HEALTH IN SCOTLAND

HC Deb 17 July 1956 vol 556 cc1046-161

3.38 p.m.

Mr. A. Woodburn (Clackmannan and East Stirlingshire)

In a discussion on health the House of Commons usually discusses disease. Health does not provide very much in the way of front-page interest, unless it is accompanied by pictures of curves and the giving of vital dimensions such as those we have seen in the Press in recent days. Otherwise, it is the abnormal which attracts our attention and arouses interest. It is disease, like war and violence, which provides the headline news. We have recently seen that even in another place murder and violence are the only things which can fill Parliamentary benches.

I should like to begin today by paying a tribute to our forgotten legions and back-room boys who provide our defences and prevent disease from attacking us—the civil engineers who ensure a clean water supply and effective draining, the sanitary authorities who give us clean streets and clean food. Parliament itself can claim some credit in the last year for having passed a Food and Drugs (Scotland) Act which, certainly in Scotland, will arm our sanitary authorities in the protection of the people's food. The medical officers of health and the sanitary authorities, from the scavenger to the scientist, are entitled to a good deal of the credit for having lengthened the life of our people by about 20 years and for having emancipated them from years of disability and disease.

On the political side, Parliament has also made a great contribution in its acceptance of responsibility for the maintenance of full employment. We sometimes do not realise the tremendous contribution that that has made to the health of the people. There is also the provision of adequate housing accommodation without which health is not likely to be secure. We all recognise our great indebtedness to the doctors, nurses and hospital staffs, but just as the idleness of the fire brigade and of the Army is something on which we should really congratulate ourselves, so I think we would gladly see the need even for our doctors and nurses disappear. There is no particular virtue in having cures. As a matter of fact, the need for cures is the measure of our failure to prevent disease.

The Secretary of State, therefore, is actually responsible for a great combined operation. It is not just a question of looking after the National Health Service, which comes at the end of the day, but of encouraging these medical and sanitation services and other measures of prevention which ensure that the people can live in health. The basis of this operation must be accurate knowledge. We must know and identify our enemies in the war against disease, and, for the facts, we naturally turn to the Report of the Department of Health for Scotland.

In that Report we discover that our great threat comes from the cardiovascular diseases. As Burns said in another context: The Heart ay's the part ay that makes us right or wrang. Perhaps the percentage of those over 65 having reached the high proportion of 36.9 per cent. of the deaths is not in itself alarming—when we have to leave the present life, that is perhaps the best way of passing on—but it is alarming that in the case of those dying between 15 and 44 years of age deaths from this disease have jumped from 8.4 per cent. to 16.4 per cent., and for those between 45 and 64 the figure has risen from 17.6 per cent. to 29 per cent. It is the greatest cause of death in that latter group.

From our own observations, doctors themselves seem to be among the worse sufferers. It may be that the coming of the motor car, which has deprived doctors of their normal exercise of walking, is a large factor here. What we must realise is that this disease is gaining on us, and it is urgent that the causes should be discovered if we are not to continue to lose some of our best and most active citizens at the height of their powers.

For many years I have taken very great interest in the progress of research into coronary thrombosis and other possible causes of angina pectoris symptoms, and it is only in recent years that the possibility of grappling with it successfully is appearing. One thing I am satisfied about is that we must give every support to our research workers in this field. Here I learn that our teaching hospitals are having difficulty because of the absence of up-to-date equipment. My information is that our Scottish teaching hospitals are falling behind, not because of the quality of the specialists employed there, but because they are being compelled to use methods which have been replaced elsewhere by more efficient and more economical methods. I hope that mention of economy in this connection will encourage the Secretary of State to take immediate action.

The front line of our offensive against disease is the general practitioner, who is entitled to the best and quickest training he can get. Doctors now have an extra year's training, and with two years of National Service it is really our duty to see that these men's time is not wasted. The stethoscope is a basic tool of the medical profession, yet, in Scotland today, experience in its use is being gained by the same methods as were used when that instrument was invented.

Just imagine a procession of students, all in a queue, listening one by one to a person's heart. While the queue is passing along, the heart-beat may change. It may differ between the time when the third student listens and when the fifth one does so. Therefore, those two students are listening to two different beats. Yet, by the use of modern electronic apparatus, it is possible for all the students and the professor at one and the same time to be listening to the heartbeat. The professor can give accurate teaching on the use of the instrument and the lessons can be learnt by the students. A student can learn as much in days or weeks as, by other methods, takes months.

There is not only to be considered the point of view of the students and the professor. Just think how important such modern methods are from the point of view of the comfort of the patient. One thing that terrifies many people from going into a hospital, especially a teaching hospital, is the knowledge that the students will come to the bed and make their examinations in turn. Where such apparatus can remove this need and also provide quicker teaching, there is an urgent duty on the Secretary of State to ensure that no false sense of economy should prevent this from being put into operation immediately.

In surgery, also, we are behind in our appliances in Scotland. There is no need now for students all to be craning their necks in the theatre to try to see what is happening in the operation, or for the professor to be trying to describe every detail of it. With the modern colour television camera it is quite possible for all the students to look at the exact operation by looking at the screen. The professor is thereby saved describing the detailed procedure and can, instead, teach as he goes along. I therefore believe that the introduction of such apparatus at the very earliest moment would result in an all-round improvement.

The National Health Service was introduced partly to overcome the difficulties voluntary hospitals had in keeping themselves fully equipped. Many years ago, I had to attend the Royal Infirmary of Edinburgh to be X-rayed with a view to operation. Dr. Hope-Fowler, one of our greatest radiologists, who was himself a martyr to his profession and sacrificed himself in following it, had to invite me to his own house because he said that the apparatus in the infirmary was quite out of date. Can anybody imagine the hospital which we claim to be almost the premier hospital in the world not having the apparatus necessary for the job?

One of the reasons for the setting up of the National Health Service was that that sort of thing could be put right. I know, of course, that all the economies that are coming along make it necessary to keep back certain bits of building, and other things of that kind. I know, also, that the coming into being of regional hospital boards means that there is an attitude of mind that seeks to ration out the money in small driblets to the different hospitals, with the result that nothing really effective is done in any of them, whereas it would be far better to get ahead with the job. I would ask the Secretary of State to make it known that the introduction of these rules never meant that hospitals were to be fettered in obtaining the appliances that are urgently required for their work.

There should be some common sense discrimination. Any rule which is introduced by the Government to stop vacuum cleaners and motor cars being sold at home seems quite irrational if it is to include the spending of the small amounts required to bring a hospital up to date. Surely everybody would agree that it is far better to build a few more laboratories and equip them properly than to spend money on building garages to carry on a stupid war between petrol companies. Those engaged in the much more important war against disease must not be starved of the means of carrying on the fight.

My information is that the teaching hospitals in England and Wales have not this difficulty. Some of our surgeons and physicians rather resent Scotland being deprived of facilities enjoyed in England. I hope that the Secretary of State will personally look into this, and will see that Scotland is equipped to keep its end up and to play its proper part in a profession in which its sons have such an honourable record.

On the other hand, I should like here to pay a tribute to the great work which is being done in spite of these handicaps by our Scottish medical schools. The work has received recognition both here and abroad and it is very satisfactory to learn that medical officers of health and general practitioners are beginning to co-operate with the medical schools in gathering the information necessary for the adequate study of this disease of cardio-vascular troubles threatening considerable numbers of our people.

Special mention should be made of the work of Dr. Fife, the Medical Officer of Health for the County of Fife, who has pioneered one of the research operations among the general practitioners from whom he has received a great deal of co-operation in providing that kind of information which is vitally necessary to people who are working in the more specialist atmosphere of the hospitals. I believe that the Medical Officer of Health for Kilmarnock has also done something in that direction. I hope that their example will be followed, because the more this work is spread and the more the general practitioner is invited to take part in research work the greater will be his interest in the job and the greater the speed of happy results for the patients.

I should like now to turn to the second greatest danger, cancer. In Scotland, we are not exempt from the rapid growth of lung cancer, which was second to tuberculosis in 1945 as a killer, but which, in five short years, increased to become three times as dangerous as tuberculosis. That is a very serious position indeed, and unless the trend is changed lung cancer will take first place as a menace to life.

There is not much we can add to the warnings issued by the medical authorities in the United Kingdom and America. Russia has also confirmed the view that cancer of the lung is growing in direct ratio to cigarette smoking, but even doctors, for all their warnings, cannot prevent humanity, if it so desires, from committing suicide for a smoke. The Report of the Department of Health for Scotland, however, discloses what was to me a surprising fact, that deaths from cancer of the digestive system form the largest group. We hear less about that and it is very interesting to note that the Russian scientist who recently gave his opinion that the cigarette smoking was connected with lung cancer went on to say that in his view cancer of the digestive system was caused by eating food of such a heat that it was capable of burning or damaging the cells in the digestive system.

That may be so, because cancer is recognised as an abnormal growth in speed, number and composition of cells as a result of a yet undiscovered provocative agent. The clay pipe, the right hon. Member for Kelvingrove (Mr. Elliot) will remember, used to be considered as a frequent cause of cancer of the tongue, though whether from the burning or the clay was not quite clear. Soot and tar are recognised as contributory factors. Since nature very often reacts by a quick reproduction if destruction takes place, it may be that some destruction of cells leads to a rapid atavistic reproduction of cells which is described as cancer. No doubt the attention of the Cancer Research Authority will be directed to that possibility.

Meantime, the Secretary of State can do a great service by causing it to be known, especially among women and others who have external evidence of cancer, how very considerable has been the increase in the number of cures and that if the disease is discovered quickly, the chance of its being cured increases proportionately.

I now turn to what has recently been described as still the most dangerous infectious disease in Britain. That is a disease which, unfortunately, has been specially alarming to us in Scotland. It was during my term of office as Secretary of State that we had to report a great increase in deaths when in every other country the proportion of people dying from tuberculosis was going down.

What shook me—and I am sure shook hon. Members—was that nobody knew why. I then realised that watching the statistics rising was like watching the kettle boiling over. We do know how to stop the kettle boiling over—by turning off the fuel supply—but nobody knew how the stop the boiling over of tuberculosis deaths in Scotland. I set up a scientific inquiry and after a year what was disclosed was even more alarming and curious still. It was that the incidence of the disease among young women between the ages of 25 and 34 had jumped to 107 per 100,000 and among men between the ages of 55 and 65 to 106 per 100,000. The curious thing was that in every other case the figure was going down and for the opposite sexes, curiously enough, for those ages it was 59 for the men and 23 for the women.

As the Committee will probably remember, one good result of this was the creation of the Scottish Advisory Committee on Medical Research and the Scottish Hospitals Endowment Research Trust. The purpose of those two bodies is to undertake the responsibility of co-ordinating and directing our scientific forces towards a solution of such problems. I hope that the Secretary of State today will be able to tell us how they are doing. Apart from my paternal interest in their development, I am confident that they will provide a great basis for our Scottish contribution to medicine and, I hope, to the subjects which I have been discussing.

As an immediate measure, in 1949 the Government continued the production of aluminium houses to enable local authorities to provide separate housing accommodation for sufferers. I like to think that that may have made some contribution to the improvement which has taken place. In any case, I am happy to know from the Report that the figures in the 25 to 34 year-old category of young women are down by 72 per cent. and are now 30 per 100,000, while for the older men the figure is down by 32 per cent.

It is believed that a great deal of infection of young children takes place because of the older men, the grandfathers who have contracted the disease, living at home, but this opinion is not wholly established. Clydeside is still the black spot of Scotland and is where one-third of our population shows a death rate twice that of the rest of Scotland. It is less satisfactory to note that the incidence of notification is down only very slightly.

In 1955, the number of notifications was 2,000 more than in 1939, nearly a 50 per cent. increase. Proportionately, we have about 66 per cent. more notifications than in England. Even if the numbers have been increasing by mass radio discoveries, that does not explain Scotland's excess proportion relative to England, where mass investigation is also used. The mass examination which is to take place in Glasgow next year will, I believe, be the biggest X-ray survey yet attempted in the world and it is likely that a quarter of a million people will be examined. I hope that the result of that information will enable the Secretary of State and his assistants to make an onslaught on this disease in the West of Scotland.

The difficulty about the present mass X-ray examination is that it is a rather spasmodic examination. The unit goes into one area and deals with it and then goes away, but the disease continues to spread. The examination will not be entirely successful until we can keep a fairly regular check on the population. I realise that there are one or two difficulties about that. The X-ray apparatus is very expensive and a highly skilled staff is needed to make the best use of it, while the amount of facilities available is rather limited. I understand from my inquiries that it is possible to get an apparatus which is more economical, which requires fewer personnel and which is more mobile.

I am aware that the authorities are slightly apprehensive of this apparatus, because a great deal of its success lies in the skilled examination of the plates which involves a double and accurate check of them. A less efficient examination, therefore, might give false confidence, which would be worse than no examination at all. Nevertheless, I think this ought to be examined to see whether it is not possible to produce apparatus which can be used by every local authority to counteract the irregular feature of mass examination.

This apparatus is widely used in Scandinavia and we should be able to find out how successful it has been there. I believe that it is used by Dr. Clayson, in Lochmaben Sanatorium, and also by Dr. Nash, the medical director of the mass X-ray service in Grove Hospital, Tooting. Is there any reason why there should not be investigation into the question of making this available to local authorities in greater numbers?

I also understand that the Ministry of Works has its own apparatus, which could be transmitted to the Western Isles. I am not sure whether it has been in use there, but it can be transported over the sea and by road. Here I want to make a suggestion. Non-pulmonary tuberculosis comes mainly from tuberculous milk, in the elimination of which Scotland has a wonderful record. Perhaps the Secretary of State can tell us exactly how far that has developed, because even when I was in office three-quarters of the cattle in Scotland had been freed of tuberculosis.

The Western Isles has been specially subject to this disease, and I suggest that this should be made an experimental area in an effort to eliminate the disease entirely. I cannot promise economy in this suggestion, because it might involve housing the people of the Western Isles in decent houses, which would be rather expensive. Nevertheless, I think that the people of the Western Isles would be happy to be treated as a laboratory in this way if they could become free of the disease. As I see it, we shall have to reconcile economics and the difficulty of getting efficient apparatus. However, this is another case where the expenditure of money and effort now will save the nation untold waste in the future, both of life and energy and means.

The reduction in the mortality rate of tuberculosis is due largely to doctors improving their methods of curing the disease. It ought to encourage sufferers who become depressed when they contract it to know that so many people have been cured. For instance, at least two friends of mine who were treated by Dr. Phillip, way back in the early days of the Edinburgh experiment, have been completely cured through his fresh air treatment. Whereas once they had severe haemorrhages and all the symptoms of an early death, both are now living happily. One was undoubtedly helped because her husband took the risk of marrying her, and so gave her hope to help in her struggle against the disease.

Therefore, we can give hope to those suffering from T.B. by pointing out that many people have been cured completely. The important thing is to discover the disease in its early stages. It is interesting to realise that as a result of recent X-ray examinations some people have had their lives saved by the discovery of incipient cancer of the throat or lungs which the person who was being examined for T.B. had not suspected.

The B.M.A. Conference has stated that there is great danger that our success in preventing death may give rise to complacency. Here I return to my theme, that we should look forward to eliminating this disease as we have eliminated smallpox, typhoid and other deadly diseases of the past.

During these worrying years we have also cautiously introduced B.C.G. experiments in an effort to prevent T.B. It will be interesting to hear from the Secretary of State how far these experiments have progressed. The Report seems to indicate that the results offer considerable hope. I was struck by the fact that prevention is mainly effective in the case of people with low standards of living. Indeed, my first thought was that an improvement of the standard of living might be the best prevention of disease, but that might not be economical.

In any case, I suggest to the right hon. Gentleman that to put up the price of the food for wee toddlers attending nursery schools from 4d. to 10d. is the silliest kind of economy imaginable. As my wife said yesterday at the meeting of the Edinburgh Town Council, "Imagine the Government of one of the greatest countries in the world saving the sinking ship by throwing the toddlers overboard." I think it is frightful to save a few pence at the expense of children in nursery schools.

Some of the people concerned in this increase think that nursery schools are day nurseries which are provided to allow parents to go out to work. They are nothing of the kind. They are one of the finest educational experiments ever made, and it is a tragedy that the early years of our children are not cared for instead of being neglected in this way. I hope, therefore, that the standard of living of the people will be kept in mind and that its connection with health will not be forgotten.

This brings me back to my first proposition, that our main job is to establish conditions in which people can be healthy, and not to wait until they contract diseases and then try to cure them. As I have said, smallpox, typhoid and other diseases have been banished in our lifetime. T.B. is being steadily, if still too slowly, pushed back, and other causes of premature death are assuming greater relative importance. As the Report states: Despite the great advances which have been made during the last twenty years in the treatment of many infectious diseases with chemotherapy and antibiotics, the natural defence mechanisms of the body remain our chief safeguard against infection. I commend the wisdom of his own Report to the Secretary of State in his consideration of this matter.

The fundamental approach of a health debate and a Minister responsible for health matters must be to give the body a chance, and in good time. We ought to try to discover all the causes, not just a few, of the diseases which are developing. We hear a great deal of cheap criticism of the Welfare State. Indeed, some hon. Gentlemen opposite have lined themselves up with the comedians who make jokes about it. I hope it is a false impression that our opponents resent the success our civilisation has had in rescuing itself from the law of the jungle, in which it was every man for himself and the devil take the hindmost.

My adherence to the policy of the party to which I belong is given because I believe that its great purpose is to create conditions in which people can live healthily, in which children can develop all the faculties that nature has given them, and in which all can have an opportunity of living a happy and reasonable life.

It is remarkable to realise the extent of the release of our people from disease and misery as a result of the discoveries of science and the development of medicine. In fifty years we have added another twenty years of life to our people, and today many live out of bed longer than, in other days, people used to be bedridden. The amount of time during which people used to be ill and sick and miserable was tragic, whereas today we see little children going on their holidays without their eyes running and all the weaknesses arising from a deficiency of the necessary vitamins. That has all disappeared, because we have learned that children must have the necessary vitamins, and so must adults.

I therefore hope that the Secretary of State will put all his energy into seeing that Scotland maintains the great reputation which it has had in this matter. Some people glory in Scotland's reputation as a fighting nation, but I feel great pride in the contribution which Scotland has made to the world in the arts, civil government, philosophy and, not least, in the art of healing. The Scots doctor is an honoured man throughout the world. It is our privilege today to give to the Secretary of State and the great National Health Service vigorous encouragement to sustain and increase our power to render great and merciful service to suffering mankind.

4.11 p.m.

The Secretary of State for Scotland (Mr. James Stuart)

I am sure that the Committee will agree that the right hon. Gentleman the Member for East Stirling-shire (Mr. Woodburn) has made a very constructive and interesting speech, and in the course of what I have to say I hope to deal with a number of the points he has raised. Those with which I cannot deal I hope will be dealt with either by my hon. Friend the Joint Under-Secretary of State or, as soon as I am in a position to answer, by correspondence.

Health in Scotland is a very important topic, as all will agree, and I think it is right that we should devote a whole day to debating it. The Committee will probably wish me, in addition to answering, as I go along, as many of the points which have been raised as I can, to give some account of what has been done and what has also been set on foot during the past year in the Health Service. I can, without complacency, because I do not want to give that impression, report certain achievements and advances, but I confess, as I think anybody in my position would have to confess, that there are some fields of major importance remaining in which we do not yet know how to organise effective preventive action or cure.

The right hon. Gentleman referred to them as, in the main, the emergence of problems such as cancer taking such a prominent place in the list, heart disease and the care of the older people. At any rate, I should like to make the point that the fact that these problems or diseases, such as cancer and heart disease, have reached positions of such prominence is proof of the fact that in the past success has been recorded in coping with other diseases which were fatal during past decades. While I am not belittling the incidence of cancer, heart disease, and so on, it is the fact that certain other diseases have been so successfully attacked that has enabled this position to come about.

Indeed, the administrative machinery concerned with health cannot solve all these problems that arise. Where the basic medical knowledge is lacking, the machinery cannot, of course, succeed, as, for example, in cancer, cerebral hemorrhage and heart disease, because the causes of these conditions are very imperfectly understood at present. I admit that they are responsible for nearly two-thirds of all the deaths recorded today. There is here a vast field for enterprise on the part of those interested in research, and I agree with the right hon. Gentleman opposite that for this we must do all we can to encourage the research workers and nothing to fetter their activities. I have no doubt that if we pursue that course, results just as remarkable as have been achieved will be discovered in the years to come.

The right hon. Gentleman referred to teaching hospitals and their equipment, and, of course, that links up with what I have just been saying. Naturally, it is important to have the very best equipment in order to carry out this research work. I should like to look into the point raised by the right hon. Gentleman, and I would ask him whether he can furnish me with any further information as to precisely where the trouble lies. It is not that I am in disagreement with him; I should like to see that the best possible equipment is made available, as far as it is possible to do it.

The right hon. Gentleman asked me about the improvement in the position regarding tuberculin tested cattle. I am not taking credit for the institution of this scheme. We all agree about its importance and are grateful for the progress which it has made. The figure I had in my mind was 92 per cent. of the cattle in Scotland as being tuberculin tested, but I am now informed, on expert advice, that the figure has risen to 93 per cent., which I think is a quite satisfactory position.

The right hon. Gentleman referred to cancer, which, I feel, is a matter on which there is much medical and scientific uncertainty, but that does not mean that no improvements in hospital facilities are being made. On the contrary, a major new department is nearing completion in Edinburgh, where treatment by high voltage radiation will be available under proper safeguards. In Glasgow, a complementary type of provision is being made by specialising in the use of artificially produced radioactive substances.

The Scottish Health Services Council recently took steps to ensure that all aspects of cancer treatment are kept under continuous review by setting up an expert committee, composed of members representing all the medical interests concerned and including not only specialists but general practitioners and a medical officer of health. In addition to that, the new committee intends, I believe, to seek ways and means of encouraging the fuller recording of information about cancer patients in such a way as to enable reliable assessments to be made of the relative value of different types of treatment.

The right hon. Gentleman also asked me about the Scottish Hospital Endowments Research Trust. I can assure him that this Trust is now well established, and that in Sir John Erskine we have a very able and active Chairman, to whom we are much indebted for his services. I understand that the first report of the Trust will be ready for presentation to Parliament, as the Statute requires, in a few weeks' time, and this will give hon. Members their first opportunity of studying an account of its progress and the various projects which the Trust has assisted.

This Research Trust is not in itself a body of experts in medical and scientific matters, but it is supplied with expert advice on all the projects which come before it by the Advisory Committee on Medical Research in Scotland. I can assure right hon. and hon. Members that there has been no shortage of suggested studies provided by the Committee as being worthy of the consideration of this Trust, and in the period covered by the first account no less than £43,000 was actually spent on research out of a total of £58,000. It is estimated that the annual income of the Trust will be about £94,000.

The hon. Member for Kirkcaldy Burghs (Mr. Hubbard) would no doubt be particularly interested to know that a single group of projects which has been supported, and to which £10,000 has been allocated, was in connection with coronary heart disease. There is also a great variety of other branches of medicine in the list of studies for which grants have been made.

As I said to the right hon. Gentleman, I have a note here on the subject of research apparatus, and I will certainly take up that matter, as he has asked, but the general position is that part of the costs of highly specialised teaching and research equipment is commonly met by the medical schools and hospitals. Those with substantial endowment resources of their own are free to draw upon those resources for the provision of such equipment.

