Motion made, and Question proposed,
That a Supplementary sum, not exceeding £4,848,000, be granted to Her Majesty, to defray the charge which will come in course of payment during the year ending on the 31st day of March, 1955, for the provision of a comprehensive health service for England and Wales and other services connected therewith, including medical services for pensioners, etc., disabled as a result of war, or of service in the Armed Forces after the 2nd day of September, 1939, the treatment abroad of respiratory tuberculosis, certain training arrangements, the purchase of appliances, equipment, stores, etc., necessary for the services, and certain expenses in connection with civil defence.
§ 3.55 p.m.
§ The Parliamentary Secretary to the Ministry of Health (Miss Patricia Hornsby-Smith)
When introducing the National Health Service Estimates last year my right hon. Friend drew attention to the fact that we had endeavoured to make these as exactly accurate as possible in accordance with the recommendations of the Public Accounts Committee, which had suggested that amounts for possible additional contingencies like wage increases, for example, were really speculative and should not be included, but, if the need for such additional sums arose, they should be the subject of a Supplementary Estimate. I think that the Committee generally accepts in principle this more realistic method of estimating.
Notwithstanding, however, this stricter interpretation of the main Estimates, the Estimates last year for the National Health Service have proved to be more accurate than in most previous years of that service. The net additional amount 401 to be provided in the Supplementary Estimate now submitted to Parliament is £4,848,000, slightly over 1 per cent. of the sum provided in the original Estimates. Covering, as the National Health Service does, nearly 3,000 hospitals, 20,000 doctors, 10,000 dentists, 8,000 ophthalmic medical practitioners and opticians, and 15,000 chemists and suppliers of appliances the smallness of this margin, in the circumstances, is, I hope the Committee will agree, a very creditable one, because the demands on the general practitioner services can never be truly predictable, nor, indeed, can wage increases be entirely foreseen or accurately estimated.
It will probably be for the convenience of the Committee if I deal briefly with some of the main items which, I think, will arouse the most interest in the Supplementary Estimate, and my right hon. Friend will deal with any additional points specifically raised by hon. Members in the debate.
While I understand that it is not in order to discuss savings in this debate, perhaps you will allow me to explain, Sir Charles, how the net figure of the Supplementary Estimate was arrived at. The sum now asked for is made up of various increases, totalling £8,562,000; but that sum is offset by savings on other subheads of £3,009,000, and by increased appropriations in aid which are likely to bring in £705,000. That leaves us with a net Supplementary Estimate of £4,848,000.
Let me deal with the most important and, in the main, the largest items in the Supplementary Estimate. The first is hospital maintenance. The main increase for hospital maintenance accounts for the sum of £2,608,000, and that is divided up under three main heads. There are increases in pay over and above the £1 million included in the original Estimates which require us to provide an additional £1,200,000; increases in costs which account for £900,000; and cash required to meet expenditure which it had been originally estimated would be met by running down stocks, and this sum is £500,000. That gives a round figure of £2,600,000 as an additional estimate for hospital maintenance.
Before leaving the question of the hospital services, I should like to pay tribute to the hospital authorities who, generally, 402 have shown every willingness to cooperate and who have efficiently considered costs. That they are using the money made available to them to very good purpose is shown by the continuously increasing services which have been given. Last year, for example, the figures showed an increase of 8,000 in the daily average of occupied beds, an increase of 125,000 in the number of new out-patients and of 277,000 in casualty attendances.
The next major increase for which the Supplementary Estimate provides is for an additional £2,133,000 for the pharmaceutical service. This is due mainly to an increase in the average cost per prescription above that originally estimated and, secondly, to an increase in the number of prescriptions dispensed. This is offset by a saving due to a change in the arrangements for paying the chemists. That has resulted from the completion of the task of overtaking the pricing arrears, which I am sure the Committee will welcome. We have had much discussion and many Questions on this subject in the past and I should like to pay tribute particularly to the staffs of the pricing bureaux for having completed this task earlier in the past year than we had estimated.
When the original Estimates were framed, the average cost per prescription appeared to be showing a tendency to fall. On that basis it was assumed that this trend would continue and would result in an average cost per prescription of 3s. 11¾d. whereas, in fact, the average cost for 1953–54 worked out at 4s. 1d. The trend was reversed shortly after the Estimates were framed and we now expect the average cost to be 4s. 2¾d., an increase of l¾d. compared with last year. In the main, this is due to a wider use of the newer and, in many cases, much more expensive drugs and preparations.
The Committee, however, will be aware of the various measures which have been taken by my right hon. Friend to keep the cost of drugs within reasonable limits. Doctors are continuously being kept cost-conscious in several ways. It is done through the activities of the Cohen Committee, by letters from the Ministry's Chief Medical Officer, through "Prescribers' Notes" issued to general practitioners and, most recently, through the introduction of arrangements whereby a doctor can compare the cost of his own prescribing with that of his colleagues.
403 The Committee will also be aware of the energy with which my right hon. Friend has initiated discussions between the Department and manufacturers on price investigations, a policy which, I believe, has the support of the whole House. At the same time, we are not unmindful of the valuable research work which is done by many of the larger firms. As a result of these investigations, price reductions have been made in a number of cases. The combined effect of all the measures has been to keep the average cost of a prescription reasonably stable over the past three years, notwithstanding the almost continuous introduction of new drugs which, certainly in the early stages, are very expensive.
Whereas the average cost in 1952–53 and in 1953–54 was 4s.1d. and we anticipate this year's final figure to be about 4s. 2¾d., in contrast the average cost in the early years of the Service jumped from 2s. 9d. in 1948–49 to 3s. 10d. in 1951–52. The increase in the number of prescriptions is now expected to be about 4½million more than was anticipated originally, but it is always impossible to predict exactly the number of prescriptions which are likely to be issued in any year. The bad summer last year produced a higher incidence of prescriptions than is normally the case, and the July figure was the highest ever for that month.
I turn now to the Supplementary Estimate for the general dental services. If any Supplementary Estimate ever finds favour in the House of Commons, I think that the reason for the increase of £1,701,000 on the general dental services should find favour in all parts of the Committee. It is entirely due to the facts that the number of patients treated exceeded the number assumed in the original Estimates and that there was an all-time record for conservative dental treatment. Whilst one may regret the dental decay that created the need, it is heartening to see that the nation is beoming more dental conscious and, in particular, that there has been a very substantial increase in the demand for treatment from children and young people.
Two very important figures are that last year conservative treatment generally rose from the 1953–54 figure of 5,400,000 to 6 million, and of that figure the number of 404 those treated who were under 21 years of age rose from 2,600,000 in 1953–54 to 3 million last year. This was in spite of the fact that the number of school dentists increased from 717 in 1950 to 979 in 1954, which, in turn, means that more children are being treated under the school service than ever before.
The increased demand for adult treatment is particularly encouraging. Though it does not show such a dramatic rise as the 16 per cent. for the priority classes of young children and expectant mothers, nevertheless there has been a 7 per cent. increase in the adult classes who, of course, pay the initial £1 charge.
The estimated increase in expenditure on the supplementary ophthalmic services is £824,000, which is again due to the increased demand. There has been an increase in the number of sight tests, which is to a large extent attributable to the time coming round for a second test for those who came earlier into the Service. Also included in that figure are the increased numbers of people who have been supplied with glasses. That, to an extent, reflects the increasing age of the population and of the number of people who are reaching the age or condition in which they require spectacles.
There is an increase of £600,000 on superannuation. Here, we originally under-estimated the amount which would fall to be paid out for death benefits, short service gratuities, and for the return of contributions to those leaving the Service. These items are never easy to forecast and can vary very much from year to year. This sum is offset by increased receipts of £345,000, so that the estimated net increased cost of the superannuation scheme this year, compared with the earlier Estimate, is £269,000.
There are still, of course, uncertainties. One cannot make a final estimate of the demands upon the different services, particularly for the general practitioner service. Even the weather can make a vast difference. Nevertheless, these Estimates are based upon our most recent experience and on the best projection forward that it is possible to make on the present evidence.
§ Mr. H. A. Marquand (Middlesbrough, East)
It is a little difficult to follow the Parliamentary Secretary into all the details which she has mentioned, though 405 I must thank her for having given a clear explanation of the various increases for which she and her right hon. Friend are asking. No doubt other hon. Members who may have a little more time than I have had to reflect upon what the hon. Lady has said may raise more detailed points than I shall attempt to do.
The hon. Lady began by reminding us that the total Supplementary Estimate now requested represented only about 1 per cent. of the total cost of the National Health Service. That, of course, is perfectly true, but although that is so there is now a total sum of £4,848,000 more than the Committee approved last May. That undoubtedly calls for a careful examination of the question whether some of the increases which the hon. Lady mentioned need to be as large as they have turned out to be.
It is true, of course, that she partially excused having to bring forward these Estimates on the ground that the Public Accounts Committee suggested that in the past some of the estimating for contingencies was a little too generous. I accept that, but I would remind the Committee that the right hon. Gentleman said, in May, in reply to the question whether the amount made available was enough, and that in his judgment it was. In May, he thought he had got very close indeed to an accurate estimate of what was required, and he thought that what he was providing was what the service needed. After all, there had been under spending in the previous year, and he explained in some detail how he arrived at his proposal to increase that sum by about £11 million.
We need a little more explanation than we have had up to now of how it comes about that underestimating of nearly £5 million should have taken place. I do not wish to talk about some of the Estimates in front of us. I have no complaint—and I doubt whether anyone will have—about increased expenditure on home nursing and domestic help. These things help mothers, old people and all sorts who are in difficulties. The very small increase in the ambulance costs no doubt ties up very closely with the welcomed increase which the Parliamentary Secretary told us about in the number of outpatients and the number of other patients receiving treatment in the hospitals.
406 I do not want to discuss these matters this afternoon, nor do I want to talk about the increase for superannuation and various miscellaneous expenses like the cost of cleaning or keeping in good order the limb fitting centres. I am glad that the limb fitting centres are evidently well looked after. I used to have a close interest in them when I was Minister of Pensions, and it is good to know that they are receiving careful attention under the new management.
We need to go into some detail about the services of the hospitals and executive councils. The biggest increases asked for are in the hospital boards, but the increases which are asked for in the services provided by the executive councils, though they are not absolutely the largest, are, in proportion, by far the largest and represent the biggest increases in demand and costs. All of these services provided by the executive councils, which include pharmaceutical, dental and ophthalmic services, which are now costing more than last May, are subject to charges on the public imposed by various Acts. As there have not been any unusual epidemics or anything of the kind since last May it looks as if the charges are less of a deterrent in their effect than they were.
It seems to suggest that the fall in the value of money, which is going on steadily under the present Government's administration, has effected, on the one hand, an increase in the cost of drugs and other services, which we will talk about in a moment, and yet has lowered the value of the shilling or other charges which people have had to pay for their prescriptions. To the latter extent and to that only it will be welcomed. If the charges are less a deterrent we on this side of the Committee are pleased.
What the hon. Lady told us about the dental service was good news. She said that there was a heartening increase in demand for treatment, and, in particular, that there was an increased demand for treatment of young persons less than 21 years of age. That was very good news indeed, and we on this side are very glad that we pressed as hard as we did when the Bill imposing these charges was before the House for the exemption of people under 21. We need have no regret about what we did in that instance.
407 4.15 p.m.
It also seems that more people in need of glasses are getting them. They are finding the charge there less onerous than it was, or that, having put up for a time with some hardship, they have now decided to go ahead and get what they need. I am glad that this is so, and I hope there will not be any temptation on the part of Her Majesty's Government, now that the charges actually mean less, to propose an increase. The right hon. Gentleman himself has already made welcome remarks about getting away from the ceiling, and I trust that there is no temptation to say that now that the charges are less onerous than they were and people are going ahead and increasing their demand for spectacles, dental treatment, and so on, the charges ought to be increased. I know that this is not a subject which we can debate this afternoon, but I just mention it in passing.
