon. Friend—though I do not feel that it is really needed in that quarter—and also to regional hospital boards to carry out in the spirit of the original circular the intention that the management committee should really be mistress in its own house and, under the board, free to run its hospital in the light of what it believes to be its needs.

6.12 p.m.

Sir Frederick Messer (Tottenham)

In the two opening speeches we had such a very comprehensive survey of the whole Service that I wondered what I should have to say, but there are particular parts of that Service to which attention can be directed with interest and benefit.

I do not think that sufficient emphasis has been placed on the preventive aspect. I have always thought it better from a humanitarian point of view, and more economical, to spend money on preventing a person from becoming a patient rather than curing him afterwards. In that regard I doubt very much whether the £2 million for research is enough. There is need for research. The medical profession has done great things, but there is still a lot for it to do.

The Service itself is justified by its results. It is a remarkable achievement that the 25,000 deaths from tuberculosis in 1939 have been reduced to 10,000 in the last year. What is more important, it was at one time a fatal complaint; when once the infection had been caught there was very little hope of anyone ever being able to throw off tuberculosis. Science has made such strides that even with tubercular meningitis, which was invariably fatal, there are now some successes. However, the antibiotic drug which is used, while able to penetrate the wax coating of the tubercle germ, does not heal the damage done to the brain by the meningitis, the inflammation itself. Consequently tubercular meningitis has mental after-effects in a large number of children.

Some little while ago the Minister was present at an inaugural meeting of a new body called the Association for the Welfare of Sclerotics—those suffering from multiple sclerosis. That is a terrible thing. Doctors do not know its cause. They only know that something erodes the covering of the nerve. As a consequence of the damage done a paralysis sets in which creeps until it covers the whole of the system, and the patient dies. There is need for money to be spent on research into things of that description, and indeed most of the associations given over to consideration of the various forms of disseminated sclerosis are acting for it.

Then spastics are victims of another terrible disease. It is usually the result of some damage to the brain at birth. Although the victim may be quite intelligent and quite capable of taking impressions, he is quite incapable of giving any expression to them. As a result, there is the possibility that large numbers of these people find themselves in mental hospitals, as it is assumed that they are mental cases. The truth is that they are imprisoned because there can be no communication from the brain to the nerve ending, as a result of which they are not responsible for what they are doing. They are not in a position to control their muscles, or to respond to the tests made to ascertain their intelligence quotients. There is need for money to be spent on research in that direction.

One can hardly doubt that there are many types of disease of which doctors even yet know very little. I spoke a moment or two ago about tuberculosis decreasing, but the alarming thing is that the number of deaths from cancer in the year is not 10,000, or 20,000, or 30,000, or 40,000—it is 87,000. That figure has risen terribly year after year. There has been no variation, no fluctuation, no rise and fall, but a steady increase in the number.

I hope, therefore, that the Minister will give some attention to the need for spending a little more—and in a different way. Here I speak with some difficulty, because I know that suggestions have been made in certain quarters that research should not be merely concentrated in the hands of the Medical Research Council but that opportunities should be stepped down right to the practical level of the hospital authorities. There is a great deal to be said for that, and that is one of the steps which might be taken in prevention.

Next there are the local authority services. I always regretted the transference of the public health service from the good borough councils to the county councils. There were some borough councils which were really unable to meet the demands made on them and it was necessary for some larger body to take over. One has to remember that, in dealing with work of this description, one must cover a population which is large enough to be divided for purposes of specialisation. One cannot have an authority to deal with a section, which may just mean a few units for special purposes. It would mean that the work would not be done. At the same time it is true that there were some borough councils with big populations whose public health work went to the county council. I am not sure that that was a good thing.

If I were asked whether I would give their powers back, I would say that it is very difficult, at the present time, to assert that every borough council should be entitled to be a local health authority. I think that it is possible to get over that difficulty by giving to every borough council the right of claiming delegated powers, and if that claim is refused for any reason, an appeal should be made to the Minister of Health. He could decide whether a borough council of reasonable size, which probably did good work in that field years ago, should continue to do so.

This is part of the reorganisation that the Minister might consider. It is quite true that many people think that this service should be unified, and that there should be one overall health body. It will be a long time before we reach that position, but even so, is it not possible to bridge the gap between the general practitioner and the local authority, between the general practitioner and the hospital authority, and between the local authority and the hospital authority? Is that beyond our wit? Personally, I think it is possible.

Some years ago a sub-committee of the Central Health Services Council produced a report on what was called co-operation. Nobody took any notice of it.

Mr. Blenkinsop

Some did.

Sir F. Messer

They may have read it, but very few people put it into practice, and I can understand why. The trouble is that there is a need for a reorganisation of the hospital service itself. A regional board has not been designed to cover an area so that its boundaries are conterminous with those of the local authority. The result is that we get one regional board which will go through parts of local health authorities, and we get one local authority part of which is covered by three regional boards. Coordination in circumstances like that is extremely difficult. How is it possible to manage in a local health authority, a county authority, when it is necessary to deal not with one regional board but with three regional boards?

If I am asked what is the actual work that needs to be done, and why coordination and co-operation are necessary, I would say that there is a great deal of work that is shared at the present time. Take tuberculosis, for instance. The chest physician and the control of the chest clinic is a joint appointment. The chest clinic is the responsibility of the local authority, and the regional board is responsible for the medical work done by the chest physician. When the chest physician is appointed, it is a joint appointment, because the regional board is responsible for providing the medical service and the local authority is responsible for dealing with the comforts, welfare and all the other matters, for tuberculosis is not merely a medical problem. It is a social problem, too.

The same thing applies to mental health. A child under a local authority is certified ineducable. He passes from the education authority to the health authority. The health authority is empowered to set up training centres and occupation centres for dealing with the mentally defective child. But if the child is of such low grade mentally, then it will need to go into an institution, which is the responsibility of the regional hospital board. We see here a necessity, if not for unification, at least for co-ordination.

I have had the painful experience of reading letters contained in the files of regional psychiatrists showing that, as a result of the low-grade mental condition, the home life has been disrupted and there has been constant pressure for the child to be admitted to a mental institution. Here, again, is a necessity for coordination between the local authority and the regional hospital board. The regional hospital board might quite possibly admit cases of less urgency unless there is the closest co-ordination in administration between the local health authority side and the hospital side.

It is not always possible to separate the health service. After all, we are dealing with human beings, and they are just the same human beings under the administration of the hospital authority as under the administration of the local authority. That being the case, it is clear that there is a need for some consideration to be given to the reorganisation of the regions. I could never understand how they were drawn. I do know that it was thought that it was necessary to get away from a geographical basis and build the thing up on a functional basis—a splendid-sounding phrase—whatever that may mean.

But in building it up on a functional basis, surely the thing that we have to remember is efficiency of function, and if that is the case, it appears to me that if the regions were so drawn as to make it more easy for co-operation to take place, we should not want any rigid machinery to bring that co-operation into being, for it would emerge. The needs of the situation would express themselves in such a way that at officer level and at committee level this co-operation would quite naturally develop.

Take the case of old people, to whom my hon. Friend the Member for Barking (Mr. Hastings) referred. An old person may not be ill; that is to say, he may not be suffering from any specific disease, such as arthritis or cardiac debility. There may be a degree of physical and mental deterioration which leaves such a person in a state of helplessness; yet he is not ill. The regional board will say, "You are not a case for us. You are a case for the welfare authority, the local health authority." The local health authority will say, "If you are not ill, you are not the type of case for our welfare homes." As a consequence of that difficulty of assessing responsibility, there are today in many homes people who ought to be in hospital, and there are in hospital many people who ought to be at home.

This is a difficulty that has been met to some extent with the assistance of voluntary associations, and in this regard I must pay my tribute to what our voluntary associations have done. But we have to remember that there are limits to what we can do under statute. When we pass a law and state in that law what can be done, by implication we indicate that no more than that can be done. When a law is made, nobody can imagine what circumstances or conditions may exist at some time in the future. In addition, there is so often the question of the need for discretion, the right of doing just what one thinks is needed at the time and not in consequence of any statute. Therefore, I think it is right to say that local authorities have been of very great help in connection with these matters.

I think that it is quite right that in times like these we should express our views on certain weaknesses which should receive attention. My hon. Friend the Member for Putney (Sir H. Linstead) said that what we want in regard to the hospital service is for the regional boards to get out of the way and let the management committees, within the limits of their estimates, get on with their job. Here we are faced with a difficulty.

The regional board is at present the body to decide the user of a hospital. If it is not to do that, every management committee will take the interesting work. It will take the acute work. It will leave the chronic T.B. cases and secondary cancers—and who will look after them? When all is said and done, we cannot fill our beds with acute cases. There is a long waiting list at the present time, as there is always, of cases which are not urgent cases. We could fill our beds with acute cases, but if we did we should not be able to take in the other cases. If it were not that the regional board had the right of deciding the user of the hospital, there is the possibility that management committees might perhaps do less than they have been doing.

Sir H. Linstead

I accept that the bed user would be a matter for the regional board, but if we would trust our hospital management committees they would accept that responsibility. I said that if they had the responsibility which I was claiming, the sort of thing which the hon. Gentleman has referred to would probably not happen, because the management committee would have greater responsibility.

Sir F. Messer

I probably misunderstood the hon. Member, but the truth is that many management committees fail to realise the amount of power which they have, and they let the regional board barge in when they could very easily tell the regional board to keep its nose out.

The trouble is that they do not know what power they have. The regional board has no right to interfere with the day-to-day management of the hospital, which is the job of the management committee. I have been the chairman of a regional board and I am a member of a management committee. It is revealing to know what some management committees put up with. No management committee in my region would ever submit to the things to which some management committees submit. If the management committees themselves would use their powers to the maximum, there is no reason why they need worry about the regional board, but the point is that unless the regional board plan the specialist service over a wide basis, we cannot get the same degree of efficiency.

In 1948 the T.B. waiting list was 12,000 —2,000 in the south and 10,000 in the rest of the country. It looked as if things were going to get worse and worse. So the regional board said to its management committees, "To the nearest bed, 10 per cent, of your beds must be given over to tuberculosis." As a result, the waiting list was wiped out. This did not mean that the 10 per cent, patients taken in were kept there all the time. Patients were admitted where it was a question of lung collapse, an operation was performed and the patient discharged to his home. If it was necessary at a later stage for further operative treatment to take place, the patient was re-admitted to the sanatorium or hospital. That brings me to the point that I want to make, which is that the maximum use was made of bed accommodation, and the waiting list disappeared.

I am not one of those people who believe that we should aim at a lot of new hospitals or a lot more beds. I believe that the fewer hospital beds we need, the better, and our efforts should be directed to that end. There are many cases where, in decent homes, the patient can be treated better at home. Sometimes there is the possibility of taking a hospital service into the homes of the people. There is an example of that not very far from the House, at St. Helier Hospital, which has a medical superintendent. People do not always like the term "medical superintendent," but he is a man of imagination, and on that housing estate in the vicinity of the hospital there are people who ought to be admitted to hospital but who cannot be admitted. He sends the nursing staff to them and collects the laundry. That is the type of medical superintendent who realises the responsibility of his position as a servant of the people.

Mr. Ellis Smith

He is an exception.

Sir F. Messer

My hon. Friend says that he is an exception, but I think that he has a little more courage than some and is prepared to dare to do what is right.

I think that on this question of bed occupancy there is something which we should consider. The figure of £400 million spent on the health services is alarming, but it is only alarming if we think that any of it is not being wisely spent. If we get a return from it, it is well worth while—it is worth every penny that we pay.

I am doubtful whether or not we have considered bed occupancy from the point of view of ensuring that there shall not be long gaps between the discharge of a patient and the admission of another patient. When one looks at the reports of the hospital management committees, one sees that in the 800-bed hospital the average accommodation throughout the year is 600. One might wonder when there is such pressure on hospital accommodation how it is that there are 200 beds unoccupied. One has to remember the type of hospital. In a hospital with short-term cases and a rapid turnover, with an average of 10 days' occupancy, it is not possible to have a patient out one day and another in the next. The more of these cases there are the greater the wastage. We are, however, still left with the need of ensuring that there shall be the maximum use made of what hospital beds are available.

I had intended to say a word about economies, but I feel that I am trespassing on the time of the Committee. There is a little journal called the "Hospital Officer." The editor wrote to me and said, "Will you write me an article describing what you would do if you were Mr. Guillebaud." I did. I said in that article that in the first place I would tell the Minister that if he wanted to save money he would have to spend some first. If he will spend money he will find that at the end he is saving money.

Reference has already been made to out-of-date boilers. I am sometimes amazed at the type of boiler which is still running in some hospitals. In hospitals throughout the country there are many boilers which to the layman look as if they are on the point of blowing up. I have read reports in which the engineer has said that the pressure he can get is only half what it should be, but that he dare go no further because any higher pressure would be dangerous.

I am not a technician and I do not understand these things, but I have heard reports, and read reports, which have said, "If only we could get an up-to-date method of fuelling we could save thousands of pounds in a year." Whatever is the difference between hard and soft fuel, I do not know, but these reports say that hard fuel is being used, whereas if they could convert their boilers they would have the new boilers paid for over and over again in a short time. If these things are true, is not that the way in which money should be saved rather than on the Service in other directions?

