NATIONAL HEALTH SERVICE (COST)

HC Deb 07 May 1956 vol 552 cc845-960

3.56 p.m.

The Minister of Health (Mr. R. H. Turton)

I beg to move, That this House takes note of the Report of the Committee of Inquiry into the Cost of the National Health Service, Command Paper No. 9663. Last Christmas, when I was transferred from the diverse and alien problems of diplomacy to the less complicated but as vital problems of health, one of the first things I found on my table was the Report of the Guillebaud Committee. It is really appropriate Christmas fare. Like Christmas pudding, it is heavy, as befits the nature of the subject. It is full of plums and here and there we find embedded attractive charms. Now that I feel that right hon. and hon. Members and I have had time to digest the Report, I welcome the opportunity of discussing it and the opportunity this debate gives to me of telling the House what action I have taken and am taking on the recommendations of the Committee.

First, I wish to express the gratitude of the Government to Mr. Guillebaud and his colleagues for the very thorough and efficient way in which they tackled their terms of reference. They were aided by a statistical analysis provided by Mr. Abel Smith and Professor Titmuss, to whom I should also like to pay tribute. The resulting 735 paragraphs of the Report present a wide field for debate. While I shall try to deal with as many as possible, in order to keep my speech within a reasonable compass, I fear that many will have to be passed over without a mention. My hon. Friend the Joint Under-Secretary of State for Scotland will be winding-up the debate and he will deal with those paragraphs to which hon. Members refer and with which I do not deal.

The Report is a welcome vindication of the National Health Service as it now exists. In its final paragraph, the Committee said: we have reached the general conclusion that the Service's record of performance since the Appointed Day has been one of very real achievement. The terms of reference of the Committee were specifically directed to economy and efficiency in the National Health Service. The Report makes it clear that economy and efficiency have increased since the Service began in 1948. It says that in real terms the increase in the gross cost of the Service between 1949 and 1954 was small, only about £30 million out of a total of about £400 million, and that during those years the Service was substantially improved and extended.

Putting the case in another way, the Committee estimates that if the proportion of the national resources devoted to the Service had been the same in 1953–54 as in 1949–50, the net cost of the Service would have been about £67 million greater than it actually was. In other words, in those years it has been possible to save £67 million by greater efficiency and thus provide a more extensive Service at little increased cost.

I was particularly interested to compare the recommendations of the Guillebaud Committee with those made in 1950–51 by the Select Committee on Estimates, of which I was a member. Broadly speaking, the Guillebaud Committee bears out the recommendations of the Select Committee. Further, many of them have already been adopted in the National Health Service.

I will quote two examples. First, the Select Committee on Estimates strongly recommended that regional hospital boards should have greater powers and referred specifically to the power to authorise hospital management committees to make transfers between sub-heads of their estimates. The Guillebaud Committee endorsed this, and it is, in fact, now current practice.

The other example I would give is that both committees, after a careful review, agreed that the carry-over of unexpended balances at the end of the financial year was wrong. Similarly, both bodies agreed that the working of the Whitley system needed to be examined. I could give the House other examples.

In many of the paragraphs which I have mentioned, the Guillebaud Committee has confirmed the findings of the Select Committee, which was then composed, as it is now, of hon. Members of all parties in the House. I mention that because if any hon. Member ever had any doubt of the value of the work of this particular Select Committee, this Report should remove the doubt.

In coming to the details of the Report, I should like to divide my comments under three headings—first, those dealing with administration; secondly, those dealing with finance; and thirdly, those dealing with certain specific recommendations to which I want to refer.

Perhaps the greatest problem of the National Health Service is the tripartite division of the administrative structure. This is fully discussed by Sir John Maude in his Reservation to the Report, and in Part II of the Report, where the diversity of opinions held on this difficult question are set out. The conclusions reached by the Committee, from which it appears that Sir John Maude, in spite of his Reservation, did not dissent, are contained in paragraphs 147–151. They can fairly be summarised by saying that the Committee regards the structure as sound; that it considers that any fundamental change of this kind at this time would be premature, although minor adjustments here and there may be advantageous, and that the greatest need is for stability for a period of years; but that there is a problem of co-operation between the different branches of the Service, and even within them, which has not yet been fully solved.

I made it clear on 26th January, when the Report was published, that the Government agree with and accept these general conclusions. To be more specific, it may be said that the Government accept that there should not at this time be any transfer to other authorities of responsibility for hospital or general practitioner services; any creation of new central or local ad hoc authorities as the recipients of particular functions; any changes in regional hospital board areas or in their methods of appointment, or any transfer to those boards of responsibility for teaching hospitals in England and Wales, or any transfer of dental clinic services from local authorities to the Central Health Departments. The acceptance of these broad principles does not, however, cover the whole ground; and it is indeed dependent on certain minor adjustments of practice, if not of organisation, which I will mention.

The first field to which attention may be directed is that of the administrative structure of the hospital service. This structure was new in 1948, and I think it is clear from the Report that it has stood the strains and stresses of the growing pains, in general, most effectively. But that is not to say that it is in no way susceptible of improvement, or that it is everywhere and at all times fully efficient.

One or two examples might usefully be selected. First, there is the question of the proper relationship between the regional hospital board and the hospital management committee in England and Wales. As the Select Committee on Estimates pointed out in 1951, when it reviewed this matter, the balance of responsibility between the Ministry, the board and the committee has varied from time to time since 1948 and a measure of uncertainty has inevitably been created.

That uncertainty is not conducive to proper administration, and although, since 1951, there has been a building up of the regional hospital boards in financial and other fields, and although boards and committees are learning to live together with a due regard for each other's rights and responsibilities, the Report suggests, in paragraph 212, that: …Regional Hospital Boards should be told, and Hospital Management Committees should accept, that the Regional Boards are responsible for exercising a general oversight and supervision over the administration of the hospital service in their Regions. It is a corollary of this recommendation that the Ministry should leave the task of supervising the Hospital Management Committees to the Regional Boards and should not itself undertake this task over the head of the Boards. The Government accept this as a statement of principle, but I think it needs some elaboration, to make quite clear what is implied and what is not implied. When the National Health Service Bill was being debated in 1946, and later, in 1948, when administrative action was being taken to bring it into operation. it was stated that the objective was the greatest possible decentralisation of responsibility and executive action within the hospital service. This is certainly the policy of the present Government.

Anything which can reasonably be decided and done at the level of the individual hospital should be done there, and, in the same way, anything which can reasonably be decided and done at the group level—the hospital management committee level—should be done there; and the regional board, and in his turn the Minister, should reserve to themselves only those functions which are inescapably theirs if they are to discharge the responsibility for providing an adequate hospital service which Parliament has put upon them.

In following out this policy, no attempt has been made—and the Guillebaud Committee confirms the practice—to define in detail the powers and functions of each level of management. Certain functions have necessarily been reserved to particular levels. For example, the regional boards are, and must be, responsible for all capital expenditure for determining the broad headings as well as the overall totals of management committees' expenditure on maintenance; and for the appointment of senior medical staff; but the guiding principle has throughout been decentralisation and flexibility.

Let me make it quite clear that that recommendation does not mean that boards in relation to management com- mittees, or, for that matter, the Minister in relation to regional boards, should seek to put them in a strait-jacket of prior approvals, or should require them in any but the most exceptional and restricted fields to get authority before taking action within the scope of their proper functions.

The conception is, rather, one of review—and, if necessary, rebuke—after the event, and not one of reference upwards beforehand in order to get approval. That seems to me to be the essential element of supervision and oversight, as distinct from control, and this relationship, which, in paragraph 211 of the Report, is called The acceptance of authority (by which we do not mean dictation)… is the objective at which management at every level must aim.

Of course, it must happen exceptionally that review and rebuke after the event are not enough; that a direction may be required or even that for a time, or for a particular purpose, a particular management committee which has shown itself to fall short of the proper levels of responsibility may have to be subjected to something more nearly approaching control. In my view, however, this should be most exceptional, and I believe that the aim of boards and committees alike should be to cultivate a mutual confidence and trust, and an acceptance of each other's functions and responsibilities within a united service, to such an extent that it would make even the exceptional use of such powers quite unthinkable.

One other thing that the recommendation does not mean is that every communication of every kind between the central Department and management committees should cease. The Report itself makes it clear, for example, that when there is dispute about functions between a board and a committee the Minister should be brought in to settle the issue, and that there is no objection to the sending of circulars directly to management committees.

Similarly, there can be no objection to the answering of queries from management committees; or the giving of advice—for example, by my organisation and methods branch; or, in exceptional cases, to my receiving representations of a management committee which feels very strongly about some particular issue. I think the important thing there is that I should never go behind the back of the regional hospital board, and that every exchange of any importance between me and a management committee should be fully known to the board concerned. That is the practice which I have adopted since I have taken over my Ministry and I can assure hon. Members that I shall try to continue it.

Let me here refer to the recommendation in paragraph 238—that the time is ripe for a review of hospital groupings. As the Committee recognises, this is a big issue which raises a number of other problems. There are, for example, the questions of delegation to house committees and to officers; of the effect on costs of administration; and of possible staff redundancy. All these are now being considered, and as soon as practicable a further statement will be made.

The other major structural problem to which the Committee devoted most consideration was that of co-operation both within the different branches of the Service and, more particularly, between them. As an example of the need for closer co-operation within one branch of the Service, the Report draws attention to the relationship between regional boards and boards of governors of teaching hospitals, which must necessarily work closely together in providing hospital services. In some areas, they do so satisfactorily; in others, they do not.

There are obvious practical difficulties. One can take London as an example, where there are four regional boards and 26 teaching hospitals. Clearly, it must be a corollary of the Government's acceptance of the recommendation to continue separate boards of governors for teaching hospitals in England and Wales that any such difficulties should be met and that the closest co-operation should exist at all times. This matter has been brought to the attention of the officers of the boards in the course of the normal periodic meetings between my Department and them, and it will be discussed with the chairmen of the regional boards at their next regular meeting.

The main problem, however, is undoubtedly that of co-operation between the three main branches of the Service. The Committee points out that it is here rather than in any sweeping changes of structure that the answer to any continuing difficulties of organisation and function must lie. The Committee, like others who have studied the problem, has found no quick and easy recipe for ensuring it.

It is no new problem. In 1952, the Central Health Services Council issued a Report on this very problem. That Report said: the need for co-ordination … was emphasised but was not created by the National Health Service. In one or two fields the new structure did produce a division of a formerly unified administration, but in general the balance was overwhelmingly the other way.

After its very exhaustive review, the Central Health Services Council, in 1952, proposed as a solution a system of local joint consultative committees, and this was commended by the Minister for consideration at special meetings of interested authorities which were convened by the regional hospital boards. I regret to say that nothing resulted from those meetings—or very little resulted—and I do not think that that is surprising. There is, generally speaking, already a surfeit of committees, and in any area where the need for a committee of this sort has been felt it had, for the most part, already come into existence.

If new liaison committees of this sort provide no solution, what does? As the Guillebaud Committee points out, the need for co-ordination is found particularly at two levels—the local and the personal; that is, between responsible authorities and between responsible individuals. At both levels the only real answer is the same—a desire and a will to co-operate on the part of the persons concerned, whether they are members of authorities or individual officers—or even individual general practitioners and consultants.

Certain specific suggestions are made in the Report, and a word should be said about them. There is the proposal for regional medical consultative committees; this has already been commended to regional hospital boards at the last meeting with the chairmen, and they have been asked to consider it. Secondly, in paragraph 714 there is the proposal that the medical officer of health or one of his staff should be a member of the medical staff committee of a hospital. This proposal is at present the subject of consultation with the bodies and associations concerned.

Thirdly, there is the indication that in making their plans hospital boards may not sufficiently consult other branches of the service. This also has already been brought to the notice of officers of regional boards, and it will be discussed with the chairmen at their next meeting with officers of the Ministry.

Let me now turn to that part of the Service where the tripartite nature of the administration raises most problems. This is covered in Part V of the Report—what the Committee describes as the "home health services and preventive health." The danger of the present structure is that we are far too inclined to work in watertight compartments. The local health authorities' services form a most important contribution to the home health services, but, as the Guillebaud Committee clearly saw, they cannot function alone. For them to try to do so would, indeed be "Hamlet" without the Prince of Denmark.

The first objective must be to place at the disposal of the patient in his home, equally with the patient in hospital, a co-ordinated team acting under the clinical guidance of his personal medical attendant. This requires the closest possible co-operation between the general practitioners and the local health authorities. It is, for instance, most important that the medical officer of health, who is administratively responsible for such a large part of the domiciliary team, should if not a full member of the executive council, at least in constant attendance at its meetings. It is for this reason that the Guillebaud Committee, in my view quite rightly, came to the conclusion that the right course is, in general, to keep the boundaries of the executive council areas co-terminus with those of the local health authorities.

The domiciliary team should include the home nurse, the health visitor, midwives and domestic helps; and, as the Committee points out, it must, of course, be closely linked with the maternity and child welfare clinics provided by the local health authorities and with the local hospitals. The membership of that team indicates the type of patient with which they are specially concerned—children and their mothers and the old people.

The recent studies of the Registrar-General show that general practitioners devote a very large amount of their time to their elderly patients of 65 and older. Approximately 50 per cent. of the time of the home nursing service is devoted to the care of the aged sick, and about two-thirds of the time of the 30,000 workers in the home help service is also devoted to the needs of the aged. Health visitors pay about a million visits a year to old people, and the proportion of their time devoted to the aged increases year by year. It should be the aim of the team to make it possible to keep out of hospital, including the mental hospitals, all patients who can be equally well treated at home.

But the domiciliary scheme is not only an instrument for caring for the sick. Its second task is to keep the people well, and this means that all the members of the domiciliary team must take an increasing interest in preventive health, as well as the general practitioners, who, I know, are anxious to play a bigger part in the preventive health service. The recent studies issued by the General Register Office show that the proportion of a general practitioner's work which is devoted to preventive medicine is yearly increasing.

Here, I should like to refer to the work already being done in the field of preventive mental health in preventing the break-up of families, with its attendant risks to the mental and physical health of the children. Following a Circular issued by my predecessor in November, 1954, local authorities have been reviewing and improving their arrangements for helping such families, in consultation with the local medical committees, which represent the general practitioners in the area. The extent of the help and the means by which it is given inevitably varies from one area to another. In developing their preventive services in this field, an increasing number of local health authorities have sought to appoint their own social workers, whilst others have employed special health visitors for work exclusively with problem families.

The Guillebaud Committee quite correctly points out that membership of the domiciliary team cannot be restricted to those specifically employed in the Health Service. The preventive health team in particular must include the welfare services provided under the National Assistance Act. These two groups of services, health and welfare, are so closely linked, at least in the domiciliary field, that they ought to be administered as one.

I should like specially to commend to the local authorities the recommendation in paragraph 606 of the Guillebaud Report, which I will quote: … all authorities who have not yet done so should review the working of their health and welfare services to see whether their efficiency might be improved, and the interests of patients better served, by combining their administration under one committee of the council, or under a joint sub-committee. The Guillebaud Committee, in paragraph 618, also suggests an association with the domiciliary scheme and with preventive work of officers from other fields, such as the children's officer, the probation officer and the school attendance officer. It also recognised that there was a need for the closest co-operation with the voluntary organisations to ensure that the family's basic problems are elicited and tackled at their source; and that there is no unnecessary overlap in home visiting by the officers concerned. Here we come up against a major problem inseparable from the system of domiciliary care which we have today. We have been going through a period of multiplication of specialties not only in the social services, but in many other spheres. This trend has originated from the view that more and more special knowledge and special training are required to enable an individual to tackle successfully some of the more difficult problems confronting us in social work, and also from the view that the ordinary person is not equipped to meddle with such matters. We must, however, guard against the irritation and inefficiency which is sometimes caused by too many people knocking on the same front door. That we have got to watch very carefully. One way of avoiding it is by examining the various specialist trainings of the different officers engaged in this work, since over-specialised training inevitably increases duplication of visiting.

I have already recived the Report of a working party under the chairmanship of Sir Wilson Jameson which has recently reviewed the training and proper field of work of health visitors. This Report will be available very shortly. It would have been printed but for the printing strike, and would have been available for hon. Members today. At the present time another working party, under the chairmanship of Miss Eileen Younghusband, is examining the training and proper field of work of social workers in the health and welfare fields, including mental welfare officers and visitors to the physically handicapped. This working party was set up jointly by the Secretary of State for Scotland and my predecessor.

The main theme of the Guillebaud Committee in relation to the domiciliary services and to preventive health is that the problem is rather one of how best to encourage more team work than of making changes in organisation. But there is one part of the organisation of the Service considered by the Committee to be in a state of some confusion—the maternity and child welfare services. I fully accept the Committee's recommendation on this point, and as the House has already been told, have set up a Committee under the chairmanship of Lord Cranbrook to carry out a review. This Committee covers England and Wales. Another Committee is considering the position in Scotland.

There is another development of preventive health suggested by the Committee which all are anxious to see instituted as soon as circumstances permit, namely, a chiropody service for old people and other special classes, such as expectant mothers. Here we are bound to wait until the financial position permits further expansion. As the Guillebaud Committee so repeatedly emphasised, the service which can be provided at any one time must depend on the resources available and, important as chiropody is, I would not feel it right at the present time, when additional moneys cannot be made available, to cut some other existing service in order to provide chiropody. In the meantime, I should like to commend the excellent work being done in this field by the voluntary bodies.

That brings me to the question of finance. No Government have laid down a precise and permanent relationship between Exchequer expenditure on the National Health Service and the gross national product. The nearest we came to it was in 1950–51 when Sir Stafford Cripps, as Chancellor of the Exchequer, fixed a ceiling for Great Britain of £400 million, excluding Civil Defence expenditure. That decision necessitated the introduction of charges. Notwithstanding the imposition of charges, the Exchequer expenditure has risen considerably. The National Health Service expenditure for Great Britain falling upon the Exchequer, again excluding Civil Defence expenditure, provided for in the 1956–57 Estimates is about £501 million, which is more than £100 million in excess of Sir Stafford Cripps's ceiling.

There are many factors which the Government of the day have to take into account in deciding how much of the national resources it is reasonable for the National Health Service to absorb at a particular time. The Guillebaud Committee, in paragraph 98, points this out very clearly, as follows: It is clear that the amount of national resources, expressed in terms of finance, manpower and materials, which are to be allocated to the National Health Service, must be determined by the Government as a matter of policy, regard being had to the competing claims of other social services and national commitments, and to the total amount of resources available. The development of the National Health Service is one among many public tasks in which objectives and standards must be realistically set and adjusted as time goes on both to means and to needs. I do not think that anyone will disagree with that analysis made by the Guillebaud Committee.

In its examination of the needs of the Service, the Guillebaud Committee makes a number of recommendations which, if adopted, would increase the charge falling upon the Exchequer. In each case the Committee points out that the adoption of these recommendations for developments and improvements is dependent upon whether, in the light of the economic situation and other considerations, it is possible for the Government to make additional funds available.

In my statement on 25th January I pointed out that in view of the economic situation the Government cannot undertake any additional financial commitments in respect of the Health Services at the present time."—[OFFICIAL REPORT, 25th January, 1956; Vol. 548, c. 208.] The Guillebaud proposals in question are, of course, proposals of the first importance. They are being carefully studied at the highest level, but at present I cannot go beyond what I then said.

Against this general background let us consider the three groups of recommendations involving increased expenditure. Those are the recommendation regarding £30 million a year being a desirable rate of capital expenditure for the hospital service for Great Britain at which to aim over the seven years succeeding 1957–58: the recommendations for a reduction of the incidence of charges for dental treatment as a first priority and of charges for spectacles as a second priority; and, thirdly, the recommendation for the introduction of a 50 per cent. Exchequer grant for residential welfare accommodation for the aged.

First let me take the question of hospital capital expenditure. That has increased slowly from £9 million in 1951–52 to £101 million in 1955–56. That that rate of expenditure was falling well behind the needs has long been felt. In February, 1955, my predecessor, the present Minister of Labour and National Service, announced plans for a substantial increase in the rate of building, covering a programme of new hospitals and other major projects. The plan provides for starting during the current year and next year new major projects to a total value of £17½ million, and for total capital expenditure each year of about £13 million and £18 million respectively.

A major step has thus already been taken in the direction proposed by the Guillebaud Committee. As the Chancellor of the Exchequer announced on 17th February, this programme has not been affected by the cuts in capital expenditure. As to the future, what capital resources can be made available for further development of the hospital service is one of the matters which, along with other claims, is now being considered by the Government.

One particular feature of the new plan worthy of mention is the emphasis which has been put upon the replacement or redeployment of obsolete or inefficient plant. Considerable waste has been caused by such plant. Accordingly £2 million is being provided during the current year and £4 million for next year to provide better, more up to date and less wasteful plant or to reorganise existing plant systems in order to give a more efficient service. By that expenditure of capital money, we believe that we shall achieve significant and worthwhile economies in the running of our hospitals.

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

The right hon. Gentleman is making an important statement about the capital provision for regional hospital boards, and I should like to get it quite clear. The Estimates provide for some £13 million in this financial year. I take it that the right hon. Gentleman is not proposing any additional sum to that provision which is already in the Estimates?

Mr. Turton

That is quite right. The Estimates are drawn up on the basis of the normal capital programme supplemented by the capital programme announced by my right hon. Friend in February, 1955

Mr. Blenkinsop

They are comprehensive?

Mr. Turton

Yes. I am stating what the Chancellor has made quite clear. The programme announced by my predecessor in February, 1955, is going forward untouched

Mr. Blenkinsop

I am sorry to interrupt again, but I presume that the increase in capital expenditure this year from all these sources will amount to about £3 million, or something of that nature, over the year?

Mr. Turton

That is the figure. Actually it is £2½ million-the difference between £10.5 million and £13 million

Mr. Kenneth Robinson (St. Pancras, North)

Will the right hon. Gentleman indicate the Government's view on the very important recommendation of the Guillebaud Committee about the approval required for regional board projects?

Mr. Turton

I am first dealing with these three specific proposals, and then I intend to deal with the other financial proposals of the Report.

Apart from provision for charges for pay beds and amenity beds and for certain local health authority services, the 1946 Act made no provision for charges. Provision for charges for the family practitioner services was first made in the 1949 Act, and then the 1951 Act provided for charges (introduced in May, 1951) for dentures and glasses with the object of keeping the Great Britain expenditure below the ceiling of £400 million. Later, the 1952 Act provided for a dental treatment charge and certain hospital appliance and other charges. For 1956–57 the estimated yield from the main charges in the family practitioner services amounted to £20 million, which was less than 20 per cent. of the total cost of those services.

Any modification of these arrangements in the way suggested by the Guillebaud Committee raises the whole question of priorities between different parts of the Service. If an individual patient is to be called on to meet a smaller part of the cost of the service, it inevitably follows, within the limits of the available resources, that either some other patient has to bear a larger share or there must be a decrease in the total services provided. These suggestions of the Guillebaud Committee must, therefore, be studied in the light of these facts and the prevailing financial situation.