A fortunate part about the increases for dental and ophthalmic treatment is that there is no suggestion of any increase in cost. It is only because there is an increase in demand and, therefore, I think the Committee will have no objection whatsoever to voting the increased sums for that purpose. We are glad that that is happening. We see no difficulties arising from it.
When we come to the pharmaceutical service, however, we find there is an increase both in demand and in costs, and this deserves more scrutiny. The expenditure upon drugs has been the most criticised part of the whole Health Service. It is one on which most criticism has been levelled from outside both by lay men and professional people. It has probably caused successive Ministers of Health more troubles and worry than any other part of the Service.
We have been told many times by professional people that some of the expenditure on drugs covers a good deal of supplies of doubtful value. A great deal has been written and said about this in the medical journals and elsewhere. We know that there has been a tendency to prescribe excessive quantities and that the prices charged by the manufacturers for many of these drugs has been excessive. So, when requested to vote more money, we have to ask ourselves how far this kind of thing is still con- 408 tinuing; how far is medicine of doubtful value still being prescribed, because that is a way out of a difficult situation; how far there may be a tendency to prescribe excessive quantities to save oneself trouble or to please some patient; or how far the prices, where the Minister has taken some welcome action, are still too high?
I will not dwell too much upon what the right hon. Gentleman said last year, but he did expect then that the pharmaceutical service cost would remain more or less where it was. Is he surprised by this increase which has, in fact, become necessary? The average cost of prescription had fallen from the peak of 49d. per prescription to 47¾d., but now the figure has risen again to over 51d. per prescription. Why?
If the right hon. Gentleman speaks later, I should like him to go into a little more detail about this. I thought the Parliamentary Secretary slipped very lightly over the subject. After all, as the Parliamentary Secretary reminded us, there are now coming to the Minister many fruits of action taken by my right hon. Friend the Member for Ebbw Vale (Mr. Bevan) in the setting up of the Cohen Committee, and in setting on foot the cost investigations and the issue by myself of prescribers' notes, all of which were referred to this afternoon. It is rather disappointing to find that, while all these things which were set on foot some time ago are now bearing fruit in a reduction in cost, the total cost is, in fact, going up. Why is it still going up?
§ The Minister of Health (Mr. Iain Macleod)
I will certainly deal with the point later if I catch your eye, Sir Charles. There is an important point that I can mention now. When Estimates are prepared, they are done on the basis of the knowledge available to the Minister at the time. Since we prepared these Estimates it has been decided to make two most expensive drugs, aureomycin and terramycin, freely prescribable. The fact that they are now prescribable on forms E.C.10 will be a major factor in the increased amount for which we are now asking the House.
§ Mr. Marquand
I have no objection to raise to that. Very often some of the more expensive drugs are very much better value for money than the less 409 expensive ones. Perhaps, if he speaks later, the right hon. Gentleman will give an even closer estimate of the amount involved.
We should like a little more information now about the result of the attack which the right hon. Gentleman launched upon the prices of certain proprietary articles. He told us of 91 articles whose cost was to be investigated, and he said that their sale accounted for 18 per cent. of the total drug bill. He stated that if he could not obtain the reductions which he thought necessary he might have to advise general practitioners not to prescribe the drugs. We are all in favour of that, and the right hon. Gentleman's statement was greeted with loud applause. Perhaps he could bring the story up to date this afternoon and assure the Committee that no part of the increase is due to unnecessary or excessive charges for proprietary drugs which continue to be prescribed.
The right hon. Gentleman has recently received, and, I believe, will shortly publish, a very valuable Report from the Central Health Services Council dealing with the work of a sub-committee, over which the hon. Member for Putney (Sir H. Linstead) presided, on the hospital pharmaceutical service. The Report, as already summarised in the Report of the Central Health Services Council, shows many ways of effecting economies in the hospital section of the provision of pharmaceuticals. I appreciate that this is a separate service under the National Health Service, but it is so closely related to the other work that it seems convenient to mention it at this point.
It would appear from the Report that there is a source of possible economy in the prescribing of drugs in hospitals, which costs a lot of money and in which a lot of drugs are used. We are assured by many people with experience who have written to us that the Report will not be carried out fully and effectively unless the pharmaceutical staffs in hospitals can be strengthened to enable them to do their job properly and to enable us to get away from the present situation in which much of the making up of medicines prescribed by hospitals is done by outside pharmacists. If that is the position, would it not be a great economy, since the cost of outside prescribing is evidently rising, to increase hospital pharmaceutical staffs 410 in order to take pharmacists back from the trade outside and build up on the modern lines recommended in the Report a good hospital pharmaceutical service which will be an example to the whole of the pharmaceutical profession?
It seems that salary adjustment alone will do this. In a way one is suggesting extra expenditure to save money, but would it not be a real economy to get more full-time pharmacists in the hospital service and let them do what their training and professional skill entitles them to do, which is to spend their whole time on pharmacy, instead of their being outside spending part of their time on pharmacy and the rest of their time as shop assistants?
I should also like to know whether the right hon. Gentleman is now satisfied—I gathered from what the Parliamentary Secretary said that he is, but I should like him to confirm it—that the number of cases of over-prescribing by doctors is diminishing. We know that there have been such cases; action has been taken by executive committees in some notorious cases. Is the number of those necessary actions diminishing, and do the reports coming from executive councils show that that sort of thing is declining?
The Parliamentary Secretary said that the Minister was getting good co-operation from the medical profession in this respect. I know that he has had a great deal of co-operation from the profession. The immense amount of voluntary labour that Sir Henry Cohen has put into all this has been mentioned several times, but I should like to say once again how much my hon. Friends and I appreciate it. It is co-operation, indeed; it is devoted and selfless service for the public good.
However, when my right hon. Friend the Member for Greenock (Mr. McNeil) and I had our long discussions with the representatives of the medical profession in 1951 about the remuneration of general practitioners, we were assured again and again—I am not disclosing any secrets—that if the question of the remuneration was put to an independent adjudicator, we could be confident that the medical profession would make a renewed effort to secure the co-operation of all general practitioners in bringing down the cost of the drug bill by reducing over-prescribing or, as far as it could be 411 done, the prescribing of less valuable medicines.
That was a solemn promise on the part of the profession, and I think I have a right to refer to it this afternoon. I am not saying that the profession is not doing what it said. I am only asking whether it is doing so, and whether any part of the increased demand for drugs comes from the persistence of a certain element of insufficient care on part of the general practitioners in their prescribing.
I pass now to the hospital services, where, the Parliamentary Secretary rightly said, the greater part of the Supplementary Estimate arises. The hon. Lady reminded us that the amount normally put into previous Estimates for the contingency of rises in staff pay had been reduced. I accept that, and in view of it I suppose the increase in pay of £1,200,000 above what was then estimated is nothing serious, spread as it must be over many tens of thousands of employees.
But how much of that is accounted for by increases in the number of staff beyond what the right hon. Gentleman expected? Some of it must be accounted for by higher wage awards than he expected, but some may be accounted for by increased numbers drawing those new payments. In May, the right hon. Gentleman referred to the possibility of getting as many as 2,000 more nurses for the Mental Health Service, and if he has them, we shall be delighted.
I thought the hon. Lady passed very lightly over the increase in costs of £900,000. To what has this increase been due? Is not this failure to estimate the increase in costs simply an example of a Minister believing the propaganda of his colleagues? Have not the costs risen more than he expected because of the action of his colleagues in the Government? Is it not the Minister of Food or the President of the Board of Trade or the Chancellor of the Exchequer, each of whom have influence upon the cost of living, who are responsible for this increase?
During our debate last May my right hon. Friend the Member for Greenock asked, "What about butter?," but he did not get an answer. Today, we are bound to ask again: what about it? What about 412 butter and tea and bread and bacon and all the other things whose prices have risen in the meantime?
§ Mr. Marquand
My hon. Friend says that the patients do not get butter. Is that true? We hear on all sides that hospitals who used to be able to supply butter to their patients are no longer able to do so.
§ Mrs. E. M. Braddock (Liverpool, Exchange)
I can tell my right hon. Friend that the Liverpool teaching hospitals have refused point-blank for the last six months to supply any of their patients with butter.
§ Mr. Marquand
That is an example of what we hear. Is that now general? Has there been any directive about this matter? Does the right hon. Gentleman intend to get up and say that margarine is as good as butter for feeding patients in teaching hospitals or in any other kind of hospitals?
The Minister may quote to me my right hon. Friend the Member for Fulham, West (Dr. Summerskill), but I hope we shall not get into that kind of debate. Exchange of the chit-chat of quotations from light-hearted speeches made outside the House is not the kind of debate that I want to get into. I am serious about this. How much of this increase is due to an unanticipated increase of costs and, therefore, solely due to the failure of the Government to keep down the cost of living?
The hon. Lady said that the reduction in stocks, about which we were told last May, had not taken place to the full extent of what was then anticipated. On the whole, I am glad to hear that because I am not certain about the reduction of stocks as a sound measure of economy. If prices continue to rise, it may not be sensible to reduce the stocks which could be bought in a cheaper period.
That leads me to ask about supplies. How much of this £900,000 is due to the increase in prices of food or to increases in the prices of other kinds of supplies? In particular, what measures are being taken to reduce the price which the hospitals have to pay for their supplies of food and other necessities without 413 reducing the quantity or the quality of what they buy? There are ways of doing that, and on this side of the Committee, whilst we deplore the astonishing and disgraceful rise in prices that has taken place, we have never stood for waste or extravagance. Even though prices are rising, if it is possible to continue to supply reasonable and sensible quantities of supplies and of food by methods of centralised purchase, then we are all for it.
Has the right hon. Gentleman read the account in the February number of a magazine called "The Hospital" of what has been achieved by the Tees-side Hospital Management Committee through the adoption of bulk buying and central storage? The article shows that it was possible for this committee, having an extraordinarily able officer in charge, to effect a 10 per cent. saving on coal and coke over the last three years, a 20 per cent. to 30 per cent. saving on foodstuffs, 16 per cent. on tea, 8 per cent. on meat, 4 per cent. on bread, 28 per cent. on standard pharmaceutical requirements and other similar savings, though, obviously, it is not so easy to state savings on medical and surgical equipment in the form of percentages. That committee adopted the practice of centralised storage of the necessary supplies as far as that is possible, thereby reducing stocks without in any way reducing the quickness of transmission to the separate hospitals, and of buying in bulk and from wholesalers instead of from local retailers.
That is a way of avoiding an extra expenditure of £900,000 without sacrificing the interests of the patients, without giving them margarine instead of butter, or giving them smaller pieces of meat. This Government boast that they got rid of rationing. Have they got rid of rationing inside the hospitals or is a new kind of rationing being imposed upon patients in hospitals, who need good food for their proper care and attention, as the result of this increase in prices and the failure to keep pace with it?
We will vote money gladly enough if it means better food for patients, and we do not intend to vote against this Supplementary Estimate this afternoon. However, we want to be sure that proved methods of economy in providing these necessary steps are really being applied, not only in Tees-side but everywhere else throughout the country.
§ Sir Hugh Linstead (Putney)
I have listened with considerable interest to the speech of the right hon. Gentleman the Member for Middlesbrough, East (Mr. Marquand). He made many points which I would like to follow, but, as I was hoping this afternoon to concentrate my remarks mainly on the pharmaceutical service, I will not do that. However, I want to refer to the very moderate terms in which his speech was couched and to contrast it with some other debates on the National Health Service to which I have listened in Committee or in the whole House. I hope that as the Service gets bedded down and established, and finds its roots, it will tend to move away from the political arena. If it does that, I am sure that it will be an extremely healthy thing, because basically the Health Service is something which all of us want to see flourishing and serving the public.
If I had any slight criticism of what the right hon. Member for Middles rough, East had to say, it would be when he rather twitted my hon. Friend the Parliamentary Secretary for having claimed that the Estimates were as substantially accurate as any Estimates could hope to be. We must always remember that here we have an unlimited liability. It is quite impossible for anybody who is looking twelve months ahead to guess what use is to be made of the Service, when the Service is freely at the disposal of the public. It seems to me that there can be no possible complaint on the ground that there was lack of foresight, because of this unlimited liability which can never be hoped to be matched from a fixed sum of money.
