§ 10.0 p.m.
§ Dr. Edith Summerskill (Warrington)
I beg to move,That art humble Address be presented to Her Majesty, praying that the Acute Rheumatism (Amendment) Regulations, 1958 (S.I., 1958, No. 17), dated 7th January, 1958, a copy of which was laid before this House on 21st January be annulled.I do not intend to keep the House very long in praying against these Regulations, and I am not praying against them because I object to the notification of endemic diseases. I want to ask the Parliamentary Secretary certain questions and to obtain this information it is necessary to pray against the Regulations.
This disease, acute rheumatism, is one of the category of diseases which we may call social diseases, because it is related to the social conditions of life of a very large proportion of people. That is one reason why I and my hon. Friends behind me are particularly interested in the notification of this disease. In case the Parliamentary Secretary may think I am being a little tendentious, I will quote Conybeare's Textbook of Medicine, which, I think, is a classic. I am glad to perceive that the Parliamentary Secretary is familiar with it. Conybeare says:Acute rheumatism seldom occurs among the well to do and its incidence is highest among the poor. Overcrowding and poverty are probably the most important factors.Furthermore, this disease is essentially a disease of children and adolescents. In the past, particularly, it was feared among the poor because it was known that it was followed by a serious form of heart disease which was responsible for a very high incidence of mortality.
I know full well that conditions, during the last quarter of a century particularly, have changed tremendously. When I was a medical student and a young doctor, cases of acute rheumatism and of the horrible heart disease which followed were very familiar sights. I am glad to see that now, according to the Registrar-General, things have improved tremendously. Nevertheless, in 1955, 8,347 people died of chronic rheumatic heart disease which followed acute rheumatism, and those deaths were, of course, preceded by many years of ill-health at a time when the individuals 989 could have been of greatest value to their families and the community, because these people die when they are comparatively young. To show the tremendous change that has occurred, I have only to say that in 1925 deaths attributable to rheumatic fever were 1,885; in 1955, 227.
Curiously enough, it was not until 1947 that we decided to notify acute rheumatism, and then we decided to notify it only in certain parts of England, the County of Cornwall, Lindsey in Lincolnshire, Bristol, Grimsby, Hull, Lincoln, Salford, Sheffield and Ilford. This is a most extraordinary collection of places. One cannot think they were chosen because they were necessarily representative of a large part of England. I think they were chosen—perhaps the Parliamentary Secretary will confirm or correct this—in 1947 because it was believed that in those areas there were specialists who would be capable of handling the chronic rheumatic heart condition which follows acute rheumatism.
That may have been so in 1947, but ten years have passed, during which the National Health Service has endeavoured to allocate these specialists more uniformly in the country. I should like to know in the first place why these new Regulations, following those made in 1953 and in 1957, of which these are a continuation, limit notification to those places.
Acute rheumatism is peculiar to Britain and to temperate climates. It is not very often encountered in tropical parts because of the heat. I am the Member for Warrington, which is in a damp northern area, and I should like to know why the Minister did not consider including some of the northern cities in the provisions made by these Regulations. Although we can congratulate ourselves on the fact that the incidence of acute rheumatism is lower in the places to which the Regulations apply, these are the only places of which we have any special knowledge, has not the time come to widen the application of the Regulations and to have figures provided by other places?
It may be said that the reduction in both the morbidity and mortality incidence is due to the fact that sulphonamides and antibiotics have been used, but the severity of incidence decreased before they were introduced and, for that 990 reason, I am sure that the Parliamentary Secretary to the Ministry of Health and his advisers will agree that there is no room for complacency. Indeed, experts say that, although there has been this quite spectacular decrease, it may be possible for a flare-up to occur and that again we may find this complaint affecting children, which indeed would be tragic.
I am sure that no doctor will disagree with me when I say that this complaint still baffles the medical profession. We certainly know one thing, which is that the decrease has coincided with the rise in the standard of living during the last twenty years. I, therefore, ask the Parliamentary Secretary, first, why our knowledge is limited to the areas which I have mentioned. In view of the fact that all doctors agree that this disease occurs in the poorest parts of Britain, it surely should be notifiable in the poorest parts. Why, for instance, is not Glasgow included?
What is being done to ensure that the condition of children in these poorest parts are observed very carefully? I was very shocked last week when I asked the Parliamentary Secretary to the Ministry of Education whether all children of unemployed men—and un-employment is increasing in various areas, particularly in South Wales—would be having free school dinners. The number of school dinners has been decreasing since the price has increased. I know that the Parliamentary Secretary to the Ministry of Health will agree that a good meal for these children every day is much more important than many drugs. This is the preventive approach which we should now ensure before there is another flare-up.