Regarding the subsidy for old people's homes, the present position is that local authorities receive from the Exchequer a small subsidy related to the number of new places provided in such homes. Because they believe that lack of a grant towards the running costs of these homes may tend to distort the balance of the National Health Service in future, the Committee recommend, as soon as financial circumstances permit. a 50 per cent. Exchequer grant towards the total cost of providing and running these homes.

That recommendation must be examined as part of the whole question of the general resources which can be made available for the health and welfare services; but there are also two special considerations which I must mention in dealing with that recommendation. First, it is the only major recommendation of the Guillebaud Committee that would require legislation; and, second, a general review of local government finance and its relationship with the Exchequer is at present proceeding. A recommendation of that kind affecting one field of local government obviously will need to be considered within the wider context of that general review.

In the meantime, I will only say that there is no evidence at the moment that the lack of this 50 per cent. Exchequer grant is holding up the provision of these homes. It is rather the control of the investment programme over the years, in this as in other fields of public capital expenditure, which has been the main limiting factor.

Dame Irene Ward (Tynemouth)

Presumably that aspect of the matter will be borne in mind in the review promised by the Minister of Housing and Local Government with regard to the provision of suitable accommodation for the elderly. He specifically said that he would be in consultation with the Minister of Health on the whole aspect of the housing of elderly people, and this is a very important point.

Mr. Turton

My right hon. Friend told the House last week that he and I are considering the whole question of what houses are to be provided for old people, and this aspect of the homes will be a part, but not necessarily the main object, of that inquiry. As I have said, that inquiry is also linked with the whole question of local government finance and will be examined in relation to that as well.

Besides making these three suggestions, the Report examines in detail many other aspects of Health Service finance, including the means of ensuring effective control and efficiency in the use of the funds provided. Total expenditure from all sources on the National Health Service for England and Wales in 1956–57 is estimated at about £560 million—£447 million met by the Exchequer, £36 million by the National Insurance Fund, £27 million by employers' and employees' superannuation contributions and transfer values, £23 million by local health authorities, and £27 million by payments by persons using the services.

Of that £560 million, about £320 million is for the hospital service, of which about £306 million is for hospital current expenditure. The estimated hospital current expenditure is therefore nearly 55 per cent. of the gross expenditure of the National Health Service. I think it is understandable that the Guillebaud Committee should have devoted considerable attention to the financial arrangements in the hospital service.

The present system of financial control is that I provide regional hospital boards and boards of governors, out of the Estimates, with overall allocations for hospital maintenance expenditure. Regional hospital boards are responsible for sharing their allocations between themselves and the hospital management committees. Within the allocations, each authority is responsible for submitting for approval a plan of expenditure by subheads to the next higher authority, and for obtaining approval to any transfers between subheads.

It is laid down that, with certain specific exceptions—namely, increased Whitley awards and price increases—the allocations represent the limit of the funds available for the hospital service, and it is the responsibility of the hospital authorities to manage their affairs in such a way that the allocations are not exceeded.

The Report finds nothing seriously amiss with that system. However, it does not favour suggestions for so-called block grants for hospital current expenditure or the elimination of the approval subheads; nor does it favour the proposal that under-spendings should be carried forward from one year to another. It is satisfactory that the Committee should have found, in paragraph 725, that any charge of widespread extravagance in the National Health Service is not borne out by the evidence.

The Report lays stress upon the importance of supplementing the present system of subjective costing by a system of departmental costing. The Committee is satisfied that the information obtained through a system of departmental costing would be a better and more reliable guide for hospital management than the existing system. The particular advantage of a system of departmental costing would be to show in which departments of a hospital expenditure was actually being incurred, so that responsibility could be brought home more effectively to those departments.

The Ministry has for some time been considering the development of a system of departmental costing. As early as 1950 the King Edward's Fund and the Nuffield Provincial Hospitals Trust were invited to undertake an experiment in departmental costing in a small number of hospitals, and the two organisations presented their Reports in 1952. I remember being a member of the Select Committee on Estimates which received evidence when that work was in its early stages. A separate report of a Committee of Regional Hospital Board Treasurers was also submitted in 1952.

The systems advocated in the different Reports were different in various ways. Therefore, a working party, representative of the different interests in the hospital service, and of the King Edward's Fund and Nuffield Trust, was set up at the end of 1953 to devise a practical scheme. The working party reported in June, 1955, and recommended the introduction of full departmental costing into the hospital service. It recommended that, initially, its main scheme of full departmental costing should be applied only to hospitals of the acute or mainly acute types with an expenditure of £150,000 or more; and that no committee or board should be required to work a scheme at the outset in more than one of its hospitals. The main scheme would apply to about 200 hospitals. Other hospitals would, for the time being, be required to adopt similar but simpler arrangements based on a subjective analysis of expenditure but involving the calculation of certain departmental costs on a simple prime cost basis—that is, not involving the reallocation of expenditure from other departments.

After considering that Report and consulting representative bodies in the hospital service, and taking account also of the Report of the Guillebaud Committee, I have decided to adopt the general recommendations of the working party. A circular was sent out to hospital authorities on 27th March this year announcing that decision. As a good deal of preliminary preparation will be necessary, it will not be possible to introduce departmental costing before 1st April, 1957. In the meantime, consultations will take place with representatives of the financial staffs of hospital authorities to ensure that all the necessary detailed plans for the introduction of the very technical arrangements are worked out in advance.

It must not be overlooked that the introduction of this additional work over such a large service is not inexpensive, either in manpower or in money. Estimates of the additional annual cost involved in introducing the recommended departmental costing range from £250,000 to £500,000. As full departmental costing is developed in other hospitals the cost may rise further. It is because I believe that in the long run this expenditure should, with the co-operation of the hospital authorities, lead to a fuller knowledge of the way in which hospitals are spending their money and so help to promote the best and most economical use of the available resources, that I have come to the conclusion that this additional expenditure is justified

Mr. John Peyton (Yeovil)

I take it that my right hon. Friend has very carefully considered the results of this decision, one of the chief results of which will be an immense increase in work by limited staffs of hospital management committees. While I perfectly understand my right hon. Friend's action, I hope that he will be very careful when he gets down to the remoter areas and smaller hospitals to see that it does not place upon them a burden which they cannot begin to bear.

Mr. Turton

I have studied this problem for some time. It was one of the matters brought before the Select Committee of which I was a member. We have the Reports of the King Edward's Fund and other bodies and of the Guillebaud Committee, and what we are doing is to bring this scheme forward in a phased method so that a greater burden is not placed on the staffs. It is for that reason that we are only doing it in acute or mainly acute hospitals with an expenditure of over £150,000. I realise the point, and that is why, having announced my decision, I explained the difficulties involved. But I am sure that it is the right way of trying to get a hold on this expenditure and to know where we are spending the money

Another aspect of hospital finance to which the Guillebaud Committee devoted some attention is the importance of the maintenance of capital assets and the danger that, with the restrictions necessarily placed on hospital current expenditure, hospital authorities may decide to save on building maintenance in order to meet growing costs under other heads. To meet that risk, the Committee suggested that there was a strong case for earmarking a specific amount for the purpose of maintaining assets, and for that purpose only.

I was glad to note that recommendation. It accords with the policy which was adopted for 1955–56 and which has again been adopted for 1956–57. That means that hospital authorities have been told that their allocations include certain specific sums which may be used for the maintenance of their buildings, and for that purpose only. It will not be possible for them to cut down on that expenditure in order to meet expenditure under other heads, though if they are able to achieve savings on other expenditure, it is permissible for them to apply those savings for improving still further, if necessary, the standard of building maintenance.

Because of the importance of the whole subject of building maintenance, my predecessor appointed some time ago a working party, representative of the different interests in the hospital service, to consider and make recommendations to him upon building maintenance standards in the hospital service. I can only say that I await the Report of that working party with great interest.

So much for hospital expenditure. I now want to refer to one of the main causes of financial anxiety in another field of expenditure—the growing drug bill. Expenditure on the pharmaceutical service and the average cost per prescription have risen from £31½ million and 3s. 1d. per prescription in 1949–50 to an estimate of £.52¾ million and 4s. 6d. per prescription in 1956–57

Under the National Health Service Acts a family doctor is entitled to prescribe any medicine—and certain appliances—which he thinks necessary for his Health Service patients. Chemists are paid for these services a fee which includes payment for the ingredients, an on-cost allowance of 25 per cent., a dispensing fee averaging a little over is per prescription, and a container allowance.

The very large increase in the drug bill which I have mentioned is due mainly to an increase in the average cost per prescription. This increase is due to a number of factors, including an increase in the proportion of proprietary preparations prescribed—which rose from 16 per cent. in 1949 to 36 per cent. in 1956—and the discovery and introduction of important and useful new drugs and preparations. General increases in costs have also had their effect. The rate of increase of the drug bill, in this country, as in every country in the world, gives ground for serious concern.

Hon. Members will have read paragraph 471, which summarises in some detail the various measures which have been taken to check the growing cost of the pharmaceutical service. What I wish to stress today is that the close co-operation of the medical profession is vital if the cost of this service is to be kept under control. A great deal of information is now being made available to individual members of the profession in various ways, and those measures will be continued and, wherever possible, developed.

If doctors, for their part, could study that information carefully and do their best to satisfy themselves that, while no patient is deprived of necessary medicines, the medicines which are prescribed are no more expensive than is really required by the patient's medical condition, it cannot be doubted that a substantial saving on this service would be possible.

Mr. John Baird (Wolverhampton, North-East)

Is not the right hon. Gentleman putting the cart before the horse? It is quite true that there is a considerable amount of over-prescribing by doctors, but, surely, unless we are willing to tackle the drug industry we shall never cut down the cost of that service

Mr. Turton

My hon. Friend answered a Question on this subject at Question Time today and I am sure that if the hon. Gentleman will study paragraph 471 of the Report he will see what we are doing. I shall be very interested to hear any suggestions that hon. Members may make on this matter, which is one of the most difficult financial problems with which I am faced.

In its Report, the Committee makes a considerable number of recommendations in addition to those that I have already mentioned. I should like now to say a few words about some of them—first, regarding the Whitley machinery. Whilst the Committee formed the opinion that the Whitley system was appropriate for agreeing centrally the salaries and gradings of the staff employed in the National Health Service, it recommended that the working of the Whitley machinery should be reviewed to see whether it could not be made more efficient.

I have already taken action. I announced on 16th April that my right hon. Friend the Secretary of State and I were prepared to accept those recommendations, and that the following action was being taken. First, the management and staff sides of the Whitley councils are being invited to explore the methods used in other large-scale undertakings to introduce flexibility into national agreements. Secondly, the management sides are being asked to propose alterations in the constitutions of the councils so as to add three hospital representatives to each. Departmental representation is being cut down in consequence. We are seeking the views of the management sides on the question of consultation with hospital authorities, and we are drawing the attention of both management and staff sides to the importance of avoiding delays.

Secondly, there is a point which I want to take up with regard to a research and statistics department. The Committee takes the view that the knowledge at present available about the working of the National Health Service needs to be considerably extended and improved. To meet this, they recommend the establishment of a research and statistics department, which would function as an intelligence branch, working in close co-operation with the Department's administrative and medical staff. Action had already been taken on those lines.

I have made a start by appointing a statistician to my Department, together with the necessary supporting staff. Furthermore, we did, a little time ago, set up a small organisation and methods section to examine and advise on hospital administrative problems, and thereby to build up a body of experience which we hope will in the long run be of great value to the Service as a whole.

I should also like to say a few words on the recruitment and training of administrative staff, to which the Committee drew attention. The hospital service at all levels is faced with problems of management, just as is any large business organisation. It is as misguided to ignore the contribution that can be made to hospital work by the methods and experience of industry, in fields such as costing, personnel management and office organisation, as it is to suppose that that experience and those methods can be applied automatically and unmodified to so human and personal a service as hospital care. But if the Service is to use what is useful in the experience of others, it must have staff of a quality to discern what is useful and have the capacity of employing it. The Committee regarded it as axiomatic that the quality of administration in the hospital service must depend first and foremost on the quality of the hospital administrators themselves That is where recruitment and training play a vital part.

Of course, there are other factors affecting quality, such as comparative salary levels, grading structure, etc., but those are constantly under review by the Whitley council concerned. Here we are concerned with two main tasks—to ensure that the pool of administrative talent available to this national Service is itself nation-wide, and to see that every administrative officer in the Service, like the doctor or the nurse, has the opportunity to train and improve himself to the limit of his capacity. It is for the carrying out of these two tasks that schemes of training and recruitment were launched on 17th April last.

The schemes cover both those already in the hospital service and those who may be recruited to it from elsewhere; and they have been worked out with the help of the Whitley Council for Administrative and Clerical Staffs. I should like to pay my tribute of gratitude to the Council for that help. Taking first those within the Service, the scheme provides for appropriate financial and other assistance to be given by hospital authorities to all grades of clerical and administrative staff in connection with attendance at classes or courses or conferences, the taking of examinations, etc.

It is no use, however, encouraging training unless the able, trained and experienced administrator can get a post worthy of his capacity, and for that mobility is essential. In England and Wales alone there are nearly 450 hospital authorities selecting and appointing their own administrative staffs. It is had for them, bad for the service and bad for the individual concerned if they make appointments by internal promotion only. An administrator who has spent all his time in one hospital, or one group or one regional board office cannot be as experienced or as valuable as one who has worked with several different authorities in hospitals of varying types. Hospital boards and committees have, therefore, been reminded of the vital importance of mobility within the service and of the necessity for advertising vacant posts widely and selecting wisely.

Finally, there is a new and special scheme—that for the recruitment on a national basis of a small annual number of younger men and women who may reasonably be expected to be the leading hospital administrators of the future. This again is a proposal commended by the Guillebaud Committee. As they pointed out, in paragraph 392, a few local schemes have been successfully launched, but these … could not he a satisfactory substitute for a nationally organised scheme. Only this could … enable the hospital service to compete with the Civil Service, the nationalised industries, commerce and private industry generally." Accordingly, as a start, 16 posts are being offered, to begin next September, to last three years during which both practical experience and theoretical training will be given, the latter either at the University of Manchester or at the Hospital Administrative Staff College of King Edward's Fund. Applications are now coming in, and selection will be the responsibility of a special committee representative of the hospital service and the training institutions

I am glad to be able to announce that the chairmanship of that Committee has been accepted by Sir John Stopford, who will bring to its work a unique experience, not only from his work as Vice-Chancellor of Manchester University, but also as a member for many years of the governing body of the Manchester teaching hospital and as Chairman of the Manchester Regional Hospital Board.

The last point of the Guillebaud Committee's recommendations relates to the ambulance service. The Committee recommended that more should be done to ensure that only those patients who needed ambulance transport should be provided with it. In particular, they recommended the appointment of transport officers in hospitals. They also recommended that ambulance journeys should be organised so that the maximum number of patients was carried per mile run and that the most economical form of transport was used.

Since the Report was made, I have issued a circular to hospital authorities explaining the need for care when ordering ambulance transport and urging the appointment of transport officers where such an officer is not already in post. Circulars have also been sent to local health authorities, reminding them of ways in which the organisation of the service can be improved, and including the suggestions for economy made by the Guillebaud Committee

Let me sum up. However the National Health Service is organised, so long as unlimited financial resources are not available, questions of priority will arise. I cannot do at once everything that needs doing. Therefore, I must have clear in my own mind an order of priorities. In my view there are three main priorities in the Service today. The first is the improvement of unsatisfactory or inadequate hospitals and the provision of new hospital accommodation where none or insufficient is now available. The second is to improve the mental and mental deficiency health services. Here much progress has been and is being made, but a good deal of leeway has still to be made up. Finally, there is the problem of the care of old people. That is one of our major social problems, and it is my wish to make the greatest contribution I can towards its solution.

Mr. Denis Howell (Birmingham, All Saints)

Can the right hon. Gentleman say whether these priorities are to go hand in hand or whether they are to be taken in the order which he has mentioned?

Mr. Turton

I think that my objective must be to take all these three priorities in the order mentioned. They are the first three priorities—first, the hospitals; second, mental deficiency; and third, the old people. These are what I must work for.

I am quite sure that at this time, when the country's economy is strained to the utmost, we shall not be able to do for the Health Service all that we would desire. I believe, however, that hon. Members of all parties should accept a measure of responsibility for my difficulties. We have done much since the war to improve our social services by building houses, by providing schools and by increasing National Insurance benefits. Our hospitals have not shared in that swift progress, and we face a growing responsibility towards our old people, who in their time have done so much for the nation.

I well remember in 1943, on my way back from the Middle East, listening in Liberia to my right hon. Friend the Member for Woodford (Sir W. Churchill) speaking on the wireless and describing the four-year plan. I thought at that time what a wonderful war memorial that would be for the nation to commemorate those who had sacrificed their lives in the war. Now I find that I have a small part to play in trying to carry out that plan.

This seems to me to be something far above all party divisions. It is my intention to keep this matter right above party divisions. We have an obligation to try to fulfil that plan, and I appeal to hon. Members, on all sides of the House to help me to make this Service worthy of those whom it commemorates.

5.12 p.m.

Dr. Edith Summerskill (Warrington)

The Minister started on rather dangerous ground when he implied that he had come from rather a difficult Department—the Foreign Office—to a Department where life was a little easier

Mr. Turton

I said that I came from a diverse and alien Department to a less complicated but equally vital Department.

Dr. Summerskill

The Minister is wise to qualify his earlier statement, because the assumption is that he is not well versed in the subjects of his Department. He has come to a Ministry which is directly concerned with certain exact sciences, which is perhaps the reason why we have such civilised meetings on these occasions. If the Ministry in which the right hon. Gentleman formerly held office had been a little more successful in arriving at a proven formula to guide them, the world might be a better place today.

I agree with the right hon. Gentleman that these matters of health should be debated without acrimony. While we on this side have always held that view, I must confess, having sat through the whole of the debate on the National Health Service Bill, that I do not recall those on the Minister's side of the House, or, perhaps, the right hon. Gentleman himself, conducting themselves in a way that was conducive to harmony. Indeed, when it came to a Division on these matters of important principle, on which I am sure we all agree this afternoon, we found that far from their being in harmony, the Minister's party went into one Lobby and this side of the House went into what I consider was the progressive Lobby of the day.

Major Tufton Beamish (Lewes)

Surely the right hon. Lady wants to be fair. We voted against the Bill on a reasoned Amendment. She knows that as well as I do.

Dr. Summerskill

The Minister is calling for harmony. Never on these occasions has my side of the House tried to do anything but identify itself with progressive movements within the Service.

Dame Irene Ward

So that we may get this straight before the debate develops, may I ask whether both the Motion and the Amendment could be included in MANSARD so that those who were not in the House at the time can see what the Motion and the Amendment were?

Dr. Summerskill

The hon. Lady's intervention only goes to prove what I say. I was trying to create an atmosphere of harmony—

Dame Irene Ward

It is not too good

Dr. Summerskill

—but I was provoked by the Minister, who made a statement which cannot be sustained. There has not always been harmony, although I always—as I am sure the Minister's predecessor, whom I am honoured to see here today, will agree—have done my best to ensure that these debates were conducted without acrimony. I shall certainly try to address myself to this matter in a constructive spirit.

On these occasions, when we discuss highly technical matters, a Minister can come to the House having the support and advice of a Department which commands my highest respect. He has the advice and direction of doctors, medical officers and eminent men, highly qualified, on whom he can place great reliance. The future may prove that they were wrong, but within the circumscribed situation in which they find themselves they try, I am sure, to give the best advice to the Minister.

The Opposition must on these occasions express its views individually and what I say is a personal point of view. Behind me there may be some of my hon. Friends who identify themselves with my point of view—I am quite sure that some of them will do so; I have known many of them for many years. On the other hand, as this is a matter of opinion, there may be those who feel they are completely opposed to the point of view I am putting. I assure them that I shall feel no ill will towards them if they wish in the strongest terms to denounce what I say. Perhaps these preliminaries will clear the air a little. I do not, of course, speak for hon. Members behind the Minister; they can say what they like.

I agree with the right hon. Gentleman that the Guillebaud Report has been' submitted by a group of people who have done a fine piece of work. We should all pay tribute to them. There is also an excellent financial analysis produced by Professor Titmuss and Mr. Abe/ Smith which also commands our respect. I hope I may say this without being attacked by the hon. Lady the Member for Tynemouth (Dame Irene Ward)—

Dame Irene Ward

Do not be certain

Dr. Summerskill

I never am certain of the hon. Lady. This financial analysis vindicates our contention that the expenditure of an amount in the region of £400 million was fully justified. I propose to spend only a short time on the figures because they can be interpreted in various ways, as, I think, any actuary would agree

It is a fact that the Health Service was absorbing a smaller proportion of the gross national product in 1953–54 than in 1949–50—3.24 per cent. compared with 3.75 per cent. The only thing that can be deduced from this is that the ceilings which have been fixed by different Chancellors of the Exchequer have been observed. Other calculations which reveal a reduction in the proportions of the money used by the National Health Service must, of course, be related to the varying demand over the years for articles like spectacles and dentures. I am not going into the whole of that story. Everybody knows it. Policy changes, demand changes because of price factors.

It is clear that the detailed information regarding the working of the service is lacking, and I am very glad to hear from the Minister that he has at least taken the first step on the recommendation that a department should be set up concerned with research and statistics. He mentioned that he had already appointed one or two people. I hope that that is only a beginning and that he will be able to tell us later how the department is developing.

The most important fact, of course, which emerges from this Report is that the Guillebaud Committee could find no evidence of widespread extravagance in the Health Service, that the finances were under control, and, furthermore, that it is essential that more money shall be spent, particularly on capital expenditure, if we are to have a service worthy of this country, and one whose reputation is second to none.

The first question—I think, rightly—which the Committee considered was, should there be any major changes in administration? It would be presumptuous of me to say that the Committee answered that question very wisely, and I would rather say that my view conforms with that of the Committee and of the Minister, that there should be no change made, anyhow at this stage. The scheme has been working only for seven years. It may have to be modified in a few years' time, but it is too early to determine whether any radical alteration in the structure is called for. I agree that there may be some alteration in detail, but I am thinking of the tripartite structure and the way it is administered today when I speak in terms of a radical alteration.

Of course, the question which commands the interest of both the professional and the lay members of the service is whether there should be any transferrence of the service to the local authorities. Apparently, the Association of Municipal Corporations, a very strong and highly respected association, is the only one of the local government authorities which framed detailed proposals. It recommended the ultimate transfer of all hospitals to local health authorities, with the immediate restoration of the administrative responsibility for the tuberculous, the maternity service and the care of the chronic sick.