Before I deal specifically with the pharmaceutical services, I should like to refer to two remarks made by the Parliamentary Secretary. I join with her in congratulating those responsible for having overtaken arrears in the pricing of prescriptions. It is not merely that there was a very substantial outstanding debt at one time which the Ministry owed to the chemists. What is more important is that, until the arrears in pricing were caught up, it was not possible for the Ministry to keep a check on the not inconsequential number of doctors who, often through carelessness, were over-prescribing. Now that pricing has caught up with the current demand, the Ministry 415 is in a position to make quite certain that, if there is over-prescribing, it can be at once investigated and I join with the Parliamentary Secretary in congratulating the staffs of the pricing bureau in having caught up.
I should imagine that the Committee, on reflection, must be appalled at the vast number of bottles of medicine which are still, in spite of all the checks put on them, being supplied to the British public. When we look at the increased costs in the pharmaceutical service and translate them into terms of 210 million or 220 million prescriptions a year, we really have cause to pause and to hope that we shall slowly educate the public away from the magic that is attached to the bottle of medicine.
Frequently the bottle of medicine is necessary, but frequently it is no more than a palliative given to the patient to satisfy him in a rather vague psychological way. I hope that general practitioners, who are in the most advantageous position to undertake this education, and the Ministry and the schools, will undertake this work. Attempts must perpetually be made to educate the public to realise that the answer to health is very often not in the bottle of medicine.
The right hon. Member for Middles-borough, East referred to the large increase in the cost of the pharmaceutical service and used a phrase about the cost of some medicines with which I want to quarrel. He said that when the prices charged by manufacturers had been investigated, they had often been found to be excessive. It is that word "often" on which he slipped, if he will allow me to say so. Certainly, on investigation, some, but relatively few, prices have been found to be excessive.
It is significant that on the one occasion that medicines have gone to the Monopolies Commission for investigation—and that was the insulin investigation—manufacturers came out with one of the rare medals which the Commission has ever pinned on anyone's breast. The Commission declared itself completely satisfied that the manufacturers in that case had steadily brought down the price of that vital drug.
416 4.45 p.m.
The points I should like to bring to the notice of the Committee about the increased cost of the pharmaceutical services are these. Basically, the increased cost is due to the fact that medicine is advancing with extreme rapidity and that new and inevitably more expensive drugs are very rapidly replacing the old and traditional and cheaper drugs. All of us who have the future of the Service and the well-being of its patients at heart would not want to see the Minister backward in adopting and encouraging the use of the new drugs as fast as they come out.
These new drugs generally reach the market and the medical profession in the form of proprietary medicines. That is largely due to the fact that a good deal of the research in the medical and pharmacological field is being undertaken in the research laboratories of manufacturing houses. Some is done in teaching hospitals and universities, but at an early stage their researches have to be turned over to manufacturing houses for private development. Consequently, there is a heavy development and research bill attached to most new drugs before they come on to the market and it is not unreasonable, indeed it is essential, that these costs should find their way into the final cost of the medicine.
The percentage of prescriptions for proprietary drugs as distinct from the old simple drugs is steadily increasing. According to my information, 18 per cent. of the prescriptions in 1950 were proprietary; 27 per cent. in 1953;and 29 per cent. in 1954. That does not mean that the manufacturers are getting an increasing grip on prescribing. It means simply that newer and better drugs are coming out, and that is reflected by these figures. It is interesting to note that in France, the United States and Italy the percentages of proprietary medicines is enormously higher, and in France probably about 80 per cent. So we really have no cause to complain that the manufacturers are, in fact, exploiting the situation here.
It is also important to realise that these new drugs are facilitating the speed of cures. There is no doubt at all that the more rapid turnover of hospital beds is due to the increasing use of, for example, antibiotics. All of us who have looked 417 back over our lifetime will recognise that pneumonia has now ceased to be the terrifying illness that it was twenty years ago. So, today, a bed need not be kept for three weeks, or a month, but be released in a week or ten days. Diphtheria has practically disappeared, again owing to the use of more expensive prophylactic methods. The same thing is happening with tuberculosis, although we are moving much more slowly in our fight against that disease.
I do not want to run away from briefly examining the very proper criticism which the right hon. Member for Middles-borough, East made and which, I think, is very much in my right hon. Friend's mind. The question is whether proprietary preparations are more expensive than is necessary to finance the research which the manufacturers undertake and to provide them with a reasonable profit. It is very interesting and encouraging that an investigation team which has been set up by the Ministry of Health and the manufacturers jointly is now settling down to what seems to be a much more rational and hopeful approach to that problem.
I think there was a natural tendency for them to start their work at arms' length, with the officials—sometimes encouraged by our Public Accounts Committee and by the Comptroller and Auditor General's Reports—looking for "niggers in woodpiles," and the industry tending to pull back in consequence. My information is that now, more and more, that team is beginning to discover that there is much to be said on the manufacturers' side as well as on the financial side. I am hoping that as a result of these investigations we shall get an outcome fair to the manufacturers as well as to the Ministry.
§ Mr. Ellis Smith (Stoke-on-Trent, South)
I know that the hon. Member is well informed on these matters, and I should like the benefit of his knowledge and experience regarding a question which has caused me concern for some time. I find myself in complete agreement with what he has been saying, and having myself benefited, I am all the more in agreement. I have heard allegations that firms from other countries—and one country in particular—which have subsidiaries in this country, are charging too much for the products being 418 sold here. I should like to have the opinion of the hon. Member on that.
§ Sir H. Linstead
I think it would be extremely dangerous for anyone to throw off a generalisation on a matter of that complication. It may be that certain foreign firms are charging extremely high prices for the proprietary medicines which they offer. If that be so, we have two instruments by which their prices may be investigated. One is the heavy instrument of the Monopolies Commission. The other is this working party between the Ministry and the industry which is now functioning. I am sure that each one of these examples must be investigated as an individual case and that we should not be wise to try to dispose of charges of this kind by generalisations.
The exports of our own home-manufactured proprietary preparations are substantial. They are accepted in foreign countries because of their known quality, and it would be an extremely unwise policy on our part so to pare down the profits from the home market that the effect was not merely to damage the pharmaceutical industry, but also to cut down the amount of research work which those manufacturing firms are doing. It is not a matter of pulling at two ends of a tug-of-war rope. It is much more a question of the Government and industry getting together, with the background of a common interest, in order to make certain that our research is not damaged; our exports are not damaged, and that the Ministry of Health is not required to spend more than is reasonably necessary on purchases from industry.
§ Mr. Marquand
Would the hon. Member enlighten the Committee a little more on this point about exports? Does he mean that British manufacturers of proprietaries are exporting their products at a lower price for foreign markets than they are charging at home?
§ Sir H. Linstead
No, I would not necessarily say that. But in this field, probably more than in any other, quality and being in the forefront of research are the things that matter. A new proprietary or drug which does not represent any significant advance in the pharmaceutical field will not easily break into the export market, because a great many countries impose barriers to make certain that such things shall not come in. All I am saying is that this is a field where we must be 419 completely in the lead. That can be done only at the expense of large research departments which inevitably have to bear a substantial share of the cost. It is along those lines, rather than on the narrower lines just mentioned by the right hon. Member for Middlesbrough, East, that I was advancing my argument.
I wish to pick up one or two further points made by the right hon. Member. He was kind enough to refer to the report of a working party, of which I was the chairman, dealing with the pharmaceutical service in hospitals, and that is very relevant to this question of the increased cost of the pharmaceutical service generally. I am sure that the right hon. Gentleman has not seen the full report, which has yet to be published, and I think that he was somewhat misinformed from the brief summary which has appeared.
In the report, we did not encourage the dispensing of medicines for out-patients outside hospitals in order to effect an economy. In fact, that would not be brought about, and is not the criterion by which to decide. One has to decide whether a patient should get his medicine in or out of hospital and the criterion by which that is decided is whether it is good for the patient to continue to come to the out-patient department to see the doctor at the hospital, or whether it is better that at as early a stage as possible the patient should be returned to the care of his general practitioner.
On the whole, I favour the second course. I believe it to be the duty of the hospital to diagnose, to prescribe the necessary treatment and then to send the patient back to his general practitioner, his family doctor—and, we hope, his personal friend—with advice from the hospital which the general practitioner will apply in the treatment of the patient. Therefore, whether we dispense medicine in the hospital or the chemist's shop is purely a secondary matter which should be determined in the interests of the patient, and in answer to the question whether the patient should stay as an outpatient of the hospital or be returned to his general practitioner.
I am sure that there are very substantial economies still to be secured in the pharmaceutical costs in hospitals. Such economies will be secured only in as far as the chief pharmaceutist in each hospital 420 is a person of substantial scientific knowledge, who is respected and whose advice is listened to by the consultant and the hospital medical staff. They will not be secured in any other way.
The right hon. Member for Middlesbrough, East was right when he emphasised that one of the tasks confronting my right hon. Friend is to make the hospital pharmaceutical service sufficiently attractive to ensure that the present drift out of the service does not continue. That will be done by giving it a career value. We do not need a large number of well-paid appointments, but we need at the top, at national level, at least in the big teaching hospitals, it may be a couple of dozen really first-class appointments which will encourage the intelligent young graduate to stay in hospital pharmacy and not go into manufacturing or industrial pharmacy.
Those men in key positions could influence the teaching in the teaching hospitals, so that young medical students would be taught sane prescribing, and they could remind consultants of better and more economical ways of treating their patients in hospitals. I hope that my right hon. Friend will give attention to this problem because I am certain that there is money to be saved by increasing the quality of the key men in this service. At present, they are drifting away.
I very much hope that the small sum of money for which my right hon. Friend is asking will be granted by the Committee.
§ 5.0 p.m.
§ Mr. Donald Chapman (Birmingham, Northfield)
I want to refer to a figure which was mentioned by my right hon. Friend the Member for Middlesbrough, East (Mr. Marquand). He asked about the sum of £900,000, which the Parliamentary Secretary told us was needed mainly for increased wages costs in hospitals. I should like some further details about mental hospital staffs and the present general situation in that respect. My right hon. Friend said that when the Minister introduced the Estimates on 10th May last he mentioned in passing—I appreciate that he did not intend it as a very meaningful figure—a figure of 2,000 more recruits to the mental nursing staffs. I want to know how much of these increased wages costs is in fact the result of getting more people into mental nursing.
421 The Minister also said that there had been an increase of about 900 in the first nine months of 1953. How has the position developed, especially as between male and female staffs—because I have some very disturbing figures in relation to my own area of Birmingham, and I want to put them to the Minister in the hope that he may say something encouraging and explain what his ideas are for improving the position? The figure of an extra 2,000 a year in recruitment to mental nursing will not get us very far. He knows that I have been pursuing him about the position in the West Midlands, and he told me, in reply to a Parliamentary Question, that we are 1,300 short in the West Midlands alone; so that the 2,000 extra will not do very much by the time it is spread over the country.
I should like to mention one hospital which I know something about, because I make it my duty to keep in close touch with it. In the Hollymoor and Rubery Hospital, the situation is quite appalling. An hon. Friend of mine has just remarked that it is the same everywhere. That may be so, but we have to keep saying that it is appalling and keep pressing the Minister to put out further ideas, particularly for recruitment, in order to alleviate the position. I have here the report of the Board of Control which visited the hospital a few days ago. The figures and comments contained therein are most alarming. It refers to gross overcrowding, inadequate staff, the fact that the hospital is having to cut down parts of the service, and so on.