Mr. Woodburn

I think that the Secretary of State is now coming to the main difficulty. I understand that the universities are required to apply to the Royal Infirmary and the Royal and Western Infirmary, Glasgow, and that the hospital boards would willingly spend out of their own funds, but that regional boards and the Government say that they must not spend more than £1,000 without permission, and that that permission is not being granted. I am glad the right hon. Gentleman has said that they are entitled to use their own funds, but I hope that this will be made clear to the bodies concerned, so that decisions can be taken.

Mr. Stuart

As I say, I certainly will have this matter looked into. I must admit that it is true that in drawing upon their own resources they are subject to scrutiny by regional boards, because of the consideration of maintenance charges which may subsequently fall on Exchequer funds. However, I should like to look into that further.

The matter of Exchequer money for purposes of this kind and for teaching hospitals generally was discussed by the Joint Under-Secretary of State in the House on 7th May, when the Guillebaud Report was under discussion. He pointed out then that Scotland's total allocation for hospital purposes was by no means unfavourable by comparison with corresponding allocations for England and Wales. It is admitted in the Guillebaud Report and by all that the pattern of distribution is not identical, but the Guillebaud Committee saw nothing wrong with the Scottish pattern, in which the teaching hospitals form part of the services administered by regional hospital boards. Those boards are now paying special attention to ensuring that the standards in the major teaching hospitals are safeguarded. As I said, there is a different pattern. I think that after the debate we had on 7th May the Committee may not desire me to go further into the rather complicated details, when it can read all about them.

The right hon. Gentleman referred to the advance which has been made in Scotland and particularly in the reduction of the death rate from respiratory tuberculosis. The 1955 figure was 17 deaths per 100,000, which is only one-third of the pre-war level and only just over one-quarter of the peak level, which was in the 1947 and 1948 period. There is no doubt that this reflects the success of the new methods of treatment by antibiotic drugs and by surgical processes which those drugs have made possible. Of course, there has been a very considerable increase since 1948 in the number of staffed beds in Scottish institutions. It has risen from 4,390 at the end of 1948 to a maximum of 6,098 at the end of 1954.

During the peak period the recorded number of patients awaiting admission was 2,877 at the end of 1949, and by the end of last year. 1955, it had fallen to the almost nominal figure of 148. That waiting list was not due to shortage of beds. It was partly due to individual preferences about which institutions patients wished to go to, and partly, also, to intervals which ensued because patients sometimes required time to arrange their personal affairs. At any rate, there need be no delay in providing sanatorium treatment for anyone in need of it. Thoracic surgery, although not always immediately available in every part of Scotland at the ideal moment, can now be provided without the long periods of waiting of the recent past.

I must put on record the Government's indebtedness, which, I am sure, hon. Members in all parts of the Committee will share, to the establishments in Switzerland for helping us over our most difficult period, and to their staffs, and to all who gave voluntary service, and to the Swiss authorities for their co-operation. Altogether, 1,043 patients went from Scotland to Switzerland between 1951 and 1955. While that is not a very large proportion of the total of about 8,000 admitted to Scottish institutions each year, it was a very real help at that time, and it also showed our earnest desire, and the desire of those who were before me in my present office, to do our very utmost to help those patients to a speedy recovery.

The standard of care afforded in the Swiss sanatoria, as I understand, was excellent. At the same time, I am assured that there is no class of patients for whom Scotland cannot now provide equally well. So there is no disadvantage or lack of the best form of treatment for anyone in the fact that we have now been able to discontinue those arrangements.

The fall in mortality from tuberculosis has been welcome, of course, but in addition to being welcome for itself it gives us now a real chance to get to grips with the disease at an earlier stage. Accordingly, as the Committee is aware, we have decided to stage a series of intensive, community-wide, mass radiography surveys, on a much larger scale than anything hitherto attempted, as part of a two-year campaign against tuberculosis in Scotland.

The Corporation of Glasgow, I am glad to say, has most enthusiastically responded to the invitation to organise a five-week campaign in that city, beginning next March, as the start to the national campaign. There will be publicity and propaganda of every kind designed to bring as many as possible of Glasgow's citizens to the X-ray units.

I have received very generous help from England in the matter of supplementing our units, and for that I am deeply grateful to the Minister of Health and his experts. I have received also reinforcements from both the Army and the Royal Air Force, and I am for that equally indebted to them. Altogether there will be upwards of 30 units operating in Glasgow during the five-week period, and with these we hope to deal with at least 250,000 Glasgow citizens. Indeed, I hope that more will come forward, because the units will be able to cope with many more than 250,000.

Every kind of assistance from voluntary organisations will be needed to make this a success, and also for the smaller campaigns which are being planned for the more thickly populated parts of Scotland during the ensuing two years. The common aim is, of course, to get as many as possible of those who have the slightest doubt about their health, as well as of those who have no doubt, to come for examination.

The argument addressed to them, the slogan of the campaign, is, "Earlier discovery means quicker recovery." But what we hope to achieve is not only the restoration to health of those who already have the disease; the more cases we can hunt down and treat in the early stages, the less will be the subsequent spread of the disease to others not yet infected. A reduction in the notification rate over the next few years, no less dramatic than the reduction in the death rate in the last few years, is the long-term goal we have in view.

Another development in the Health Service to which I should refer is poliomyelitis vaccination. What has been done reflects credit on the adaptability of our machine. A start has been made with the provision of polio vaccine for those in the age groups most susceptible to the disease. Experience in other countries with similar but not identical vaccines encourages us to believe that the 30,000 Scottish children who have been vaccinated have received a very valuable and worthwhile measure of protection.

As the Committee knows, the amount of vaccine available before the polio season began was not sufficient to have any marked effect this year on incidence in the population at large, but we did not think it right to withhold all vaccine because we could not provide more. The choice of those who received the small amount available was made in such a way that we could assess hereafter more accurately than has so far been possible the relative value of vaccination at different ages.

The response of Scottish parents in registering their children for vaccination was quite as high as we had expected, with almost 42 per cent. of all eligible children registered. This compared with 29 per cent. in England and Wales. While I do not wish to single out any particular authorities, special credit should go to the county councils in Scotland, for in the aggregate of their areas, in spite of difficulties of distance, and so on, the level of registration reached 57 per cent.

Vaccination of the selected children has been completed without any hitch of which I am aware. For the present, no more vaccinations are being carried out, but when the season of highest incidence is over and notifications tail off, probably in November or December, those children already registered, but not vaccinated, will have priority in the allocation of the more ample supplies of vaccine that by then we hope we shall have available.

The case for singling out polio for special attention is not only that this vaccine is of real value but that there has been a very considerable increase in the incidence of polio in recent years and we want to stop that or stop it as far as possible before it becomes a serious matter. If we can control it now, we hope to be able to avoid the really serious outbreaks on the scale experienced in Copenhagen a few years ago.

There has been some talk recently, at a meeting of the Scottish Standing Committee, about home accidents. I thought that I should refer to the problem of deaths from accidents in the home and associated causes because they account for 4 per cent. of all deaths. Indeed, they account for a much larger percentage—around 30 per cent.—of deaths at ages from one 14 and even for 15 per cent. of deaths at ages from 15 to 44. In this last age group, accidents at work and on the roads are, I admit, the main elements but the hon. Lady the Member for Coat-bridge and Airdrie (Mrs. Mann) will agree that those are not suitable subjects for debate today and I will not pursue them further.

At the younger ages, home accidents far outweigh the others. At ages over 65 also, although the accident percentage is low the number of home accident deaths makes a big contribution to the Scottish annual total of around 1,100 from this cause at present—more, indeed, than from all forms of tuberculosis. These statistics of deaths come from the Registrar-General, a point which I did not know at Question Time the other day, and full information is available about the various causes.

Accidental falls are by far the largest factor in deaths by accident at ages of over 65. Gas poisoning is in second place, whilst burns and scalds predominate among children, and among babies accidental suffocation. Corresponding figures are not available for the large numbers of accidents which cause disability, not death, except in a few areas where special studies have been made.

A system of universal notification is not needed to tackle this problem, but where local authorities could use statistics to give emphasis to local publicity it should be possible for hospitals to provide current figures about home accident victims treated as in-patients or out-patients. This we are pursuing, not as a matter of legislation, of course, but as one of administration. We shall also examine whether it would be useful to seek the co-operation of general practitioners in providing information about non-hospital cases.

Much more is needed in this field than action by official bodies alone. I warmly welcome the interest shown by hon. Members as well as the activities of the Royal Society for the Prevention of Accidents and the local home safety committees. Obviously, the objective common to all must be to inculcate in the minds of parents and everybody else the risks attending carelessness and thoughtlessness in everyday matters in the home. In this sphere, the schools have an important part to play. I am sure that they are alive to the need to warn pupils against the dangers of accidents and to advise them on how they are to be avoided. Girls are given training in safety precautions as part of their instruction in homecraft, and boys as part of their instruction in technical subjects.

The Scottish Education Department has also referred to the matter in various memoranda which it has published. In a memorandum on homecraft it has suggested that safety precautions and simple first-aid should be included in the syllabus. Particulars were published last autumn in the "Health Bulletin" which circulates to health departments throughout Scotland of the various kinds of activities that are open to local authorities. These include the support of home safety committees, where they exist, and where they do not exist their setting up and, in their absence, the conduct of local education campaigns.

Public health departments have ready to hand a most valuable means of stimulating awareness of the risks in households to young children, through the agency of their health visitors whose ordinary duties take them into many of these homes. I hope that every authority includes among the standing orders to its health visitors a note of the importance of these matters. For my part, I have been very glad to help by the supply of suitable educational material, such as the illustrated pamphlet mentioned last year, which proved so popular that it had to be reprinted.

I hope that the Committee will agree that general progress has been maintained. In Scotland, the chief problems are still those relating to mental illness and mental defect on the one hand and to the aged and chronic sick on the other. Patients in both these groups take up a considerable amount of hospital accommodation, but neither group is a problem for the hospital service alone, nor indeed for the Health Service alone. The promotion of mental health, for example, depends on a wide variety of factors, including social and family relationships, working conditions and leisure facilities. Voluntary effort can play a part of very great value here.

In 1955, no fewer than 6,585 admissions to mental hospitals, almost 72 per cent. of the total, were voluntary patients, many of them for periods of treatment limited to a few weeks or months. Many more persons were seen as out-patients, or treated in their homes by general practitioners. The isolation of the mental hospitals from the rest of the hospital service is fading away; consultants in other special branches of medicine take an increasing part in the work of the mental hospitals, and out-patient psychiatric clinics now function at or in connection with many general hospitals. Accommodation has also been set aside in one or two mental hospitals for patients who spend the day under observation and treatment, returning to their own homes at night. This plan can shorten the period of in-patient treatment, or even avoid the need for in-patient treatment altogether.

While some mental hospitals are at present overcrowded, this is not the universal state of affairs, and there are good reasons for thinking that no great volume of additional mental accommodation is needed. Much modernisation is undoubtedly required, including the provision of better facilities for the initial assessment of patients and their active treatment by modern means. The three-year programme of increased hospital construction announced in February, 1955, includes two projects of this kind, one at Dundee which was started in April, 1955, and another at Edinburgh which is due to begin in 1957–58.

There is a much clearer need today for additional accommodation for mental defectives whose enforced detention in their own homes may mean very real hardships for their parents, and there are, accordingly, three projects of this kind in the same programme, all due to start in the current financial year, at Dundee, Banff and Larbert.

A large proportion of patients in mental hospitals, especially the long-stay patients, are elderly. While I am assured that none of these patients is admitted otherwise than in strict accordance with the law, yet it may be that some could be cared for in hospitals of another type or, even in old folk's homes, if suitable accommodation and staff were available. This is one of those points where the relationship between the hospital service and welfare homes provided by local authorities under the National Assistance Act needs constant attention.

Studies have been carried out in different parts of the country covering all aspects of the problem, including the part the general practitioners can play, with the assistance of health visiting, home nursing and home help services of the local authorities, in making it possible for old people to remain in their own homes. In the light of these studies, I intend shortly to have further discussions with both hospital and local authorities, in the hope of ensuring that each will do as much as it can to help the other, so that the best use may be made of all available facilities.

I referred earlier to the fact that the Guillebaud Report was debated in this House recently and I do not think that the Committee would wish me to cover that ground again. The Guillebaud Committee reported that there was nothing radically wrong with the present structure of the Health Service. I do not suppose that anyone would dissent from the views expressed in the Report that the hospital service could with advantage absorb more capital expenditure than at present provided. That, of course, is a matter on which I do not think there will be disagreement, but the Report did record the fact that it was, of course, a matter which only the Government could decide as to how much of the capital resources of the country could be allotted to this purpose.

I think I should mention that we received recently the Report on the Recruitment and Training of Health Visitors. The value of their work is, I know, admitted, and the various recommendations in the Report will be considered most carefully in consultation with the local authorities and the other interests concerned.

There has been another Report in the nursing field, made some time ago by the Standing Nursing Advisory Committee of the Scottish Health Services Council, which is about to bear fruit. With very welcome financial help from the Nuffield Provincial Hospitals Trust, an experimental scheme of nurse training is starting at Glasgow Royal Infirmary in the autumn. The theoretical instruction in this course will be concentrated in the first two years, instead of being spread over three, although a third year of hospital experience will be necessary before successful students can be granted State registration.

While the course is designed to attract entrants with more than the average educational qualification, including university students, the subsequent advancement of successful students to senior posts in the nuring service will depend not on the accident that they have entered the profession through this particular channel, but on the capacity and abilities which they display thereafter.

I have endeavoured to cover a considerable amount of ground in dealing with these Estimates. I do not wish to take up an undue amount of the Committee's time, and I hope that hon. Members will agree that I have covered to some extent some points of importance. My hon. Friend the Joint Parliamentary Under-Secretary will be replying at the end of the debate, to which we shall both listen, and will do his best to answer further points as they arise.

4.48 p.m.

Dr. J. Dickson Mabon (Greenock)

The right hon. Gentleman the Secretary of State for Scotland has made two references in his commentary on the Report of the Department of Health which, I think, I ought to follow up. The first is really a personal one in relation to my predecessor, the late Hector McNeil, who, when Secretary of State for Scotland, was responsible for passing the sanction which brought in the Swiss Sanatorium scheme, which did a very great deal to help in the cure and convalescence of many Scotsmen who, because of their particular place in life, would have been denied the type of treatment which is open only to the wealthy. I think that it would be neglectful of me if I did not make a passing reference to my predecessor's work in that regard.

I hope that the assurance which the right hon. Gentleman has given to the Committee this afternoon, that he is convinced that there is no class of patient in Scotland who cannot be dealt with in Scotland, and who might have been dealt with under this scheme, is quite valid, and that he is quite certain of it. It would be very regrettable if a fine scheme like that were abandoned for financial reasons. In the by-election in my own burgh I refrained deliberately from going into the unfortunate controversy begun a year ago concerning the ending of that admirable scheme, small although it may have been in respect of numbers, but which nevertheless was so successful in its treatment of patients.

The second reference which he made was in regard to the Nuffield Provincial Hospitals Trust. I hope that the right hon. Gentleman will not take it amiss if I make some strictures upon the Scottish Office in this connection. I thought that he might have stressed the grateful feelings of many people in Scotland, at least those who know of the work of this fine Trust. At the moment the only good work in Scotland that is being done upon a reasonable scale in medical and hospital treatment is being done at the expense and direction of the Trust. I welcome the news that the Royal Infirmary in Glasgow is going to see the introduction of a new experiment in nurse training at the expense and initiative of the Trust.

I am glad that Greenock has in commission in Larkfield Hospital the experimental design unit which was built by the Trust. We welcome the new scheme of patient assignment nursing which is another example of the work of the Trust mentioned in the Report. We are indebted to the Trust for the work it has done in the health services of Great Britain, if not Scotland, and also for the fact that the Trust is making a further effort in Edinburgh to introduce a diagnostic health centre. I am not completely happy about that; I think that it leads us away from the general idea of health centres. Nevertheless, the Trust will be entering into all sorts of controversial fields of medical and health administration in doing all these things.

While a fine body has every right to use its money for charitable purposes it is a sad reflection that the Department of Health is not a healthy competitor with the Trust in doing good in these fields. It seems to me that the Department is concerned only with carrying on the general work of administration of the health services in Scotland. Anyone reading the Report right through can gain little satisfaction from the general picture which it paints of Scottish health. I do not say that in any ungrateful spirit in respect of the officials or the present Administration; they have a tremendous heritage of bad housing and poor conditions to overcome. Nevertheless, we cannot be satisfied with the progress shown in the Report.

The figures mentioned compare very unfavourably with those for England and Wales. We still have not caught up with England and Wales. The finest example of this is shown in the first few lines of the introduction, which says: Infant and maternal mortality rates both showed further reductions, although the lower levels attained in England and Wales and other Western European countries suggest that there is still room for improvement in Scotland. That is a very polite and clever way of putting a very harsh point. The fact is that the infant and maternal mortality rates in Scotland are a disgrace not only to Scotland but to Great Britain. We are even more backward than some of the so-called "backward countries" of Western Europe.

This is not due simply to a lack of medical advancement, nor to a lack of social application. It is due to a combination of both factors. I remember a person who is now a distinguished Member of the House but was formerly outside, who used to say: It is not the M.P. who does this, but the M.B. meaning that it was the doctors and the drugs, and not Parliament, who had been responsible for the improvement in the figures contained in such reports as this. I have no doubt that in their advocacy of their policies many of my colleagues have at times overstepped themselves and have claimed that it was the M.P. and not the M.B. who has done that. In this matter there should be a balance between the two. In many cases it is certainly the responsibility of doctors and research workers, but Parliament also has some responsibility, and the two should work hand in hand.

These figures are disgraceful, and should we be able to break them down we would find some dreadful facts. There are some really hard cases which seem to be permanent. Given one slight adverse circumstance of climate these difficult cases suddenly flare up. A year ago I crossed swords with the right hon. Member for Renfrew, West (Mr. Maclay). I had occasion to look at the figures in connection with the Burgh of Port Glasgow, which is adjacent to that which I represent. Port Glasgow has the rather doubtful privilege of having one of the highest infant mortality rates in Scotland. It is the worst burgh in one of the worst countries of Western Europe, in that respect.

It is a remarkable fact that the social circumstances of the various towns of Scotland are directly relevant to the infant and maternal mortality rates prevalent in those towns. I always remember, when taking my midwifery course as a student at Glasgow University, being struck forcibly by the figures quoted by Professor Lennie, taken from a survey carried out by himself and his colleagues, which showed the infant and maternal mortality rates for the various districts of Glasgow. It was shocking to see that the worst-housed districts, where the people were worst off, had the most dreadful figures, which were terribly high compared with the average, which was high enough itself. It was certainly indicative of the fact that a great deal must be done socially if medicine is to be practised effectively.

There are two elements in these mortality rates. The first is the social component and the second the medical component. I do not deny that, given all the gifts that we have and may have in future, medicine can make a great contribution in reducing the proportion of the medical component to what was termed by Lord Beveridge the "frictional residuum" below which one cannot fall—the true acts of God which we cannot influence. That should be the rate at which we should aim.

But Members of this House have a responsibility in dealing with the other component—the social component. We often tend to think that certain matters come within the responsibility of the doctors when in reality they are our responsibilities. We can make as wonderful a contribution in terms of good health as can many of our doctors. The question is, are we doing that today?

The essential fact about the Report is that it still records matters of ill health and not positive health. We really do not have a Department and a Ministry of Health; we really have a Department and a Ministry of Disease. The figures record disease and not positive health. We do not rejoice in preventive methods except in the case of the obvious infectious diseases. Here we must remember that the campaigns of preventive medicine were stimulated by the fact that they affected many people in many classes. The fact is that preventive medicine has not aimed necessarily at dealing with conditions in all classes because all classes do not suffer from certain conditions of life which are in themselves a reflection of the social pattern of that particular civilisation.

I content myself with those comments about the Report generally and go on to a somewhat narrower field, which I think will be of interest to hon. Members, but which, nevertheless, is strictly confined to the position of doctors. I know it is often alleged that doctors regard the National Health Service as a service for their employment rather than one for the cure of patients. We do not mean it that way, but that judgment is often passed upon us.

My right hon. Friend the Member for East Stirlingshire (Mr. Woodburn) said that general practitioners were in the front line of the war against disease. That is very true. Single-handed practitioners, like men in any other front line, are at an even worse disadvantage than those working in teams and groups. That is why Appendix 10 is a very interesting one. The Report shows that within the total of 2,503 general practitioners providing unrestricted medical services there has been a decrease of 47 in single-handed practices. There has been a rise in partnerships, etc., though not very significant or world shaking. It is, however, recorded that there has been a slight change-over in the constitution of Scottish group practices.

My right hon. Friend postulated, rather riskily in medical terms, that the incidence of coronary artery disease in the medical profession was entirely due to the motor car. That may be a factor, but there certainly is another factor, the ringing of the infernal telephone bell. Alexander Bell did a great dis-service to his fellow countrymen when he invented the telephone—at least, he appears so to doctors who are sometimes disturbed in their sleep—because the ringing of the telephone bell causes the momentary—it is really in terms of seconds—spasm of the coronary arteries which, if repeated two or three times many nights in many long years, can be an aetiological factor in the occurrence of the disease. It is certainly a fact that one in two doctors will die ten years before their time because of coronary artery disease.

Mr. Woodburn

Can my hon. Friend explain why so few wives of doctors die from the disease? Most of them have to listen to the telephone?

Dr. Dickson Mahon

As a bachelor, I find it difficult to answer that question, but I will do my best. It leads to my point about a survey of general practice in Scotland. The answer to my right hon. Friend's question is that many a hardworking wife of a doctor—incidentally, she is not paid in any way by the National Health Service—takes the day shift while her husband has the night shift. It would be a very harsh or a very hard-pressed man in a single-handed practice who obliged his wife to work all day and all night, which is what the country demands of him.

If some of my hon. Friends do not like anything that I say in its medical context, I shall be delighted if they would interrupt me. I am sure that hon. Members opposite would like to see something of a dog fight on this side of the House.

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

With regard to the ringing of bells, what is the hon. Member's forecast about hon. Members? There are many nights here when the bells ring with great violence a number of times. Has he any observations to make about hon. Members of both sexes?

Dr. Dickson Mabon

The important difference is that no doctor can arrange a pair. The ringing of bells that he has to endure is a permanent imposition, and there is no possibility of escape from it. What makes it a factor is not that it occurs on certain nights but that it may continue for several consecutive nights.

Also, many a single-handed doctor, who, in the words of the Report, provides unlimited medical service, which means that he does anything, might be unlucky enough to have a bad night, getting to bed about midnight and having to get up at, say, two o'clock and four o'clock to attend to patients. That may not be many calls, but it represents a broken night. At all events, his night is ruined in terms of the round of sleep which, in physiological terms, should be, even for the best people, at least five hours. The next night he may have a midwifery session. One of the greatest joys afforded any man or woman is to attend the birth of a child. The doctor does not regret it, but it means a long night of work. The third night the doctor may be called out to see another patient.

Is it fair on the doctor? Let us put the question the other way round, because many of the doctors wish to remain single-handed. Is it fair to the patient that he should have to call out in the middle of the night a man who has already gone through two or three terrible nights? I would particularly stress this in respect of cases which are difficult to diagnose, cases which may often give rise to a sudden and painful emergency. Even at the best of times it may be difficult to discern symptoms. It may mean a very great deal in relation to the comfort and life of the patient if the doctor is tired, overworked, not at his best, and unable to appreciate the finer subtleties of the symptoms.

I believe that the time for the single-handed practice, except in very sparsely populated districts, has gone and that Parliament ought to take steps to get as many men as possible to give up single-handed practices, in heavily populated areas at least.

