§ 4.23 p.m.
§ Mr. Aneurin Bevan (Ebbw Vale)
The National Health Service became ten years of age on the 5th of this month and my right hon. and hon. Friends on this side of the House thought that it would be suitable that we should have a debate at the earliest possible moment to commemorate that fact. It also provides us with an opportunity of assessing the achievements of the Service as well as considering its shortcomings and making suggestions as to how it can be improved. I hope that it will not be considered inappropriate that it has been decided that I should open the debate.
I should like to take advantage of this opportunity to say something which it has not been possible to say before; that is, to call attention to the extraordinary achievement for which the Ministry of Health was responsible in launching the Health Service on 5th July, 1948, and to pay a very special tribute to the permanent officials who were at the Ministry at that time, both in London and in Scotland. It is not possible for me to identify the civil servants who were engaged in that work because, if I did, I should be depriving them of the protection of anonymity with which it is our practice to provide the Civil Service.
But there are one or two people whom I can mention with propriety. One is Sir William Douglas, Permanent Secretary at the time, who, unfortunately, has died. The other is Sir Wilson Jameson, the Chief Medical Officer, who, I am glad to say, is still very much alive and at work, although he has retired from the Ministry. The nation was extremely fortunate in having two eminent civil servants of that calibre at the Ministry at that time. I am quite certain that if hon. Members and the nation generally knew how much work they did and what a huge task it was, they would feel very grateful indeed.
1383 On this occasion, I should like to put on public record my personal appreciation of the loyal, efficient and inexhaustible service which I received at the time from the officials at the Ministry of Health. It was no light task. We had not very much time. We had to be ready with all the machinery on 5th July, because people had to have access to the rights which we said that the legislation would provide. There was, therefore, a very great risk that, unless we did work night and day, we should not be able to be ready in time.
Two main conceptions underlay the National Health Service. The first was to provide a comprehensive, free, health service for all the people of the country at time of need. The second—I shall call particular attention to this later, because it has been somewhat overlooked—was the redistribution of national income by a special method of financing the Health Service.
As to the first principle, there has always been more medical care in existence than the masses have been able to reach. Many people have died and many have suffered not because the knowledge was not there, but because they did not have access to it. To all the suffering which attends illness, there was always added the bitterness that, if the poor could have had access to the knowledge available, they might have been saved or, at least, might have been helped. It was this situation that the National Health Service was intended to put right. The general availability of the knowledge could be achieved, of course, only by a National Health Service.
I shall not give very many figures, because, if I try to give a comprehensive picture of what the National Health Service is now doing, I should be invading the time that you, Sir, have already allotted to those who wish to raise matters on the Consolidated Fund Bill later. But it is necessary to keep certain figures in mind in order to have an idea of what has been accomplished.
Today, 98 per cent. of the people of Great Britain are registered with general practitioners, that is to say, almost the whole population of the country. There are today 147,676 nurses—or, rather, there were last year; I have not the up-to-date figures for this year—as against 1384 125,752 in 1949. There are today 38,149 part-time nurses, as against 23,060 in 1949, making a grand total of 185,825. There are also more than 30,000 additional hospital beds in existence today.
One of the troubles I had when starting the Health Service in 1948 was that mass radiography had disclosed the existence of early tuberculosis, and applications were made for beds, of course, which were not there and for nurses whom we could not recruit. One of the chief reasons that we could not recruit them was that, in the voluntary hospital service which existed before, they were so inadequately paid and the conditions were so bad that we could not recruit them in sufficient numbers. Indeed, I myself had to take the unusual step, rather different from that taken by the Government today, of intervening in negotiations to secure an increase of wages for the nurses. Otherwise, we should never have had sufficient nurses to man the hospitals—if I may use an Irishism. Today, of course, the Government have done the opposite; they have intervened to stop the rises.
In addition, we had the very considerable problem of converting old infirmaries which had been workhouses into modern hospitals. One of the most pleasant features of the country today is the extent to which what were buildings of horror are now bright buildings, many of them maternity hospitals. All this had to be done very quickly, and the burden, administrative and physical, was very great indeed.
To turn to the picture today, here are some more figures. In 1947, there were 23,076 notifications of tuberculosis, giving a rate of 552 per million of the population for tuberculosis in all forms. Last year, there were 4,784, representing a rate of 107 per million, a reduction from 552 to 107 per million of the population. Those are very remarkable figures. In the ten years of the National Health Service, new cases in England and Wales have fallen by 38 per cent., and deaths by no less than 78 per cent.
It is perfectly true, of course, that all the credit for this might not go to the Health Service. To some extent, it is due to higher standards of nutrition and better housing—though we were to some extent responsible for that also—and also 1385 to new drugs. But the main point still remains: all those drugs and medical facilities would not have been available under the old system. That is the point. The new knowledge would be there, but it would not reach the people needing it.
This must be borne in mind in everything we say about the Health Service, and this is why our medical profession got it all wrong when it started to oppose the National Health Service in 1946. Medical men seemed to believe, or some of them, at least, pretended to believe, that all that nationalised medicine would do would be to interfere in the practice of medicine. I had no such intention at all. What the Health Service was intended to do was to organise the practice of medicine in such a fashion as to reach the people who needed it most. That, of course, has been done.
The incidence of children's diseases is falling so rapidly that hospital beds are now becoming vacant in great numbers. It must be exceedingly pleasant news for the country that, instead of children being in hospital, they are now going to school in greater and greater numbers, largely due, once more, to the maternity and child welfare services, of which, I am glad to say, the women of Great Britain now take full advantage.
There is no more pleasant sight to be seen in the world than can be seen outside a maternity clinic in Great Britain today, where women of all classes in the community mingle together, taking their children to be weighed and to be examined, to receive their lessons in maternal care, to have advice about what food to give their children, and to listen to the doctors' advice as to what may be wrong with them. That is an exceedingly pleasant spectacle, and, of course, this part of the Service is in great measure responsible for the fact that we can probably boast in Britain today that we have the bonniest children in the world.
There are other vital statistics which are equally remarkable. The infant mortality rate has fallen from 33.9 to 23 per 1,000. The maternal mortality rate has fallen from 1.02 in 1948 to 0.47 per 1,000 today. Those are extremely interesting figures.
We were able to turn our attention, also—I commend this to hon. Members in all parts of the House—to another feature which was quite novel. At the 1386 end of a war, the industries and crafts which make artificial limbs and give assistance in other forms to injured soldiers, sailors and airmen are, of course, at their height because they have many unfortunate applicants; but, as the years go by and the number of ex-Service men diminishes, the call for that skill and industry diminishes. The pool of knowledge and skill is lost. But, of course, industry produces far more casualties in the aggregate than does war, and, of course, those skills were not generally available or, at least, were available only in a very small degree.
We were able to keep that pool of experience, knowledge and craftsmanship in existence and make it available to the civil population as well as to ex-Service men. That is going on. To take invalid chairs and tricycles as an example, the number issued from 1949 to 1957 was 109,037. At the end of 1957, 1,647 motor cars made available for disabled war pensioners were in use in England and Wales. However, I shall not give very many figures because they are easily available and it would add too much to the burden of my speech and impose upon the patience of the House if I were to do so.
We can say, therefore, that the National Health Service in the facilities provided to the population as a whole can be regarded as a marked success. Indeed, so successful is it that there is now competition in claiming its paternity. I have found even Conservative Members who have forgotten that they voted against it on every conceivable occasion and for every conceivable reason. It has been said, of course, that the National Health Service had a curious kind of beginning, that all parties were in favour of it. I am bound to say that, when I went to the Ministry of Health, I found no evidence of that.
I will tell right hon. and hon. Members, on my word, that the poor people there had realised that the Government of the day had practically abandoned them. The Minister of Health at that time had not even been made a member of the Cabinet, so as to show how unimportant the Government regarded the creation and launching of the National Health Service. As for the hospital system, I must say that I found absolutely no preparation at all for integrating the hospitals with the rest of the Health Service. On the 1387 contrary, the opposite was the case. The old voluntary hospitals were to remain.
Of course, opposition was being whipped up, but I was singularly fortunate in my opponents. First, I had the Conservative Party, and no one could be luckier than to have that at that time. Then, of course, we had the Association of Voluntary Hospitals, which was bitterly opposed to the taking over of the hospitals, and that was led by no less a distinguished a person than Sir Bernard Docker. Who could be luckier than that? He described the National Health Service Bill as a mass ofmechanism in which the patient will get caught and mangledand as providing forthe mass murder of the hospitals.I remember meeting a deputation led by the good knight. After listening to him and to his case I knew that the way ahead was quite clear.
I was also fortunate in another matter, very fortunate indeed, and that was that we had in the London County Council a Labour Council. Therefore, although reluctantly—and one can understand that—it was prepared to hand its hospitals to the nation. I tremble to think what would have happened if, instead of there being a Labour majority at County Hall, at that time there had been a Conservative majority led by the present Minister of Housing and Local Government.
So we were able to take over the hospitals without too much friction from those who were responsible for them. Of course, in addition to all that I had the singular advantage of being opposed by the present Chancellor of the Duchy of Lancaster. He led his men up the hill and he led them down again. Therefore, with all those advantages in our favour we were able to go ahead, and with the Health Service on its therapeutical side I am quite certain that there is general satisfaction, although, of course, there will be some criticism, and I propose to make a little criticism myself.
It is when we come to the financial side that I am getting a little worried because, as I said to the House just now, the second principle was to bring about the redistribution of the national income by means of the method of financing the Health Scheme. I rejected the insurance 1388 principle as being wholly inapplicable in a scheme of this kind. We really cannot give different types of treatment in respect of a different order of contributions. We cannot perform a second-class operation on a patient if he is not quite paid up.
§ Mr. Bevan
I am talking of the insurance principle. If the hon. Member were to go to the United States he would find that that is happening now. I will try to explain to the hon. Member a little more about this because, unfortunately, the whole thing has been slightly blurred.
One of the reasons why there was such a rush by the people of the country to enlist in the Health Service in 1948, just before the launching of the Service, to sign on with the doctors, was that the propaganda of the British Medical Association had conveyed the impression to the country that it was an insurance scheme. It was the singular benefit of the lucidity of Chancellor of the Duchy, because to mobilise opposition he convinced the country that from 5th July, 1948, it would be paying for something that was not to be there. He converted the country to the quite mistaken belief that there was an insurance scheme. Therefore, they all joined up to get their money's worth. As a recruiting sergeant for the National Health Service he was successful.
Very large numbers of people today still believe that their weekly contributions are in respect of the National Health Service. That arises partly because of the confusion of the terminology—National Insurance and National Health Service and the old National Health Insurance. All that language is very confusing for people not expert in it. Therefore, today there are very many people who think it is an insurance scheme.
I refused to have the insurance principle not only for the reasons I have already given, but for another reason, and that is that the whole idea of insurance is inapplicable, because if everybody is in it it is no longer insurance. Insurance, by its very nature, assumes a group, a group within the community. If all the community is in it, it is not 1389 insurance: it is a tax, unless the amount of the contributions is related to a variety of benefits, and we could not relate it to a variety of benefits for the reason I have given. The insurance scheme was inapplicable.
§ Mr. Bevan
Next, and equally important, was the fact that we had found group insurance to be highly undesirable, whether in respect of occupation or in respect of vertical groupings of the community; and we discovered that with the National Health Service. Hon. Members with experience of industrial areas will know that additional medical benefits which were available to the better-off members of the working class were denied to those who needed them most.
Miners, steel workers, textile workers were unable to obtain additional benefits from the National Health Insurance whereas the better-off members of the 20 million insured were able to get them because the incidence of sickness and unemployment was less among those than amongst the others. So we found group insurance, occupational insurance, to be highly undesirable. Occupational insurance is particularly undesirable, because medical benefits for the workers engaged would follow the fortunes of their industry and the funds available would expand and contract with the sales or lack of sales of their products.
For all these reasons and very many others we rejected the principle of insurance and decided that the best way to finance the scheme, the fairest and most equitable way, would be to obtain the finance from the Exchequer funds by general taxation, and those who had the most would pay the most. [An HON. MEMBER: "There is nothing wrong with that, either."] It is a very good principle. What more pleasure can a millionaire have than to know that his taxes will help the sick? I know how enthusiastic they have always been in following that up.
The redistributive aspect of the scheme was one which attracted me almost as much as the therapeutical.
§ Mr. Bevan
I would not say "more". I hope that my instincts are slightly more civilised than that.
We shall see how civilised hon. Members opposite are. To them, the financial principles are much more important than the therapeutical principles. They have been engaged in trying to reverse the redistributive aspect of the Service, and one of their chief supporters in that is the man who tried to stop it coming into existence at all, that is to say, the Chancellor of the Duchy of Lancaster. I am sorry not to see him in his place. I was hoping that he would be there on the Front Bench. As it is the National Health Service that we are discussing the saboteur in chief ought to be present to hear the results of his handiwork.
What has happened since then? I have certain figures here which, I think, the House will find quite illuminating. In this case, the then Chancellor of the Exchequer, my right hon. Friend the Member for Bishop Auckland (Mr. Dalton)—I must give him credit for this—accepted the principle of financing the National Health Service from the Exchequer with enthusiasm, because he entirely agreed with my point of view about this. But, of course, there was one particular item which even he could not deny himself. That was that portion of the contribution of the old National Health Insurance which had been used for medical benefits. The Treasury could not forgo putting its fingers on that. I do not blame them too much, and it did not matter to me at all.
The Treasury said, "All right, if the Treasury is to carry the full cost of the National Health Service, we will take that portion of the National Health Insurance contribution which was used formerly for medical benefits." From one point of view, that was perfectly just. In other words, if in future the provision of all medical benefits was to be financed from the Treasury, it seemed quite reasonable that the portion of insurance contributions formerly used for that purpose should be an appropriation-in-aid for the Treasury.
That amounted to something in the nature of £40 million to £41 million. As a matter of fact, it was fairly constant. It was in 1949–50, £40.8 million; in 1950–51, £41.5 million; in 1951–52, £42 million; in 1952–53, £40.9 million; in 1391 1953–54, £41.2 million; in 1954–55, £41.2 million; in 1955–56, £41.3 million; and in 1956–57, £41.7 million. In other words, we had a contribution there which was almost constant because it represented an appropriation-in-aid, but it did not represent a contribution to the cost of the National Health Service. I hope that hon. Members will get that clear in their minds. It had nothing to do with the National Health Service. It was not paid to the National Health Service. It was an appropriation-in-aid taken from the Insurance Fund by the Treasury. There was no organic, financial or administrative link between National Insurance and the National Health Service. I want to make that point as strongly as I can, because unless that is seen in its full significance, no one will appreciate the dishonesty of the Government in the way in which they have used this purley historical accident as a justification for undermining the redistribution principle of the National Health Service.
For instance, the Chancellor of the Duchy of Lancaster, in a speech the other day—I think it was on 5th March—when he sought to justify an increase in National Insurance contributions in aid of the National Health Service, spoke about a flat rate contribution from the National Insurance Fund to the National Health Service as a principle adopted in the 1946 Act. It was not in the Act at all. There is no reference in the 1946 Act, so far as my memory serves me, to any relationship between National Insurance and the National Health Service.
But, of course, he wanted to make a case, so what he did was this. He expressed as a percentage of the total of National Health expenditure the £40 million to £41 million taken as an appropriation-in-aid. In other words, he made a retrospective judgment and said: "That being the percentage there, all we are doing is bringing it up." As I have tried to show, so far as we were concerned, it was constant and although expenditure on the National Health Service went up by £200 million, the appropriation-in-aid remained the same. In other words, there was no organic link between insurance and National Health. It has been created in the mind of the Government in order to justify a tax on the poor.
I will show exactly how it has been done. Whereas the contribution was 1392 about £40 million to £41 million over those years, it has now been raised to £95 million for England and Wales only. What has happened is this. By assuming this link, instead of increasing taxation to provide the additional money, the Government have called for the money from the National Insurance Fund, and they can only call for it from the National Insurance Fund by a poll tax, because it is no longer an insurance contribution. It is, in fact, a transfer of the burden from the shoulders of the rich to those of the poor. The reason why I resent it today is not only because it is inimical to the second important principle of the scheme but because, if it is persisted in, it would appear to justify a gradual transfer of the whole of the cost of the National Health Service to the shoulders of the poorest members of the community.
Let us just consider, for example, these figures for England and Wales. I am sorry to weary the House with them, but it is necessary that they should be on record so that we shall understand what has happened. In England and Wales, the appropriation-in-aid was constant at about £37 million, £36 million, £36.7 million, £36 million—the same each year; it does not change at all. But then it went up. In 1957–58 it went up to £57.9 million, and the estimate for 1958–59 is £95 million. So we have there a very complete picture of the transfer of the cost of the National Health Service.
§ Mr. Shepherd
Why does the right hon. Gentleman make such a point of this? Surely he realises that against this £401 million, £2,000 million a year is spent by people on drink and tobacco?
§ Mr. Bevan
I do not know that the well-to-do abstain from drink and smoking. They are in the same category as the rest.