With all this, the Service has justified itself. Some of us who had spent years in local authority work wondered how a National Health Service would fit in with local needs. We could see all the difficulties of centralisation and all the dangers inherent in uniformity. If we had attempted to run the Health Service in a uniform way, then indeed it would have been true that the dead hand of Whitehall would have strangled the soul of humanity. But what has happened has been a stepping down and a devolution, as a result of which it is now possible at the management committee level to obtain that closeness of contact which is so important in work of this description.

We shall not solve this problem by any mechanical efficiency. No instrument has yet been devised in the mind of man which can plumb the depths of feeling of human beings. This Service requires something more than just cleverness. It calls for humanity and for willingness to serve, by those who can to those who need.

6.43 p.m.

Commander C. E. M. Donaldson (Roxburgh and Selkirk)

The hon. Member for Tottenham (Sir F. Messer) has addressed the Committee with his usual eloquence and from the vast fund of knowledge which he has acquired in service given to the House of Commons and to the country in this sphere for many years. The Committee is always grateful to him for so doing.

Towards the end of his remarks, he used the word "devolution," and as I am the first hon. Member to be called today to speak for a Scottish constituency, perhaps I may say that the word "devolution" is one which will be appreciated by my right hon. and gallant Friend the Joint Under-Secretary of State for Scotland, who is to wind up the debate. Let me say, however, that it is not my intention to introduce any atmosphere of controversy in a debate which has been so smooth in its operation and so sincere in its deliberations.

It is my duty to refer to matters which particularly affect Scotland. It is with some regret that I admit that I do not possess the knowledge of the hon. Member for Tottenham, whereby he led us through all the intricacies and difficulties of the administration of the Health Service, nor have I the combined knowledge of administration and of medicine possessed by the hon. Member for Barking (Mr. Hastings) or my hon. Friend the Member for Putney (Sir H. Linstead).

That is not to say that my sincerity on these matters is any the less. If I speak mostly for one area, I think the Committee will forgive me. In the area which I represent in the South-East of Scotland we have one large hospital, called the Peel Hospital, which tends for the needs of people in a very large geographical area and which performs its functions ably and well. Indeed, in the past few months a new operating theatre has been constructed in it and new amenities have been provided for out-patients and for those who are visiting their friends and relations in hospital. The nursing sisters have very good quarters in which to live. The training classes which are carried on there for the teaching of nurses are well conducted and well organised. I have had the pleasure of listening to some of the instruction.

But in this hospital, which serves at least part of five counties in the southeast of Scotland, is inherited from a wartime, temporary hospital built on large private grounds, which were acquired many years ago. It is not a permanent hospital, and I want to ask my right hon. Friend some questions about the future and about a permanent hospital for this large and important area. I understand that some years ago plans were drawn up for the building of a new general hospital in an area about St. Boswell in Roxburghshire. Those plans are not being proceeded with at the present time. I want to ask whether there is any possibility of a new hospital being erected in the future, and, if so, when an announcement can be made about it.

The hospital at Peel possesses a peculiar spirit. Hon. Members on both sides of the Committee have paid compliments to the administrative staffs of hospitals and to the medical officers and nursing services, and nowhere could these attributes of attention to patients be better exemplified than in the Peel Hospital, which is like a large family hospital. The people who have been there and who have returned to live healthily in their homes, return later to the hospital to see their friends who may be having treatment. When they have functions to raise funds for benevolent purposes to do with the hospital, these patients return and are proud to associate themselves with the competitions which take place to see whether ward A can do better than ward B, etc.

I think that is a splendid thing and it shows that in the administration of hospitals, large and small—this hospital is a cross-section of the two—we can, -by good leadership, by imagination and by enthusiasm, develop an esprit -de corps which is not only evident in the hospital when patients are there but which remains in the minds of the patients after they have left the hospital and which conduces to the well-being of any community.

The one danger which I apprehended when I first saw the Health Service being introduced in this country was that, particularly in Scotland, it might create a tendency to lead people's minds away from the neighbourliness which has always existed among Scottish folk in the past. If the next-door neighbour or someone down the street were ill, they felt a personal responsibility. I was afraid that people might say after the Health Service was introduced, "We will leave it to the Health Service. The district nurse will come; it is not my worry; they will be in hospital." I am glad to say that, certainly in my area, that has not happened. There is a sense of responsibility. Long may it continue, and, indeed, may it be enhanced.

I should like to go from that to the point of administration. The hon. Member for Newcastle-upon-Tyne, East (Mr. Blenkinsop) made some reference to staff administration and to medical administration. One thing that should be guarded against is to see that these two branches are kept in proper perspective, one to the other. I feel there is a danger in some of the larger hospitals in Scotland—I do not wish to mention any—where the secretarial administrative side might tend to have an undue influence on the medical administrative side. That is something which should be closely watched by the Scottish Office. At this time I do not want to go further into that subject. There may be opportunities in the Scottish Grand Committee for a debate in more detail on these things, and I do not wish to press them unduly here.

There is one other point I should like to mention in connection with South-East Scotland, and that is the supply and repair and maintenance of hearing aids. Cases have come to my political surgery, as differentiating from medical surgeries, of complaints of the difficulty in getting hearing aids adjusted or repaired. People find that it is necessary to go to Edinburgh or to send them in which case the adjustment is not always satisfactory. But in either case they have to wait a long time.

I wonder whether my right hon. and gallant Friend the Joint Under-Secretary of State for Scotland would investigate the position and see whether the number of hearing aids in the South-East of Scotland, well clear of the metropolitan boundary of Edinburgh, is sufficient to be serviced by the setting up of a small centre either in Peel Hospital or one of the other burgh hospitals centrally located, which would save people working in the mills a day's pay to go to Edinburgh to get these things adjusted. I would not wish to make such a suggestion if it were unduly expensive, but I know there have been cases of hardship where there has been a considerable loss of wages.

I should like now to go outside the Border area. There are other subsidiary services which are given voluntarily to aid the Health Service in its great work. I refer, in particular to the Women's Voluntary Service, which, in some areas of Scotland, including the more rural areas where ambulances are not readily available, bring patients into hospitals. This work is greatly to be commended in the country, and I am sure the Minister of Health and my right hon. and gallant Friend are grateful for these services.

The only question in my mind is the practical point when considering this service in relation to the national economy. It may well be that there should be some investigation here, particularly in relation to the cost. For instance, is expenditure for petrol allowances advisable, or would it be better to have some other basis of payment for getting these people into hospitals, particularly the outpatients who are not able to go unaided?

I should like to make some reference to general practitioners and specialists. Both have been referred to in the course of the debate. From my own observations I feel that there is a tendency in some areas—and it is more in the crowded city areas than in the country- side—for medical practitioners to send people to specialists whereas they themselves might do some of the work. I have known of this happening. I do not know what can be done to cure it, but it is something about which we should be thinking.

Then I should like to make one or two remarks about research, a subject mentioned by the hon. Gentleman the Member for Tottenham. It has been my pleasure to have known a very great man in Canada, Dr. Best, who was associated with Dr. Banting in the discovery of insulin. They did a great deal of research, and Dr. Best subsequently discovered something which brought great benefits in the curing of sclerosis of the liver. I have heard the whole story of how Dr. Best came to discover this benefit, and I have also heard him express himself about cancer, which concerns all of us.

If some young doctor or a couple of young doctors or three or four associated together such as Dr. Banting and Dr. Best come across the basic answer for which the medical profession is looking for cancer, I hope that notice will be taken of it. I hope that in the medical research services there is provision for such a contingency. If not, there ought to be a provision whereby young doctors can come forward when they have an idea, and some recognition can be given to it instead of them having to fight and work and spend years of fruitless effort in advancing their scheme. I hope that my right hon. and gallant Friend can give us an assurance that there is some provision for increasing research, particularly in the field of cancer.

I have one final point. I, personally, feel that an occasion such as this the subject of the fear of cancer should be mentioned. I have said in other debates, and I hope I may be allowed to repeat it today that far too many people who leave it too long, and that particularly applies to young women. That is because they fear the answer they may receive. But I hope that the public will realise that the answer they get is not always something which they need dread. If they will only go at the sign of the first symptom—and the symptoms are fairly well known to the general public—to their medical adviser fox an examination it will be to their advantage. In a great many cases they will find that their fear is unfounded and in other instances an early report might lead to an early cure. If this debate does nothing else but bring that message to people in that particular state of mind, then I believe that we will have done a good day's work.

6.58 p.m.

Mr. W. A. Wilkins (Bristol, South)

I hope that the hon. and gallant Gentleman the Member for Roxburgh and Selkirk (Commander Donaldson) will forgive me for not following him in any detail, because I know very little about the operation of the Health Service in that part of the British Isles which he represents. I am also aware that some of my hon. Friends are very anxious to speak in this debate, so I want to make my remarks as brief as possible.

I should like to express my thanks and that of the Committee to my hon. Friend the Member for Newcastle-upon-Tyne, East (Mr. Blenkinsop) for the way in which he introduced this subject. He made a comprehensive speech and he brought out many important points. I should also like to thank the Minister. During the time he was speaking a smile appeared on my face, but it was not because of amusement at the things the Minister was saying. I was thinking of the days when he used to be rather more aggressive than he is now. Today, he made what I might call a rather conciliatory speech. That is all to the good, because many of us are very deeply interested in this subject, and I think we should give our minds to it without undue political bias on either side of the Committee.

Whatever side we sit on we can say that there have been very rapid strides and great improvements in the Health Service during the past few years. I think it ought to be a matter of pride, and certainly not of prejudice, that we have been able to make this progress.

It is amazing what can be done when we set our minds to it. Last Friday I visited a hospital which I had mentioned in this House only a few weeks previously, when we were discussing the mental health services. I had not seen this hospital since 1946 and it was then used mainly for the chronic and aged sick and a few mental defectives. Since then, however, there have been improvements, the mental defective cases have been transferred to other accommodation and a remarkable job of adaptation has been done on a rather grim place.

The number of beds has been reduced from 900 to a little over 700, and this has enabled a number of structural alterations which have made the hospital more light, airy, roomy and comfortable, for the nursing staff in particular. It was a matter of gratification to me when one of the patients said, "We are being cared for marvellously in this place, both medically and otherwise."

I would not dare to cross swords with my hon. Friend the Member for Barking (Mr. Hastings), who is a specialist, but I was concerned over some of his observations about accommodation for older people and the chronic sick. The demand for hospital accommodation is still great and something must be done about it. As far back as 1936, when I was serving on the Bristol health authority, to which the Minister has referred, we were talking about erecting a hospital on the south side of the city, which is in my own constituency. Indeed, we were on the point of submitting plans. I wonder whether the Minister will be able to say that this great need of over 20 years might not now be met by the hospital being begun in the near future?

My next point was referred to both by the Minister and by my hon. Friend, namely, the Bristol clinic. I assume that they were not referring to the local authority health centers, because I believe that the clinic to which the Minister referred was one which he opened?

Mr. Iain Macleod

indicated assent.

Mr. Wilkins

I wish I had known that the right hon. Gentleman was to open it, because it is situated in my own constituency and I visited it a month ago at the invitation of the doctors who use it. I am sure the Minister will agree that it is a fine example of the way a group practice can work in conjunction with a local health authority. The estate in question had been a source of constant worry to us as members of the local health authority, because no doctor would live there. It is a tragic fact that doctors fight shy of our housing estates, the tenants of which are desperately anxious to have a doctor in residence on whom to call in an emergency in the middle of the night.

In the case of this clinic the erection of the necessary building was urged by the doctors, who put their views to the medical officer of health. In it there are six doctors, working either as principals or partners in close conjunction and harmony with the local authority, whose midwifery service and clinics operate from this centre. So there are two functions side by side, the private practitioners working a group practice and the local health authority using the facilities to carry on its local health work. A little encouragement might start something similar in other parts of the country. I should point out that this is not a complete set-up because, while attention is given to minor accidents and treatment is given to someone in urgent need, the patient is then passed on to his own doctor. So additional facilities could be provided there.

It is unfortunate that group practice of this kind is not greatly appreciated by the medical profession, apart from those who are engaged in it and who think it is a wonderful opportunity. I do not understand why the profession generally seems to frown on this form of service, because it operates for the good of the doctor as well as the good of the patient. For instance, arrangements can be made whereby each doctor is on call only one night a week, whereas a doctor running a private practice on his own must anticipate being called upon during any hour of any night. There is a new estate in my constituency not far from the one to which I have been referring, which will house 7,000 to 8,000 people when it is fully developed. I am hoping that a similar organisation will be encouraged for that estate also.

I attach great importance to preventive medicine and am of the opinion that our efforts should be concentrated in that direction. Before the war our average deaths among children were between 200 and 400 a year. It was not easy to persuade the mothers of Bristol to have their children immunised. We spent a lot of money on advertising as well as on the immunisation itself, but the results have been well worth while. We have not had a death from diphtheria in Bristol for four years. I wonder whether our ratepayers, who did not look too kindly on this development, realise the amount of money now being saved to our city in respect of nursing services alone. It must run into thousands of pounds.