In one part of the hospital there are about 400 women, who need 90 nurses. That is about 4½patients to a nurse. The hospital has in fact 40 nurses and some part-time workers who are equivalent to about 20 more full time. These part-time people do not always turn up, and in parts of a big industrial city it is very difficult to keep them for very long because of the alternative attractions in well-paid employment. In this case, the hospital has a maximum of 60 nurses where 90 are needed. In another part there are 335 men, needing about 75 nurses, but all the hospital has is 50. A further point to remember is that recruitment on the male side is getting worse and worse. Far from achieving any increase, the figures sup- 422 plied to me show a continued depletion of the male nursing staff. Does this apply nationally? I should like the Minister to tell us what is the general position.
The situation is made much worse by gross overcrowding. Wards intended for 35 women now contain 66. The beds are placed in the normal sitting and eating parts of wards, and the Commissioners found that the day before they visited the hospital one male nurse was available for a tuberculosis unit of about 20 men. If this situation continues the unit may have to close down.
What is the Minister doing about recruitment? He has told me that he is carrying forward further publicity, but I have not seen a great deal of it, and I should like to know what it consists of. He mentioned the cadet service. Is that getting anywhere? Does it hold out any hope of increasing the staffs in mental hospitals?
The hospital which I have mentioned has, as the Minister knows, one of the biggest problems to face in connection with the increased ratio of the aged and chronic sick who are entering hospital. I believe that its figures are much worse than those for the rest of the country—that is, in the case of admissions of people of over 65 years of age; and this aggravates the nursing staff problem, because these people need so much more attention than those who may be treated for mental illness at an earlier age.
Compared with 20 per year in the years 1939 to 1947, the figure of admissions of the over-65s to this hospital has risen in recent years to 170 per year. That is a rise from 7 per cent. to 24 per cent. of all the hospital admissions. The national figure is below 20 per cent., so the situation at this hospital is much worse, and the staff problem is going from crisis to crisis, partly as a result of the increased attention which is needed by these old people.
I now turn to the question of capital expenditure. The Estimates show a £60,000 Supplementary. Estimate for capital expenditure in Wales. That contrasts very forcibly with the reduced expenditure of approximately £500,000 in England. What is the meaning of this? What is happening, especially in regard to mental health? Why is Wales doing so well as compared with England? Not so long ago the Minister told us that 423 only about two-thirds of the much-publicised "mental million" pounds is likely to be spent in the current year. In my area it is months before we can hope to receive approval for the expansion of buildings. The Minister has now come forward with ideas for new hospitals, but we have been pressing for permission to expand existing hospitals, where the central services are already available.
Why is it that Wales is forging ahead and asking for a Supplementary Estimate while we cannot get permission from him except under considerable pressure? He has now given us permission to put up another 80 beds at the hospital which I have mentioned. We need and can take about 360. The central services are already available and we have plenty of land to build upon. We are entitled to some explanation why it is that Wales is going ahead and England is not even managing to spend the whole of its Estimates on capital expenditure.
In reply to a Parliamentary Question on 15th November, the Minister told me:… I have made very special and careful provision for the needs of the mental health services in the last year or two."—[OFFICIAL REPORT, 15th November, 1954; Vol. 532, c. 28.]I think that is probably true, and I do not grudge the right hon. Gentleman a word of praise. All I would say is that, in my part of Birmingham—and not only there, but in other parts as well—we do not see much result from this increased provision in regard to buildings, getting on with the job of providing better facilities and increasing the number of staff. I know that it is not only the Minister's official responsibility, and that he cannot conjure people out of thin air, especially from jobs which are more highly paid; but we in Birmingham have not felt the increased attention which he claims.
In this hospital, it is really a case of a devoted staff, and of a very enthusiastic management committee, for whom no praise is too high, because it is really getting on with the job. But the talk is always of crises over staff and buildings, and I therefore ask the Minister to give us some hope of a better outlook and some ideas for alleviating the very bad conditions I have been describing.
§ Major H. Legge-Bourke (Isle of Ely)
I hope that the Committee will forgive me if I leave the large city area of Birmingham and go into the wider spaces of East Anglia, because this is one of the opportunities for hon. Members to make points of great interest to their own constituencies. I therefore hope that other hon. Members will not think that too insular an outlook.
Of all the health services operating in a constituency such as mine, I think that home nursing, district nursing, health visiting and that type of work is probably as important as anything. What I find a little surprising in this Supplementary Estimate is that the items for health visitors, midwifery and the care of mothers and young children all show a considerable reduction below the estimate originally made for the year. That is true even of the prevention of illness, which comes under the heading of "Grants to Local Health Authorities."
Yet, when we look at the grants made to local health authorities, as set out on the first page of the Estimates, we find that the amount required for home nursing has increased by £154,000 and for domestic help by £234,000. I find something a little inconsistent in these figures, because I have thought that, to some extent, home nursing would have involved a certain amount of post-natal or even pre-natal care. Yet we see that the amount for midwifery is down by £87,000. I shall be grateful if the Minister will tell us how the increased costs of home nursing have been produced.
According to the explanation given, it isbecause of the revision by local health authorities of their estimates of expenditure as a result of expansion of services and increased costs.I should like to know the measure of the expansion of the services and of the increased costs, because I know that in my own constituency we have had some difficulty in replacing district nurses.
One of the troubles there is the somewhat unsatisfactory situation in regard to the salaries of district nurses, and the disparity between those salaries and those of other nurses. I believe that, at the present moment, some negotiations are proceeding on this subject, and I will not therefore pursue the matter in detail. It seems to me that we need to be assured, 425 when voting another £154,000 for the purpose of home nursing, that we are, in fact, getting full value, that the money voted is being wisely spent, and that we are really increasing the service.
I am quite certain that, in rural areas in particular, these services can prevent a very great deal of the overburdening which is taking place in the hospitals, and I should have thought that home nursing was the greatest single factor in the health services in diverting people away from the hospitals. When one sees the increased cost of the regional hospital boards and of the teaching hospitals, amounting to over £2 million, one is obviously only too anxious to try to find some way of improving the services provided through the National Health Service and the local authorities which would tend to restrict the pressure on hospital beds. Therefore, I hope that the Minister will give us fairly full information on this subject.
I wish to refer to one matter of considerable concern in the area of the Eastern Regional Hospital Board, and that is the question of a teaching hospital. As far as I am aware, there is no teaching hospital in the whole of that area, and we are naturally very interested in ensuring that the hospitals' in our area are provided with skilled staffs who realise the somewhat special needs of the region. I know that one must not debate this matter in detail, but I must say that when the Minister announced his plans for the future, the greatest disapointment was caused in East Anglia by the fact that, apart from Harlow, no other new hospital was to be built in the area.
§ Major Legge-Bourke
The hon. Gentleman asks me whether there is not one at Cambridge, but the hospital at Cambridge cannot be regarded as a teaching hospital. I think that a certain amount of teaching does go on there, but it is not organised on the basis of a teaching hospital, for which there is a very great need. I hope that my right hon. Friend will, perhaps, be able to give more encouragement to that in the future. I am grateful to the hon. Gentleman for his interruption, because it has helped me to emphasise a point which I wanted to make.
426 5.15 p.m.
I apologise to the hon. Member for Newcastle-under-Lyme (Mr. Swingler) who, I think, wishes to raise the question of a report which appeared the other day of an experiment with antibiotics on infants. It seems to me to be utterly outrageous—and I use this phrase deliberately—that experiments should be carried out with drugs, no matter how safe they are known to be, without the parents being consulted. I should have thought that it was the obvious duty of hon. Members of this House to try to provide all patients in the National Health Service with the finest service they can have, including the latest drugs and so forth. It seems to me that, where there is a question of choice between two forms of treatment, or of choosing between two different types of drugs, both of which are known to be excellent in their own way, the parent should certainly be considered.
I wish to make this protest, because I think there is a tendency today, about which we have to be very careful, for parents' choice to be overlooked, and towards the attitude that the management committee or the man in County Hall knows best, and for these people to take these decisions without allowing another point of view to be considered. I am quite certain that the treatment that is given in our hospitals is always given in good faith and with the intention of providing the most rapid cure, but I am not at all satisfied that it should always be the only consideration to be taken into account. It seems to me that the principle of liberty of choice is a very important one to safeguard, and I am not at all satisfied that it is always regarded with the care that it should be.
I see a reduction in the amount spent by local authorities upon prevention, and am glad to note that it is not more below its original estimate than I expected. Nevertheless, it is £42,000 below that estimate. I should have thought that one of the aims of the service, if it is not to be simply a hospital service, was the prevention of disease. I find it surprising, knowing the pressure that there is on all our hospitals, that a local authority should not find it possible to spend all that it spent originally on prevention of illness.
§ Mr. Iain Macleod
On a point of order. I am most anxious to answer all the points in this debate, but I imagine that practically every point that is being raised by my hon. and gallant Friend the Member for the Isle of Ely (Major Legge-Bourke) is related to the item concerned with savings. If that is so, I shall not be able to reply to those points. May I ask whether my hon. and gallant Friend is in order?
§ Major Legge-Bourke
Before you give your Ruling, Mr. Williams, may I point out that we are considering the increased cost of the hospital service, and that my argument is that before we vote increases for the hospital service we ought to make sure that every possible avenue is explored to prevent that increase from taking place.
§ The Temporary Chairman (Mr. W. R. Williams)
We are not dealing with savings in this debate, and it would be just as well to confine ourselves to the relevant aspects of the matter. The hon. and gallant Member was rather drifting.
§ Mr. A. C. Manuel (Central Ayrshire)
This point is of importance. If the hon. and gallant Member was putting the point forward that local authority health services are now spending more money than they did initially, it is clear that if that money had not been spent there would be less need for a Supplementary Estimate. This is a point which might be in order.
§ The Temporary Chairman
That is an ingenious argument, but we had better leave the situation as it is.
§ Major Legge-Bourke
I am grateful, Mr. Williams, for your Ruling, and I will bow to it without any question whatever. I am sorry if I have strayed from the strict path of order, but I have now reached the conclusion of my speech.
§ Mr. Stephen Swingler (Newcastle-under-Lyme)
I welcome this Vote, in so far as it represents an extension of the National Health Service. If it is a result of rising prices, it simply reveals the Government's failure to keep down the cost of living. I do not rise for the purpose of entering into any general controversy about the voting of this money, but the hon. and gallant Member for the Isle of Ely (Major Legge-Bourke) has given me a lead. He must have been already aware that I had notified the Minister of Health that I wished to raise a special point 428 which I believe to be of importance to all of us.
The Vote is partly concerned with the extra money needed for hospital services. Part of the work of that service is properly devoted to medical research and experiment. On the subject of clinical experiments in hospitals, I have recently had some communication with the Minister. I am entirely in favour of voting money for medical research in the hospital service. British medical scientists have made an outstanding contribution to discovery in this century, and we would all wish to give them the best possible facilities for enlarging the scope of medical knowledge.
There must be a combination of work in the laboratory and experimentation in the hospital. Experiments on human beings are necessary and desirable to increase medical knowledge. While the community should give to medical scientists and doctors the best possible facilities and conditions for medical research, medical scientists and doctors should be extremely careful not to use their privileged position to treat human beings merely as laboratory specimens. I agree with what the Minister of Health recently said, that difficult problems of ethics are raised by clinical experiments on patients in hospitals. With all diffidence, and speaking merely as a layman, I think two principles are clear. Medical experiments on patients should not be conducted unless there is a chance of patients benefiting.
Clinical experiments in hospitals should not be conducted unless the consent of the patients has been freely given in the knowledge of the nature of the experiments. The doctor should explain to a patient that experimental treatment is necessary, the nature of the experiment, the risks involved, and the benefits that might be obtained or the injury that might result, in order that the patient might understand as much as possible so as to give or withhold consent. I should have thought that the giving of consent was an important matter in experiments conducted by doctors in hospitals.
This principle is not being universally observed. I recently drew the Minister's attention to a case where penicillin had been administered to newly-born babies for the purely scientific purpose of observing their reaction to penicillin, and to 429 establish the properties of that preparation.