I am speaking now about the perfectly unjustified transfer of the burden from the well-to-do to the poorest, because the poorest have to pay those contributions. I say that it is entirely unjustified, and more particularly so because the cost of the National Health Service to the present Government is a smaller percentage of the national income than it was in 1950. In other words, when the burden has become less for the nation it is made heavier for the poorest. That seems to me to be an entirely unjustifiable attitude 1393 of approach. Of course, the party opposite would make even more inroads on the Service if they thought that it was politically expedient to do so. [An HON. MEMBER: "On the Service?"] Certainly, on the Service. In addition, hon. and right hon. Members opposite have imposed charges.
The party to which I belong put on some small charges in 1951, intending that they should last for four years. When the party opposite came in, it made them permanent and increased them, until now they represented a payment of nearly £35 million for England and Wales alone. But that procedure was so unpopular that the party opposite did not go very far with it. It did the other thing; it got itself out of its financial troubles by increasing the tax on the Insurance Fund. The figures as percentages of the national income are 4.2 in 1949 and 3.9 in 1956. Therefore, as we grow richer and more able to bear the burden, the more and more the party opposite throws it on the shoulders of the poorer members of the community.
I want to give another example, which I hope will appeal to the House, of the way in which the Treasury is nibbling away at the Service in every respect. In, I think, 1947–48, it seemed to me a very good idea to establish a college of a very unusual type. That was a college for the teaching of teacher-midwives. We in this country have always been very proud of our maternity service, which I think is the best in the world. But we had to increase the numbers rather rapidly. In particular, I wanted to provide a very quick increase of midwives for the Commonwealth, and especially for the backward areas. In the Commonwealth, and especially in the Colonial Empire, doctors are very thin on the ground. In the rural areas, particularly, they practically do not exist.
It seemed to me and to my medical advisers at the time that the quickest way of providing efficient help for these areas would be to provide them not only with midwives—and that we could not do in sufficient numbers—but with teacher-midwives to teach others as the quickest and cheapest way of helping, because if one could get a trained midwife to preside at births in these areas an enormous amount of mischief would be stopped. We set up the college. It 1394 is at Kingston-on-Thames and is a very small affair.
It has turned out 267 students in the short time it has been in existence. Seventy-five of these have gone to the Commonwealth. The numbers of students from the Commonwealth are: Australia 5, Burma 3, Canada 2, British West Indies 5, India 7, Malaya 7, Singapore 3, Hong Kong 1, Sarawak 1, Ghana 2, Sierra Leone 2, Uganda 1, Nigeria 7, Southern Rhodesia 3, Sudan 1, and Ceylon 1, making 51 in all. I do not hesitate to say that I do not believe that there is a single service of more value for so little money as that. Nor do I think that there is a service which has a better public relations aspect for this country, because these teacher-midwives go out and teach midwives there so as to increase the number available. I am certain that they are ambassadresses for this country in a very singular sense.
We had a little assistance to finance this college in the first instance, but now the college is threatened to be closed because the Treasury will not find £3,500 in a year in subvention. [HON. MEMBERS: "Shame."] This is a characteristic example of the relationship between the spending Departments and the Treasury about which I have protested over and over again. I do not object, but, on the contrary, admit that it is necessary that there should be some global relationship between what the Treasury is prepared to spend and what the Service is entitled to get. It cannot get what it likes, but I insist that when the Treasury has decided that it is able to afford certain money for certain purposes it should leave the spending of the money to those who know most about it and about how they can get the most good for the Service. What happens over and over again is that some minor official at the Treasury wipes the dust from his eyes and looks at all these items and sees how he can nibble them away. Out of a vast expenditure of £600 million, the Treasury goes poking away, trying to nibble at that £3,500.
At present, these students are paying fees, and now they will have their fees increased. Whereas we ought to be finding more money and not less for this college, I am now told by those responsible that the college may close down unless some financial assistance 1395 is given—that modest sum of £3,500 a year. I am not attacking the Minister. I do not believe that he is responsible for it. If he is, he should be ashamed of himself. Indeed, he should resign if that is his view of the Service; but I am sure that this is not his disposition, and I am making this speech today about this matter in order to enable him to exercise the necessary leverage with his colleague. If he wants further assistance, I shall be delighted to give it to him.
One of the difficulties about the National Health Service is that there have been far too many Ministers. They have followed one after the other, not only to their mutual embarrassment, but to the dismay of the nation as a whole. I was at the Ministry from August, 1945, to January, 1951,—a very long term—and my right hon. Friend the Member for Middlesbrough, East (Mr. Marquand) was there, but for a short time, unfortunately, because the electorate deserted us at that time. The present Minister of Labour's tenure of office was disastrous, although he became educated before the end. Towards the end, he became really a defender of the Service, although he started off as its most advertised executioner. He said so himself from the Front Bench opposite. He was there from May, 1952, to December, 1955.
§ Mr. Bevan
Yes, I beg the pardon of hon. Members. He was there—and was a most unfortunate choice.
Then, from December, 1955 to 1957, the right hon. Member for Thirsk and Malton (Mr. Turton) was the Minister, a very short term. The next one, unfortunately, fell ill, and now the right hon. and learned Member for Hertfordshire, East (Mr. Walker-Smith) occupies the office. I hope that it will not be for long—not for any personal reasons. I hope that he also will be deserted by the electorate before very long.
I make this point because if we have a succession of Ministers in an important Department like this two things happen. By the time they have acquired a jealousy for their position and a knowledge of it they are sent away. They also do not acquire in that office sufficient stature to 1396 be able to stand up against the importunities of the Treasury. It is necessary for them to be senior, experienced, longstanding Ministers to be able to get their own way. I am not talking about the global sum spent on the Service, but about its internal administration. They can stand up against this nibbling by the Treasury only if they are men of stature in the Government, men of experience and long standing. Therefore, I think that great mischief has been done to this Service by the continual changing of occupiers of the office of Minister of Health.
One or two features were introduced into the National Health Service in 1948, which I always regarded as concessions to the pressures of the moment for reasons which I think were at the time perfectly proper. For instance, we wanted to bring an end to these nursing homes, expensive places not properly looked after in my opinion. We could do that only by persuading surgeons to stay at the general hospitals, and that could be done only by having pay-beds at the general hospitals. So we made a concession; it was that there should be pay-bed blocks and that the consultants should take paying patients into hospital.
I know from what I have heard from different parts of the country, because I receive letters about this every week, that this position is in some respects and in some cases seriously abused. Apparently the middle classes cannot help preying upon the middle classes. The consultants, if they can get a paying patient into the hospital, jump the waiting list and get him in, and there is no justification for saying that in every instance they go in for medical reasons, because they go in for financial reasons. This is a serious abuse.
I am not saying for a single moment that it is universal, that it has amounted to so grave an abuse as to impair the Service, but I do say that it has caused great grief. I hope, therefore, that hospital management committees will pay more attention to this and will ensure that patients are admitted to hospital for medical reasons first, and that people should not be able to buy their way in ahead of those who need hospital more than they do. Unless we can put a firm administrative foot on this practice, we shall find a kind of Gresham's Law 1397 operating in the National Health Service by which the worst practices will drive out the better.
Again, the administration ought to stand up for the better consultants against the others. It ought to discourage these consultants having financial advantages over their colleagues by getting fees, whereas their colleagues apply a medical test and a medical test only. So I hope that this kind of thing will stop, because if it is stopped the whole climate of the Service will be much happier, and certainly the hospitals will be much more wholesome. If it is not stopped, then I am afraid—despite the fact that some of the consultants may take me to court—that I shall send their names to the Minister. We will see what happens, and I shall not even try to claim qualified privilege.
Many other things could be said. For instance, I could pay some attention to the mental health service, but that would take me too far afield, although we know it is very necessary indeed that more money should be spent on it. Some of our mental hospitals are in a disgraceful condition, and there is every justification for the Minister asking the Treasury for more capital moneys to be spent on this aspect of the National Health Service.
Before I sit down, I want to say how especially happy I was to pay some attention to the deaf for the first time in the history of public administration in this nation. Deafness is a most disabling disability. It is worse than blindness; it is stupefying. Large numbers of people could not attend their work, could not take part in normal social intercourse, because of this terrible misfortune. How many there were we did not know. An estimate was made. I was told that the figure was probably between 130,000 and 150,000. It turned out to be far more than that. The number of Medresco hearing aids issued between 1948 and 1957 amounted to 580,000. I am not saying that at any given moment 580,000 people are wearing them, although as one moves about one sees many people wearing them and leading perfectly normal lives.
When people are talking about the cost of the National Health Service, I hope they will keep such facts as that in mind; because not only does the Service rescue people from a kind of twilight 1398 life, but their rehabilitation is of an enormous economic advantage. People are able to go about their normal avocations and to lead happy and contented lives, rescued from what was a near death.
Also, when people are talking about the cost of the National Health Service as expressed in these figures, I hope they take into account the fact that the Service has a column—a secret, silent column, which never appears in the balance sheet. That comprises the enormous number of people who are back at work and who would not be there had they not received hospital treatment. It is not only that the hospitals are providing more beds, but the turnover is much greater there. People are getting back to work more quickly. These are assets that are unassessable and require imagination to be seen. It is that function which the House of Commons must perform.
I hope, therefore, that as we celebrate the tenth anniversary of the National Health Service, more and more people in this House will become its guardians, because it is regarded all over the world as the most civilised achievement of modern Government.
§ 5.16 p.m.
§ The Minister of Health (Mr. Derek Walker-Smith)
It is indeed a gratifying circumstance that, at a time of compelling and absorbing interest in international affairs, the right hon. Gentleman the Member for Ebbw Vale (Mr. Bevan), as shadow Foreign Secretary, should be able to find time to revisit the scenes of his earlier activity. [HON. MEMBERS: "Triumph."] I am assuming, of course, that we are not to read into his appearance on this occasion at the Dispatch Box opposite any change in his status as shadow Foreign Secretary.
On that assumption, it is rather like the distinguished old boy who has achieved eminence in other spheres returning to the scenes of his former successes—if hon. Gentlemen opposite so like—to award the prizes. At least, that was the agreeable impression given by the earlier part of his speech. On the whole, I think, the House will agree that the right hon. Gentleman did it very nicely, even if he was not altogether able to resist the temptation to award a prize 1399 or two here and there to himself. That is normally considered an unconventional exercise, though perhaps not wholly uncharacteristic in the case of the right hon. Gentleman.
§ Mr. W. A. Wilkins (Bristol, South)
Let the Minister be generous and give my right hon. Friend some credit.
§ Mr. Walker-Smith
No one would wish to grudge the right hon. Gentleman any credit due to him in the inception of the National Health Service, and certainly the whole House will appreciate his generous references to the officials of those days. Yet, I thought he was less than generous in his reference to his predecessors at the Ministry of Health and in his total omission of any reference to the Coalition Government's White Paper of 1944.
The right hon. Gentleman said at one stage of his speech that he considered himself fortunate in his opponents in those days. I always understood that the difficulty of the right hon. Gentleman in these health matters, which came a little later on, was that he considered himself unfortunate in his friends. Certainly, in 1951, the right hon. Gentleman differed from his right hon. Friends on some of these basic health matters, and, in fact, it took the shades of opposition to heal these wounds and conflicts. If they have succeeded in doing that, no doubt it will be good for the amity and unity of the Labour Party, as well as for the interests of the country, that hon. and right hon. Gentlemen opposite should sojourn indefinitely in those cooling and salubrious shades.
§ Mr. Walker-Smith
I am replying to the speech of the right hon. Gentleman. That is considered a usual Parliamentary exercise, as I am sure the hon. Member for Oldham, West (Mr. Hale) will appreciate.
It would not be wholly instructive to follow all the right hon. Gentleman's speech, because as to a large part it was a highly selective remembrance of things past and I, as the Minister responsible for the Service today, am more concerned with the pattern of the future than with questions of the past.
1400 The right hon. Gentleman devoted a good deal of his speech, as he was entitled to do, to the financial question and to what he called the transfer of the burden. I must remind him, and I am sure that hon. Members require no reminding that we debated this question fully and exhaustively in the spring of this year, albeit, not with the benefit of the right hon. Gentleman's presence, although we had the right hon. Lady the Member for Warrington (Dr. Summerskill) and the right hon. Member for Middlesbrough, East (Mr. Marquand). I made many speeches, and I dealt with the points which the right hon. Gentleman has raised on 25th February, and again on 5th March and on 11th March. The right hon. Gentleman must not charge me with not answering when he was not present to listen to my speeches and when he has not read them since.
§ Mr. Walker-Smith
I recollect that the right hon. Gentleman was present during the speech of my right hon. Friend the Chancellor of the Duchy of Lancaster, and I recollect that the reason was that my right hon. Friend did what it would appear the right hon. Gentleman has not done today—he gave the right hon. Gentleman notice that he intended to refer to him. Has the right hon. Gentleman given my right hon. Friend notice that he intended to criticise his intervention on that occasion?
§ Mr. Bevan
The right hon. and learned Gentleman must not make a point of that. The Chancellor of the Duchy of Lancaster was speaking for the Government. When a Government spokesman has spoken for the Government, we attack the Government and him. One does not give notice. This is not an eighteenth century quadrille, or a mediæval tourney.
§ Mr. Walker-Smith
We are on a simple issue of fact, and when the right hon. Gentleman uses extravagant language it is because he finds the facts embarrassing to him in this context. That was the only intervention of the right hon. Gentleman and it was the only occasion on 1401 which he was present in the debates. Simply because he was not here to listen to them, I shall not weary the House again with repetition of all the arguments which I put forward on those themes. I intend to try to put before the House some new dishes and not a mere rechauffé of the spring menu which we had in the absence of the right hon. Gentleman at that time.
As the right hon. Gentleman said, we have just had the tenth anniversary of the Health Service. Ten years is not a very long time, long enough to establish some sound record of performance, but short enough to make it appropriate that we should concentrate our interests on the future rather than on the past. I make only this comment: one of the things which has turned out better than some people expected in the ten years has been that the strength of the voluntary spirit in our Health Service and hospital work has continued unabated, and we still have a very sound basis of voluntary work, freely given and highly regarded.
I said on the occasion of the debates on the National Health Service Contributions Bill, to which I have referred, that the country was getting a good bargain for the very large amount of money which the Health Service was costing. I think that that is so. We have an increase in the number of effective beds in the hospitals, greater speed and efficiency of treatment, and a great increase in the range of drugs to heal and vaccines to prevent disease.
I do not want to give a lot of figures, any more than the right hon. Gentleman did, but I want to give these few illustrative figures to show the progress which has been achieved since 1949. Effective beds are up by 6½ per cent.; in-patients admitted are up by 29½ per cent.; the ratio of treatment to beds is up by 22 per cent.; new out-patients treated are up by 12 per cent., and the waiting lists are down by 11½ per cent. On the domiciliary side, home nurses are up by 23 per cent. and visits paid by home nurses are up by no less than 50 per cent.
On the therapeutic side we have a striking change in the pattern of disease, chiefly notable in the welcome downward curve of some of the historic scourges which have afflicted mankind through the ages—infant and maternity mortality, tuberculosis, diphtheria, and syphilis, to 1402 mention a few. The progress in the case of tuberculosis and diphtheria, as the House knows, has been especially dramatic. Tuberculosis mortality has declined from nearly 22,000 cases in 1948 to well under 5,000 in 1957, and most of the rapid progress has been in the last few years. The slump in diphtheria dates from well before the National Health Service, from the immunization campaign in the early 1940s. In 1940, there were 46,000 notifications and nearly 2,500 deaths. Last year, there were only 37 notifications and only six deaths.
I would not like to be taken to suggest that we have a universal pattern of success to match the conquest of diphtheria and the approaching conquest of tuberculosis. On the other side of the balance sheet, we have the upward curve in such things as cancer of the lung, leukaemia and arterio-sclerotic diseases. In this, as so often in this imperfect world, our very successes leave their problems. If one is less likely to die of diphtheria as a child, or from pneumonia as an adult, one has a greater chance of succumbing later to coronary disease or cancer. That must be so. By increasing the expectation of life, we put greater emphasis on the malignant and degenerative diseases which are characteristic of the later years. That is part of one of the great problems on which I want to say a few words.
§ Mr. John Baird (Wolverhampton, North-East)
Does the right hon. and learned Gentleman have any figures for leukaemia?
§ Mr. Walker-Smith
I do not have them at the moment. Perhaps it will be possible for them to be given later.
I want to indicate the two signposts for our future action which are provided by our successes with tuberculosis and diphtheria. First, there is the importance and potential of preventive medicine and action, and, secondly, there is the contribution which we can make towards a solution of the accommodation problem of our hospitals by the virtual elimination of some diseases.
Our surplus tuberculosis beds are being devoted to other purposes—in part to non-tubercular chest conditions and also to uses where there is a great need, such as geriatrics, chronic sick and mental health. On the preventive side, I am anxious to apply the principle of 1403 preventive medicine wherever possible. In this context, as the House knows, we have carried through a heavy programme of vaccination against poliomyelitis in the course of the summer.
The incidence of polio has varied widely over the years and one has to tread very delicately on this very unpredictable ground, but it is perhaps significant that up to and including the twenty-ninth week of this year, there were fewer cases and fewer paralytic cases than in the same period in any recent year and, of course, we are far below the average figure.