I hope I am not speaking too strongly when I say that I believe that that would be a retrograde step. [HON. MEMBERS: "Hear, hear."] I can assure the House that I am very glad to hear that cheer because I have to decide on these things as an individual and they are matters of great concern to the whole country, and when an organisation like the Association of Municipal Corporations takes a view contrary to mine I feel a little hesitant, and certainly I hesitate before I speak as strongly as I have done. I am encouraged by hon. Members.

I regard that as a retrograde step for this reason. It would establish two hospital authorities, a central and a local, and thereby introduce into the minds of the patients an important factor which sometimes tends to be overlooked by the tidy administrators—certain doubts regarding the standing in the medical world of these different institutions. I regard the approach of the patients to the administration of the Health Service as very important. I am of the opinion that increasing specialisation calls for more regional planning, not less; and I am glad to see that many important bodies are opposed to any transfer.

I recall an interesting article by my hon. Friend the Member for Barking (Mr. Hastings), in the Lancet for—I think it was—December, 1955. I would ask the Minister to read it. It was an article on the planning of hospital services to meet modern needs, and I think all those interested in local authorities should consider what my hon. Friend, with his great experience of hospital work, elaborated. His proposal was to establish hospital out-patients'—what, I think, he called—" out-stations." Quite a new phrase.

Mr. Somerville Hastings (Barking)

Consulting stations

Dr. Summerskill

Hospital out-patients' consulting stations, apart from the hospitals. The hospitals would be fed by patients from these stations who needed in-patient treatment. These stations would, of course, avoid the wastefulness of having consultants serving outpatients' departments in hospitals all over the country. It is possible—my hon. Friend will correct me if I am wrong about this—for a consultant to turn up at a hospital to find, perhaps, only three or four psychiatric cases or patients requiring some other specialist treatment. This happens all over the country, because we have always observed the tradition in the medical world that a properly equipped hospital should have an out-patients' department served by specialists of all kinds. It is very difficult in a conservative profession—I use the expression in its broadest sense—for people to change their approach to these things. I regard this debate as a very important one because in it we can approach these matters in a tentative manner. In no circumstances would I be dogmatic about these matters, but I think that what my hon. Friend suggests ought very seriously to be considered.

He raises also the whole question of hospital beds. Undoubtedly we need new hospitals, but do we need more beds? The incidence of infectious diseases has dropped in a quite dramatic fashion owing to less overcrowding. When I first began practice, if there was a measles epidemic, I would drive out on my round and park my car, not outside any one house where I had to see a patient but in some central position in a street and then I would stroll down the road calling at three or four houses to tend to patients with the measles, and one or more of the mothers would say to me, "Would you go to Mrs. So and So's, for they have got it there, too." The change that has taken place is dramatic. I think it was before the war that we had the last very big measles epidemic.

In consequence of the drop in the incidence of infectious diseases, of course the pressure on the isolation hospitals, pressure which we used to know very well in my early days of practice, has completely gone. Those beds are empty. Therefore, we must think in terms of bed accommodation throughout the whole country, taking into consideration these great changes. The latest reports on the morbidity and mortality of tuberculosis are very promising.

The only ailments which now cause us some concern, apart from the horrors of the killing ailments of cancer and cardiovascular disease, are the psychosomatic ailments. I am shocked to perceive that the Minister does not know what psychosomatic is.

Mr. James Griffiths (Llanelly)

Let my right hon. Friend tell us what it is

Dr. Summerskill

I shall watch the right hon. Gentleman at that Box very carefully in future, and if I see any symptoms in him of it I shall hurry behind Mr. Speaker's Chair and explain to him precisely what we mean by it.

Mr. Turton

I may go to Barking.

Dr. Summerskill

I think my hon. Friend specialised in ear, nose and throat ailments. It may be that some of them may have been psychosomatic, but I have a feeling most of them were organic. I am prepared, however, to give anybody an examination afterwards.

Dr. Barnett Stross (Stoke-on-Trent. Central)

It is possible to get psychosomatic ailments even in ear surgery, and the defect which induces one to refuse to listen to someone else's argument is a particular example of a psychosomatic condition.

Dr. Summerskill

I would say that a great deal of it is attributable to politics and that is why we get a curious kind of complaint which shuts our ears to all kinds of things. But do not let us dismiss this matter. Many hospital beds are filled with people who are suffering from psychosomatic ailments and I am relating my remarks on the disease to the practical problems that we have to face. Perhaps the number of cases is increasing because we recognise their condition more easily today.

I hope that the Minister will correct me if I am wrong in saying that "thousands" of beds are unused owing to shortage of staff. I do not press the Minister to tell me now, but perhaps he can let me know later, possibly by letter, what estimate he has made of supply and demand in beds assuming that it were possible to staff them.

In thinking in terms of reorganisation, I should like to see closer collaboration between the local authorities and the general practitioner service. I am not talking about administration but about co-ordination. I feel that here I am on dangerous ground but, as I have said, all this is tentative. The conditions of service of the general practitioner should bear a closer resemblance to those of the medical officer of health.

It was Dr. Hadfield, assistant secretary of the British Medical Association, who said: The human gaps must be closed. This is of supreme importance, but is one of the most difficult things to do not only in the sphere of medicine but in much wider spheres. The salaried medical officer's approach to medicine, with the emphasis on prevention, has been dissimilar to that of the general practitioner, chiefly occupied with the curative side of medicine and dependent upon fees.

Unfortunately, the National Health Service still makes the doctor dependent upon fees—there are still the capitation fees—and that gap between these two doctors, working in two different medical worlds, is unfortunately not made smaller. The time is coming when we must consider the best means of remunerating the general practitioner

Mr. Arthur Moyle (Oldbury and Halesowen)

It is the B.M.A. alone that is responsible for the fact that there is a fee and not a system of salaried remuneration

Dr. Summerskill

When my hon. Friend talks about the B.M.A. he is suggesting that the doctors are so well organised that the B.M.A. speaks for them. It is a question also of creating the right climate, but on occasions of this kind one should air one's views. It may be that many doctors will read HANSARD and perhaps reorientate.

I am talking about the relationship of the general practitioner with the rest of the Service. It is unfortunate that whoever was responsible for the memorandum of the Royal College of Physicians should have used terms in reference to the medical practitioner such as, "a mere disposal agent." Such a disparaging reference is calculated only to widen the human gaps.

I regard this as of the utmost importance when we are thinking of the administration of the National Health Service. This misunderstanding of the general practitioner and the difficulties with which he is confronted in an overcrowded area must be dispelled. The Minister can do a great deal towards that end.

The right hon. Gentleman mentioned maternity services and I will not deal with them now. A committee has been set up. The position is quite confusing. The average working woman finds it difficult to know what to do. Having seen the general practitioner she does not know whether she should waste another morning at the clinic and she does not know whose advice she should take. There is a danger that the general practitioner's advice might conflict with that of the medical officer at the clinic.

I am pleased that the Minister has set up a committee. I hope that I shall not be misunderstood when I say that I was disappointed that he had not put a real consumer on it. The right hon. Gentleman appears to want to interrupt, but he must not jump up. I know more about maternity than he does and therefore he must not get excited.

The right hon. Gentleman has appointed two people on the committee. I know one of them very well and have the highest respect for her. The other is the wife of an hon. Member opposite who commands my respect because she is prepared to do public work. But I would remind the Minister that perhaps it makes it a little different for a woman in looking at these things if she has not had to face during pregnancy the question of whether she should go to a general practitioner or to a maternity clinic and whether she should try to get to hospital because she is living in overcrowded conditions which would make it difficult to conduct the confinement at home.

The one thing on which the Minister would get the finest advice possible from a working woman is on maternity. The right hon. Gentleman is not introducing the question of maternity nursing homes here. He is thinking about those things with which the ordinary working woman is concerned at the time of her confinement. I hope that the House will not think that I am criticising the qualifications of the women whom he has already appointed to the Committee, but I should like him to fortify them.

Mr. Turton

The two ladies who are kindly serving on the committee have had 15 children between them and I should have thought, therefore, that they came within the category of consumers. One lady has been a candidate for a Parliamentary constituency and therefore must know, as a candidate always knows, the life and working conditions of people. She was a Socialist candidate for Oxford. The other is the wife of a Member of Parliament, who knows the working conditions in her husband's constituency. She is actually a member of the local authority and is the mayor. I should have thought that I could not have chosen better

Mr. Peyton

Is it not both inaccurate and ungrateful to describe these ladies as consumers? [Laughter.]

Dr. Summerskill

I am sorry that this matter should have caused laughter and that the Minister should have thought it important to intervene to remind me about things I know perfectly well. Here is a practical suggestion and something in which I have no ulterior motive whatsoever. I should have thought that the Minister would have accepted that as an idea worthy of consideration without jumping up and making some smart retort. I am a little disappointed in the right hon. Gentleman.

We have not moved into a position in which any major administrative change demands attention and, as a believer in the characteristically British, empirical approach to these matters, I am content to wait longer and see how the machinery responds to the various demands made upon it before I would advocate radical change.

It was an omission not to have included welfare in the terms of reference of the Guillebaud Committee. I do not believe it is possible to discuss the administration and financing of the National Health Service in isolation if the objective is to find a means whereby all those in need of some degree of nursing or medical care shall be brought within a comprehensive scheme.

The physiological condition of old age is commanding as much attention today as any other single pathological state. Health and welfare should be treated together in all future planning. The Minister certainly talks about health and welfare at the floor level, but I want to see them combined at his own level. It is the duty of the Treasury to see that money allocated for a certain purpose is properly spent. Consequently, we have tended to departmentalise services which should be merged. I listened very carefully to everything that the Minister said. He talked about working in watertight compartments, and he deplored it—but what happened this afternoon, at Question time? We had a most astonishing illustration of his preparedness to work in a watertight compartment.

There were two occasions. First, there was a Question on clean air—a subject mentioned in the Report in relation to the prevention of disease and preventive medicine—and although, if I had been in his position I should have jumped at the Question and said, "This is mine", he imported the Parliamentary Secretary to the Ministry of Housing and Local Government to answer it for him. That was a health question which was mentioned in the Report which he was going to talk about within one hour.

The second occasion concerned the Parliamentary Secretary. I am not trying to embarrass her, and I do not want to be patronising. She does her job extraordinarily well; she is knowledgeable, and she always has her facts, but I was a little astonished to find her guilty of the same thing this afternoon. One of my hon. Friends raised a question concerning a dental plate for a poor man who had had some horrible mouth injury. I could envisage that man. It is a terrible thing to lose one's palate. But the hon. Lady said, "This is not my Department; it is somebody else's." Here was an illustration of the Minister and the Parliamentary Secretary departmentalising their work. That is the wrong approach. The Guillebaud Committee says that it is the wrong approach, and the Minister pays lip service to the Report and talks about the inadvisability of watertight compartments, but by his action today he has made me feel that he does not realise that the Committee's recommendations should be put into practice.

I believe it was the week before last when the Minister of Housing and Local Government said that the question of the housing of the aged was a welfare problem. Undoubtedly, if appropriate housing accommodation were available, the pressure upon institutions providing accommodation and even on our hospital beds would be relieved. I regard this cooperation between Departments as a matter of extreme urgency, because 44 per cent. of our beds are occupied by those suffering from some mental instability, including thousands of old people for whom housing accommodation, in its fullest sense, is not needed.

I should like to say something about the need for more modern hospitals and increased capital expenditure. I was very disappointed that the Minister did not say at least that he will accept the recommendation of the Guillebaud Committee in this respect. In fact, he has not accepted any of the financial recommendations of that Committee. The fact is that 45 per cent. of our hospitals were built before 1891—and 21 per cent. were built before 1861. The capital expenditure upon hospitals was three times as high in 1938–39 as it was in 1952–53.

I know that hon. Members opposite will say that we were in power before 1952. We came to power in 1945 when, I believe, one out of every three houses in this country was damaged in some way. I do not think anybody could condemn us in 1945 for putting housing first. I am not criticising the Government; I am merely asking the Minister to say that he will give this matter priority now. It is stated that some of these hospitals are so old and inefficient that they are hardly worth keeping. These old hospitals are tragic places, for they house mainly the aged and the mental patients. These patients have the fewest visitors in proportion to their number, and, together with their overworked staffs, they are condemned for months and sometimes years to a life in these obsolete institutions.

The Minister has visited some of these mental hospitals lately, and I think he will agree that the patients are clean and are looked after as well as possible in the circumstances by their overworked nurses. But all that can be done is to leave them sitting in rows round a room. There is no time for the nurses to help to interest or amuse them, or to keep alive that spark of sanity which remains. Under these conditions there is a slow but certain deterioration of those mental processes which had hitherto remained normal. During his visits the Minister may have missed the importance of the fact that these people sit in one position month after month and year after year because there are no nurses to interest or entertain them in any way.

One hon. Member opposite said that the differential between nurses and assistant nurses was too small. In my opinion, what is wrong is that the pay of the fully qualified nurses is too low for the very fine contribution which these women and men make to society. I recently visited Winwick Hospital, which serves Warrington, and if the hospitals in the constituencies of my hon. Friends and hon. Members opposite are similarly understaffed and overcrowded I can quite understand why, week after week, the Minister has to face hostile Questions upon the subject of conditions in our mental hospitals.

I believe that the Minister made a profound mistake in agreeing to reduce the incentives to any category of mental student nurse. He should have made the most careful inquiries to see whether the Midwives and Nurses Council was fully representative of these mental nurses. We welcome what the Minister said about the Whitley Councils and the fact that there will be greater representation.

Upon the subject of mental student nurses, which I regard as of such great importance, he told the House that negotiations were completed very rapidly. Of course that is so, because those most seriously concerned were not represented, except in respect of one person, upon the committee which decided their terms of service. The Minister has now implied that he is not prepared to accept the Guillebaud recommendation that £30 million annually should be the rate of capital expenditure over the seven years succeeding 1957–58. I think that this is most unfortunate, because it is in this field that we should make capital expenditure.

I now want to say something about the teaching hospitals. I apologise for going on for such a long time, but this is a highly important matter. In my opinion, teaching hospitals should be integrated with regional hospital boards.

Colonel Malcolm Stoddart-Scott (Ripon)

Hear, hear

Dr. Summerskill

I feel almost emotional when I receive support from hon. Members like the hon. and gallant Member for Ripon (Colonel StoddartScott) who has such intimate knowledge of the subject with which this debate is concerned. It is surprising but very, very gratifying to receive such support.

I think that they should be integrated with the regional hospital boards. It is an anachronism for them to be autonomous. This splendid isolation of the teaching hospitals tends to introduce a snob element into the Health Service which militates against the close cooperation and the closing of the human gap. Apart from all the reasons given by Miss Godwin there is another astonishing feature of our London teaching hospitals which perhaps only a woman doctor can appreciate.

Medical students in London are not admitted only on grounds of ability but according to sex. The University Grants Committee compelled teaching hospitals at least to open their doors to women only a few years ago. In my day there were only 4 per cent. of doctors who were women. Today women number nearly 30 per cent. of the doctors, and there is no question of our not being wanted. The demand is greater than the supply. If any hon. Member considers this an overstatement I ask him to look at the advertisements in the British Medical Journal. In my day an advertisement for an assistant used to read: "Wanted an assistant: man only."

During the last few weeks I have been looking at advertisements in the British Medical Journal. They read: "Wanted assistant: women only need apply." That is surely a justification for our existence. Yet it is an astonishing fact, and the Minister is upholding the position, that teaching hospitals in London are to be left alone.

The Minister told us that he desired advice in these matters and I propose to grasp the nettle firmly. Professor Titmuss and Mr. Abel-Smith stated that they would put the reduction in the gross cost of the pharmaceutical service, following the introduction of a subscription charge of one shilling, at £4 million. In 1954 the total cost of prescriptions in England and Wales was £45,969,621. The Minister told us just now that the Estimate for next year will be £56 million. I think that is right—

Mr. Turton

The figure is £53 million; that is the gross figure.

Dr. Summerskill

This huge sum of £46 million has been reduced by £4 million in consequence of the imposition of a prescription charge. I do not want to appear irresponsible about these matters, and we should ask ourselves who are the people who are deterred from seeking medical advice because of the shilling prescription charge. I do not think that anyone would argue that nobody is deterred from seeking advice, but certainly the hypochondriac is not. He will continue to seek advice, whatever the charge. The better-off people are not deterred and nor are those in receipt of a good regular wage. Only the poorest in the community are deterred and these people, as we are told by statisticians and social workers, are those with large dependent families or old-age pensioners. Those are just the people who should have no financial barrier between themselves and the doctor. For those reasons I say that these charges cannot be justified. I do not say that for any party reason and not on actuarial grounds, but because these people are in the greatest need of medical service.

Paragraph 92 of the Report states: The rise of £6 million in the net cost of the pharmaceutical service resulted from a rise of £12 million in gross expenditure, partly offset by £6 million in revenue from charges. I wish to emphasise this: Owing to lack of information, it is impossible to give a complete explanation of the rise in gross expenditure. It states that the rise may be attributable, among other things, to a 36 per cent. "increase in the amount prescribed" and 40 per cent. to certain other factors including the increased use of new and expensive drugs. I wish to ask the House to remember that the gross cost of this service is nearly £45 million. Last week we were told that the cost of prescriptions had risen to 4s. 4d. We are told that it is estimated that the figure would go up to 4s. 6d. The Report states: Negotiations between the Departments representative of the industry have been under way for some considerable period and there has been public criticism of the delay in reaching agreement. I bring that to the Minister's attention and remind him what happened today when one of his hon. Friends put down three Questions about the cost of prescriptions.

One thing which I have always regarded unfavourably is the production of exhibits in this Chamber. I have never done that in the whole of my Parliamentary career. But this afternoon I intend to make an exception, because I believe the Minister does not realise the importance of this matter. I wish to bring home to him the effect of high pressure salesmanship on the doctors of this country. I try to be absolutely fair and honest in these matters. I did not pick out examples to impress the Minister. I simply waited for the last post at my own home and brought my examples with me. Had this debate occurred on Friday, I could have brought another example. This communication came by the last post. Let me show the Minister precisely why this colossal sum is spent which we require in hospitals for other services.

This letter I am about to read came by the last post. I have no intention of mentioning the drug house or the drug because this letter might refer to any drug. In fact I received another similar letter last Friday. As the Minister will observe this has been sent in an expensive packing and of course another sample was sent to my husband. In our house there are two doctors, my husband and myself. We are used to these letters arriving at our house. This letter gives the name of a well-known drug house and the name of some tablets. I wish hon. Members to visualise this kind of thing happening all over the country every day to all the doctors in the country as these letters come from one proprietary drug house or another. The letter states: Dear Sir… That is the only mistake. Some time ago we sent you a carton of … tablets for your personal trial. The number of prescriptions which have since been written for… have led us to believe that … tablets have met with the general approval of the medical profession. With this letter, we are sending you yet another carton for clinical trial with gastric patients. May we remind you of the … formula which has as its active ingredients per tablet "— then they go on to give the ingredients, and continue that these tablets, have been allotted Category 4 by the National Health Committee, and may be freely prescribed on Form E.C.10. Their cost is 2s. 1d. for 30 tablets. If you are interested in making further tests with … we shall be pleased to send you a prescription pack of 500 … tablets free of charge. This is the second I have had in a very short time. I am promised another 500 sample tablets if I want them.

I am not concerned with any form of victimisation but with exposing high-pressure salesmanship. Is it any wonder that the Minister has to keep on coming to the House to ask for more money for proprietary drugs? He has just given figures showing that the proprietary drugs used in this country have risen from 16 per cent. to 36 per cent, in a year. We keep pressing him and asking him, but he takes no action. He rather weakly says that this matter must be left to the doctors. I will not express myself as strongly as I should like to, but my hon. Friend the Member for Barking knows what is going on, and quite rightly says that the Minister and not the doctors must take action in this matter.

I am relating everything I say to the Report. I am glad to see on page 22 that an inquiry into this matter is called for. I have asked time after time for investigation and report on these matters. The Minister has said that other countries are faced with the same problem. That is no defence, but he is quite right. Australia and New Zealand have had the same problem and have tried to deal with it in their different ways.

Three weeks ago I was invited to Norway to give two or three lectures, and I had the opportunity to speak to the Secretary for Health about this matter. He said, "This is most interesting. We are a small country and have always had to limit our imports because we are unable to pay for more out of our trade. We have always said that, as a progressive country with highly-respected social services, as many drugs as possible can come in, but this year we are flooded with proprietary goods ". Norway is closing the door.

Other countries are faced with the same problem, but they are taking action. The Minister is being really weak when he says that only the medical profession can take action in this matter. I find it very difficult to reconcile the colossal sum spent on drugs and the weak attitude of the Minister towards it, with the decision to cut the milk supply to the under-fives in the nursery. Let us put some of the millions used on proprietary drugs—for which there are equivalents from the national formulary—and spend them on milk to prevent disease among our children

Major Beamish

A pamphlet dated May, 1955, was issued in September by the Ministry of Health, showing that the cost of 312 proprietary medicines had been investigated and that 74 per cent. of them either had no standard equivalent or were substantially cheaper than their standard equivalent. I hope, therefore, that the right hon. Lady the Member for Warrington (Dr. Summerskill) is not prejudiced against all proprietary medicines as such.

Dr. Summerskill

I do not want to delay the House but the hon. and gallant Member for Lewes (Major Beamish) provokes me. By a curious coincidence, again in my last post, I found the Annual Report of the Association of British Pharmaceutical Industries. Here is the report of the drug houses. It is interesting to see that they have an establishment at Tavistock House South, Tavistock Square, which is very near to the British Medical Association.

Mr. Turton

They are the houses that do not advertise

Dr. Summerskill

The Minister must not invite such elementary advice. Of course they are not houses which do not advertise. Is not this letter advertising to the doctors?

Mr. Turton

That was the point of my intervention. The Association of British Pharmaceutical Industries consists of the houses who have agreed not to advertise in the way that the right hon. Lady describes.

Dr. Summerskill

I do not want to develop this point, but the Minister has said enough to show that he has become a little confused. This is the position. A doctor is not allowed to prescribe a drug which is publicly advertised, but is allowed to prescribe a drug which is advertised in this manner. The Minister, by showing his ignorance of something so utterly elementary, really shakes me. Here we are discussing a matter of vital importance to the Health Service and he does not seem to know the basis of it.

Mr. Turton

I pointed out that the right hon. Lady had referred unfairly to an organisation which is a professional body with fairly high standards. It is an organisation that agrees not to advertise to the public. It is true that I forgot that the right hon. Lady, with her double capacity, was getting these communications as a professional lady. They would be allowed to advertise to her

Dr. Summerskill

The Minister has stuck his neck out, as I think the expression is. I will let him have this information. I will not in public instruct him. I am glad to see the hon. and gallant Member for Ripon behind him looking a little uncomfortable about the position. Among these organisations are people like Glaxo. The Minister will know that name. Has he ever heard of Glaxo advertisements? I will not say any more. I will let him have this information. It is shocking that the Minister does not know, and he must not try to hide it by jumping up and interrupting me. It provokes me.