I should like to know, therefore, a little more about the feeding of these children and what the Ministry is doing about it. Could the Parliamentary Secretary also tell us something about the medical services in his Department these days? I believe that his Chief Medical Officer is the Chief Medical Officer for the Ministry of Education as well, unless the arrangements have been changed very recently. What investigations and observations are made, and why are these Regulations introduced again with the information limited to those areas which we felt it was only possible to cover in 1947?
§ 10.10 p.m.
§ Mr. A. Blenkinsop (Newcastle-upon-Tyne, East)
I beg to second the Motion.
As my right hon. Friend has pointed out, this is an important subject. It is of interest that recently we have had important reports from the World Health Organisation on the need for more thorough and more effective notification of this disease. We have also had a certain suggestion for extending the field of notification and also, in the last few days, we have had reports from Bristol of the developments that have taken place there.
There have also been articles written by Professor Bruce Perry, who is Professor of Medicine at the University of Bristol, one of the favoured areas where notification has been approved over these past years, in which he makes clear the very real advances that have occurred in that area and the great improvements that have been effected. Again, in the report of the Medical Officer of Health for 1956, which was published relatively recently, some account was given of the system of notification, and details were given which emphasise the points made by my right hon. Friend about the valuable improvement that has taken place.
In reinforcing the remarks of my right hon. Friend, I want to take the case of my own city. Newcastle is somewhat aggrieved that it should not be included in the list of cities where notification is required. Indeed, it has been in touch with the Ministry after some recent discussions in the city council, and there has been agreement amongst the general practitioners in the university and outside that Newcastle should be included.
§ Mr. Blenkinsop
I am glad to have the support of the hon. Lady the Member for Tynemouth (Dame Irene Ward). If I may say so, I see no reason why notification should not also take place in Tynemouth and elsewhere.
§ Mr. Blenkinsop
We find it incomprehensible that the list should be retained on its present narrow basis. It was understandable initially that there should 992 be experiments in a limited number of areas, but now, after five years' experience, there is no reason why these Regulations should be restricted. Also there is no reason why they should not include the City of Newcastle or a much wider range of cities than it does at present.
It is a great surprise to us that the opportunity should not have been taken when the Regulations were being presented of reviewing the matter and of making an inquiry around the country into areas where it would be practicable to carry out notification. I understand from the medical officer of health for Newcastle that a diagnostic team is required to ensure proper control. I am certain that in Newcastle we have adequate provision, and this must be the case in other cities. Therefore, I want to know from the Parliamentary Secretary why there is not a wider scope for these Regulations and, in particular, why Newcastle, which has made application, should not be included in them.
§ 10.15 p.m.
§ The Parliamentary Secretary to the Ministry of Health (Mr. Richard Thompson) rose—
§ Mr. Thompson
I am obliged to the right hon. Lady the Member for Warrington (Dr. Summerskill) for the agreeable manner in which she moved this Motion this evening, and I shall hope, although some would think it a thankless task, to satisfy her, at least in some respects, in what I have to say about it.
As hon. Members appreciate, this Amendment to Regulations extends for an indefinite period the operation of Regulations made in 1957. At least, the last ones were made in 1957; there has been quite a succession of them. The last ones, to which I was referring, had a time limit of only one year.
The Regulations refer to acute rheumatism, and, obviously I do not have to explain to the right hon. Lady the difference between that and the chronic form of the disease; but it is quite important, because it limits their effect to a considerable extent. Rheumatic fever and heart disease which is of rheumatic origin are not to be confused with the aches and pains from which many of us may suffer 993 and call rheumatism in the more generally accepted sense of the word. The cause is not fully known, but an attack of rheumatic fever in childhood can seriously damage the heart and lead to chronic rheumatic heart disease in later life.
Notification under these Regulations means that a doctor attending a patient suffering from the disease in question must inform the medical officer of health. Usually, it is infectious diseases which are made notifiable in this way, so that the medical officer of health can take steps to control the spread of the disease. Acute rheumatism is not infectious, but there are other good reasons for making it notifiable in certain areas. Successive Ministers, in making or renewing the Regulations since 1947, have been acting on the recommendations made by the Rheumatic Fever Committee of the Royal College of Physicians, which was set up in 1947 to consider the prevention and management of rheumatic heart disease. This Committee examined among other problems the possible value of the notification of acute rheumatism in assisting early diagnosis and adequate treatment.
The Committee recommended, and has continued to recommend, that the disease should be made notifiable in selected areas. The reasons may be summarised as follows. First of all, to provide an index of the prevalence of rheumatic fever in the country as a whole. Secondly, to enable children who have had rheumatic fever to be supervised by medical specialists—paediatricians or cardiologists, research workers and health visitors—for what may be a lengthy period during which the disease is liable to recur—the "flare-up", to which the right hon. Lady referred.