Another promising preventive measure is the fluoridation of water supplies. It has been shown in the United States and elsewhere that this is capable of reducing the incidence of dental decay in young children by as much as 60 per cent., with beneficial effects persisting well into adult life. In view of the shortage of dentists and the high cost of the General Dental Service, any Minister of Health would obviously be attracted by the long-term implications of this preventive measure. I hope that in the areas where fluoridation is being practised or contemplated, people will appreciate its benefits and understand that there is no harmful effect arising from it.
§ Mr. Walker-Smith
As the right hon. Gentleman will know, demonstration schemes are in progress. All the schemes that have been started are continuing with the exception of that at Andover, where there was a change of mind or heart on the part of the local authority.
§ Mr. Walker-Smith
We are embarked upon this policy of demonstrations and we would rather see a continuance of that as the policy which has already been adumbrated to the House.
1404 I now come to the rather major point that I was seeking to make about the impact of age structure on the changing pattern of disease and on our problems. This is one of the two great special problems which must condition our thinking and planning for the future of the National Health Service both in the social context of the happiness and well-being of our people and in the logistical context of easing the load on the Health Service and thereby its pressure on the economy.
The other problem is the mental health problem to which the right hon. Gentleman referred towards the end of his speech. As the House knows, we in this country have an ageing population. By 1975, one person in seven will be over 65 years of age as against one in 21 at the beginning of the century. Therefore, we have to accept our extended expectation of life not merely as a fact to be noted, but as a challenge to be met.
We have here, as in all our health problems, a double duty—a social duty to see, so far as we can, that the increased span of life is a time of happiness, and an economic duty to see that looking after the old does not place an undue burden on the working part of the population, and, therefore, on the future of the country.
Our policy, therefore, is to seek to keep the elderly in their homes as long as possible, and when they have to go to hospital to rehabilitate them wherever possible so that they can live at home again, helped by home nursing and the other domiciliary services. We have been able to achieve two encouraging developments covering the treatment of in-patients and out-patients. There has been a steady rise in attendances at the chronic sick and geriatric clinics, from just under 7,000 in 1950 to over 39,000 last year. On the in-patient side, although there has only been a small increase in the number of beds a better use of them has enabled more in-patients to be treated.
The House will recall that we debated this question very fully in November and, in particular the memorandum and circular which I issued in October last year. I do not want to repeat now what we then discussed, but I would just mention that we now have over 70 geriatric departments to assess and rehabilitate elderly patients by active treatment, and more 1405 will be set up as resources permit. It is obviously not enough, in this keenly competitive world, merely to enable the old to live longer. What we have to try to do is to help them to stay fit longer and thus remain active members of the community, contributing to its vigour and well-being.
The other great special problem is mental health. Inevitably, the speed and stress of modern life have increased the ratio of mental to physical illness. As we know, more than two out of five of our hospital beds today are devoted to those suffering from mental disorder, though on the credit side, especially in recent years, has come an increased awareness and public understanding of the importance and complexity of these problems.
The Royal Commission, as the House knows, recorded in its Report a notable advance in the social progress. It recommended among other things the abandonment of the assumption of the need for compulsion in favour of the offer of care without deprivation of liberty to all who need it and who are not unwilling to receive it.
To implement this as far as we could without legislation, I issued a circular in January asking hospital authorities to admit patients to mental deficiency hospitals on an informal basis wherever possible and to review existing patients on the lines recommended by the Royal Commission. This review is now in progress. Approximately 18,000 recommendations for discharge from compulsory powers have been received by the Board of Control and about 12,000 accepted. Only about 100 have been refused, and the examination of the rest is going on.
§ Mr. A. Blenkinsop (Newcastle-upon-Tyne, East)
Can the right hon. and learned Gentleman say what action is being taken to provide alternative accommodation for those who are discharged in this process?
§ Mr. Walker-Smith
The question of alternative accommodation is, of course, a long-term problem, as the hon. Gentleman knows. I know that he has a particular interest in the local authority side of this matter and my hon. Friend is hoping to say a word or two on this aspect later in the evening, if that is agreeable to the House.
1406 Over the whole field of practice and procedure in mental health, Parliament will, of course, have an opportunity, when the time comes for mental health legislation, to add to the volume of our social progress a notable new chapter on this very human theme. Meanwhile, we are making encouraging progress in the sphere of treatment, particularly in the increased range of out-patient services where a wide range of psychiatric services are now provided at out-patient clinics, more than three-quarters of them at general hospitals. Between 1953 and 1957 out-patient attendances went up by well over a third. We have now, too, 25 day hospitals for these purposes, with four more expected to be opened shortly.
The right hon. Gentleman referred to the hospital building side in the context of mental hospitals. It is significant that the first new major hospital buildings to be brought into use—Greaves Hall and Balderton—have been for mentally deficient patients, and our programme of major schemes includes extensions and development schemes at many mental deficiency and mental hospitals, together with many new psychiatric blocks at general hospitals.
There is, I think, a striking common denominator in the approach to those two great problems. In both we seek a shift of emphasis to outpatient treatment, and we are trying to retain more people in the community during treatment and to return them to the community after treatment. In this way, and only in this way, can we hope to have a service adequate to the needs of patients without creating a crushing burden too great for our resources and finances to bear.
The House can see this principle at work in the pattern of our capital expenditure on hospitals. New out-patient departments and improvements to existing departments at more than 100 hospitals in all have accounted for more than £7 million of our expenditure, and nearly one-fifth of the money available has been spent on special medical departments including operating theatres and diagnostic departments, which have enabled better use to be made of existing beds.
It has naturally, of course, been widely said that too little money is available for hospitals. Ideally, that is certainly true, though we are limited in this context by the economic factors which are well 1407 understood. Nevertheless, there has been a sharp upward turn. In the first ten years £100 million was spent on hospital buildings of which £42 million was spent in the last three years. In no year up to 1955–56 was more than £10 million provided for capital development for hospitals. This year there is £20 million, and next year we hope to have £22 million. I certainly hope that the upward curve will be at least continued.
§ Mr. Walker-Smith
The capital expenditure is, of course, deployed over a wide field. Now, 29 of the schemes in our programme of major building works have been started. Work is in hand, for example, on important additions to new hospitals at Hensingham, in West Cumberland, Swindon and Swansea. Site works are in progress for new hospitals at Welwyn, Harlow and Huddersfield, work is proceeding on a new surgical block at Guy's Hospital and about 50 major schemes are being planned, including 11 more new hospitals. This is in addition to the many and varied schemes, some of them rather sizeable, which are being carried out by the hospital boards themselves from their own capital allocations.
Whatever success we achieve in our policy of out-patient treatment and treatment in the community, there will always be a vastly important residue of cases calling for in-patient treatment at the hospitals. The hospital service will always loom large. Indeed, in the economic sense, we know that, because the running costs of hospitals take up nearly 54 per cent. of our total expenditure on the Health Service. Obviously, it is vital, where so much is involved in money and resources, that we should strenuously continue to seek the highest common factor of efficiency and economy in administration.
Where the total sums are so large, obviously, there will be criticism, some of it informed and some of it less informed. I have a very receptive mind to all constructive suggestions for efficiency and economy in this field. Indeed, the House 1408 and the public at large can be assured that no critics are more resolute than we—and when I say "we", I do not mean only the Ministers, but everybody connected with the hospital service—that time and money should not be lost through waste or unproductive effort. I certainly intend that everything possible should be done to prevent that in every way.
I should like, on that point, to say a word or two on the organisation and methods service in hospitals. The work of this O. and M. service has shown that we can best ensure that time and money are not wasted by critical and detailed analysis of hospital work on the spot, and such studies are a constructive challenge to the traditional, and should be accepted as such by all concerned. The results of such inquiries can be quite dramatic, particularly where manual work is concerned, where large savings of time can sometimes be achieved. These potential savings, which we have there, are, in effect, a hidden reserve of the greatest value to us. They can be used, for example, to offset the recent reduction in working hours, to avoid an increase in staff consequent thereon, to relieve nursing staff of extraneous tasks, and generally to reduce costs.
Where these studies have already been undertaken, the details of their methods, the work standards used and the improvements achieved, will be published for the use of hospital authorities. Improving efficiency is reflected also in the well-being of the patients. For example, striking improvements have been achieved in avoiding overcrowding and delays where these studies have been put into operation. I think that the House will, therefore, agree that it is clearly desirable that the development of organisation and methods and work study in the hospital service should be encouraged, and its good results demonstrated to hospital authorities as fully as possible.
§ Sir Godfrey Nicholson (Farnham)
May I ask my right hon. and learned Friend a question? He may recollect that the Select Committee on Estimates recommended that the Ministry of Health organisation and methods service should be established on a permanent basis. When that recommendation of the Committee was applied to my right hon. and 1409 learned Friend's Department, his answer was that the experience gained was being assessed. He did not say whether the recommendation was accepted or not. Is it being established on a permanent basis?
§ Mr. Walker-Smith
I am much obliged to my hon. Friend for the point that he has raised. The present experimental organisation and methods unit at the Ministry will be enlarged and made permanent, under a full-time Assistant Secretary of the Ministry. It will, I think, have a particular contribution to make in the conduct of assignments and investigations, the results of which are likely to be of general application, and lead to furthering the general development of this organisation and methods and works study arrangements which are carried out by the hospital authorities themselves.
In this context, I should also like to say that a group of management consultants have generously offered to undertake a series of surveys at their own expense to demonstrate the economies and improvements in efficiency which can be achieved in the hospital service by this work study. I have accepted this offer with appreciation, and, in consultation with the boards of governors, regional hospital boards and hospital management committees concerned, I have suggested the following four subjects for investigation.
First, a work study of the portering services at a provincial teaching group of hospitals; secondly, a study of general maintenance work at a London Group Hospital Management Committee; thirdly, a survey of the work of the hospital laundry at a mental hospital; and, fourthly, an inquiry into the possibility of making better use of the nursing and other ward staff at a London teaching hospital. The reports of the management consultants will be studied with the greatest interest, and their conclusions will, no doubt, help us in the planning of further developments in the extension of organisation and methods and works study activities throughout the hospital service, whether conducted by our own staff or by outside experts brought in to advise.
§ Mr. Kenneth Robinson (St. Pancras, North)
Could the right hon. and learned 1410 Gentleman say what it was that made this group of management consultants make this offer? Was it pure public spirit?
§ Mr. Walker-Smith
I should say that the management consultants hope to demonstrate not only the general value of the work that is done, but the value of bringing in outside expertise into this field. It would obviously be a matter which was in their minds, I should have thought.
May I now refer to one other valuable suggestion which I have received from the Royal College of Nursing? Following its recent conference on work study, the Royal College has suggested that an advisory council on work study should be set up to assist the development of this activity in the Health Service. Naturally, I shall consult the other interests involved before settling the rôle and membership of this advisory council, but I think that such a body could play a most important part in advising on general issues of major importance, affecting the extension and profitable application of these studies in the Service, as well as in helping to overcome any unwarranted fears about them.
All these steps are designed to assist and improve effective management in the hospital service, and should, in the future, have a marked and progressive effect on the economy and efficiency of the service. They should provide a means of assisting hospital authorities to make the best use of available resources, and they will certainly contribute to the general improvement of the hospital services provided to the public.
Perhaps it would be wrong to conclude without a very brief word on the people whose labours are essential to the Service. Here our efforts are deployed over a wide range. On the remuneration of doctors and dentists, the Royal Commission is hard at work. On the important question of the staff structure of hospitals a joint working party has been set up and is getting down to work. I announced last Thursday the Government's acceptance of the McNair Committee's recommendation to increase the output of dentists to practise in Great Britain. That, broadly, completes our acceptance of the recommendations of that Committee
1411 The professional arrangements of opticians have made a notable advance through the passage of the Opticians Act, due to the legislative enterprise of my hon. Friend the Member for Wembley, South (Mr. Russell). Following the Noel Hall Report there will be an entirely new grading and pay structure for the clerical workers and junior administrative grades. The precise details of this have been the subject of arbitration, the award in respect of which we now await.
This leaves the question of the salaries and posts of the senior administrative grades—people of great importance in the hospital service. To enable discussion to be undertaken in the light of facts about comparable spheres outside a small committee, under the chairmanship of Sir Noel Hall, has been set up by the two sides of the Whitley Council to carry out a fact-finding investigation. When its report is available it will form the basis of subsequent negotiations of new salary scales. I am grateful to Sir Noel and his two colleagues, Sir William Matthews and Mr. R. E. Peers, for undertaking this task, which will greatly help the assessment of a fair rate of remuneration for these important posts.
From these various operations and endeavours there should emerge a new administrative and clerical staffing structure, which will help the Service to recruit and retain a staff of the right calibre at all levels
§ Mr. Leslie Hale (Oldham, West)
There is one subject which the right hon. and learned Gentleman has not mentioned. He has not said anything about the responsibilities conferred upon the Minister of Health in 1956 in respect of the evacuation of the civil population in time of war. In view of the present Government's foreign policy, surely we need to know whether, for example, Oldham is to be an evacuation or a reception area.
§ Mr. Walker-Smith
If the hon. Member is able to catch Mr. Speaker's eye he will no doubt be able to elaborate his argument—and on the hypothesis that my hon. Friend also catches Mr. Speaker's eye, he will be able to evaluate the hon. Member's suggestions and accord them such part of his speech as they seem to deserve.
1412 The right hon. Member mentioned a subject in which the House has always taken a great interest, namely, the question of nursing. Here the trend is certainly good. The figures speak for themselves. From the end of 1949 to the latest figures available, for last March, the whole-time nursing staff has risen by 20 per cent. and the part-time by no less than 75 per cent. The fact that we are now able to contemplate an early reduction in the standard working hours from 98 to 88 a fortnight is some evidence of the progress made. It is true that we still have shortages in some areas, but we are grappling with the problem of distribution, notably through the subcommittee specially set up by the National Consultative Council.
In so wide a subject it is very difficult to be able to touch upon anything like all the matters which are of interest to hon. Members. I was visiting a hospital a week or two ago when the physician superintendent said to an old lady patient, "I would like you to meet the Minister." The old lady said, "I am always glad to meet a Minister. What may your parish be?" I said, "My parish is the parish of health." It is certainly a large one, and, I think, an important one.
I have tried in the time available to me to give some record of the progress of my parish—if I may call it that—and some definition of the problems that beset us. The country has made a very considerable investment in health, and I think that with the years we shall see an increasing return. The return we need is not merely better methods of treatment and greater prospects of cure, important as those things are. We have to aim at the prevention and, where possible, the elimination of illness, resulting in a positive improvement in health, reflected in the factory, the foundry and the farm, and not merely in the convalescent home.
If we do this, better health will go hand in hand with diminished cost, and we shall be able successfully to discharge both our social and our economic duty. We shall achieve for our people that positive advance in health and well-being which is, and should be, the simple basic object of all who toil in the field of health.
§ 5.55 p.m.
§ Dr. A. D. D. Broughton (Batley and Morley)
This is an occasion on which the House has the opportunity of reviewing the National Health Service and taking pride in its achievements during the first ten years of its existence. Before I begin the speech that I have in mind to make on this subject, I want to refer to the two Front Bench speeches to which we have just listened. My right hon. Friend the Member for Ebbw Vale (Mr. Bevan) opened his speech by paying a tribute to the civil servants who had helped him at the Ministry of Health when he was there in the Parliament of 1945–50. It was a typically generous gesture of his. I very much regretted that when the present Minister of Health followed him he did not take the opportunity of being generous and of paying a fitting tribute to my right hon. Friend.
We on these benches were very pleased that my right hon. Friend was successful in catching Mr. Speaker's eye and thereby able to open the debate. We feel that there is no one who should have pride of place over him when we are celebrating ten years of the National Health Service. I was one of a small band of people who advocated in public the need for a National Health Service some years before the war. I saw the need for such a Service. I spoke and wrote of that need, and I was delighted when the Service was launched. Today, I am very glad to see that the Service is generally accepted, and to find that it has been so extremely useful in its first ten years.
I will not speak of the struggle to launch the Service. My right hon. Friend has referred to that, and only a man of his calibre would have made so little of the difficulties that he then had to face. They were formidable, but, fortunately for Britain, he was able to overcome them. Nor shall I say much about the success of the Service in the past ten years. I want to follow the example of the Minister of Health and look to the future. I want to look to the next ten years.
As the Service is a comprehensive one, covering all forms of treatment for all people in need, there is an enormous amount that could be said, but I shall confine my remarks to one aspect. I want 1414 to take the opportunity of making a special plea for the mentally ill and to draw the attention of the Minister and the House to the treatment and care of persons suffering from mental illness. I must declare a personal interest in this matter because I practise as a psychiatrist and I hold a hospital appointment in the National Health Service. I make no apology for attempting to draw the attention of the House to this subject for we must remember that approximately 50 per cent. of hospital beds in this country are occupied by patients suffering from mental illness.
The problem is a large and serious one. It is not only a problem of so many beds being occupied by patients suffering from this type of illness, but of many of the mental hospitals being overcrowded and understaffed. I shall illustrate this by reference to the West Riding of Yorkshire. Storthes Hall Hospital which is a very good hospital and one at which I have had the privilege of working as a member of the staff—and which, incidentally, serves my constituency of Batley and Morley—has statutory accommodation for approximately 2,000 beds. The approximate number of patients is 2,500. At Menston Hospital the figures are almost identical. Middlewood and Stanley Royd Hospitals show similar pictures of overcrowding.