Money spent on research and preventive medicine is not wasted. It will return magnificent dividends in sound public health to the people who are prepared to spend it. I could go on endlessly talking about what we have done in our city as regards medical facilities because we are progressive, but I shall not delay the Committee further and perhaps I shall have another opportunity. I hope that the Minister will continue to press forward with our health services in the way he has outlined, because they are already a model and the envy of many parts of the world.

7.10 p.m.

Mr. J. K. Vaughan-Morgan (Reigate)

I hope that the hon. Member for Bristol, South (Mr. Wilkins) will forgive me if I do not follow him on the rather localised points which he raised, though I echo very heartily the remarks which he made in his closing sentences, of which I am sure he will be very proud when he reads them in the OFFICIAL REPORT. I should like to return to one or two of the themes of the hon. Member for Newcastle-upon-Tyne, East (Mr. Blenkinsop) and of my right hon. Friend the Minister of Health.

My right hon. Friend gave some particulars of the capital sums to be spent on the hospitals in the forthcoming year, which, at £10 million, he said was the highest since the war. When I saw this figure in the Estimates I tried to find out what was the parallel figure for the years before the war. As far as I could ascertain from the inadequate statistics that are available, it was about £8 million. If that is the case, allowing for the increase in costs since then, which would have brought that figure to between £16 million and £20 million, we should realise that with £10 million, though if is the highest figure since the war, we are not making any real progress at all. We are, as it were, only treading water, but the figures show that the neglect which it is said took place before the war was not as bad as it is sometimes stated to have been.

My right hon. Friend, in his various circulars from the Ministry, has laid down the priorities in hospital capital expenditure which he recommends. There has been some discussion today on the very rightful expenditure on plant which will reduce maintenance costs. My right hon. Friend also referred to accommodation for mental patients. I should like to say something about another priority, namely that for geriatric units. Nothing like enough has been spent in that direction. If we are seeking ways and means to reduce the costs which will ultimately fall on the National Health Service, here is something which should be given equal if not greater priority than some of the other factors that I have mentioned.

In the principal hospital in my own area, where the average age of the" population is slightly above the national average, we have no geriatric unit. Representations have been made by the local hospital committee, but the answer given is that the regional hospital board has overspent on consultant services and can do nothing to meet the needs of this case.

We would all agree that for a geriatric unit to work really efficiently it would need to be associated with other similar services. In this case we also have a voluntary body which, with a little encouragement, is only too anxious to start a half-way house to be run in conjunction with a geriatric unit. Those concerned are also anxious to provide a holiday home, of the kind with which many hon. Members are familiar, which will allow families to send their infirm and elderly relations there for a time while they are on holiday. That would mean that the relations would be much more anxious to look after the old people in their own homes. All this work has been held up because of the failure to provide a geriatric unit. I I hope that my right hon. Friend, in his circulars to the regional hospital board, will put a good deal more impetus behind that drive, because that is one aspect of expenditure where money can be saved in the future.

In the main, expenditure on hospitals so far has been related to patching up and improvement and it is to be noted that no general hospital has been built since the war. I hope that if and when the time comes to embark on another general hospital nothing will be done until we are in a position to learn the full lessons which can be drawn from the improved turnover rates in the hospitals, to which the Ministry of Health's last Report drew attention.

I am told that the average number of patients per bed in a hospital has, during the last six years, risen from 11.9 to 13.16 per year. Those percentages mean very little, but I am also told that the effect is equivalent to the construction of hospitals providing between 40,000 and 50,000 beds. That shows very impressively what can be and has been done by increased efficiency in the medical profession. I hope, therefore, that no steps will be taken to build general hospitals till the full lessons have been learned from those facts.

The hon. Member for Newcastle-upon-Tyne, East made some very interesting remarks about hospital administration. Many of us on this side of the Committee would share his views that more responsibility could be and should be given to local authorities in matters of health. There was some foretaste of his views in the document called "Challenge to Britain," that interesting document which is a garland of millstones round the neck of the next Socialist Government, if there should be one. That document stated: We are not in favour of returning the whole service to local authority government, but we are resolved that local authorities should play a larger part in its administration. All of us on this side of the Committee would wish that that had formed part of the thought of the party opposite in the years before 1948.

I was very interested in the remarks of the hon. Member for Tottenham (Sir F. Messer) about the personal health services and his suggestion that in many cases these might be handed back to the lower-tier local authorities with the permission of the Ministry of Health. In another form, that suggestion formed part of the manifesto of the Conservative Party in the last but one General Election, and I hope that it will be given very earnest consideration by my right hon. Friend. I was a member of the London County Council some years ago when the National Health Service was introduced and I think that many members of all parties in that council very much regretted the quid pro quo by which, when the county councils lost the hospitals, they took over the personal health service from the borough councils in London and the borough and district councils elsewhere. Anything that can be done to redress that tendency will be very popular in all parts of the country.

On the need for preventive treatment, to which many hon. Members have referred, I want to digress to one particular aspect where more might be done. The hon. Member for Newcastle-upon-Tyne, East quoted from that very interesting book by Dr. Stephen Taylor, "Good General Practice," a book which, I feel, will form the infrastructure of a good many speeches on health matters here in the future. I was very much struck by what Dr. Taylor had to say on the question of problem families, a matter in which I am greatly interested. These he mentioned as being a burden upon the general practitioner.

He reckoned that problem families, which we know in other respects as slum families, the feckless, inefficient and incompetent, form between 1 per cent, and 2 per cent, of the population. This is not only a medical problem but a social problem. It is one which the community should take very seriously, not only in the cause of health, but because of other evils that arise from a low standard of health and living. Very remarkable work has been done by a body, which many hon. Members know, called the Family Service Units. It works with these problem families and endeavours to instil into them the elements of hygiene and decent living. Recently, it has had its work curtailed because my right hon. Friend has not found it possible to allow grants to the local authorities in conjunction with whom the Family Service Units work.

I have been in correspondence with my right hon. Friend on this matter and I know that he hopes to be able to revise his attitude at a later date. But at present he is out of step with the Home Secretary and the Minister of Education. From the point of view of the body of voluntary workers it is a little confusing that local authorities can get grants for this work from two Ministries, but not from another.

I admit that the type of work done may seem expensive in relation to the comparatively small results and that there are other ways of tackling this problem. However, I shall forgive my right hon. Friend for his quite rightful sense of economy in these matters if he will see that his Ministry devotes some thought to this problem. I have dwelt on this subject because it gives some idea of the sources of ill-health and expenditure, which lie outside the normal purview of the National Health Service.

There has been much talk this afternoon of the need for preventive medicine. I entirely welcome that and approve the new and appropriate attitude it represents, because it is quite clearly known to all of us that the amount which can be spent on cure is unlimited. We have to strike a balance between what we must spend and what we could spend. Therefore, it is far wiser to make provision for the future by concentrating on prevention.

So many of the sources of ill-health lie outside the scope of the strictly limited area of the National Health Service£mdash;in inadequate health education in spheres where my right hon. Friend has no jurisdiction, such as factories where the conditions may promote ill-health. I hope we shall concentrate on preventive work, not only within the National Health Service, but on the periphery where the Service overlaps and even conflicts with other social services and, also, where the duties of others overlap with what should really be the duties of the Minister of Health.

7.24 p.m.

Dr. Barnett Stress (Stoke-on-Trent, Central)

Although I do not appear to follow him immediately, many of the points that I shall take up will cover some of the things that the hon. Member for Reigate (Mr. Vaughan-Morgan) has said. In particular, I was interested in his last remarks, where he seemed to foreshadow the need for a complete occupational health service co-ordinated with and integrated in a comprehensive National Health Service. I am sure he is quite right.

The Minister finished his long and interesting speech today on a note of optimism, but it was guarded optimism. I understand that he has been able to gain a little hay for his donkey this year compared with last year£mdash;he will remember the analogy he gave us the last time we discussed this matter. We are very proud of it, but some of us are frightened that the note of optimism of the right hon. Gentleman may be betrayed by events. We are afraid that the hospital service may find itself not only, as he said, in difficult straits, but facing a difficult period. If we find in addition that beds and wards have to be closed, the right hon. Gentleman will expect us at once to make the strongest protestations, just as we shall expect him to foresee the difficulty and prevent it from ever happening.

There has been a great change in the tenor of our debates since 1948, as the right hon. Gentleman will admit. Let us be quite frank about it; we are all proud of the Service, although we know there are many ways in which it can still be improved, and we are all determined to improve it. The right hon. Gentleman rather shied away from that part of the Vote which is concerned with Civil Defence. He thought that we would not say much about it this afternoon, and I do not intend to do so, but I wish to ask how it is possible to save nearly £1 million on Civil Defence. The right hon. Gentleman said something about beds and mattresses, but if we are to have appropriations for Civil Defence, I should expect us to think in terms of stocking drugs, dressings, blood plasma, substitutes for plasma and antibiotics.

In particular, blood is tremendously important, if Viscount Montgomery and others are right and if the warnings in the Defence White Paper are correct. If we are to face the possibility of atomic war£mdash; and Viscount Montgomery suggests that we should all go into the Army, because right in the front line would be the only safe place£mdashwe ought to have some stocks of antibiotics, such as the sulpha drugs, perhaps such other drugs and dressings as are available, and large quantities of dried blood.

When we discussed the question of Civil Defence before, I said that it is estimated that if one is badly burned one needs about 35 pints of blood. The Minister has reported that he gets about half a million bottles of blood a year, each of them about three-quarters of a pint, a total of about 400,000 pints. At 35 pints to a person, that would allow us to treat only 12,000 such casualties if we did not use blood for any other purpose whatever.

Therefore, I must ask the Minister whether he has joined the Coventry brigade, or whether what he is saying in this Vote means that he does not think there is going to be a war. I hope that is the case. We ought to have some explanation and I hope that either the right hon. Gentleman or his hon. Friend will tell us hi reply to the debate that there are ways and means of at least stocking blood and dry plasma. That is worth its weight in gold for normal civilian purposes.

Mr. Macleod

This is even more apposite than the hon. Member knows. He probably noticed that I left the Chamber for about half an hour. I was making a broadcast on the B.B.C. about blood and the need for an increased amount to be available. The reduction in the Vote for Civil Defence to which the hon. Member referred is genuinely covered by the sort of items to which I drew attention in my speech and does not mean in any way a reduction of the stocks that we have, nor does it affect in the slightest the grave need for an increased panel of blood donors, which I hope will be achieved.

Dr. Stress

I am delighted to hear the Minister say that, and his interruption means that I need not apologise for having brought the matter forward, as it is of some importance. We must face these things realistically and know where we are.

Mr. McNeil

I must have misjudged the Minister. It appeared to me that he was telling the Committee that he intended to abandon the build-up of drugs and dressings, and that he was not adding to the stocks which we started.

Mr. Macleod

No, that would not be right. I will ask my right hon. and gallant Friend the Joint Under-Secretary of State for Scotland to give more detail of the change in the Civil Defence Vote.

Dr. Stross

The Minister will agree that all of us who gave thought to the type of Service we wanted£mdash;and he was one of them£mdash;used to think of it in terms of trying to make it as comprehensive as possible and trying to make it apply to every citizen who needed it. We also wanted it to be freely available. It is on the question of free availability that we on this side do not see eye to eye with the Minister, because he still defends the charges. I must say that he does not defend them with quite the same gusto today as he did in the past. If, by any chance, after two or three years' experience of one of the greatest organisations in the world, he knows more about it than he did earlier, who am I to blame him? I do not blame him at all. I am happy to note the kind of speech he made today and the obvious pride which he showed in his work.

People like myself who are still enthusiasts will do all we can, if we get into power, to remove these charges which, from the financial point of view, now represent only an insignificant part of the Health Service as a whole. On the question of cost, it will be agreed that everybody has to have a health service, wherever they are, according to how rich they are or, apparently, according to how poor they are. In the United States there is no comprehensive or unified service, nor one which is freely available, like ours. There people have to pay either through personal insurance in those cities where it is available for them, through their trade unions or by some other means; or, alternatively, in most cases they must pay when they get the bill or even before they get the service.

In the United States, if we take into account the fact that there are three times as many people as in this country and that costs are roughly two and a half times as high as ours, it is estimated that their service cost £480 million a year compared with our £400 million a year. In other words, we get a very good bargain. We get a comprehensive, free service which touches our lives at every point, which allows for no despair among people who fall ill because they are unable to afford the cost. In the United States, as we know from President Eisenhower and ex-President Truman, people often despair because they may be ruined financially through sickness.

At the other end of the scale, in South-East Asia the cost of the health service is, on the average, 2s. per year per person. The World Health Organisation tells us that about 1 million people a year die in this area of malaria even now. Our donation to the World Health Organisation is no higher than it was last year. I fear that it is a trifle lower. I am sorry to see that, because there is a great need for the work to be continued and indeed intensified.

I cannot state the cost of the health service in Egypt but, again from the World Health Organisation source, I know that one disease, and one only, bilharzia, which is an infestation by a certain type of worm, costs the country more than half the total amount of money which the Egyptian Government spend to cover all expenses every year. One can imagine what it would mean for Egypt in actual wealth if they had the resources and the medical manpower to carry out an attack on this disease and get rid of it.