I have already said that I will try to debate this matter in harmony. There are categories 1, 2, 3, and 4. The Minister probably knows that in category 1 are new drugs of proved value and of known standard, and it is recommended that they should be freely prescribed, while the other categories can only be prescribed subject to satisfactory agreement as to price. The Minister has to take this into account as well where there is an equivalent in the national formulary. I am trying to finish my speech quickly but this is a rather long Report with important matters in it.

On preventive medicine I have spoken about the importance of integrating the welfare service and the health service. We should make an effort to reverse the existing trend of sending people easily into hospital although it is inevitable when many people come from poor homes and have no accommodation. I welcome what the Minister says about not only the health service but the home-help service and the home-health service, which are of the greatest importance.

I was recently engaged on the Clean Air Bill, and I therefore welcome the reference in the Report to the elimination of air pollution. I hope that when this matter is discussed in future the Minister or his Parliamentary Secretary will endeavour to identify themselves with the discussion. We were very surprised in the Clean Air Bill Committee that the Ministry of Health was not represented.

My hon. Friends, I am sure, will elaborate on the question of health centres, which the Minister did not mention. I quite agree that a well-equipped health centre as a place where preventive medicine is stressed, and where that cooperation between the medical officer and his staff and the general practitioner can be fostered, could have a practical effect. I think that these centres are most success- ful in the new towns, but I do not think they will be very successful in places where doctors have already got consulting rooms and waiting rooms and have established a pattern of life.

I will leave the question of the general dental service to my hon. Friend the Member for Wolverhampton, North-East (Mr. Baird) who, I hope, will make a contribution on the subject. The shortage of dentists is such a serious matter that I hope the Government representative who replies to the debate will tell us when the McNair Committee is to report.

This Service is of prime importance because it serves the whole country—every one of us—and particularly the least fortunate among us, the aged poor, the diseased and the mentally afflicted, who are deserving of our most careful and sympathetic consideration. Therefore, I regard this opportunity of discussing the Health Service as of great value. I can only hope that any contribution I have made will be regarded as tentative and will perhaps be considered by the Minister carefully.

6.12 p.m.

Mr. Hubert Ashton (Chelmsford)

It is a formidable task to follow the Minister of Health and the right hon. Lady the Member for Warrington (Dr. Summerskill), who has special knowledge and qualification in this whole complicated matter. I should like to address myself to one or two aspects of the Health Service generally, with which I have come into contact over the last ten years and more as a member of a county council and of a board of governors of a teaching hospital.

I am sure that anyone who serves on a local authority is sometimes a little dismayed by the enormous numbers of committees on which one is expected to serve. Therefore, I welcome a great deal the suggestion of the Minister that if in any way some of the duties of the many committees could be combined, thereby reducing their number, I am sure that that would be very welcome in every quarter. As one looks to the future one sometimes wonders how it may be possible to fill adequately all the positions required in the public service in matters relating to health and education alone.

I want to say a word about the composition of the health committees. In paragraph 731 (9) of the Guillebaud Report it is suggested that the number of medical members on those committees should not exceed 25 per cent. I believe that that is a sound recommendation. I say that in the knowledge that sometimes to educationists and men learned in medicine and surgery it may be rather a nuisance to have a layman who cannot always follow their complicated arguments.

On the other hand, I think it would be true to say that, occasionally at any rate, the technical individual may be concerned directly with a decision which comes before the committee and may, therefore, be slightly biassed in any recommendation that he or she may make. I agree that, whether in education or in health, these committees should not be over-weighted by technical people. At the same time, I pay my tribute to what I have learned from these people and hope that they will continue to come forward not only in the quantity in which they have come forward, but also in the quality, which is of a very high standard.

In one matter I agree with the right hon. Lady. I do not think that it would be a good thing to take the domicilary hospital services from the health authority, the county council, and return them to the small authority, the municipal borough, etc. Nevertheless, we have to remember that those authorities used to run these services and, therefore, it is not unnatural that they should desire to regain them if possible. I think that the recommendation of the Report is very specific on that point, and I believe that it is a right recommendation.

I come to another matter, which probably is somewhat more controversial, the question of how the teaching hospitals should be dealt with. The right hon. Lady said that she thought teaching hospitals should be integrated and that there was an element of snobbishness and reaction in teaching hospitals. I have already said that I have been a governor of a teaching hospital in London for many years. I hope I cannot be accused of being either a snob or a great reactionary, but I think it is as well to bear in mind that the manner in which the teaching hospitals have been dealt with under the great health scheme is one which had many years very careful consideration.

For example, when the National Health Service was being considered after the war, the Good enough Report on Medical Education reported, in 1945, and used these words: The facilities required for successful teaching will not readily be provided if the management of the hospital is in the hands of a body administering a number of hospitals and having to act on principles applicable to all. If a parent teaching hospital is to function efficiently as an institute for medical education and is to work in close association with the medical school, it must have a governing body that has acquired an intimate knowledge of the institution and its staff. Such a governing body must be personal to the hospital. The words in the Guillebaud Report on this point are very specific. I agree that on this problem there was a minority report, but this is what the Report said, in paragraph 731: It seems to us that one of the dangers of a national hospital system lies in over-standardisation and uniformity. There is a distinct advantage therefore in preserving the separate status of the teaching hospitals outside the Regional Hospital Board framework. In the past, the great advances in medical techniques and knowledge have come from the teaching centres, and these benefits have accrued thereafter to the non-teaching hospitals. In our view, it would be a shortsighted policy now to subordinate these institutions, upon which so much depends for the future development of the service to the Regional Hospital Boards. The Report goes on, as a natural corollary, to say that it is absolutely vital that there should be the closest possible co-operation—that is a word which has been used in these debates and rightly so—between the teaching hospitals and regional hospital boards. I believe that at the outset of a huge set-up like the National Health Service, there were, naturally, minor difficulties, but today there is very close co-operation between the teaching hospitals and regional hospital boards. I believe that there is room for argument on this matter, but I suggest to the House that it is a question which has had very careful consideration. Before there is any change, as is suggested in certain quarters and as was suggested by the right hon. Lady, I hope we shall pause and consider very carefully what has been said in the Guillebaud Report.

Arising from my experience of these hospitals, I was interested to hear what the Minister said about the desirability of creating a career for the administrative staff in our hospitals. I shall be glad to see tomorrow exactly what my right hon. Friend said in this connection. It was not quite clear to me whether the improved conditions or opportunities for a valuable and remunerative life referred also to hospital secretaries, house governors and catering officers.

One further aspect of the matter, concerning hospital secretaries, is important, for in page 253 the Report reads: As we believe that the hospital secretary holds one of the key positions in the hospital service, we recommend that steps be taken to ensure that the prospects, responsibilities, salary, and other conditions of service of hospital secretaries are such as to attract persons of the right quality to these highly important posts. I hope that the Minister had this very much in mind when he spoke about recruitment and the attention which is being paid to ensure that there is a career for people who wish to spend their lives in the administration of our great hospital service.

I am one who believes that administration is absolutely vital in all aspects of life. Whether the sum available for the hospital service is £400 million or £500 million per annum—it may not be as much as we should like to see—I am quite satisfied that good administration and good administrators will see that the money is spent wisely. It is always possible in an organisation of such a size to achieve some economies without interfering basically with the efficiency of the service itself.

Turning to the Whitley machinery, it seems that the new investigation which is being carried out will bring about some flexibility, which is, of course, highly desirable, whether in the Health Service or in the local government service generally. I know the difficulties in dealing with these things. We have to have a national scale of wages, but when we are anxious to give some small additional remuneration for a person who is specially qualified, we do not find the problem easy. I believe that if sonic latitude in this respect could be given to hospital management committees, particularly in regard to catering officers, it would be an advantage. If they are efficient—and some of them are—these officers have to be paid fairly well, but they earn their additional remuneration over and over again.

Having served on a mental hospital management committee, I recognise that the problem of mental health is a very real one, but, of course, we in this country always add to our own problems. Some of these people live to a very old age—a much greater age today, thanks to the splendid discoveries of medicine and—none of us would have it otherwise, but we must bear in mind that we sometimes make rods with which to strike our own backs.

One thing which was pushed rather into the background when the hospital service was started, I feel was the voluntary effort in hospitals. It has been much encouraged to return by my right hon. Friend the Minister of Labour, who was Minister of Health for some years, and I hope and believe that this is an aspect which we shall see encouraged, not merely in the National Health Service, but in our whole national life.

I believe that the National Health Service has been of immense value to the country and that it has brought about almost a revolution in the attitude towards being ill of very large sections of the community. It must have contributed very considerably, in its turn, to what we term preventive medicine. I join with the Minister in his comments and with the right hon. Lady in her chorus of praise.

I should like to repeat my view that we must keep before us the standard of the people who serve on these committees—not only the voluntary members but, in particular, the administrative staff. Frankly, I believe that not sufficient attention has been paid to them in the past. I shall be very glad to see in HANSARD tomorrow exactly what the Minister said on this, for I believe that it is vital for us to ensure that we have the right and proper administrators in what are probably key positions of this great hospital service.

6.26 p.m

Sir Frederick Messer (Tottenham)

I am glad to follow the hon. Member for Chelmsford (Mr. Ashton), because I know that he has had experience of local government, having been a county alderman of Essex while I was a county alderman of Middlesex. I know, of course, that his county was inferior to ours, but nevertheless that experience justifies him in taking part in the debate.

When the Guillebaud Report was published, I was particularly interested to read it, for it gave me such varying I saw and recognised things which we had long known—the anomalies, the inconsistencies, the weaknesses all those problems which we thought would receive attention in due course. As we read the Report, we thought we should hear how some of the problems would be solved. But we found that the Committee while agreeing with all these things, said, "It is best to leave things as they are". What recommendations the Committee makes are by no means of a radical character. With one or two exceptions, they might, in the main, have been dealt with administratively.

There is, of course, one important point: we know that there has been stimulated in the country a belief that this was a terribly costly service and that there was wastefulness and lack of is that economy in it. At the back of my mind is the thought that the Committee was set up to find out just where it was. It did not do so. It came to the conclusion that the controls were there and, while it did not go to the length of saying that the economically as it could possibly be carried out, at any rate it said that there was nothing to worry about.

Instead of saying where money could be saved, it told us that what we wanted was more money to spend. Everybody realises that in such a Service as this our finest investment is in spending money which can prevent people from becoming non-producers through illness and prevent children from growing up into weak men and women—spending money which will find its return in the physique of the people. I do not think the Report paid enough attention to the preventive service. That might have been developed a little more. It is a truism that the more we spend on preventive treatment the less we need to spend on curative treatment. I therefore want to say a word about the local authority service.

When the scheme came into existence powers were transferred from borough councils to county councils. There were some who believed that that was done because the hospitals were being taken from the county councils, and that they would be in a position to deal with the environmental, preventive and sanitary services. In my view, there is room for considering whether or not certain of those services should be transferred to the large boroughs.

if it is a question of population, there are boroughs such Harrow, which has a population of nearby 250,000: Ealing with 170,000: Enfield with 110,000, and Tottenham with a population of 127,000. Incidentally, Tottenham has been known for the high standard of its public health work for many years. Indeed, only a short time ago Earl Verulam, Chairman of the national Baby Welfare Council. Gave Tottemham a trophy which could only be won by the local authority which was able to show a high standard of baby health work.

it is worth considering whether or not some means could not be found whereby certain of the power now invested in the country council could be transferred to the boroughs. One reason for that is that with work for this description the authority responsible for administration should be as near to the people as possible. A country council can be responsible for those services which can called "mass" services domiciliary services, nurses, domestic helps and so on could be more efficient done by the boroughs than by the country council.

in point of fact, the country councils are driven to expedients to get this work done. London for instance, is divided into nine health area committees, and Middlesex into a number of committees. Whilst the chairman of such of a committee may be a country councilor, the member are not members of the country council. Country councils, therefore, have to call upon boroughs councils to be their agents. I am referring to this because the Guillebaud committee does not consider that there is any need for alterations.

The problem which poses itself is this if we retain the country council as the public health authority, in what way can we ensure that borough councils and urban district council of a fitting size shall have the opportunity of doing this work? I suggest that the council should be retained as the public health authority, but that the right should be given to boroughs containing over a certain given population to claim dele-gated powers. Failing the consent of the county council to give those delegated powers, the Minister could arbitrate.

As a consequence, we would get just as great, if not greater, efficiency. We talk about efficiency, but this Service does not depend upon a mechanical efficiency. Something more is required. There are qualities of approach. I am certain that one gets a better understanding of the problems of people in one's own town as a town councillor than as a county councillor who has to cater for people living perhaps 50 miles or more away.

Every locality has its own peculiar characteristics. It has, as it were, a life of its own. I make that suggestion for what it is worth. It would do two things. First, it would bring a very welcome closer contact between the people to be served and those serving. Secondly, it would give some greater incentive to those who want to spend their time in public service to do something worth while. We have excepted districts in the field of education; why cannot we have a similar arrangement in this field?

There are some things in this Report which confuse me. I remember that when we were discussing the setting up of this Committee I ventured to doubt whether its findings would be in accordance with the realities of the situation unless there were people on the Committee who were able to assess the value of the evidence it received. In this work, probably more than in any other, a Committee that knows very little about the work in question has to accept the evidence given before it by its volume rather than by any other test. The only member on this Committee who really could apply that test was Sir John Maude, the Permanent Secretary to the Ministry in the days of Mr. Ernest Brown, when the Coalition White Paper on the National Health Service was introduced He was still occupying that position when Mr. Henry Willink became Minister of Health. He does, therefore, know the subject inside out—and we find that he has made reservations.

The Report contains several anomalies, but running right through it from beginning to end is emphasis on the weakness of it being a tripartite service. All the way through we find a groping for some means of getting co-operation. There is a reference to a Report of a Committee set up by the Central Health Services Council on this question of co-operation. The Report says quite plainly that this Committee brought out a recommendation of which very few people took any notice.

It is quite true that there were one or two regions which attempted to carry out the recommendation of that Committee on co-operation. Why was it that a Committee which applied its mind for a very long time to that problem was unable to find a way of doing this job that would be acceptable? We know, of course, that it introduced new machinery, and everybody who has anything to do with this work is fed up with the wheels of this machine. There is no room for more machinery. Indeed, I would like to see much of the machinery cut out. and I agree with the hon. Member for Chelmsford in one respect—a reduction in the number of committees.

Let the management committees have a look at what committees are meeting now and doing work which really does not call for a committee at all. If the management committee itself determines policy, all that is required are sub-committees to ensure that policy is being carried into effect. We want to produce the type of officer able to work independently, without having to get the consent of a committee every time something needs to be done.

In a hospital of which I am aware, it was the case some time ago—but not now—that when it was desired to remove an electric light switch from one side of a door to the other, they had to call in the engineer who had to make a report to a works committee before it could be done. That sort of thing seems to me to be over-organisation. If we have officers on whom we can depend, we ought to leave these jobs to them to do; if we have officers on whom we cannot depend, then let us get rid of them and get somebody in their places. That is not so easy in work of this description, because in most cases, when they get these jobs, they get them for life.

However, I return to the question which I posed. Why was it that this committee found it so difficult to discover a way of bringing about this coordination? The Guillebaud Committee keeps referring to the need for cooperation, if there is the will for it. We want something more than will; we want the head for it too. I think I know why nobody has succeeded in getting this co-operation. It is not because there is not the will; it is not because there is not a desire for it. It is not because of snobbery by one section to the others, although let us put it on record that snobbery does exist, and that the consultant looks down on the general practitioner, and the general practitioner looks down on the medical officer of health. Mr. Henry Willink, when he was Minister of Health, wanted these services to come under the local authority. Who prevented it? The doctors? No; they would not come under the medical officer of health. He was of lesser clay.

One of the reasons why it was not possible to create an instrument for cooperation was this. Because of the way in which the service at the moment is built up, it does not lend itself to co-operation. The Report of the Guillebaud Committee says that the Committee recommended no change in regard to the regional boards, which had been very carefully thought out. They have been thought out in such a way that one would be worried just by counting the patterns. The Report by the Central Health Services Council on Co-operation between Hospital, Local Authority and General Practitioners Services says this: In London, to take the extreme example, the London County Council area itself contains the one local health authority"— so we get in the very big metropolitan area one local health authority— with nine divisional areas and the one Exective Council, but it is split between four Metropolitan Regional Hospital Boards. When we ask for co-operation with the London County Council, as the local health authority, it means co-operation with four regional hospital boards. In addition to these four metropolitan regional hospital boards, there are 26 boards of governors of teaching hospitals and 25 hospital management committees. If one looks at the area covered by the four Metropolitan Regional Hospital Boards, one finds 31 local health authorities. because the regional boards extend outside London. In order to hold a conference for the purpose of co-ordination, it was necessary to draw people from all these, and indeed other, areas. The conference was called to discuss co-operation, and it was found just impossible to devise a means whereby it could be effective.

The boundaries, for instance, are drawn in such a way as to overlap the areas of many authorities. One particular regional hospital board covers the administrative county of Bedford—the whole of the county—the County of Hertford, except the part included in the East Anglian and North-East Metropolitan regional hospital boards. In Hertfordshire, there are three regional boards having a share with Middlesex, except the part included in the North-East Metropolitan Regional Board. So that this particular region includes Bedfordshire, part of Hertfordshire, part of Buckinghamshire, part of Berkshire and the whole of Middlesex, except Edmonton, Tottenham and Enfield. It also has part of London, and this is the part of London which is included: So much of the administrative county of London as comprises the metropolitan boroughs of Hampstead. Holborn, Islington. St. Marylebone and St. Pancras; the part of the Metropolitan Borough of Hammersmith lying north of Goldhawk Road and Stamford Brook; part of the Metropolitan Borough of Kensington, lying north of Holland Park Avenue, Notting Hill Gate and Bayswater Road; part of the Metropolitan Borough of Paddington, lying north of Bayswater Road; part of the Metropolitan Borough of Westminster, lying north east of Park Lane and north of Constitution Hill, Birdcage Walk, Great George Street and Bridge Street. That is a region which cuts through parishes. In these circumstances, how can we get co-operation? What we really want is a region so drawn that its periphery conforms to that of certain local health authorities. It might be said that this is untidy administration, but it seems to me to be commonsense; and perhaps that is a little more valuable. It is for this reason, since we are not dealing with figures but with human beings, that I plead with the Minister to alter the boundaries in order to make it possible to get this co-operation.

The Guillebaud Committee does not want to change the responsibility for the ambulance service. It admits that 75 per cent. of the ambulance work is hospital work. I do not know what the other 25 per cent. can be. The Guillebaud Committee has said that, on the evidence it has received, everything was satisfactory. I wonder whether any patients were called as witnesses before the Committee. I wonder whether the Committee heard evidence of the way in which this divided responsibility works.

One of the weaknesses of the Service is divided responsibility. Here we have a service for part of which the local authority is responsible, and the regional hospital board is responsible for the other part. In this Service the regional board is responsible for the sick old people, and the local health authority is responsible for those who are not supposed to be sick but who are old, weak, deaf, nearly blind and who cannot walk. Those are known as welfare cases, and they lack attention because there is no clear decision as to who is responsible for them.

On one occasion a woman was taken into hospital at Poplar, and when the time came for her to go to a convalescent home at Edgbury, Woburn Sands, Bedfordshire, she was taken by ambulance. A period of convalescence improved her condition, but not sufficiently to enable her to walk home. When the time came for her to return home, she was asked by the matron, "Have you made arrangements?" to which she replied, "No, I was brought by ambulance and expected to go home by ambulance". She was unable to do so because her home was not in the local health authority area from which she had been brought by ambulance. She was brought by ambulance from the local authority area in which the hospital was situated.

Somebody telephoned me and I said, "The answer is simple, but do not tell anybody that I told you. You should ring up the hospital and tell them to get an ambulance from their local authority area and take this woman back to the hospital. Then let the other local authority. in whose area the woman resides, send an ambulance to the hospital pick her up and take her home."

I wonder whether members of the Guillebaud Committee have been to a large hospital where there is a physiotherapy department. In one such hospital I saw an old man walking about at 2.15 p.m. asking where he could find somebody who would arrange to take him home. He had been taken there at 10 o'clock in the morning. He had had diathermic treatment and sun-ray treatment and was waiting to be taken home. I was once waiting to see the operator in a sun-ray department and I saw a man sitting there. I said to him, "Why don't you go in?" He said," I have been in. I have been waiting here an hour and a half to be taken home." The hospital had no authority over ambulances and could not do anything for him. It was the responsibility of the local health authority.

Hospitals should have full authority over ambulances. To those who say that it cannot be done, I would say that it is already being done in Scotland. The Guillebaud Committee's Report says, "Oh, but things are different in Scotland. Look at the large number of county burghs." Look at them. Look at them in Lancashire, for instance, where there are eighteen county boroughs and one county council, all of them local health authorities and all responsible for an ambulance service. The principle for one authority to be responsible for financing a service which another authority uses is wrong.

The Guillebaud Committee says that the medical officer of health is in a position to check abuses. How is he? In Middlesex there are fifty hospitals and one medical officer of health. If members of his staff are posted to every hospital it will have taken the whole of his staff to check abuses. However, the authority which supplies a service is bound to be interested in finance, and the authority which is using the service is bound to be interested in the amount of service given.

A local health authority received an award of the Whitley Council which said that ambulance drivers who change wheels when they get a puncture shall receive 1 s. 9d. a week extra. Certain economy-minded county councils said, "This will not do", and they issued an instruction saying that no driver should change a wheel. If an ambulance broke down because of a puncture, it would have to wait. The driver would have to telephone for a relief. In that ambulance there might be a woman suffering from uncontrolled haemorrage, or a patient with a perforated ulcer, or a strangulated hernia. Surely there is room for consideration whether or not we can get greater efficiency in this service by adopting a little common sense. However it is looked at, if ever there was a service which is part of the hospital service, it is the ambulance service.

I apologise for having spoken for so long. I gave an undertaking to my friends that I would not speak for an hour, but there is enough in the Report to justify it. The Report stimulates our thinking. We may not agree with all of its contents, but it contains enough to give us some views on improvement. Take, for example, the question of integration of the teaching hospitals. I am not wedded to the idea, but let us consider the situation. There are twenty-six teaching hospitals in London. Out of those, in one region alone there are five graduate and nine post-graduate teaching hospitals. That is fourteen in one region. The others are in the provinces.