It was quite clear in this case that the penicillin was not required by the baby. There was no question of its having any beneficial effect on the babies. It was also established by the Minister on inquiry that the consent of the parents was not sought. The mothers or fathers of the children were not informed that the experiment was being conducted in the hospital concerned, and they were not given an opportunity either to give or to withhold their consent. In my opinion, even if consent had been given in these cases, the experiment was ethically dubious.
I wonder how far the consent of a parent to permitting experiments on children should be taken. We would not agree that the parents' consent to allowing an assault to take place on a child could be valid. The parents' consent could not morally justify anything like that being done to a baby. It is obviously impossible to consult babies about the conduct of experiments conducted upon them, but, in the opinion of those who conducted this experiment, and in the opinion of the Minister of Health, there was no possibility of harm being done.
That, I think, is considered to be a vital point. All that I would say on that is that in the same issue of the "British Medical Journal" in which this experiment and its results were reported, there appeared a report of a speech by a distinguished doctor to a meeting of the Royal Society of Medicine, in which he gave a warning about the uses and abuses of antibiotics. One of the things which he was reported to have said in his speech was that a doctor should think twice before prescribing the first-ever dose of penicillin to any patient.
It would seem, therefore, that when a very distinguished member of the medical profession has warned doctors and the Royal Society of Medicine about prescribing the first-ever dose of penicillin, unless it is absolutely necessary, there is some risk involved in allowing members of the profession to experiment for purely scientific purposes in the administering of penicillin to new-born babies without informing or obtaining the consent of the parents.
430 This is not an isolated case. I do not pretend in any way to be an expert on this matter, but, since my attention was drawn to this case, which I passed on to the Minister, I have searched through the medical Press of the last two or three years, and I can tell the Minister that if his advisers search through it for those years they will find at least half a dozen cases reported of clinical experiments on children in hospitals, not designed to benefit the children in any way, experiments which may, like the one I have mentioned, have been conducted without the parents' consent, but which are reported to have been carried out merely to test the reaction of children to the administration of certain drugs.
That is treating children as guinea pigs. Let us be perfectly plain about it. It is treating children in these cases as laboratory specimens. The Minister says that judgment on this sort of question could be left to the clinician in charge of these cases, but I would point out to him that some clinicians allow their enthusiasm for science to override all moral considerations.
I should have thought that it was the responsibility of the Minister of Health, in conjunction with the Ethics Committee of the British Medical Association and the Medical Research Council, to lay down some guiding principles for all such cases. It is because I feel that this kind of thing is liable to continue, and that there will be general agreement on the two principles which I have previously stated—that consent should be previously given by people before they are experimented upon, and that the nature of the experiment should be designed to benefit patients—that I would urge the Minister to consult with his advisers, and with the B.M.A. and the Medical Research Council, to see if some kind of directive or code could be sent to hospitals in order to prevent and prohibit experiments, especially on children, which are for purely scientific purposes and which are not designed in any way for the promotion of health.
§ Mr. John Rankin (Glasgow, Tradeston)
I understand that my hon. Friend is dealing with children in hospital, but is he aware that these experiments are being carried out on children who are not in hospital and that an experiment of that nature has been going on at the Bridge of Weir Orphans Home?
§ Mr. Swingler
I am aware of that, but you, Sir Rhys, would rule me out of order if I attempted to discuss something which would clearly be outside the Supplementary Estimate with which we are dealing.
I am simply dealing with the aspect of clinical experiments in hospitals. I do not want to exaggerate it at all, or to suggest that it is a widespread practice, or that these things have arisen from anything except enthusiasm for science. But there are other things besides enthusiasm for science which should govern the conduct of clinical experiments in hospitals. That is why I am urging the Minister, or whoever is responsible in this matter, to consult the scientists and doctors about the ethical aspects, so that some ethical guidance may be given which will act as a necessary and desirable curb on the enthusiasm for enlarging scientific knowledge.
§ Major W. J. Anstruther-Gray (Berwick and East Lothian)
I find myself largely in agreement with the general purport of the remarks of the hon. Member for Newcastle-under-Lyme (Mr. Swingler). What worries me is that all consideration of the parents appears to have been overlooked. I wish to echo what was said by my hon. and gallant Friend the Member for the Isle of Ely (Major Legge-Bourke) on that subject.
It seems to me intolerable that children should be used for any experiment, however innocuous it may be, of things to do with new drugs, such as penicillin, which are bound to have a slight element of danger. It seems to me intolerable that children should be used for that experiment without even the parents being asked if they are willing to allow it. We should look at this matter from a personal point of view, because children are very precious. We have been considering newly-born children. There are always dangers connected with a new-born child. Is it right that a hospital should take a risk, however slight, without informing the parents that this risk is to be taken?
I do not want to overstate the case, and I think that the hon. Member for Newcastle-under-Lyme was careful to steer clear of any such error. I am, however, prompted to go ahead by a statement which I read in the Press that my right hon. Friend the Minister of Health, when questioned on this case, was reported to 432 have said that, in his opinion, it would have been better if consent had been sought.
When I saw in "The Times" today that the hon. Member for Newcastle-under-Lyme was to raise this point, and that the information was available in detail in the "British Medical Journal," I hastened to provide myself with a copy. Very shortly, and in order to put the case in its perspective, I should like to read out the facts. The article was entitled "Penicillin by Mouth in Infancy"—that is certainly less alarming than by injection. It was written by the Tutor of the Department of Child Health, University of Bristol. This is the description:…the present trial was begun in order to compare the efficiency of oral benzathine penicillin and oral crystaline sodium penicillin when given to infants and to determine (1) What practical minimum dose of penicillin is required to give adequate blood levels and how long an adequate blood level is maintained after one dose, and (2) What is the optimum interval between doses and what should be the dosage.That is a perfectly fair experiment, and I have no criticism of its being carried out, but I do think that the parents of the child should first have been asked—and I am not sure that all of us in this Committee today would have been agreeable to our children being experimented on. The article continues:This study was carried out on babies born at the Bristol Maternity Hospital. In this hospital there are two nurseries, each administered by a sister and nursing staff. A total of 20 babies under 12 days of age were selected at random …that is, selected at random without their parents' consent.
I have no doubt that the experiment was quite harmless. The infants merely took teaspoonfuls of these two preparations; some took one and some took the other. I am happy to say that, according to the information given, none of the children is any the worse, though one can never tell whether an experiment will prejudice the effect of a particular drug on children when they grow a little older. The conclusions were not spectacular. Apparently one sort of preparation tastes rather better than the other, while the other works rather more quickly. A whole series of doses of one cost 12s. 7d. and of the other 7s. 8d. None of us, I 433 think, is in opposition to these facts being elicited.
It comes down purely to the guinea pig aspect mentioned by the hon. Member for Newcastle-under-Lyme, but that must certainly not be over-emphasised because, as I know my right hon. Friend would agree, nothing is more important than public confidence. This is like justice; it should not only be done but it should appear to be done; but here I am not satisfied.
There is a note at the foot of the article in which such a lot of people are thanked. The consultant obstetricians and the consultant paediatrician were thanked. Thirdly, the professor was thanked for guidance; fourthly, the doctor was thanked for laboratory facilities; fifthly, the lecturer in statistics was thanked; sixthly, the resident medical officers; seventhly, the nursing staff; eighthly, the technician was thanked for help with the blood samples, and ninthly the firm which produced the penicillin was thanked. But were the parents or the children thanked? No. The children were too young, but the parents were not only not thanked but were not even consulted. I hope that my right hon. Friend will deal with that when he replies.
§ Mr. Blenkinsop
This has been an interesting and rather exceptionally wide debate so far, and I hope that none of the previous speakers will object if I direct my attention more specifically to the particular expenditure provided by the Supplementary Estimate. At a later date I hope to have an opportunity to deal with many matters concerning hospitals. I want to see more money rather than less being spent, and I should find it very difficult to carry out an examination of a Supplementary Estimate which, in the case of hospitals, proposes a relatively modest increase in expenditure which we all welcome. We only wish that it was a great deal larger than it is.
I want to make a further inquiry into the pharmaceutical bill, about which my right hon. Friend the Member for Middlesbrough, East (Mr. Marquand) asked some pertinent questions and on which, earlier in the debate, the hon. Member for Putney (Sir H. Linstead) made some very useful and helpful comments. The actual increase in the expenditure on the pharmaceutical service 434 is not really exceptionally large—an increase of about 5 per cent. On the other hand, it is perhaps a little disappointing—I am sure to the Minister as well as to everyoneelse—in view of the great interest there has been in this subject, and the Minister's own active campaign to reduce costs.
Quite naturally, many hon. Members who have already spoken on the subject, and many of those who have written articles in the Press, have concentrated on the proprietary medicines, which, as the hon. Member for Putney rightly said, are taking an ever larger share of our drug bill. With the hon. Member for Putney, I am not surprised at that. Like him, I rather feel that, on the whole, it should be expected in view of the development of new types of modern drugs such as we are getting today. I quite agree that in relation to the experience of other countries, such as America, we are still using proportionately a good deal less of the proprietary brands. I should, however, like to know a good deal more about the action the Minister is taking.
We understand from the Parliamentary Secretary that negotiations with the industry are going on at present. The hon. Member for Putney referred to the progress so far made in those negotiations. We all wish them well and hope that a satisfactory conclusion can be reached. It is a matter of concern that, in spite of what is said by the Comptroller and Auditor General in his last Report on the Civil Appropriation Accounts about voluntary reductions in prices by some firms producing proprietary brands—there are quite considerable savings there—nevertheless, in one or two particular cases the bill is still going up rather considerably.
In the Report of the Comptroller and Auditor General on the 1953–54 Accounts this appears:These firms had already, since the accountants' reports, made price reductions estimated to save the Exchequer about £850,000 per annum. Further price reductions were expected in response to the recent approach.Has the Minister any report to make of any further voluntary price reductions?
There are some quite startling figures given in the Report. Some firms, on a 435 calculation of profits obtained on the various preparations, gave figures ranging up to 60 per cent. on selling prices. We should all look at that with some care. Unless there is a very special reason in an individual case we should certainly not accept that as desirable in the general public interest.
The proprietaries are by no means the only problem. It is fair to say that, perhaps increasingly, the prices of proprietary brands may be coming down in relation to those of other drugs. I would be glad to know what the position is there. I should like to know rather more, also, about what is happening about other drugs and the related problem of dressings, and so on.
In the case of selective basic drugs, including anti-biotics, vitamins, hormones and insulin, which, I understand, the Ministry has been investigating and which costs about £10 million a year, a great deal is being done. There have been some announcements about savings which have been made, but I should be glad to hear from the Minister about any further report which he may have to make and whether he is proposing to recommend that doctors should not prescribe any further items among those that he has been investigating. There is also the general question of non-proprietary drugs, about which I am not satisfied that we have done enough.
Some hon. Members have referred to the importance of the export market. I think we all recognise its importance. We recognise that there is a considerable pharmaceutical export trade. I am rather disturbed to find, looking at the recent figures in the Trade and Navigation returns for last year, that the increase over the year in the value of pharmaceutical exports is very modest, to put it mildly, while the increase in the imports of pharmaceutical products is considerable.
I agree that the imports of pharmaceutical products are still very much below the value of the exports, but, nevertheless, it must be of some concern that we seem to be importing today quite a large amount in value of proprietaries and in vitamins and matters of that kind, all of which contribute to our drug bill. I should like to know from the Minister whether he can say anything about that aspect of the problem and whether he is 436 satisfied that those drugs which are being imported are being satisfactorily costed by his Department with those which are being produced in this country.
Last autumn, I had the opportunity of going to Switzerland, where I discussed with the authorities there the control that they exercise over drugs, and I was rather impressed by the independent investigations that they make. It may well be that the team that is now being built up by the Ministry to deal with cost investigation may eventually cover adequately the whole field, but the Swiss have had a long experience of control of drugs, both new drugs brought on to the market and drugs of the widest character, including medical preparations of all kinds, with regard to quality, advertisement and price, and it would be well worth considering whether their ideas are of any value to us.