It was suggested by my hon. Friend the Member for Newcastle-upon-Tyne, East (Mr. Blenkinsop) that if we compared the real cost of our Service in terms of national income or output, we should find that it had not increased by very much compared with before the war. I agree with that assumption, which can be based on the P.E.P. Report of 1937. Of course, there are some extravagances. There are extravagances in all big organisations. All of us hear about them. The overall picture is very different. It is obvious that, by and large, we are doing very well.

Everyone has said that the way to get the best value for money and to prevent unnecessary suffering is to emphasise the preventive aspect of the Service. That cannot be done without a change of the type of administration. There are three strands in the Service: the local authority strand; the one through the local executive committee for doctors, dentists and opticians; and the hospital services through the regional boards. If we are to weld them together, we must have a different form of administration.

I do not apologise for throwing this idea into the pool. The idea is not my own. Probably the Minister has heard it ad nauseum. It is that the time has come for the creation of suitable regional areas. We should have regional health committees or bodies responsible for all the needs of the individual, so that human beings shall no longer be shuttled backwards and forwards according to the boundaries of the areas that the different parts of the Service cover.

I am certain that the Minister will hear more about this idea. We cannot possibly gat this idea put into effect unless and until we reconsider the whole of the boundary problem. When that time comes we must not lose our chance. We want a different method of election of administrative personnel. This is not the fault of the Minister. If he had had to create the Service, he would have faced all the difficulties that my right hon. Friend the Member for Ebbw Vale (Mr. Bevan) found. My right hon. Friend had to build and get the machinery working.

It is a wonderful achievement to have so many people giving their services freely, but I should like to see the system more democratically controlled. The Minister must be able to appoint some members to the sort of bodies which I envisage, but the majority could be democratically elected. It is our genius in this country to do things in that way, and such a system may very well work satisfactorily.

Mr. Ellis Smith

We should try it in North Staffordshire first.

Dr. Stross

We would like to do that. We will have a North Staffordshire region.

This is always an exciting subject, and I do not want to speak for too long, because other hon. Members wish to take part in the debate. I conclude by speaking of the general practitioner services. These have been looked upon too much as the first line of defence against disease. We must look upon the general practitioner services as the first line of attack, as our shock troops to go into attack if we are to get preventive medicine at its best.

How can they help us? They can do it by educating our people. We are not a continent; we live in an island. We are a small composite people, and we live close to one another and know one another, and we even like one another. Our Scots colleague, the hon. and gallant Member for Roxburgh and Selkirk (Commander Donaldson), has found to his astonishment that even the National Health Service does not prevent people from liking one another.

We must use the general practitioner more than we have done in the past. It is wrong for him to work in isolation, particularly in cities. He ought to work in a team. Group practice is best for him. The Minister cannot possibly deny this, for his father at Skipton started the first well-established group practice in England.

I cannot exaggerate the importance to a doctor of having colleagues whom he can consult and whose advice he can obtain. Therefore, the doctor should be in group practice in a suitable building. One then gets non-competitive, cooperative private practice, whether it be in a health centre or in a group practice. It is necessary to have in the building a suitable room where doctors can lecture to their patients.

An experiment was recently conducted by some practitioners in London who were disturbed about the fate of old people who had no one to whom they could turn for help. The practitioners called a meeting of their patients and put the problem to them and asked whether any of the patients were willing to volunteer to help the old folk by staying with them and ensuring that they were not so lonely. It is reported that the response was staggering and overwhelming. We have not yet properly touched the desire and genius of our people to help each other.

The medical practitioner cannot do much on these lines in his own home; he must have a place where he can meet his patients. We who think on these lines have the dictum "The health of the people is really the concern of the people themselves." One cannot contract out of this responsibility; one cannot leave it to other people to keep one fit or to make one well when one becomes ill, when the fact that one is ill may often be due to one's own ignorance and carelessness.

Year by year I have watched the country accept the Service and become more and more proud of it. It is true that an increased grant for the hospitals is required so that we can embark upon new types of administration and other work in order to learn further lessons. By and large, we have enough general practitioners in the country if they were more evenly distributed and enough consultants if they were evenly distributed.

I asked the Minister the other day about the long waiting time in some areas. I said it was a pity that geography should enter into the problem of whether one lives or dies. Living near Westminster Hospital and St. Thomas's Hospital gives one much reassurance, and I should also like the Welsh and the Scots to have that reassurance if it is at all possible. By the use of good administration, we could overcome the difficulty.

I was happy at the way the Minister spoke today. I hope he will remember what I said at the beginning. If he finds that the hospitals are getting into trouble and cannot manage this year, let him come early to the House and we shall give him our support.

7.44 p.m.

Mr. Richard Fort (Clitheroe)

The hon. Member for Stoke-on-Trent, Central (Dr. Stross) has managed to vary the theme of our debate, in that he has touched upon the differences between the two sides in this matter. He said that we had enough general practitioners and consultants and consequently that his party would be justified in doing away with all the charges though he did not meet the point made by my right hon. Friend in that the hon. Gentleman did not deal with the very great difficulty in relation to dentists. There cannot conceivably be enough dentists for the demands which are made upon them.

Dr. Stross

I did not do so because I did not want to take up much time. It seems simple enough to me. All these dentists are in the Service. The Minister has a right to ask them, as part of their terms of service, for a variation, in that they should give up some of their work to children in clinics or in their surgeries. In that way we could safeguard the situation for the children.

Mr. Fort

In other words, the hon. Member is prepared to see more compulsion used in dealing with these professional matters than most of my hon. Friends would.

Mr. McNeil

There is an alternative to compulsion, and that is co-operation from the profession.

Mr. Fort

The right hon. Member for Greenock (Mr. McNeil) is no doubt correct, but he knows as well as I do that co-operation can be encouraged by a variety of inducements. To talk as if no inducements are required, particularly for dentists, is a little unfair to the profession, in view of the success which is undoubtedly attending the present policy. The figures about the increase in treatment given to school children are very remarkable, particularly when it is realised that that increase has been achieved with negligible or no sacrifice of conservative treatment for adults.

I do not want to enter into a political argument with hon. Members opposite, but I have been particularly struck by one of the themes which has been running through our debate, and that is the importance of the general practitioner, not only as the person to whom we first turn when we feel ill, but as the spearhead of preventive medicine. Some of the earlier speeches, particularly the speech by the hon. Member for Bristol, South (Mr. Wilkins) about the success of preventime medicine, gave us an idea of what has been achieved and a glimpse of what may be achieved in the future.

This thread is, as it were, tied together by two excellent publications which have appeared during the last year, the book by the well-known medical journalist, Dr. Stephen Taylor, and the September issue of the British Medical Journal, which included Dr. Hadfield's field survey on several hundred general practitioners, and also the B.M.A.'s postal inquiry. Reading both publications, it seemed to me that the problems of general practice are very much the same as the problems of other professions whose members have to have considerable scientific qualifications. The frustrations, the annoyances, the satisfactions and the prospects for the future were similar to those of my friends who work in technical industries.

Indeed, the very figure that was given of those who were contented—about 50 per cent, of the general practitioners—seems to me to be about the same as in many other professions based upon technology and science. The Committee, discussing some of the reasons for the dissatisfactions, said: The Committee cannot help feeling that more young men in general practice tend to get on rather too early and too quickly; they want the cream before they can milk the cow. How true that is as a reason for disappointment, the feeling that somebody is not getting on in the profession, not only in general practice, but also in the case of many similar professions.

Another of the difficulties which seems to be common to all these professions is the increased specialisation, and it is obvious that, as technical knowledge advances it is inevitable that, in order to have a deep understanding of a particular section of a profession, one has to specialise. One of the difficulties of the general practitioner in medicine, as is the case with many of the other professions, is that he must know when and to which branch he ought to send his patients in order that they may be properly examined and treated. Yet, general practitioners and specialists, as part of their jobs, should be able to work together.

In that connection, it is certainly disappointing to find that, according to the article in the "British Medical Journal," the consultants fail to have the general practitioner present during the consultation quite as much as formerly, particularly in hospitals. It may be well worth while trying to bring to the notice of the specialists how important it is to keep their general practitioner colleagues working alongside them.

In particular cases, the general practitioner is the only person who knows the whole medical history of the patient whom the specialist or consultant is examining. No doubt, written records are kept and can be presented to the specialist or consultant, but it is not the same as having at the consultation the general practitioner, who may quite likely have attended the patient for several years and who knows the whole medical background in a way in which no written record can provide. By this means, we should be trying to bring into the Service a "sense of one-ness," which was the expression used by the hon. Member for Newcastle-upon-Tyne, East (Mr. Blenkinsop), who opened the debate.

It is rather disappointing when one sees changes, as I have in my own locality, which take away opportunities from the general practitioner. In the case I have in mind it was a maternity home, Springfield in Blackburn, which gave the general practitioners the opportunity to have rather more facilities for practising midwifery than they have now, when the home has disappeared, and the number of general practitioner maternity beds has decreased. I think the argument used was that there were too many before, but this sort of thing has the effect of making the general practitioners in my district feel that they belong to the neglected side of the Health Service, or at least the one which can be pushed aside in favour of their consultant and specialist colleagues.

Another case in which there could be more co-operation in many parts of the country is in the work of the general practitioner and the local Medical Officer of Health. In Lancashire, it seems that we are perhaps more fortunate than in other parts of the country, but I should like to see the use of liaison committees, on which both general practitioners and Medical Officers of Health could jointly meet at regular but not too frequent intervals—say, three or four times a year— in order to bring together these two sides of the Health Service.

The last point on general practice with which I want to deal is this. I was very glad to hear the figures which the Minister gave about the great increase in the number of medical partnerships which followed the introduction of the recommendations of the Working Party after the Danckwerts Report, because all administrative action which will bring together those working in the National Health Service ought to be encouraged. Those in the Ministry who are operating the present arrangements should always have that in mind when they are altering the present arrangements. They should be altered only in the direction of bringing the different parts of the Health Service closer together.

The other matter to which I want to refer is the cost of the pharmaceutical service. There are two points which have struck me recently. First of all, how successful has been the combination of exhortation and the work of the Cohen Committee in categorising drugs, which is one of the reasons why the cost has been kept down in the satisfactory way in which the Minister told us this afternoon. I have noticed that almost every speaker, and notably my hon. Friend the Member for Putney (Sir H. Linstead), emphasised the importance of pharmaceutical exports, and the way in which they have risen in recent years is quite remarkable. In 1948, there were £2 million worth of new pharmacentical exports from this country, mostly penicillin. In 1951, the amount had risen to £10¾ million, covering a much larger range of drugs, including the new antibiotics and other new drugs, such as the anti-histamine and anti-malaria drugs. By 1953, the figure had reached nearly £11½million, which represents a great and important addition to our export trade.

One point which the Cohen Committee should keep in mind when it is putting new preparations into different categories is that it does not jeopardise the export possibilities of a particular drug, because the Cohen Committee has a great reputation abroad, and the licensing of British drugs by foreign countries is affected by the decisions of that Committee.

The Minister told us about the pricing investigations which his Ministry have been carrying out into the manufacturing cost of basic drugs and proprietaries. Has he any information about distribution? I know that these are primarily determined by the discounts which are given to drug and pharmaceutical wholesalers and retailers, but I wondered whether the Department is satisfied that the traditional rates are still satisfactory under new conditions, and whether research is going on into new methods of distributing drugs in bulk, new packages and so on.

Although the cost of pharmaceutical services has decreased, it is still very large. I should like to repeat the suggestion I made before, that those who are responsible for training medical students should consider whether pharmacology should not be made a more important subject, and taken later in the student's training than is customary at the present time. Doctors about to prescribe would then start off with a profounder knowledge than is common now in this subject and with knowledge at which they would arrive much later in their general training. By not neglecting that matter, we shall go further on the road towards keeping the cost of the whole pharmaceutical service within bounds, despite the fact that medical science is producing drugs which cost more and more rather than less, merely because of their greater complexity.

8.4 p.m.

Miss Margaret Herbison (Lanarkshire, North)

A good deal has been said about preventive medicine. In connection with this I wish to refer to the tuberculosis death rate in Scotland.

It is clear that last year and for a number of previous years the death rate has gone down considerably. I am certain that hon. Members will be very pleased at that, and pleased also that it is due to the great attention given to the disease by general practitioners, hospitals and members of our Department of Health for Scotland. Everyone concerned with the treatment of tuberculosis has given much thought and time to it in these last years, yet in spite of the great reduction there is still too high a death rate from tuberculosis in our country.

One of the sad factors of that death rate is that it is highest among young women between 15 and 25 years of age. I wonder whether we have done sufficient, particularly in our schools, to show to our young girls the importance of proper feeding. If we could get our school girls to realise the importance of proper nutrition, they would know when they leave school and begin work that the type of meal which many of them have in the middle of the day is of no use to safeguard them against the dread disease, tuberculosis. Something definite should be done in our schools, whether by propaganda work or by teaching, to make our young women realise before they leave school the importance of this matter.

I note that the number of beds available for T.B. patients has been increasing every year, but health authorities in Scotland still face a lack of nurses for T.B. patients. I read with interest and disappointment on page 25 of our Report that some of our hospitals are still reluctant to allow students to be seconded for six months for training in T.B. hospitals. The supply of nurses for T.B. patients is one of our biggest problems, and it is a very great pity that one single hospital should be against the seconding of student nurses.