Many things which could be said about general practice are often said without the basis of a survey, particularly in respect of Scotland, and I suggest that it would be wise for the profession or the Department of Health—here the Department might rival the Nuffield Provincial Hospitals Trust in a new form of initiative—to carry out a survey of general practice in Scotland. I believe that general practice in Scotland is not quite the same as general practice in England. At all events, it is not right to assume that all the things which are relevant to general practice or medical practice in England are necessarily mirrored in terms of Scottish practice.

I also want to refer to assistants. Appendix 10 shows that there are at present employed by principals——

Mr. Thomas Fraser (Hamilton)

My hon. Friend has told us about the difficulties of the doctor in general practice. I thought he had come to the point where he was about to make out a case for group practice. He spoke about some initiative to be taken by Parliament, and called for a survey. Will he tell us about the attitude of the over-worked doctors to the business of setting up in group practice? Does not some education need to be undertaken among the doctors?

Dr. Dickson Mabon

I agree with what my hon. Friend says. I had in mind to leave the actual argument for group practice until after my comments on the health centres. I am sorry if I depress hon. Members by giving them the knowledge that I have a great deal more to say.

I want to deal with other kinds of general practitioner, not those in groups and not the single-handed ones, but those working as assistants to principals, and I then want to pass to the subject of trainees. According to the figures, there were 358 assistants last year, and this year there are 355—quite significant figures. Without any fear of contradiction, I can say that, in general, these 355 men and women assistant doctors work harder, work longer, and are paid less than anybody else in general medical practice. They are really the exploited section of the medical profession, in my eyes. They are not trainee assistants; they are assistants, taken in by principals, and asked to work with principals on the promise that some day they may well join in the practices as junior partners.

Assistants are often asked, with that prospect of partnership as an incentive, to stay in a practice in a very difficult capacity. It is rarely that one finds a principal willing to share equitably, or almost equitably, the work which his junior colleague is asked to do. It is never the case, I think I can safely say, that a principal gives his assistant anywhere near his own salary.

It would be a wise move on the part of the Department of Health if it were, in the interests of these men and women, to look at this matter and pose certain questions. I mentioned the figures; they show that there has been a drop of three from the total of 358 last year. One might say that that presents a fairly stable level, but one should then ask the following interesting questions, and see whether something else might be revealed. First, how many of these people have been two years in practice as assistants? How many young men and women are finding it terribly difficult—in their own phrase—" to crash into general practice" as a principal? There seems to be some sort of conspiracy to keep assistants out for as long as possible, because when they are in the assistant market they work on less favourable terms than their colleagues in other positions. It would be interesting to know the number of assistants who have been in practice for more than two years.

It would be interesting to know the turnover there is in assistants after they have served more than three or four years in general practice. How many do we lose to England? How many do we lose to the hospitals and elsewhere? How many of these people who, frankly, ought still to remain in general practice, do we lose in one way or another?

Before I began to study public health in the University of Glasgow, I did a great deal of work during the summer as locum tenens, and in that way I gained a great deal of experience of the differences in attitude between principals towards their assistants. I may say that I have absolutely no complaint against those doctors who were kind enough to ask me to work as locum tenens at that time. There is this to be said on the other side, that I was able to choose the positions I wanted, because this was a comparatively good market for a young medical man trained in the medical sciences and not anxious for the moment to find a place in general practice. On the whole, my contact with assistants in Scotland leads me to believe, as I have said, that they work harder, that they work longer, and are paid less, than anybody else in the profession. This is not a fair reflection either on the medical profession or on Parliament.

I come now to the training of assistants, as it is so politely called in the Report. I notice from the figures given that the number of trainer general practitioners—the general practitioners who train young men in the accomplishments of general practice—has risen from 119 in 1954 to 122 in 1955, an increase of three. Trainer general practitioners are the men who are considered by the regional selection committees to be suitable people with whom trainee assistants can receive their training. Although we have 2,503 general practitioners in Scotland, principals or doctors working in group practices, we have only 122 who are recommended by the regional selection committees as being able to train young doctors to be good G.P.s.

I do not know whether this matter has been raised in Parliament before. I should like to say now that in the medical profession, irrespective of politics, there is a great deal of dissatisfaction with this system of selection, and indeed with the system of trainee assistants. There are two grounds for this dissatisfaction. First, it is felt that the committees seem to appoint people for reasons which are uncertain. Nobody knows what are the criteria employed to distinguish one doctor from another as regards capacity to be a trainer G.P. In fact, there is a suspicion on the part of many ill-disposed doctors to think that there is a racket in this regard, that those who are trainer G.P.s are those who are in positions of influence and authority in the medical associations and are able to influence their peers to grant them the right to be recognised as trainer G.P.s.

I do not suggest that all these 122 men, or indeed the bulk of them, are in that category at all. They are, however, privileged men in the profession in Scotland among the 2,500-odd general practitioners. They have not only the facilities in their own practice, but they are recognised as able to train men for general practice. There is a great deal of concern in Scotland about this limitation of the numbers of trainer G.P.s and about how the decisions are arrived at in their selection.

I ask the Ministers concerned to say what are the criteria adopted by the selection committees. Why are there not more doctors on the list? In order to obviate public criticism, why do we not ensure that a general practitioner who has a trainee for a year should not have a trainee, let us say, for another two years? It is the fact that many general practitioners have been able to have trainee assistants coming to them year by year. That constitutes a tremendous financial advantage.

Mrs. Jean Mann (Coatbridge and Airdrie)

May I ask my hon. Friend whether this does not make a market in unpaid assistants? Is not a trainee an unpaid assistant, and do not the Government pay the doctor for all the work that the trainee does? Is it not the fact that a trainee's services are very often abused, particularly in Glasgow, the trainee being given night work and so forth, to the detriment of opportunities for study?

Dr. Dickson Mabon

Yes; I agree very much with my hon. Friend. The maximum allowance given to a trainer G.P. is between £700 and £775 in respect of salary and boarding allowances. Many of the young men who are employed in this capacity as trainee assistants, with their present pay and these allowances, are in fact a free gift to the general practioner.

I have no wish at present to criticise the trainer G.P.s as such; I have not enough information. I have information about one or two, but I am not going to present an argumentum ad hominem. I will leave the matter there, and I merely suggest that this is one which we must look into.

What do the young men who have come out of general practice think about this trainer G.P. system? I have a letter here from an Edinburgh doctor, quite a distinguished young doctor who has gone very far in the profession by his medical abilities. He says he has been discussing this matter with many of his colleagues, and he writes to me as follows: I would suggest that the matter of the continuance of the trainee system be put to the vote of ex-trainees. I guarantee 100 per cent. opposition. Indeed, on sounding one or two quite recently, they declared themselves willing to testify to the department about it. That is a significant comment from Edinburgh, which can hardly be said to be the home of Socialist revolution, in professional terms at least. It seems to me that the usefulness of the trainee scheme has been offset by its limited application in respect of so very few doctors throughout the years.

The main item upon which I should like to concentrate my concluding remarks is the reference on page 45 of the Report to health centres. Health centres are, without doubt, the backbone of the National Health Service Act, 1946. The whole scheme is not quite itself without those centres. Therefore, we have never yet fully achieved the underlying idea behind the National Health Service Act.

We rejoice to know from the Report that we have two of these health centres in Scotland. There are 12 in Great Britain. Three of them are provided by the Nuffield Provincial Hospitals Trust. Thank goodness we have that Trust to do the work of the Ministry of Health and the Department of Health, otherwise we would be even further behind.

The two health centres in Scotland are not bad as branch surgeries for general practitioners, and they are not bad as local authority clinics, but quite honestly they are not the kind of health centre envisaged by most medical people when the National Health Service Act was being passed. I am not reproaching the present Administration—I realise that the point is a difficult one—but I am bringing it to the Committee's notice because I do not wish us to drift away from the original concept of health centres as such.

At Sighthill, a lot of good work is being done, and it is very pleasant to see the reference to old people in the Report. We are charmed that this work should be done, but we should not be led away from the general criticism. When considering Scotland, one sees the quite good work which is being done, but nevertheless we see clearly from the detailed report on the centre that the economics of competition come very much into this matter. In relation to Sighthill, for example, many general practitioners in Edinburgh—I do not know whether this is true of Stranraer—say that there is unfair competition from the health centre. In other words, the judgment of the services of the centre is in terms of economics. The complaint is made that the rent is either too high for those who work there or is too low to please those outside.

It is often said that health centres draw away patients from their own doctors to the others in the health centre. The centres are attracting patients because of the better facilities which they have to offer. They have nice rooms, well painted and well kept, plenty of accommodation and the additional ancillary services that help patients to realise that a visit to the doctor can be a very pleasant affair indeed and not a painful, long wait in a cold badly-lit surgery, after which one is hustled out again in two or three minutes because of the very large queue of others who are seeking medical advice.

There are three criticisms against the health centres in Scotland, as in fact against all of them but one in England. The three criticisms are that the collaboration between the general practitioner side and the local authority side is very limited indeed. To say that they are two separate compartments would be an exaggeration but it is certainly untrue to say that they are completely integrated one with the other.

The second criticism is that the health centres are really branch surgeries, because many of the doctors have not given up their interests in other parts of the town. The third criticism is that they represent the terms of competition which still persists in the medical profession, despite what may be said in some quarters to the contrary.

To my mind, the best centre in the country and one on which we in Scotland could model our future centres is the Darbishire House, in Manchester. I should like to read this extract from a recent report. The striking exception of Darbishire House illustrates in the words of the G.P.s working there what enormous advantages exist, when proper arrangements are made in advance of the health centre beginning to function. In this instance the G.P.s negotiated a contract which provides them with a salary, and with the perspective of reducing their list to 2,500 each. Three of the four doctors here have sold their houses and surgeries and moved into newly built houses without surgery accommodation. In other words, the Nuffield Provincial Hospitals Trust, which was responsible for the centre, negotiated contracts with the doctors beforehand. This gives them a good salary. Three of them have already sold their houses and moved into the centre, having decided that there is their work. Instead of encouraging additional people to come to them, however, they have decided that the optimum list should be 2,500. They are, in fact, turning people away from the centre, saying that they can deal adequately with 2,500 but do not want any more.

This is what one of the doctors has said: We had no idea of the incidence of anaemia in our practices. Haemoglobins of less than 60 per cent. are common and the patients have been anaemic for so long that they have come to accept their poor state of health as normal. Fifty per cent. of our blood tests showed haemoglobins under 85 per cent. After one year of general practice"— in the health centre— with X-ray help the doctors wondered how they managed without it for all the years they have been in practice. Some criticism has been on the grounds of cost, but it is felt that the help given to the patients and the high percentage of abnormals (26 per cent.) fully justified capital outlay and the expense of running an X-ray plant. What a great boon it is to the patients to get their X-rays done on the premises and not to have to go through the out-patients' departments of the hospital, and what a saving of time to both patients and doctors alike. In other words, we could well devote our energies not to the building of more surgeries, but in concentrating upon health centres, not of the kind at Sighthill and Stranraer, but of the type represented by Darbishire House. Centres of this kind make for improved medical practice and strike the remaining shackles of commercialism from G.P.s, not only in the centre but outside it. The work which has been rendered by the Nuffield Provincial Hospitals Trust underlines the fact that we need more health centres like Darbishire House.

The health centre is, without doubt, part of the kind of society that we want. The best opportunity that we have in Scotland of getting health centres is by choosing places where the new housing schemes are to be built. My own local authority has hoped that some day it might have a health centre of this kind, and it proposed such a centre in Auchmead. The suggestion has been rejected for the present by the Department of Health on financial grounds. In Glasgow, the suggestion has been made by local practitioners and by that well-known general practitioner, Dr. Winning, that there should be a health centre in the Gorbals. What a fine thing it would be to redevelop the Gorbals as we intend to do and at the same time to construct a health centre of the kind that Darbishire House represents.

I do not deny that the medical profession, like any other profession, fears change. It fears change because it may be frightened of poorer practice. I think that it fears it also because of poorer purses. If ever the medical profession worries about its purse, it should cast an eye over the wide range of public health legislation. I can say without fear of contradiction that there is scarcely a single Public Health Act which the medical porfession has not, at one time or other, resisted. It has, as a body, fought against them all, right from the days of the first Public Health Act. After every Act has been passed, however, the salaries of practitioners have, indirectly, or directly, gone up. It is my belief that new Health Service proposals associated with health centres would lead to the profession getting, not a poorer salary, as many practitioners are getting now in relation to their abilities, but a much better salary.

It is not just the case that we have to challenge the reluctance or fearfulness of the medical profession. We have also to deal with the public. But I think that if the public knew what a real health centre was and were able to see one in action, then the cry for more of these centres would be so overwhelming that Parliament would have to assent. Without doubt the health centre is the twentieth century surgery of the general practitioner. It is the real advance in medicine which marks our time, but we here have not quite caught up with it. It is not a matter about which we ought to be happy. We should look to a future in which we have more of these centres which are the backbone, the life-blood and the inspiration of medical service which the National Health Service Act sought to implement.

5.30 p.m.

Sir Thomas Moore (Ayr)

Despite his professional qualifications, I cannot agree with the hon. Member for Greenock (Dr. Dickson Mabon) in his comprehensive analysis of this Report. It is not often that I feel this way, but I find the Report quite fascinating. It is both informative and enlightening, and it is also encouraging, especially regarding the improved health and future of mothers and children and particularly in relation to tuberculosis.

Many reasons were advanced by the hon. Member for Greenock for the improvement in the tuberculosis figures, and also by the right hon. Member for East Stirlingshire (Mr. Woodburn) who referred to the early diagnosis and suitable treatment given in Scotland as well as the enormous benefit of visits to Switzerland. But I am sure that a number of people will agree with me that the very pronounced advance in the cure of tuberculosis is due to the better housing of our people during the past few years. We cannot expect anything but tuberculosis when we consider the damp, dark and insanitary houses in which so many people lived during the last half-century. I feel convinced that in the end the better progress we make in building clean, bright and airy housing accommodation, the better progress we shall make in the fight against tuberculosis.

The only depressing feature in this Report is the implication that there is a threat to the elderly male, in other words, the men of my generation. It might be argued, I suppose, that in any case we are redundant; that we have fulfilled our purpose in life and, therefore, we need not grumble if our tenure of life is becoming more tenuous. But I am not convinced that my right hon. Friend need worry too much about this factor. I do not think that it is a recurring factor. In my opinion the reason why men of 55, 60 and 70 become more ill now is because of the conditions they experienced during the First World War. Many of us are beginning at last to yield to the disabilities which we have been able so lightly to throw off for the past twenty or thirty years. One cannot live in mud and in exposed conditions, with an unpalatable and often inadequate diet, for many years without it sooner or later having an effect on one's constitution, and it is that effect which we are now experiencing. But it does not necessarily follow that the same will be the case for future generations.

The only black part of the Report is the obvious weakening of our efforts to solve the problem of the chronic sick. They represent one of the most pathetic sections of the community. They are old and feeble, and although sometimes a married pair can live together, very often chronic sick people are alone. This problem seems to be baffling the community, although I am convinced that all are doing their best to solve it. Local authorities provide home-helps, and even care for the chronic sick at night and in the evenings. They do everything in their power, with the help of medical attention, to make easier the lives of these people.

It is the case, however, that many local authorities are realising more and more the heavy drain upon their financial resources resulting from the provision of an increased number of home-helps. Local authorities say that these old people are a charge on the hospitals, and there may be some truth in that. In fact, hospital boards are willing to accept responsibility for these old people. But that means more money, more buildings and more beds as well as more equipment, and so we are up against a stone wall and I cannot see how we may surmount it.

I know that this is not the time to press for increased capital expenditure, but that is what it required. The only question I would pose to my right hon. Friend is whether the order of priorities for capital expenditure is the right one. In a Welfare State our chief obligations, in my opinion, are to the children and to the old. The young will be responsible for the future of the country which the old folk have helped to build up.

We may have no doubt that we have been successful in honouring our obligation to the children. They are bonny, straight-limbed and healthy as a result of the provision of vitamins and orange juice and the pre-natal care given to mothers. Regarding the old people, the story is different. I do not think I am alone in feeling that in every town in the country of 10,000 inhabitants and over hostels should he provided for the old people in which there would be double and single rooms, a matron and nurses, medical attention, and so on. To my mind such hostels would at least help to solve the problem confronting local authorities of finding home-helps and the problem presented to hospital boards of finding beds, equipment and buildings for the chronic sick.

In common with my constituents, I was particularly sorry that my right hon. Friend could not consider the claims of Ayr in his allocation of capital expenditure in February of last year. In Ayr we find ourselves in a precarious position. The county hospital is now charged with a number of different duties, none of which it is fully equipped to carry out. It is used as an out-patients department, and patients may be seen lying about in draughty and insanitary corridors. No one can help that because it is an old building. Of course, the doctors and the hospital board desire to transfer the out-patients department to Heathfield, where the town council has provided adequate land for building and where the whole hospital could be put under a single roof or series of roofs with proper control. Then the chronic sick, if they are not accommodated by then in suitable hostels, could have the old county hospital in Ayr reserved for them.

Many points may have to be made by other hon. Members who are present. But I would advise my right hon. Friend the Secretary of State that I propose to bring forward a long-term policy for hospital accommodation in Ayr and that I hope these few words will soften him up to receive it with sympathy and agreement.

I return to the point at which I started. The Report should give us all every reason to he greatly encouraged, and comforted to feel that we have at our service a splendid body of doctors and an equally splendid body of nurses. I know many doctors and nurses in and around Ayr and I find them filled with devotion, humanity and a sense of duty towards their patients and to the community which has sometimes greatly moved me. I only hope that my right hon. Friend the Secretary of State can maintain such a good Report, and that next year he will give us improvements such as I have endeavoured to indicate.

5.42 p.m.

Mr. Thomas Steele (Dunbartonshire, West)

I am delighted to follow the hon. Member for Ayr (Sir T. Moore). He brought two matters in particular to the attention of the Committee. The first was the good work which had been done by the provision of housing accommodation and how this had played its part in the treatment of tuberculosis. When the Secretary of State explains what he proposes to do in taking away housing subsidies for general needs, I hope that we shall have the support of the hon. Member for Ayr in opposing that policy of his right hon. Friend.

I was interested in the speech of the Secretary of State. It is evident that the campaign of my hon. Friend the Member for Coatbridge and Airdrie (Mrs. Mann) is having some effect because a large part of the speech of the right hon. Gentleman was devoted to accidents in the home. I was impressed by the statement he made that the second greatest cause of death of old people—if I understood him rightly—was gas poisoning.

It happens that I have a constituent who feels he has an invention which, attached to a gas meter, would cause many of these gas poisonings to be avoided. I have brought this matter to the attention of the Minister of Fuel and Power and other Ministers, and I hope that the Gas Board will look at it. There is something in this invention. I know that it is not the duty of Members of Parliament to promote the inventions of their constituents, but this is an attachment to a gas meter which prevents the gas being turned on again after the supply has run out until all the gas taps has been turned back. When gas meters run out taps are often left on. Somebody puts another shilling in the meter, and gas escapes and causes an accident.

The other point to which I listened with interest was about the waiting list for sanatoria. The statement should give us a great deal of satisfaction. I trust that the figures, low as they are, will disappear. In my constituency, we have the only new hospital that has been built in this country since the war. I advise my hon. Friends and hon. Gentlemen opposite to visit it. It has not been officially opened, but it is in operation. It is worth seeing what can be done by an architect in the provision of convenience, comfort and colour. The wards are something to be desired by patients. If hon. Members paid a visit to the hospital they would badger Ministers to provide such facilities in their own constituencies.

Now let me return to another subject mentioned by the hon. Member for Ayr. Over the years, the problems of the aged have been recognised and have, to some extent, been tackled, but there has been no systematic development of a policy for their welfare. The work is spread over many fields without any particular person having overall responsibility. There is the welfare work of the National Assistance Board, of the voluntary services, of the local authorities in the provision of home-helps, health visitors, social clubs and meals on wheels, and of the hospital boards in their work for the aged sick.

All these authorities are anxious to go forward with a proper administration of the service as a whole. It is not an easy matter. Any welfare policy must consider not only the hale and hearty old people, but the infirm, the incapacitated and the incurable. Everybody with experience has come to the conclusion that a definition of the categories is not easy. The Guillebaud Report, in paragraph 645, suggests that a definition of the types of cases, for instance between the welfare authorities and the hospital authorities, is necessary. What does that mean? That a definition is required shows that either or both authorities are shifting some responsibility, though they both think they are doing what they can.

In his speech today the Secretary of State mentioned this question and indicated that discussions are taking place with local authorities and others as to what could be the best approach to it. There seems no doubt that certain local authorities are not shouldering their accommodation responsibilities. That is understandable and there seems no doubt why that is not being done. It is obvious that there is a great reluctance on the part of local authorities to admit aged persons, who will shortly be bedridden, to beds which attract a grant of only £11 for a single room and £9 10s. for a room occupied by a number of persons.

As a practical example, the cost of Leven Cottage, Alexandria—the old people's home or hostel which was referred to by the hon. Member for Ayr—for the year 1956–57 is estimated at £5,075, and the grant will be in the region of only £130 10s. Therefore, it is understandable that local authorities are reluctant to have in these hospitals people who very shortly may be confined to bed all the time. I have no doubt that an increased grant such as that recommended by the Guillebaud Committee in paragraph 612 of its Report is part of the answer and would be warmly welcomed by local authorities.

On the hospital side, the sheer pressure of general needs means that they cannot block accommodation by looking after the chronic sick. It is a shame that such an expensive service should be asked to use beds because of the sheer weight of public opinion when it would be cheaper and more humane to allow old persons to remain in hostels wherever possible. In that connection we ought to have some person or body responsible in an area to act as a referee in deciding whether a case may be admitted to a hostel or a hospital. At present the situation leads to some confusion and ill-feeling. In Dunbartonshire, the hospital board of management and the local authority have agreed that this should be done by the county medical officers. That practice works quite well, but it seems that something more is necessary.

I believe that individual cases of hardship arise because there is no focal responsibility for each and every old person. At present, a general practitioner rings up a hospital to ask for a bed. If he gets the case into the hospital everything is all right, but, if not, he may not tell the local authority. Not having that knowledge, the authority does not give the benefits, by way of home-help, of whatever assistance can be rendered to the old person concerned. There is a crying need for some person to be nominated in each area as entirely responsible for the welfare of old people so that no mistake can arise as to the eventual outcome of any individual problem.

Whilst this may seem an administrative detail which could easily be remedied locally, that is not being done. It means so much to the old people. If this suggestion were adopted it would be putting into operation something which we had prior to 1948. On page 77 of the Report voluntary workers are asked to keep themselves well-informed about facilities available for old people. It would be a much better proposition if, as I have suggested, we had some person in each area responsible for the welfare of the old people to whom the voluntary worker, or any person, could turn for advice if that advice were necessary. I believe the medical officer of health is the person to whom that duty should be given.

I want to say a word or two about geriatric clinics. That is a new name for the care and welfare of the aged. I think these clinics are excellent and should be widely established. I say this particularly to my hon. Friend the Member for Greenock (Dr. Dickson Mabon) who is a medical practitioner. One of the difficulties is that the weight of general practitioner opinion causes the belief that they would be given unnecessary work by cases being referred to them from the clinics or by people thinking that once they have been to a clinic there is something really wrong with them and that they ought to be attended by a doctor.