I should also like to know from the Minister whether there has been any further development in the discussions with the pharmacists on the question of their remuneration. I presume that the Minister cannot be including in this Supplementary Estimate any provision for any increased pay for pharmacists. I notice that there has, indeed, been some alteration in the terms of payment which has brought some relief to the Exchequer, and I welcome that.
If I may turn to the ophthalmic service, in the note that the Ministry of Health sent to the Public Accounts Committee in May last year they commented on the fact that prices for lenses, metal frames and cases had been increased after a full investigation, but that increase which was estimated then to cost £170,000 a year was a good deal less than what had been originally claimed by the opticians themselves. Could the Minister tell us how that figure has, in fact, turned out? Has £170,000 been the sum required to meet that extra cost, and is that included in the Supplementary Estimate which we are now considering?
Has the Minister considered at all the question of the relative fees paid for sight testing as against fees paid for prescription of glasses? Sometimes the question is raised whether glasses which are prescribed are always necessary. I know it can be argued that everybody needs glasses, and that, excluding political myopia, there are forms of shortsightedness which afflict everyone to some 437 degree. If we paid slightly more for sight testing and included in that fee the cost of the provision of glasses as well, would we, on balance, find, as is sometimes suggested, some reduction in the number of glasses prescribed? I should like to have the Minister's views on that.
On the question of dentists, again we know that discussions are going on with the dental profession about the restoration of the last 10 per cent. cut in their fees. I suppose I am right in assuming that no provision for that restoration has been made in these Supplementary Estimates, but, again, that is a matter on which we should like to have some further information. As I say, on the whole, we on this side of the Committee wish that the Minister were spending a good deal more than he is. That is a matter that I hope we can develop on some other occasion.
A point which was raised by my right hon. Friend on which I would like to comment related to the use of hospital pharmacists. The hon. Member for Putney made some very useful comments on that matter—and surely there is no one more knowledgeable on that subject than he is. I would remind the Minister that it is suggested that the total number of hospital pharmacists needed throughout the country to provide adequate staffing is something like 1,500. I support what my right hon. Friend said earlier in this connection, that if we could have the hospital pharmaceutical service built up we might make some very useful financial savings. I do not suggest that we should do it purely with that object in view. I think it would be of great value to the hospital services as a whole if we could build up the pharmaceutical service in the hospitals, but I think that we could, at the same time, make a useful economy.
I welcome the fact that this debate is taking place in a much quieter and more moderate atmosphere than when I had the opportunity of introducing some modest Supplementary Estimates for this very Service a few years ago. I hope that the intemperate criticism that we received as a Government from hon. Members opposite in those days taught everyone that we should not follow their example. The way in which many hon. Members opposite are today having to adopt a very different attitude towards the Service which they assailed so bitterly in the past 438 shows how right we were in much of what we then said and how right we all are today in concentrating on the positive value of helping to build what is and can be a very wonderful Service.
§ 6.0 p.m.
§ Mr. Arthur Moyle (Oldbury and Halesowen)
I see in the Supplementary Estimate that provision is made for an additional sum of £234,000 to cover domestic help and services.
I know that it would be wrong for me in this debate to raise the lack of adequate provision of special schools in my own County of Worcestershire, for spastic children and handicapped children generally, and it would be wrong, too, in this debate, for me to stress the need for the home teaching of these children.
Nevertheless, I want to ask the Minister very seriously to consider that when these grants are made to the local authorities, he should impress upon the authorities, and particularly the county authorities, the need to give domestic help, especially to working-class parents of spastic children and of handicapped children in special cases. The Minister is aware of that need. There are certain cases in which expert domestic help is necessary to assist the parents in doing their best for these handicapped children.
I want to stress that point in connection with my constituency which, of course, falls within the County of Worcestershire.
§ Dr. H. Morgan (Warrington)
I suppose I have to be very brief, Sir Rhys, although you have been kind enough to call me to speak in a debate on a subject about which one could speak for four or five hours. This has been a most interesting debate. Hon. Members who have the least knowledge of the subject have developed arguments which can be cast to the ground with a puff of wind and have pretended that they know a great deal about the subject when, in fact, they know nothing.
I am one of those who have done medical research. My research was as a result of a scholarship which I won at my university. I had the experience of working under one of the best research professors in Glasgow for a time. Apparently, I am causing some perturbation on the Front Bench. I do not know what it is about.
Mr. Hector McNeil (Greenock)
What is the professor's name?
§ The Deputy-Chairman (Sir Rhys Hopkin Morris)
I hope that the hon. Member will not carry this too far.
He was a very distinguished medical professor, formerly of Glasgow University, and I am sure that the Committee would like to know his name.
§ Dr. Morgan
If other hon. Members had been called to order when apparently as irrelevant as I have been, I am sure that the punishment would have been more justified.
These researches are done for definite medical reasons. They are done because research into pharmacological products has to be undertaken separately in independent and impartial laboratories, even although research work on them has been done previously in private laboratories; because, with the best intentions, these firms have to sell their products which, therefore, have to be vetted by the independent research worker.
You are watching me very carefully, Sir Rhys. I do not know whether I am in order. These drugs have to be vetted officially by the official bodies when they are produced in private laboratories, who announce them in the medical Press. We have, therefore, to distinguish between private research and the impartial research laboratory. A whole batch of new drugs has been put on the market over the last ten years. Everything is done to prevent a proper trial of these drugs. I know because of experience in hospitals which are run privately—not Government hospitals. These drugs are put into private hands, their sales are through private shops. The whole thing is absolutely absurd.
One hon. Member has spoken about tuberculosis and has suggested that tuberculosis ought to be treated experimentally with some of the new drugs. Great work is being done on tuberculosis even now in the ordinary hospitals and sometimes in the Poor Law hospitals. One of my hon. Friends reminds me that they are to 440 be Government hospitals. The fact remains that research into treatment can be done not only in the voluntary hospitals, but also in hospitals under Government bodies run by electors who have sent their representatives to run them.
Not only do we produce drugs of the Continental type in our laboratories, but we are doing a great deal of research work by private individuals. It is the duty of hospitals not only to treat well, but also to diagnose well. There are many constituencies in the country in which the out-patient department does not exist. It is only in some of the teaching schools and exceptional hospitals that these out-patient departments exist. From the point of view of obtaining experience with new drugs, these facilities should be available to almost any hospital. Many economies can be made in hospitals when making prescriptions. Each hospital makes up a list of prescriptions and sticks to it for five or seven years without change. Yet they say that all the modern medicines, all the new drugs, are available when they are not.
There is no co-ordination between the different public bodies which run these hospitals and there is no Government supervision except for particular purposes. Even the staff at the Ministry of Health seems to know very little about the chronological reactions of certain drugs which are being used.
§ The Deputy-Chairman
I have no desire at all to interrupt the hon. Member, but I hope he will keep somewhere near the Supplementary Estimate.
§ Dr. Morgan
I hope I shall, Sir Rhys. I am trying my very best, but I really must refer to these drugs, where they have come from, how they are recognised and what laboratories are investigating them. Surely that comes within the purview of this debate—how these drugs come to the market and are used? I am entirely in your hands and I realise that I am not a very good follower of instructions, but I am doing by very best to keep within the terms and the ambit of your Ruling.
I want to try to crack open the private control of drugs which, in my opinion, are being put on the market too soon before a proper investigation. Patients are treated with drugs about which there 441 has been comparatively little and superficial investigation. I do not know how they do it, but staffs get into Government Departments and give their approval of where drugs should be used in certain institutions. It is extraordinary. Sometimes those drugs are not cheap. The voluntary hospitals can take them and no one asks questions, but the Government hospitals have to ask questions. The recruitment and remuneration of the medical officers who have to give their consent is extraordinary.
§ The Deputy-Chairman
I do not think that the recruitment of medical officers comes within these Estimates.
§ Dr. Morgan
If you rule that, Sir Rhys, I shall have to accept it, but surely consent and reports on these new treatments have to be made by some officials in Government Departments? For example, the Ministry of Health must usually take the advice of Government officers before approving of certain people to go into institutions. I know that is the custom of various Departments, but, if you rule that it does not come within the purview of this discussion, I bow to your Ruling. It is very difficult to talk on a matter like this when one is hemmed in and does not know when one is in order or not.
Take, for example, the remarks about parents and the treatment of children ——
§ The Deputy-Chairman
I would remind the hon. Member that there is no difficulty about keeping in order. All he has to do is to keep within the limits of the Estimate.
§ Dr. Morgan
Thank you, Sir Rhys. All I can say is that I have sat very patiently all through this debate today and have not even indulged in my usual rude interruptions.
§ Dr. Morgan
All right, twice. Having done that and heard other hon. Members indulging in remarks, I thought I might be able to take a little off the fringe of what some of them have been saying.
If you will allow me to proceed, Sir Rhys, I would mention the choice of treatment. This, of course, could be left to the medical practitioner, whether he is a consultant or a general practitioner. Sometimes parents get advice from all sorts of people—including Members of 442 Parliament—as to the treatment which should be given to their baby. Tears have been shed about the baby being treated in a certain way.
As a medical practitioner I went into many homes. I saw how the ordinary civilian, of whatever profession—especially if he is a Member of Parliament—pretends to know something about medicine, although he knows absolutely nothing at all about it. Sometimes the treatment is dangerous for the child. I presume that dangerous treatment is within the purview of this Vote.
Sometimes it is very difficult to decide what type of treatment to undertake. That is why the fools who go into the medical profession and try to learn something from the physiology of the diseased human body try to know how to treat a case and to choose drugs which are either new, or as old as the hills. I suppose that if any medical man started to treat malarial fever in the tropics or anywhere else with something not touched with quinine radical he would be in trouble——
§ The Deputy-Chairman
I must draw the attention of the hon. Member to the fact that he is very wide of the Estimate.
§ Dr. Morgan
I am grateful to you, Sir Rhys. It is rather difficult for an ordinary layman who knows something about medicine to keep within the actual terms circumscribed by the Vote; at least, I find it so. I have often found it so in this Parliament. I hope you will pardon my transgressions, because this is a subject on which I want to get the interest of the Committee. I find medicine important and especially of public interest at the moment.
§ The Deputy-Chairman
The point may be very important; I am not disputing that, but this is not the proper occasion to deal with that subject. There are other occasions. This is an occasion to deal with the specific Estimate.
§ Dr. Morgan
There is a sum mentioned in this Estimate. We have to satisfy the Committee and ourselves that the matter comes within the fringe of the amount mentioned in this Vote. I am doing my very best to do that and I want to do it honestly. Suppose, for example, that I talked about treatment and said that one expensive treatment is not particularly 443 necessary, although I realise that these things have to be used in their proper places from the point of view of experiment——
§ Dr. Morgan
Thank you, I am glad to know that on one point at any rate I am in order. We train the physician so that—whether he has been in practice for long or is on his first trial—he shall know whether a particular drug should be used in certain conditions from which a patient is suffering. That may be useful for treatment in subsequent cases.
Human derangements are very difficult matters, and sometimes it is difficult to treat a patient who has not only physical symptoms, but mental symptoms. Some people who are not ill have mental symptoms, but some who are ill have mental derangements at the same time, and they have to be treated both with sedative treatment as well as for their physical derangements. I urge that in cases of this kind, the drugs that are used should be of a certain quality—I wish their result could be guaranteed—and should be put in the hands of men who are qualified by long years of training and experience to deal with illness and to provide the proper treatment.
I beg of you, Sir Rhys, to allow the Committee to have free discussion in dealing with medicine, treatment and diagnosis. I ask you to allow latitude to a man like myself, who, although he has been in Parliament for some years, is not a brilliant absorber of Parliamentary rules. Outside the House, I like to say what I think, and in the House of Commons I sometimes think that I should be able to do the same thing here, but that is not always the case. I ask you, Sir Rhys, to allow as free discussion as possible on this Vote, not only to me but to the whole Committee.
§ The Deputy-Chairman
That is precisely what I am trying to do. There are occasions for doing what the hon. Member desires to be done, but we are now dealing with the Supplementary Estimate.