My hon. Friends and I are very concerned about this matter. We have discussed it on numerous occasions and many of us have taken the opportunity of visiting some of these hospitals to see the conditions for ourselves. I ask the Minister what he is going to do about it. I understand he is being pressed to build new hospitals in order to relieve the congestion in existing hospitals. I hope he will resist those suggestions. The reason I ask him to resist them is that I hold the opinion that mental cases should only be sent into residential hospitals if that line of action is absolutely unavoidable. I believe that whenever possible the patient should remain in his or her familiar surroundings, should remain at work if possible and at home if the home conditions are satisfactory and the patient's condition allows that. I believe hospitalisation does harm in quite a large number of cases.
I shall try to illustrate this to the House. If it is generally known in an 1415 area that the usual treatment for mental illness is admission to a mental hospital, that knowledge can be harmful to patients with slight mental trouble. For example, if a person has a heavy load of worry which causes him to be bewildered it is not unusual for him to wonder about the state of his mind. Then fear may enter. Fear of having to enter the new environment of a mental hospital to be shut away can produce a secondary anxiety which can be far worse and over-mask the primary symptoms. If the patient goes into hospital a fear of never being able to get out and a fear of becoming as ill as some of the others he sees, a feeling that he may be unable ever to face the world again, can cause such anxiety, panic, despair and confusion of the mind as to make that patient worse.
I admit that there must be mental hospitals and I believe it absolutely essential that some patients should go there, but I think the number of patients who should go into residential mental hospitals need be only small. Perhaps the Minister may ask what is my answer to the problem? I gathered from his speech that his mind is already working on these lines, and I suggest that the answer may be found in the extension of day hospitals, out-patient departments, psychiatric clinics and domiciliary services. It may be that I am biased in my opinion by reason of the fact that I am employed on the staff of a day hospital, but I ask the Minister to examine this proposal very carefully indeed.
I am sure he can be relied upon to approach it with an open mind and to consider it either by himself or if he thinks it wise with the help of a Committee he might set up. I would point out to him that the Marlborough Day Hospital has now been operating for ten years and has some useful records of cases which he might like to examine. I ask him also to consider the very good work which is being done at Graylingwell Hospital. I had the pleasure of visiting that hospital a few weeks ago and found that it has opened a day hospital for Chichester and a day hospital and domiciliary service for Worthing. The result was that instead of there being overcrowding in that hospital there were many empty beds. I understand there is a scheme in Nottingham which is also 1416 well worth close study. If I understood the Minister aright, he said there were now 25 day hospitals. I suggest that every one of them is worth examining.
The Minister certainly cannot overlook the question of finance in connection with this policy. I stand subject to correction, but I believe that to build a hospital with wards for patients, accommodation for staff, laundry, kitchen stores and other buildings and a modern outpatient department for the treatment of 1,000 patients per year would probably cost in the region of £1 million. I suggest it is possible to acquire a day hospital to treat about 700 patients per year as day-patients and out-patients for about £20,000. I think that figure would cover the cost of buying a suitable house, carrying out structural alterations, decorations and equipping the place. The running cost of the residential hospital to which I referred would, I estimate, be in the region of £150,000 a year whereas the running cost of a day hospital such as that to which I referred would be in the region of £25,000 a year. There is an enormous difference in the cost.
I ask the Minister to be good enough to look into this question, and more particularly for the sake of the patients, because, I repeat, hospitalisation should be used only as a last resort and it is really necessary only for comparatively few patients.
Another point on which I would like to lay emphasis in this connection concerns empty sanatoria. The Minister has reminded us that the battle against tuberculosis is being waged very successfully. Of course, we are all delighted that the incidence of tuberculosis should have diminished to the dramatic extent that it has, but the result is that the Minister has empty sanatoria on his hands. I would like the right hon. and learned Gentleman to consider using those empty sanatoria for mental cases. I do not ask him to convert them into mental hospitals, for the reasons which I have already given. They might make very suitable convalescent homes for patients who have had the misfortune to suffer mental illness and have had to be admitted to a residential hospital, when they are considered almost well enough to return to normal activities.
We might ask why the battle against tuberculosis has been so successful. I 1417 suggest that the reason is that money and brains have been poured into the fight. When we ask why that battle has been more successful than the battle against mental illness, the answer is that far too little money and too few of the best brains have gone into the battle against mental illness. Psychiatry is still the Cinderella of the National Health Service and awaits a Minister of Health who will show himself a bountiful Prince Charming.
Bearing in mind that half the hospital beds are occupied by mental cases, the amount of money spent on this branch of medicine is ridiculously small when compared with what is spent on the other branches of medicine. Psychiatry has made good progress in recent years, but how can it be expected to advance at the speed that it should when a large number of hospitals have more than 100 patients in a ward and when the treatment—if one can call it treatment—consists of little more than keeping the patients locked up.
How can psychiatry have enough of the best brains when it is so neglected? We must not carry on with the old, passive way of putting patients into mental hospitals and leaving them there to the extent of causing serious overcrowding. New methods are needed in treatment and a modern, dynamic approach to the whole problem is required. Most hon. Members already know that the suffering of the mentally ill is intense. Psychiatry has advanced, but there is still a wide realm to explore and to conquer. I trust that, ten years hence, when the House of Commons is again discussing the National Health Service, speeches will be made praising the energetic steps that have been taken between now and then to conquer mental illness.
§ 6.14 p.m.
§ Mr. Robert Cooke (Bristol, West)
I think that the right hon. Member for Ebbw Vale (Mr. Bevan) was rather less than fair when he suggested that before the National Health Service came in patients did not get the best surgical treatment unless they were prepared to pay for it. I hope that I heard the right hon. Gentleman rather badly.
I want to intervene in the debate because of my family connections with the medical profession. My grandfather worked with Dr. Addison in the early 1418 days of National Insurance. My mother is a general practitioner, and my father is a consultant and a professorial gentleman. It is against that background that I want to see a better National Health Service with better value for money. We have one of the best overall services in the world, but it could be much better. There is still too much administrative interference and wasteful expenditure.
I very much regret the decline in the professional status of general practitioners. That is a matter of more importance to them than many matters of pay. The State scheme has not improved the doctor-patient relationship. Another result of the scheme has been to take away from the general practitioner that little bit of specialist work which he used to enjoy so much. I am afraid that the doctor's surgery has become a mere clearing house from which the doctor either sends his patients home with a bottle of medicine or sends them into hospital.
The cost of medical prescriptions is already earnestly under consideration, but I think all hon. Members will agree that something should be done to cut the cost of these items. I would give an example which adds force to that argument. A general practitioner who is well known in my city, and who has one of the most successful practices there by any standard, was able to get by with a drug bill very much less than half the average.
The increase in the drug bill is due to a number of things. One of the major difficulties is the public craving for antibiotic drugs, the over-use of which renders the drug useless. It has already done so in a number of cases. There is also the use of cortisone derivatives, which are extremely expensive. We must beware lest we approach the stage when we are spending more on drugs than upon doctors. We would do well to try to discourage the superstitious belief of the public in the box of pills or the bottle of medicine.
The National Health Service would be a greater success if the public knew more about it. This is a rather difficult problem, because the popular approach has its grave dangers, as we have seen from the use of television recently. Somewhat lurid accounts have been given about what goes on in hospitals although some good, balanced programmes have also been broadcast which tended to stress the 1419 value of the general practitioner. It is undesirable that psychological problems should be paraded on the television screen. That brings me to a point about mental health and I would pay my personal tribute to the work done by the hon. Member for Batley and Morley (Dr. Broughton) whose hospital I have had an opportunity to visit. To get people out of institutions and back into the community as healthy persons must surely be our aim. Day hospitals and clubs are doing excellent work in that respect.
Now I would say something about the relationship between the profession and the administrative side. It is not all that it might be. There are still too many administrators, which is due to the fact that paper breeds paper and that there is an over-complicated accounting procedure in many aspects of the hospital service. There is checking and crosschecking of stores to an alarming degree. It is estimated by business experts that a saving of about 12½ per cent. a year could be made in this administrative expenditure, at a risk of about ¼ per cent. loss by pilfering. We need a little less security and a little more trust in those concerned in this work.
The present system is somewhat demoralising. We have many first-rate hospital administrators who are most anxious to achieve value for money, and they should be given more scope. The Select Committee suggested that doctors, in the course of their training, might be made cost-conscious in regard to the National Health Service. That, surely, is a very helpful suggestion, because it is no good Parliament thinking that it can impose its will on doctors and administrators. The suggestion here is that the doctors themselves might become more conscious of the cost, and more economical as a result.
The use of drugs in hospitals, the great increase in drug bills in hospitals, is alarming those people working in the buildings to the extent that they have set up their own committees. There is also the danger in the craving for new apparatus and every latest piece of equipment in every hospital. These things quickly become out-of-date and considerable wastage results. Obviously, the best facilities should be available, but not necessarily in every hospital. There are 1420 many ancillary services where there are bad shortages, and I am sure that my right hon. Friend is aware of this. One has only to look in the medical journals to see the enormous number of vacancies in some ancillaries in order to realise the problem.
I support the optimism of my right hon. Friend, but I would say after ten years' experience of the National Health Service that it is not all that it ought to be, and the cost is threatening to get out of control. The problem cannot be tackled merely by imposing wholesale cuts in expenditure. We have to enlist the support of doctors and administrators and help them to put their own house in order. I hope that this debate will show those working in the Service that Parliament has more than just a passing interest in what they do, and that we in this House really want them to have a Service of which they can be proud.
§ 6.22 p.m.
The Rev. Llywelyn Williams (Abertillery)
This has been a very interesting month for hon. Members on this side of the House, who are firm believers in the National Health Service, for we have had opportunities to read in various newspapers and journals what would almost amount to a complete vindication of the creation of the Service and of the way in which it has developed and has been nurtured during the last ten years.
I pay tribute to the doctors, nurses and administrators who have made this Service our pride and the envy of the world. To introduce just one partisan note into my speech—I promise that it will be the only one—I doubt very much whether there is a single Conservative Member of Parliament, or, indeed, any Conservative Parliamentary candidate who may take part in future Elections, who would state in his Election address that he was opposed to the basic principles of the National Health Service.
During my visit to the United States I was flabbergasted at the appalling ignorance about our National Health Service revealed in circles where one would not expect to find it. I am not referring to yokels in hill-billy villages in Tennessee, but to people who hold eminent positions in the medical world. I met a consultant, attached to a large city hospital and a large medical school in a university, who believed that all the doctors in this 1421 country are directed by Whitehall, exactly like soldiers in the Army. He had other strange ideas about our Health Service and it gave me great pleasure to disabuse the mind of this eminent medical gentleman of them. A useful service would be performed by our Foreign Office, or the Ministry of Health, or by both acting together, if they did something to inform American people about what our Service is, what it does, and what we wish it to do in the future.
§ Mr. Baird
My hon. Friend was not a Member of the House when the Health Service legislation was being debated, but it is a fact that hon. Members opposite told people in the country that that is what we were going to do; that it was intended that doctors should be ordered about as if they were soldiers.
The Rev. Ll. Williams
I can well believe that to be true, but I was not a Member of Parliament then and I cannot speak with authority about something of which I have not first-hand knowledge.
I have been reading the debate in another place on 2nd July when their Lordships were almost unanimous in their approbation of the National Health Service. True, there were criticisms, some of them sound ones—and hon. Members on this side of the House will offer some constructive suggestions and criticisms as well—but, by and large, their Lordships spoke in the highest praise of the Service.
The contribution of Lord Moran was a good example of what I mean. I read with appreciation a similar contribution in a medical journal by Dr. Guy Dain, Chairman of the Council of the British Medical Association, and an article by Sir Harry Platt, President of the Royal College of Surgeons. These men who are eminent in the medical profession now accept the Service as being one of the finest creative efforts in the social legislation of this country since the war.
As I said, we on these benches, while we are, naturally, filled with a sense of elation and justifiable pride with this Service, do not believe that it is perfect. But we believe that the note to strike is not one of contraction, but of expansion and of greater efficiency. I read a very interesting memorandum, packed with good sound practical common sense such as I should associate with my hon. 1422 Friend the Member for Tottenham (Sir F. Messer), about the need for a chiropody service. I do not want to take from my hon. Friend the opportunity of developing that theme, but I believe that is one direction in which we could advance usefully and profitably. Osteopathy has a good claim for our consideration. We have been conservative-minded about osteopathy. In view of the scores of thousands of people who suffer from a slipped disc, as I have been suffering for the last two or three years, there must be many people who feel very strongly that a good osteopath could perform very useful work within the Health Service.
I wish now to refer to an aspect of the Service that it would probably not occur to anyone else to discuss. It is the contribution made by hospital chaplains. Provision was made for such chaplaincies to be an integral part of the Service and I think that it has met with great success. My hon. Friend the Member for Batley and Morley (Dr. Broughton) referred to the stresses and strains of the days in which we live; and all of us interested in health matters know that the inter-connection between the mind, spirit and body is very close and very sensitively poised. That is why I think that we were wisely led when we allowed these chaplaincy facilities in our hospitals.
It grieves me that there are some hospital management committees which have not seen fit to use the hospital chaplaincy service as it was intended to be used. In large hospitals full-time chaplains may be employed and part-time chaplains in the smaller hospitals. They are, of course, remunerated accordingly. But I regret to say that there are some hospital management committees in the Principality of Wales which still prefer the old system. I believe that a hospital chaplain specifically and authoritatively appointed to a hospital is more likely to do good to the welfare of the patients than if the old haphazard method is employed of clergymen and ministers of religion coming to the hospital according to their own inclination.
I would say a word of praise for the co-operation which has existed between the Ministry, hospital management committees, and the Free Churches—the Roman Catholic hierarchy and the 1423 Anglican establishments—in the provision of this very good service to our hospital administration and welfare.
I have, unfortunately, seen a good deal of hospitals from the inside during these last few years, and I wish to testify that I have seen a number of marked improvements. In out-patient departments my experience, which, I believe, tallies with that of most people who come to these departments, is that the waiting time has now been radically diminished, compared with ten years ago. Now the average waiting time is about 30 minutes. That certainly tallies with my experience both in the London Hospitals, which I have attended, and the hospitals in South Wales where I have been as an out-patient. The waiting lists for admission to hospitals also have been reduced. In 1950, for instance, there were 531,000 on the waiting lists. In 1956, the number had decreased to 431,000, which is a very fine achievement.
The Report on the Reception and Welfare of Patients contains useful and practical suggestions to hospital staffs on how to make the stay of patients in hospitals more interesting and more comfortable and, because of that, more beneficial. I believe that many hospital staffs have taken notice of the recommendations contained in that Report. The old "mystique"—I can think of no more appropriate word—which was too rigidly attached to the hospital service years ago is breaking down. Patients are not now treated as morons and illiterates. When they ask reasonable questions they are, generally speaking, given reasonable answers.
The approachability of the staff is better than it was. I should say that television has helped in this direction. The interrogation by ordinary people of eminent personalities in the scientific, political and medical worlds on T.V. has helped to break down some of the old conservative mystique which, I think, was a very unfortunate and unpleasant feature of hospital life.
From my observation I would say that the administration—I am confining myself to the hospitals at the moment—has been generally sound and that there is a fairly good liaison between the Ministry, the regional hospital boards and the hospital management committees right down to 1424 the League of Friends, i.e., volunteers who are so proud to be able to do something to make other people's lives more pleasant. The only complaint that I have—and I ask the Minister to take note of this—is that the choice of personnel on the regional hospital boards and on the hospital managements committees is too circumscribed. The field of selection is limited to Ministerial nominees, local authorities, trade unions and university representatives.
I submit that there are some very good people outside those circles who could be introduced profitably into the work of the regional hospital boards and the hospital management committees.
The Rev. Ll. Williams
In that case, my criticism must be confined to the hospital management committees. I know of some very fine people who have desired to serve in that capacity, and because they do not fall into the categories to which I have referred they have not been included.
§ Sir F. Messer
They are appointed by the regional board, and, while the regional board may give guidance on who should be consulted, nobody is prevented from coming forward.
The Rev. Ll. Williams
This may be a technical point, but I am sure that my hon. Friend will agree that preponderantly the personnel of the hospital management committees is constituted of the categories to which I have referred.
I should like to conclude by underlining as far as I can what was said by my hon. Friend the Member for Batley and Morley about the mental hospitals. In England and Wales, one-third of the total number of hospital beds are in mental hospitals. Between 1950 and 1956—this is a staggering figure and is a challenge to all of us—the number of patients admitted or readmitted increased by 50 per cent. This is a most sobering and alarming thought.
Obviously, the great future developments in the National Health Service must be in our mental hospitals and in our dealings with people who have crumbled under the strain of the times in which we 1425 live. Of course, there is an acute shortage of doctors, nurses, and psychiatric social workers. I would agree that possibly the solution is to be found not so much in the construction of new mental hospitals as in the development of out-patient and domiciliary services, on the one hand, and in a tremendous amount of research, on the other hand.
In mental health there is almost unexplored territory and the amount of money spent on mental research is appallingly low. In 1946–47, the Medical Research Council spent on its total research work £450,000, and of that sum only £300 was spent on mental health research. In 1949–50, the total amount spent on research was £1,216,000 and the amount spent on research on mental health was only £14,963. In 1952–53, the total amount spent was £1,550,917 and of that sum only £21,361 was spent on research in the mental field.