The North-Eastern and South-Eastern Regions have been highly successful in this work but there is no mention of what hospitals are doing in the Western Region, where the death rate and the incidence rate are highest. I fear that these hospitals are among those which are not encouraging the seconding of students. I hope that the Joint Under-Secretary of State for Scotland will deal with this point when he replies and perhaps the publicity will bring home to these hospital authorities the need for this procedure. The safe- guards are very great, and no greater risk exists for young student nurses in a tuberculosis hospital than in any other branch of nursing.

There has been talk about group practice and health centres. In Scotland we have only two health centres, one at Sighithill and one at Stranraer. There is a suggestion that there should be one in a new town. I was disappointed to find that, apart from a probable further experiment on the Stranraer scale, no further experiment is contemplated pending experience of the arrangements for encouraging partnership in group practice. The previous page of the Report tells us what is being done to encourage group practices. If we could get a great many group practices, it would be a very good thing for health in Scotland. I should like the Joint Under-Secretary of State to say whether publication has yet taken place of details of the arrangements whereby doctors will be helped from the £100,000 to set up group practices. We were told in the Report that this information would be available at the end of the year—that was December, 1953.

Group practices, however, are only a second best. The health centre is better than the group practice, because the health centre embraces not only a group of general practitioners, but also the local health authorities. This encourages very close liaison between doctors and the Health authorities, which will not be found in group practice. My hon. Friend the Member for Newcastle-upon-Tyne, East (Mr. Blenkinsop) gave many of the reasons why we should try to encourage the setting up of health centres. I want to give two further reasons.

If there is a health centre, with its group of general practitioners, there is for each of the doctors a greater possibility each doctor having time not only for leisure, which is important, but a greater opportunity of time for study—time to keep pace with all the modern developments in medicine, which take place almost daily. There is also—this is of the greatest importance—the chance for each of the doctors to develop some specialist study.

I think of the very large village in which I live, where we have a number of doctors. I know that one would not want to say that this doctor should specialise in one subject and the next doctor in something else, but with the group practice—or, better still, the health centre—it would be possible for each of them to specialise in one branch. That would be of benefit to the doctors themselves and certainly would be of great benefit to the community in which they were practising, not only on the curative side, but eventually on the preventive side.

I want to deal with the question of prescriptions. One hon. Member opposite spoke about "Challenge to Britain" and the garland of millstones that we were tying round the necks of future Chancellors of the Exchequer. If we abolished the charge on prescriptions and the charge on surgical appliances as far as Scotland is concerned, we would be removing a very tiny millstone. Indeed, it would be such a little pebble that it would not be noticed.

In the paragraph dealing with prescriptions, the Report, referring to 1953, says: The number of prescriptions issued is still markedly below what it would have been but for the imposition of the charge. That is a bald statement. Is the Joint Under-Secretary of State satisfied with it, or is the Secretary of State simply complacent in allowing that statement to go into the Report?

Mr. Marquand

He probably wrote it.

Miss Herbison

As my right hon. hon. Friend says, the Secretary of State probably wrote it. It is a serious statement, because to be told that the charge on prescriptions makes the number of prescriptions much less than it would otherwise be, means that future trouble for individuals and for the nation is being stored up.

That statement is a criticism also of the doctors in suggesting that doctors were so negligent of their public responsibility that they have issued prescriptions right and left whether or not patients needed them. On the other hand I believe, as that bald statement says, that many patients who require medicine are not getting it because of the shilling charge.

I have raised the subject of surgical appliances on a number of occasions. The amount of money collected in Scotland for boots and other surgical appliances from 1st June to 31st March was £7,077. That is a very small amount, but it applies to a limited number of individuals who do not have the ordinary good health that most of us enjoy and who already have one burden, without having this extra burden of charges placed upon them. From the evidence of the Report alone, surely the Secretary of State and the Joint Under-Secretary of State should give serious consideration, before waiting for a Labour Government, to do away with the charges on prescriptions and on surgical appliances.

I was worried to read on page 54 of the Report on Mental Hospitals that: A continued increase in the number of people needing mental hospital treatment can be expected because of the general ageing of the population. Does this mean that more and more of our old people, because they are living longer, will end their days certified in mental hospitals? I do not think the Joint Under-Secretary would want this to happen. It is a matter which has concerned the Department of Health for Scotland and has concerned many of us for a number of years. If it were considered, not from the humanitarian point of view, not from the aspect of stigma, but merely from the financial point of view, it would be much better for the Department of Health for Scotland immediately to consider what could be done to help these old people, who, simply because of age, are unable to look after themselves, and who are in what the medical profession call a confused state, by the provision of annexes in hostels for those who do not need medical or expert nursing and where, I am certain, many women who are not expert nurses but who have feelings of humanity would be ready to help.

8.19 p.m.

Mrs. Eveline Hill (Manchester, Wythenshawe)

I wish to take up one or two of the points to which the hon. Lady the Member for Lanarkshire, North (Miss Herbison) has referred. I am sure that on both sides we have every sympathy with her anxiety for those suffering from tuberculosis. It is one of the illnesses with which we have the deepest sympathy and the greatest anxiety to overcome. On figures, we in this country are perhaps a little better off than in Scotland. I was interested in the hon. Lady's point about charges. Whilst they seem to be a small amount in Scotland, I do not know whether the Minister will therefore allow Scotland to contract out.

I was interested also in the point she raised with regard to mental senile cases. That problem has exercised our minds, and the mind of the Minister, very much indeed. We have all become more conscious that, whether the stigma be there or not, we do indeed put our old people in mental homes when in fact they are, as the hon. Lady said, mentally confused. There is the greatest need for something other than the mental home for this type of case.

I am quite certain that the Minister will be giving much thought to that, as indeed will the Royal Commission which is now sitting. It is one of our very gravest problems. Nobody likes to feel that their older or old relatives are branded in that way, or put together in that way, in what is known as a mental home. There is need for a halfway house of some description, and it should not be beyond our ingenuity to provide the right sort of place.

We all have sympathy with the Minister in his anxiety to spread his allotment of money over the widest possible field. The hon. Member for Reigate (Mr. Vaughan-Morgan) compared the amount of money spent on capital works before the war and now. Many of those interested in this service think that we should find another way of calculating capital works finance. The Treasury probably would not like it, but there seems to be very good reason for spreading out the cost of capital works instead of laying it out in large sums in one place out of the current year's allotment. Many of us feel very strongly about that.

What can happen, even now, is that capital works can be completed and the regional board then find that it has not enough money to operate the service for which the capital work has been done. It is not unknown that the service has to wait quite a while before starting simply because the regional board cannot give the management committee enough money to provide for the extra staff and other things necessary for the particular work. Therefore, while we have a good deal of sympathy for the Minister, we who are interested in a voluntary way in the Health Service would be very glad if more money could be allocated to enable services to commence as soon as the facilities are available.

We are told that 60 per cent, of the money allocated for hospitals goes in salaries and wages. Therefore one might say that, after that payment, the Minister has not really a very large sum with which to juggle. At the same time, one wishes economies could be made in administration. I know the hospital management committees of the ordinary hospitals in the non-teaching groups would be very glad to have a little more power in their hands instead of having to wait, as they so often have, for approvals for expenditure and for schemes to go a long journey through the regional boards to the Ministry and back again to the hospital management committees.

I am told that the time which a scheme can take, from its approval by the hospital management committee through the various Departments and back again with permission to start, is not less than 22 months. That is a very long time, and often the delay means that a scheme costs more.

I was very interested in the wish of one hon. Member that hospital administrators could achieve a higher standard. In some cases we have the difficulty that in hospitals—for example many of the ex-Poor Law hospitals—which formerly had a medical superintendent, there is now just an ordinary hospital secretary. It would be a good thing if the standard could be raised. Very often the people concerned are in difficulties in dealing with the hospital medical and nursing staffs. It would be a very great help if we could have a high standard of administrator in hospitals.

It would be necessary to have some revision of the salary scales of hospital administrators. Formerly the medical superintendent doing the administrative work in an ordinary hospital enjoyed quite a high salary. The salary which can now be paid to a hospital secretary in the same hospital, whether it be of a 1,000 beds or not, is not nearly so high, and one is not likely to attract quite the standard of man and woman one otherwise would.

Much mention has been made of the geriatric service. Some regions are fortunate in having geriatric consultants, but not all regions can have them as there are not yet enough to go round. There is no question, however, that such consultants do help materially in getting a quicker turnover of patients in the beds under their control. Apart from that, they have got people on to their feet and able to go back to their homes who had looked upon themselves as lucky to be bedridden for the rest of their lives.

Those geriatric consultants can and do visit these cases in their homes and ate able to assess the necessity or otherwise of hospital treatment. If we are to keep many of these cases at home there is no question but that local authority services will need to be stepped up. I have in mind particularly the home help service. More home helps will be required, and probably more health visitors and district nurses to call on the cases.

I think that is all tied up again with the need for a fresh assessment of the amount of money allowed to local authorities. I feel quite sure that one of the deterrents to a local health authority enlarging its home help service to deal with these cases is the amount of grant that it receives towards that service. Therefore, it would probably be a good thing for us to look at that side of finance and see whether there can be some greater assistance given to local authorities to enable help to be given to people at home and thus avoid the necessity for them to go into hospital.

It is necessary to consider all these points before we go to great lengths building lots of new hospitals. Our aim surely should be to have fewer hospitals rather than more, and surely this can be done if the other services are well organised and doing their job. That, of course, means an improvement in the preventive services given by the local authorities. There has been mention of the re-orientation of hospital services and of closer integration. Let us have closer integration by all means, but the other matter is tied up with some future changes in local boundaries. We cannot wait until that time to improve our Health Service, so it is necessary for us to make as many improvements as we can at this stage.

I want to mention another point that worries some of -us in the non-teaching hospitals, and that is our difficulty in retaining good consultants who want and have the opportunity to go to teaching hospitals. I personally am very jealous of the non-teaching hospitals. I think they do a wonderful work, and we have to remember that there are a large number of beds under their control. But it is not always easy to retain good men or women of consultant status when there are attractive jobs in the teaching hospitals. I, and I am sure others in the Service, would be very glad indeed if the Minister would look at that point and help us.

I know of a case at the moment of a first-class consultant who has been tempted by a job in a teaching hospital but who would rather stay with us. But, of course, he is human. There are attractions, particularly as regards status, in a teaching hospital as against a non-teaching hospital, and it is that differentiation which is our worry. I am afraid that we are going to lose that man, and the hospital will be all the poorer if we do, but one can hardly blame him. At the same time, one of the things that I hope the Health Service will do is to raise the status of the non-teaching hospitals so that there will not be that temptation for that type of man to leave us and go to a teaching hospital.

Mention has been made more than once of the dental service. We know—and these figures do not lie—that there are most dentists in the service now, and particularly in those parts of the service dealing with mothers and children. But there is need for still more, and the recruitment to the dental schools is far short of the number needed to keep up a supply of dentists. It has been suggested that we should have oral hygienists and train them in some of the duties involved in the so-called simple work connected with young children. I am not sure that I am too happy about that. I feel that the young children need very skilled attention. Much can go wrong in the early days, and if attention is not given in time, the trouble will continue for the rest of the children's lives.

There is possibly a need for a good look at the whole dental service and its structure to ascertain whether there are other ways of helping to get a complete service for the whole of the country. There may be something in the point which has been made by the dental technicians' association, who would prefer to have a higher standard demanded of them and to give a better service at what one might term the mechanical end of dentistry. I should like to see something on those lines rather than that the children should not receive the most skilled treatment to which, in my view, they are entitled.

Sir F. Messer

Is the hon. Lady not aware that the idea of the dental hygienists is not to displace the dentist but rather to give attention to the limits of their capacity until the need for the dentist arises, so that it is adding to the service and not taking anyone away from it?

Mrs. Hill

I agree with the hon. Gentleman. It would be adding to the service, but we are very short of senior men to supervise them. I hope that if it does become a service we shall at least see that there is every safeguard that the children shall not run any risks at all. This is a service which is still a young service, and it can only function successfully if every one does his share.

I should like to refer to the point made by the Minister with regard to the X-ray service in hospitals. We are going to come up against this question of increased costs, but if we are to develop this service, as we are doing in my hospital, I hope that there will not be too much restriction of additional machinery or additional staff to aid general practitioners in the treatment of their patients, because if there is a hold up of the patient in the hospital waiting for an X-ray examination, that is a very costly business. It is a question of putting first things first. I feel that while this is a good service which most hospitals could give their general practitioners, they must be allowed to have the necessary finance to conduct that service.

8.38 p.m.

Mr. James H. Hoy (Leith)

My remarks will be fairly brief, because I know that my hon. Friend the Member for Fife, West (Mr. Hamilton) has been sitting here all day hoping to address the Committee. I am, therefore, sorry that I cannot follow the lines of the interesting speech made by the hon. Member for Wythenshawe (Mrs. Hill). I want to say something about the Scottish Service. My remarks have an application to the whole of the medical services of Great Britain, but I think that it ought to be recognised, even at this late hour, that we are dealing with two Services and in many ways we think the Scottish Health Service and the Scottish Health Act are a little better than the English ones.