Those who were in the House when this service started will remember that it was said that a teaching hospital should be attached to a region. I have many friends on teaching hospital staffs. I remember attending a conference of representatives of teaching hospital regional boards, and after we had had the usual hospitality—sherry and biscuits, or something of the sort—we began to discuss problems. Someone said, "You have got a long list of nurses. You cannot take them all in. Why do you not second some of your nurses to our T.B. services in the region?" We did not get much co-operation. But at any rate we reached the hand-shaking stage. I presided over that conference, and I remember saying, "Well, we have reached this hand-shaking stage. Why cannot we now walk along the road arm in arm?" We were very lover-like. What we did find was that the attempts made by the Ministry itself were made difficult.

For instance, quite rightly the Ministry said that in order to get efficient working they wanted to concentrate power where it was required. Accordingly, there was put out a circular on cancer centres, and there was to be a co-ordinating cancer committee. A cancer committee is all right in a region where there is one teaching hospital and probably two or three local health authorities; all one has to do is to call half a dozen people together and co-ordinate the work. The committee can decide where the centre is going to be and the method whereby patients will get there. In a region having fourteen teaching hospitals and several local health authorities, the committee ceases to be a co-ordinating committee; it is a mass meeting, and it is quite impossible to do anything.

In our case, we did not attempt it. What we had to do was to decide that the co-ordinating committee could elect a committee to do the actual work. Incidentally, I have found on some occasions that the best work is done by a committee of two when one member is absent.

Co-operation is possible, but we must make the machinery ready for that co-operation. We must make it possible. In a set-up such as we have, the difficulties are considerable. The Guillebaud Committee has done a real service in pinpointing certain of these factors. In regard to teaching hospitals being within the region, in Scotland they do it, and intelligence is by no means of a lower standard in Scotland than it is in England. The Goodenough Committee did not like it. I showed in my evidence to the Goodenough Committee that there were many teaching hospitals which were so small that they had not got the bed capacity to be able to divide their bed population into the specialties they required. Consequently, a recommendation was made that no teaching hospital should have less than 800 beds, and, when this Service came in, teaching hospital bed accommodation was increased. The Goodenough Committee, when making its decisions, did not know we were to have a National Health Service such as we now have. When it sat, as hon. Members will remember, we were deciding what sort of scheme it was to be.

The Goodenough Committee—and the teaching hospitals agreed—said, quite rightly, that the chief function of teaching hospitals is to teach and train students; but they have also the task of caring for patients and treating them. The students cannot learn effectively otherwise. There was a time when a student could get his degree and qualify, coming out without having seen a chronic case, probably without having seen a tuberculosis case or a cancer case.

The teaching hospitals have something to learn in co-operation with the regional board hospitals. There is a large teaching hospital in the west of London which told the regional board it lacked beds of a particular sort and asked for help. The board agreed, and as a result an arrangement was made whereby a certain number of those beds were given over to the teaching hospital. The teaching hospital sent its staff along, and, as a consequence, both of them were helped. But it was quite voluntary; it was done because the will was there. It would have been very much easier if, by some means, there had been a closer association between the teaching hospital and the regional board hospital.

This Service has come to stay, and now we must have the right people to run it. We must have those who believe in it. Unfortunately, not all those who were appointed to regional boards believe in it. This, of course, is a weird and wonderful process. How are members appointed to regional hospital boards? Does the Minister have a number of names in front of him, all the people being of equal standard of fitness, and does he shut his eyes, put in a pin, and in that way decide who the members shall be?

Perhaps I might offer a suggestion here. There is a strong feeling in some quarters that hospital management committees and regional boards do not reflect the interests of the people who will benefit by the Service if they ever need it. Some better method of appointment may, perhaps, be needed. The House has been very patient with me, and it would be at the risk of wearying hon. Members if I were to make any more suggestions.

This Service has come to stay. Let us recognise that, and, in doing so, let us help to make it what it ought to be—one of the finest monuments to the ability good will, understanding, generosity, and sympathy of the people of this country.

7.7 p.m.

Mrs. Evelyn Emmet (East Grinstead)

I have read the Guillebaud Report with very great interest, having spent a large part of my local government service on the health and hospital side.

I find myself in agreement with a great deal of what the hon. Gentleman the Member for Tottenham (Sir F. Messer) has been saying, though I do not know that he would go arm in arm with me all the way I want to go, and I am afraid that, if he were to do so, he would incur the displeasure of the right hon. Lady the Member for Warrington (Dr. Summerskill). I am referring here particularly to possible alteration in the system of Health Service administration. My hon. Friend the Member for Chelmsford (Mr. Ashton), in my view, exaggerated the conclusion to which the Guillebaud Committee came.

In page 243 the Report says that the Committee is of the opinion that it is altogether premature to make an alteration. One might agree with that; the new Service has not been running sufficiently long. The Committee says, also, that it does not feel that a convincing case has been made out for transferring the hospital service to the local health authorities. That is not a very strong statement. After all, a convincing case might be made out at a later stage.

I am an unrepentant sinner in this matter. I believe that I am in a minority in this House but I do not believe that to be in a minority is necessarily to be wrong. I would like to see this matter carefully reconsidered when the local authority reorganisation takes place. At that time, we should consider very carefully the three advantages which will result from transfer.

The operation of the health services which are now split into three divisions. would be greatly improved by an amalgamation. The welfare and preventive work of the county councils would be dovetailed much more easily into the medical and hospital arrangements than is now possible. The elected member would be accountable on a public platform for the spending of public money. which would correct what I believe to be one of the great weaknesses of the present system.

I might remind the House that we used to be brought up on the saying that there should be no taxation without representation. In addition, with an elected member the patient has his proper avenue for complaints and one with which he is familiar. Thirdly, I believe that an enormous economy in administration, both as regards personnel and in offices and premises, would be achieved.

It was probably necessary to start the new service in that way because it helped us to attain some measure of uniformity and an improved standard over the country. I feel, however, that we shall not be able to afford, certainly in manpower, that kind of double set-up. Both the hospital boards and the local authorities recruit their personnel from the same market and labour is in very short supply. If, when local government is reorganised and this question is considered, some form of reintegration is evolved, the hospital boards would, after all, only be following the historical sequence of events of, for example, the Board of Education and the Board of Guardians.

A return of responsibility to local government would counteract the tendency, which is growing strongly and which I deplore, that the hospital committees are coming more and more to be run by their medical staff. I have the greatest respect for doctors, especially in their own practice, but I do not like government by experts. It is a tendency which certainly is growing.

In page 128, the Report goes at some length into the question of hospital costing, which is a most important consideration in the running of any service. It seems to me that we may run into rather serious dangers and expense if we go all out for a central costing system. Proper costing needs up-to-date costing and accounting machinery, which is very expensive, and there would need to be a great capital outlay on this form of machinery if it was to be successful.

I was told recently by the secretary of a hospital that there is great danger of too much centralisation and in the requirements of the Ministry by way of returns. He told me that his hospital, which, formerly, had six medical secretaries, now has fourteen—a rise of 60 per cent.—but that the hospital service does not seem to have benefited thereby.

In addition, it is extraordinarily difficult to show the necessary variations that hospitals must have, because of their peculiar character. There may be a quick turnover of beds at one hospital while in another the turnover is much slower, for perfectly good reasons. This kind of thing makes it difficult to compare costs centrally, and it seems to me that if a local authority had some kind of supervision locally it would be much easier to obtain better accounting and better costing.

When I suggested that the hospital service might be handed back to local authorities, I was considering the local authority as agent and not as an authority completely responsible for the hospitals. The agency principle is used extensively in local government for the Ministries and appears to work quite well. If we have these new costing experiments, I hope that they will be pilot schemes.

I should like to say a word about the administrative staff. We read in pages 230 to 231 of the Report that the Guile-baud Committee admits that the hospitals are tied very rigidly by the Whitley Council rules and are having great difficulty in recruiting and maintaining their administrative staff. I wonder whether the Minister might consider starting a pool, as in education, for posts of special responsibility. This would give a local authority a great deal more flexibility in its arrangements for its teaching staff.

If a pool of this nature could be evolved for the administrative staff, it might be feasible to retain the services of a key hospital officer such as a steward, secretary or engineer, who has a responsible local position but who, otherwise, would move and so weaken the efficiency of his hospital severely. I merely put forward this suggestion as one which might be considered.

I should like to say how glad I am that the Guillebaud Committee has come down against the block grant system. It is a grossly incompetent method of obtaining a first-class administration and it perpetuates the faults of the extravagant hospitals and penalises the thrifty ones. When I served on these committees, I found that when a block grant was made the local hospital committee increased an item to an unnecessarily large extent so as to have a hidden reserve; then, the hospital management committee also budgeted for a reserve and, of course, the Minister, too, budgets for a reserve. By this system, a much larger amount of money is set aside than is necessary when there is careful administration which goes into all the necessary details and admits claims when required.

The Elizabethan conception of the sick, the poor and the aged remaining as far as possible a local responsibility—supported nowadays, of course, by national finances—is more conducive to the retention of humane and understanding handling of their problems than the present three-there system, which, I cannot help feeling, will eventually break down through lack of proper manpower, both administrative and voluntary members, and because complications seem to grow rather than lessen.

7.18 p.m.

Mr. John Baird (Wolverhampton, North-East)

The Minister, who gave a very good summary of the problems facing the Health Service, appealed to us in his closing remarks to keep the subject out of party politics. I entirely agree with him. We have recently finished discussing the Dentists Bill, which we were also able to keep out of party politics, and we got on very well. But the Minister cannot get away with it just as easily as all that. I am one of the few people in the House tonight who was in at the birth of the Health Service—there are a few of us left, but not so many now.

While I am glad that we now want to keep the issue out of party politics, some of us remember the discussions, especially in Committee, on the National Health Service Bill, when many of the Amendments moved by the party opposite, who were then in opposition, were not Amendments to help the Bill but wrecking Amendments. One of them, for instance, proposed to keep the voluntary hospitals out of the hospital service. Until the last year, throughout our discussions of the Health Service it is a pity that some of the younger Members do not remember this, but they were not here—hon. Members opposite on every possible occasion attacked the Service, its fundamentals and its basis.

Indeed one of the major saboteurs, if not the major saboteur, was the present Minister of Labour. He came to power by slandering the National Health Service. Perhaps that is too strong a word; but he came to power by attacking it. He has clung to power by plundering it. It is a pity that the present Minister of Labour is not still Minister of Health and standing at that Box having to eat humble pie, because the Guillebaud Committee which was set up with the object of proving wastages, which the Minister of Labour and other hon. and right hon. Gentlemen opposite believed existed in the Service, has shown them to be completely wrong.

The Minister of Health, at the beginning of his speech, said the Guillebaud Committee had justified the Health Service as it now exists. He seemed thereby to suggest that there had been some major changes in the Service in recent years. The establishment of the National Health Service was one of the greatest of the revolutionary changes this country has ever seen, and it was administratively a tremendous job to accomplish. One would have thought that we should have made many mistakes in establishing the Service, especially as the National Health Service Act was not an agreed Measure. If the Minister intended to suggest that there had been major changes in the Service he was wrong, because the Guillebaud Committee's Report says there have been no fundamental changes in the Service and that it should remain as it is. That is a very great compliment to my right hon. Friend the Member for Ebbw Vale (Mr. Bevan) and to his assistants at the Ministry at the time the Service was established.

I was wrong to say there have been no fundamental changes in the Service. There has been one fundamental change, but only one, and that one fundamental change was the imposition of charges in the Service. The Guillebaud Report condemns that in principle.

At the time when the first charges were introduced people were rushing to have dentures, because before the introduction of the Health Service people were not able to afford them, but even at the time of the introduction of the charges the demand was falling. I argued that fact then. I said then that the demand was falling before the charges were introduced. My right hon. Friend the Member for Warrington (Dr. Summerskill) may remember that, and that she or the Parliamentary Secretary said that there was no statistical proof of the fact. She was a Minister then. Her figures were a year out of date, The Guillebaud Report says in paragraph 49: As we have already seen, the decline in resources used by the general dental service had already started before the charges were introduced, and there are some reasons for believing that the downward trend would have continued even without their introduction. Therefore, the one fundamental change which was made was unnecessary, and I hope that before long the Government will follow the recommendation of the Committee and remove charges altogether.

I want to speak especially of the dental aspects of the Health Service, but first I want to touch on one or two matters brought up during the debate. Like my hon. Friend the Member for Tottenham (Sir F. Messer), I feel that those of us who were at the birth of the National Health Service Act are, perhaps, more critical of the Health Service than the Guillebaud Committee. Perhaps, having lived with it longer, we know more of its weaknesses. My hon. Friend attacked the lack of co-ordination in the Service. We all know of it. I would ask my hon. Friend to remember that the lack of coordination does not always arise—indeed, in the majority of cases it does not arise—through the fault of the National Health Service. To a great extent the fault lies with the local authorities, and we cannot possibly have the co-ordination which is necessary until we have reform of local government. That is the first step towards co-ordination between the local authorities and the Service.

I was astonished at the figures the Minister gave us today about the rising price of prescriptions. As I said in an interruption earlier, to blame the doctors for over-prescribing is to put the cart before the horse. The busy doctor is inundated with advertisements for drugs, and he finds it much easier to prescribe proprietary brands than to write out a full prescription. The Cohen Report recommended practitioners to try to modify this, but though that Report was full of recommendations it was not binding. The Minister in this House must warn the doctors and the manufacturers of these proprietary medicines that, if they do not put their house in order, then the Government must step in to see that there is public control over this industry.

As a dentist, the example I know best and can speak most about is that of toothpastes. There are wireless and television advertisements claiming for toothpastes qualities which they do not possess, and those advertisements do harm to the dental health of people, because they are induced to believe that by buying some toothpastes they can stop or cure dental decay. In many cases some proprietary firms are being unethical. If they do not toe the line the Government must take action against them.

The hon. Member for Chelmsford (Mr. Ashton) quoted from a Report published in 1945, I think it was, and he said that we must not amalgamate the teaching hospitals with the general hospitals. Perhaps in 1945, 1946 and 1947 the time was not ripe to bring the teaching hospitals within the orbit of the regional hospital boards, but at that time we were only experimenting with the scheme. The position has now changed very much, and I think the time has come to see if we can integrate the teaching hospitals into the general hospital structure.

The Minister talked of the two-tier system of hospital treatment. When we introduced the Health Service we knew there were many weaknesses in it, and one was that at that time we allowed for part-time consultants as well as full-time consultants. I believe it was wrong, but at that time we thought that was necessary to get the co-operation of consultants. Today, however, things are changing. Towards the end of the tenure of office of the Labour Government there was a tendency to cut down the number of the part-time consultants and to encourage people to enter the Service full-time. Since the present Government came in that tendency has been altered, and now there is encouragement for more part-time consultants. We should warn the House that when we come back to power we have to see to it that we impose full-time service for consultants, because that is the only way in which we can got a first-class Service.

The Minister dealt at length with the problem of the old people and of domiciliary treatment. I think I was the first to raise this proposal in the House when, many years ago, I suggested we could save a lot of money if only we were to introduce chiropody for old people in their own homes. One of the great troubles with old people is that they are not mobile. If only we could keep their feet in order they would be able to get around and do much more work for themselves, and I believe that in the long run we should save money and not lose it by such a chiropody service, because we should not only save money but save on the health visitors staff employed at the present time.

This brings me to what I think is the fundamental issue in the financing of the National Health Service. If we want to save money we must spend it. The Minister was entirely wrong when he said that he was sorry for the old people, that he wanted a chiropody service for them but the finance was not available. I submit that unless we realise that we must spend money to save it we shall never get anywhere.

The Minister quoted paragraph 98 of the Guillebaud Report: It is clear that the amount of national resources, expressed in terms of finance, manpower and materials, which are to be allocated to the National Health Service, must be determined by the Government as a matter of policy, regard being had to the competing claims of other social services and national commitments, and to the total amount of resources available The right hon. Gentleman might also have quoted paragraph 96, which says: It should not be forgotten, however, that the National Health Service is a wealth producing as well as a health producing Service. In so far as it improves the health and efficiency of the working population, money spent on the National Health Service may properly be regarded as productive '—even in the narrowly economic sense of the term. If the right hon. Gentleman had quoted that paragraph I might have agreed with him, but the one paragraph contradicts the other as the right hon. Gentleman put the matter.

I agree with the Minister that we must have priorities, but the right hon. Gentleman did not take his argument for priorities far enough. The National Health Service is a money-saving Service. If we talk about priorities we must compare them. We must compare the armament programme, for example, with the Health Service. If we look at it in that sense I must say that I have never accepted 4000 million as the ceiling. I did not do so even in the time of Sir Stafford Cripps, and I do not do so now. I think that the figure must be more flexible and that we must spend the money, whether we like it or not.

I agree with what the Minister said about priorities—on the building of new hospitals, the improvement of hospitals, provision of mental hospitals, and the care of old people—but I want to speak about an aspect of the Guillebaud Report which is not a matter of priority, namely, the dental service. First, I hope that the Minister will look at the Guillebaud's Committee's suggestion that where people are attending dentists regularly for conservation treatment they should be charged £1, not every six months but every 12 months. We on this side of the House moved an Amendment to that effect when the legislation was in Committee, but it was turned down by hon. Members opposite. I hope that the Government will look at the matter again, because such a provision would encourage people to go to the dentist for regular consultation and regular treatment.

The major problem in the dental aspect of the Guillebaud Report is that of shortage of manpower. It is a very serious one indeed. We discussed it when we debated the Dentists Bill. First, we must get more dentists, and secondly, to save dental manpower, we must prevent dental decay as much as possible. As the House knows, there is a Committee sitting under the chairmanship of Lord McNair on the question of manpower. It will be reporting soon.

I am sure that the House will be glad to know that, while for some years now our dental schools have certainly not been full and some have been only half-full and it has been difficult to get young people to enter the dental profession, the position today has altered and the dental schools are again full. The change has taken place only this year. I hope that the discussion which we had in the House some time ago had something to do with it.

Today there is an entry of 623 students and there are only 35 vacancies in the whole country. If the McNair Report recommends 35 vacancies a year it will be easy, but if the Report suggests 300 more dentists—and the Teviot Committee recommended 900 a year—there is a great physical and financial problem. We cannot get these 900 dentists unless the Ministry and the Treasury are willing to spend money on building new and converting old dental schools.

There is not a single dental school in the whole of Wales. We must build a school capable of taking 100 students a year in Wales alone. There is an argument also for having a dental school in Aberdeen, although Dundee is not very far away. Some of my dentist friends say that one of the major problems is that of prestige. The Minister might look at the possibility of setting up a dental faculty in either Oxford or Cambridge. There is also the question of extending the present teaching hospitals. University College Hospital in London, one of the finest in the country, has room for an annual intake of only 25 students, and last year there were 1,000 applicants for those places. If more room were made available for more students in our present old and well-established schools with a long tradition, that alone would be an important contribution towards solving the manpower problem.

Apart from that, if we want students we must help to pay for their education. The trouble just now is that some local authorities seem to encourage dental students more than do others. I should like to see a co-ordinated policy to encourage young men and women, and we certainly want many more women, to enter the profession.

I had a discussion the other night with the secretary of the Nuffield Trust. He said something for which some of my hon. Friends might not care, but which might be looked at. Some parents are given a grant towards the education of their son because their income is below a certain limit. Parents whose income is above that limit are willing to educate the first child, but the second child is something of a Cinderella and there is no money to spare. He suggested to me that where a parent's income is above the limit qualifying for a grant for the education of the first child, the limit of income qualifying for grant should be increased in cases where the parent is willing to contribute something towards the education of the second child. Everyone knows that it is more difficult to educate two children than to educate one. And where it is socially desirable to have more dentists—and there are perhaps too many doctors while we have too few dentists—why not pay bigger grants to dentists than to the doctors? I have recently been in Russia, and that is what happens there.

There is finally the question of preventing dental caries. Prevention is much more important than cure. Those who have had to treat young children will appreciate that that is particularly true in the case of teeth. Certain local authorities are carrying out some interesting experiments with the introduction of fluoride into the water supply. It has been found that its introduction reduces the incidence of dental caries. I know that my hon. Friend the Member for Stoke-on-Trent, Central (Dr. Stross) does not agree with me.

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

Not necessarily

Mr. Baird

The suggestion is that one part of fluoride to one million parts of water is effective. But like many other innovations, the use of fluoride causes a certain amount of antagonism in certain quarters. All sorts of local prejudices creep in, and it is very difficult to get local authorities to adopt it. Kilmarnock has adopted it, but only after a great struggle—because some people argued that it would spoil the flavour of the whisky. It has been adopted now in Kilmarnock, Anglesey and Watford, and other authorities are carrying out experiments. We must be grateful to these local authorities who have been educating their people to accept this experiment, because they will benefit from it. I hope that before long this fluoridation will be practised throughout the country.

Hon. Members on this side of the House are very grateful to the members of the Guillebaud Committee for the way they have handled the Report. Those of us who were here in 1945 and 1946 and had to go through all the early battles to put the National Health Service on the Statute Book are very proud that we have now been vindicated, and I hope that the electors will read the Report and realise that we had to have great courage in those days to carry out this great experiment, when the medical practitioner, the dental profession and the Tory Party were against us. We were proved right then as we shall be proved right many times in future.

7.41 p.m

Sir Hugh Linstead (Putney)

I am glad to have the opportunity of following the hon. Member for Wolverhampton, North-East (Mr. Baird) and of thanking him for the contribution which he has made about the recruitment of dentists. which is one problem facing the Health Service. The hon. Member brings to the debate special knowledge of the methods of handling that problem. The only point with which I find myself strongly in disagreement with him is in relation to his casual suggestion of the absorption of the teaching schools into the regional hospital boards, ignoring what seems to me to be the fundamental principle which is involved, namely, university freedom and the right of universities, university colleges and teaching schools to conduct their own academic lives in their own way.

There was one matter upon which I had not intended to touch, but when I listened to the ill-considered part of the speech of the right hon. and learned Member for Warrington (Dr. Summers-kill) which dealt with drugs and their advertising, I felt that I must switch the course of my remarks completely and deal with that matter. Basically, she took the view that this was a condition of things in the Service which was badly in need of remedy; but she left the remedy completely in the air. She did not offer my right hon. Friend a single constructive suggestion.

The right hon. Lady's speech fell to the ground because she failed to face the one fundamental question of principle. I very much regret that she is not now in the Chamber, because I should like to know her reaction to what I am about to say. She failed to face the fundamental question whether or not a doctor is to be entitled to prescribe for his patient what, in his professional opinion, that patient needs. If any directions about prescribing are to be issued by my right hon. Friend to the medical profession—as the right hon. Lady seemed to be intending—they will have to infringe that principle. The medical profession must face the question whether or not it regards that principle as basic to its professional freedom.