The main object of this supervision is to prevent the development of chronic rheumatic heart disease and to ameliorate its effects. The areas in which the disease is notifiable were originally chosen—and the right hon. Lady was perfectly right here—because of the known existence in them of competent observers who can assess the value of the particular supervisory procedures which are being used. Such supervision is made easier by the existence of a register of rheumatic children compiled by the medical officer of health on the basis of notification.
994 Thirdly, to impose a formal requirement on the doctor to notify a case so that a child is more likely to be brought under expert supervision, which will then be maintained over a sufficiently long period for the effective application of the measures believed to prevent and ameliorate heart disease.
If I may say a word or two on this question of the number of the restricted areas in which these Regulations apply, I would point out that the original Regulations applied to five areas—one county and four county boroughs. They have subsequently been extended so that they now include nine areas—Cornwall and Lindsey (Lincolnshire),Bristol, Grimsby, Hull, Lincoln, Salford, Sheffield and Ilford.
I mention the fact that the original five areas have been increased over a period of time because I should not want hon. Members to conclude that there was anything rigid or sacrosanct about them. Nor is there about the nine that we have now. The scope has been increased, not perhaps as far as the hon. Member for Newcastle-upon-Tyne, East would wish, but it has been increased and we do not rule out that it may be further increased.
To reply particularly to the right hon. Lady, who made a plea for the North, Sheffield is one of the areas already designated.
§ Mr. Blenkinsop
Can the hon. Gentleman say how long it will take the Ministry to decide to include Newcastle? It is as simple as that. When will the Ministry agree to the representations which have been made by Newcastle?
§ Mr. Thompson
There is a sturdy simplicity about that intervention, and I shall endeavour to satisfy the hon. Gentleman.
These areas have been chosen not because of any particular prevalence of acute rheumatism in them but because they provide a good sample of the country as a whole and because, as already stated, they have adequate arrangements for assessing the value of the medical procedures which are being applied. As I have said, it does not mean that in other areas the same methods of treatment are not now available; in other words, it is not necessary to be a patient in those areas to get adequate treatment.
995 There is certainly no reason why the Regulations should not be extended to other areas in the future. There are known to be some areas—I would certainly include Newcastle among them—where the general practitioners, the hospitals and specialist services, the local authorities and their medical officers of health are ready and willing to co-operate. When the number of such areas makes a further amending order justifiable, my right hon. and learned Friend will certainly be glad to consider including them.
Extension to the whole of the country—I think this was implicit in what the right hon. Lady and the hon. Gentleman said—could not, in my view, be justified, at least at present. To start with, there has been no recommendation to this effect from the Rheumatic Fever Committee of the Royal College of Physicians. Such a wide extension is not needed for providing the necessary statistical information about the disease, and compulsory notification can be justified only if one is satisfied that the cases notified will be followed up.
Having said that, I repeat what I said earlier, that one should not conclude that because the greater part of the country is not subject to a compulsory notification order proper treatment cannot be obtained by patients and sufferers in that part of the country. It can. One should realise that this is more of a research and observation exercise than a treatment exercise, and for that purpose it is not necessary that every single area of the country should be covered by an Order of this kind.
The right hon. Lady inquired what the attitude of the Ministry was to the nutritional problem involved. She said that the incidence of the disease was undoubtedly related to questions of feeding and matters of that kind. I am advised that there is no known specific dietary factor involved, but inasmuch as rheumatic fever is a sequel to preceding infection—it is usually, I think a sore throat—good general nutrition is, of course, important. One may safely say, although little is known about this disease, that greatly improved standards of nutrition during the past years, certainly since the war, have contributed very largely to the much more favourable figures now reported. I am sure that the 996 right hon. Lady will welcome the statement in the Report of the Chief Medical Officer that this disease is steadily becoming less prevalent as well as less serious in its effects.
The re-enactment of these Regulations in permanent form merely ensures that the continuity of existing procedures shall be preserved. I do not think that anyone would wish to quarrel with that. We do not close our minds to the idea of amending Regulations extending the area of compulsory notification when we judge that the time is ripe for that. I explained earlier what I think the considerations should be. To annul these Regulations would inevitably put an end to the important body of observation and doctrine being built up by the practice as it is now. Were that to happen, a considerable blow would be dealt to research into this great problem. I am sure that that would not be the wish of any hon. Member of this House, and so I hope that, in the circumstances the right hon. Lady will not press her Motion.
§ Mr. Blenkinsop
Can the hon. Member at least say whether the application made by Newcastle-upon-Tyne has been referred to the committee which he mentioned and how long have we to wait?
§ Mr. Thompson
The application has been so referred, and I hope it will not be long before we can give an answer.
§ Dr. Summerskill
In view of the undertaking of the Parliamentary Secretary, I beg to ask leave to withdraw the Motion.
§ Motion, by leave, withdrawn.