I say to the Joint Under-Secretary that it is hardly likely that we shall have the weight of the medical profession behind us in the establishment of these clinics. In view of that, it would seem that the Secretary of State will have to place the duty of running those clinics on the shoulders of one of the partners under the National Health Act. They would be of immense value, and I suggest that the obvious choice here, again, would appear to be the local authority with its home services available.

There is no doubt that many hospitals are doing an excellent job at the moment, limited as they are by accommodation and other difficulties. Their main problem lies in dealing with the aged who cannot benefit from treatment and, where there is such pressing need for the treatment of acute, recoverable cases, that is understandable. Like the hon. Member for Ayr, I take the view that looking after old people does not require the skilled attention needed in hospitals. It can be done in hostels provided that a nurse is available to supervise the work. If that were done it would relieve hospital accommodation for cases which need that accommodation even more.

My final word is on an entirely different topic, but one which I have always considered rather important. I have always taken an interest in the medical services provided by various firms and factories. I have often wondered whether we were making the best use of the medical forces in the country in some of the jobs they are asked to do. I mention this matter now because I understand that discussions are going on at present about a suitable medical auxiliary service for factories and workshops. I am led to believe that the trend is for a service completely divorced from any of the present administrative structures under the National Health Service. That surely is a great mistake.

The condition of the health of factory workers is created not only by their work, but, in many cases, by the environment of their home circumstances. Surely the link between the home and the work is one which should be maintained. That is something which should be borne in mind. Large factories have their own medical services and medical officers. It might be wise to leave well alone in those cases. Many of them have the local doctor as their medical adviser, and I think that is a good thing.

There are many small firms, however, which require advice on working conditions and hazards, and some services are necessary for them. As the medical officer of health is responsible for so many services in the home, dealing with the welfare of the family, it seems to me that this is a task which could very well be tackled by him, and I trust that the Minister will give this point his consideration. It would be a shame and a tragedy if we set up another organisation to deal only with the health and welfare of people in factories and shops and divorced it completely from the general medical service, or, for that matter, dissociated it from the county medical officers of health. I hope and trust that my words today will be a warning that I, for one, would look very critically at any organisation of that kind.

6.2 p.m.

Lady Tweedsmuir (Aberdeen, South)

I was very interested in the speech of the hon. Member for Dunbartonshire, West (Mr. Steele), first in respect of his reference to the care of the aged, because a great deal has been done in this connection in my home city of Aberdeen. I am not sure that I agree with his view that it would be a mistake to have a separate medical service within industry. During the war I had a chance to work within industry. We had to work in close co-operation with our hospital services; we were in charge, although no doubt most inadequately, of the firm's medical services. A great deal has been done, as the hon. Member said, in private industry to ensure a first-class service, and if that could be encouraged throughout the smaller firms in industry, either voluntarily or, if necessary, through the Factories Acts, I believe it would be of very great benefit to the country as a whole.

Mr. Steele

Possibly I did not make myself clear. I would welcome the introduction of this medical work in the small factories. I was hoping, however, with that we should not dissipate our medical services to such an extent as to set up new machinery for that purpose. I think that the county medical officer of health could take that task under his control, so that the present medical service could cope with it.

Lady Tweedsmuir

I am sorry if I misinterpreted the hon. Gentleman. I think there is a large measure of agreement between us, at all events, on the fact that something should be done within all factories, whether large or small.

I want, without detaining the Committee for long, to speak of the work which I think we should discuss in connection with this Report of the Department of Health—the preventive work which is done under the National Health Service. While it is admirable that we should enjoy these increasingly satisfying statistics about tuberculosis, we must try to seek means of ensuring that the country as a whole, and the medical services, have a more positive approach to health. Perhaps one day we shall reach the stage reached by a certain Chinese potentate who paid his doctor only if he were well.

I feel that the key factor within the National Health Service is the family doctor. It is on his account that I should like to make a few remarks today. We could do a great deal to strengthen the family doctor's service and to back it by the domiciliary services which are run by the local authorities, such as home helps, nursing helps and health visitors. It is a very disturbing fact that one-third of all absences from work in Scotland are due to neurosis. It exceeds even the common cold as a cause of absenteeism. Out of a total of 63,100 staffed beds in Scottish hospitals, 22,225 are used for mental and physio-neurotic disorders. That does not take into account mental deficiency, which takes up another 4,661 staffed beds.

The 1955 Report of the Scottish Department of Health made two comments in this connection. First, we must aim to get the best facilities for early diagnosis; and secondly, we must aim to get treatments which avoid admission to hospitals.

Of course, as has been said in the debate in other connections, the promotion of good health depends to a large extent on the general social conditions of the country as a whole—not only housing conditions but, even more important, whether a man enjoys his work, his personal relations and his scope for leisure. Of course in the end it all revolves round the individual's capacity to meet life as he or she finds it. To obtain such guidance a great many people turn to the family doctor. We are not talking about mental disease, but about the mind of a normal person which is ill-adjusted to cope with life, and which, according to statistics, is to be found a very large cause of absenteeism in industry. While all study psychiatry with care, sometimes it can go too far. I am reminded of the psychiatrist who wrote over his surgery, "Maybe you have not a complex. Maybe you are inferior".

This year it is a hundred years since the birth of Freud, and whether we believe in his doctrines or not, the fact remains that throughout our national life we are increasingly coming to recognise the importance of human relations. That means the right mental adjustment to environment. Certainly in health it has long been recognised that in the treatment of an illness one must have regard to the mental attitude of the patient, just as much as to his physical disability.

I therefore submit to the Committee that the position of the family doctor is vital, because he alone is in a position, perhaps over the years, to have a knowledge of the patient's background. It seems to me that the pressure of work on the general practitioner today is colossal, as was so ably said by the hon. Member for Greenock (Dr. Dickson Mabon).

Of course, the general practitioner has facilities for sending patients to specialists and to hospitals, which will relieve his work to a certain degree, but I should like to draw the Committee's attention to some comments made by Dr. Hall, in his Presidential address to the B.M.A. at Brighton. He said, Much of the work which family doctors should normally undertake is passed on to the hospital or to local government clinics. This process of disintegration is progressive and, if not checked, will inevitably and rapidly lead to the disappearance of family or general practice as we have hitherto known it. First, I think more preventive work could be done in a patient's home if the domiciliary services could be expanded—not only preventive work but also work in after-hospital care. Half the cost of these services comes from the rates, and I therefore trust that in the review of local government expenditure and finance that matter will be taken seriously into account.

Turning to the conditions of work of a family doctor, I should like to join with the hon. Member for Greenock in asking whether something, at any rate to a limited extent, could not be done in the establishment of health centres, because it is true that the background to the National Health Service was the establishment of health centres. I agree with the hon. Member for Greenock on the importance of establishing health centres. At this time of general economy I do not expect ot see a large financial grant for the establishment of large health centres all over Scotland, but surely, Sir Charles, there are houses and buildings, and certainly in parts of our industrial areas, which are suitable for, at any rate, part-conversion into health centres. Something of that nature should be examined as a positive way of improving the working conditions of the family doctor.

Of course, scarcely anything is ever said about the doctor's wife who, by the time she has answered the telephone night and day, is practically a G.P. in her own right and has absolutely no privacy of any kind. The health centres would be an advantage, not only to the doctor and his wife, but also to the patient, not necessarily because of improved facilities, but because there could be a better appointments system.

It is always said that in comparison with other practitioners within the health service the general practitioner does not get enough pay. I do not think that at present we can advocate a general rise in medical rates of pay. Nevertheless, I think that a study should be made of the relationship between the pay and conditions of the G.P. and those, for instance, of the specialist. I think that the family doctor, vital link as he is in the Health Service, is not being given his proper status or proper conditions in which to work. Such a study would, perhaps, in itself ensure better co-operation from the general public, who are often inclined to think that the G.P. is there and can be had at any time, whatever may be the trouble to him.

Mr. John Baird (Wolverhampton, North-East)

Is it not a fact that the general practitioners have not had any increase of pay during the last five years? The cost of living has gone up in that time and most other people have had increased pay. The general practitioners should have the same advantages as other classes of worker.

Lady Tweedsmuir

Everybody can make out a case for an increase in pay. Indeed, the hon. Gentleman himself may have supported the case for increased pay for Members of this House. But we all agree, I think, that there is a time for such increases. Nothing will reduce the pay and conditions in this country more than a runaway inflation such as I saw in Germany after the war.

That is not to say that increased pay and better working conditions should not come in proper time. Certainly, I think that a study should be made of the position within the Health Service of the family doctor in relation to the specialists, and a study made also of the respective services given. I make that particular plea, and hope that some note will be made of it by the Joint Under-Secretary when he replies, because I think that the G.P. is a key factor in the Health Service as a whole.

6.14 p.m.

Mr. William Hamilton (Fife, West)

I could agree with a great deal of what the noble Lady the Member for Aberdeen, South (Lady Tweedsmuir) has said about the preventive side of medicine. I always feel that a health debate is somehow artificial in that we try to divorce it from the social services, and from the facilities provided within the educational, the housing and other fields. She rather suggested that we should be called upon to pay if we were in good health. That, of course, is the basis of the National Health Service. We pay when we are well, and when we are ill we get free treatment—unless the view of the former Minister of Health is taken, that additional health charges should be imposed in illness. I must point out that, despite the noble Lady's advocacy of preventive measures, it was her Government which introduced the charge for dental treatment, and have said, in the face of the recommendations of the Guillebaud Committee, that they have no intention of withdrawing that charge.

Lady Tweedsmuir

While that is true, the hon. Member will no doubt remember that it was his Government, when the right hon. Gentleman the Member for Ebbw Vale (Mr. Bevan) was Minister of Health, who introduced the scheme for the increased prescription charge. Although the Government changed, we brought that into effect because we thought it very good.

Mr. Hamilton

The noble Lady will, no doubt, recall that in our last General Election programme we said that we would get rid of all charges, and we intend to do so. The present Government, who claim five wonderful years of prosperity, are now saying that they are in no position to do away with the charges.

It is a shortsighted act to put a charge on dental treatment. All it does is to keep people away from the dentists. The Joint Under-Secretary will probably quote figures showing that there has been an increase in the amount of dental treatment, but the facts not given in the Report are perhaps more significant than those which are. I am glad to see my hon. Friend the Member for Wolverhampton, North-East (Mr. Baird) in the Chamber. He is the only dentist in the House, and he will no doubt agree that there must be thousands of people today who refrain from going to the dentist until the last moment—perhaps until it is too late—because of these charges.

I would say to the noble Lady and to hon. Members opposite that when talking about this national economy campaign they should remember that it is not necessarily economic to spend less money. They want to get that into their heads. If we spend more money, if we forgo the money which the Government are raking in from these dental charges, we may still find that in the long run the loss of work due to ill-health—upon which the noble Lady commented—will be less.

We have heard a lot about the difficulties of the general medical practitioner from my hon. Friend the Member for Greenock (Dr. Dickson Mabon) and from the noble Lady. To hear them talking, one wonders how it is that we have any doctors at all. Of course, one solution is the institution of health centres, but I am quite certain that if and when we ever get into the position nationally to put the health-centre policy into effect, we shall get the undoubted opposition of the medical profession. The very practitioners who now claim that they are overworked—and I would agree that there is a great deal in that claim—will be those who will oppose that policy.

To suggest, as the Minister of Health yesterday suggested in advance, that the doctors are to have no further pay increase—and what applies to doctors the Government are trying to apply throughout industry generally—is an extremely dangerous doctrine to propagate politically. The Government are interfering all along the line with the negotiating machinery. If they do that, and if they interfere, or attempt to interfere, politically with the negotiating machinery within industry, they will be on very dangerous ground.

Let me now refer to one or two points in the current Report. I want to make a specific reference to the dysentery figures, to which I called attention during the Committee stage of the Food and Drugs (Scotland) Bill. I find those figures disquieting, and do not like their perfunctory dismissal in the Report. In page 15, the Report says: … dysentery continues to have considerable nuisance value …". It adds that we should reproach ourselves because the fault lies in personal hygiene.

To a large extent that may be true, but the figures given in Appendix 14 are extremely alarming to the layman's eye. I should like some explanation of them. They show that between 1928 and 1932 the average yearly figure for this disease was 319. I do not know why those years are selected, but perhaps the Joint Under-Secretary will explain. The average figure between 1948 and 1952 was 3,638. In 1955, there were 13,331. In other words, there has been at least a fourfold increase in the last four years. If we compare 1955 with the average of those earlier years, 1928 to 1932, there has been a 4,000 per cent. increase in the dysentery figures for Scotland. I cannot believe that that is due entirely, or even in major part, to an increasing neglect of personal hygiene.

After quoting those figures in Committee, I followed the matter up by putting down a Question asking for the breakdown of these figures according to age groups. I found that approximately 75 per cent. of the cases were among children up to 14 years of age. If these cases are due, as the Report says, primarily to a lack of personal hygiene or carelessness in personal hygiene, then it seems from the figures that that neglect of personal hygiene is to be found primarily in the schools. I suggest that we ought to engage in a vigorous campaign to encourage personal hygiene within our schools.

We come back to a consideration of all the social services, and in discussing this matter, as in discussing other health matters, we should have regard to the importance of providing more and better washing facilities in many of our old and decrepit schools in Scotland, providing good clean towels not once a month or even once a week, but every day. I wonder how many of our schools could claim that the towels provided in their washing accommodation are changed every day. I should be very interested to have the figures.

I want to call attention now to something which has been brought to my notice as a constituency point, but which is, none the less, of rather more general application. I have recently been in correspondence with the Joint Under-Secretary of State concerning the difficulties experienced by women in my division in having to go to maternity hospitals some distance from where they live. In the Lochore and Bowhill area, for instance, they very often have to go to Newport Maternity Hospital, which involves a return journey of about sixty miles. I suppose it is bad enough to make one journey when there is only a two-hourly bus service. Quite naturally, the husband is keen to visit both before and after the birth, and he is put to an expense of something like £1, or perhaps even more, with the loss of work which might be involved. This is particularly hard on miners who, of course, lose the bonus shift in addition to the actual lost time.

That matter of expense is not, however, the main basis of my complaint. My complaint is, as the hon. Gentleman knows, that, on discharge from the maternity hospital, all too frequently the mothers and children are obliged to use public transport in order to get back home. Travelling a distance of thirty miles on public transport, perhaps a week or ten days after confinement, is quite intolerable for a woman even at the best of times. With an inadequate bus service, one can imagine what the journey is like in the winter for a weakened mother and a child only some days old.

I took up this matter with the Department, and the answer was that decisions of this kind must in all cases be left to the doctors. I take the contrary view. In my opinion, the provision of an ambulance should be automatic in maternity cases, and I ask the hon. Gentleman to look at the matter again. One does not want to be extravagant and abuse the ambulance services, but in this sort of case all over Scotland the provision of an ambulance for the journey from the maternity hospital back home should be the rule rather than the exception.

I would go even farther and risk adverse comment, perhaps, but I must say it. A doctor might be put in the position of being influenced by the social and economic standing of his patient. There is not a Member of this Committee who would tolerate his wife having, immediately after confinement, to use public transport to get home from the maternity hospital. In most cases, if the doctor did not provide it or make a decision providing for it, then one would pay for it. But many of these working people are not in a position to do that, and by far the simplest solution to the problem would be to make it obligatory to provide ambulance services in all cases.

I do not want to say very much more, but there is one other matter concerning my constituency which I must raise. This, again, is of rather more general application. I have been in communication with the hon. Gentleman about the provision of hospital services in West Fife, which, I emphasise, is a developing mining area. There has been little or no increase in the provision of surgical beds in that area since 1948. It has been known for even a simple hernia case to have a waiting period of three years, and, of course, in that time complications may arise resulting in a much more dangerous operation in the end. Despite the fact that in 1948 there were 1,890 operations carried out in the West Fife Hospital, and in 1953 there were 3,018, there has been no general increase in the provision of surgical beds.

What I and, I think, the authorities in the area are concerned to know is what are the long-term plans for the area. We know that in the vicinity of the Dunfermline area, in Bowhill, Valleyfield and Kincardine, there are extensive mining developments taking place, and we are trying to attract miners to the area. The provision of social amenities, health services, educational services, and the like, plays a vital part in attracting miners from the declining mining areas. I should have thought it was in the national economic interest that the Government should pay increasing attention to those areas which will be so important in the future for the prosperity of the country.

In particular, I would ask the Government to pay attention to the provision of orthopaedic beds in the area to which I have referred. In the 1952 survey by the South-East Regional Hospital Board, a ratio of 6 beds per 10,000 population for traumatic and orthopaedic surgery was accepted. At the moment, the ratio in the South-East Region is less than half that figure. This is particularly disturbing when one remembers that West Fife, being a mining area, is inevitably prone to pit accidents and injuries arising from incidents of that kind. For instance, last year we had 2,000 orthopaedic cases from West Fife going to the Bridge of Earn Hospital. Incidentally, that is the answer which the hon. Gentleman always gives—they can always go to that hospital. But, again, the expense and inconvenience involved is an unnecessary hardship which ought not to be borne.

Those are my only points, and I hope the hon. Gentleman will take notice of them and give us a satisfactory reply.

6.30 p.m.

Mr. Walter Elliot (Glasgow, Kelvingrove)

The debate this afternoon has shown an interesting trend, a trend towards preventive as against curative medicine. The most interesting speech of the right hon. Gentleman the Member for East Stirlingshire (Mr. Woodburn) hinged on that fact, although he gave more emphasis than I shall to the provision of equipment. I am not sure that equipment is always the best avenue towards the understanding of the human frame. Indeed, I was a little alarmed at the prospect of the heart sounds being learned by a mass of students listening through electronic devices to a single heart, leaving the important factor of the patient almost entirely out of the question.

Mr. Woodburn

May I put it to the right hon. Gentleman that when 20 students have to examine the same patient, if that can be done by one examination it is a great relief to the patient. Also, if the heart is being examined by the professor and the students at the same time, all of them listening to the same beats, the professor is more likely to give an accurate account of what is happening than is the case when the student listens alone.

Mr. Elliot

I would quarrel with both points. A healthy difference with one's professor is the way to salvation whether in medicine or biology. The danger of 20 students examining one patient is a real one, but the way to avoid that is to cut down the number of students in the class to less than 20 rather than to have all listening to one machine. I fear the production of devices to enable mass educatived production to be carried on, because I am not sure that this does not tend to eliminate the human factor, which carries such great weight in any process of doctoring, or indeed of getting well, if one is a patient.

However, these are merely differences of opinion which we are bound to have. I agreed very much with the right hon. Gentleman in his later remarks about the remarkable recent increase and decrease in tuberculosis in Scotland. Like the right hon. Gentleman, I was most disquieted by the fact that nobody could give us any explanation of this fact, not even the very scientific committee which he himself appointed and which afterwards reported. Nor was it fully explained by any of the hypotheses which were brought forward.

I remember myself bringing forward an hypothesis, that it might be due to the injection into our population of a considerable number of a highly susceptible group of persons, namely, the Polish soldiers. That is as good an explanation as any other. Now the Polish soldiers have disappeared, and the rate of tuberculosis in Scotland has returned, I think, to the previous normal rate of decline before this hump in the curve arose. I suppose it would be going too far to say that the particularly susceptible group mentioned by the right hon. Gentleman as being responsible for a high percentage of the cases, namely, young women, had anything to do with the particular group of young men who were brought into the country.

Mr. Woodburn

That would not account for the old men.

Mr. Elliot

No, nothing completely accounts for this phenomenon. We must go on investigating this disease, though it has been the subject of intense examination for a hundred years, and about which one would have thought almost everything was known. Why should it suddenly develop this particular flare-up in one country under close scientific observation, not south of the Border, not connected with industrialisation, because it did not take place in the industrial cities of Wales, and why should it pass off? We are as wise as we were before it started. We know no more about it than we did before the sudden outburst took place.

It is true, as has been said repeatedly during the debate, that we are mastering the epidemics, the infectious diseases. This has thrown into sharp relief the diseases of the circulatory system, such as cardiac diseases, diseases of the gastro-intestinal tract, the duodenal ulcers, the diseases of the respiratory tract, such as the new outburst of the malignant diseases of cancer of the lung, which is causing us all a great deal of uneasiness just now. These are inevitably throwing up a different set of problems, because they are long-distance problems concerned closely with the history of the whole individual. They are not sharp, sudden things like the infections which come on, can be watched through, and clear off. They are long-distance things, whose causes may lie far back in the history of the individual or even into the parents of the individual.

Certainly, we shall have to give a great deal more attention to these long-distance developments than we have done in the past. I am sure that comparison will be one line along which we may make advance; that is to say, comparing widely different areas of country, widely different populations. In that way we may by-pass much intense and laborious observation. To take one case as an example, it will be within the memory of the hon Gentleman the Member for Fife, West (Mr. Hamilton) that when we were in West Africa one of our colleagues, the hon. Member for Kirkcaldy Burghs (Mr. Hubbard) was instructed to have a check-up for a coronary condition in the Ibadan hospital which is one of the great hospitals of West Africa.

When the hon. Member went there it was found that there was no provision for a check-up because these coronary conditions were so little known in West Africa that it was not worth while to undertake any provision for them. These circulatory system diseases, which are so great a factor in our health statistics nowadays, are practically unknown there.

It might be said that this was partly due to the fact that diagnosis of these diseases has not gone so far as it has into the major disease of malaria and such diseases as are caused by malnutrition. It is not entirely that. There is no doubt that diseases due to the high pressure of our modern civilisation are developed amongst our population to a far greater extent than they are among some of the populations living under what might seem to be far less healthy conditions in other parts of the world.

To take another example. Yesterday, I had a short conversation about cancer of the lung with one of the Russian delegates who is over here with the Parliamentary delegation, which we are all pleased to see among us. He is one of the leading surgeons in Moscow. Indeed, I believe he is one of the leading surgeons in all the Soviet Union, and is President of the Medical Academy there. I broached with him the question of cancer of the lung. He said, "Yes, it is increasing with us, also." I asked, "Do you put it down to smoking?" He said "No." He was smoking at the time, so he may have been biased. I asked, "What do you attribute it to?" He said, "Well, we do not know, but we think that perhaps the great use of tar in street paving and conditioning may have something to do with it."

There is no doubt that tar derivatives do play a part in the inducement of neoplasms in some of the smaller animals. He said also that it might be caused by fumes from internal combustion engines, but he added that, in any case, it was increasing with them, and, as far as they understood, it was not increasing among the more primitive populations of the world.

The other thing to remember, of course, is that these events are indeed finally inevitable. We all have to die some day, and some of these conditions are inescapable. That is worth remembering, especially in a debate of this kind. We have not really added to the length of life. The old Scriptural formula about three score years and ten—and if it were four score, then with much trouble—is not a bad insurance formula for the present day. After all, when Shakespeare's character Rosalind was setting out to leave home and walk through the Forest of Arden, she took with her as her companion an old shepherd of 80. A shepherd of 80 would think twice today before setting out with a bright young girl to sleep in the open in the woods.

It has to be remembered that we have added 15 or 20 years only in the earlier years of life, and that in the later years of life it is only a matter of a year or two years—not very much more. The addition to the length of life of almost any of us in this Chamber at the moment is not significantly more than in the Psalmist's day. A group of the elders of that time would have as much expectation of life as the majority of those of us who are sitting here in this Committee in the Palace of Westminster in 1956.

We are also introducing a lot of new factors into our existing conditions. I have mentioned duodenal ulcers, which must be considered as very largely resulting from a condition of strain and worry. It is interesting to note that bus drivers rank very high in the group of people suffering from those troubles, and anybody who sits even as a passenger in a London Transport vehicle must sympathise greatly with the sense of frustration and worry which must be caused to anybody who has to spend his whole life trying to get through the traffic jams of today. In America, if one does not have a duodenal ulcer, one is classed as a slacker. To lack one is regarded as having a "cissy" existence, and it is considered that a man who does not have an ulcer does not take a real interest in his work.