§ Mr. Sydney Silverman (Nelson and Colne)
On a point of order. My hon. Friend and I are no longer responsible for one another in any sense——
§ Mr. Silverman
—but I see, in page 79 of the Supplementary Estimate, an additional sum of £8,562,000, which is then sub-divided, and I see an item which is calledK.6—Prevention of Illness &c.—£42,000.Would not my hon. Friend be in order—[HON. MEMBERS: "That is a saving."]—I beg pardon. That is a saving, certainly, but, nevertheless, it comes into the accounting which has led to the Supplementary Estimate.
§ Dr. Morgan
Where do I come in in all this? I wanted to make my preliminary remarks in order to come to certain conclusions. I want to try to reply to certain of the illustrations which have been put forward, some of which were really extraordinary. It has been said that an infant should not be given treatment by an ordinary outside doctor. Many of the remarks which have been made reflect upon the whole medical training of the general practitioner.
Some men do not pass their examination at the end of five years. Some of us are lucky enough to do it, but sometimes it takes seven, eight or nine years for men to pass their examinations. These men, after working hard and treating patients according to their judgment, are being told in the House of Commons, where every word spoken is recorded, that they are not doing the right thing by way of treatment and should not be allowed to treat young patients in a dangerous state of health with the drugs which they select for use. Why should they not be allowed to do so? If they have done anything wrong, they can be punished for it. Even Members of Parliament make mistakes.
The medical men have to treat their cases, but some people who get into Parliament have no knowledge whatever of medicine, of the difficulties of medical diagnosis or of the difference between a young baby and a supposed adult, and yet they blame the doctor for the way he treats his patients.
I have not said half of what I wanted to say. I have not been allowed by the rules of order, apparently, to deal with the arguments which were allowed from 445 one side and which, I thought, would be allowed to be answered from the other side. I can only say that some most stupid, indifferent and ignorant remarks have been made in the House of Commons, as they are usually made, about medicine. They are allowed to pass by, while somebody who wants to prove them wrong is prevented by the rules from giving the appropriate answer. I am very sorry. One of these days we must ask for a special non-Parliamentary debate, outside the Chamber. We will ask you, Sir Rhys, to be chairman and then we will see what a free hand we have in the debate.
I regret very much that this debate is not wide enough to allow me to deal with all the criticisms, both of particular cases and regarding the medical profession, which handles a very difficult job in the finest way possible. I know all the difficulties, because I have gone through every phase of medical practice—general practice, research, specialist practice, and consulting practice. I have done all that and I have escaped, so far, the clutches of the law.
I was hoping that tonight I should be allowed an opportunity of making some appropriate remarks with a view to putting medicine in its right place in the debate. I hope that when I have learnt more about procedure to be able to take part in debate and to prove that what the medical profession has been doing is fine. We all make mistakes, but most of the mistakes are made by the lawyers. I hope that on a future occasion I will be able to speak more fully on this subject, which touches my heart strings and about which the ordinary layman knows nothing at all.
§ 6.30 p.m.
§ Mr. Iain Macleod
We have had a wide and very interesting debate, which has turned out to be a half day's debate, on the National Health Service, and now I shall do my best, fairly shortly because I know there are other matters which interest hon. Members and to which they would like to proceed, to answer the points which have been made. The three main matters raised have been costs and wages in the hospital service; the experimental, clinical research in hospitals with particular reference to one case that has been mentioned on both sides of the Committee; and the question of the 446 pharmaceutical service. There are other most important matters such as those about mental nurses to which I shall try to refer.
Perhaps I may be allowed to start by repeating to the Committee the last words of my speech on 10th May, 1954, when I put forward the Estimates to which this Supplementary Estimate is a postscript. I said this: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."—[OFFICIAL REPORT, 10th May, 1954; Vol. 527, c. 893.]I am quite ready to stand by those words today. We cannot debate it now, but it has proved true that the capital position has pointed the way to a much brighter future, which we are all glad to see, and beyond doubt it is true that the year has proved a difficult one for the hospitals.
I would take three general points before I come to the particular ones which I mentioned. First of all, I do not think we always give in our debates and Questions in this Chamber a very accurate picture of what is happening in this great Service. Inevitably, we concentrate—and quite rightly so—on what is wrong. An hon. Member will put Questions down to say that something is going wrong in his constituency, and others draw the attention of the Minister to any difficulty there may be and urge certain action upon him. Therefore, the public gets an idea that there are more things wrong with the National Health Service than is, in fact, the case.
As I said in my speech on the main Estimates last year, I am very proud to be the Minister of this Service. It is, perhaps, worth mentioning that since 1948 the number of beds available has gone up every year; that the number of beds staffed has gone up every year; that the number of beds occupied has gone up every year; and, turning from the in to the out-patients, the number of outpatients treated has gone up every year. There is a very great deal of progress against the background of which we must look at the difficulties that have been put forward.
The second general point I should like to make is this. I explained in my speech 447 on the main Estimates that we were embarking, largely on the advice of the Public Accounts Committee, on a rather more realistic method of estimating, in which we took no advance provision for wages beyond a token amount of £1 million last year, and no amount at all for increased costs. The right hon. Gentleman the Member for Middlesbrough, East (Mr. Marquand) made some reference to this. I should be very happy to debate the cost of living with him. He trailed his coat once or twice, but I do not particularly want to tread on it at the moment, so I will say that if, as has been the experience of all of us since the end of the war, we are to have increases in wages which we must accept from year to year, and if, at the same time, the general trend of prices is to be upwards, then it will follow that, if the estimating is accurate, we must look forward to a series of Supplementary Estimates such as this. I do not think that this is necessarily something to be deplored, because if we take into the Estimates amounts to cover possible Whitley awards and possible increases in food and other costs, we do to that extent mask the true figure for which we ask Parliament. I think the argument on both sides of the Committee is that we are right to follow the procedure which is being followed at present.
There is one important footnote to something which the right hon. Gentleman said. It is quite true that a good deal of this Supplementary Estimate, and of the main Estimates, of course, is outside my control because it depends entirely on the amount of demand that there may be. A fair amount of the hospital service is within my control, in that if it appears to me, as it did some time ago, because we have monthly figures of how the expenditure is going, that a Supplementary Estimate will be needed, one can then face the necessity for the Supplementary Estimate or one can order the boards to cut services or close certain departments. We did not take that course, and we have come to the Committee with a Supplementary Estimate.
The right hon. Gentleman asked some questions about the amount of money that is involved, as mentioned by the Parliamentary Secretary. The £12 million for increased wages is over and above the £1 million which we took as a token reserve 448 in the Estimate. The right hon. Gentleman asked, "Is this due to more nurses or to increased pay rates?" The answer is that it is due entirely to increased pay rates. We did allow, in our estimating in the original Estimates, for an expansion of between 3,000 and 4,000 over the whole of the country. As far as we know, that figure will turn out right. Therefore, the amount we are asking for is applicable not to more staff than we thought of in our Estimate, although there are more staff, but to increased wages.
The right hon. Gentleman asked about the £900,000 which reflects additional costs that have had to be met by the hospital authorities. That reflects all sorts of rises, mainly, no doubt, in food, and also, of course, a number of minor decreases that there have been in household goods and some other things of which hospitals are very substantial consumers indeed. I should be very ready indeed, if this were the occasion to do so, to deal with how much would have been needed to have covered comparable costs in the last year of the Labor Government, but, if the Committee will forgive me, I think that on the whole I should avoid that comparison.
The right hon. Gentleman will agree, will he not, however comparative the figures are, that the savings in this case are in respect of those commodities for which the Government have no responsibility and that the increases are in respect of the commodities for which the Government have responsibility.
§ Mr. Macleod
No. That is a good deal too wide a proposition, but the right hon. Gentleman and I can debate that on another occasion.
I should make this clear, that no directives go out from me, from the Ministry, about the amount or the quantity or the quality of food—apart from general advice on catering matters—that should be given to the patients in the different hospitals. A number of questions have been asked about this. It is true that from time to time regional boards, to keep more closely to their estimates, may lay down certain wide instructions to the hospital management committees, but they do not come from me.
If it prove that such costs increase, and if we are satisfied that the regional 449 boards and the hospital authorities cannot face those amounts from other sources, and while we expect them to explore every avenue, as the phrase goes, before we can be so satisfied, we should be prepared to meet those amounts, just as, indeed, we have included this amount of £900,000 in the Supplementary Estimate.
I want to turn from that point to a matter which has aroused great interest. It was raised originally by my hon. and gallant Friend the Member for the Isle of Ely (Major Legge-Bourke), but the main speech on it was made by the hon. Member for Newcastle-under-Lyme (Mr. Swingler). It is the question of experimental clinical research in hospitals. Particular reference was made to a case which was quoted in learned papers and particularly in the "British Medical Journal."
Let us be quite clear what we are discussing. We are not discussing at all whether, in that particular instance, the consent of the parents should have been asked for. It is admitted that it should have been asked for. The people responsible, who are people of the very greatest authority and competence, regret very much, as I do, that that was not done. What we are really discussing is whether such experiments are proper and whether any action should be taken by the Minister of Health in these matters.
The hon. Member for Newcastle-under-Lyme raised this matter in a very reasonable way, of which I have no complaint. He put forward two propositions and I am not certain whether I agree with one of them. In fact I am sure that I disagree with his proposal that it would be wrong and unethical for any clinical investigation—I prefer that to "experiment"—to be carried out which would not immediately benefit the person on whom it was carried out. If it is to add to our knowledge for the future I do not see how that could be so. For instance, the reward that will come to those who try to catch the common cold at the research unit which is in operation at Salisbury is not that they will derive direct benefit to themselves, but that the general pool of knowledge may be increased and that others may be helped in the future.
It is true, therefore, that when the hon. Member for Newcastle-under-Lyme asks who benefits from this, the answer is that 450 all the babies yet unborn may well benefit from this continued thrusting forward to new frontiers. I make that one reservation about what has been said. It seems to me that there are two propositions with which most of the Committee would agree. First, there is bound to be clinical investigation and experiment. Indeed, if that was not so, our knowledge of surgery and medicine would not have changed over the centuries. Secondly, only the clinician in charge can say what is right and proper and what safeguards are needed in the actions which he takes.
In the Parliamentary Question which he put to me, the hon. Member for Newcastle-under-Lyme suggested that… before further clinical experiments on children are undertaken, the nature of such experiments …be reported to my Department, so that my medical staffcan ensure that there are adequate safeguards against harmful effects; …"—[OFFICIAL REPORT, 14th February, 1955; Vol. 537, c. 4.]He also asked that I should issue a directive to hospital management committees on the ethical principles involved.
In my view, that is a wrong conception of the duty of the Minister of Health. I do not think that it is my duty, indeed, I think that it would be wholly improper for me, to try to lay down what ethical and medical principles should govern the conduct of professional men in the work which they undertake in the hospitals. In this instance, there was undertaken an experiment which all those concerned—who are of the highest capability—were quite certain was completely harmless. I have regretted, and I say it again, that the parents were not informed and their consent was not sought.
As far as I am concerned, if a small child of mine, or a child of any age, was in hospital and I was told by people of the standing, for example, of a professor of medicine and child health at the university concerned, "We are interested to know the effects of a perfectly safe clinical investigation. It may very well be that we can learn from what is done and as a result can drive still lower the infant mortality rate in this country," I should be more than ready to give my consent. I should be delighted.
I do not want to use legal words because I am not a lawyer, or to use medical words because I am not a doctor 451 but, if I may borrow the phrase used by the hon. Member for Newcastle-under-Lyme and speak "with due diffidence because I am a layman," the common sense of the matter is that where a clinician intends to undertake an investigation which is so novel as to amount to an experiment, he would be wise to seek consent from the patient or parent, as the case may be, for what is proposed. That seems to me the common sense of the matter, but I am absolutely convinced that it would be quite wrong for a Minister of Health to issue directives on a matter which is one essentially of medical ethics to those concerned.