One is interested to see that the health of the nation is being maintained. The last Report shows that the great improvements which have taken place over recent years have been maintained, particularly with regard to maternal mortality rates, which in Scotland now represent only one -per thousand births. That is a remarkable change from the years before the war, and we are grateful for it. I am pleased to see that the Report even goes so far as to say that that figure can be improved upon.

Another point which struck me was the paragraph which said that the health problems now coming to the fore are those relating to diseases of maturity and old age and mental health. I should like to have dealt with this matter at greater length, but I am certain that the Joint Under-Secretary of State must realise that we have to find accommodation for these old people and that in many cases it can be found only if they have been certified and sent to an institution which they ought not to be sent to. We ought to have some intermediary service where we can place these old folks who require constant attention but who are certainly not mentally afflicted. I hope that the Minister will pay considerable attention to that point.

I want to devote the few minutes that I have to the question of administration. The hon. and gallant Member for Roxburgh and Selkirk (Commander Donaldson) claimed that he was the first Scot to be called in the debate, but, after all, he was the only Scot on the benches opposite who wanted to speak in it, and he was one of the only two who have attended the debate at all.

The hon. and gallant Member said that he wanted the service to be safeguarded against over-weighting on the clerical side. I am certain that the figures cannot bear out anything like that, because the clerical staff in the administration of the Health Service in Scotland amount to only 1.7 of the total number engaged in the Service. Investigations have been made by the Department with a view to trying to cut down the number. The Joint Undersecretary of State is bound to be aware of the examination which his Department received in the Public Accounts Committee, where the evidence was that, although they had gone into the matter fully, no drastic change could be made. While its figures differ considerably from those of the boards of management concerned, the sub-committee which the Department set up had to admit that if these economies were to be effected, first of all a fairly large sum would have to be spent in capital expenditure to provide the appliances which would cut down the staff.

My hon. Friend the Member for Tottenham (Sir F. Messer), in an excellent speech, has already dealt with this subject. He talked about capital expenditure being able to play a part in reducing staff, and I want to quote two instances which I believe are typical. Boilers and the part which they play in the hospital service have been mentioned. Perhaps we may take a case which arose in the Public Accounts Committee in connection with the Scottish hospitals.

During the war, certain temporary hospitals were set up—they have now become nearly permanent—and the heating of them was very expensive. When you realise, Sir Charles, that the Comptroller and Auditor General reported that we had 22 stokers at these hospitals, or one for every 12 beds, you will see how expensive the heating was.

New boilers were planned in 1945–51, but there was considerable delay. The first boiler was installed in June, 1951, and the second in January, 1952, but the pipes to connect them with the blocks have not yet been installed because the Government stepped in and said, "We must have a cut in capital expenditure." As a result, the boilers are in position but the pipes to join them up are not there.

This scheme was estimated to save £10,000 a year, and we can see that not only would there be a saving in fuel but there would also be a saving in manpower. Surely it would be wise expenditure for this work to be undertaken. The Public Accounts Committee, let me make it perfectly clear, expressed its great regret that this work had not been undertaken.

There are two lessons here. First, the difficulties and delays which have arisen might have been reduced had there been a closer co-operation between the Department and the various regional boards and boards of management. Secondly, they could have been reduced had we not imposed these notional cuts on the Service, which make it impossible for this type of job to be undertaken. I suggest to the Joint Under-Secretary of State that if he wants to effect first-class economies, he might easily do so by increasing the amount of capital expenditure which the hospitals are allowed to undertake. I think it might be a very wise economy.

I quote that as one example that came before the Public Accounts Committee. I do not think it is typical, but it is outstanding, and the appalling thing is that I understand that even at this late stage the Treasury has not given approval for the work to be undertaken.

There are one or two other remarks I should like to make. In the Public Accounts Committee we also spent considerable time dealing with the question of ambulance costs, and it would appear that this matter calls for some investigation, because in far too many cases these ambulances have been in the service of a particular firm or individual and it has been left to certain local people to carry out this work. According to the reports, this has proved very expensive, and in many cases it was not always the first-class service that the patient ought to have.

I suggest to the Joint Under-Secretary of State for Scotland that he and his Department, along with the Department in England if he so desires, should have some investigation into this particular service, first of all, to see whether a better service could be provided, and secondly, whether it could not be run more economically. Apparently the running of the present system calls for a great deal of attention.

I do not want to go further than that at the present moment, because I have agreed to try to make it possible for my hon. Friend the Member for Fife, West, who has been in the Committee all day, to speak before this debate concludes. I hope that what I have said about administration and capital expenditure will be considered by the Scottish Office, and that perhaps by this method we shall provide an even better Service than the-one we have.

I was a Member of Parliament when both the Scottish and English National Health Service Acts were debated and approved. Many were the dangers that were threatened then, but in the working this Service has proved to be a great boon to the people of the country, and what we are doing today is making suggestions to improve it and make it better still.

The Chairman

Colonel Stoddart-Scott.

Mr. William Hamilton (Fife, West)

On a point of order, Sir Charles. The hon. and gallant Gentleman the Member for Ripon (Colonel Stoddart-Scott), who has just been called, came into the Committee at 8.15 this evening and has now been invited to take part in the debate. It is pretty rough on hon. Members who have sat here all day and have not been called that the hon. and gallant Gentleman should be called to make the final speech from the back benches.

The Chairman

That is not a point of order. The Chair calls whom it wishes.

8.48 p.m.

Colonel Malcolm Stoddart-Scott (Ripon)

I will try to be brief in order that the hon. Member for Fife, West (Mr. Hamilton) may make his contribution if he catches your eye, Sir Charles. I wish to refer to three points, and the first concerns the regional hospitals boards. I think the time has come when we have to make up our minds whether the regional hospitals boards in England —I know there is a different set-up in Scotland and I cannot speak with any authority about their working there—are the best organisation for our Health Service. It is not absolutely certain that the first organisation that was designed is the best, and after a five-year trial the time has come when we ought to ask ourselves one or two pertinent questions.

We have to ask ourselves whether the boards work well, work efficiently and work economically. Are they not rather an expensive luxury, acting as another post office through which all the management committees have to go before they can get their views or decisions attended to? We have got to look at this question with a frank and open mind and see whether the time has not come when we should abolish these boards completely, or certainly reduce their power and influence.

At the same time we must raise the standard of hospital management committees to that which we have in the boards of governors of teaching hospitals. In our great cities we have one teaching hospital side by side with another, equally important, in which teaching goes on, one having direct access to the Ministry and the other, because it is not scheduled as an official teaching hospital, having to go through the regional hospital board. Why should this be so?

The time has come to review this position, not only from the point of view that I have suggested, but also from that suggested by the hon. Member for Tottenham (Sir F. Messer). We must look at this with an open mind, because I am convinced that we have not got the best set-up that is possible. I hope that both the Guillebaud Committee and the Ministry are looking at this problem, because if we either lower in status the regional hospital boards or abolish them, we shall get not only greater efficiency in the system but also greater economy.

I agree with the hon. Lady the Member for Wythenshawe (Mrs. Hill) that the time has come to review the situation with regard to capital expenditure in the hospital system. We must deal with this not by a piecemeal, year-to-year allocation of money, but more as the Ministry of Education or the Privy Council look upon grants to the universities. We must make grants to our hospital regions or boards or management committees over a longer period than one year, so that they can make plans, have better facilities for their work, and have more efficient management.

My final point concerns dental hygienists who are accepted by the dental profession and used with great success in many of our dental hospitals. Although there was some opposition when they were first appointed, they have proved their worth over and over again and there is room for more of them in the Service. However, when we consider dental nurses, we must ask ourselves whether there are enough dentists to carry out the service we want for our schoolchildren. There can be only one answer to that question. The answer is that there are not sufficient dentists or students going into the profession, to provide an Adequate number of dentists. Nor are there sufficient facilities to give the dental service we require for our schools.

Therefore, my reply to our critics in the dental profession, if there are any left, is that if we cannot get dentists, it is better to have dental nurses dealing with our schoolchildren than not to have an adequate dental service, as is the case at present. That is the criterion by which the dental profession, as well as unbiased people, should assess this problem.

8.54 p.m.

Mr. Hector McNeil (Greenock)

Everyone will agree that this has been a pleasant and useful debate. We have heard a great deal of constructive discussion and, with one or two, or possibly three, minor exceptions to which the Minister committed himself, and which I shall deal with later, the right hon. Gentleman was obviously anxious to follow the calm and constructive tone set by my hon. Friend the Member for Newcastle-upon-Tyne, East (Mr. Blenkinsop). The Minister, except in some little matters of arithmetic, did not depart from that. I hope he will not think me offensive or effusive if I say that it was moving to hear his leadership in this scheme, since from time to time, he has played another rôle.

I have permitted myself to think that it was a rather happy fact that his hon. Friend the Member for Wolverhampton, South-West (Mr. Powell), who used to appear with him in a more destructive role, was not here today. I think that the Minister's moderation would have pained his hon. Friend exceedingly. If the Minister were not effusive about my right hon. Friend the Member for Ebbw Vale (Mr. Bevan), who from time to time is criticised, and no doubt from time to time the criticism is legitimate, he was at any rate punctilious in pointing to at least two important phenomena in this service for which my right hon. Friend was initially responsible, for example, the setting up of the Cohen Committee.

I am sure that everyone on this side of the Committee will want to congratulate the Minister upon two aspects of his speech. On behalf of the Opposition, I should like to say that we would be delighted to support him if an attack should come on those counts. It was thought at one time that my right hon. Friend the Member for Ebbw Vale was too cautious in setting up the Cohen Committee, but, as the Minister has shown today, my right hon. Friend's judgment has been proved right. An effective method has been evolved of indirectly criticising and even attacking the rare but still extant lazy and extragavant general practitioner, and also the over-credulous, perhaps over-greedy, occasional member of the public who is to be found in his waiting-room. The Minister told us today about his examination of the 91 proprietary drugs which, I think he told us, represented about 60 per cent, of the national drug bill. I think that I am right in saying that that was the percentage.

Mr. Macleod

I had better check the figure. Certainly it is not as high as 60 per cent. Perhaps it is nearer 30 per cent.

Mr. McNeil

That is why I said that I thought that that was the figure which the right hon. Gentleman gave. I thought that he said 60 per cent. At any rate, when the right hon. Gentleman told us of the examination of these 91 proprietary drugs, which represent a high proportion of the national drug bill, we felt that we wanted to congratulate him upon the firmness which he quietly displayed in his reaction to the uncooperative manufacturers of an unnamed proprietary drug. He told us that examination had disclosed an undue profit margin and that so far this manufacturer had refused to respond to what the Minister's officials thought to be a reasonable figure. He told us further that if the manufacturer should continue to prove intractable then, if I understood him correctly, he would take steps to ensure that this proprietary drug is no longer prescribed.

Mr. Macleod

If I may take up that last point on the question of figures, we are looking at 91 preparations out of 6,000, but those 91 are 30 per cent, of the total cost of proprietaries and 18 per cent, of the total drug bill. To say that I will take steps to ensure that they are no longer prescribed, I am afraid goes a little too far. All I can do is to tell doctors that, having carried out the recommendations of the Cohen Committee, I am not satisfied with the price arrangements that have been made and to ask them not to prescribe those drugs. But the final right, if a doctor decides that it is necessary in the interests of the patient, remains with him; there is no ultimate sanction.

Mr. McNeil

We quite understand that, and we do not ask the Minister to go further. I am quite certain that if the public are made to understand, as they can be made to understand, that a doctor will not permit their treatment to be prejudiced by his reluctance to continue prescribing to the benefit of the unfair commercialist, the Minister can also expect the support of the general run of the physicians of this country and, if an attack comes against him on this issue, he can depend on the support of the Opposition also.

The second point upon which the Minister is to be congratulated is the improvement in the proportion of doctors available in the under-doctored areas. This is a problem with which the whole Committee is familiar— that where the doctor was most needed he was least rewarded and that where he was best rewarded there was less opportunity for the real employment of his professional skill. Long before the scheme came into operation, hon. Members on both sides of the Committee had concerned themselves with the problem, and many sectors of the medical profession had equally concerned themselves with it. Since the scheme came into operation it has been almost a Ministerial responsibility, if I may not unfairly put it that way.

If I understood the Minister correctly today, he said that there had been a reduction since 1952 of 14 per cent, of the population who at that time were under-doctored and who now escaped from being under-doctored. Here again this result springs from a number of efforts initiated from this side of the Committee. My right hon. Friend the Member for Ebbw Vale, my right hon. Friend the Member for Middlesbrough, East (Mr. Marquand) and I did play a part, and sometimes an uncomfortable part, in the negotiations. I do not seek to take any credit from the Minister but only want to record that it did spring from our activities, activities which at one time were very fiercely criticised.

Here I have an allied reservation to make. In those same negotiations, encouragement of group practice was quite definitely part of the bargain the medicals, made with us before we agreed to adjudication by Danckwerts. When the working party reported, it will be within the recollection of many hon. Members, we were disappointed to see that only £100,000 had been earmarked out of the increased amount for this purpose.