Only the selfish and churlish, I suppose, would deny that our great Health Service is the envy of the world but I would stress that the old adage, "Prevention is better than cure," is still apposite and relevant. We must do much more than we have done on the preventive side. I criticise not one Ministry but three, if not four Ministries, in this respect. There is a great lack of good liaison between the Ministry of Health, the Ministry of Housing and Local Government and the Ministry of Labour in certain aspects. For instances, air pollution is responsible for much bronchitis. I have said before, and I repeat, that this country is the worst in the world for the incidence of and deaths from bronchitis, and the incidence of bronchitis in Britain is caused largely by air pollution. But, strangely enough, this is the responsibility not of the Ministry of Health, but of the Ministry of Housing and Local Government.
We have factories in the Midlands and in the north-west of England, as well as one or two in South Wales, which are smoke ridden and dust laden. The Ministry of Labour is responsible for the medical inspectorates of these industrial establishements, but surely these unhygienic conditions should be the concern of the Ministry of Health. I appeal for a better liaison between the Ministries so that we can carry on the wonderful work that we have done since the war in removing diseases which, hitherto, have been a blight and a curse. If we 1426 move in this direction I am sure that we shall deservedly earn the praise of posterity.
§ 6.43 p.m.
§ Mr. Raymond Gower (Barry)
The right hon. Member for Ebbw Vale (Mr. Bevan), the hon. Member for Abertillery (The Rev. Ll. Williams), and, indeed, the hon. Member for Wolverhampton, North-East (Mr. Baird), have stressed the point that we on this side of the House opposed the scheme which was introduced by the right hon. Member for Ebbw Vale. In so doing they spoke as though they had never heard of a reasoned Amendment. They all spoke as though there were no alternative scheme advanced by those who opposed the proposals of that Bill.
§ Mr. E. Fernyhough (Jarrow)
Suppose that on the Third Reading hon. Members opposite had been successful, what would the alternative have been?
§ Mr. Gower
It was made perfectly clear that while they had great doubts about the scheme as it was then introduced, they had a very real desire that a comprehensive Health Service should be brought in. Indeed, that was also supported by all parties in the House at the time of the Coalition Government.
§ Mr. Gower
I do not doubt that that year there were real doubts in the minds of many people outside as well as inside the House as to what would be the impact of the new scheme on the relationship between doctor and patient and, indeed, upon the hospitals which had been developed by various local government and other agencies—voluntary hospitals and hospitals developed by certain industrial schemes, including the coal industry. It was reasonable in those circumstances that people should express their apprehensions. I agree with what has been said in this debate, that most people would say that at the end of ten years an excellent and improving Service has been provided in this country.
1427 Yet I thought I detected some exaggeration in some of the speeches which we have heard. It was suggested that the great progress that has been made has been due solely to the kind of Service that we have. Figures have been quoted—I do not quarrel with them, for they were accurate—about the decline in deaths in childbirth and the increase in longevity. But I would remind the House that this sort of thing is happening all over the world. We are not first in longevity. In the United States the average expectation of life is greater than it is here. Neither are we first in the matter of deaths in childbirth. I was reading the Britannica Year Book for last year in the Library, and according to that book there are several countries ahead of us in that respect. Some of those countries have a national health service and some have not. The contribution of medical science to these happy results is probably greater than some hon. Members would believe. As I say, our National Health Service has made its contribution, but I do not think it should be exaggerated.
There has been a reference to certain aspects of the financing of the Service. It has been suggested that the present Administration has been niggardly and has damaged the Service by not providing the necessary Treasury allocations, and has placed an undesirable and unjustified burden on certain classes of the community. I would remind hon. Members that during the period we are reviewing the Exchequer contribution to the National Health Service has increased from £345 million to nearly £540 million. And that is merely the Exchequer contribution.
I can appreciate that there are those who feel that by lavishing more and more money on a service it will be improved immensely. To some people, spending money is synonymous with improving a service. I think we should adopt caution in this respect. I cannot help recalling an account of the Armada by the famous historian, J. H. Froude. He pointed out that the Spaniards lavished on the Armada all the wealth of the Indies. On the other hand, no one was more mean and cheeseparing in providing for the safety of this country than was Queen Elizabeth and her Ministers. 1428 In some cases, they deprived the shipbuilders and those responsible for the maintenance of their ships of the necessary moneys, but the result was a Navy far better equipped than the Armada because the money that was provided was put to the very best use. That, I think, is what my right hon. Friend and his predecessors have set out to do.
I think that we have been right in attaching very great importance to certain priorities. The right hon. Member for Ebbw Vale tried to minimise the very great change which occurred in the policy of the party opposite when it modified its original scheme by bringing in charges, but, in some degree, the charges that were introduced and which have been maintained have, by directing priorities, led to the resuscitation, in part, of the school dental service, which was in need of improvement—
§ Mr. Gower
Nevertheless, its condition today is far better than, say, in 1951.
Money wisely spent can, of course, lead to improvement, and it is our duty to see that what money is available is spent in the right direction. During these years, this Government have also embarked on something quite important and significant. For the first time since the war, we have started building new hospitals. That is a valuable priority, because new buildings are desperately needed in many parts of the country.
I hope that my right hon. and learned Friend will soon be able to tell me and other hon. Members who represent Welsh constituencies that progress will be expedited in the building of a teaching hospital in South Wales. I would also like to know what plans there are for the future of Sully Hospital which, happily, will not need to be so busy curing tuberculosis in the future.
Certain steps have rightly been taken to minimise the impact of the charges on individuals. For instance, there are the automatic refunds for the war disabled pensioners, automatic refunds for people on National Assistance and certain refunds for others showing need. There are also the multiple packs that have been brought in, while with the approval of my right hon. and learned Friend doctors can, in appropriate cases, prescribe 1429 for their patients for long periods ahead. I would, however, ask my right hon. and learned Friend to study the impact of these charges on some of those who are just about on the National Assistance level. May I also ask him to see if the system of multiple packs can be extended to one or two other chronic illnesses? That might be a very desirable reform.
I well remember a broadcast by J. B. Priestley at the time of the 1950 Election, when he attributed all the improvement in our health and conditions of living to the wise beneficence of the party opposite. I suppose that today I, and others on this side, might make speeches attributing all the improvement that has taken place since then to the wise administration of the Conservative Party. Both, however, would be equally a little exaggerated.
§ Mr. Gower
I think that we are speaking of two different things.
The death rate from tuberculosis which in 1953—after the party opposite had gone out of office—was 18 per 1,000 is now 10.9 per 1,000. There has been a reduction in the incidence of diphtheria from 654 notified cases in 1951 to only 53 notifications last year. Those are all reductions since 1951. The patient-doctor ratio also shows an improvement. In 1951 the average number of patients per doctor was 2,500. Today, it is about 2,250—
§ Dr. Summerskill
I am sure that the hon. Gentleman is under a misapprehension. There is one reason for these spectacular changes that have taken place, and that is that the Labour Government removed the financial obstacle between patient and doctor. The result now is, of course, that remuneration does not enter into the question, so when he dismisses Labour's contribution and speaks of what has happened during the last few years, he does not recognise the fact that we laid the foundations of this improvement.
§ Mr. Gower
I did not attempt to deny any contribution made by the party opposite. What I said was that if it was reasonable in 1950 to make such exaggerated claims of what the Labour Government had achieved, it would be just as reasonable for us today to say that the service has improved immensely under this Government and their predecessors. The increase in the number of nurses, cited by the right hon. Member for Ebbw Vale, is another indication.
I said that I would abbreviate my speech in the interests of so many other hon. Members who wish to take part in this debate, but I must again say that this is an excellent and improving Service. That is among my main points. On the other hand, we should not make exaggerated claims about it, but, within the measure of our national wealth, should try further to improve it. I know that there are those who believe that we should always lavish more money on this Service, but, generally, those who call for greater expenditure on health are the same people who call for greater expenditure on pensions, on education, on capital investment in this country and on capital investment in the undeveloped parts abroad. Really, there has to be this allocation of priorities, and we would, indeed, embark on a rake's progress were we to follow all, or even some, of the advice that is tendered.
There has been criticism of the Treasury. The truth is that, in some respects, the individual Members of this House are no longer, in the classical sense, the guardians of the nation's purse as they once were. Very often the pressure from hon. Members is for the spending of more money, and it is probably because of that fact that the classical disinclination of the Treasury to provide the money has increased. In many respects, it can be said that the Treasury is now the only effective guardian of the nation's purse, because the usual pressure from the back benches today is for the spending of more money.
The National Health Service can, and will, improve. Its improvement will proceed side by side with the advance of medical science. Let us not minimise the contribution made by our doctors and those in other countries, let us not be parochial, but, in celebrating ten years of this scheme, let us hope that in another 1431 ten years it will be an even more effective instrument in the interests of better health.
§ 6.58 p.m.
§ Sir Frederick Messer (Tottenham)
I shall not follow the hon. Member for Barry (Mr. Gower) in all that he has said, although later I will, perhaps, refer, as he did, to finance. Even though I may risk being misunderstood, I must repeat what I have said before in the House, which is that I would not for one moment favour the irresponsible spending of money on the National Health Service, because I believe that money misspent is to the disadvantage of patients and potential patients.
I have spent forty years in the health service; ten years as a hospital secretary; twenty-odd years as a member of a local authority; six years as chairman of a regional hospital board and eight years as chairman of the Central Health Services Council. I am, therefore, deeply committed to a Service that I believe to be of the greatest importance. What we have to consider is where the money is most widely spent, and here it is interesting—and it might be more widely publicised—to think over the type of administration of the Service.
My hon. Friend the Member for Abertillery (The Rev. Ll. Williams) referred to the appointment of members on management committees. I think that it was a work of genius on the part of those who were associated with my right hon. Friend the Member for Ebbw Vale (Mr. Bevan) in building up this wonderful administrative machine. Obviously, the Minister has to be responsible to the Parliament of the country, so he is the titular head. But no one individual can know enough to be able to administer a service of this sort, for it is so wide in its ramifications. The knowledge and experience which is required could never be found in one individual. Therefore, it was wise for the Minister to set up nine advisory committees to advise him on mental health, tuberculosis, cancer, ophthalmology, dental matters, midwifery and other matters.
The then Minister realised the competing claim of advisory bodies and that it is possible for an advisory committee to press for a certain thing to be done without regard to other sides of the Service. 1432 So the Minister set up the Central Health Services Council, and the rule was that when an advisory committee tendered advice to the Minister, before the Minister acted on it the matter would go before the Central Health Services Council, which consisted of 41 people, 21 of whom were doctors and the remainder representing other aspects of the Service. The Minister had the wonderful assistance of high ranking people at the top of their profession.
The criticism was that the voluntary services would be destroyed. The Central Health Service Council is a voluntary body; it is not paid for the work that it does. It is made up of people from various parts of the country and its work occupies a lot of time. Its chairman at the moment is Lord Cohen, who is at the top of his profession and is recognised by everybody as being an exceptional man, apart from his professional qualifications. I do not know whether he agrees with my politics, but while I was chairman I got on very well with him. He was my vice-chairman and one of the best that I ever had. I was very pleased to hand over to him at the end of my period of office.
Anybody who cares to read my Second Reading speech will see that I did not agree with the Minister of the day. I thought that we were destroying democracy. To administer the hospitals, first a regional board was to be set up composed of people to be appointed by the Minister. He chose whoever he thought was suitable. I have not yet found out how the Minister chooses them. I shall not say that some are rather weird and wonderful discoveries, but that has been suggested to me.
A Minister of Health, who was Minister for only a very brief time, once said to me, "I do not know these people from Adam. What method can I adopt of appointing people?" I said, "Go to the telephone directory stick a pin in it and choose the first one you come to. That might be as good a way as any other". At any rate, the members of regional hospital boards are chosen because of their knowledge, background and experience. So a regional hospital board is set up that would never be thrown up in an election. The people who sit on these boards are business people, doctors, those engaged in local authority service—a real cross-section of the community 1433 with special qualifications for the work that has to be done.
It must not be thought, as some people think, that the management committees are the product of the Minister. All that the Minister does is to say that certain bodies shall be consulted, such as the local health authority, the specialist staff of various hospitals, and people of that description. But it is the regional board that equates them, and, after having appointed them, it is responsible for the overall direction of the Service. They are absolutely independent bodies apart from the fact that they do not get as much money as they think they ought to have and can spend only as much as they are allowed.
In my opinion, finance is one of the problems of the service. I do not say that not enough money is allocated for the Service. I do not think that Treasury methods of finance are suitable for a service of this description. I am not in position at the moment to say whether it would be possible to bring in local authorities from the financial point of view, but on 31st March of each year the axe falls on whatever allocation may have been made, and this can lead to unwise spending. If, for instance, it is known in January that the whole allocation will not be spent, there is a danger of seeking other ways in which it can be spent. Local authorities' finances are worked in such a way that they can carry forward balances; unspent allocations can be carried forward to the next year. It would appear to be reasonable, at least sensible, that if an authority is engaged in a certain project which is not completed it should be able to retain the money allocated for the project until it is completed. That is just one suggestion.
There has been over-emphasis in this debate on the hospital service. It may be the most important part of the Service; it certainly is a very interesting part; but I think it would be far better if we spent money in avoiding the necessity for the use of hospital beds rather than spend money on patients in hospital. If I am asked how that is to be done, I would say that we should concentrate on the local health authority and on the general practitioner service.
In referring to administration, I did not make any reference to the administration of the general practitioner service. The 1434 executive committee covers a county or a county borough. The area covered by the administrative unit for general practice is the same as that of the local health authority. There is not a great deal of complex work done by that executive committee. Perhaps, if it were a more effective administrative unit and there were closer liaison between the general practitioner service and the local health authority, we might be able to arrange for an extension of the domiciliary service. I am certain that many patients are in hospital who could quite easily be effectively treated in their own homes if there were facilities other than medical facilities afforded them.
It would be wrong, of course, for us to ignore the progress which has been made in, let us say, the home help service, but it is to that sort of thing that I am referring. A patient may be ill at home suffering from a medical condition—not a surgical case requiring operation—but the doctor has to have that patient admitted to hospital because there is no one at home to look after him. Perhaps there is one person available, but that one person, in addition to looking after the patient, has too many other things to do and, again, the doctor does his best to get the patient into hospital.
It is said that an extension of the home help service will cost money. It will not cost as much as keeping the patient in hospital. One of the inconsistencies of the Service is that, if a home help is sent to a patient's home, the patient is assessed according to his means and he has to pay. If a patient goes into hospital, he is not asked for any contribution towards the wages of the ward maid who does the domestic work there or, indeed, towards anything else. I believe that it would be better if we were to create stronger incentives for a more efficient domiciliary service, not merely because it would very often be better for the patient to be at home but because it would be cheaper, too. I am sure that this is worthy of careful consideration.
I believe that the local health authority service could be made more efficient. This is where we need a closer connection, because the home help is provided by the local health authority. I was never sure that it was a good plan to take from the municipal boroughs and large urban districts the health powers which they 1435 had and transfer them to the county council. A county council covers a wide area and a very large population, and I doubt whether it is the right sort of body for this work. A large unit of local government is all right for what I may call the mechanistic work, land drainage, highways, and that sort of thing which can be economically handled by a large unit, but in health, education and welfare what matters is not merely what one does but the way one does it. It is the nearness of the administrative body to the person concerned which is important.
I should like to see large municipal boroughs and urban districts given back some of the powers they had. The county council of which I was a member for over twenty years became the local health authority when the Health Service was introduced. As a consequence, the council split up the county into what it called health areas. These had no great regard for the boundaries of the boroughs. A medical officer of health divided his time and service between two boroughs. I do not believe that such an arrangement is efficient, and I think that the time has come for the Minister to consider whether at least part of the powers formerly exercised by the borough councils should be restored to them.
The care of old people is very important. I am not a doctor and have never pretended to a doctor's knowledge, but I am told by doctors that there are bedridden old people who have gone to bed because their condition was neglected when they needed foot treatment. I want to say a word or two about a national chiropody service. Anyone who has suffered from a bad corn will know very well that that very simple thing is not merely painful but very inconvenient, too. Old people, as a result of stiffness or, perhaps, being subject to rheumatoid conditions, are not very active and they develop foot troubles which require attention. It is not a medical condition. It is not the sort of thing for which one needs a doctor. Strictly speaking, it is not part of the Health Service as such, except in its welfare aspect. I consider that we would do well to include chiropody in the Health Service.
1436 I know that there are difficulties. There are about 7,000 chiropodists in the country. I understand that about 5,000 of them belong to two organisations and the other 2,000 belong to none. Chiropodists have made some estimate of what would be required and, in the memoranda which they have prepared, they have indicated that we could have a national chiropody service which, on their estimate of the probable number of people requiring attention, would be satisfactory. They estimate that, on average, about three treatments a year per person would be required. The value of that would lie in more than just preventing people becoming ill before they need. The real value would lie in the continued mobility of old people. In considering the care of the aged, we must always remember that it is a bad thing to sit back and do nothing.