New things are beginning to happen which must make us pay much more attention to these long-distance effects than we have given so far. In particular, there is the change-over from the conventional fuels to the nuclear fuels which is beginning. It will have to come, inevitably, in this country far faster than almost in any other, because we are nearer exhaustion of our own stocks of what are called fossil fuels than any other industrial country in the world. We have debated and argued about the dangers of the fall-out from atomic weapons and atomic test explosions.

Naturally, I do not wish to go into that at all today, except to say that it is part of the reason for the compiling of the extremely interesting Report on the Hazards to Man of Nuclear and Allied Radiations. It brought out a number of points which I do not think any of us have fully appreciated. For instance, the dosage of radiation from X-ray treatment is 22 times as great as anything we receive, or are likely to receive, from test explosions of atomic weapons which are likely to take place during our lifetime.

In Scotland, we are particularly interested in these new nuclear developments, because at Dounreay we have one of the new atomic plants—a breeder plant—going up. There we shall be specially exposed to anything wrong that may happen in the uses of this new fuel. Certainly, we shall have to watch very carefully this change-over, because I think that the hazards of atoms in peace are much greater than the hazards of atoms in war. The hazards of atoms in war are so terrible and so desperate that, unless the human race decides on its own suicide, it will not embark on such a war. But atoms for peace we have already embarked upon in Scotland, and these new developments are bound to go on because our other sources of fuel are diminishing.

This Report is full of intensely interesting by-product information, as, for instance, that one receives a calculable dose of radiation every year from the house in which one lives. I was quite startled to find, in page 49 of the Report, that, while 0.078 roentgens would represent the amount received inside buildings by the inhabitants, in the open air the figure would perhaps be 0.048; that is to say, very substantially less than the figure of the amount received by the dwellers in houses. I do not bring that forward as an argument for living in the woods and in the open, especially in our country in Scotland, where the discomforts would probably outweigh any improvement in health which might result from it, but I had not anticipated that there was any recognisable amount of radiation from the actual buildings in which we live.

It was also pointed out that, in the granite areas, such as Aberdeen, the concentration is greater, buildings in granite rock are more active than buildings of sedimentary rocks, because granite has a higher degree of decomposing radio-active elements. Indeed, the idea that the soil on which we live and the rocks amongst which we move actually penetrate our bodies, and that we are to some extent the actual creatures of the soil on which we live and move, that our association with our mountains and floods is not merely from the picturesque scenery which we see with our eyes, but actual radiation, actually absorbed into our systems, is a completely novel idea to me, and one for which I am indebted to those who compiled this Report. It is premature to discuss this in any detail from the purely health point of view, but it does indicate that there are hidden factors in health of which we have perhaps taken too little note—recognisable and measureable factors.

We should, therefore, give more attention to such things in view of the new developments which are taking place. All the more, perhaps, since strontium 90, the new bogy, is a product of the only element in the whole of the table of elements with a Gaelic name. Strontium comes from Strontian, on the West Coast of Scotland. My Gaelic instructors quarrel, as do most Gaelic instructors, as to whether the Gaelic name means the "the metal of John's nose" or "the metal of the hill of the fairies." Be that as it may, it is interesting to note that it was in Scotland that this new element was first identified; and the old rocks and hills of which so much of Scotland is composed have, perhaps, more to do with the nature of the people living amongst them than one has fully realised.

Problems of health are certainly very varied. Life is short and science is long. We shall have a great deal to do in discussing these matters in future if, as we hope, we gradually, or, indeed, swiftly, reduce the epidemics and infectious diseases. So, in making use of our new powers, it is very necessary for us to beware of introducing new and noxious factors. Some of these have certainly had something to do with the increase in cancer which has been taking place. We must also beware, in the change-over to nuclear power in the new industrial era, that we do not introduce factors which would, in many ways, wipe out the advantages from the new, clean, accessible and cheap form of energy and power which we hope to have in our country.

6.50 p.m.

Mr. William Hannan (Glasgow, Maryhill)

It would be ungracious if I did not, at the beginning, express the opinion, certainly held by my hon. Friends on this side of the Committee and probably held among hon. Members opposite, after listening to that speech, of that temper and nature, which the right hon. Member for Kelvingrove (Mr. Elliot) has just made, that the right hon. Gentleman, when he engages in that type of speech, is much more interesting and much more factual and makes much more appeal to the people of Scotland than when he makes speeches of another kind.

Perhaps the right hon. Gentleman will allow me to inform him that, when he was referring to the decline of tuberculosis and to the fact that the Polish soldiers had gone, I heard one of my hon. Friends say that there had been a decline in something else in Scotland at the same time. Perhaps, also, the right hon. Gentleman will allow me to remind him, since he referred to Rosalind and a shepherd aged 80, that we in Scotland have our own Scottish character, Will Fyffe, who, at the age of 94, was to be married and who was expected to be a father by the time he was 95.

As to the main content of the right hon. Gentleman's speech, we on this side of the Committee, I think, are indebted to him for the warnings he gave us, particularly about radiation. He struck a responsive cord in me when he spoke of cancer and the possibility that its incidence grows relatively with the increased tempo at which our population is living. The Joint Under-Secretary of State will remember that I addressed a Question to him about the after-care of patients who had been in hospital and had been discharged after having been operated on for this terrible disease. In his reply, he said that in only two regions had a full organisation been set up to cope with this increased activity.

Reference is made to this in the Report of the Department of Health for Scotland. The third paragraph, in page 16, says: Cancer registration and follow-up is developing and may be said to be almost complete in two of the hospital regions. Elsewhere there is still leeway to be made up on this important subject, and in any case it will be some years before sufficient information for analysis will have been accumulated. This applies especially to survival rates. While I am sure that the Committee appreciates the efforts which have already been made, I hope that the Department will pursue this matter and have an organisation set up as quickly as possible to perform this function and so add its quota to the great research work which is going on to find the cause of this dreadful disease.

I turn to another matter featured in the Report, the School Health Service, and I ask the Secretary of State to try to cause another Department under his control to make its contribution to the better health of Scotland. I refer him especially to the schools whose sanitary conditions are inadequate. In my opinion, those schools contribute to the increased dysentery figures which my hon. Friend the Member for Fife, West (Mr. Hamilton) has quoted today.

The Report of the Health and Welfare Department of Glasgow Corporation shows that there are 340 schools in Glasgow, and that in the session 1954 to 1955, 144 schools were visited, and that reports were furnished of their sanitary conditions. In 76 of them there were inadequate washing facilities. In 43 there was disrepair of the playgrounds and a lack of sufficient shelters. In 27 the medical inspection room was quite inadequate, or entirely absent. There were 55 where the lighting and heating were defective, and 60—half of them—had defective lavatories and water closets.

That last is not a very nice subject to dwell on, but it is essentially related to the good health and to the training of children. If the sanitary conveniences of 60 schools are quite inadequate, and if the washing facilities are inadequate, then I think there is good reason to believe that those schools are making a big contribution to the remaining infectious diseases. This state of affairs is quite intolerable. It is not an adequate answer to say that it is a matter for the local authority.

I can tell the right hon. Gentleman this, that in one school in my constituency, the Maryhill School, the lavatories are 60 to 70 yards from the main building, that the flushing system in them does not work, and that when the children have to meet the needs of nature, they find that the stools have already been used. The parents warn them before they leave for school. A child in that position suffers not only physical torment. Most of us will agree that, psychologically also, the child suffers a great disability.

Those are the conditions in Maryhill School. Despite representations, despite the fact that the local authority has asked for permission to go ahead with the necessary work, the right hon. Gentleman has replied that, although he agrees in principle, the work has to wait.

There are many other projects to which the right hon. Gentleman agrees in principle, and yet we are still awaiting dates for starting this work. The same sort of thing applies to hospital buildings, and in page 53 of the Department's Report, the point is made that In particular the Government's announcement in February, 1955, of an increase in the amount of hospital building work to be undertaken in 1956–57 and in 1957–58 made it possible for preparatory work to be put in hand on a number of major development schemes of the highest priority, several of them in the mental health field. That was in February, 1955. That was in the halcyon days, the happy days prior to the General Election, when not only health services but roads and transport were to get thousands of pounds. I wonder, does that Government announcement still hold good? What about hospital building? Are the same amounts still to be available, and are the hospital boards to rely on the estimates of the amounts of money which were then promised?

There is another matter to which I should like to draw the right hon. Gentleman's attention, and which I invite the Committee to examine with me. It is the increase in the number of consultants and senior hospital medical officers. Each year since 1951 there has been an increase in the number not only of part-time consultants but of whole-time consultants, to the extraordinary number in the case of the full-time consultants of 125, whereas the number of part-time consultants has increased only by 20.

There has been a decrease of 12 in the number of senior hospital part-time medical officers and an increase of only 44 in the number of full-time officers. Bearing that information in mind, the Committee will be aware that in February and March of this year there were Press reports of representations being made by the Scottish T.U.C. to the hospital boards about the status of these consultants and of some complaints that were made.

Only on Friday last the chairman of the hospital board for the Paisley area was reported as having made a very strong protest because the consultant and specialist organisation had seen fit to refuse an advertisement which the board wanted to place in the Lancet asking for a consultant for one of its hospitals. There is a story behind all this. Some of us know some part of it and are taking strong exception to the whole matter. I hope that the Joint Under-Secretary will give us some information. We should like to know why there has been this tendency to increase the number of full-time consultants.

Mrs. Mann

Is my hon. Friend suggesting that there should not be an increase in the number of full-time consultants? Does he not realise that under the National Health Service every patient is entitled to the service of one of these men?

Mr. Hannan

That may be my hon. Friend's interpretation, but it is not the interpretation that some others are inclined to put on it, including the Scottish T.U.C. I am only asking questions, but it is suggested, for example, that where specialists are appointed whole-time the appointment is only made for two or three months. They then ask to be appointed part-time consultants and thereby derive certain Income Tax advantages. If this is a development which the Department thinks is undesirable, we should like to know about it.

The Reports of the Department of Health for Scotland and the Scottish Health Services Council for 1952 state that there was a consultation between the Department and the consultants' organisation when the Department itself wanted to create a new grade so that the senior hospital officers who wanted to become consultants would spend some time as specialists and then go on to take up the higher grade. I understand that the negotiations broke down but that talks were resumed at a later date. I should like to know the real facts about this apparent disagreement.

The Department's 1955 Report conveys some heartening prospects for the future. It points out, for example, that the decrease in the infectious diseases, and particularly in tuberculosis, will make it possible in future to make use of for the aged and infirm some of the accommodation previously used by those patients. I admit that that is looking rather far ahead and that in particular spots, like Glasgow, the tuberculosis rate is still very high and we cannot accept the present position. But I should like to say to the Department and to the medical people in Scotland that we have the greatest admiration for their work. We hope that their efforts with the more pressing problems will be attended with success in the very near future and that as a result mankind may have fewer worries about future prospects and that in that way the Health Service will make a contribution to the welfare of our people and their children.

7.6 p.m.

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

I will confine myself to only one or two references to the remarks just made by the hon. Member for Maryhill (Mr. Hannan). Most of the hon. Member's speech was directed to the Joint Under-Secretary of State for Scotland in the form of questions to which he wishes to have answers. He is quite right in posing those questions at this time. I would draw his attention only to the fact that he referred to the plans as announced in 1955 for 1956, 1957 and 1958, and referred the Committee to page 53 of the Report of the Department of Health for Scotland. But the answer to the question which the hon. Member posed is surely contained in the paragraph headed "current building", which sets out the programme for 1956–58 in detail and in items of expenditure.

Mr. Hannan

May I suggest to the hon. and gallant Member that reference to page 54 of the Report, under the heading "Regional hospital board programmes", shows that while these have been approved in principle by the Secretary of State, nevertheless the boards will find it difficult to make decisions on questions of relative priority?

Commander Donaldson

I understand the point the hon. Member is now making, but the accepted programme and the expressed desire is recorded in the paragraph to which I referred. However, I do not with to argue that with the hon. Member because on these occasions when we discuss matters of health in Scotland the Committee is at its happiest and most sympathetic. It has been so today, with one or two exceptions, in accepting the Report presented to it by the Secretary of State.

The exception I first noted was the hon. Member for Greenock (Dr. Dickson Mabon) who, I am sorry to say, has once more just left the Chamber. In passing, I should like to observe that we have a curious custom in this Chamber in that we refer to those who have qualified in the profession of arms as hon. and gallant Members and to those qualified and learned in the law as hon. and learned Members, but there are those who are qualified in other professions, such as the medical profession, and we have no particular title for them. I could not refer to the hon. Member for Greenock as the hon. and medicated Member, although he is well qualified, as is my right hon. Friend the Member for Kelvingrove (Mr. Elliot).

Be that as it may, the hon. Member for Greenock criticised the Department's Report in some measure and referred to the Department not as the Department of Health for Scotland but as the "Department of Ill-Health". Later in his speech he told us that the Report contained no statistics of health and that all that was available in it was the statistics of ill-health.

That is reasonable. If every healthy person had to be mentioned we should have more bureaucrats than we have now. The hon. Member referred, and there were subsequent references, to the setting up of health centres, and I think that the Committee on both sides was in agreement with that thought, as expressed by him and by the hon. Member for Dunbartonshire, West (Mr. Steele). We hope that the day will be hastened when these health centres are more adequately provided not only in Scotland, but throughout the United Kingdom.

I wish to direct my attention for a short time not to the provision of health centres or, in particular, to the provision of hospitals, but to the people who have to man the hospitals and clinics which we have now established, for there, indeed, is one of the great difficulties which faces the Health Services of Scotland at present. I have now, as always, in mind, when discussing this subject in these debates, the difficulties which are being experienced in the central hospital for the Borders, located just outside Galashiels, the Peel Hospital, where there is an excellent supply of equipment of every kind and type for the instruction of nurses who wish to join as probationers and to become qualified in the nursing profession.

All is there, ready and available, and the only thing that is lacking is a sufficient supply of recruits. The new superintendent of the hospital has appealed frequently in the Borders for recruits, but they will not come forward and, of course, there are reasons why they do not. One is that fortunately or unfortunately, according to how we look at it, we have full employment in that part. The mill towns of the Borders are in full employment, with fewer than 1 per cent. unemployed in Roxburgh, Selkirk and Peebles.

The wages paid to young women are attractive, but there are still, in my belief, young people coming out of the schools who have passed their basic education, who have a sense of calling and who would be called into the service of their neighbours and their friends in the nursing service but for other attractions. I still believe that there are some who have heard the call but have not heard the question put.

I ask my right hon. Friend, through the Department of Health for Scotland, when he appeals for volunteers to come forward as nurses to staff our hospitals, to make it clear that, if there are any teaching schools in Scotland which have their full quota, there are other hospitals elsewhere, and certainly in the Border, which have adequate and good equipment and reasonable and proper facilities for people to live, and where the desire is great to obtain people to maintain the hospitals which we have.

Some hon. Members opposite have spoken of the mental health services and only in passing would I refer to them. I recall, however, that two or three years ago the emphasis in this annual debate which we have was greatly on the mental hospital services. I am refreshed and relieved to know that there is some improvement in the standard of the mental hospital service and in the numbers available to take part in that important work in our hospital and medical services.

I have in my constituency, at Melrose, the Dingleton Mental Institution, where the superintendent has carried out, over a period of years, a most extraordinary experiment in relation to mental treatment; where the patients are free to come and go; where they are not confined: where they are on trust and to which they invariably return when they stray. It has been a great experiment which has been watched not only in this country but by those engaged in mental healing in other parts of the world. I hope that there will never be any lack of people to supply the nursing needs of that hospital.

There is one other aspect to which I should like to refer. It is in relation to those who have to administer the Health Services. It is my opinion, from the experience of a friend of mine, who is not a constituent and who lives in another part of Scotland, that there may be a tendency for too much impingement of the Civil Service into administration which should be purely under the control of the medical side of the hospitals, particularly the great hospitals.

I remember one case very distinctly. 1 had occasion to refer it to the previous Joint Under-Secretary, now Lord Strathclyde, and the matter was amicably adjusted. In the case which I have in mind, there was far too much control over the medical side of that particular institution by a civil servant who was not qualified in medicine and who had not the qualification or the right, in my opinion, to interfere in matters which should have been purely under the jurisdiction of the medical side of the administration.

My final point relates to costings. We know that it is necessary for the Government to consider certain restraints in expenditure, but we must not, nor is it the desire of the Government, curtail the Health Service. I believe, however, that economies could be effected without causing any hurt to the Health Service. I should like to have some information about the prescription side of the Service. Reference was made to this subject earlier in the debate. The Report, in page 39, under the heading "Prescribing", says: Many other doctors were interviewed by local medical committees and given guidance about means of reducing their prescribing costs to justifiable levels. "Justifiable" is a word which must have been put there by intent. The Report goes on to say: Every doctor now has the opportunity to examine his own priced prescriptions for the months covered by the statistics at the Executive Council offices if he wishes, and many have found this helpful. There are indications that, as a result of the greater attention given to prescribing costs, doctors are tending to prescribe smaller quantities of drugs (i.e., for a shorter period of treatment at a time), with some consequent increase in the number of separate prescriptions issued. I am not so interested in the number of prescriptions issued as I am in the total cost for any one year of the actual prescriptions issued for patients.

I wonder whether the Under-Secretary will be able to give us some information on the matter of prescriptions and how the costings are running; whether the costings of prescriptions are rising, or whether they are being more evened out. I do not think that anyone on either side of the Committee wishes to see people deprived of any prescriptions which they ought to have, but I think that all of us representing Scottish constituencies wish to see that reasonable care is taken as to the amount of each prescription that is given, and that drugs which are costly should not be wasted.

7.19 p.m.

Mr. John Rankin (Glasgow, Govan)

It is good to listen to hon. Members, on both sides of the Committee, congratula- ting the people who are responsible for running the great public services which are dealt with in the Report. On the local authority side, on the specialist side and on the general practitioner side, we can welcome the good work which is being done and of which the Report gives details.

Naturally, in some aspects advance has not been as rapid as many of us would have hoped. I have spoken before of the Victoria Hospital in my own area. While it seems that some little progress is being made in expanding the potentialities of the hospital, I should like the Under-Secretary of State, when he replies to the debate, to be able to indicate that more rapid progress will be made.

As the Secretary of State knows, there has been a big shift in the population of the City of Glasgow. There has been a movement from the northern side of the city to the southern part. At the same time, however, there has not been a sufficient expansion of the hospital services to meet the needs of the increased population on the south side of the city. I believe that a programme has now been approved by the hospital board, and that over a period of years there may be a sufficient expansion in the hospital, which services, I imagine, at least half of the south side of Glasgow, to enable it more adequately to undertake the work which it is called upon to do. I hope that the Secretary of State will use his great influence to urge the Hospital Board to still greater endeavours in this direction.

What we on this side of the Committee particularly welcome is that the Tory Government are now vigorously defending this admirable Service, the birth of which they did their very best to prevent. We remember their vigorous opposition to its inception. We hope that they will now support the Service as vigorously as they opposed it at the time of its introduction by the Labour Party.

One aspect to which I should like to refer briefly is the general practitioner side. The Report tells us that the number of principals in Scotland is 2,584, that there are 249 assistants, and that the average number of patients on each principal's list is 1,974. This works out at a salary to each principal in line with the desire expressed in the Report that a principal should have around £2,200 a year. No one will quarrel with that average number of 1,974.

From Appendix 11, however, we learn that 109 doctors, working single-handed without an assistant, have from 2,500 to 3,600 patients on their list and that 12 doctors have lists of over 3,600 patients. I have discussed with many doctors the maximum number which should be permitted for a doctor's list, and every doctor whom I have consulted has said that it is quite impossible for any single medical practitioner to deal adequately with a list of 3,600 patients. Many of them go so far as to say that anything over 2,500 is more than sufficient.

I have seen consulting rooms of doctors whose lists, I suspect, are around 3,000. The number of people seeking consultation is sometimes so great that a wait of two hours is entailed. I often wonder what would happen if, with that number of patients on a doctor's list, we were suddenly faced with an epidemic. My feeling is that on the general practitioner side there would be a danger of the scheme breaking clown, because doctors who have no assistance and who are dealing with such a large number as 3,600 patients would find the work beyond their physical powers.

Time and again, we are told in the Press, and it is urged upon us by medical people, that in the event of illness, the need for early diagnosis is important, but when waiting rooms are in some cases excessively overcrowded and when lists are too heavy, the possibility of carrying out a careful diagnosis at an early stage is, in my opinion at least, not so easily achieved.

We are told in the Report that the number of doctors with fewer than 1,500 patients is 425. That is to say, one-sixth of the principals have patients numbering fewer than 1,500. With those numbers, however, that one-sixth of Scotland's doctors may find it almost impossible to achieve the salary which the Report visualises for principals in Scotland.

The time has been reached when the Secretary of State should consider again reducing the maximum number on a doctor's list. At present, each doctor is entitled to have 3,800 patients on his list. I think that that number ought now to be reduced, and reduced considerably, to around 3,500, if not 3,000. It should be reduced in the interests of the patients and of providing the medical attention required to make early diagnosis where that is necessary. It should be reduced in the interests of the doctors themselves, because those who have 3,000 patients or more on their lists are undertaking far too heavy a job for one man. Were the permitted maximum reduced, it would mean a fairer distribution of the available number of patients.

If the maximum has to be reduced I think that, in fairness, we should reconsider the capitation fee. Whether that would result in an increase in the Estimate I am not sure, because there would be a reduction in the number of patients in the case of doctors with large practices. But if the Secretary of State is to consider a reduction of the maximum permitted number of patients, at the same time I think he should consider an increase in the capitation fee and in the fee allowed for loading.

Another item to which I wish to draw the attention of the right hon. Gentleman is the procedure followed when a doctor is appointed to a new practice. The vacancy is advertised, and the local executive makes the appointment. Immediately a notice is issued to every person on the list of the previous doctor intimating that the new doctor has been appointed and that patients may now change their doctor. I should like the Secretary of State to think about that procedure. I consider it the wrong thing to do. It is unfair to the incoming doctor because the result is that nearly every patient thinks about the fact that the former doctor has gone, and that the new doctor is someone whom they know nothing about. Consequently there is a tendency for those people to consider changing to another doctor who is already in practice in the area.

That sort of thing can do a great deal of harm to a young doctor taking over a new practice. He gets off to a false start. The whole procedure is a complete reversal of the former attitude, which was to try to keep the practice together and, as it were, to hand it over as a going concern. It would seem that now we are doing our best to disperse the practice whereas we should try to keep it together in order to give the incoming doctor a reasonable chance to make good.

To do so is not to do injustice to the patients who are on the list, because at any time they have the right to change their doctor. There is no bar to that, nor is there a special period when notice is given advising people that they may now change their doctor. Everyone knows that under the National Health Service they can change to another doctor at short notice.

In examining the work done by this magnificent Service, it would seem that there are some things which might be tightened up to the advantage of the men and women who have to carry on the work and without harm being done to the interests of the patients. These are one or two of the matters which occurred to me as I read parts of the Report. I did not read the whole of it but merely those parts in which I was interested and which deal with matters which I had discussed with those who are helping to make a success of this work.