The Minister seemed complacent about this, asked us not to expect miracles, and not to be impatient. But it is approximately two and a half years in which we have had the possibility of applying this principle and applying this sum of £100,000. I say to the Minister respectively that, although the difficulties are very real, I hope he will not be complacent. Indeed, I should be happy if he were prepared to display his impatience in seeing that this sum is applied to the improvement of general practices by the creation and extension of group practice.

That does not mean that I disagree with my hon. Friend the Member for Lanarkshire, North (Miss Herbison), who had a reservation to make about group practices. Undoubtedly, as many hon. Members have argued today, positive, preventive medicine is in danger of not being given sufficient emphasis and sufficient place in the operation of the National Health Service. Indeed, as one hon. Gentleman opposite said, there seems almost to be a halt in the tendency which medicine was exhibiting a few years ago, as part of its anxiety about preventive and positive medicine, to reach out and associate itself with this periphery operation in education and in industry.

If we are systematically and earnestly to concern ourselves with the creation of good health rather than with the curing of sickness, then the creation of health centres and faute de mieux of group practices are essential. A patient is not a pared to be bundled about, to be shuttled about as my hon. Friend the Member for Stoke-on-Trent, Central (Dr. Stross) said, from the general practioner to the outdoor clinic and from the outdoor clinic inside from one specialist to another.

As a proposition to put alongside that, a scheme is not necessarily a service. It does not become the kind of service which we wanted it to be unless we are satisfied that there are trained enthusiasts inside the scheme anxious to make it a service, and educate people outside the scheme anxious to use it as a national service. Therefore, as both sides of the Committee have argued, we must at the very least have group practices quickly and health services in significant numbers reasonably quickly.

In referring to what was said by my hon. Friend the Member for Barking (Mr. Hastings), I am tempted to digress and to ask the Minister whether, when he heard that speech which was moving in its wisdom and tenderness, he did not regret that one way or another the National Health Service was losing the public service of such a man as my hon. Friend. I am not making a point of it or a speech about it, but no service is so rich that it can afford to be without the experience, the skill, the administrative ability and the kind of morality that men like my hon. Friend bring to it, wherever they are found.

We have to see, as my hon. Friend told us, that the consultant is related to the health centre. Is not the consultant but an effective co-operating physician who accepts not a parcel, not a case, not even a patient, but a person? I am not criticising these men in the Service at this stage because, great as has been the development of the scheme, in some respects they still lack the tools to make it the Service that we all want it to be.

I am bound to take the point made by my hon. Friend in this context. There is a great danger in a skeleton scheme with busy men that environment will be neglected as a therapeutic factor, but because there is this relationship between the general practitioner, the place where he works, the consultant upon whom he leans and the clinic at the hospital to which he has access, frequently an administrative decision is taken which means that the very young and, more often, the very aged are just pushed along the line.

I know how desperate is the need for certain types of bed in some parts of the country, but, at the risk of being misunderstood, I would say to the right hon. Gentleman that if his Government now believe that they are as effectively in control of the building industry and the supplying of building materials as some Ministers claim they are, I should have thought there was an overwhelming case, even if it meant delay in the hospital building programme, for the Ministry to direct itself in Scotland and England to a not necessarily ambitious but certainly systematic attempt to put up the required health centres.

The need for hospital beds to which the Report of the Department of Health for Scotland draws our attention and to which the Minister drew our attention leads me to another point which has been discussed in some part on both sides of the Committee. It is whether or not we are making the best use of our existing beds. Here I particularly refer to the use of beds for aged people. I had not heard about geriatrics before the National Health Service was established. I do not criticise the science so far as it is a science; geriatrics has become an effective word for covering a fair amount of not very precise handling of patients [...] beds. The distinction between the chronic sick, who are the responsibility of the regional board, and the aged and infirm, who must continue to be the responsibility of the local authority, is a very fine one indeed, and there must be times when no real distinction is made.

It sometimes appears to me—and I am not original in this, but I have tried to confirm it from my own observations—that something less than hospital accommodation is required for some of these aged people. I hesitate to use the word hostel, because I do not like it in relation to these people, but it is something a little less ambitious and quite different in character and colour that we want for a large proportion of these people. Moreover, it does not engender—I was going to say the atmosphere of a sick bay—the atmosphere almost of a "dying bay."

If I may digress for a moment, I am frequently appalled by the unwillingness of local authorities to break up their aged populations in their housing schemes, and I was trying to persuade my colleagues in Greenock, in setting up a most excellent home for aged people, that the health of these people will, in some part, depend on having around them normal activities, and that, more often, they want the affection of a child rather than the attention of a doctor. One hon. Gentleman opposite made a compelling speech on this point.

Where there are no kith and kin of these people to supply that affection, I think the local authority, if it is really in earnest in operating this scheme, and the people of these communities, if they want to demonstrate their citizenship, should take upon themselves a relationship to these old people. We do not want a row of old people's houses, and we may find a type of building better for these people, cheaper in terms of building output and which would release a proportion of beds which, in many areas, are urgently needed for the treatment of the acute sick.

The Report of the Department of Health points out very forcibly that the changing pattern of the age group in the country makes this problem of how to deal with these people and the best use to be made of these beds not only the more urgent, but of growing dimensions and one likely to be with us for a considerable time.

I wonder if I might now turn to another aspect of the congested hospital list, about which I confess I am not nearly so certain that I am right in my approach. Hon. Members will have noticed, at least with interest and perhaps with a little more than interest, the apparent inclination of the public more and more to seek a remedy in our courts for inadequate medical attention or what they think to be negligence in treatment. I have a suspicion that this is leading to a tendency among some general practitioners—who are very often overworked and over-tired—where they have a difficult patient, to shove the patient off on to a consultant. I suspect that the consultant knows that the person concerned is a difficult patient, and, therefore, the less that the consultant can find wrong with such a patient, the more likely is he to give him "all the works," as it were. They have the usual bacteriological and biochemical examinations, and a proportion of them find their way into beds badly needed for really sick people.

I am not suggesting that it is improper for the public to find their remedy in a court, and above all I am not arguing that the medical profession should be given any particular protection from such actions; indeed, I am inclined to think, for reasons which are not irrelevant, that the profession has from time to time had rather more protection than is available to most professions. I am wondering if there could not be a neater and perhaps a quicker way—some -form of tribunal, assisted perhaps by medical assessors such as we have seen in the Ministry of Pensions—by which a remedy would be available to the public and about which the doctor would not feel so fussy or so nervous.

The doctor is usually not worried about the amount of damages, because he is automatically insured against that. He is worried about his personal reputation or the reputation of his hospital. If I am wrong, it can be established by inquiry. If I am right, and there is extravagant use of skill or of beds due to the tendency I have mentioned, it will be worth making an inquiry and considering whether any remedy is available.

I intended to talk about tuberculosis in Scotland, but I cannot add to the excellent speech of my hon. Friend the Member for Lanarkshire, North. Perhaps I may be forgiven if I point out that there has been a steady and representative attendance of Scottish Members on this side of the Committee, a phenomenon which, outside the Government Front Bench which has been exceedingly well behaved today, I have not seen displayed on the benches opposite.

I am sure that Members of the Committee will deplore with my hon. Friend the fact that the Secretary of State for Scotland has not secured from some hospitals in Scotland the co-operation in seconding nurses to T.B. hospitals which he had the right to expect and which the community would welcome. I am pleased that apparently there is no intention in the Scottish Office to depart from having the small number of beds in Switzerland which are available for Scottish patients. The value of them in maintaining the morale of T.B. patients is out of all proportion to their number.

I will not ask the Secretary of State to go into details about the curious Table which appears in Appendix No. 8. The figures are interesting and a little extraordinary, but perhaps they are not comparable samples. There are two slight points in which I found myself in disagreement with the Minister. I suppose that a horse which has been for so long in such a curious stable cannot forget at once his recent tricks. And so, if I might mix my metaphors, the Minister decided that he might twist our tail and tweak our beard; but he did not do so very wisely. His argument about capital expenditure was not, I say bluntly, a good one.

The Minister said to my hon. Friend the Member for Newcastle-upon-Tyne, East that it was not proper to compare Estimate with Estimate, but that we must compare the 1951 Estimate with the outturn of 1951—a most ingenious argument. Who determined the Estimate for 1951? We did, of course. Who determined the out-turn? It was not the right hon. Gentleman, but his Government, who brought building to a standstill. And so the nasty urchin kicks down our castle, builds up his own pitiful thing and, having kicked down ours, says, "Look, mine is bigger than yours." It was not a good argument. There are several other corrections that should be made in the argument to make it even comparable.

The main weakness in the Minister's argument, however, is that at that time we were still coping with bomb damage. We were trying to restore, not only hospitals, but buildings throughout the country. That position has gone. The Minister's Government is permitting luxury building in every part of the country. It is not, perhaps, luxury building, but £10 million worth is to be allowed in London in three years. Then, the Minister tries to impress the Committee by saying that he has restored to the capital programme the cuts which were made by his predecessor the Lord Privy Seal.

Equally, the Minister's argument about dental charges was not very persuasive. I shall look again at the figures, but I have looked out a quotation from the "Economist" for 13th May—and I should not think that the "Economist" writes with the same colour of ink as the "Tribune." The "Economist" says: For every four extra children brought into the surgery, 11 adults have been pushed out. Perhaps the figures are wrong, perhaps the Minister is right, but I should like another look at his figures. It seemed to me that the whole percentage increase which he quoted was completely, or almost completely, accounted for by the increase in the usage of children, which we all wanted to see—let there be no mistake about that; but I should think that the right hon. Gentleman's gross amount of work done has gone down. Of course, it has gone down, not at the expense of those who necessarily least need dental treatment, but at the expense of those who cannot afford it.

I also suspect a little the Minister's figures about the shilling prescription charge. It is difficult, I quite agree, but it does not look convincing to me, and it did not look convincing in the report of the Department of Health. The Joint Under-Secretary, who has a great respect for figures and who is a well known statistician, is not likely to explain these in great detail to us tonight. At any rate, I repeat on behalf of my party that when we return to power we will demolish these two charges, because we do not think that they do the job which the right hon. Gentleman has claimed they do and we think that they operate unfairly upon a section of the community and not in the best interests of the service.

There is, however, one aspect of preventive medicine to which the Minister made no reference. That is, the provision of essential foods in adequate quantities at prices which all sections of the community can afford.

Mr. Iain Macleod

That does not come under the Vote.

Mr. McNeil

Oh, yes it does. I interrupted the right hon. Gentleman to ask if he is making provision for the increased price of butter. I hope, Sir Charles, that you will not look perplexed—it comes within this Estimate. The right hon. Gentleman thought that I was being a little flippant, but my hon. Friend the Member for Willesden, East (Mr. Orbach) tells me that the increased cost of butter will add £850 to the bill of the Middlesex group of hospitals for the current year. That will be true up and down the country.

As I have said on more than one occasion, I would rather spend money on one good bottle of milk than on one indifferent bottle of medicine. I would say to the right hon. Gentleman that he will not be the Minister of Health he might be if he permits his colleagues to deny to any section of the community that kind of medicine—essential foods—which Government policy is taking from the people who need it.

9.30 p.m.

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

Like my right hon. Friend and the right hon. Gentleman the Member for Greenock (Mr. McNeil), I am sure that the whole of this Committee is very grateful to the hon. Member for Newcastle-upon-Tyne, East (Mr. Blenkinsop) for the manner in which he opened this debate and for the very high tone that his speech set for it. I think it is also right to remark that that tone has persisted throughout the whole of our proceedings today. Everyone has spoken with the very greatest sincerity and many with the most intimate knowledge of what is a considerably complex subject but, at the same time, a very human one.

I do not think that I can remember having taken part in a debate in which so much helpful comment has been made, nor one in which there has been such a great measure of unanimity. I think that we are all agreed that the National Health Service, although it may need tuning up here and there, is today doing a splendid job of work.

I have been asked to reply to certain definite matters which were put during the course of the debate. First of all I was asked by the hon. Member for Newcastle-upon-Tyne, East to say something in respect of hospital cost accounting. The Committee will have learned that the objectives of the Working Parties which are operating in England and Scotland on hospital costing are to devise methods of analysing hospital expenditure that will enable some valid comparisons to be made between the costs of providing similar services in different hospitals and changes of costs from year to year in the same hospitals. Hitherto it has been possible only to compare all-in costs under certain broad headings. On the basis of these figures the conclusions that can be drawn about relative extravagance or economy have only a limited validity, though I do think that, despite their limitations, they have served as useful pointers.

The Working Parties have much valuable material in the reports prepared under the auspices of the Nuffield Trust, the King Edward Hospital Fund, and the Sub-Committee of English Regional Board Treasurers, and we hope that useful recommendations will be forthcoming in due course. The task is to devise costing systems which will provide more useful pointers for inquiry without requiring so much elaboration and clerical labour that they defeat their own end.

Both the right hon. Member for Middlesbrough, East (Mr. Marquand) and the hon. Lady the Member for Lanarkshire, North (Miss Herbison) were interested in the development of group practice—as also, of course, was the right hon. Member for Greenock—and in particular in the application of the £100,000 a year which has been set aside from the national pool for the development of group practice.