I remember broadcasting on the Midland Region some years ago and taking part with a team in discussing the care of the aged. One of the members of the team was a doctor. I said that when people retired they ought to engage in some activity; if they allowed the engine to run down, they would find it difficult to start it again when they wanted to. The doctor said that that was true; he had solicitors, lawyers and bank managers, patients of his, who, after they retired, as he put it, seemed to wilt and die. I replied that that was not the result of inactivity in their case but of conscience. It is true, however, that if a person can maintain himself in activity he certainly will live longer. Sometimes, I feel, people think that the solution to the problem is not to let people live too long.
A service of this sort is not merely for the purpose of curing disease and saving life. Its aim should surely be to enable people to live and get out of life what little happiness they can in the few years which remain to them. If we look at this task as stewards having a duty, we must not be blinded by the glamour of the sensational. The hospital is attractive, but I do not believe that the hospital is the only thing we should consider. If we were to spend a little more on the prevention of conditions which are preventable, on the prevention of disease, this would be not merely a very much more 1437 valuable thing to do but it would be a kinder, more generous and more fitting thing, as well as more economic.
§ 7.20 p.m.
§ Sir Godfrey Nicholson (Farnham)
If activity is a guarantee of longevity, then the hon. Member for Tottenham (Sir F. Messer) will live for ever, and I am sure that the whole House would be delighted if he did, because there is no more respected Member. The hon. Gentleman set a very good example in this debate, if I may say so, by prefacing his remarks by a statement of his qualifications for intervening. I will follow him, stating my slight qualification for intervening. I took part in an inquiry conducted by the Select Committee on Estimates last year into the Running Costs of Hospitals. I had the honour to be Chairman of the Sub-Committee which conducted that inquiry, and I feel that the House may be interested in some of the impressions which we gathered after a most painstaking and careful investigation.
In passing, may I say that I feel that the Report of the Committee has been treated rather cursorily by my right hon. Friend the Minister of Health. He took over six months to send us his observations upon our recommendations, and, when they were sent, they did not amount to very much. I do not make a point of that for reasons of personal pride, but because I think that, when a sub-Committee of seven or eight Members and a full Committee of 36 Members spend a lot of time and care upon a subject, their recommendations should, at any rate, receive careful thought by the Minister.
§ Mr. Walker-Smith
Since my hon. Friend has been good enough to make that observation, he will surely appreciate that the fact that it took some time to scrutinise all the suggestions made and assess the weight due to them was evidence of the care taken in looking at these points. He will recall that I was able to show, in answer, that many of the matters to which reference was made were matters on which action was already initiated within my Department.
§ Sir G. Nicholson
I think that any hon. Member who reads the Fourth Special Report of the Committee on Estimates containing the Minister's replies will be able to judge for himself whether 1438 those replies amounted to very much. However, I do not wish to quarrel with my right hon. and learned Friend. It is, of course, very likely that our Report did not deserve much careful thought, although I felt that it did.
Naturally, the Committee approached the whole subject from the financial angle. In our terms of reference, we are told to recommend economies consistent with policy. By and large, our finding was that there was very little evidence of actual waste or extravagance. I hope that the House is glad to hear that. The short-term problems in the Service seem to be tackled with the greatest energy and care, but we were left with some sense of disquiet about the long-term problems and the way they were being tackled. Perhaps I might read—it is really the quickest way—three or four sentences from our conclusion:It is not within the province of Your Committee to pass a verdict upon the hospital service as a whole. It is clear to them, however, that if full value is to be obtained for the large sums of public money that are spent every year, there must be more time and attention devoted to long-term planning. They have been impressed by the devotion and enthusiasm that prevails throughout the service But they have also been depressed by the apparent lack of vigour with which some fundamental problems are being faced by the Ministry.Those were measured and carefully considered words, and I am afraid that they may have annoyed my right hon. Friend
§ Mr. Walker-Smith
There is surely no reason for my hon. Friend to say that. He knows quite well that the Committee was considering the situation before I even went to the Ministry. I assure him that I looked at the matter very objectively.
§ Sir G. Nicholson
I do not wish to quarrel with my right hon. and learned Friend, for whom I have the greatest esteem and, indeed, liking. I expect he felt that it was a reflection on the Department, the Head of which he had just become, and he was standing up for it, and I honour him for that. It is, however, of vital importance that the long-term problems should receive just as careful consideration as the short-term problems, for the 1439 interests of the patient and of the taxpayer are identical.
The long-term problems are fraught and beset with the utmost difficulty, the basic difficulty being that we are attempting to run a service partly on a voluntary and partly on a paid basis. There is no easy, clear-cut answer or solution. But I have got the impression, as others may have done, that the Department is prone to take up the attitude that the Service is still in its teething stage. We are today celebrating its tenth birthday. That is long past any teething stage I have ever heard of. I beseech my right hon. and learned Friend to beware of too slow an approach. I have already said that the interests of the taxpayer and of the patient are identical. We should always bear in mind that this is one of the largest chunks of public money that is spent and that it has the smallest measure of Treasury, or, indeed, departmental, control over it of any sector of the public finances.
I will give two examples, one a major problem and the other a minor problem, to which, I think, thought has been long delayed and insufficient. The future of this Service depends almost entirely upon whether we attract to it men of the greatest possible talent, gift and character. It depends—I am not speaking now of the purely medical aspects—upon the qualities of the hospital secretaries and the secretaries of regional boards, and so on. It depends upon all the staff who direct the activities of the scientists and professional men. I do not need to convince the House of the truth of the statement that the success of the Service depends upon the quality of the staffing and the manning.
The quality of the staffing and the manning turns not only upon the rate of remuneration, but upon the way in which vacancies are filled and whether there is a ladder of promotion. We want in the hospital service people of the same high calibre as are found in the Ministry of Health and the whole Civil Service. We will not get that unless we have thought out carefully our method of staffing the Service.
It is easy to be an armchair critic, but I should have thought that it would have struck those responsible, on both sides of the House, very early on that this was the keystone on which the safety of the whole arch depends. But the Service had 1440 been going eight or nine years before the Noel Hall Committee was appointed. Even now, I do not know whether satisfactory final long-term plans have been laid, much less adopted. I say that to my right hon. Friend as justification for a criticism which may have hurt him, although he says that it did not.
While activities and people are almost entirely engaged in the very complex day-to-day problems of the Service to the exclusion of the long-term problems, money will be wasted, not in the sense that it is thrown away, but in the sense that the best possible value is not obtained for it. Let me say in passing to the hon. Member for Tottenham that the Select Committee could not think of a better method of controlling finance than by annual budgeting. I remind the hon. Member that the annual budget for a hospital or a regional board, or whatever the unit may be, is revenue expenditure; it maintains the Service. The same rigid rules do not apply to capital expenditure, which can be carried on from year to year.
§ Sir F. Messer
I recognise that. That is why I said that the Treasury methods of finance were not strictly applicable but must be used.
§ Sir G. Nicholson
The hon. Member must recognise that there is no satisfactory alternative. If a body engaged on maintaining a Service and paying for its day-to-day running makes a substantial saving by the end of the year, that is good evidence that the budgeting has not been done accurately. There is always the danger of an urge to spend up to the hilt to the last possible moment. That is inherent in the system. I do not think there is a better system. That tendency cannot be avoided. I do not think there is much of it, although there is sure to be a little of it. Any member of the Select Committee who is present will, I am sure, agree on that.
Now I turn to a problem of lesser importance in which, again, there has been lack of long-term planning on the part of the Ministry and of successive Ministers. That is, the whole problem of what might be called group or joint purchasing and contracting. Many hospital management committees have their own purchasing officer. Many of them buy things like glass or linen or anything like that at random and independently.
§ Sir F. Messer
Does the hon. Member not know that, as a result of his Committee expressing its view, the Minister asked the Central Health Services Council to investigate that? The Committee sat for three years. It has now reported, and I expect that its report will be published in a week or two.
§ Sir G. Nicholson
I am glad to hear that. The point is, however, that many years of the hospital service passed before that was looked into. It should have occurred to the minds of those responsible for the Service from the start that if the best value was to be got for the money voted by Parliament it must depend in some degree on economical purchasing. Regions vary in this way. I should like to present a bouquet to the Manchester region, which is almost a model in this respect, as, I am sure, the Minister knows. So far as I know, however, the Ministry has not gone far in encouraging other regions to follow the same example. I do not think that any spectacular economies are to be achieved in this way, but substantial savings can be made. These are two examples in which the Service has been deficient in long-term planning.
I apologise to my right hon. and learned Friend if I have expressed myself too strongly, because we know him to be an excellent Minister of Health. I hope, however, that his loyalty to his Department will not lead him to overlook these long-term aspects of the problem that faces him.
§ 7.33 p.m.
§ Mr. Kenneth Robinson (St. Pancras, North)
It was a happy choice that brought my right hon. Friend the Member for Ebbw Vale (Mr. Bevan) to the Dispatch Box this afternoon to open this debate. He said in the course of his remarks that the successes of the National Health Service had led to a certain amount of quarrelling about its paternity. He can rest assured that even if he were to leave political life today, which is about as unlikely a prospect as I can imagine, his place in the mind of the public as the "father" of the National Health Service is secured for all time.
On this tenth anniversary debate, it would be a very pleasant exercise to devote one's speech entirely to a eulogy of the Service and a narration of its success. Unfortunately, however, our 1442 Health Service debates are not sufficiently frequent to pass up the opportunity of making some criticisms about the shortcomings of the Service and, perhaps, a few suggestions for possible improvement. So that my remarks may, however, be suitably balanced, perhaps I may say, at the outset, that in my view the ten years of the Health Service have seen, in effect, a social revolution. We have, without doubt, the finest Health Service in the world.
The surprising thing about this revolution is that it has come so quietly that almost all of us take it for granted. If we go abroad and, perhaps fall ill or have a minor accident, we are rather surprised and a little hurt when we find that there is not the same pattern in other countries, also. One of the things that the Health Service has done, and a very important thing it is, is to eliminate the fear of the economic consequences of serious or protracted illness, the fear of the doctor's bill. Anybody who goes across the Atlantic, as I did for a fairly brief period last autumn, can see very quickly what a real fear this is in Canada and the United States. The knowledge that a serious illness can run away with one's life savings, and probably put one into debt in no time at all, constitutes a neurosis in itself. That is something, thank heaven, that we have been able to eliminate here once and for all.
I want to talk mainly about the hospital service, because that is the part of the Service I know best. It will, I think, be agreed on all sides that our hospitals and the service they provide to the patient have improved immeasurably during the ten years of the Health Service. The hospitals as a whole are better equipped, better staffed and better organised and they are undoubtedly carrying a much heavier burden than they were ten years ago. But, as many speakers in this debate have said, the hospitals suffer from out-of-date buildings and a shortage of capital expenditure which has been endemic since the begining of the National Health Service.
I know that in his speech the Minister claimed, as he is entitled to do, that the amounts spent currently on capital are greater in monetary terms than they were at the beginning of the Service, but my right hon. Friend the Member for Ebbw Vale made the relevant observation that 1443 in the early years of the Service the money actually devoted to capital was much more than was earmarked in the Estimates for capital expenditure. A lot of concealed capital expenditure was provided out of maintenance moneys. It was two or three years before that loophole was closed.
Nowhere is this lack of capital more apparent than in the mental hospitals. I would very much like to devote the whole of my speech to the mental hospital problem, but I hope that we shall have an early opportunity, possibly next Session, to speak at length on the problems of mental health. I wish to be brief on this occasion, but I would say that the mental health services are suffering acutely from the old, out-of-date buildings in which modern treatments have to be carried on.
The average, the typical, mental hospital is a building with, perhaps, 2,000 beds, intended probably for 1,500 patients but with rather more than 2,000 patients in it today, built about the year 1860 and with very large wards. Very little provision for the comfort of patients was originally included in its structure. The building has probably been upgraded substantially in the last ten years. It has been brightened up with decent furnishings and improved decorations. Nevertheless, it is still a totally unsuitable place for the treatment of mentally sick people. Although it is all very well to say that we must not put our emphasis on buildings in the mental health service, I still say that for many years to come we shall need mental hospitals. What we want are modern and up-to-date mental hospitals, so that we can show what modern treatments can do in the rehabilitation of the mentally sick.
The mental hospitals are also suffering from staffing difficulties. The nursing situation is, however, rather better than it has been, as, indeed, it is in general nursing. So far as medical staffing goes, the mental hospitals are undoubtedly the most under-staffed hospitals in the whole Service. I think it would be no exaggeration to say that we could profitably employ double the number of psychiatrists we have in the mental hospitals, if, indeed, double the number of good ones were available.
1444 We want to make considerable advances in liaison with local health authorities in the provision of community services. That is common ground, I think, between both sides of the House. What I want to know is how are we to get decent community services with the block grant system the Government are introducing. It seems to me that if it does anything at all it must militate against any substantial expansion of local health authority services.
The last thing I want to say tonight on the mental health service is on a question I have raised many times in this House and which several hon. Friends of mine have mentioned, and that is the abysmally small sum of money which is spent on research into mental health. The conclusion I have reluctantly come to is that mental health research can no longer be left to the Medical Research Council to carry out. It is quite clear that it applies standards to research which are inappropriate to research into psychiatric problems. Therefore, I believe that the time has come to set up a separate mental health research fund, rather on the lines they have in the United States of America. I believe that only when that is done will mental health research get the resources to which it is entitled.
I said earlier that hospitals are better organised now than they were at the inception of the Service. I believe that the structure of administration we have in the hospital service has now settled down and is working reasonably well. It is not the ideal structure. It would be a miracle if it were. However, it has begun to work smoothly, and although there are some attractive suggestions for improvements here and there—there was a very interesting editorial article in the Lancet of 5th July, with some suggestions I would not accept but many of which are worth consideration—I believe that this is not yet the time to make any radical change in the structure of the administration of the hospital service.
The reason why the administration has improved is very largely that we have got some very good people on that side of the hospital service. What is disturbing is that the quality of recruits we are now attracting to the service suggests that the standards will begin to fall before 1445 very long, unless we can make some improvement. This was recognised by the Minister, or by one of his predecessors, when he set up the Committee under Sir Noel Hall. Certainly, it was recognised by Sir Noel Hall, who produced what I think was an admirable report, which contained a blueprint of a proper career structure in hospital administration.
What happened after that has really been a rather melancholy story. I understood that the Minister was to implement the Noel Hall recommendations quickly. They went before the appropriate Whitley Council, and there have been interminable delays. I must repeat what I have said before in this House, that the delays have been very largely, if not entirely, due to the Minister and his representatives on that Whitley Council. He told us rather airily that the problems were now before the arbitration tribunal. What, of course, he did not say was that it was entirely due to his representatives on the Whitley Council that they ever had to go to arbitration. Indeed, at one stage, I gather, there was some difficulty about even getting an agreed reference to arbitration.
What is needed if we are to improve the type of recruits in this service is a sudden and dramatic change, instead of which we have had a sort of whittling away of the impact of the Report, so that if it is implemented nobody will notice it. The fact is that we are not getting the type of recruits this service deserves, and the responsibility is the Minister's to see that this move towards a proper career structure is made very quickly. If he does not do that, undoubtedly the hospital service on the administration side will run down.
The rest of my remarks I want to devote to the problem of consultants, who are, in a sense, the pivot of the hospital service. I have been very disturbed for some time about the steady drift from whole-time to part-time consultants. It is very difficult to get statistical evidence, but I have no doubt whatever that this drift has been going on for some time and is still going on; and, what is more, it is encouraged by the Minister himself.
There is every financial incentive to a consultant to change from whole-time to part-time. He gets a considerable tax 1446 advantage which, personally, I think ought to be put right, but I see no reason whatever why the Minister should, by circular, encourage regional boards to employ part-time rather than whole-time consultants. I want to see this trend reversed. Of course, it is tied up with the question of pay-beds which my right hon. Friend the Member for Ebbw Vale mentioned. There is plenty of evidence—he is not the only one who has evidence—that the pay-bed facilities in our hospitals are being abused by certain of the part-time consultants.
The main thing to be said about consultants is that we have not nearly enough of them. In some areas and in certain specialties we need a considerable expansion of the consultant establishment. There is evidence all over the country that senior registrars and even registrars are doing work, possibly the bulk of the work, which should be done by consultants, and this applies equally to surgery as to other specialties. What is even more disturbing is that so far as one can see the quality of registrars coming forward is beginning to deteriorate, and if this trend is allowed to continue it will certainly operate to the detriment of the Health Service as a whole.
Why is this so? I believe this is tied up very largely with this senior registrar problem. The House knows that far too many senior registrars were appointed for the number of consultant vacancies which were likely to be thrown up by the end of their period of training. The answer to that is there are too few consultant posts. The result has been enormous worry and frustration amongst registrars, the knowledge of which has filtered through the whole medical profession and has, I believe, acted as a very powerful disincentive to medical graduates to make their way on to the consultants' ladder.
In a way, the Minister recognised this, and he set up a working party to look into this problem and to examine the medical staffing structure of the hospitals. Innocently, I welcomed that decision when the Minister announced it. I must say that everything that I have learned about this working party since has made me feel that it is really going to serve no useful purpose whatever.
First, the composition of the working party was most unsuitable. It comprises a number of distinguished consultants all 1447 or nearly all of whom are from teaching hospitals, a very limited sector of the medical profession. There is nobody who represents the senior registrars' point of view on the working party. There is no psychiatrist, although, as the Minister himself said, more than two out of every five beds in the hospitals are devoted to mental illness.