Most of the people with whom I have talked concurred with my view that the size of the list is too great for a single doctor to overtake, and that the maximum permitted number of patients ought to be reduced; and, in order that there should be no unfairness, that the capitation fee should be increased from the present figure of 17s. They agreed also with my other point, that when a new doctor comes into the area there should not be this unnecessary procedure of informing all the people on the list of the previous doctor that they have the right to change, when that right is already inherent in the Service. That does no good to the people who are on the list, and may do harm to the incoming doctor. I hope that the Secretary of State will be able to give me a favourable reply to the points which I have raised.

7.37 p.m.

Captain J. A. L. Duncan (South Angus)

Evidently the hon. Member for Govan (Mr. Rankin) has studied the question of doctors. I hope that he will excuse me if I do not follow his observations, because I am not qualified to discuss that matter. He said that the Tories were now pleased with the National Health Service although originally they had opposed it. I would remind him that it was during the war-time Government, led by my right hon. Friend the Member for Woodford (Sir W. Churchill) that the idea of a review of the health services was initiated and under the distinguished Liberal, Lord Beveridge, and that it was under Mr. Willink, then at the Health Ministry, that details of these proposals were formulated. The proposals were almost ready when the Labour Government came into office, and so it is a false representation of history to say that the Tories who at first opposed the idea are now in support of it. I will not say more than that in a debate which has proved so non-controversial.

Mr. Rankin

I was merely stating the facts which are on record, that when the National Health Service was introduced the Tory Opposition gave it no welcome.

Captain Duncan

I was not present myself but a reasoned Amendment was put down indicating how the Tory Party would have done it, but they did not oppose the idea.

May I now refer to some of the good features of the Report which we are discussing today? Some of the figures, comparing pre-war conditions with now, are most remarkable. For instance, the number of maternal deaths in 1939 was 135 per thousand live births. Last year the number of mothers who died in childbirth was only 43, representing a death rate of 0.3 per thousand, out of more than 90,000 live births. It is now, the Report says, a rare occurrence in Scotland for a mother to die in childbirth. We all ought to welcome that fact as a most remarkable change. Year after year that death-rate has gone down until it is now well below one per thousand.

In 1939 there were 3,241 deaths of children under one month old, a rate of 36.9 per thousand. Last year there were only 1,826, a death rate of 19.7 per thousand, almost half. Of children under one year, there were 6,650 deaths in 1939, a death rate of 75.8 per thousand. Last year the deaths were only 2,811, a death rate of 30.4, a truly remarkable reduction.

I am not going to try to attribute the causes either to the present Government or to the last Government, The reduction may be due to the development of medical skill and science, to treatment, to better nutrition or to a whole host of other causes. The fact remains that in respect of a number of matters about which we were very worried in pre-war days there has been a most remarkable reduction in the death rate, particularly among mothers and young children.

Tuberculosis has been referred to. In 1939, the respiratory deaths were 54 per thousand cases. Last year they were 17, a very remarkable reduction. The non-respiratory deaths are now down to two per thousand cases as compared with 16 in 1939. These are most remarkable figures, and everybody in Scotland ought to be proud of them. All who have contributed to these results deserve our praise.

A most remarkable fact about milk emerges in the Report. My right hon. Friend the Secretary of State was not quite accurate because he did not quote what is in his own Report, in which it is stated that 93 per cent. of all the milk consumed in Scotland is T.T. and certified. That is the figure which my right hon. Friend gave. In addition, as indicated on page 84 of the Report, 5 per cent. of our milk comes from T.T. herds and therefore leaves the cow in T.T. condition. The figure is therefore that 98 per cent. and not 93 per cent. of all milk used in Scotland for human consumption is T.T., certified, and clean.

That figure is a very great tribute to the farmers in Scotland, and particularly to the dairy farmers, for taking such a great interest in the T.T. scheme. It is also a tribute to the local authorities who deal with the milk when it reaches the retailers, The milk that people drink today in Scotland, is, to all intents and purposes, 100 per cent. pure and clean when it reaches them. That is also a great tribute to all concerned.

Mr. Woodburn

The figure that I wanted from the Secretary of State was one showing how far we now have whole areas of Scotland with T.T. herds. The point that the hon. and gallant Member is making is about farmers. We got to that level in Argyll some years ago. I was wondering what counties were not certified now.

Captain Duncan

The right hon. Gentleman was asking for the number of what we farmers call the "free testing areas". That is in the Report, and applies to a very large part of the south, west and central areas of Scotland, which are now 100 per cent. T.T. Fife is a free testing area. Perthshire is on the verge of being a free testing area and Angus is on the way too.

Mr. Woodburn

These are very interesting figures.

Captain Duncan

They are all on page 84 of the Report.

In addition, I think I am correct in saying that all the large towns in Scotland now receive 100 per cent. certified milk. From the point of view of the farmer that goes some way to getting the 100 per cent. free testing area, and from the point of view of the consumer we have pretty well 100 per cent. clean and T.T. milk sold in the towns.

The next thing I want to say is slightly more critical, and is about slaughterhouses. This is also in the Report. We had a Departmental Committee a long time ago, and its Report was eagerly awaited. We read it, some of us did not like it. My right hon. Friend had discussions with the local authorities and put forward plans. The local authorities did not like the plans, which were based upon the Report; nor did I or my hon. Friends. I am glad to say that my right hon. Friend took the original plans back, started renewed consultations with the local authorities and tried to get the matter settled.

It cannot wait much longer. There are many slaughterhouses in Scotland, nearly all owned by local authorities, and something will really have to be done to them. I know that my own local authority is only too anxious to get on with this job, if it is allowed to. Some local authorities may have to put up new slaughterhouses, and many of them will have to spend a lot of money on repairs and modernisation. Until they know the plans, and my right hon. Friend gets agreement between himself and the local authority associations upon them, the local authorities do not, in the interests of their ratepayers, feel justified in going forward at the moment.

The matter is urgent, in the interests of health. I hope that my right hon. Friend will announce very shortly—before the summer Recess, if he cannot do it this evening—what his plans are, so that the local authorities will be able to go ahead with modernising their slaughterhouses. That will be in the interests of our people, of economy, and of the fatstock industry. If we can get the plans adopted I believe it will lead to economy and efficiency in the fatstock industry, in the butchery and in the retailing of meat and livestock.

Various aspects of the question of health in Scotland appear in the Report, and I wish to say a word or two about mental health. I was delighted a few years ago when a new building plan was announced. There is reference to that on page 53 of the Report. I am glad to know that a great deal of new building has been done in my part of Scotland, and that more is being done. That is very urgent and I congratulate the Scottish Office on realising the need for such building for we shall never get contented staff unless we get decent buildings for that staff. On the mental side, as against the mental deficiency side, I believe there is an increasing hope of better results every year as a result of new methods of treatment, new drugs and new scientific apparatus, particularly when cases come early enough for diagnosis and early treatment.

I am sorry that there was an unfortunate incident in Baldovan which necessitated a court case and a subsequent inquiry. There is a great deal of interest locally in what the commissioner said. Although my right hon. Friend is probably right in treating the report of the commissioner as confidential between him and the regional hospital board, I hope that he will at least say in public what conclusions were reached by the board and the action taken on that report. I think it would very largely satisfy local opinion if people knew that as a result of that unfortunate case matters had been put right for the future, and that such a case will not recur.

I had a great deal of experience of mental deficiency work when I was chairman of mental deficiency institutions thirty years ago in London. I know what a soul-destroying job it is. Unless one has a happy institution with a happy staff it is just not possible to treat patients in the way in which they should be treated.

The main object of my rising tonight—I hope I shall not cut across too much of what the hon. Lady the Member for Coatbridge and Airdrie (Mrs. Mann) is going to say—was, first, to pay tribute to the work which she has been doing in the last few years on the question of home safety, and, secondly, to say a few words about the subject to which she might like to add later.

The references to this subject are on pages 47 and 48 of the Report. In the statistical mortality analysis in the Report there are some very curious figures. They show that deaths by violence reach a very high percentage in certain age groups. For instance, between the ages of 1 and 4 violence comes top of the causes, with 28.9 per cent. in that age group. In the age group 5 to 14 it is again top with 32.3 per cent. It tends to go down to third place between the ages of 15 and 44 and comes last after the age of 65. It must be very dangerous to be alive between the ages of 5 and 14.

I do not know what "violence" means as there is no detailed description of the word in this Report. It must cover road accidents, murder and many other things, but I am sure that it must also include home accidents. If anyone falls down a stairway, is burned, or has an accident, that is presumably described as something violent. I should like to sec the figures broken down.

We ought to know officially about deaths in the home. There was a Standing Inter-Departmental Committee set up in 1947 by the Home Secretary. It included a member from the Health Department of Scotland and a member from the Home Department of Scotland. It has only reported once, in 1953. I have that Report, which is entitled "Accidents in the Home". It gives a certain amount of information, but it is already largely out of date. I cannot help feeling that that Committee may be doing some good work, but it seems to be hiding its light under a very big bushel.

I should like to know a lot more about this Inter-departmental Committee, what it is doing, and why it does not publish a report every year and keep us in touch with this matter. I should like to see some detailed investigation in a sample area and to see if we cannot break down the figures of deaths from accidents in the home. Incidentally, there are no figures of non-fatal accidents in the home. In the natural course of events, if those cases do not go to hospital there is no means of finding out about them.

There is a whole range of possible reasons for accidents in the home, and the 1953 Report which I have mentioned referred to some of them. For instance, there may be a staircase where there is a difference in the level between one floor and another, of, may be, a couple of stairs, the stair tread may be worn or it may be structurally unsound from the safety point of view. The stairs may be badly lit. The bulk of these accidents occur to old people, not young people.

Then there is the the question of materials. The hon. Lady the Member for Coatbridge and Airdrie continually asks Questions about dangerous materials. Putting a child in a flannelette nightdress before an unguarded gas fire is like committing murder. When a baby or young child just able to crawl and wearing a flannelette nightdress comes in contact with an open fire that is almost certain to lead to the death of that child. I think I am right in saying that if a quarter of the surface of the skin of a child is burned there is no hope of its recovery.

Mrs. Mann

It is 30 per cent.

Captain Duncan

In any case, a quarter is bad enough.

So much for the Inter-departmental Committee. I hope that my hon. Friend the Joint Under-Secretary of State will put some life into it. If the English will not play, let us have our own Committee.

There are some figures which the Royal Society and the hon. Lady have dug out from one source or another which are of interest. On 10th July, the figures were given in the House of deaths from home accidents in the four big cities in Scotland. They totalled 466, 457 and 472 in 1953, 1954 and 1955. That is a fairly steady rate of just under 500 deaths each year from accidents in the home.

An interesting point is that whereas in Dundee, which has no home safety committee and, so far as I know, has done no propaganda in this matter, the figures were 65 in 1953, 64 in 1954 and 67 in 1955, showing a slight increase, in Aberdeen, which had an accident week last year, the figures had fallen from 45 in 1953 to 39 in 1955. That is not a very significant decrease, but it is a decrease. The populations of Dundee and Aberdeen are almost the same, yet there is a difference of 20 deaths a year from home accidents as between Aberdeen and Dundee. I do not know why that is, but it may be that the trend of fatal accidents in Aberdeen is downwards, first, because of the accident week there and, secondly, because more propaganda in this direction is being undertaken in Aberdeen than in Dundee.

Mr. Steele

Can the hon. and gallant Gentleman break down the statistics for Aberdeen and Dundee to show how many were caused by gas poisoning?

Captain Duncan

I am afraid that I cannot do that, nor can the Scottish Office, and that is why I am asking for a more detailed investigation. It may be that if safety committees were appointed in Aberdeen and Dundee, this detailed investigation and comparison between the death rates in the two towns of comparable population might produce some results on which we could work in the future.

There is no official information on the death rate from home accidents in the rest of Scotland. The Royal Society for the Prevention of Accidents has, however, dug out some figures from which it appears that the total for Scotland in 1954 was 1,108. In other words, more than 1,000 people are being killed every year in Scotland as a result of accidents in the home which could well be avoided. The figures are rising slightly.

What can we do about it? I should like to make some suggestions. The Department's Report states, on page 48: The prevention of home accidents is essentially a matter for regular education of the public in the need for consideration and foresight, particularly in homes where there are young children. … What propaganda is being conducted? Practically none.

Mr. E. G. Willis (Edinburgh, East)

What about Edinburgh.

Captain Duncan

There are only four home safety committees in Scotland.

Mr. Willis

There is one in Edinburgh.

Captain Duncan

There is one in Edinburgh, one in Glasgow, one in Kilmarnock and one somewhere else.

Mrs. Mann

In Aberdeen.

Captain Duncan

That may be one of the reasons for the better figures in Aberdeen.

The Royal Society for the Prevention of Accidents scarcely exists in Scotland. It has an office in Edinburgh, but it is unable to spread its experience and usefulness north of the Border, and it operates mainly in England. I should like to see greater encouragement given to the Royal Society to take its propaganda, films and lectures into Scotland. But it must receive co-operation from the local people.

I should like to see a special propaganda effort made, as in Aberdeen. If we had an accident week in Dundee, for instance, we might be able to reduce the figures of these accidents by 20 per cent. or even 40 per cent., and in the future we could in this way keep in touch with the health visitors, the midwives, the nurses and the schools. I believe that the schools are probably as important as any other factor in this matter. If we make the children safety conscious we make the mothers much more responsible in their attitude towards the safety of their young children.

I want a much more detailed study of the causes of accidents by breaking down the figures, as the hon. Member for Dunbartonshire, West (Mr. Steele) asked, so that we know whether they are the builders' fault, the landlords' fault, the tenants' fault, the electricians' fault or, in textiles, the fault of the manufacturers of textiles. Let us try to put these things right so that at least we may know what is dangerous and what is not.

Much electricity is used in the modern home and the knowledge of how to look after electrical equipment, such as kettles and irons, and keep it safe, using the proper flex and plug, ought to be greater than it is. I must say, however, that the electrical industry is better than many others. We want co-operation from the local authorities, which I believe to be essential. If they set up home safety committees, I believe that those committees, with the blessing of the authorities, could do a great deal to save life.

My last suggestion directly affects my hon. Friend the Joint Under-Secretary of State. I suggest that a circular should be sent to local authorities advising them on what can be done. I should like the Inter-departmental Committee, with more active co-operation from the local authorities, to call attention from time to time to the suggestions that it has to make and to urge local authorities that this is a serious problem of saving the lives of many young mothers and many other young people.

It may be difficult to prevent every accident, but a great deal can be done, particularly for the old people, to ensure, for example, that they do not break their legs through falling downstairs, having slipped on slippery linoleum or on a faulty stair-tread. In that way we can do something to save lives and, as we all wish, to prolong happiness.

8.9 p.m.

Mr. John Taylor (West Lothian)

The speech of the hon. and gallant Member for South Angus (Captain Duncan), particularly the main part of it, was on a fascinating subject, one into which I am sorely tempted to follow him, but it occurs to me as not at all improbable that my hon. Friend the Member for Coatbridge and Airdrie (Mrs. Mann), who is to wind up the debate for the Opposition, will wish to devote part of her speech to that subject, because it is a subject to which she has given a great deal of careful and objective thought. I think we may safely leave it in her hands.

I am tempted to make one very brief comment about one train of thought which the hon. and gallant Member started in my mind when he spoke of the responsibility of the manufacturers of textiles or of electrical appliances. I believe that the time has come when Parliament should take a hand in this, particularly in the control of the manufacture of electrical appliances, as it did fairly recently when it required that every electric or gas fire should have a guard. We should take a hand, also, in requiring that the two-pin round electric plug should be abolished, and that the use of the flat-pinned plug with the shuttered receptive part should be made universal and compulsory. That type of plug has reduced the risk of electrocution and electric shocks to what is, in our present state of knowledge, almost the irreducible minimum.

After two well-informed and erudite speeches from two hon. Members belonging to the medical profession, I enter this debate with some circumspection. I imagine that it is a good many years since in a Scottish health debate we had two physicians contributing so valuably. I was particularly interested in the excellent speech of the right hon. Gentleman the Member for Kelvingrove (Mr. Elliot), and especially in his intriguing suggestion that Scots are radioactive. That is a completely new thought. It may be that the many people who come to Scotland at this time of year, and forthwith claim Scottish parentage, can be tested for radioactivity with a geiger counter.

I want, however, to devote my speech to one aspect of the Health Service, which has been mentioned by the hon. and gallant Member for South Angus and one or two other hon. Members but which is only very briefly mentioned in the Report. It is the subject of mental illness. A White Paper was presented to Parliament last December by the Secretary of State for Scotland entitled "The Law Relating to Mental Illness and Mental Deficiency in Scotland". It is Command 9623. I wish to quote only two small extracts to show its purpose. The White Paper states: The purpose of this Paper is to put forward proposals for changes in the present law so that these may be freely examined and discussed. The proposed changes outlined in the following pages are designed to bring the present law and practice into line with current and more enlightened ideas of psychological medicine, and to secure the more effective care of persons suffering from mental illness or defect. The opportunity is also taken to include a number of amendments which experience has shown to be administratively desirable. It may be doubtful whether to discuss that is in order as it forecasts legislation, but let me make this very short quotation from the next paragraph but one: The Government will welcome discussions of the proposals in this Paper, which are intended to form the basis of consultations with all interested bodies and organisations. In the light of that I submit that it is in order to make a few remarks upon the proposals. That last quotation clearly indicates that the White Paper is to a very large extent exploratory and contains some serious proposals for our consideration.

I want to comment briefly on two of the main proposals, because they have raised doubts in my mind about which I should like the Committee to know and about which I should like to have some assurance. The first deals with the admission and discharge of voluntary patients. With the very best intentions, the White Paper seeks to encourage those patients. To do this it proposes to abolish the existing requirement that the assent of a Commissioner of the General Board of Control must be obtained within three days of a voluntary patient's admission. I have no objection to that abolition. In practically all cases it is probably purely formal.

I have, however, certain misgivings about the proposal for the discharge of such patients. This would provide for discharge either on the direction of the board of management of the hospital, which is normal, or upon the written request of the next-of-kin, with a proviso that the medical superintendent can represent to the Board of Control that the patient is not fit for discharge. If he did so represent, the consent of the Board of Control would be required.

These are called safeguards, but I have the feeling that the safeguard is all on the side of the hospital, of the medical superintendent and his staff, and that there is not quite sufficient safeguard on the side of the patient. The prospective voluntary patient may well consider that it is very easy to enter a mental hospital but less easy, if these proposals are accepted, to leave it. Entry would be made more easy, discharge a little more difficult.

As I say, the intention is to encourage more people who may benefit from treatment in a mental hospital to become voluntary patients. At the beginning of this debate we heard from the Secretary of State that, last year, 72 per cent. of all admissions to the mental hospitals in Scotland were voluntary. I have not the figures for England and Wales last year, but in 1954 the voluntary patient percentage there was 66 per cent.

On the face of those figures there does not seem to be a great deal of encouragement necessary in Scotland for people to become voluntary patients, and what we should be trying to do is to avoid any discouragement of them. I hope that the Government will give the most careful scrutiny to the proposal, so that any change in the existing law provides safeguards for patients to leave hospital as well as safeguards for the general public.

What I consider to be more important is that the White Paper also asks us to consider the establishment of a new category of mental patients, to be called recommended patients. If the proposal is approved this will become a new term in our medical vocabulary. At the first reading, this proposal for recommended patients seemed to be extremely reasonable. When I first read it I thought it a good idea and reasonable in the extreme. On closer examination, however, grave doubts have been raised in my mind.

It is proposed that the recommended patient should be admitted at once on an application by an appropriate relative or by an authorised officer, the latter I gather, being the local medical officer, an officer of the local authority. The authorised officer's recommendation or application must be supported by two medical certificates. So far, that seems reasonable and fair. Under existing arrangements for the admission of those who are not voluntary patients, however, some legal or judicial authorisation is also required, and there is no such provision in the suggested proposals which we, in common with other interested authorities in Scotland, are asked to consider. A direction by the sheriff or any other form of judicial order is, it seems to me, carefully and deliberately avoided.

We ought to examine for a moment or two how this might operate. It is suggested that a recommended patient is one who is, or would be, incapable of deciding, or unwilling, to enter a mental hospital voluntarily. As to one who is incapable of deciding, the decision would be made for him by the medical authorities, and one could not possibly complain against that. A decision may, however, be made for someone who is unwilling to enter a mental hospital, and, in his case, consider that there ought to be some other authority, some judicial authority, to which he can turn in order to help that decision to be a right one.

Once application has been made by a relative in a case of this kind, who is to decide?—only the doctors. There is no provision made for any judicial investigation whatever. The doctors are to be directly responsible for certification and, as I shall show, for detention. At present, the doctors have not this direct responsibility. They have merely to supply evidence to a judicial authority which must satisfy itself that detention is proper and is in the true interests of the public, of the patient, and of society. It seems to me that these two proposals I have mentioned require much closer examination before we proceed further with them.

There are some other proposals which cause me some anxiety. The medical certificates on admission of recommended patients do not, according to these proposals in the White Paper, have to certify that the patient is insane or is of unsound mind; they have merely to state—and I quote—that he is suffering from mental illness and is likely to benefit from in-patient treatment". A citizen suffering from some degree of mental illness, perhaps a temporary illness, can thus become subject to deprivation of liberty for an indefinite period, without a judicial inquiry and without a judicial order, purely upon a medical ipse dixit.

That is not fair to the doctors. I am quite certain it is not fair to the patient. I may be old-fashioned in this matter, but I believe that personal liberty is our most precious possession, and that we in the House of Commons should be alert to safeguard it. It may be said that nothing wrong is likely to happen. That is a perfectly fair argument; but the fact that it could, or might, happen, even to only one poor unfortunate person in the whole of Scotland in one year, should be sufficient for us to be on the alert. I believe it is our duty to prevent that possibility.

The recommended patient has a right of appeal within one month of admission, and that appeal is to the General Board of Control. But the Board, in deciding upon this appeal, does not examine the patient. It examines the medical certificates. Even at that stage, when a patient is consciously fighting for his liberty, he is denied judicial consideration, or any consideration other than medical. I have no complaint against these medical decisions; normally, they are proper and right. Even at that stage the patient is denied the consideration by the trained judicial mind which is provided for under our present practice in dealing with mental patients.

Perhaps I am making a mountain out of a molehill, but this White Paper was presented to Parliament. We were asked to look at and consider it. These matters occurred to me, and seemed to be of sufficient importance, because of their possible consequence, that I thought it wise to raise them in this Committee tonight.

8.27 p.m.

Mr. J. C. George (Glasgow, Pollok)

I have not the knowledge and experience of the hon. Member for West Lothian (Mr. J. Taylor) about mental health and mental institutions, but I was deeply impressed by the broad outlook and depth of sympathy he has shown for that type of patient. He has mentioned recommended patients and involuntary patients. I have recently had experience of being concerned with the welfare of a voluntary patient.

I know how serious is the shock which parents receive when finding that one of their children, perhaps in middle age or in adolescence, is affected by mental illness. I remember how, throughout the years, we in Scotland have looked upon mental illness as something to hide, to be ashamed of, something not to be brought to light. This young man to whom I am referring, and his parents, had this shock. He suffered mental illness, and for months his parents worried about his future, undecided what they should do. They were pressed by the local doctor to let the young man go into hospital as a voluntary patient. Ultimately he did go, and showed great courage under rather severe and testing treatment.

I understand that this young man was given huge injections of insulin over a long period. He wrote to me every week when he was undergoing that treatment. Later, and not long ago, I met him. He was no longer suffering from mental illness but was the picture of strong physical health, in every way restored to his home and parents, a good son and a useful citizen.