§ Major Anstruther-Gray
May we take it from what my right hon. Friend has said that he will send directives to hospitals in the sense in which he has spoken?
§ 6.45 p.m.
§ Mr. Macleod
No, Sir. I am sure that it is entirely unnecessary and wrong. The "British Medical Journal" and other learned papers have already reported the Questions asked and the answer given to the hon. Member for Newcastle-under-Lyme, and what I have said and he has said will no doubt be reported in the professional papers. I am sure that it is best to leave the matter to the profession and not to have a lay Minister of Health interfering in a matter that is very precious to those professionally concerned.
I have no quick reaction to this matter but I agree that my hon. Friend the Member for Newcastle-under-Lyme (Mr. Swingler) has presented it with great care. Should I understand the Minister—and perhaps I should not—to say that a patient in a hospital shall only be consulted if the methods of investigation or experiment to which he is part are novel? I think that those were the words which the Minister used. It seems to me that a patient primarily goes to hospital for therapeutic measures directed towards his condition. It may be true that, thereafter, he offers to take part in an experiment, but surely the Minister was going a little wide.
§ Mr. Macleod
I do not think so. If the right hon. Gentleman studies my words he will see that the point which he was making is not excluded in any way. I said that the man who must be concerned 452 in this is the clinician in charge of the case, but the one person who cannot be concerned is a medical or lay officer of the Ministry.
This is very important. I am sure that the right hon. Gentleman would not attempt to sustain the plea that only the clinician is responsible, for no court in the country would hold that view. Indeed, more and more frequently actions are taken, I suppose properly, against the administration.
§ Dr. Morgan
Is this in order, Sir Leonard? When I tried to speak on a subject which was just as foreign to the debate I was ruled out of order.
§ The Temporary Chairman (Colonel Sir Leonard Ropner)
I understand that the Minister is replying to a statement made earlier, and to that extent he is perfectly in order.
§ Mr. Macleod rose—
§ Major Anstruther-Gray
It is kind of my right hon. Friend to give way. The only point that I am making is the very narrow one that in the case of small children the consent of the parents should be obtained. That is all. I do not need to be a medical practitioner to think that a parent has a right to be consulted where his child's health is concerned.
§ Mr. Macleod
I do not know whether my hon. and gallant Friend was in the Committee, but I started my remarks by saying just exactly that. I have said it in terms over and over again. A mistake has been made and it has been——
§ Mr. Swingler
I appreciate completely why the Minister should resist the idea that he himself should go into this matter and send a directive, but in view of the complexity of the situation does he not think that it is the duty and responsibility of the heads of the medical profession to give some ethical guidance? As it has been brought to his attention that there are cases where, for example, consent has not been obtained and where experiments are being conducted which have nothing to do with the actual treatment, will he not use his good offices to ask the heads of the medical profession to give some guidance on that?
§ Mr. Macleod
That is a very different matter and one with which I am in some sympathy. Of course, if I have the slightest reason to believe that the position today is not fully understood then I will informally—and it can only be informally in a matter like this—draw the attention of those responsible to what has been said. As the hon. Member knows—I think I sent him a copy of it—the Medical Research Council sent out a confidential memorandum rather on those lines. If I have any reason to believe that the position is not completely clear and that it is desirable for these things to be drawn to the attention of those responsible then, of course, I would not object at all to what I may perhaps call an informal notification from myself. Of one thing I am clear, no directive must come from the Ministry of Health on a matter of this delicacy.
I should like to pass from that to the third of the main matters that were raised, which was the question of the pharmaceutical service. I was asked to report on what is happening about cost investigation, and to say whether the Estimate included any reflection of the progress made as well as reply to a number of other minor matters that were raised by the hon. Member for Newcastle-upon-Tyne, East (Mr. Blenkinsop).
If I may briefly report on the three main heads, we have completed our general investigation into the question of the secondary manufacture and compounding of drugs, and we have stated a preliminary view that we have no evidence before us to show that excessive profits are being made. On the question of basic drugs, we are still considering the accountants' report.
The question of proprietaries is the one that interests the public most. I announced to the House some time ago that I intended to make an investigation into all these matters, but particularly into proprietary medicines. Some information has been given to the House about reductions made by three firms, estimated to save £850,000 a year, and a number of other reductions have been made which are estimated to save some £350,000.
But I should add that there has been a general downward tendency in price, and I have no reason to suppose that the investigations that have been carried out 454 are the only, if, indeed, they are even the main, reason for the reductions. I would invite the Committee to consider for a moment the very genuine dilemma that this position involves. After I started my investigation I was asked by the Association of British Pharmaceutical Industry if I would consider proposals that they wanted to put to me which would alter the basis of the investigation, and one which they considered fairer and more realistic. I agreed to do so, and that, in part, accounts for some of the delay.
We all know there are preparations which are unworthy of being sold under our National Health Service, but we must also remember that this industry has made a wonderful advance in recent years. It has an export trade of very great importance indeed and research is absolutely vital to it. Also, an infinite amount of research may be necessary before one single product proves worth putting on the market. All these matters are apt to be reflected in the price.
The dilemma is how to reconcile the preservation of these features with the fact—recognised by the industry itself—that the duty I have to the House and to the taxpayers is to see that no undue strain is put upon the National Health Service. That being so, I think we are right to proceed slowly, although possibly the pace is a little slower than I should like to see, but I am very grateful for the co-operation I have had from the industry. I am sure I can rely upon it in the future and I am sure it means what it said some little time ago—that it did not seek in any way to defend the indefensible.
A number of references have been made to what we may call the Linstead Report, which I have agreed to publish and which will be issued in a few weeks' time. I do not want to go into that in detail tonight except to say that I am very interested in the quality of hospital pharmacists. Perhaps the best thing is to see how the Report is received in the country and, for a short time, to let opinion crystalise around it after it has been produced.
The hon. Member for Newcastle-upon-Tyne, East asked some questions about this and allied matters to which perhaps I can give very short answers. It is not a very good comparison to look at the 455 import figures into this country because, of course, they may and do cover drugs and preparations which are not necessarily applicable to the National Health Service. It remains true that we have to import many drugs because they are not made in this country and they are of the first importance, although, on the whole, we are finding that many of the important firms are beginning to contribute to their manufacture.
§ Mr. Blenkinsop
Is not the Minister aware that the Pharmaceutical Society, through its journal, is calling attention to this matter and is rather anxious about the rapid extent of the increase?
§ Mr. Macleod
I have not seen that particular reference, but now that it has been drawn to my attention I will certainly look at it.
Perhaps the next main point which I should take up was that made by the hon. Member for Northfield (Mr. Chapman), about capital expenditure, which he managed to bring within the rules of order by referring to overspending in Wales as against saving in other parts of the country. With one exception, there has been very substantial under spending of capital almost every year since the Health Service started and the reason, I think, is that we have underestimated the time that it takes to get big new work going. That is why I deliberately announced a three-year programme. We can then see farther ahead and get these matters clear.
But when it became apparent in the summer of last year that there was to be under spending I deliberately over-allocated to those regions which I felt could take a considerable extra amount. That is why Wales is overspending, but if we divide the English saving up into its regional compartments there would be one or two regions—Newcastle is a case in point—which might also find themselves in a similar position. The fact is Birmingham has under-spent considerably—I am not making any criticism of the region—but, on the other hand, it is unfair to suggest that this is due to delays in my Ministry.
The hon. Gentleman asked me questions about the nursing staff which concern us all. When I referred to the figure of 2,000 456 a year ago, I was taking that not as a practical proposition—as a glance at HANSARD will show—but as a wildly optimistic estimate, so that we could be certain that even if such a figure were reached the amount of money available would enable us to enrol the nurses. Here again, although it is small and not satisfactory, there has been a steady increase in the three quarters of 1954 for which I have figures. There is an increase of full-time nurses of 166 and of part-time nurses of 130. Those figures can be added to the trends which I showed in my earlier speech.
§ Mr. Macleod
Probably, although they cover only three quarters of the year, but they are better than the years previous to 1953 though there is an immense amount to be done in this respect which I must try to do with the assistance of the Minister of Labour. It may well be that there are special difficulties in Birmingham because of the competing demands for labour.
On the question of what we are doing, I do not know whether the hon Gentleman has seen the pamphlets and circulars we have issued. I can summarise quickly what we are trying to do. First, by better selection we are trying to check the wastage which has been particularly bad in mental nursing; secondly, we are trying to increase the use of the nursing assistant; thirdly, we are trying better and more imaginative methods of training the nursing assistant; fourthly, although it is difficult to do by circular, we are trying to do something in the most vital section, staff relations. If the hon. Gentleman has not seen those circulars, I shall be glad to send him copies.
§ Mr. Chapman
My hon. Friend the Member for St. Pancras, North (Mr. Robinson) mentioned at one time the shortage of money for recruiting campaigns. Is it not the case that any idea of a film would be ruled out because, although one hospital board has made a film for attracting recruitment, the Ministry would not put up the money?
§ Mr. Macleod
If I may digress, it was also an extremely good film—but I do not propose to follow the hon. Gentleman down that path.
457 My hon. and gallant Friend the Member for the Isle of Ely raised some points, one of which was also taken up by the hon. Gentleman the Member for Oldbury and Halesowen (Mr. Moyle). I cannot say much to my hon. and gallant Friend on the question of development capital for the teaching hospital in the East Anglian area. Also, on the interesting question he raised about savings in the midwifery and other fields, it would be out of order for me to attempt any detailed reply. However, his speech is on record and I will write my hon. and gallant Friend a detailed reply to his points, whether they were in or out of order.
A point which was in order referred to the increases for services under the local health authorities for which I am asking. I am sure that there is no increase which the House of Commons grudges less than that, because all such increases mean more work by home helps, home nurses, and so on, and to that extent do a great deal to take the strain off the hospitals.
The hon. Gentleman the Member for Newcastle-upon-Tyne, East referred to dentists' pay. I am aware that this has taken a long time, but it is being discussed now between the Chancellor and myself, and I hope that it will be only a short time before an announcement is made. There is no provision in the Supplementary Estimate now before the Committee for this.
The investigation of chemists' earnings is still proceeding. The method by which it was agreed we must proceed in face of the Public Accounts Committee was by questionnaires, and these are still coming in. On the question of the opticians, the full amount of £170,000 is not included, but there is a certain amount in the Supplementary Estimate for the increased costs. Owing to increased demand, it is likely that the amount of £170,000 will be exceeded. There, again, the pay claim is under investigation.
I have tried to answer the immense variety of points put before me, but I will write to any hon. Members who feel that I have not covered their points satisfactorily. In conclusion, may I say that this is an amount which it is wholly right the Committee should examine searchingly because, although it is only 1 per cent. of the Estimate, it represents nearly £5 mil- 458 lion. But I cannot help observing to the hon. Member for Newcastle-upon-Tyne, East, who contrasted the temper of the debate with that on the last Supplementary Estimate he introduced, that there is a difference between £4.8 million and £89.4 million, which was the amount for which he was asking.
§ Mr. Blenkinsop
But under different circumstances. Also, it must be remembered, in the previous two years there was no Supplementary Estimate.
§ Mr. Macleod
The circumstances are always different when they do not suit us, but I merely make the point in passing.
This Supplementary Estimate is an amount of reasonably close estimating. The possibility—perhaps even the probability—of a Supplementary Estimate is contained in the new methods we have adopted, and I hope that the explanations I have been able to give the Committee will enable it to feel that it can pass this Estimate.
§ Question put and agreed to.
That a Supplementary sum, not exceeding £4,848,000, be granted to Her Majesty, to defray the charge which will come in course of payment during the year ending on the 31st day of March, 1955, for the provision of a comprehensive health service for England and Wales and other services connected therewith, including medical services for pensioners, &c, disabled as a result of war, or of service in the Armed Forces after the 2nd day of September 1939, the treatment abroad of respiratory tuberculosis, certain training arrangements, the purchase of appliances, equipment, stores, &c, necessary for the services, and certain expenses in connection with civil defence.