Above all, the one thing which the working party is not allowed to do is to recommend increases in the consultant establishment of hospitals, although everyone who has any knowledge of the problem at all appreciates that that is the only possible solution. I must say to the right hon. and learned Gentleman that he really has produced a delaying mechanism and nothing more, and that this problem will still be on his plate or his successor's plate when this working party reports, no less than it is at the moment.
In conclusion, I want to express the hope that this National Health Service of ours will make the same sort of progress during the next ten years as it has made in the last ten years and to express my confidence that it provides a pattern that will be copied by many other countries in the years to come.
§ 7.50 p.m.
§ Mr. William Shepherd (Cheadle)
I would not dissent from the views which the hon. Member for St. Pancras, North (Mr. K. Robinson) expressed on most of the topics with which he has dealt. Because I do not want to go into so much detail and I want to be brief, I will not comment very much on what he had to say.
I welcome the National Health Service without reservation. I think we have accomplished that part of the social revolution with very little disturbance. Indeed, when one considers that there has been a revolution in this respect and that the right hon. Gentleman the Member for Ebbw Vale (Mr. Bevan) was in charge of it in the first place, it is remarkable that we got away so well. The right hon. Gentleman complained earlier about the resistance he met when he tried to set up the National Health Service. I think he might well have met some resistance.
Some of that resistance was partly due to his own character, and had some other 1448 person less truculent and less concerned with the political aspects been in charge in 1948 and the previous year, I am quite satisfied there would not have been so much trouble in setting up the National Health Service. Hon. Gentlemen opposite should not ignore the fact that this change did mean a substantial disturbance in the lives of a lot of people and that we are innately conservative. If there had not been in charge of this change a man who wanted to wield the axe with considerable vigour, perhaps generating more uncertainty, more fear and more mistrust than was strictly necessary, I say that someone a little more agreeable and a little less politically truculent would have achieved this change with less trouble than we actually had.
§ Mr. John Cronin (Loughborough)
I hope the hon. Member will recollect that the original proposals made by a Conservative Minister of Health were turned down unanimously by the whole medical profession, whereas the scheme produced by my right hon. Friend the Member for Ebbw Vale (Mr. Bevan) eventually received its unanimous assent.
§ Mr. W. R. Williams (Manchester, Openshaw)
Is the hon. Member aware that there are thousands of people who feel that had it not been for the vigour and imagination of my right hon. Friend we would never have had this scheme?
§ Mr. Shepherd
I do not wish to pursue this matter unduly. It may well be that vigour and drive were necessary, but one can be vigorous and one can drive without upsetting everybody. Moreover, there may well have been justification for taking the view that had this Service proceeded at the outset a little more slowly, bringing in various aspects of it in stages, there might have been less trouble than actually took place.
§ Mr. Shepherd
I do not want to go over the history of the Service, because I am accepting what took place. I am pointing out that the right hon. Gentleman is a little unreasonable in some of the complaints which he made.
1449 I accept the National Health Service wholeheartedly and believe that this process is part of the way in which modern society must go. We have to accept our responsibility to the rest of the community, and I even accept a certain part of the redistributive aspects to which the right hon. Gentleman referred, although I believe that the therapeutic aspects are more important. I think there has grown up in the last years a great deal of illusion about the National Health Service and about the Welfare State generally. Far too many people have been critical of the Health Service and what we roughly describe as the Welfare State. It is my impression that they have attributed to the Health Service and certain other aspects of our life faults which are not derived from this Service. For example, there is a great tendency to attribute a great number of faults that can arise out of overfull employment to the Health Service. I hope that we can clear our minds as to the effect of the Health Service by taking the view that it improves the whole prospects of our country and that, on the whole, it has very few disadvantages.
I want to say a word about payments, not to raise controversy, but to say that one does not have to stay to the pattern introduced by the right hon. Gentleman the Member for Ebbw Vale. There is nothing sacred about the method of payments in this Service. I believe there is a lot of merit in going away from the right hon. Gentleman's pattern. I should like to see an extension of the means by which this Service is paid for by contributions. I would not be in any way against increasing the amount that the employers pay as a contribution towards the Health Service. I do not want to go into the economic reasons why I think that is justifiable, but I think they are very real indeed.
Many hon. Gentlemen and many people outside this House have talked about the cost of the Health Service as being inordinately large. I cannot myself accept this view. It has been said by many hon. Members in this debate that the percentage of the national income devoted to the National Health Service has gone down in the last year or so. I think that is true. I think that the original spate of teeth and spectacles may have inflated the earlier percentage.
1450 Another fact is perhaps even more significant. If one takes the amount of money spent today on medical services, both privately and through the National Health Service, contrasting that with the amount of money spent pre-war on similar services, and expresses it as a percentage, it is true to say that the increase today, if any, is very small indeed. We are not really spending much more, if any more, of the percentage of the national income on health than we did in 1938. I would take the view that if we were able to lighten our burden in other directions there might well be a case, not for reducing the amount of money spent on health, but actually increasing it.
One cannot help but think that we have not yet reached in this country a sufficiently high standard of health. When I see some of our industrial workers, I often think how unhealthy they look. I know that we all look unhealthy here, but this is a very unhealthy place. When one goes around the industrial establishments, one feels that there is a great deal yet to be done to raise the standard of health of the community.
May I turn to another aspect which interests me very much? That is the voluntary aspect of the National Health Service.
§ Mr. Arthur Moyle (Oldbury and Halesowen)
I am grateful to the hon. Member for his very encouraging observations with regard to finance. May I ask him if he does not think, in view of what he has just said, that there is a very strong case for the integration of the industrial health service into the National Health Service, particularly in regard to nursing?
§ Mr. Shepherd
I am going to say something about that. First, I want to say a few words about the voluntary aspect of the Service. I do not want to be critical of the Minister of Health, because he has already had a pretty fierce broadside from one of my hon. Friends. I think there has been a failure to present to the people the extent to which volunteers play such a big part in the hospital service. May I very quickly try to recount what they in fact do?
As the House knows, they largely man the regional hospital boards and the group hospital boards and the advisory services, the regional health committees 1451 and the hospital management committees. I do not know how many men and women are engaged voluntarily in these capacities alone. The number must be many thousands, but that is not the end of the number of people who are engaged in assisting hospitals voluntarily. There are the League of Friends, a very active body indeed, the Red Cross, the St. John Ambulance Brigade, the Women's Voluntary Service, the Rotary Clubs, Toc H and the British Legion. I may well have missed some out.
What do these people do for the hospitals? The variety of tasks undertaken by them is surprisingly large. They visit people in hospitals, they provide entertainments, they do knitting and sewing for hospital patients. They do library work and they shop for patients. They escort patients when that is necessary, and they staff canteens for the benefit of patients. They provide home help where necessary. They interest patients in handicrafts and help them with them.
They also provide outings for patients. They provide wireless sets and television sets for them. They actually help redecorate parts of hospitals, and they provide furniture. They make Christmas gifts, especially to the children. They read and write for patients who unfortunately cannot see. They provide transport, and they provide flowers. That is a very wide variety of activities, and I have not included all things that are done by voluntary workers. I hope that the House and the Minister and all hon. Members will try to put over to the country the extent to which volunteers help the Service. They play a very large part indeed.
I was about to say something about the industrial health service when I was interrupted a few minutes ago. The extent to which working days are lost through ill-health is not realised even in this House. When we lost, as we did last year, most painfully and regrettably, 8 million working days through strikes, we thought it a very poor show indeed, but that is a tithe compared with the days lost through illess. During the last year for which I have figures 281 million working days were lost through illness. That equals the service of almost one million workers per year. That is a 1452 colossal loss. Our efforts must be directed in a number of ways towards avoiding that loss to the community.
There has been little or no investigation to this problem. In 1947 the Industrial Health Research Board, a committee of the Medical Research Association, was set up to find out why so many people were away from work. It reached the conclusion, in broad terms, that 30 per cent. of absences were accounted for by some form of neurosis and that a great deal of that could be eliminated. Since 1947, no inquiry has been made. I suggest that the time has come when the board should be reconstituted to examine present conditions and see how far we can eliminate this grievous loss of working time through ill-health.
The loss is not all due to illness in the sense of physical illness. A great deal of it is due to neurosis, and much of it is due to home conditions. A great deal also is due to human weakness, perhaps on the part of medical practitioners. If a man goes to sign off on Wednesday or Thursday, for example, there is a human tendency to say, "Start work on Monday." If we can persuade medical practitioners to say to these patients, "Start work at the earliest possible moment," it will save millions of these working days. Now that people are paid during periods of illness there is also a tendency for them to be away from work more often than they should be. When this pay was instituted in Government service in 1948 the number of days away from work through illness doubled. But let us not think that civil servants are bad, because research undertaken by the Industrial Research Board revealed that when this pay was instituted the percentage of absences in one firm went up from 2 to 6 per cent.
We have, therefore, a problem of education, a problem of morale as well as of illness. I cannot go fully into this matter now, but I believe that we should have another investigation by the Industrial Research Board and that the Ministry of Health should see how far it can assist industrial medicine. I am satisfied that that is the most fruitful source of improvement of the national wealth as well as the national health.
I conclude with a brief review of four matters which I think the Service must tackle. We accept the achievements of the past ten years. We might have done 1453 better and we might have done worse. At any rate, we have something which is better than any similar service anywhere else in the world. It is only when one investigates services in other countries that one realises how poor theirs are and how good is ours. I interviewed a man the other day who was seeking employment. He had been earning more money in Canada than he could earn here, and I asked him why he wanted to come back to earn less. He replied that the better money was all very well in Canada but, he added, "By the time you pay doctors' bills and subscriptions to the church there is nothing left." I do not know about the subscriptions to the church, but I realise that the danger of having to face huge bills is a very substantial one to a great many people and that in this country we have done something which should be an example to the rest of the world.
Where do we lack? The hon. Member for St. Pancras, North pointed to the main matter—mental health. I have been associated for some years with the effort to press for better mental health facilities. We are up against all kinds of obstacles and prejudices. We are breaking them down, but there remains a vast amount of work to be done in research and, perhaps even more, in changing the public attitude towards mental health. Far too many people still adopt the attitude of the 1850s instead of the 1950s. However strenuous it may be financially, we must provide better physical conditions for patients.
I have already mentioned the second point—industrial medicine. We certainly also want to improve our hospital buildings. The very fine hospital service in this country rests a great deal on the quality of our nurses. We can say without question that nowhere else in the world does one find better nursing service than that in this country. On that foundation rests a great deal of the work of our hospitals. But there is a real need to improve our buildings on which far too little has been spent in the last decade.
We must also aim at reducing the total number of patients which a medical practitioner is entitled to treat. A doctor would not like my saying this, but I should prefer to see that happen than that there should be any increase in 1454 salaries. This is a most urgent matter. The present arrangements in cases where a doctor takes the maximum number of patients must impose upon an individual and his skill a burden during certain months of the year greater than he ought to be called upon to bear. I hope, therefore, that when we have a little more elbow room we shall do what we can to reduce the total number of patients per doctor.
I would not like to end by thinking that only medicine can help us towards better health. That would be the worst possible view to take. Better than all the doctors and all the research organisations would be to persuade people to eat and drink intelligently. How many people kill themselves by their methods of eating and by the things they eat? A great number; in fact many more than those who kill themselves by what they drink. Health can be achieved to a remarkable degree by caring for what we eat and drink. In far too many homes today, even when there are considerable sums of money coming into the household, the fish and chip mentality still prevails. So there is an urgent need to teach people what they ought to eat. If we can do so, far fewer doctors will be needed than are needed at the present time.
I have skipped briefly over what I have to say because my hon. Friends also want to speak. Whatever misgivings we may have had at the beginning about this Service; whatever differences there may have been between us; whether we as a party were wise or unwise to take the view we did on the Third Reading of the National Health Service Bill, there always was, and there still remains, a concerted desire to provide the people of this country with a comprehensive Health Service. I think we have done it effectively, without disturbing too much the tenor of the ways of those engaged in the various professions concerned, and I hope that the next ten years will show as much progress as the past ten years have shown.
§ 8.12 p.m.
§ Mr. A. Blenkinsop (Newcastle-upon-Tyne, East)
Most of us will welcome a great deal of what has been said by the hon. Member for Cheadle (Mr. Shepherd). It says a great deal for the 1455 development of our National Health Service that it is possible to have this kind of debate and this contribution from the hon. Gentleman, which, frankly, it would have been difficult to get nine or ten years ago when, unhappily, the atmosphere was very different. I particularly welcome what the hon. Gentleman said about expenditure. I do not think we can confidently look at the future of the National Health Service unless we get our minds clear about our expenditure upon it. There is a calm assumption that we are wasting enormous sums of money on the Service when, in fact, the total expenditure is by no means as terrifyingly great in real terms as some people imagine.
The truth is that people are terrified because, for the first time, we are seeing the total expenditure expressed in money terms, which in past years people did not see. As far as we can find by careful investigation in other countries, our expenditure per head of the population is no greater than theirs. Indeed, it is very much less than that of the United States. It is one of the tributes which should be paid to the National Health Service that we are using the resources we have made available for it very much more efficiently than, on the whole, other countries are doing. That is a fair tribute which can be paid and it is one of the valuable forms of the administration and development of the Service we have established.
I have been rather disappointed that in this debate there has been very little looking ahead to the type of service we want over the next ten years. There have been some useful comments about the past. There have been some interesting criticisms and suggestions about present difficulties. However, I had no impression from the Minister that he has a vision of the kind of service he wants established over the next ten years. I missed any sense of drive or vigour, and that is a tragedy, because at the present time it seems to me there is no sense of leadership, either from the Ministry or from the professions concerned in the Service.
This means that a great deal of the time of highly intelligent and well-trained people is taken up with all kinds of internal professional squabbles which would not be necessary if there were a greater 1456 sense of what kind of service we are busy building and what are the main problems we are seeking to overcome together. I agree very much with the hon. Gentleman that these are by no means all medical problems. Indeed they are not. There is a very close link between medical and social and welfare problems, as he illustrated by much of what he said.
The exciting thing about the period ahead must be that it should be a great challenge to us to see whether we can make progress to overcome the medical-cum-social problems with which we are faced, such as those of mental health, and the overwhelming problems facing us because of the growing number of old people in our population. Then there are the more specific medical problems of bronchitis and rheumatism, as well as the common or garden health problems which are so common or garden that in the past they have been rather neglected.
We cannot deal with any of these issues adequately if we think of a National Health Service in terms of separate small compartments, either doctors in their medical work of general practitioners, the hospitals or the local health authorities. Even less is it possible to think of it if the professional people themselves put up their own little barriers between one section and another and try to consider the problems in relation to their own minute, special interest.
No, the future undoubtedly demands a closer knitting together of the various branches of the service, and I was disappointed that in his survey the Minister made little reference to the general practitioner side or to the local health authorities. It may be that the Parliamentary Secretary will say more when he winds up the debate, since this is one of the vital issues for the next ten years especially.
I have been struck by the paean of praise that has poured out from the medical Press about the success on the hospital side of the National Health Service during these ten years. Most of the medical papers have said, I think rightly, that although there is a lot still to be done, our hospital service has achieved a great deal, and we can be immensely proud of this achievement. At the same time they point out, with some truth, that we cannot be so proud of what has happened in the case of the 1457 general practitioners or in their relationship with the local health authorities. I am sorry, therefore, that the Minister did not place more emphasis on this side of the work.
When we examine the problems which we are likely to face in the future, such as old age and so on, we realise that it is essential for our general practitioners to be able to deal with them. But can the general practitioner deal with them effectively if he is working either in isolation or in near-isolation? I do not think he can. He has neither the time not the opportunity, but if he can be given the opportunity of working with other doctors and in close association with the local health authority, with health visitors and other staff, it would be immensely valuable. This could be in the form of group practice in his own form of development or in health centres, as, for example, the excellent development at Manchester of the Derbyshire House experiment which is not, unhappily, within the National Health Service, or of the Harlow centres, both supported by the Nuffield Trust.
Why cannot we get from the Minister a real sense of drive and urgency behind that kind of experiment and development which, I believe, offers to the general practitioner a real opportunity of contribution which he has never had before?
The evidence for that is in the reaction of general practitioners who have had an opportunity of working in the Derbyshire House experiment. They were not by any means general practitioners who had any advanced love of the idea. They were typical doctors who, because of their experience, had become enamoured of the idea and who were appreciative of the new opportunities of considering some of the social problems, as well as the narrow medical problems, and being able to see their cases in a much wider setting and having facilities at their beck and call, facilities which doctors do not often have, and the closest association with hospitals. We ought to want that for all our doctors, or as many as are able to make good use of it.
I found no sense of eagerness in the Minister's approach to this development. We had a rather pedestrian speech giving a whole catalogue of developments, but with no sense of urgency. It is pitiable, 1458 now that there is a much greater opportunity for development and with much of the old political squabble set aside—it was a waste of time anyhow—that, now that it is possible to move forward so much further, the opportunities are not being taken either by the Minister or, I agree, by the professions themselves.