Mr. Blenkinsop

Neither my right hon. Friend nor any hon. Member on this side of the House has suggested any limitation upon the professional right to prescribe what is thought to be necessary for the patient; indeed my right hon. Friend referred to that right. What we insist upon is a much more effective administrative check upon the prescribing—a check which, in some measure, has already showed very valuable results. We want that check enforced much more vigorously, to ensure that the waste which we still feel is going on shall be stopped

Sir H. Linstead

The hon. Member has gallantly come to the rescue of the right hon. Lady, and has made that point much more clearly than she did, but it still brings that line of argument up against the question whether the Minister of Health should be entitled to rely upon his professional knowledge, discretion and sense of responsibility of the general practitioner and the prescribing doctor. I would have said that it would be a bad day for medicine if doctors were forced to accept a political decision, and not left in a position of judging between one type of advertising and another, or one type of drug and a proprietary type, but had to rely upon instructions and directions from the Ministry of Health or regional hospital boards.

Dr. Stross

I am sure that the hon. Member does not wish to be unfair to my right hon. Friend. He will remember that, in effect, she was arguing that the medical profession should be protected from the receipt of an excessive number of advertisements through the post. She quoted an instance of advertisers who, after two samples had been accepted, offered a third sample of 500 tablets. That would mean 11 million free tablets a year for the profession.

Sir H. Linstead

The hon. Member is now emphasising and underlining my point. It is surely not for the medical profession to ask the Minister of Health for protection against this, that or the other type of advertising. If it is a liberal, intelligent and responsible profession, one expects it to be able to stand upon its own feet and make up its own mind about any proposition which may be put to it.

The point which the right hon. Lady's speech requires me to emphasise is that on the question of the development of the pharmaceutical industry we cannot have it both ways. We cannot expect to have the latest advances in medical and chemical science developed by the manufacturing industry—which is the present function of that industry—and, at the same time, to cripple it in what it is doing. It is true that Sir Alexander Fleming discovered penicillin, but it was developed by the pharmaceutical industry. The same is true of cortisone and insulin. We have now put diptheria practically out of the picture as a serious menace to public health, and we hope that poliomyelitis is on the way to being brought under control. Thanks to penicillin and antibiotics, venereal disease is no longer the scourge that it was 30 years ago.

All these things have been done because of research and development work carried out in the laboratories of pharmaceutical houses. The turnover of hospital beds has been enormously accelerated because of the use of these drugs. People are now sent back to work in 10 days when, 20 or 30 years ago, they would have been off work for a month. It is quite idle for us to think that we can pare down the profits of the pharmaceutical industry and, at the same time, carry on with the development of research and the export trade.

I did not intend to make these remarks at ail, but I have been led to do so because of the very ill-judged and, it seemed to me, ill-informed remarks of the right hon. Lady. [HON. MEMBERS: "No."] Well, let us take a remark which she threw across the Table to my right hon. Friend. She said that Glaxo was a firm which advertised to the public. Glaxo has not advertised to the public for 20 or 30 years. It did then advertise, when it was making a milk food, but it advertises no longer. The right hon. Lady was quite uninformed about that.

I wish to follow what was said by the hon. Member for Tottenham (Sir F. Messer) about the need for co-operation in the development of the different sections of the Health Service. I am surprised to find that there is coming over people interested in the Service a desire to argue in favour of the hospitals going back to local authorities and for the whole of the Service to be co-ordinated from the local authorities. Hon. Members on this side of the House, in opposing the Third Reading of the National Health Service Bill wished to save the hospitals for the local authorities. It was one of the four things we desired to do. Now we find that the tide is sweeping round the other way.

It may be simply a desire for a change for the sake of change. I hope that it is not. I believe that Guillebaud is right in stating that we should leave the Service alone for a little longer, to grow its roots and make its traditions. The hospital service alone has been bandied backwards and forwards over the last 20 years and to make any change would bring no reward in its train. There is not so much lack of co-ordination as tidy-minded people who are fond of blue prints would like us to think. I believe that at local level, where it is necessary, co-ordination does, in fact, take place.

I served on the Central Committee of the Central Health Council, of which the hon. Member for Tottenham is the Chairman, and I remember our report, from which I dissented, and the abortive attempts to try to co-ordinate at county level. If we cannot co-ordinate at county level now, I do not believe that it will be possible if we put the county councils in control of the whole machine. Coordination is essentially a local job, radiating from the local general hospital where all the services naturally centre. I was sorry to hear my right hon. Friend apparently suggesting a combination round the medical officer of health. I do not believe that co-ordination can be developed in that way. It is, I think, essentially a job for the group and for the local hospital.

I wish to refer to what the Guillebaud Committee had to say about the future of the regional hospital boards and the hospital management committees. On the question of the boards, the Report is apparently, capable of being read in two ways. We know that sometimes one has to compromise in a committee. My reading of the Committee's recommendation was that it wanted to see regional boards giving more attention to the day-to-day management of hospitals in their region. I gather from the speeches which we have heard today that other people have read differently and have not seen, in the paragraph to which I refer, a desire to take away the freedom of the hospital management committee.

I wish to declare myself strongly in favour of regional hospital boards pulling back from day-to-day administration and leaving as much freedom as possible to the hospital management committees to run their local hospitals in the way they believe that the local people want them to be run. Even in finance I should like to see the boards say to management committees, "Here is your annual budget. Within that budget you will run your hospital in your own way without interference from us. If you want 14 physiotherapists, you will have to do without two radiographers, which is your business and a matter for your medical advisory committee to decide."

I do not wish to take up the time of the House beyond drawing attention to the fact that most of the problems in the Service as I see them are now personal problems which have to be sorted out by my right hon. Friend. As the hon. Member for Wolverhampton, North-East has said, there is a great deal of anxiety in the dental profession about its future position and status. That is not a matter merely among the dental section of the Service. It is a matter of giving the people in that profession a feeling that they really matter in the scheme of things so that young men and women who intend to go in as students will be attracted to do so.

I am sure that it is the same sort of problem as is met with by the general practitioners. I am told by general practitioner friends that they find that their relationship with their patients has suddenly changed. The patients tell them what they are to prescribe. That is leading to a feeling that the general practitioner is losing his position in the community and his position of authority.

Mr. George Lawson (Motherwell)

The hon. Gentleman says that patients sometimes go to the doctor and say what he is to prescribe. Does not that support the point made by my right hon. Friend the Member for Warrington (Dr. Summerskill), that advertisements influence patients?

Sir H. Linstead

I should not quarrel about that, but it also emphasises my remedy, which is that there must be a tougher and a more responsible attitude by the general practitioner in dealing with his patients. The suggestion by someone, who has read a recommendation by "Aunt Daisy" in "Peg's Paper" that something will do her good should be resisted by the doctor.

Mr. F. H. Hayman (Falmouth and Camborne)

What remedy would the hon. Gentleman suggest for the lazy practitioner who is only too ready to accept advertising from the pharmaceutical firms? Presumably, there will be a few delinquents of that kind.

Sir H. Linstead

I am sure that the lazy practitioner can be dealt with only in one way, by the pressure of his professional colleagues in local meetings and organisations to which he belongs. The lazy practitioner can be brought into line only by being made to feel that he is not playing the game according to the standards of his colleagues.

In the Lancet, a year ago, I found an article which liberated a thought which I think may very well be more widely realised in the National Health Service and which goes far indeed to answer some of the points, such as the transfer to local authorities, made in this debate. The hon. Gentleman suggested that in the hospital service, at any rate, an attempt be made to cease to regard the hospital as a "service" and to try to regard it as an "institution." The author of the article defines a "service" as an organisation where an order was given at the top and made its way down until it reached the level at which it had to be carried out. An "institution" he described as a place where each member of the staff had a private and personal contact with every patient for the well-being of the patient.

I believe that is the sort of spirit which we must try to get into the National Health Service. We do not require a Service where an order is issued and carried out, from my right hon. Friend downwards, but an organisation in which doctors and staffs of hospitals feel their own personal responsibility to each patient. If we can develop along those lines, some of the problems which I have mentioned will be solved.

8.0 p.m

Mr. George Lawson (Motherwell)

I hope that the hon. Member for Putney (Sir H. Linstead) will forgive me if I do not follow his arguments. I intend to deal with only one aspect of the National Health Service, and as shortly as I can.

I listened with great interest to the list of priorities that the Minister gave. He did not put them in this order, but he mentioned hospitals, mental health and the care of the aged. I wondered whether he included the maternity and child welfare service with the hospitals. In that service we go, as it were, to the root of the business, because we go to the beginning of life itself. I am sure that many hon. Members will agree that many cases of mental illness may be due to injury at birth, or perhaps prior to birth, and that sometimes injury to the mother in the process of child-bearing will cause suffering which may result in the mother being unable to bear other children. Clearly, in these matters we are at the beginning of things.

Without suggesting that the Minister's list of priorities was not important, I maintain that the maternity and child-welfare service should be very high indeed in the list. I was glad to note that the Minister of Health for England and Wales and the Secretary of State for Scotland have accepted the recommendation for an inquiry into this service.

It emerges quite clearly from the Report that deficiencies in the maternity and child welfare service arise out of division of responsibility and of function. That division has been spoken about already this afternoon and I need not go into it. I will just read part of a sentence from the Report where it is quoting from the Royal College of Obstetricians and Gynaecologists. It says that the present division tends to produce an atmosphere of competition, not co-operation, between the various components of the service. It is wise to inquire into this state of affairs in order to overcome the difficulties that seem to be developing. I want the Minister to attempt to overcome them.

I am wondering whether I might mention a local institution. I see no harm in mentioning it, as it is within my own constituency, but I hope that doing so will not make my speech a constituency speech. There happens to be a small maternity hospital in my constituency in the charge of an obstetrician who must be regarded as a most devoted man. He came to the hospital when it was under the local authority. He is now a very disappointed man because he cannot persuade the National Health Authority to make improvements as easily as he was able to persuade the local authority. He has been struggling to keep the hospital in good order and to develop the service to which he has devoted his life.

He has for some time been trying to overcome the problem of the division of function. The hospital has developed a very good name for itself in the burgh. The women and the mothers who have had their children there think very highly of it. The hospital has a large number of "regulars," if I may use that expression. Of course, many women naturally go to their own medical practitioners, and there are instances of women who, after having been seen by the obstetrician and told, "Come back on such and such a date," do not do so. It is not normally the function of the ordinary general practitioner to chase up a patient who does not come back to him on a given date. That is the responsibility of the patient. It means that women who need special care are not getting it.

The relationship of this obstetrician with most of the general practitioners in the burgh is excellent, and he has tried to establish a voluntary reciprocal arrangement. The general practitioners send their patients to him for diagnosis where they are likely to be difficult cases and he advises that the mother should have the child in the hospital. In return for this service of guiding and advising the mothers, the obstetrician undertakes to send back to the general practitioner women who come to him directly and of their own volition whom he considers will not be troublesome cases. He undertakes to provide the general practitioners with cases in return for the cases from them.

I understand that this voluntary service is working quite well. Not all the general practitioners are prepared to co-operate in it, but quite a number do, and it overcomes certain of the difficulties which I have already mentioned. When the inquiry into the maternity and child welfare service is carried out, perhaps this experiment can be examined more closely.

The Joint Under-Secretary of State for Scotland will know that a very large maternity hospital is being built in Lanarkshire. It will have several hundred beds. I want to voice an opinion of people who are well-informed on the matter, which is that the building of a very large maternity hospital will put the smaller maternity hospitals out of business. I make a special plea. It would be wrong of me to argue that we should have only small maternity hospitals catering for a few people. I am not in a position to do so.

What I have heard leads me to the conclusion that there seems to be a great advantage in having a woman under the care of one person in a maternity hospital from start to finish. The maternity hospital should be of such a size as would permit one person handling the case, being responsible for each case and knowing the person intimately. I know that is the case in the hospital in Motherwell of which I have spoken. The fear is that when this new maternity hospital is completed the small hospital at Motherwell will pass out of use and mothers from miles around will be sent to the large maternity hospital in Belshill.

It may be an excellent thing to have large hospitals—I do not know. It may be that they can be run with practitioners responsible for individual wards, but I make a plea that when the question of the maternity services is examined the role of the small hospital shall be kept very much in mind. This is a service in which we should be open to experimental practices. We should seek to encourage the type of person who can dedicate himself to a given job and to a hospital. If we develop the service only on the basis of the large hospital we might be in danger of losing that intimacy, close knowledge and expert handling of cases which there can be in small hospitals.

My plea is that we should do what we can to preserve smaller hospitals, that we should regard them as very important and not merely preserve them, but make them first-rate. The hospital I have in mind has been neglected. I should like to see care and attention given to such a hospital as well as to larger hospitals. I am speaking particularly to the Joint Under-Secretary of State for Scotland. I hope he will take up this point in his reply to the debate but that what I have said will also apply to the wider area of the United Kingdom as a whole.

8.12 p.m.

Colonel Malcolm Stoddart-Scott (Ripon)

This debate on the Health Service, like so many of our recent health debates, shows the House of Commons at its best. We have had some constructive speeches and suggestions this afternoon. I hope the hon. Member for Motherwell (Mr. Lawson) will forgive me if I do not follow him immediately in his remarks.

We had a delightful hour from the right hon. Lady the Member for Warrington (Dr. Summerskill). There were times when it took me back to my medical student days. If I had closed my eyes at times I should have thought I was in a clinical lecture on midwifery, on psycho sematic conditions, mental conditions, hypochondriacs, and even pharmacology.

Dr. Summerskill

Hypo, not hyper

Colonel Stoddart-Scott

Yes, that is what I said. I think that if the right hon. Lady looks at HANSARD tomorrow she will see that in that whole hour she referred to the Guillebaud Report only three times. I know that it is a very big Report and that to be a member of the Labour Party Executive nowadays is a very exciting and exacting position, but I sometimes wondered whether some of her remarks were so much away from the Report that she had not had time to go through the Report.

Dr. Summerskill

I ask the hon. and gallant Member to be serious. Will he tell me of one matter which I mentioned which could not be related to the Report? I gave my references to every part of my speech. I appreciate the humour of the hon. and gallant Member, but let us be realistic.

Colonel Stoddart-Scott

I dare say that the right hon. Lady, with the nimble mind she has, could relate clean air and human life to the Report, but, if she looks at HANSARD tomorrow, she will see that she made reference to the Guillebaud Report on three occasions.

The Motion asks the House to take note of the Report, not approve the Report, because in some ways the Report is an appreciation of the Health Service rather than—as some of us expected—critical analysis of the Health Service. It leaves much unsaid. In some cases it exposes problems and points out difficulties without making any suggestions for their solution. Often the Report repeats the obvious, which is a good thing, because over the last four or five years we have created impressions and many of the things which the Report says confirm those impressions.

The Report makes some very valuable and constructive suggestions, but, like the hon. Member for Tottenham (Sir F. Messer), I think it sometimes draws wrong and, at times, even absurd conclusions. I think it is wise that the House should not swallow the whole Report, but rather chew it over and swallow those parts which are good and nutritive, but expectorate those parts which are impossible for intelligent people to digest.

One thing which the Report confirms, probably the most important of all, is that the Health Service must become, in the very near future, the first priority of our social services. It was quite right and proper that after the war, during which there was so much destruction of housing, we should spend seven years in putting emphasis on housing as the most important of our social services. With the large increase in the birthrate during the war, it was equally important that for the last five years we should put the emphasis on education—first, on primary schools, then secondary schools, and then technical schools—but I hope that the next social service to receive priority will be the Health Service. I beseech my right hon. Friend, who, I know, is a persuasive fellow, to persuade the Cabinet to spend no less than £50 million a year for five years from 1957, when the present building programme comes to an end, so that we can have new hospitals and rebuild and re-equip some of the old hospitals. I am sure the whole House will agree that that would be money well spent.

Another thing which the Report confirms is that with rising prices and rising wages there has been some very clever and efficient administration of the Health Service over the last five years. The Report reflects very great credit on the wise and careful administration of my right hon. Friend the present Minister of Labour. The Report also confirms—probably one of the most important things it confirms—how crazy it is to split up the maternity service into three different sections. The party on this side of the House divided the House in Committee in 1946 on that issue, and we divided the House on the Report stage of the National Health Service Bill. We have taken every opportunity to point out that absurdity. If the Guillebaud Report does nothing else, it was worth while setting up the Committee. The first thing the Minister did was to set up a committee to see how we could co-ordinate the maternity service.

Another point which the Report confirms is the priority of the dental service. The words "priority dental service" were written into the Bill. In the next five years the priority dental service took not first but second priority. The number of dentists in the priority service fell while the party opposite were in office by no less than 25 per cent. The Report is wise to bring out the fact that if we are to have a priority dental service we must see that there is some approximation between the salaries of those in the school dental service and those of dental practitioners doing private practice.

Mr. Baird

No doubt the hon. and gallant Gentleman realises that there are about 1,000 dentists in the school dental service now. The former Minister of Health, now Minister of Labour, said in a debate, replying to me, that we require between 2,000 and 3,000 dentists if we are to have an adequate school dental service. There is nothing in the plans of the present Government to give us an adequate school dental service.

Colonel Stoddart-Scott

Some school dental services have more dentists now than at any time previously. That is a step in the right direction, whereas when hon. Members opposite were in power the number of dentists in the school service diminished by a quarter.

The Report also confirms the need for pay beds and amenity beds and does not in any way suggest that they should be abolished. It also confirms that the Is charge on prescriptions, for which I think the right hon. Member for Ebbw Vale (Mr. Bevan) legislated, although he said it was administratively impossible to impose it, has proved no drawback and has not prevented people from getting drugs.

The hon. Member for Wolverhampton, North (Mr. Baird) had much to say about the dental charges, but it was his party which first imposed them, and, although he regards them as a fundamental breach in our Health Service, I notice that the Guillebaud Report suggests that they should not be taken off until there are sufficient dentists. In view of the number of people going into dentistry—although there has been an increase this year—and of the rate at which dentists retire, that can never occur in the lifetime of anyone present in the House.

The Report also confirms the view which we took throughout the debates on the Bill that health centres should be set up in an experimental way and developed solely on an experimental basis and that there should be no great haste in driving general practitioners into group practice in health centres. I hope that the view expressed by the Report will make hon. Members opposite, who took the contrary view, have second thoughts on the subject.

When the Bill was passing through the House we also opposed the abolition of the supplementary ophthalmic service. We divided the House in Committee on the subject and we also divided the House on Report. I am glad that, again, our view is confirmed by the Guillebaud Report, which suggests that it would be a waste of both manpower and money to set up a comprehensive hospital eye service.

When the Bill was before the House, in 1946, we were promised that everything possible would be done to bring about collaboration between general practitioners and their patients who went in for hospital treatment. We were given such assurances during the Committee stage. I hope the Minister will read very carefully what the Guillebaud Committee says and will at last, after nearly ten years. take some action to see that general practitioners are in some way brought into closer co-operation with those who treat their patients in hospital.

The Report, very wisely, draws attention to the salary scale of hospital secretaries. I am sure that the whole House will agree that this is most important; if we are to have the hospitals administered efficiently and economically we must have first-class people doing it and I do not believe that the present salary scale is adequate to bring the right people into hospital administration.

I am glad, too, that the Guillebaud Report draws attention to hospital grouping. When the hospitals were grouped together in groups of 2,000 beds, ten years ago, I am sure that it was never thought that these would be fixed and unalterable units, and I hope that a committee will be set up in the various regional board areas, or generally throughout the three kingdoms, to see whether some cannot be amalgamated and some cannot be split up because they are too big. I hope that there will also be another test—whether they are being run efficiently; because, as the Minister is well aware, in addition to many good hospital committees, there are also some bad ones.

The Minister knows of one which I have in mind where there have been no fewer than four police inquiries or prosecutions, and where there has been some very bad leadership and great inefficiency; yet in the same town there is another hospital committee run with great efficiency and run extremely well. Where a hospital management committee has failed over a considerable number of years we ought to consider amalgamating it with another or changing the hospitals into different groups.

Bearing in mind the question of hospital grouping, we must realise that in the past ten years some of our fever hospitals have gone out of use. I had a tuberculosis hospital in my division where the beds were staffed with nurses, but where there were few patients. Not always are our fever and tuberculosis hospitals situated in convenient places where they can be used for some other purpose, and I think that certain hospital management committees, and probably regional boards, are hanging on to buildings and to hospitals which may never be required for their purpose again. In the last ten years the picture has changed and it is quite right that we should review the hospital grouping, probably every ten years.

The Guillebaud Report remains very silent on one or two questions. It says hardly anything about the needs of mental health, although this is one of the most pressing problems of our time. It is extraordinary that that great and pressing problem should have been overlooked by this important Committee.

The Report says very little indeed about preventive health work. This is a most important question, and I should have thought that the Committee would have had some constructive suggestions to make on it. It says nothing at all about the development of the industrial health service and what relationship it should bear to our National Health Service. In my opinion, it would be right and proper at some time for the two to be amalgamated and for us to have one National Health Service both for industry and for the civil population.

The Report says nothing about hospital farms which, during the ten years of the Health Service, have lost many millions of pounds. Millions of pounds which we have voted in the House for the treatment of the sick and the ailing have gone to pay for losses on hospital farms. I gather that at present the losses are not great, but over the ten years they have been great.

Mr. K. Robinson

The farms have now gone

Colonel Stoddart-Scott

Not all of them.

The Report says nothing about the fact that private patients are not provided with free drugs and dressings, and I hope that the Government will take the view which was expressed most strongly and almost unanimously by a Conservative Party conference recently, and will see that that injustice is terminated.

I disagree, as did the hon. Member for Tottenham, with what the Report says about the ambulance service. Rather do I accept the view expressed by the Public Accounts Committee and Sir Frank Tribe, the Comptroller and Auditor General, that there is considerable misuse of this service by some hospital management committees—in some cases, on a large scale. I hope that the Minister will once again look at the financing of the ambulance service, because this division of responsibility and financing cannot, I am sure, be a satisfactory arrangement. I hope that he will look at the system which exists in Scotland to see whether we cannot employ it in our own country.

I share the view of the right hon. Lady the Member for Warrington that the Report is illogical when speaking about the teaching hospitals. I have spent 13 years—in fact, the whole of my professional life—on the staff of a teaching hospital, so that if I have any sympathies one way or the other it is on the side of those hospitals. It is quite illogical for the Report to say that in Scotland it is good for the teaching hospitals to be associated with the regional hospital boards, but that it is bad for them to be so associated in England and Wales.

It actually suggests that it is a good thing to have two stages of hospital treatment. That is a most retrograde suggestion and I hope that it will not become a Ministry view. The Minister would be well advised to look into the whole administration of the teaching hospitals. A London teaching hospital costs £22 18s. per patient per week; the provincial one costs £5 less and the Scottish one £8 less per patient per week. When we are confronted with such figures, I am sure that there is something which demands an inquiry.

If the Minister is called upon to make economies in the Health Service in order that the Chancellor of the Exchequer may cut Government expenditure by £100 million, I hope that he will see that the economies he makes do not in any way affect the efficiency of the Service. I will, therefore, suggest one or two economies that he might make which would not in any way interfere with the adequacy of the present Health Service.

