SCOTLAND (TUBERCULOSIS TREATMENT) (Hansard, 22 November 1956)

§ Dr. J. Dickson Mabon (Greenock)

The House will recall that in my first attempt to put a supplementary question I got into difficulty in trying to put the point which I now wish to put, and I am grateful for the opportunity of the Adjournment to raise the matter again.

The House will be aware that in Scotland there will be in the spring a series of anti-tuberculosis campaigns in which, in the words of the Secretary of State for Scotland, we hope to be able to X-ray over 1 million people. If, in this million, we have the present incidence rate of tuberculosis it is not unfair to say that we shall probably find, unhappily, 1,000 new contacts. It is unhappy in the sense that it will bring a feeling of tragedy to many homes which are at present unaware that the breadwinner or the mother is suffering from tuberculosis. It is in another sense fortunate that we shall have been able to make a start on arresting one of the worst ravages among people in Scotland.

We are beginning to see in the present years the first warning signs—which, regrettably, are only seen by members of the medical profession—of the apparent failure of some part of the domiciliary treatment of tuberculosis. That seems a rather sweeping statement and I cannot back it up by any surveys or any facts based on a reasonable series of cases. But I have been invited by chest physicians of my acquaintance to look more closely at the matter and discover whether the Department of Health for Scotland cannot undertake fresh inquiries which would set the minds of these physicians at rest and certainly comfort those of us on this side of the House who wonder whether there is any real substance in the claim that domiciliary treatment is not as effective as it would appear.

As the Secretary of State has very properly said, when people are being asked to come forward for these X-rays by these anti-tuberculosis campaign 2076 organisations they are being coaxed with the knowledge that if they are discovered to be suffering from tuberculosis there is a very strong possibility that they will not have to go to hospital but can be treated at home. The dilemma facing us is whether we can continue to so coax them in order to get a good response and, at the same time, be fair to them in the matter of the effectiveness of domiciliary treatment.

I do not want to go into personal details about the doctors, and I have given an undertaking that I will not name them. The House will appreciate that, and we can respect that in medical circles. I have a letter in my hand from a doctor who talks of patients whom he has seen. He says I have recently seen two cases who had been on domiciliary chemotherapy and who had relapsed during the course of treatment. The answer was that in neither instance was the patient troubling to take the drugs prescribed. Patients in hospital are subject to a hospital régime where drugs are administered promptly and regularly. Sometimes the patient is not keen about it but, nevertheless, nursing and medical staffs are loyal to their duties. Because of that regularity of treatment, we know the effectiveness of antibiotics and chemotherapy and can quickly clear up difficulties. But what has happened when a patient is clinically and radiologically stable, is sputum-negative and, to all appearance, is well? All we do is send him home and carry on after-treatment.

What is easier than that? So we send the patients home, and we ask individual general practitioners, many of them overworked and tired, to look after the patients with the same clinical intensity as they are looked after in hospital. It just cannot be done.

Although we cannot claim that we have figures broadly to substantiate this, these little warning bells are sounding all over Scotland in the rooms of chest physicians and in the surgeries of general practitioners. A few relapsed cases are trickling in. We find to our horror that many of the cases, because the patients have misused the drugs in that they have not taken them regularly, arrive with a new form of bacteria, bacteria resistant to the antibiotics and resistant to the new chemotherapeutic drugs.

2077 This is terrifying. It reminds us of the old days when we had no drugs to fight tuberculosis, when the knife and the surgeon were the only recourse. People today bear the scars of the surgical procedures carried out in the last desperate effort in those days to stop the course of tuberculosis. The last thing we want to do is to return to those days. But it is not inconceivable that we may have returning to us patients upon whom the State has spent a lot of money in hospital, but who have been neglected. I do not deny that they may have neglected themselves in that they have failed to go to the doctor every so often to ensure that the treatment was going well and at home have failed to take their drugs regularly.

We have not much medical evidence to go on, but I have here a submission published in the United States. The United States Veterans Administration has been conducting a survey of outpatient chemotherapy since 1952, and on a very small series of 137 patients observed for periods of 30 to 48 months there have been 18 relapses in that group, while 12 of the patients actually died.