That money is being laid out in this way. Practitioners who wish to incur capital expenditure on the provision of premises for group practice are invited to apply for interest-free loans from the sum so set aside. Decisions on particular applications—which are only now coming in—will be taken by joint committees, one in England and Wales and one in Scotland.

The Committees will be composed of representatives of the general body of practitioners on the one hand, and of the appropriate Health Department on the other. We have no rigid preconceived notions of what for this purpose constitutes group practice, but I feel sure that the committee will endeavour to select from applications that they receive those which hold out most promise of improving the standard of service which the group of doctors concerned will be able to offer. The loans will be repayable normally over a period of 10 years, and the money thus repaid will become available for further loans.

Apart from that statement in reply to a specific query, I should like to refer also to the considerable amount of discussion we have had about group practice and health centres generally. I should have thought that with the health centres that we have set up—and I think the Committee will agree that they were set up for experimental purposes—we should await development until we have seen how these present centres are serving the purposes for which they were intended. I think it would be a wise precaution to act in that way.

At the same time, I believe that a great deal can be done by group practice and by group doctors themselves. I remember that when I visited Harlow I was very impressed by a small group practice unit which had been set up there which incorporated two general practitioners, a dentist and the local authority service. It seemed to be an admirable set-up. The doctors worked completely in co-operation with each other and with the dentist and the local authority. I believe that if something more could be done on those lines a useful purpose would be served and it would be a great help to everyone concerned.

My hon. and gallant Friend the Member for Roxburgh and Selkirk (Commander Donaldson) was interested to know what was going to happen in the district of Peel Hospital. I should like to be able to tell him that a new hospital will be built in the Border area, but it would be wrong if I suggested that there was any early prospect of that hospital being built. Possible sites are being reviewed, as my hon. and gallant Friend said, but in present circumstances I am afraid it will be many years before any work on a new hospital can be begun.

Commander Donaldson

Can my right hon. and gallant Friend say whether it has been abandoned altogether, or is there still some hope that at some future date there will be a hospital there?

Commander Calbraith

I would not like my hon. and gallant Friend to be under the impression that the whole project has been abandoned. That is not the case, but it is still under review and it will have to be fitted in with necessities in other parts of the country.

Mr. McNeil

We will do it for you.

Commander Galbraith

That is a generous offer that my hon. and gallant Friend has received from the right hon. Member for Greenock. If the right hon. Member for Greenock arrives on this bench, I hope my hon. and gallant Friend will keep him to that promise.

I was invited by the right hon. Member for Greenock and the hon. Member for Stoke-on-Trent, Central (Dr. Stress) to make a statement on the breakdown of the reduction in expenditure for Civil Defence in 1954–55 as compared with 1953–54. The total reduction is about £2.9 million in England and Wales, and about £200,000 in Scotland. The main items in the reduction are made up thus: there is less capital expenditure on providing hutted accommodation for wards and staff; the reduction there is £550,000. Then there is the postponement of making up canvas into tents for hospitals or making it up into accommodation for homeless people, and the figure of that item is £1.5 million. Then there is the postponement of purchases of stores such as mattresses, and the saving there is £1 million, so that the total is £3.05 million.

We had considerable comment from the hon. Member for Tottenham (Sir F. Messer) in relation to cancer, which led him to the matter of research into that and other diseases. He was of the opinion, I think, that research should not solely be in the hands of the Medical Research Council. I think that he must have forgotten that that is not the case. The universities do a good deal of research on their own account, and many of the hospitals use their endowments for research purposes. In Scotland it is certainly not the case, because the Hospital Endowments Research Trust, which will have an income of up to £ 120,000 a year, is available for any research which the Advisory Committee on Medical Research may endorse. That means that any young doctor or doctors who happen to have a wish to do research in a certain direction can apply to the Advisory Committee on Medical Research and, if it endorses the project and it is not a repetition of work being done somewhere else, it may well be that funds will be supplied to carry on that research from the endowment funds.

We had a number of themes running through the debate. One of them was prevention, which was spoken to by the right hon. Member for Greenock, the hon. Member for Barking (Dr. Hastings), the hon. Member for Bristol, South (Mr. Wilkins) and others. I found myself very much in agreement with many of the things which they said. I am sure that every hon. Member at least agrees that prevention is far better than cure. I do not think that we in this Committee would for one moment assess the comparative importance which any Government would attach to the two aspects of health from the relative amount of National Health Service expenditure given to the hospitals on the one hand and to the preventive local authority services on the other hand. I say that to remind people, perhaps elsewhere, that there would be no sense in such a comparison. There are many services which, although not medical preventive services, are in fact preventive services, such as pure water, efficient drainage, and good houses, whose costs would not come into a calculation of that kind at all.

I think that the most important point on prevention is early detection and much of that is done by the hospital service. For example, it carries the whole cost of mass radiography, which is playing a very important part in the discovery of tuberculosis and in safeguarding not only the members of the patient's family but also others who have been in contact with the patient. In that way we greatly limit the spread of the disease.

As hon. Members have said, there is a tremendous lot still to be done in regard to prevention. I put it quite seriously to the Committee that the local authorities at any rate are not hindered from getting ahead by any limitation of their statutory powers. In addition to their specific duties to make arrangements for vaccination and immunisation against diphtheria, the local authorities have very wide powers to make arrangements for the prevention of illness, and I feel that the scope of these powers is too often underestimated by the local authorities themselves and by their medical officers of health.

It is under these powers that B.C.G. vaccination is being carried out at the present time. There are other directions, too, in which the local authorities can help in the preventive field. There is, for instance, a great deal that they can do for elderly people.

I think that other local authorities who have not already done so might well follow the example of the town council of Rutherglen which has established a special clinic for elderly people. In this clinic they are regularly examined by consultant physicians, who inform their general practitioners and give guidance, where appropriate. Many of those elderly people are receiving some form of physiotherapy and more than 70 per cent, of them are receiving some form of chiropody. These are good preventive treatments. They are preventing these old people from becoming a drag to themselves and possibly to their relatives and friends. It is keeping them alive and interested in life and is a most useful service indeed.

Some hon. Members have said that a good deal can be done in health education. I agree that local authorities can do valuable work in this field, and perhaps as a Scottish Minister I may be allowed to pay tribute to the work of the Scottish Council for Health Education, which has provided both the health and education authorities throughout Scotland with so much valuable material and other facilities in helping to educate the public in sound principles of healthy living.

Mr. A. Woodburn (Clackmannan and East Stirlingshire)

Does the Scottish Council for Health Education work in the schools? Is it doing much in the schools?

Commander Galbraith

The Council is supplying education authorities with the necessary material to enable them to carry on the work which the right hon. Gentleman has so much at heart

Rightly or wrongly, I have always considered dentistry, particularly among young people, as truly a preventive service. Accordingly, I attach considerable importance to the increase which has taken place in the number of dentists employed in the school dental service. The Minister of Health gave the figures of the increase in the school dental service for England and Wales, and it is only right that I should put on record the increase which has taken place in the service in Scotland. The number in the school dental service in Scotland in 1948 was 131. It fell in 1950 to 94 and has risen every year since 1952, reaching 148 in 1953. On 31st March of this year, I understand it reached the record figure of 164.

Another very impressive statistic which my right hon. Friend gave for England and Wales concerns dental courses. My right hon. Friend gave it in the form of percentages, and, as someone remarked during the debate, "50 per cent, of nothing is not very much." I am prepared to give the figures. The number of courses provided for young people in the general dental service in Scotland shows an increase from 183,000 in 1951 to 296,000 in 1952 and 535,000 in 1953. I think that is an extraordinary achievement.

There was also some discussion during the debate about suggested alterations in the set-up of the hospital services. I take it that what hon. Members had in mind was the transfer of responsibility to local authorities. A short time ago the right hon. Member for Bbbw Vale (Mr. Bevan), whom I always consider to be a great expert in these matters, committed himself to writing on this subject in an article which appeared in the "Municipal Journal." I read it with considerable interest, and after reading the first two or three paragraphs I came to the conclusion that he proved conclusively that, whatever the situation might be in the future, the transfer of the hospital services to the local authorities at the moment is quite impracticable. Perhaps I may quote to the Committee two paragraphs which give the reason I formed that opinion. The right hon. Gentleman wrote: The idea is for the local authority to act for the Minister on an agency basis, on financial terms which should not present too much difficulty in working out. All staff appointments Should be in the control of the local authority, with the exception of the specialists. These could be appointed on the recommendation of a regional advisory body, with adequate representation from the medical and other allied professions. By this means a considerable measure of local responsibility would be restored. There is set out the view of the right hon. Gentleman. But he also had this to say: A solution might be found if the reorganisation of local government is sufficiently fundamental to allow the administration of the hospitals to be entrusted to the revised units of local government. There are two matters about which there might be arguments for long enough—reorganisation of local government and the financial measures by which those services transferred are to be undertaken.

Over and above that—and I put this point of view because other views have been stressed during the debate—we have to remember that the present hospital and administrative structure was called into being only some six years ago and that the task undertaken by the various boards was one of very great magnitude and complexity. They had to undertake it without any precedents whatever to guide them. It seems to me that they are only now getting over their teething troubles and beginning to settle down. To suggest at this stage that they should be thrown overboard seems to me to be very shortsighted and too precipitate.

I should like to say one or two words about tuberculosis, that being one of the other themes in the debate. It may well be that we are on the eve of very great achievements in connection with tuberculosis. I wonder whether the Committee is aware that the death rate from respiratory tuberculosis last year showed a drop of 18 per cent, in Scotland and the death rate is now 23 deaths per 100,000 of the population. That figure, when compared with 66 in 1948, 37 in 1951 and 27 in 1952, is most remarkable progress. I am very glad to say that on this occasion England and Wales are with us. The drop is 16 per cent, and the death rate is down to 20–2 deaths per 100,000.

The awkward thing is—what has happened about notifications? The facts are that in 1953 the notifications in England and Wales were down by 1,547 and unfortunately up in Scotland by 124. In the first 17 weeks of this year, if that is a period worth judging by, they were 254 lower in Scotland than in the corresponding period in 1953.

We are getting going with the mass radiography drives which we introduced last year. In this connection, I should warn the Committee that if we are successful, then the number of notifications is almost bound to go up, judging by our previous experience. The right hon. Gentleman the Member for Greenock knows that we had a drive in Greenock last year which was so successful that we are going to have drives in another six districts this year. If these meet with equal success, we intend to attack the great industrial area of Glasgow later on.

I want to stress that these drives depend for success essentially on local organisation and local efforts, and also on close co-operation between the local authority, the local Press, and the Health Service. The local authorities have to enlist all forms of voluntary and official support before, during and after the drive, and they have to follow up and bring to examination all the contacts they have and carry out B.C.G. vaccinations in suitable cases. This very day mass radiography units are moving into the Pilton district of Edinburgh.

I should like to say a word about the waiting lists, but my time is getting short. All I would say is that constantly more beds are being brought into use. I find that in England and Wales the number brought into use since 1948 exceeds 7,000 and that in Scotland it is over 1,500, but more beds could be brought in if only we had the nurses to man them. I was glad to have the support of hon. Members in relation to the scheme under which nurses training in general hospitals can volunteer for secondment to sanatoria. That scheme has proved of the greatest possible value and if it were extended, if all the general hospitals cooperated, it might well be that within a generation we could get rid of our waiting list altogether, if not earlier.

I should have liked to have said a word or two in relation to the care of the aged sick, which has been another of the themes throughout the debate, but I have not time to do that. I have been intensely interested in the work done in that connection and the new ideas that are being developed. I have seen people who were completely crippled, through having given up hope, having gone to bed and having lost the use of their limbs altogether, but who are now walking about without even the use of a stick. Great work can be done by giving these old folk an interest in life, and keeping them active is of amazing value, not only humanly, but also on the practical side, in that it relieves many beds which these people would not have occupied if they had been looked after properly in the first instance. The results of this work are most promising.

I have endeavoured to the best of my ability to deal fully with the main points raised in the debate and I regret that time does not allow me to answer all of them. It will be within the recollection of many right hon. and hon. Members that there was a time when a previous Government were wont to claim all the credit for the improvement in the health of the people which had taken place during their period of office. In that claim they included as attributable to their work even the increase in the number of bonnier, happier and healthier babies who, they held, had been ushered into the world under their auspices. This Government, hard-working though they be, really cannot make that claim—

Mr. Stan Awbery (Bristol, Central)

No time for babies.

Commander Galbraith

Rather do we award the credit to the doctors, scientists, research workers and nurses, and to that great army of ancillary workers in the Health Service, including too those who voluntarily and ungrudgingly give their time and energy to the service of the sick. I am certain that this Committee tonight would like to pay tribute to those who have done that work, in recognition of the fact that it is as the result of their labours that our health statistics continue to show that encouraging trend which has been so marked a feature in recent years. At the same time, their efforts could not be turned to such practical value were it not for the continuing development and expansion of the National Health Service under the inspiration and guidance of my two right hon. Friends.

Whereupon Motion made, and Question, "That the Chairman do report Progress, and ask leave to sit again.'' —[Mr. Kaberry]—put, and agreed to.

Committee report Progress; to sit again Tomorrow.