If we were to adopt the old principle of the panel days, that whenever a bottle of medicine was obtained there was a deposit of a coin or two on the bottle, we could save, in the cost of containers alone, £1 million a year. It is no good our pharmaceutical friends saying that the pharmacists have not the facilities for washing and sterilising bottles. They all ask their customers to bring the bottle back to be used again and so save the cost of providing a new bottle for the next prescription. In my own division, I have found that the pharmacists have facilities for washing bottles. A small economy like that—going back to the old medical thrift of paying 2d. on a bottle and getting it back when the bottle was returned—would, as I say, save about £1 million a year

I hope, too, that my right hon. Friend will look at some of the accommodation of our regional hospital boards. They do not need to be housed in the most expensive and luxurious hotels and find it difficult to fill all the rooms which they rent. They do not need to pay a rent of £4,000 a year for 25 years, and at the end of 25 years still have no headquarters. The Minister would be wise if he could persuade his colleagues to build some headquarters, because if we were now to set about building regional board headquarters in the most convenient situations we would, in 25 years, in terms of that rent, save the cost of the building.

In spite of these criticisms, may I say that this is a most useful Report. It would have been a greater use and would have been more valuable had the Committee travelled about the country, visited hospitals, clinics, regional board headquarters and health centres, seen people on the spot, working in the hospitals, and been able to have conversations with the men and women who are running our Health Service. I hope that if, in 10 years' time, my right hon. Friend has not been called to higher spheres, he will repeat this experiment by setting up another committee to inquire into the Health Service, because I am sure that out of these inquiries nothing but benefit to the Service, benefit to the hospitals and benefit to our people can possibly come.

8.35 p.m.

Mr. Harry Randall (Gateshead, West)

The hon. and gallant Member for Ripon (Colonel Stoddart-Scott) will not expect me, at this rather late hour, to follow him in the arguments which he has put to the House. I have sat throughout the whole of this debate, and though I am not sure. I rather fancy that I may well be the first lay hon. Member—not a specialist—who has participated in the debate so far. I think it is just as well that someone with the lay approach should have an opportunity of making a contribution.

I appreciate straight away the fact that, from the voluminous nature of the Guillebaud Report, it is quite impossible for any hon. Member to wend his way right through it. I thought the Minister did his very best this afternoon. He made a very long speech. I also think that my right hon. Friend the Member for Warrington (Dr. Summerskill) did extremely well, despite what was said on the other side of the House. Some very pointed things were said they had to be said, and I am very glad that my right hon. Friend said them.

I want to deal with two problems which are closely associated with the staffs of the hospitals; and not a great deal has been said about the staffs this afternoon. I think this is the opportunity for doing so, because the Report itself refers to staffing, administration and structure in the sense in which—and here I am following him—the hon. and gallant Member for Ripon referred to hospital secretaries' salaries. I hope to refer to it myself presently, because I so much agree with what he said. I think that this is the crux of the whole problem of adequate staffing in the hospitals.

Before I pass to that, let me say in general terms that I am delighted that the Health Service has emerged so triumphantly from the very full inquiry into it. There were not a few who expected that there would be some complaints of waste and extravagance, but, in fact, after a very full inquiry, that suggestion has been found completely without foundation. As was said this afternoon, in terms of money only about £11 million more per year is being spent now than in 1949–50, and the cost per head of the population has actually declined. In 1949–50, it was 3¾ per cent., whereas in 1954 it was 3¼ per cent. Moreover, and this point has been made this afternoon, the remarkable thing is that the decline in the demands on the Service began before the imposition of the charges, which, as the Report tells us, have played a relatively small part in keeping down the gross costs.

The general comment I wish to make on the Report is that it clearly states that there is evidence that the service is demonstrably inadequate. There are grave deficiencies in the matters of mental health, supervision for the elderly sick, and the dental and domicilary services. It is also clear from the Report that capital assets have been run down, and I think that most of us, if not all of us, in the House are well aware of the condition of many of our hospitals when taken over and the condition in which we find them today.

Like other hon. Members, I visit hospitals, and certainly the one in the area where I live—at Newhaven. My right hon. Friend the Member for Warrington was talking this afternoon about the great tragedy of some of the old people in these very old buildings. I have seen this sort of thing. In that hospital there is no central heating yet. Think what happens to the old people in a place like Newhaven, on the coast, when there are blustering winter winds. A bird has whispered to me that central heating may be installed before the next winter. I very much hope that this is so, because otherwise, in view of the Minister's announcement that he will not carry out that part of the Report in which he is invited to spend £30 million, there will be little hope of anything being done at that hospital.

I want to pass to the question of recruitment of staff. I agree with paragraph 731 (16) of the Report relating to the hospital specialist services, where it says that at the earliest date provision must be made for a national plan of recruitment and training of administrative staff. It deals with matters of recruitment, promotion, training, structure and salary grading of posts to provide sufficient people of the right calibre at all levels. Without such provision the service will be unable to compete with outside industry for administrative staff. There must be reasonable schemes and chances of promotion, for it is essential that there should be a proper career structure.

Higher posts should be available to those coming up from the bottom, and in this respect I have some personal interest. My son-in-law is on the administrative staff at a hospital. He sweated away for three years, and eventually he got the necessary certificate. But the prospects of promotion are not particularly good. I am asking the question that he has asked, namely, whether it was all worth while in view of the salary and other factors.

The hospital secretary is in a key position. Here the value of the whole Service is put to the test. Patients are entitled to the best medical skill. They are also entitled to be treated as human beings, and this is where I believe the hospital secretary and the administrative staff can play such an important part. The hospital secretary is a kind of general manager of the hospital. His task—and a very difficult task—is to bring together and coordinate the medical, nursing and lay administration sections, and in the ultimate he is held responsible for the hospital unit.

Not long ago I heard of an interesting case involving a person who attempted to commit suicide and was admitted to hospital. There was a wrong diagnosis and the patient died. It was the hospital secretary who had to go to the coroner's court to represent the hospital. True, the medical officer was there to give evidence, but it was the hospital secretary who represented the hospital.

Let us consider the salary in comparison with salaries of other administrative positions in the same group. An internal audit assistant gets £580 a year. An accountancy assistant in the same group gets £640 per annum. An officer in charge of group wages gets £730 per annum. The hospital secretary gets only £610. As another example, an assistant engineer at the same hospital receives £645 per annum, compared with the salary of the hospital secretary at £610.

The best comparison is with the position of a matron. There is only one matron at each hospital, and the matron does not supervise or have charge over two hospitals, whereas the hospital secretary can be concerned with two or three. In a 700-bed. general hospital, the hospital secretary gets £1,060, and the matron will be getting £1,160. She has longer holidays; she is given a £25 uniform allowance; she has the services of a maid. The matron has only one hospital, but the hospital secretary can have two under his charge. The hospital secretary, for example, may have in his charge a general hospital and a T.B. hospital with 860 beds and a staff of approximately 500, the annual expenditure of which may be nearly £ ½ million. Yet the secretary's salary is lower than that of a matron.

There is a good case to be made here, and the Guillebaud Committee has made it. I very much hope that something will be done very quickly about it. The very status of the hospital secretary is imperilled. He is the key man, the coordinator, upon whom the smooth running and efficiency of the hospital depends, yet his salary totally fails to reflect his responsibilities.

There is another serious aspect. It is not unnatural for the hospital secretaryship to be the goal and ambition of those in lower positions. The secretaryship just does not attract, and not only does this have a detrimental effect upon recruitment, but those who do come in tend to leave and return to outside industry where better pay and conditions exist. There was a very interesting letter which I found in the Hospital and Social Service Journal, dated 17th February, 1956. The writer is anonymous, but I would ask the House to listen to it: I was astounded to read in the daily Press that the Parliamentary Secretary to the Ministry of Health had expressed herself as unaware of any dissatisfaction amongst the Administrative and Clerical grades in the National Health Service. The Management Committee office in which I work has an establishment of 12. Last May, it was staffed by 10 men and 2 women. Since that date, 8 officers have left, 6 to take jobs outside the Health Service. We have now 6 men and 6 women. all the men being over 40 years of age with a total pensionable service of 115 years. Of this remaining 6, 3 are trying hard for other positions—surely, a decision of desperation, when you are over 40, have only learnt one set of tricks, and must give up pension rights. If this state of affairs does not indicate dissatisfaction to those whose business it is to advise the Minister, I should be glad to know what will. That letter is a very clear indication of the dissatisfaction which exists among hospital staff, and I am glad that the Report attempts to deal with it.

I now want to say a word about the Whitley Councils. Some of my hon. Friends may not agree with me, but I happen to be one of those who believe that it was wrong ever to introduce Whitleyism into National Health Service in the manner in which it is being operated. It is not true Whitleyism. Whitleyism does not permit the two sides to sit round a table and argue wages. That is the normal function of a trade union; that is why the trade unions established themselves.

As some of us may remember, Whitleyism is the outcome of the work of the Whitley Committee, set up in 1916. Mr. Whitley was Speaker of the House of Commons at that time. There were shop stewards' movements and an outbreak of strikes among munition workers, particularly in Scotland, and, as a result, it was suggested that Whitley committees should be set up, but that wages and hours should not be discussed on the Whitley councils. It was accepted even at that date that problems of this kind were not amenable to round-table discussion.

I have spent a lifetime in the Post Office and know something about Whitley Council procedure. I know the contribution that Whitleyism can make, from both sides of the table. Great advances have been made, certainly in the Civil Service, and no one would want to give up the procedure; but one of the things we try to avoid in the Civil Service is discussion on wages, because we know very well that if there is a contentious problem it will be that of wages, not only as between employer and employee but also sometimes between employees.

That is part of the trouble of the Whitley Councils at the moment. It is trying to impose on the councils something which Whitleyism just cannot take unto itself. The system just cannot deal with wages. Incidentally, the Guillebaud Report indicts Whitleyism. It says that there is frustration, delay and discontent and that the Whitley Committee is responsible for it. The Report adds that we should let the Whitley Committee get down to a solution. I do not think that it is capable of producing a solution.

I suggest to the Minister that he should call in the trade unions, the T.U.C. and those other services which have had experience of Whitleyism over a very long time. I am certain that they would find a solution to the problem. I could develop my argument, but I have been watching the clock. I am certain from my long experience of Whitleyism that this is quite the wrong type of problem for it to deal with, and that this frustration and delay will continue.

Whitley Councils in the Health Service have again and again been forcing arbitration courts to become wage-fixing machines. That is absolutely wrong. That is an attitude of mind which ought to be changed, though it applies not only to the Health Service but also to a number of other organisations. Again, it is indicative of the general position. Rather than solving the problem in the Whitley Council, let us send it to arbitration.

I am very sorry to have detained hon. Members for so long. I conclude by saying that I am proud of our Health Service. It is the finest in the world, a grand example to other nations. The Guillebaud Report clearly shows that there is still much to be done. I know that much will be done, and I hope very much that as the years go by improvements will take place.

8.54 p.m.

Mr. Anthony Kershaw (Stroud)

I hope that the hon. Member for Gateshead, West (Mr. Randall) will forgive me if, in the few minutes before nine o'clock, I do not follow him in his interesting and extremely well-informed remarks about the wages structure of the Service, save to say that I think that he is right in saying that the secretaries of hospitals are too lowly paid.

I wish to make a few comments about the status of the general practitioner. I am not entirely at one with the Guillebaud Report, which thinks that the relationship between the patient and the doctor has not deteriorated. I think it has. I think that the status of the G.P. today is lower in the public esteem than it was. There are many reasons for this. One, perhaps, is specialisation, which necessarily leaves the general practitioner to some extent behind. The new attention which has been given to the hospitals in recent years has naturally put the G.P. slightly into the background compared with the local hospitals. In addition, his constant preoccupation with the very large number of patients on his list—at any rate, in the towns—must give him less time to concentrate on individual patients.

Apart from what the public think about the doctors, I think that the doctors think less of themselves. This is a serious matter. They feel themselves less essential to the Health Service and to their own patients than they were. They have difficulties within the profession itself. It is quite difficult for a young man or woman—perhaps not quite as difficult as it was for the young woman, but still difficult for the young man—to get a post on becoming qualified as a doctor. Although at present one might think that there would be no difficulty in this way, I am informed that in any part of the country where people would wish to go there are as many as 100 applicants for any one job in general practice. It is extraordinary that this is so.

One of the reasons is that with the rigidity which now afflicts the general practitioner it is almost impossible for him to move once he has made his choice. He can move only by an exchange. Obviously he can normally exchange only to a place which is less favourable than, or equally favourable to, his existing position. He cannot normally change to a more favourable position. It must frequently happen that a doctor working in one part of the country which does not suit his health—say, the West Country—where he may perhaps be liable to chest diseases, wants to move over to the east, but has great difficulty in doing so.

Then there is the question of partnerships. The Minister is rightly anxious that doctors should go as soon as possible into partnership, but that is quite difficult to do. For six months of the year many practices could support an extra partner, but for the remaining six months they could not, especially in country districts, which would affect by far the largest number of doctors. In country districts they are limited by the numbers of patients available in the areas they serve, and they cannot take on the number of partners which some people might consider possible.

In that connection, I know that my right hon. Friend has often had put to him the problem of whether it might be possible for doctors who have been paid compensation under the Act for the loss of the right to sell their practices could not to some extent anticipate part of that capital, upon which they are being paid 2¾ per cent. The taking on of a partner naturally entails the outlay of money. Often it means that a doctor has to move, a bigger surgery must be provided and various other arrangements made. If for these professional reasons it could be possible for general practitioners to realise part of their capital which is held by the State, and one which they are paid the miserly sum of 2¾ per cent. interest, it would be made much easier for doctors to get into practice as partners and not only as assistants.

It is essential that the feeling of inferiority among doctors should be dispelled as soon as possible. The Guillebaud Report, not realising, perhaps, that the problem exists, makes one or two small suggestions. It suggests that the general practitioner should undertake more part-time work in hospitals. That is extremely difficult to do, for the general practitioner is already fully occupied all the time. As the hon. Member for Wolverhampton, North-East (Mr. Baird) said, there are objections to part-time consultants and part-time work in hospitals which the occasional visit of a general practitioner would not overcome. It is only with difficulty that a solution in this direction will be found.

I am certain that in the long run another look must be taken at the structure of the Health Service on the organisational side. The hon. Member for Tottenham (Sir F. Messer) mentioned many of the anomalies which arise, and I am certain that the three Departments work rather in watertight compartments. It is perhaps premature to make great changes at present. It is important that the Health Service should settle down for a time and improve, and we are all pleased to see from the Report that it is improving all the time. Something must be done before long to give a leg-up to the general practitioner, to restore him in his own eyes and in the eyes of the public to the status he used to have. I am certain that that will be of great value to the country and to the Service.

9.0 p.m.

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

I will not follow the hon. Member for Stroud (Mr. Kershaw), except to say that I think the comments he has made on the position of the general practitioners, though they may apply to certain parts of the South-West, would certainly not be generally true of the country as a whole. There may be a large number of applicants for attractive practices in the South and South-West, but that is not, unhappily, the case in the North-East and in the industrial areas where we are still badly in need of additional practitioners.

There are many suggestions which could be made to general practitioners who apparently feel that they are stuck in one spot. We could unstick them. I am sure, to the general good. One of the great advantages of the development of the National Health Service is the far better spread of the number of general practitioners over the country as a whole. At one time there were great congregations of doctors in some of the delightful watering places, and there were precious few of them where we needed them most. I am glad that since the National Health Service was introduced there has been a gradual but real better distribution of doctors. That is by no means to say that we have reached perfection. There are many problems in connection with the general practitioners that undoubtedly we could properly discuss.

I was rather struck this morning by a comment in the Manchester Guardian, which, as it has turned out, is peculiarly pertinent to our debate. The Manchester Guardian said that the Guillebaud Committee's Report on the Cost of the National Health Service was to come up for discussion in the House today under the shadow of the Chancellor's promise to prune Government expenditure by £100 million. There has been some shadow of gloom, particularly over the speech of the Minister when he spoke in the debate. I felt he was hampered from giving us the encouraging and hopeful forward-looking review that I am sure he would have liked to have given by the fact that at the back of his mind was worry about just where the Chancellor was going in the last resort to impose one of his promised cuts, which will affect the policy of various social services, no doubt. I am afraid that nothing that the right hon. Gentleman said dispelled our anxieties and fears about this matter. There are many questions we should like to put to the Government, and I hope that the Joint Under-Secretary of State for Scotland will be able to reply to them. I repeat, we have many anxieties about the future of the Service.

I think it is in general a reprehensible habit to refer back, still more to quote, one's own speeches. However, I would crave the indulgence of the House in inviting it to consider a speech which I made in this House from this place almost exactly to the day two years ago. I said: … the Guillebaud Committee is clearly being given the opportunity of time for studying this matter with care and apparently fairly fully, which we welcome…. We were anxious …lest that Committee should be used, as other Committees had been used in the past, for making spot interim recommendations that might have a serious detrimental effect on the working of the National Health Service. We feel certain that the more fully the Guillebaud Committee investigates the whole set-up of the National Health Service, the more it will be convinced that true economy in many fields of the Service will demand increased rather than reduced expenditure."—[OFFICIAL REPORT, 10th May, 1954; Vol. 527, c. 855–6.] That was a pretty good prophesy of what the Guillebaud Committee has reported. The Guillebaud Committee was set up with what, to our minds, were rather frightening terms of reference—to suggest means of ensuring effective control and efficient use of such Exchequer funds as might be made available, and how, because of the burdens on the Exchequer, rising charges upon it could be avoided.

Now the Committee in effect report, and we are delighted that it should do so, that the premise was mistaken, that there is not an increasing charge upon the Exchequer and that in any proper economic estimation of the charge to the economy, the National Health Service has not imposed an increasing burden. Not only are we enormously grateful to the Committee for its general work and recommendations, but we are very much indebted to those who prepared the excellent additional report—Mr. Abel-Smith and Professor Titmuss—on whose work much of the Guillebaud Report is founded. Their statistical survey must suggest to us the need of some further check and elucidation of the statistics as presented to us in the House not only in respect of the National Health Service but possibly in other matters of accounting as well.

The comment of the Guillebaud Committee is that the cash accounts presented to us in the House from time to time in respect of the Health Service have been shown to be utterly misleading and have created in people's minds a wholly mistaken impression of the cost falling on the economy. We have all been affected by that misleading information. Therefore, it is a matter of first importance, as indeed the Manchester Guardian points out, that the Ministry should set up a research and statistics department to produce the information that is now lacking.

We are very glad to learn from announcements which we have had today and earlier from the Minister that the first steps have been taken, but frankly we would be happier if we heard a little more about what is being done. Is anything being done in the right hon. Gentleman's Department, for example, to keep up-to-date the clarification of statistics which was carried out by Professor Titmuss and Mr. Abel-Smith? Can we have the figures following on those of 1954?

What hope is there of the regular production for the public of information about how the Health Service is going? If the public is to have the fullest possible information and knowledge and be able to discuss the matter intelligently, it is vitally important that we should have the regular—possibly quarterly—production of simple statistics which will give us some useful idea of the development of the National Health Service. As many hon. Members on both sides of the House have pointed out, and as my right hon. Friend the Member for Warrington (Dr. Summerskill) has emphasised, the Guillebaud Report has made it clear that the general charges of extravagance are wholly unfounded. I repeat that we have all been influenced to some extent by the aura of these utterly unfounded charges.

As to the actual figures of estimates for the future, it is a matter of some anxiety that we have had from the Minister such limited satisfaction so far. He has told us that some extra capital provision is to be made during this and future years. In fact, what does it amount to? It is really not so very much. Certainly we should not wish to vote against this small addition, but it is very inadequate in face of the needs, which are so apparent. It amounts to about £2½million extra this year, and, in terms of the provision of bricks, mortar, steel, glass and all the other materials required to build hospitals, there can be no doubt that we are providing altogether no more than was provided in 1951, when we left office; no more than the £10 million which was voted then.

Mr. J. Griffiths

If that.

Mr. Blenkinsop

If that. Again, the Committee's Report shows clearly that in terms of real value there has been a considerable decline in capital allocations as compared to 1951–52. That is a very serious matter because we have a very big backlog to make up. Taking into account both the backlog—the sins of the past—and also the fact that during this year costs have again risen very substantially, which must take away at any rate part of the value of that £2½million. the extra provision is a very modest one.

I hope that the Joint Under-Secretary of State for Scotland will be able to say something about the Committee's recommendation in connection with the Treasury and Ministry of Health controls, which require that where capital projects exceeding a certain value are proposed they must be vetted both by the Ministry of Health and the Treasury. It is the vetting by the Treasury which is most objectionable. I should like to know whether the Minister is in a position to accept the Committee's proposal that the limits should be greatly raised and that, for example, Treasury sanction should not be required in relation to any project of a capital value—I believe—of less than £100,000.

We are all disappointed that the Minister has not been able to say that he can accept the recommendation of the Committee with regard to future capital projects. It was a recommendation that as from the 1957–58 financial year about £30 million a year, for seven years, should be guaranteed. Considering the situation, that is a fairly modest suggestion. I really felt that we might have expected the right hon. Gentleman to indicate that although he might not be able to make these changes straightaway—this year, or even next year—he was hoping to be able to do something in a few years' time. He must expect very strong pressure from hon. Members—I hope from both sides of the House—to get busy with the Chancellor and make sure that this vital capital work is carried on.

Within that work, as we all know, the provision in respect of mental hospitals is one of the most urgent. We are all very much affected by the fact that it is almost impossible to carry out the modern treatment which can be given to patients, because the accommodation is so unsatisfactory, and includes so many old hospitals, designed for a different age and climate of opinion. It is a matter of great anxiety to us all.

Leaving capital for the moment, and turning to the revenue account, I cannot see that the Minister has reason to be proud about that. According to the estimates for this financial year, he is providing another £12 million of a total of about £306 million for hospital boards, something like 4 per cent. if I have made my calculations right. But from that must be deducted what the Minister has already told me in answer to Questions; £34 million for wage claims already settled before the last wage claim and another figure, I think of £4 million, or was it £4½ million—

Mr. Turton

It was £3¾million

Mr. Blenkinsop

We will say £4 million, for the current year for expected rises in the cost of goods purchased—food and other supplies. That means a little over £7 million of the £12 million has already gone down the drain and there will be no benefit from that at all. There is therefore precious little improvement in the Service which will be available out of the extra money. I do not consider it a provision to be proud of.

The Guillebaud Committee made clear that in fact there has been a minute increase in the running costs of the hospital services. Such as there has been is due to wage increases, salary increases and the like. Considering the increase of something under a million in the population which has occurred during the years in which the Health Service has been in operation, it is a remarkable thing that the diversion of resources to the Health Service has been so small. There is also a higher proportion of older people who are at risk.