I do not deny that we do not know all the facts surrounding the survey; there may be other circumstances which influence the figures. However, let us ignore for the moment the mortality rate and deal with the relapses. Even 13 per cent. out of that small group is enough to make us worried.

Arising from all that, I wish to put three points to the Joint Under-Secretary. I respect the anxiety of his Department, and, I am sure, of the Minister concerned, to deal with the matter as adequately as possible.

First, will he assure me that in the propaganda leaflets, the notices, which are issued to encourage people to come forward, there is not an undue stress placed on the claim that we can treat people at home and that, really, they will not have to go to hospital at all? To my mind, even that suggestion in a minority of cases is mischievous.

I should like the Department to put on record the fact that people ought to go to hospital and be well assessed there and then discharged, but only with 2078 the knowledge that no danger of this kind would arise in their case. That is the first point, one of administration.

Secondly, I would draw the attention of the Joint Under-Secretary to page 27 of the current Report of the Department of Health, which says The fall in the hospital waiting list is not, however, accompanied by a corresponding decrease in the number of new notifications of the disease. The improvement in the hospital position must be attributed to the increasing efficiency of domiciliary and out-patient management and a more effective use of the accommodation available. The last sentence is The position will continue to be watched carefully and it is the intention so far as is possible that all patients suffering from respiratory tuberculosis should receive some part of their treatment in hospital. That is the second point that I want to emphasise. I should very much like the Department to put that last part into operation. They should watch the position very carefully and, as far as possible, all patients suffering from respiratory tuberculosis should receive part of their treatment in hospital.

I do not consider that it is a good point of administration to claim that because we have so many empty beds all is well and that the more empty beds we have the better things are. That is not quite a reasonable claim. I should prefer to see all the beds filled rather than so many people out on domiciliary treatment, if I were as anxious, as I am, that we might in future have some adverse effects from extensive uncontrolled domiciliary treatment.

The third point which I should like to make is this: I do not deny that Ministers and Departments are disinclined to interfere directly in medical inquiries, but I put this to the Minister in all seriousness. I think it the function of all political heads of Departments, where possible, to try to encourage the Department and its advisers to take on as many medical inquiries as they think consistent with public policy. Here is a matter of public policy. The survey from which I have quoted is a United States survey conducted by a quasi-public body. I see no reason why the Department of Health for Scotland should not agree to organise, either directly or through indirect organisation, a pilot survey in Scotland, beginning now, to assess the effect of domiciliary treatment in Scotland.

2079 We are in a splendid position to make that a reasonable survey, because we are proposing to X-ray one million people next year and follow up the treatment of those cases which are found. On the basis of a series of probably 1,000 contacts, we shall, in three or four years, be able to produce information which will be considered all over the world as of extreme value in the assessment of the effect of the new chemotherapeutic and antibiotic agents now used in the treatment of tuberculosis.

We would be doing a wonderful job not only for our own people, but for the advance of medical science; so I would respectfully draw the attention of the Minister to these three points in the hope that they may be considered. I do not deny that this is a matter of public policy which is not without certain criticism from members of my own profession, but I am raising it primarily not as a doctor but as a Member of Parliament. I believe this to be a matter which the Department and the Minister concerned should tackle with energy and resource.

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

The hon. Member for Greenock (Dr. Dickson Mabon) has done a great service by sounding a Warning note when we are all feeling so encouraged by the progress made in dealing with tuberculosis. When my right hon. Friend replied to him last week on this question of treating tuberculosis patients at home, he said that he had received no representations on the matter, but would consider any that were sent to him. That is the position in which we are this evening. Apart from what the hon. Member has said, neither the Secretary of State nor I have received any representations on this matter.

Even in the constituency of the hon. Member, the area chest physician—a hospital specialist of consultant rank—has no difficulties to report on this matter, and has received no complaints from the general medical practitioners in the area. However, the hon. Member has taken the opportunity this evening of putting forward with great sincerity certain views on the relative merits of home and hospital treatment of tuberculosis. I am not a medical man, and even if I were, it would not be possible in the short time 2080 available for this Adjournment debate to analyse the significance and assess the importance of the points which the hon. Member has put before the House.