I hope that, as a result of what I have said, anyone in Scotland who may be in the same position as were the parents of this young man, worrying what they should do about their child who has shown similar symptoms, will realise that medical science has advanced a long way along that road and can today give help which was undreamed of not long ago.

I listened to the speech of the hon. Gentleman the Member for Govan (Mr. Rankin) in which he referred to the Victoria Hospital, which is in my area and on the border of my constituency. I had occasion to visit that hospital at the request of the staff committee and found there much need for capital expenditure, much need for an extension of the hospital. I follow the hon. Member in everything he said about the need for money being spent in that place. I shall not draw a black picture of it. There are difficulties there for a loyal, faithful and able staff. There are, for instance, difficulties in a population which has almost trebled in the last ten years. We have asked that something should be done. I understand that something is to be done but, like the hon. Member for Govan, I ask my hon. Friend the Under-Secretary to see that it is done urgently and is done on a scale to meet the obvious needs.

This has been a serious debate all the way through, with only one discordant note. That came from the hon. Gentleman the Member for Greenock (Dr. Dickson Mabon), who said that he had felt little satisfaction in reading the Report. That, coming from a physician, a member of the medical profession, made me wonder whether I had read the Report properly. After hearing his speech. I wondered whether he had read the Report at all. One has no need to go far into it to receive satisfaction, and if the hon. Gentleman found little, he must have gone very little into it. This is what is stated on the first page: … the gains recorded in previous years are mostly being steadily increased. There have been improvements in the statistics relating to infant life … Maternal death rates are lower than ever. There has been a continuation of the remarkable change in the picture as regards tuberculosis …

Dr. Dickson Mabon

Let me, first, assure the hon. Gentleman that I have read the Report fully, in fact several times. Secondly, I doubt whether he has done me the courtesy of looking really far into my speech. My point was that as Scotsmen we ought not to be satisfied with the relative improvement in our own statistics. We can only be satisfied when our statistics are better than those of England and Wales. That was the burden of my speech. As yet very few of these statistics are better than those of England and Wales, and that is something of which we ought to be ashamed.

Mr. George

I hope that the hon. Member will recollect his own speech, because I took down what he said and he was talking about the Report in general in saying that it gave him very little satisfaction. He made the other remark about the infant and maternal death rates and used rather extravagant language. He said that these were disgraceful, dreadful and shocking. Is that really the view of a responsible medical man, a Member of Parliament, in these days?

Let us look at the figures of Glasgow, let alone Greenock. In 1942, in Glasgow there were 90 deaths per 1,000 live births. In 1954, that figure had dropped to 36. Undoubtedly, every effort of the medical profession is directed towards reducing that figure still further. When I hear from a medical man an extravagant condemnation of the progress made, I expect it to be followed by some suggestion for improvement. Here is a young man not long from a university, full of vigour, making an extravagant condemnation of the system in force and of the people operating that system.

Dr. Dickson Mabon

Would the hon. Gentleman agree with me that these stand amongst the worst figures in Western Europe?

Mr. George

I heard the same argument used upstairs about housing. There seems to be a tendency on the part of hon. Gentlemen opposite to decry Scotland in the eyes of the world. We are always the worst, and always the worst in Western Europe.

Dr. Dickson Mabon

In this category we are.

Mr. George

I do not accept that. I am giving the figures for Scotland to show the improvement. If the hon. Gentleman is shocked, if these figures are dreadful, it is upon his shoulders to tell us how they can be improved. He did not do so. I trust that in the future the destructive dialectical ability he has shown will not be proved to be greater than his medical ability. I know it will not.

Dr. Dickson Mabon

I apologise for interrupting for the third time, but may I direct the attention of the hon. Gentleman to the third sentence of the first paragraph in page 11 of the Report: Infant and maternal mortality rates both showed further reductions, although the lower levels attained in England and Wales and in other Western European countries suggest that there is still room for improvement in Scotland. The Department of Health is on my side in this matter.

Mr. George

I did not suggest that there was no room for improvement. What I said was that the hon. Member, with all his medical experience and recent knowledge from the university, did not show us any.

We know that the health authorities are trying to get these figures down, and I say no more because I appreciated one thing the hon. Gentleman said. He said that in this question of Scottish health, there was a social component as well as a medical one. That is a deep thought which we should always keep in mind when we discuss matters of health in this House. We should not seek to filch for the political side that which in reality is due to the medical side. That was a wise saying on the part of the hon. Gentleman, and one which I take to heart.

Many and varied have been the subjects raised today, but I want to be quite parochial in the matters which I wish to discuss. I want to stick closely to the question of tuberculosis in Glasgow, in particular, and to the welfare of the old people. I want to analyse the tuberculosis position, having regard, first, to our failure in Glasgow to keep in line with the reduction in the death rate from tuberculosis which has been shown throughout the country, and, in particular in the large cities of England. I want to try to investigate whether housing plays any part in that failure, and also to try to discover whether we can obtain any benefits from the Clean Air Act, which was recently passed by Parliament.

First, to deal with our failure to keep pace with the large cities in reducing the death rate from tuberculosis, we have long known that bad housing is related to the incidence and severity of tuberculosis. We have been well warned by our local authorities, and I have myself served on the health committees of local authorities for a number of years. The officers of these committees have pleaded with us to do everything we could to give contacts and sufferers rooms in which they could live by themselves, so that other people need not have contact with them. For far too long we have failed to make this elementary provision in Glasgow, but the housing authority has been extremely co-operative with the medical officer and has given priority to tuberculosis patients, so far as its building programme would sensibly allow.

It would seem, on looking through the records of housing progress in Glasgow, that the rate of building better houses and transferring tuberculosis cases to them has some effect on the death rate from that disease. In Glasgow, as in other cities in the country, the death rate for tuberculosis has fallen substantially, but we are concerned with the figures today, and the Medical Officer of Health for Glasgow expressed his concern about them to me in a discussion recently.

In 1931, the death rate in Glasgow from tuberculosis per 100,000 of the population was 87; in Edinburgh it was 70; and in Dundee 73. In 1954, the Glasgow death rate on the same basis had happily fallen to 39, but the Edinburgh and Dundee rates had both fallen far below that to 19. Looking at the position in English cities, for example, Liverpool and Manchester, in 1931 Liverpool had a death rate of 115, which was far higher than that of Glasgow, and Manchester had a rate of 112, also far higher than Glasgow. Yet these two cities have managed to reduce their death rates to 29 and 27 respectively, whereas the Glasgow rate still sticks at 39.

We are concerned about our lack of progress, as compared with other cities. Our medical people are not at fault. They do everything in their power, day in and day out, to deal with this and other diseases under their charge. Immense efforts are being made to control tuberculosis in Glasgow. There are now no empty beds in sanatoria, the waiting lists have disappeared, but the Glasgow figures are still in excess of those for other cities. We have vigorously employed the use of B.C.G. vaccines for the protection of contacts, newly-born infants and school children, but it will be some years before we see the effect of that.

Our failure to keep abreast of other cities in reducing the death rate, and in reducing the incidence of the disease, has caused the medical officer of health to raise the matter in recent months. The rate of incidence of tuberculosis gives us more concern. The rate in Glasgow remains stubbornly above 200 per 100,000 of the population, although elsewhere in the country the rate has fallen and does not much exceed 100. The housing committee has co-operated fully, and we have heard today about the plans for 1957, for the great X-ray campaign in Glasgow, to try to track down sources of infection yet unknown. All these efforts are being made in Glasgow, and yet the rate of incidence and the death rate, compared with those of other cities, still cause worry.

We cannot but feel disappointed at our housing position in Glasgow, especially as compared with that in other cities. I mentioned earlier that a room should be provided for every sufferer where he can sleep alone. That is not possible in half the City of Glasgow. I would draw attention to some figures, which, I think are quite staggering. In Glasgow, 48 per cent. of all the houses consists of houses of one or two apartments; in Birmingham, 2 per cent.; in Manchester, 2 per cent.; in Liverpool, 3.4 per cent.

Here are the numbers of houses in those cities with from one to three apartments: in Glasgow, 76.6 per cent.; in Birmingham, 14.6 per cent.; in Manchester, 10.7 per cent.; in Liverpool, 12 per cent. They show clearly that we in Glasgow have a housing problem in that we have a far, far higher percentage of houses with one, two and three apartments than there is in the other great cities.

Let us look back a few years to see what progress has been made in Scotland as a whole, and whether Glasgow has even kept pace with that progress. In 1861, of all the houses in Scotland 65.2 per cent. were of one or two apartments. In 1951, that proportion had fallen to 28.6 per cent. In Glasgow, as I have said, the figure was 48 per cent. In 1861, the proportion of houses in Scotland with more than two rooms was 37.9 per cent., and that proportion has risen today to 71.5 per cent. In Glasgow, the proportion is only 52 per cent.

I agree that slum clearance must be undertaken, and that in many cities and counties the time has come to do it. While accepting that Glasgow Corporation must undertake some clearance of slums, to give the slum dwellers a hope of better things for the future, I still say that overcrowding is still by far the major problem in Glasgow. I do not wish to overstate the position in Glasgow or the dangers arising from the statistics which I have quoted, but I suggest that when we are considering the health of the country in relation to projected financial provisions for new housing we cannot have a common policy for the country as a whole. All ailments and diseases must be treated according to their cause and severity.

If overcrowding in Scotland as a whole has been reduced, so that the picture is presented of slum clearance being the main problem, are we not bound to look in detail throughout the country to see whether we are not applying one remedy to different sorts of ailments? Glasgow has a slum clearance problem and so has Scotland, but I maintain that Glasgow has an overcrowding problem which dwarfs slum clearance, and that any steps taken by the Government at this stage which may result in diminishing the provisions for overcrowding will be a retrograde one, and so will handicap the health authorities in their fight against tuberculosis, and not only penalise those who suffer but endanger those who are bound to live in close contact with them.

Therefore, I ask my right hon. Friend not to be too hidebound by mathematics if he finds that he must make changes which might reduce the number of houses built here and there in Scotland. I beg of him to have the courage, if need be, to treat Glasgow as a separate problem in the light of the figures which I have presented. Glasgow Corporation has been diligent in providing houses, but it is reaching a point where it is using up all the available sites. In the last thirty-five years the population of Glasgow has been completely static, which is a rather amazing fact. Therefore, if the population has been static and nearly all the sites have been used conditions are bound to have been improved.

The question is whether the methods used in building upon the remaining sites are wise. In two districts it is proposed to build 150 habitable rooms per acre, which gives a density of 270 persons per acre. That fact gives the medical officer some concern, which he expressed in his 1954 Report in these words: These densities are far in excess of what has been customary and it is difficult to believe that they will not have an adverse effect on the health of the rehoused community. I ask the Minister to consider that point.

This brings me back to new towns and the speed with which they can be brought into being to assist in dealing with the problem in Glasgow, and to a study of whether or not we are tackling new towns on anything like the requisite scale. Glasgow overspill is supposed to be 300,000. Has my right hon. Friend checked that figure? On the statistics available to me, I cannot arrive at an overspill of anything like that figure. If we are to cater for overspill we must know its extent, but let us assume that that is the figure for Glasgow. The overspill of London is said to be 400,000, and eight new towns are being built to deal with it. On a basis of simple proportion we should be building six new towns to deal with Glasgow. That is the magnitude of the problem. When we have determined the extent of the overspill I hope that a programme will be drawn up showing how it will be tackled with some degree of rapidity in the years ahead.

Recently, after considerable discussion, the House of Commons passed the Clean Air Act. Undoubtedly, the condition of the atmosphere in Glasgow has some bearing on the incidence of tuberculosis in the city. Glasgow Corporation has not been idle in this matter of ensuring clean air. Some years ago it started a very comprehensive survey, especially of the city centre, and it was ready to put into operation a plan for smokeless zones. The precipitation of dust throughout Glasgow has been studied. It was found that in 1953 there was a precipitation of 207 tons per square mile and in 1954 a precipitation of 237 tons and that 15,000 tons of dust fell on Glasgow citizens each year. An analysis of the dust showed the presence of the tar of which the right hon. Member for East Stirlingshire (Mr. Woodburn) spoke.

In Glasgow, something must be done to implement the requirements of the Clean Air Act. What can be done to bring about smokeless zones? We know that industry will continue to try to improve its methods. If it does not, powers are given to the authorities to ensure that the new Act is implemented. We can expect improvements in the case of industry, but can we expect any improvement in the domestic situation? The prospect ahead suggests that we shall see little change. Not a ton of smokeless fuel is produced in Scotland, with the exception of coke produced at gasworks. If we have no smokeless fuel, how can we ensure an improvement in the domestic aspect of this clean air problem?

I wonder whether my hon. Friend can tell me if he knows of any plan from the National Coal Board to deal with this, and whether there are any schemes at all in being or in project for encouraging private enterprise to start making smokeless fuel, for without smokeless fuel the Clean Air Act will mean nothing to Glasgow from the point of view of dealing with disease problems. I hope that we shall be told something about these matters.

8.50 p.m.

Mrs. Jean Mann (Coatbridge and Airdrie)

We have had a very long and interesting debate. I thought that we were letting the Scots down very badly because we have all been rather too much in agreement with each other. That is really contrary to the spirit of Scotland and certainly contrary to the nature of this House, which has Government benches and Opposition benches. I was rather pleased when the Member for Pollok (Mr. George) began talking about a discordant note because I thought that Scotland had arrived again in the House of Commons.

I feel inclined to associate myself with my hon. Friend the Member for Greenock (Dr. Dickson Mabon), because when he picked out of this very interesting, comprehensive and able Report, which gives us the maximum amount of information in the minimum amount of space—what more could a politician desire?—three matters, still births, the maternal death rate and the neonatal death rate, I thought that he had concentrated on something at which we ought to look.

I was very charmed with the rest of the speech of the hon. Member for Pollok and very perturbed indeed when he stated, if I heard him correctly, that Glasgow was contemplating rehousing at a density of 200 persons. That is surely unheard of in Great Britain. I do not know whether he was referring to gross or net density.

Mr. George

The figure was 270 persons.

Mrs. Mann

I hope that the Secretary of State will put his foot down. There was an outcry in London when Professor Abercrombie announced a density for some of the London areas of 200, and it was stopped. London would not stand for it. I hope that we shall not go back over the last fifty or a hundred years in the matter of overdensity of housing within the City of Glasgow.

When I come to the question of controversy concerning this Report, I choose from page 87 the paragraph on nutrition, I am calling the attention of the Committee to women and children, and I begin with the children. I have been interested in the National Food Survey and particularly in the fact that in that Survey we find that where a family reaches three children or more the diet in vital items falls far below the standard set by the British Medical Association. That leaves us no room for complacency.

It is all very well to go through the Report and to see how tuberculosis has decreased, how the figures for infectious diseases have fallen, and how diphtheria has been almost wiped out. We have no right to take that credit unto ourselves—we owe most of it to medical science; but when we probe the diseases over which we as politicians have some control, what do we do?

I come back to the question of nutrition and the standard set by the British Medical Association. I do not want to quote all nine items but will take just one. In total protein, while the standard is 124, in families with three or more children the figure goes down to 96. The National Food Survey deplores the fact that the nutritional level is falling. I wondered how Scotland fared in this respect, for I could not break down the figures from the national Report. I had an idea that Scotland would be found to be very much worse.

This is what I find in the paragraph on nutrition: In general the Scottish diet appeared to be lower in animal protein, fat and Vitamin C, than the British diet and richer in carbohydrate. The man who coined that phrase is capable of turning boogie-woogie into a Beethoven symphony. "Rich in carbohydrate". Suppose that a Scottish mother sends dad out with slices of bread—no cheese, nothing between; that is to be his mid-day lunch—but says, "When you come home tonight, I will have a lovely meal for you", and she heaps up a great big plate of nothing but potatoes. When he grumbles, she says, "Look at the Report. I am giving you a diet rich in carbohydrate."

I notice also that the Scottish mother is blamed. This is what the Report says: a special analysis was made of the Scottish section of the group of approximately 3,000 families in Britain whose expenditure on food is analysed by the National Food Survey. The results indicate appreciable differences between the average Scottish diet and that of Britain generally. Most noticeable was the higher consumption of cakes and biscuits (mirrored by lower purchases of flour for home-baking) … The lazy Scottish housewife: unlike her English sister, she does not bake so much. She buys cakes and biscuits. The hon. Member for Pollok, who told us of the terrible housing conditions in Glasgow, would agree that there are very few facilities in Scotland for getting down to cake-baking, except, perhaps, in our new housing schemes.

There is a great difference in the consumption of potatoes and other vegetables. There is a higher consumption of potatoes and root vegetables coupled with a lower consumption of fresh green vegetables and fruit. Why is the Scots housewife not buying fresh green vegetables and fruit, and why is she not buying animal protein? There are those who say that she could have bought it quite well but she has bought a television set instead. I think that for the housewife a television set is a very good investment. It keeps the husband at home, it keeps the children together, and, over a number of years it probably saves members of the family from standing in the rain in queues at the picture houses and also the money spent in the picture houses. However, we will let that matter lie for the moment.

It is not sufficiently known that in Scotland we are paying far too high a price for fresh fruit and vegetables. I had suspected that for a long time and I asked the Joint Under-Secretary about it at Question Time one day. In Scotland we pay an average of 4d. per lb. more for all fresh fruit and vegetables compared with the rest of the country. As this cannot be accounted for wholly by freight rates, I asked the Joint Under-Secretary the reason for it. I was prepared for a denial, but there was no denial.

The reason given to me was a very good reason, and one which I understand. I think that every Scot should know that reason. The hon. Gentleman told me that it was a question of the law of supply and demand and a question of markets. Scotland has a population of only 5 million, very scattered geographically, whereas in England, where the population is proportionately very much greater, there is speedy access to great markets in the Midlands, Birmingham, Coventry, Leicester, and so on. The greater London area has a population of 11 million.

Let the compilers of the Report be fair to the Scottish mother and explain that the reason for the lower nutritional standard in Scotland is probably the higher cost. The English are more kind. They say in the national Report that the reason why potatoes and root vegetables are bought in larger quantities in England is that they cost less.

I now come to the point that Scottish children are below the nutritional level set by the British Medical Association. What are we going to do about it? We are not going to do anything. We are merely going to make it a little more difficult for them. The one meal compiled by the dietician which satisfies the British Medical Association is that provided by the school meals service. But we have decided to increase the price of that meal, in spite of the fact that all the reports show that these are the children who are below the standard of nutrition.

I will read to the House what the Lanarkshire Council has to say about it. It says: After the last increase in meal prices there had been a drop"—in Lanarkshire—"from 41 per cent. to 29 per cent. in the number of children taking them, and in the four years since then it had been possible only to build the percentage up to 36. The proposed new increases were bound to result in a further reduction. It may be said that it is only an increase of 1d. per meal, but the Lanarkshire Council points out that after the last increase it introduced its own system under which it fixed the price of a meal to the eldest child in a family at 8d. If there were three other children in the same family the price of their meals was fixed at 7d. each. It now says that it may have to increase the price of all meals to 10d.

Surely, the Secretary of State and the Joint Under-Secretaries could not have known that our children in Scotland were under the nutritional standard set by the British Medical Association when they made this decision. Surely, they will now repent. Surely, they will issue instructions to stop that increase.

Worst of all, I read that the free milk to nursery school pupils is to go down while the price of the meals goes up. The amount to the nursery school pupils is to go down from two-thirds to one-third of a pint a day. These measures will save the State about £248,000 a year, it was announced last night.

Hon. Members

Women and children first.

Mrs. Mann

I hear some of my hon. Friends saying, "Women and children first". It is true that mothers and children cannot form a pressure group. They have no time to be organised, and therefore they should have the first call on our consideration. Some philosopher once said that the well-being of a nation lies in the health and happiness of her children.

Here I join issue with the hon. Member for Pollok, who criticised my hon. Friend the Member for Greenock. Reading the stillbirth and neonatal death rate figures, I find little difference in the past six years. In fact, in the United Kingdom Report it states that deaths from toxaemia have stayed at the same level for six years and stillbirths are increasing. This disease causes one-fifth of the stillbirths, and if we examine the figures for 1955, compared with 1953 we find that they have increased. Last year they increased over 1953 and even the Report, which tries to be fair to the Government, indicates that the changes in these rates, although a certain amount of improvement is revealed are refractory compared for example with the improvements in the post-natal . period which has declined from 15.6 per thousand in 1950 to 10.7 per thousand in 1955. I think this a salient part of the paragraph: Of the total infant deaths occurring within 28 days of birth in 1954, namely 1,904, no fewer than 1,641 occurred within the first week and 888 within the first day. Of these early infant deaths immaturity, asphyxia and atelectasis, birth injuries and congenital malformations are the main causes. I am bound to confess that I stumbled over that word, "atelectasis". I did not know its meaning. I consulted the Oxford Dictionary and it was not there. I consulted a medical dictionary and I am told that it means a failure of the lung to expand. I consulted two doctors and, as usual, they differed.

There is no reason for us to be complacent about the 1,904 infant deaths, the stillbirth, and neonatal death rate. The gynaecologists of Scotland are far from complacent. My hon. Friend the Member for Greenock is in the best possible company in criticising these figures. No less a person than Professor Dugald Baird, of Aberdeen, in a paper given to a conference two or three years ago, pointed out that the figures were far too high, and he indicated some of the remedies. High prices, mothers going out to work, and bad housing were mentioned as causes, and he compared conditions in Scotland with the very fine air in the South of England where perhaps the richest people live and life is very sunny, easy and comfortable. He pointed out that the deaths in Scotland were five times higher than in the South of England. There is no reason for us to be complacent.

I read in the Report that the greatest risk for children aged from 1 month to 12 months arises from respiratory disease and gastro-enteritis. Respiratory diseases can be mainly traced to bad housing. Gastro-enteritis almost never occurs in breast-fed infants. I deplore these facts. I believe that much of the reason for the figures remaining static may lie in the fact that young mothers go out to work. A mother may remain too long at work before her confinement and get up too quickly, so as to go out to work again.

Doctors are insistent on these points in all the clinics, and are doing great work. Young mothers want to breast-feed their babies but how can they do so if they are all going out to jobs? I should like mothers not to take on jobs, but the cost of living makes it difficult for them to stay at home. I do not think that the mother goes out to work because she likes it but because she feels that it is necessary in order to make ends meet.

I want to end on the subject of housing, but at this point I should like to say how gratified I am at the references made to the subject of accidents in the home. I did not mean to speak on this subject at all tonight, but I know that we are awakening interest in the House of Commons. A great many hon. Members have already joined the Home Safety Group here, and in the autumn we shall have a good, going campaign.

We must have education on this matter among the children. It is very nice for the Secretary of State to tell us about giving out leaflets at health centres and clinics, but leaflets can easily be destroyed. I think I have already said that my keenest memory of effective work was what I saw in Belfast where the fire brigade was taken to the schools and the firemen gave out the leaflets. The education authority gave prizes to the children who wrote the best essay. I would use the surgeons especially the plastic surgeons and the doctors. It is well worth a domiciliary fee to get one of those who is on the spot and sees the deaths and the drama of it all, to go in his white coat and talk to the youngsters. That would have a great effect.

We shall get nowhere unless home accidents are made notifiable. Please do not tell us that it is impossible to make them notifiable. Every general practitioner takes a list of the notifiable diseases to the medical officer of health almost daily. He could take a list of accidents in the home. Then we would get to know where they are occurring most frequently. In the same way as we know of dangerous roads, we would know the dangerous towns, and shame them into going ahead with propaganda on this subject. I think we have the co-operation and sympathy of the Secretary of State and of the Joint Under-Secretary, who will follow me in this debate.