Various comments and suggestions have been made during this debate about proper economies which may be carried out, and ways in which expenditure is perhaps unnecessarily heavy. They have been referred to by the Guillebaud Committee and by Professor Titmuss and Mr. Abel-Smith, in their report. I wish to refer to one example, mentioned by an hon. Friend, that of part-time and full-time consultants. It is worthwhile keeping in mind the cost figure as it affects the Hospital Service of part-time and full-time appointments. In the paper on costs of the National Health Service it is suggested that in the South-West Metropolitan Region it works out that the cost per session of actual work at the hospital of a whole-time consultant would be £4 ls. 10d.; whereas the cost per session of the actual work of a part-time consultant, after making allowances for travelling time, is £5 17s. 9d.

When that is multiplied by the very large and the increasing number of part-time consultants in the Service, it is a financial matter which must be considered. The Guillebaud Committee recommenced that what appeared to be present incentives to turn over from full-time to part-time appointments ought to be reviewed. From the point of view of Income Tax, travelling allowances and so on they are well known, and these incentives should be gone into again. It is in a sense a shocking thing that we should be encouraging an added charge to the Exchequer.

I was worried by the information that the British Medical Journal, for example, has, at least in the past—I do not know the present policy—refused to accept advertisements from hospitals advertising full-time appointments only, and has insisted on the inclusion of an alternative offer of part-time employment. That is a serious matter which I hope we do not accept lightly.

Mr. Tom Brown (Ince)

It is a restrictive practice

Mr. Blenkinsop

Then it might very well be considered in this House tomorrow.

There has been a lot said about prescriptions. My right hon. Friend the Member for Warrington very properly brought to the notice of the Government the day-by-day pouring in of literature, samples and all the rest of it into doctors' houses. Doctors have complained bitterly about this at their meetings from time to time. I noticed an interesting reference to the matter in the Lancet a week ago, in its amusing column "In England now". It started with a quotation from G. K. Chesterton that an advertisement was a rich man asking you to give him more money. Then it had this amusing parody: The postman homeward plods his weary way, His shoulders lightened of his heavy load, Thinking he ought to get a rise in pay With seven doctors on his daily road. That is quite true.

It is a matter of some interest to read in the current British Medical Journal a very important article bringing to attention the danger of indiscriminate prescribing of what are called "chemical tranquilisers," which are now, I understand, the rage and which are being vigorously advertised, not publicly, but to medical men through the post and with canvassers on the doorstep. These activities are undoubtedly causing a considerably increased charge upon the National Health Service at the present time.

In its leading article and in the contributed article the British Medical Journal regards this example of pressure as a matter of concern. Part of the difficulty arises out of high-pressure advertising,' from the fact that when a number of firms adopt American pressure-techniques other firms apparently have to follow suit. It seems astonishing that the Chancellor of the Exchequer should be paying for most of this advertising. Why should he allow it for Income Tax purposes as an allowable expense? The Minister ought to get in touch with the Chancellor and see whether something cannot be done along those lines.

He might also tighten up the investigation into the averages of doctors' prescriptions, which already shows a valuable return. Some doctors, out of all reason, are prescribing drugs like aureomycin for common colds, doing some danger to the proper use of that valuable drug. This practice should be called to account, as to some extent it is, but there should be further effort on those lines. The inquiry respecting drug firms has been hanging fire for a long time. I hope that the Minister will soon be in a position to say something about it. I hope that it will be possible to consider setting up a central testing laboratory to take over the work of the Cohen Committee, something on the lines of the Swiss State scheme of testing all kinds of drugs that are put on the market. There ought to be some guarantee to the public in this matter.

I hoped very much we should hear something today about charges in the National Health Service. It was a disappointment to me, after the strong recommendation by the Guillebaud Committee, that we had no indication from the Minister on the subject. It is unreasonable to expect him to announce an immediate decision, but we could expect an indication of his views, especially to bring out the example of the dental service. It is surprising that we have heard no comment, despite the strong views of the Guillebaud Committee that in the dental and ophthalmic services the charges are having a definitely detrimental effect. The Committee urges that steps should be taken.

The Committee made interesting suggestions for modifications for a start in dental charges. Surely we should have had some word about it. It is very disappointing that we have heard nothing. It is clear from the Report that the argument that the charges prevent abuse does not work; it is not the case. Indeed, the total costs involved are relatively so small that all of us are fortified in our view that the sooner we get rid of the charges the better.

What about the future? Here I must say I am rather disappointed that the Guillebaud Committee has not more forceful ideas to offer. We are grateful to the Committee for giving us some, sense of stability for the present, but we must accept some responsibility for considering the future, even though the Report has not made many suggestions. What do we want as our main emphasis for the future? My right hon. Friend rightly stressed that we want to give proper place to the question of prevention. It may well be argued that the curative services have had too much attention as against the preventive services, but we must remember that when we talk about prevention we are talking outside the narrow concept of the Health Service as it is today. We are talking about housing and a great number of things which are not within the direct responsibility of the Minister of Health. Therefore, it is urgently necessary that the Minister should have close contact with his right hon. Friends and press forward in these fields.

I think it is agreed today that our modern health problems and their solution—issues like cancer, bronchitis, heart trouble, mental illness, care of the elderly—cannot be solved within the narrow concept of the Health Service as it is today. We must think of them in the wider terms of housing, in terms certainly of an industrial health service not isolated but brought within the sphere of the local authority and other health services, in terms of clean air—we were sorry not to see the Minister of Health when we were discussing the Clean Air Bill in Committee—in terms of clean food, and, above all, in terms of housing provision.

We want more co-operation. That has been the theme song of this debate on all sides of the House. I was reading a speech by Professor Fraser Brockington a week or two ago at Blackpool, and I was glad to have the chance of a discussion with him. He comes down in favour of linking the health executive council with the local health authority. I understand the difficulties, but I hope we shall look at that point in the future. The councils and the authorities cover the same field. It is important possibly as one means administratively of encouraging greater emphasis on the preventive side and encouraging the actual day-to-day contact—which is what we want—between general practitioners and local health authority officials. I have been disturbed to find how few doctors in different parts of the country have made contact with health visitors and others working for the local health authorities.

That is one of the reasons why we are sorry that there has been so little develop- ment of health centres, or even of group practices, where there can be contact by general practitioners with local health services and also, possibly, more effective contact with hospitals. There is an enormous field open to the general practitioner today, a far greater field than he seems to realise. I believe that the ball is at his feet. The lack of co-operation can be blamed on many people, but partly the blame is on the general practitioner himself, who must take some steps to make contact with others working in this field.

To hon. Members on this side of the House the Health Service has always meant something more than a means of providing better individual care. It has meant the acceptance of joint responsibility in the community for one of the community's most urgent needs. It is our fear that that sense of joint responsibility may be weakened which has caused our anxieties in the past. We have held firmly to the belief, with John Donne, No man is an Iland intire of it selfe;… Any man's death diminishes me, because I am involved in Mankinde… It is because we have always believed our National Health Service to be promoting this sense of joint responsibility that we have been so delighted at its development, so pleased to play some part in it and so happy to see the interest taken in it in so many other parts of the world which is very important—and why, after the debate, we are still so anxious about its possible future.

9.32 p.m.

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

The Guillebaud Committee's Report, as was to be expected, has met with diverse comments and criticisms. Mr. Guillebaud and his colleagues have done a very thorough job, and one major benefit which has not yet been mentioned is the full and authoritative ventilation of all current points of view.

Many authorities, bodies and people, I myself among them, sincerely believed that some policies were wrong. Criticisms and ideas for improvements were a main topic of conversation at all levels. The opportunity to voice criticisms and ideas has now been given. Everything said and submitted has been weighed fairly and without bias, and on major points the decision for acceptance or rejection has been given. We have all had our say. The discussion can now die down and for the next few years we can get on with the job.

A major complaint, which was voiced by the hon. Member for Tottenham (Sir F. Messer) and others. was that the Report did not go far enough and that it involved no radical revision of the existing administrative structure. That is true, but why should it, if none was necessary? Quite a number of important recommendations have been made on which, as my right hon. Friend said, action is being taken. Furthermore, clear signposts now indicate the way to go. The problem is no longer which road to travel; that has been decided. The problem is, how fast are we to travel along that road? The Report is, in fact, a major milestone in the history of the Health Service; it is neither the end nor the beginning of our journey. Investigation and improvement is a continuing process.

Hon. Members will have noticed that on several major points the Report defers judgment because expert committees are still sitting. On other points the Report has resulted in the initiation of detailed inquiries. If we are to improve the Service this process must go on indefinitely.

I make no complaint at all that right hon. and hon. Members opposite take credit for the essential soundness of the national health edifice which they have built. It is not a party issue that we both desire for this nation the best Health Service in the world. There are, however, some points which will always remain a proper subject for conflict of opinion, both in and between parties. The first is the extent of the national resources to be devoted to each facet of the Welfare State—health, education and the like. The speeches of my hon. and gallant Friend the Member for Ripon (Colonel Stoddart-Scott) and of the hon. Member for Wolverhampton, North-East (Mr. Baird) made those points.

It having been decided how much of the national resources is to be given to health, the next point at issue is the use to which those resources should be put—that is, the priorities within the service, as mentioned to some extent by the hon. Member for Motherwell (Mr. Lawson). The Government's position has been made quite clear. We want to see the best Health Service the country can afford, and in the present economic situation, with the economy already overstrained, the country cannot and should not undertake additional financial commitments.

That does not mean that the Health Service is imperilled. It does not mean that it will stagnate, nor that the basic services to the patient are in danger. The basic value of this very valuable Report is its confirmation that the ship is sound. I know that a little rewiring is needed in the communications, perhaps a lick of paint here and there—some cracks in the woodwork—but the ship is sound, sailing in safe waters and there are no rocks ahead.

Mr. Blenkinsop

The hon. Gentleman says that there are no rocks ahead. Does that mean that we need not fear at all any new charges in the Health Service or anything of that kind?

Mr. Browne

Perhaps the hon. Gentleman would let me finish. I was about to say that though there are no rocks ahead there is rather a strong headwind and that we still have a long way to go.

As the Report says, what is needed in the immediate years ahead is a period of consolidation. It is in the very nature of things that in the immediate years to come we cannot hope to satisfy fully, and we dare not ever be fully satisfied. I would refer the House to the end of paragraph 730, in page 243, which says: It is still sometimes assumed that the Health Service can and should be self-limiting, in the sense that its own contribution to national health will limit the demands upon it to a volume which can be fully met. We cannot hope, the Report says, to satisfy fully

It goes on: It is equally illusory to imagine that everything which is desirable for the improvement of the Health Service can be achieved at once. We cannot, as I have said, ever dare to be fully satisfied. Of course, problems, irritants, weaknesses will always be with us. We have been discussing some of them today, but we are discussing and worrying about these problems against a background of solid achievement, and it is in that spirit that I should like to answer some of the points that have been made.

The right hon. Lady the Member for Warrington (Dr. Summerskill), in what I thought was a moderate and constructive speech, endorsed, as do the Government, the tripartite structure, though I realise that my hon. Friend the Member for East Grinstead (Mrs. Emmet) and others do not agree. I agree with the right hon. Lady that we should wait longer and see how the machine responds, as she put it. She posed an important question, which will be examined. She asked, "We need more hospitals, but do we need more beds? "That is the sort of thing that gives us reason for close examination. It will be looked at.

The right hon. Lady was chiding and constructive at the same time on the question of the division of health and welfare, not at the bottom level but at all levels. I will tell her that "the penny has dropped," but she, too, has been in the Ministry and she, too, knows the difficulties. She referred to the contribution made to national health by women doctors. She told us that when she first went into the Service, or became a doctor, there were only 4 per cent. of lady doctors and that the number had now greatly increased. That is a movement which I am sure every one in the country welcomes. The right hon. Lady has herself been a notable example and a notable advocate.

The right hon. Lady also asked when the McNair Committee's Report on the Recruitment of Dental Students might be expected. I can tell her that it is expected in the late summer. I am also grateful for the constructive speech of the hon. Member for Wolverhampton, North-East, which, I know, will help recruitment. The Government will also do everything they can to help it.

The right hon. Lady then turned to the question of charges which, she said, affected the poorest sections of the community. This is something about which we must all be very worried, and it is not in any spirit of fighting back that I give her some particulars, which I think are very interesting, showing the extent to which the National Assistance Board helps with charges and to which those who require the money go to the Board for that help. The Assistance Board system of repayment of charges imposed in the family practitioner services during 1955 are estimated for Great Britain at £1.14 million, made up as follows: Dental and dentures, £234,000; ophthalmic charges £451,000; prescription charges, £455,000.

I do not say that I can tell the House the reason, but the figures are at least interesting. The details are as follows. Refunds of denture and dental treatment charges were made in 71,000 cases, or approximately 1¼ per cent. of the total number of cases in which charges were levied. Refunds of ophthalmic charges were made in 260,000 cases, representing over 6 per cent. of the total, and refunds of pharmaceutical charges were made in respect of 9 million prescription forms, also representing about 6 per cent. of the total number of prescription forms. We can draw some comfort from those figures that people are, in fact, going to the Assistance Board and getting that help.

The hon. Member for Newcastle-upon-Tyne, East (Mr. Blenkinsop), who wound up the debate for the Opposition, spoke of the desirability of up-to-date statistical information being available. My right hon. Friend has already emphasised that we are going ahead in this field, and we shall go ahead as fast as we can, but having due regard to not wanting to turn back or incurring too great cost. The hon. Gentleman also spoke of Treasury and the Ministry of Health controls. That matter is under active consideration, and I regret that I can make no announcement at present.

Lastly, the hon. Gentleman made some play with the question of capital cuts, or capital expenditure. I do not want to become involved in an argument with him about that, but perhaps I had better put on record what I am advised are the actual figures. In 1949–50, the amount of capital available was £7 million; in 1950–51, it went up to £11 million; in 1951–52, owing to what I believe were the cuts made by the late Sir Stafford Cripps, it went down from £11 million to £10 million; this year, the figure is £13 million; and next year it will be £18 million, in spite of difficulties. I do not want to make any party claims about that, but I think it is quite a good record for this Government at the present time.

The hon. Member for Tottenham spoke of the transfer of some of what he referred to as the more personal services from the county councils to some of the borough councils. I can assure him that his constructive suggestions and his constructive speech will be examined very carefully. He spoke, as did so many hon. Members, of the lack of co-operation and co-ordination, and he gave us powerful examples and arguments, which will be noted. I am sorry that he is not in his place, because I should like to refer him to page 235 of the Guillebaud Report.

It is clear from the Report of the Central Health Services Council, of which I understand the hon. Gentleman is the Chairman, that It is unreasonable to look for perfect coordination in so vast a concern as the National Health Service. The Report goes on to say that … the duty to co-operate is merely one aspect—though none the less an important one—of the work of all the key persons employed in the hospital, local authority and Executive Council services; and further improvements will only be effected if the persons concerned can be brought to understand what this duty implies. We have all been very worried about the difficulty of co-ordination and co-operation in this vast Service, and I believe that the Guillebaud Report is right in saying that it is a question of personalities and of these personalities appreciating their duties as part of this great Service.

The right hon. Lady the Member for Warrington spoke of the proprietary drugs and was answered to a great extent by my hon. Friend the Member for Putney (Sir H. Linstead). I am seized of all the points. The negotiations on these matters are complex. They are being pressed forward, but we must be careful to avoid harm to our export trade, which is worth about £30 million a year. Any crippling of the industry would prejudice pharmaceutical research and would risk dependence on foreign drugs. These are not reasons for avoiding the problem, but they are reasons for exercising the greatest care. Proper sales promotion is a necessary part of efficient industrial operation, but it can be overdone. We must rely to a large extent on the sensible discrimination of doctors.

The hon. Member for Motherwell raised the question—and I agree with what he said—of the place of the smaller maternity hospitals, although Motherwell Maternity Hospital is one of the larger smaller maternity hospitals. Continuity of medical care generally is agreed to be a most important factor in a good maternity service, and the hon. Member need have no fear that the urgently needed expansion of the Bellshill hospital will prejudice this consideration.

I should like to turn for a moment to the question of the Health Service in Scotland. The Scottish service is a distinct service. Scottish conditions are different, and these differences are referred to in the Report. The Report gives valuable comparisons, and these show that there are valuable lessons that we can learn one from the other. We see nothing illogical in differences of practice between Scotland and England. As has been said before, there are more ways of killing a calf than by choking it with melted butter.

The hon. Members for Tottenham, Wolverhampton, North-East, East Grinstead, and others, spoke of the teaching hospitals in England. I do not want to say any more than my right hon. Friend has said on this matter, but there is one point concerning organisation of teaching hospitals in Scotland on which I should like to touch. Scottish teaching hospitals come within the field of responsibility of regional hospital boards, and the day-to-day administration is in the hands of the boards of management, which are the same as the hospital management committees in England and Wales. The reason, as is pointed out in paragraph 189 of the Report, is that in at least three of the five hospital regions there is such a high proportion of hospital beds in these teaching hospitals that without their inclusion under the regional hospital boards the organisation of an effective regional service would be impossible.

It has sometimes been suggested in the light of comparison of teaching hospital costs that Scotland does not get her fair share of the total resources available for the hospital service. I can say without hesitation that Scotland does, in fact, receive her due share. Indeed, a strictly arithmetical division of the total available funds in relation to population would give Scotland about £1¾ million less in the year for revenue expenditure. The fact is that the distribution of resources in Scotland takes a different pattern from that followed in England and Wales. There is less concentration of resources in teaching hospitals, and, by the same token, less disparity in standards generally.

This is not a new feature of the Scottish Health Service. The present relationship between levels of expenditure in Scottish and London teaching hospitals goes back much before the introduction of the National Health Service. This question is one to which the Scottish Standing Medical Advisory Committee gave close study in 1953 after its attention had been drawn to the more generous levels of nurse staffing adopted in London.

Its conclusions were that as far as treatment of patients was concerned, there was not sufficient evidence to justify any major redistribution of staff, particularly nursing staff, in Scotland, and that there was no evidence that the existing staffing of Scottish teaching hospitals either affected medical training or was detrimental to research work. The problem is one of consequence. The regional hospital boards have it very much in mind, and my right hon. Friend intends to keep the position under review.

Several hon. Members referred to the difficult problem of the care of the aged, a problem on which the Guillebaud Committee makes a number of important comments and suggestions. The Committee is, I think, right in expressing the view that it should not be thought that there is a gap between the hospital and the local authority services for the care and treatment of the aged which can be filled only by the provision of a half-way house. To this end, the Report, in paragraph 644, notes a convenient working definition of the division of responsibilities in this field between the hospitals and the local authorities. The important aim of policy must be to enable old people to be cared for as far as possible in their own homes, where they can remain part of the community.

The right hon. Lady the Member for Warrington spoke of old hospitals as tragic places. There is, I agree, so much to do. As the Committee points out in its Report, it would be unrealistic to suppose that the deficiencies in services for the treatment and care of the aged can be made good overnight. In the meantime, what is needed is a full measure of co-operation between the responsible officials of the authorities in day-to-day contacts, with the object of seeing that the most suitable arrangement is made in each case

Mr. Blenkinsop

Would the hon. Gentleman allow me to ask a question about that definition as to responsibilities in the care of old people? Would he make sure that that instruction is widely dispersed and known in the country? I know a number of organisations which have not heard it.

Mr. Browne

Yes, I can assure the hon. Gentleman that that will be done.

The hon. Gentleman the Member for Wolverhampton, North-East raised the question of fluoridation. The hon. Gentleman probably knows of it, but for the sake of general interest I will say that the United Kingdom mission which visited the United States and Canada, in 1952, confirmed that fluoridation in America justified the claim which had been made for it—a reduction of about 60 per cent. in dental caries among children up to 6 years of age who lived in areas where the water has been artificially fluoridated with a trace element of one part per million of fluoride in the water. The mission found a complete absence of scientific evidence that fluoridation was any danger to the general community, and recommended that fluoride should be added to the water supply in a few selected areas which should be regarded as study centres.

These studies are being undertaken now not because there is thought to be any danger at all, but to obtain the fullest information on the conditions ruling in this country, particularly of the dietary habits of the people and the consumption and composition of the water and also, I understand, how it affects whisky and whether it kills goldfish.

Four areas have been selected for these studies—Kilmarnock, in Scotland, and Andover, Anglesey and Watford, in England and Wales. Fluoridation in Anglesey started in November last and in Kilmarnock it started on 19th April. It should begin in Andover and Watford fairly soon.

My hon. Friend the hon. Member for Chelmsford (Mr. Ashton) referred to the importance of proper career prospects for hospital secretaries, catering officers and others. My right hon. Friend in his statement was referring to new arrangements for training hospital administrative staffs which include hospital secretaries. He did not refer to catering officers, and the new scheme does not cover them. The Minister mentioned that other factors affecting the career prospects of these staffs—for example, salary levels, grading structure, etc—are constantly under review by the appropriate Whitley councils.

I should like to make one point about Scottish mental health before I conclude. A good deal has been said about the need for improvement in the mental health services. My right hon. Friend said something about the steps being taken in England and Wales to deal with the problem of overcrowding, and I should like to say something about Scotland. These problems have been causing us concern in Scotland. Although overcrowding in our mental hospitals is perhaps less acute, we are undoubtedly faced with the need for modernisation, for renewal of services and for the extension of facilities for carrying out modern methods of treatment. We have still a long way to go in dealing with waiting lists for admission to mental deficiency hospitals.

We certainly cannot be complacent about these problems, but it is significant that in those hospitals where modern treatment methods can be fully exploited there have been very great increases in the turnover of beds. If we can, as we intend, carry through a programme which will make possible a dynamic approach to the problems of mental health, such as early treatment, and out-patient attendance, the sheer problem of overcrowding may assume different proportions.

Lastly, I should like to turn to page 240, paragraph 725, of the Report, which says this: The administrative organisation of the hospital service, with its Boards and Management Committees composed entirely of voluntary members, may be a novel one … but the experience of the last seven years does not suggest that the organisation has failed to cope with its heavy responsibilities or to control, with greater regard for economy than is commonly credited, the large sums of Exchequer money which have been devoted annually to the Health Service. It is remarkable that the third largest concern in the country employing over half a million people, and spending over £600 million each year, is a concern in which the spending, the employing and the administration is done by boards, councils and committees on which sit thousands of busy responsible people who give their time and thought voluntarily and without reward. Without their help the Service could not continue.

As the Report points out in paragraph 724, the record of the Health Service since the appointed day has been one of very real achievement and of increasingly better value for money. It is fitting that in taking note of the Report and acknowledging the country's debt to the medical and the dental profession and to all the nurses and other staff in all branches, we should not forget or take for granted all those on whose voluntary and unpaid help we have relied so much.

Question put and agreed to.

Resolved, That this House takes note of the Report of the Committee of Inquiry into the Cost of the National Health Service, Command Paper No. 9663.