This is not a matter which can very well be debated. It requires an impartial medical approach, the object being to find the best way of providing the best course of treatment for each individual patient. The hon. Member may rest assured that I shall look with great care into all that he has said. In doing so, I shall of course seek medical advice. As the hon. Member will know, the Department of Health for Scotland is in close touch with the Medical Research Council, which has made a notable contribution to knowledge on the prevention and treatment of this disease. When we have had the points made by the hon. Member examined, and carefully examined, in this way, I will write to him so that he can give further careful consideration to the whole matter, a matter in which he is obviously sincerely and quite properly interested, and which concerns the health of the nation.

Having given him that assurance, I feel it right that I should make some general observations on the question of home and hospital treatment of this disease. My first point is that the choice of hospital treatment or home treatment, or a combination of both, is a matter for the doctor in charge of the patient to decide. Home treatment is very often combined with hospital treatment so that the patient can have the advantages of both, in which case, as the hon. Member will know, the chest physician in the hospital service takes his decision in consultation with the patient's family doctor.

In one of his supplementary questions—in his record supplementary questions—last week, the hon. Member suggested that, for the present, encouragement should be given to all concerned, patients and doctors, to make full use of hospital facilities in preference to home treatment. He referred to the literature and propaganda at present going out, at which I shall look very carefully indeed.

I think it would be unwise for any Government to interfere in a matter of this kind. I would prefer to leave it, as at present, to the judgment of the medical man on the spot. I am advised that, generally speaking, the medical profession prefer to treat their patients in 2081 hospital during the initial stages of their illness, and to continue them on home treatment only when they have been rendered non-infectious to others and no special form of treatment, such as surgery, is necessary. The chest physician and the family doctor are also in the best position to assess the patient's own wishes in the matter—they are important—his home conditions, and nursing aid which can be given to him by his family and by the local authority.

I should like to make it clear that the doctors on the spot have a free choice in this matter. There is no question of any pressure being put on them to treat a patient at home because of shortage of beds. As the hon. Member said, nearly every sanatorium now has some empty beds. Waiting lists which stood at 1,700 three years ago have now vanished except for a handful of patients who have to wait for a short time because they wish to get a bed in a hospital near home. Three years ago not many hon. Members would have expected a junior Minister would be able to stand at this Box and make that statement today.

It is clear that doctors have been giving patients an increasing amount of home treatment. One of the reasons for that is the early ascertainment of tuberculosis through mass radiography and other means, which throw up cases for which home treatment is satisfactory at some stage. Another important reason, as the hon. Member said, is the improved efficiency of treatment. The extended use of drug therapy has resulted in a general reduction of the time spent in hospital by tuberculous patients, and the effect of that is to release a substantial number of beds in hospitals.

The next point is that home treatment has its own particular safeguards. The patient is in the immediate care of his own family doctor, while the treatment he gets is under the supervision of the chest physician. The family doctor not only knows the past history of the patient 2082 and his family but is able, in consultation with the chest physician, to apply the latest in scientific methods of treatment to his patient. This is in full harmony with our policy of giving the general practitioner every possible chance of widening and enhancing the range of his work. In the case of the patient treated at home, the family doctor is encouraged to take a continuing interest in his welfare right through convalescence and rehabilitation to the stage of complete recovery.

The final safeguard is very simple, and I am surprised that the hon. Member should have quoted two cases where these safeguards all failed to apply. As I have said, the treatment given by the general practitioner is under the supervision of the chest physician from the hospital service. If home treatment is not successful—if the nursing is not good enough or if the drugs are not producing the right effect or are not being taken properly—the chest physician can arrange for the patient's admission to hospital, and that he can do immediately. I should have thought that the chest physician or the health visitor would have found out that something was going wrong.

The tuberculosis problem in Scotland is too big to be looked at with any complacency. I would emphasise that, although the House is aware that there have been favourable trends within the last year or two. In spite of the increasing use of diagnostic services the notification rate is still falling, if somewhat slowly, and the death rate was halved between 1951 and 1955. I should like, therefore, to assure the House that we shall keep a close watch on the issues raised tonight to ensure that nothing is being done to endanger the favourable trends to which I have referred.