There is a traffic going on in housing in Scotland. It is a new kind of traffic, a traffic in selling slums. Every day we hear of people saying, "I bought a house scheduled for demolition". I have a report by Mr. Pollock, sanitary inspector for Lanark, in which he speaks of people who, perhaps through forces outside their control or through the ulterior motive of jumping the queue for local authority housing allocations, are purchasing properties scheduled to be dealt with as unfit for human habitation.

A deputation came to me in my constituency at what we politicians call our "surgery". They were not grumbling at paying £90 for a house which they knew was scheduled for demolition. They were willing to pay £90, £100, or £150 to get an unfit slum because by acquiring it they knew they would be all right for life. They would be rehoused and they were jumping the queue. While many are ready, quite illegally, to pay key money for an old ruined kitchen, they find it much more worth while to pay a larger amount of key money to get a subsidised house for life and to jump the queue.

Hon. Members opposite indicate agreement, but I want to know what they are going to do about this. It is quite illegal. Once a house is scheduled for demolition it is an offence to let it. What about the landlord who sells such a house? Why are we not prosecuting those landlords? I have raised this matter at Question Time; it is nothing new. I am always told that it is a matter for the local authority. I hope that local authorities will do something about it. It is utterly wrong to allow owners, who under the 1930 Act are entitled to no compensation whatever for a house once it is scheduled—they are not entitled to receive a penny in rent—to receive large sums of money in this way. I believe that in England they are going even a little further and compensating some of the people who are jumping the queue. They are compensating the landlord for acting illegally. I hope that if the Press has any influence at all it will make known in Scotland the fact that these landlords ought to be prosecuted.

There are some snags, and one is the question: is the house just about to be scheduled or is it actually scheduled? I know that in Scotland for years there has been doubt over that fine distinction, but we now have the Housing (Rents and Repairs) (Scotland) Act under which local authorities declare, in their survey, the number of houses scheduled, and it surely ought to be possible to put the notices up at local authority headquarters and to stop this traffic in selling the slums.

Another point about housing concerns the reference in the Report to hutted camps. Great publicity has been given to the families in Lanarkshire who are about to be evicted. There is one family of ten living in one of these deplorable hutted camps. Why should they live in hutted camps? Why should we not take into consideration the number of empty houses in Glasgow or in Scotland generally? Why is there no record of the number of houses which have been standing empty in the City of Glasgow and elsewhere in Scotland for a year or eighteen months?

I have heard hon. Members on this side of the Committee say that they have fought relentlessly on this matter. My hon. Friend the Member for Shettleston (Mr. McGovern) and I were the first to raise this question of selling houses instead of letting them. We were on the Government benches at the time, and were asking our own Government, who were pressed for time; it was 1951, and we were about to leave office. They could not promise legislation.

We formed a backroom committee, the hon. Member for Shettleston and myself; we were the backroom boys. We got every Labour Member to agree that this practice should be stopped, and the only way we could think of stopping it was by the introduction of a Private Member's Bill. We decided that we would all put our names into the Ballot and that whoever drew his name out of the Ballot would present the Bill. Such a Bill would, of course, have no chance with this Government in office, because I do not think they would consent to it.

We were told by our Lord Advocate at the time—he is now a lord justice—that there was another way of dealing with the matter, and that was for local authorities to step in and take over the houses. We hear about the houses in Traquair Drive, Cardonald, which have been empty for some years. Why does not the local authority step in and take them over? Why do not authorities do so here and there and experiment, if they see fit to do so? I presented my local authority with that memorandum, drawn up by the former Lord Advocate, in which he pointed out the powers which all authorities have under the 1947 Housing Act. I said, "What about stepping in and taking over these houses?" In his memorandum the Lord Advocate said the authorities could take them over at a great advantage since, under compulsory purchase, the arbitrator's price would not include the enhanced value of vacant possession. The local authority, therefore, was in a position to get such houses at a lower price than was the private individual.

At the time when the houses in Cardonald were forcibly seized by the tenants' association, and women and children put into them by the association—and that step ended in the court—I again wondered why the Glasgow Corporation did not do something. I asked some of the members of the Corporation why something had not been done. I felt sure that had I been chairman of the housing committee, as I once was, I should have risked a compulsory purchase order. I told them so, and the reply was, "It takes so long. You have to give notice and then you have to take all the objections". But those houses in Traquair Drive have been standing empty for eighteen months. It would not have taken all that time to have given notice.

There is another point. When the Labour Party comes back to power we will introduce our policy, which will mean local authorities taking over vacant houses and houses still tenanted under the Rent Restriction Acts. We shall then seek to know what amendments will be required to that legislation, but I still feel that we should experiment. Using the present powers, let us find out whether they are weak, so that later on they can be amended. I believe that vacant houses should always enter into a report on housing. Why talk about the number of houses we are to build if we are to shut our eyes to the number that are empty in our own burghs or cities?

I have covered quite a wide range of topics. I have spoken of the children and of stillbirths. While I am thinking of that latter subject, I wonder if, when he replies, the Joint Under-Secretary could throw some light on the 57 bodies that where found in the tea chest, and which were obviously stillborn. Public opinion has been very perturbed about that. I am glad that we have had such an interesting debate, and I hope that Scotland, Scottish mothers, and, in particular, Scottish children, will profit from our discussions today.

9.29 p.m.

The Joint Under-Secretary of State for Scotland (Mr. J. Nixon Browne)

I should like, first, as I am sure would the Committee, to congratulate the hon. Lady the Member for Coatbridge and Airdrie (Mrs. Mann) on what I believe is a maiden appearance at the Dispatch Box. I am sure she will agree that it is very nice to have somewhere to put one's papers, and comforting, on occasion, to have something to hold on to—especially in moments of crisis.

The hon. Lady said that she was pleased that there was so little opposition, but in raising the important points which she did raise regarding nutrition, though she did not attack this side of the Committee I think that when she reads her speech she may feel that she has something to answer for to the Scottish housewives, because her criticism of their cooking and their purchasing was quite strong. What the hon. Lady said about malnutrition, however, and I agreed with every word of it, was a complete justification of family allowances. Without question, the Government are pursuing the right policy here. The hon. Lady criticised the price of school meals and, of course, we take her point, but she will remember that no parent has to pay for school meals for his child if he cannot afford to do so.

The hon. Member for West Lothian (Mr. J. Taylor) made a sincere and constructive speech on some important points on the White Paper relating to mental illness and mental deficiency in Scotland. The whole matter is now under review by those concerned, and I can assure him that his speech will be most carefully studied.

The hon. Member for Greenock (Dr. Dickson Mabon), the hon. Member for Govan (Mr. Rankin) and other hon. Members, questioned whether the arrangements under which the general practitioner service is at present operating are satisfactory. Many valuable suggestions and criticisms have been made. I will not attempt to answer them all, but they will be studied. Hon. Members will, I know, appreciate that in very many respects the profession, quite properly, runs its own show. My right hon. Friend is, however, keeping and will keep the problems under review.

The hon. Member for Govan spoke of the size of the lists. As he said, a reduction in the maximum number on a general practitioner's list would involve the recasting of remuneration, and we cannot at the moment contemplate that. He spoke, also, of the problems of the young doctor taking over a new practice. The notice about a new doctor tells the patients of the practice that, unless they ask for a change, they will go on to the new doctor's list. To do anything less than that would surely be short of honest to the patients, who may not otherwise know that the old doctor has gone away.

Mr. Rankin

I ask the hon. Gentleman not to tie himself to a final answer on those two matters. Originally, the permitted figure was 4,000 patients per doctor. After a great deal of pressure, we agreed that that should be reduced to 3,500. I am now asking him to reconsider that number, with a view to a reduction in the long run. I will not pursue the other point now.

Mr. Browne

I quite agree with the hon. Gentleman; we are of course, feeling our way with this comparatively new Health Service, and within that context we must not tie ourselves finally to any policy about anything.

The hon. Member for Greenock said something about the Nuffield Trust, of which I took a note. He said that in Scotland the only good work is being done at the initiative and expense of the Nuffield Provincial Hospitals Trust. He knows that it is not true. We are, nevertheless, very grateful indeed to the Nuffield Trust for all the help it gives. It has helped us with a variety of projects in Scotland. The Trust drew the plans for the Greenock wards, incorporating the ideas of the nursing organisation, which I myself saw last year. The main cost of the building of the wards was met by the Exchequer.

Dr. Dickson Mabon

Since I am accused of making an untrue statement, may I point out that my words were that the only good work done on a reasonable scale in relation to these matters was done by the Nuffield Provincial Hospitals Trust? That is a very important qualification. I bolstered it with the facts which I submitted, which the hon. Gentleman is now quoting.

Mr. Browne

We shall be able to read his words tomorrow. If I have misquoted what the hon. Gentleman said, I apologise.

The hon. Gentleman spoke of the relationship between assistants and principals in general practice. This is a matter entirely in the hands of the medical profession. My right hon. Friend has sufficient on his hands without acting, or undertaking to act, as its guide, and surely this is something which the profession itself can look after. He spoke, also, about trainer practitioners. Trainer practitioners are not endorsed as such unless and until they contemplate taking a trainee. The selection committee represents all branches of the profession, and my right hon. Friend would be loath to interfere with its decisions. Here I can say, to cover one point made by the hon. Lady the Member for Coatbridge and Airdrie, in an interjection, that this is not a corner in cheap assistance for the doctor concerned, because if he has a trainee he cannot increase the size of his lists.

Dr. Dickson Mabon

He gets free services.

Mrs. Mann

I do not think I implied that he did. I thought my hon. Friend was arguing that the same doctors always get trainee assistants, and I pointed out that there was great danger of exploitation of the practice of trainee assistants.

Mr. Browne

My hon. Friend the Member for Aberdeen, South (Lady Tweedsmuir) and my right hon. Friend the Member for Kelvingrove (Mr. Elliot) referred to health centres. We are feeling our way about health centres——

Mr. Willis

Very slowly.

Mr. Browne

Many group practices are today well on their way to becoming health centres themselves. My right hon. Friend has to work with the medical profession and with the public, and support for the principle of health centres is by no means universal. We must wait and see how those that we have already are progressing.

My hon. and gallant Friend the Member for Roxburgh, Selkirk and Peebles (Commander Donaldson) asked about prescribing. The drug bill in Scotland is already costing over £5 million a year and is still rising. What can we do to control this? Essentially, the control of prescribing is in the hands of the doctor himself, whose complete clinical freedom to prescribe whatever drug he thinks best for his patients is limited only by his judgment and by the need in certain cases to justify his prescribing to his professional colleagues.

The National Health Service should not lay down rules for economical prescribing. All it can do is, by issuing guidance and information, to create a climate in which doctors are encouraged to seek economy in the use of drugs without detriment to the treatment of the patient. One of the most effective instruments for developing cost consciousness in prescribing has proved to be the statistics which are issued to each doctor three times a year, showing the cost of his prescriptions.

The same figures are made available to the local medical committee, so that it can look at the prescriptions issued by the doctor whose costs are high. The committee can either suggest ways in which he might effect an improvement or, if necessary, it can take disciplinary action under the regulations. The main factors contributing to the high cost, as revealed by reports from local medical committees, seem to be the excessive use of antibiotics, the prescribing of proprietary preparations, where cheaper standard drugs would do equally well, and a high frequency in prescribing.

Looking at the average cost per prescription over the past three years, it might seem that the doctors are beginning to realise the necessity for economy in prescribing. In 1953, there were 20½ million prescriptions, which averaged 64d. each. In 1954, a slightly higher number averaged over 65d. each, an increase of 1d. In 1955, over 21 million prescriptions averaged 64.2d. each, a saving over the year 1955 compared with 1954 of .8 of 1d. per prescription. We must, alas, redouble our efforts because, in 1956, over the first three months as compared with the first three months of 1955, prescriptions are almost 3d. each higher. The doctors themselves must look at this tendency with alarm, and will, I am sure, co-operate with the nation in trying to get the cost down.

The right hon. Gentleman the Member for East Stirlingshire (Mr. Woodburn) and my right hon. Friend the Member for Kelvingrove spoke of coronary diseases. In 1931, these diseases resulted in just over 1 per cent. of all deaths in Scotland, while in 1954 they resulted in 14 per cent. of deaths from all causes. The number of deaths in 1931 was about 800, and in 1954 slightly over 8,000.

Even when account is taken of the greater number of people surviving to old age and the fall in mortality rates from various other causes, it is clear that, as my right hon. Friend said, we are faced with a substantial increase in coronary diseases. These diseases are more common in men than in women, among whom they do not assume serious proportions until after the age of 50. The trend is towards an increase in successively younger age groups, and a marked increase is at present occurring in the age group 40–49—which lets me out.

The general trend towards an increase of those diseases is not peculiar to Scotland, and research into their origin and treatment is being carried on in many countries. This trend is apparently common to all the free countries of Western Europe and also to America. Scotland is playing an important part in this work, and much active study is being done in the course of ordinary clinical work of treating patients. In the field of more practical research, the Scottish Hospital Endowments Research Trust is at present supporting a group of projects in Edinburgh, Dundee and Glasgow. So far, there has not been established any precise cause for these diseases, and no sure way of preventing them or any standard method of treatment, but more is becoming known about the genetic, psychological and social factors involved.

Of more immediate importance are the advances in knowledge which can now be brought to bear on the diagnosis and treatment of the diseases. If the risks of contracting them have increased, the prospects for the recoverable type of case are becoming better. For them, much can now be done to hasten recovery and mitigate the after-effects.

The right hon. Gentleman also asked me about B.C.G. vaccination. We can report good progress with this vaccination, as well as with other measures. When B.C.G. vaccination appeared in Scotland in 1950, it necessarily had to be limited to those in closest contact with the disease—the doctors, the nurses and the family contacts of the tuberculous patients. Every local authority in Scotland offered vaccination to these groups. Later, the scheme was extended to cover children who are about to leave school, with a view to conferring a degree of protection against the disease on children just before they reach the most vulnerable age. All but two of the 55 local authorities are now undertaking vaccination of these school children, and the other two authorities—Aberdeenshire and Kincardineshire—have the matter under active consideration.

Between 1950 and 1955, over 153,000 persons were vaccinated, and the current level of vaccination is now running at about 50,000 people a year, of whom fully two-thirds are school children between 12 and 14 years of age. My hon. Friend the Member for Pollok (Mr. George) underlined with facts and figures the necessity for our continued efforts in Scotland, and in Glasgow in particular, to fight tuberculosis by every means in our power.

The right hon. Gentleman the Member for East Stirlingshire also asked about radiography facilities. The regular routine examination of the general population will, we feel, not be worth while when the incidence of the disease drops, so that a major extension of the radiography service is not really a good long-term investment. We know about the Scandinavian and Tooting apparatus, and we are keeping these possibilities under review. The very portable unit for the Highlands and Islands has been having some teething troubles, but I am glad to report that it is getting over them.

The hon. Member for Fife, West (Mr. Hamilton), who has told me that he could not be here tonight, asked me to comment on the dysentery figures. The increase is of no real significance. As the Report says, the disease has a "nuisance value", but this does not mean that we do not want to see it avoided by proper regard to hygiene. In the health picture as a whole increase in notifications is not as I have said of any real consequence. It may be that better and more careful notification is the major factor, but it is certainly not the only factor. There has certainly been an increase, but the causes of this cannot be identified.

A question was asked about the urgency of taking more action about unsatisfactory toilet accommodation in the schools. This matter does not come before the Committee today on these Estimates, but everything that has been said about it will be carefully noted.

Mr. Woodburn

Has anybody investigated the possibility of a connection between dysentery and the eating of fruit, such as grapes, which has been sprayed and not washed afterwards before being eaten? Many of these arsenical sprays may be a cause of dysentery. I am speaking from practical experience.

Mr. Browne

I am grateful to the right hon. Gentleman. I will look into that.

The hon. Member for Dunbartonshire, West (Mr. Steele) spoke of the welfare of the aged, saying, to use his own phrase, that we were "fumbling forward and groping in an undefined direction."

Mr. Willis

Very apt.

Mr. Browne

My right hon. Friend referred at length to the welfare of the aged. I agree that there is need for local efforts to be co-ordinated. Whether the local medical officer of health is in every case the right person to co-ordinate them, I should not like to say, but I know that in some areas—I believe in Dundee—all the bodies and authorities concerned with the welfare of the aged have agreed that one person should have the final say, and that is what we would like to see in every area.

Mr. Steele

I appreciate that that is what we should like to see in every area, but surely there should be some initiative by the Scottish Office in these matters, so that something can be done. The difficulties still exist, and unless some initiative comes from the Scottish Office nothing will be done in many cases.

Mr. Browne

It is a matter for my right hon. Friend to draw the attention of the authorities to these things, and that has been done. This matter was discussed fully in the debate last year. Perhaps the hon. Member remembers it.

Mr. Willis

But that was a year ago and does not mean much now.

Mr. Browne

The hon. Member should read the Report.

Mr. Willis

I have read it.

Mr. Browne

The hon. Lady the Member for Coatbridge and Airdrie spoke of the high neo-natal death rate. We are very concerned with this matter, and my right hon. Friend has taken some positive action. The Scottish Health Services Council has, at the request of my right hon. Friend, appointed a strong committee to review the whole matter, and to find out precisely what services are needed for mothers and young children, and how these can best be provided in the framework of the National Health Service.

The hon. Lady asked me to speak about the burial of the stillborn infants. My right hon. Friend wrote to the hon. Member for Provan (Mr. W. Reid) about the discovery of the bodies of the 35 stillborn infants in the mortuary of the Glasgow Maternity Hospital last month. An early investigation was promised into all the circumstances. At the same time, all other hospitals were asked to carry out immediately a review of their arrangements relating to stillborn babies and neo-natal deaths in hospital, with emphasis on the importance of arrangements for burial being carried out in a seemly and reverent manner.

It is now possible to report the results of this review. There is no longer any hospital in Scotland where a member of the staff receives money from parents for the burial of infants. The ordinary procedure is to inform parents that they themselves are responsible for making arrangements for an undertaker. This has been done at the Glasgow Maternity Hospital since the discovery of the bodies on 15th June. I am satisfied that what happened at that hospital could not happen again there or elsewhere. I should like to repeat to all concerned my right hon. Friend's expression of our sincere regret at this unfortunate occurrence.

In connection with the day-to-day administration of the Health Service, a number of hon. Members spoke of the hospitals. They included my hon. and gallant Friend the Member for South Angus (Captain Duncan) and the hon. Member for Maryhill (Mr. Hannan). In answer to the hon. Member for Maryhill, I should like to make it quite clear that our hospital programme as announced stands in its entirety and that good progress is being made. My hon. and gallant Friend the Member for South Angus asked about the Baldovan inquiry. The regional hospital board will issue a statement of the conclusions reached after consideration of the Commissioner's report. Certain facts established by the inquiry may be communicated to the board of management for consideration of further action in its sphere.

My hon. Friend the Member for Ayr (Sir T. Moore) asked why Ayr does not figure in the hospital building programme. What is involved is simply a matter of priorities. The regional hospital board, whose task it is to assess priorities, has plans for the development of Heathfield Hospital as the main Ayr hospital, but I cannot say at present when the work will start.

The hon. Member for Fife, West asked why ambulance transport home from maternity hospitals in Fife should not always be provided. The question of whether a patient on discharge requires ambulance transport is a matter for the decision of the doctor in charge of the case. It is entirely for him to say whether an ambulance is needed, taking all factors into account, of which the length and complexity of the journey is most certainly an important one.

I would draw the attention of the Committee to the Annual Report for 1955 because, for the first time since the beginning of the National Health Service, the ambulance mileage has gone down. This downward trend is continuing. For the first four months of this year it is 5 per cent. down on last year and the cost per mile has risen only from 1s. 6d. to 1s. 7½d. since 1952.

How has this been achieved? First, regional ambulance committees have been formed on which are represented the providers, the Scottish Ambulance Service and the W.V.S. car service and the users, the hospitals and the general practitioners. Therefore, everybody concerned appreciates everybody else's problems. Secondly, it has been achieved by good co-ordination with the assistance of ambulance officers at the larger hospitals. Demands for transport are co-ordinated so that we do not have on our main roads now a procession of ambulances each going in the same direction and each carrying only one patient. Though we insist that only patients needing ambulances should travel in them, nevertheless reductions must not be achieved at the expense of the service to the hospitals and to the patients. No patient who has to get quickly to hospital should be delayed because some other patient has to be picked up.

Mr. George Lawson (Motherwell)

Is the hon. Gentleman sure that this reduction in ambulance mileage has not been achieved at the expense of patients? Is he sure that patients are not being taken great distances in order that a full load of patients may be obtained and that patients are not made to wait long periods in hospitals to ensure that a full load is taken back?

Mr. Browne

I am sure that that is not so. The hon. Member will appreciate that this reduction in mileage has carried a greater number of patients, but if he knows of a particular case of the kind he has in mind I hope that he will draw my attention to it.

Mr. T. Fraser

I wrote to the hon. Gentleman's predecessor giving particulars of a case where a young mother was discharged from hospital and had to take two bus journeys. She was in hospital again in four days' time for another operation and the baby was sent out in the care of the grandmother by public service vehicle again. Generally, where a young mother with a baby is allowed to go home by public service vehicle, has she not been kept in hospital longer than she should have been and should she not have been sent home earlier by ambulance?

Mr. Browne

I can assure the hon. Gentleman that any case that he lets me have will have the most careful and sympathetic consideration. We do not want to save ambulance mileage at the expense of the patients.

Finally, the hon. Member for Maryhill spoke of the changing pattern of the hospital service. Hon. Members may have noted from the Report of the Department of Health that although there has been an increase in the number of patients passing through the hospitals, the average number of occupied beds showed a slight reduction in 1955 as compared with 1954. This reduction in the number of occupied beds attended by an actual increase in the total number of patients, is, I think, of interest. It seems to me fair to say that a continual growth in the total number of persons in hospital at any due time is not an end in itself. What we want to see is the best use of the resources of the hospital service in the interest of the patient.

Already, with the decline in the demand for tuberculosis beds, it is becoming possible to divert to other purposes some of the expanded tuberculosis accommodation. As time goes on, we must expect a changing pattern of requirements in the hospital service. Indeed, it is a primary function of the regional hospital boards to keep existing facilities under regular review so as to make sure that our resources are applied to the best advantage.

I know that suggestions for a change of use of a particular hospital—or even its closing—often give rise to local difficulties, for a local community is very properly attached to its local hospital. But changes of this kind are sometimes imperative if the hospital service is to respond in a flexible way to the demands made upon it. No one wants to see a static or a stagnant service, and I hope that when changes of this kind are proposed after mature consideration the public will realise that they are in the best interests of the hospital service and of the community as a whole.

The Report for 1955 discloses steady advancement in nearly every field. I find that most heartening, and I agree with the hon. Lady the Member for Coatbridge and Airdrie that it is an interesting, comprehensive and very able Report. But, as I have said, it is not a bigger and better Health Service that we want, but just a better one.

We may well be reaching the peak of size and numbers. We may well be arriving at the stage when our ideal will be to reduce and consolidate; an ideal not of more hospital beds but of a quicker turnover; an ideal not of more and larger hospitals, but of more efficient and more up-to-date premises; an ideal not of more specialists, doctors and nurses, but of better facilities for them to do their work; an ideal not of ever increasing battalions of patients with minor ills and ever increasing millions of costly prescriptions, but rather of a healthier nation freed from many of today's scourges, freed from the time-wasting and heart-break of minor ills, and understanding that good health depends not on the bottle of medicine but, most of all, on ourselves.

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

Committee report Progress; to sit again Tomorrow.