I agree that it is completely true that in this country we do not appreciate the urgency and importance of industrial health. We have had an interim report about the position in Halifax from the Committee which was set up by the Minister of Labour. We have a curious system for industrial health. Almost every Department, except the Ministry of Health, is concerned with it. That is not quite true, for the Ministry of Health has a sneaking interest and comes in the back door.
We have also to tackle this matter. It should be the natural job of practitioners, working in groups and linked with industry, as has been the case in Harlow and Slough. Those are examples of how it could be done. Here is something which could provide enormous economic benefit, and the extra expenditure would unquestionably bring a substantial return in terms of greater working time, more facility and happiness for our working people.
Some of my hon. Friends have rightly stressed—although not as many as I had wished—the tremendous importance of putting far more emphasis on the local authority side of health work, in conjunction with the general practitioner, the two linked together. Present local authority health services are very haphazard. In some parts of the country they are extremely good, while in others they are not so good. It is the job of the Minister to see that this work is co-ordinated and that standards are raised in those areas where they are not now high. It is his job to see that standards are improved generally, but that is not being done.
There has been one minute example of that in reports compiled by members of the Fabian Society who have been collecting information about the development of old people's welfare services in various parts of the country. It is very interesting to compare what is being done in one city and what is being done in another, what is done in one rural area and what is done in another. There are 1459 tremendous gaps in the standards. In some areas, especially Scotland, for example, work has gone ahead much more vigorously with chiropody services for old people—and what is done in Salford is another example.
That is one of the aspects of the work about which we should be concerned for the future. We must face the fact that we shall have a much higher proportion of old people in our future population. We need not be terrified about that. In fact, we are reverting to a more normal situation in the composition of our population. The situation fifty or sixty years ago was very unusual. We do not need to be frightened about it, but we should face it, and we now have the opportunity to prepare for it. In those preparations we must ensure that our local authority services are given a far higher priority than they have today.
The Minister sometimes says that the Government appreciate the importance of local authority services. However, the Government do precisely the opposite of what is needed. For example, by introducing the block grant procedure they will make it much more difficult for local authorities to expand their health services, an expansion which would save a great deal of expenditure and pressure on the hospitals.
We all know that there are many cases of people who have been diagnosed as mentally ill or mentally deficient and who are now in institutions, but who do not need to be there. This afternoon the Minister referred to large numbers who had been de-certified, as it were, and who were apparently ready to leave mental deficiency institutions. However, when I asked him where they were to go, he did not know. He did not know because there is no provision for them, and there is no provision because local authorities are not encouraged to provide the accommodation which will be needed if this kind of work is to continue.
It is hypocritical of the Minister to say on one occasion that we are doing very well because we are managing to persuade hospitals to de-certify—or at least because we are suggesting that cases should be re-examined with a view to discharge—when he is doing nothing to make it possible for local authorities to provide the necessary accommodation. That is 1460 part of the future which we should be considering.
We now need to switch our attention more to domiciliary and general practitioner services. There is as great a revolution in the future for general practitioner services as we have been encouraged to see in our hospital services. That revolution can bring untold advantage to the general practitioners as well as to the general public, and I believe that if the opportunity were put before them, most general practitioners would welcome it. We badly need a Minister to put that clearly before the doctors and the public.
Our expenditure upon health is not as terrifying as some people sometimes try to make out.
§ Mr. Shepherd
The hon. Member keeps on saying that. The burden of £600 million on the Budget is terrifying. There should be more elasticity of thought on the other side of the House about how we are to finance that.
§ Mr. Blenkinsop
We must be clear about what we are getting in return for that expenditure. We are getting a return in people going back to work and a quicker turnover in our hospitals, and we are providing other social benefits, so that the expenditure is not wasted. I think that the hon. Member for Cheadle agrees with that.
I want the Ministry to undertake some effective propaganda of its own to explain to the general public what is provided for this £600 million, so that the public can decide on the known facts. In the past, the Ministry has been too timid about putting its own case for this expenditure. I hope that in the next ten years it will not be so afraid.
§ 8.30 p.m.
§ Sir Hugh Linstead (Putney)
The House must have enjoyed, as I did, the speech of the hon. Member for Newcastle-upon-Tyne, East (Mr. Blenkinsop), because he was doing exactly the job of back-bench Members, especially back-bench Members of the Opposition, which is to put a sense of urgency and enthusiasm into debates and in that way to help to overcome the inevitable slowness with which any great Government machine moves.
Nevertheless, in his enthusiasm he tended to under-estimate the enormous 1461 achievements in health matters which the country has made in the last ten years. If we take housing, education, town planning and water supplies, to say nothing of the National Health Service, I doubt if any ten years in our history have shown such an enormous expansion of the services to the common good. When one comes down to it, the Minister's job in the Health Service in particular is to provide not a service by civil servants himself, but a machine which enables the professions who have to give the service to the patients to work with the greatest freedom and enthusiasm.
The hon. Member for Newcastle-upon-Tyne, East was right when he emphasised that there is one part of the machine which needs attention, and that is the provision made for general practitioners. I believe we should get much more out of our general practitioners if we made the circumstances in which they work more congenial to them. That is a weakness in the present scheme, where I am sure that attention given by the Minister would be repaid.
I should like to refer to the speech made by the hon. Member for Tottenham (Sir F. Messer). I had the privilege of serving under him on the Central Services Health Council for ten years. We have just lost him as our Chairman, and I know that every member of that Council would want to pay tribute to his energy, enthusiasm, his great knowledge and wisdom, and to the way in which he has guided that Council over ten very critical years of its existence. I should like to thank him for doing one thing which restored the equilibrium of this debate. He was not afraid to say that in the Second Reading debate on the National Health Service Bill he had been critical of the hospital set-up on the ground that there was danger that it would not be democratic.
I ask hon. Members opposite to believe that it is conceivably possible that when we on this side of the House were critical of that form of National Health Service, we were doing it with a sincere belief that we had something better to offer and that it was not just sheer political obstructionism on our part which led to the acrimonious discussions and debates of those days which I remember so well. What we were trying to do was to maintain a large amount of the voluntary element in the National Health Service, 1462 and, in fact, it has been necessary in practice slowly to recreate the voluntary element which in the hospital services, at any rate, the National Health Service put out of existence.
What is of some interest in the debate has been the lack of serious criticism of the organisation of the National Health Service. I think that a few years ago in a debate of this kind we would have found hon. Members quite critical of the lack of arrangements for co-ordinating the three branches of the National Health Service at local level. We have none of that today, and I think that it is important to recognise that at local level, on what we call in this country the "old boy" basis, there is a very good liaison between the hospital service, the local authority service and the executive council services.
I think, too, that the hospital service has now shaken itself down. If one had any criticism to make, it would be that regional hospital boards are too closely concerning themselves with the day-to-day work of the hospital management committees, and I think there the hospital management committees are losing the freedom which it was the intention of the founders of the Service that they should have.
It may be necessary to give the hospital service a shake up because there is a danger of it settling down under the direct control of the regional hospital boards into a pattern which is not the best pattern and which is in danger of killing local enthusiasm and local interest.
I am very glad that a number of hon. Members who have taken part in the debate have referred to the administrative side of the hospital service. There is an attempt—I believe it is the official policy of the Ministry—that that hospital service should be administered on a tripartite basis—tripartite in the sense that in any hospital or in any group the administration shall be in the hands of the matron as the senior nurse, the senior doctor and the senior administrator, none of them having authority over the others, but the three of them proceeding by discussion, by compromise and by persuasion.
If that is to be, as I believe it is, the official policy of the Ministry, the position of the group secretaries and the hospital 1463 secretaries becomes a key position in the administration, and I do not believe that the present career value of hospital administration is sufficiently attractive to bring into the hospital service the right type of men to fill what are going to be some of the key positions in the hospital service and in the National Health Service of the future.
We have somehow got to make our hospitals no longer places of fear, but places to which the local population go willingly because they have been accustomed to it, because they know the staff, because the matrons and the secretaries have gone out and have given lectures, because the doctors have given lectures in the hospitals to which the public have been admitted, and in particular because the general practitioners have had some access to the hospitals and have been able to follow their own patients through, so that a patient going into hospital knows that he will find at least one friendly and familiar face among the staff. That attitude can only be developed by giving much greater importance to the rôle of the hospital secretary and to the administration and organisation of the hospitals.
I recognise that we are limited for time, in fact if not in theory. The last item with which I want to deal relates to the cost of the pharmaceutical service, and in particular to a reference to the recently published Report of the Hinchliffe Committee on the cost of prescribing. In relation to this, I should like to make my right hon. and learned Friend a suggestion which has, I think, some fundamental value.
One of the most worrying features of the National Health Service has been, as we all know, the steadily mounting cost of prescriptions. It is not substantially caused by any increased demand on the part of the public. The number of prescriptions has run at a fairly steady level from 1949 to the present day. Those ten years have shown only a 10 per cent. increase.
It is not due to excessive prescribing, because the Hinchliffe Committee makes it quite clear that, with a few exceptions here and there, doctors have been extremely cautious and responsible in their prescribing. It is due almost entirely to the introduction of new and modern drugs, the cost of production of 1464 which and the price of which have been steadily increasing. As we know, that is the main reason for prescriptions having gone up from an average of 3s. to an average of well over 6s. 6d.
The Hinchliffe Committee has made a substantial number of recommendations which may check the excessive use of these medicines, but, basically, my right hon. and learned Friend has to face the fact that modern drugs are expensive, and will become more so. He also has to face the fact that so long as general practitioners are to be free to prescribe what they consider to be necessary, the cost of prescribing is also certain to go up still further. I am quite certain that he would be the first not to wish the Service to be associated with the idea of cheapness. Its essence must be the provision of the best drugs that are needed for a particular patient.
The tendency at the moment—and there have, perhaps, been causes for it—has been to regard the manufacturers of pharmaceutical preparations as being somewhat beyond the pale; as people who, naturally, should be criticised for the cost of the materials they produce, and for the methods by which they try to persuade doctors to prescribe those products. These manufacturers are criticised in the House, and they are criticised by the Public Accounts Committee in circumstances where they have no opportunity of replying to that Committee. In addition, of course, they have to meet the investigations by the Ministry's accountants into their costs of production.
It is worth our realising that, as a result of those costs investigations, the prices of a great number of these preparations have now been agreed with the Ministry as being reasonable. My right hon. and learned Friend ought to reconsider the relationship of his Department with these manufacturers. After all, they are rendering a great service within the Service, as it is their products that, in fact, represent some of the most important advances in the pharmaceutical world. They need clinical testings, and my right hon. and learned Friend, on his side, needs assurances as to the quality of their products.
Control over the claims made by the manufacturers is, obviously, a matter of interest to my right hon. and learned 1465 Friend. There is also the very vexed question of names and labelling, to which the Hinchliffe Committee gives a great deal of space. How can these things be named in such a way as to facilitate their prescription by doctors? One thing that has given me concern for many years is the multiplicity of similar products with different names which confuse, instead of helping, the prescriber. Another problem, of wider interest in the Service, is that of the foreign medicine coming into this country and our own medicine being exported, and the additional costs that both have to bear because of the different requirements in the countries of origin and of sale.
I would hope, therefore, that my right hon. and learned Friend might feel that, in relation to the pharmaceutical industry, this focussing of attention on costs only is not enough, and that the time has come when the Ministry and the industry can get closer together over the fundamental problem of how to produce good medicines cheaply for the needs of the people, and the needs of the Service. The Minister already has the Central Health Services Council as one piece of machinery, and he could obviously devise others. When one considers what an enormous contribution the industry has already made, and will have to make to the Service, I cannot feel that the present arm's-length attitude between the manufacturers and the Ministry is the most helpful way of making use of the manufacturers' services.
§ 8.45 p.m.
§ Mr. John Cronin (Loughborough)
Health is far too serious a subject to be left to doctors. The truth of that maxim is exemplified by the very helpful and instructive debate that we have had. The hon. Member for Putney (Sir H. Linstead) made a very thoughtful speech, but I am inclined to take issue with him about the question of the cost of drugs. I shall refer to that point later.
The Minister had the grace to touch very lightly upon the question of poliomyelitis vaccination. Many of us on this side feel that vaccination is moving almost at a snail's pace; it certainly has over the last two years or so. I concede that the Minister has produced some improvements in the last two months, but even so it is clear that vaccination is not moving fast enough and we are not pro- 1466 gressing at the same pace as other countries which are in a similar economic position to ourselves.
We cannot escape the melancholy fact that there are a few people who will suffer from this fell disease simply because the Government have not acted with sufficient and reasonable severity.
§ Mr. Cronin
Hon. Members may shake their heads, but that is certainly the view of many responsible members in the profession who deal almost exclusively with this disease.
I am glad that the Minister did not refer to the very severe blow that he struck at the morale of the clinical and administrative staffs of hospitals by turning down the Whitley Council award. This has certainly had a serious effect and has produced a widespread feeling of discontent among hospital secretaries, shorthand typists, almoners and other people in the hospitals who play such an important part in the Service.
I should like to say a few words about the economic side of the National Health Service. One of the most striking things is the very large increase in the total cost of the Service. The total overall cost was £435 million in 1949–50. It is estimated that this year it will be £736 million. As a percentage of the gross national product, there has not been a substantial increase, but, nevertheless, on those figures one cannot be completely complacent in assessing the possibility of further economy. We should consider where further economies can be made.
The hon. Member for Putney envisaged the prospect of the pharmaceutical bill becoming greater and greater. It has risen from £35 million in 1949 to the £74 million in this year's Estimates. These drugs are prescribed by doctors. I do not think that there has been over-prescribing, but the ordinary doctor, the general practitioner, certainly has no incentive to consider economic questions. None of us would like to think of the National Health Service being run on the cheap. It is very important that patients should have all the drugs and treatment that they need, irrespective of expense. But if it is possible to obtain the same result with a less expensive preparation, there is surely some advantage in that.
1467 General practitioners are competing with one another to obtain patients. At present, there are 19,000 general practitioner principals, together with a few thousand assistants. All of them are individualists. They all have a more or less blank cheque in the finance of the National Health Service, but they have no sort of effective supervision except in very expensive drugs.
The same kind of situation obtains in the hospital medical services. There are nearly 7,000 consultants, all of whom, in prescribing and ordering ordinary treatment, are completely autonomous individually. There is no supervision of any kind. No one questions the extent to which they prescribe medicines or order treatment. All these consultants are dependent on general practitioners to send them private cases. In a way, they are all competing with each other, again with no incentive to economy. Obviously, the more they please their patients, the more economic advantage there is to them. One cannot escape the fact that the more complicated an investigation is and the more complicated the treatment is the more likely is the patient to be pleased.
It may well be that hon. Gentlemen may not altogether like having their attention drawn to this situation, but there is no doubt that it would be possible for hospital consultants to treat patients more economically. I will give just one example. In the early days of the National Health Service I worked in a famous children's hospital. At the clinic in which I worked, one frequently saw children with flat feet. It so happens that the vast majority of children with flat feet get better without any treatment. My tendency was to tell mothers that there was no need for any treatment, but my chief, a most enlightened person and a very honourable and respected figure, said, "No, you must not do that. You must order some insoles and some exercises and massage; otherwise the mothers will be discontented and they will go to some other hospital which will not do anybody any good."
One probably had twenty cases like that in a week. I suppose that they each had about £20 worth of treatment, which was unnecessary. A little elementary arithmetic shows that the cost was about 1468 £400 a week and over £20,000 a year. That sort of thing can happen without any check at all. I do not suggest that it happens on a large scale, but it would be pleasant to think that there was some sort of control.
Consultants are dependent for their remuneration on the number of patients they see, because the number of patients they see governs the number of sessions for which they are paid. The person who decides, to a large extent, how many patients attend a consultant's clinic is the consultant himself. He merely has to make his patients come more frequently and thus increase the numbers of his clinics. The consultant himself is the person who decides how many operations he does. No one would suggest that operations are done unnecessarily, but it must sometimes be difficult in borderline cases, of which there is a wide range, to decide whether one should do a large number of operations or not.
I emphasise that the medical profession has co-operated in the National Health Service in a remarkably able and honourable way, but one cannot escape the fact that very few members of the medical profession have any idea of the economics of the Service. None of them has any incentive towards reasonable economy, towards economy even in the best interests of the patient.
The Guillebaud Committee suggested that there was little room for economy in the National Health Service, but there were not members of the medical profession on that Committee. It seems to me that there is a case for some sort of administrative control of the medical profession itself. This already exists in hospitals to a limited extent, in the junior grades, and it exists in the medical services of the Armed Forces. It did exist in municipal hospitals before 1948.
Although all of us are very proud of the National Health Service and regard it as one of the most splendid achievements which has occurred at any time in the history of medicine, there seems to be room for some economic control. There can be little doubt that a measure of mild financial supervision would not be resented by the medical profession. The National Health Service as a whole would certainly gain considerably from a mild and general economic supervision of doctors, as doctors, by doctors.
§ 8.55 p.m.
§ Dr. Edith Summerskill (Warrington)
It gives me the greatest satisfaction to speak on this memorable occasion, the tenth anniversary of the National Health Service, and after listening to the debate I feel that we can properly describe it as having been a highly civilised debate. At a time when the nations of the world are suspicious and apprehensive and when we in this House debate matters far removed from health, we can, nevertheless, turn from those things and, as we have today, discuss a social service designed to protect life, to cure disease and relieve human suffering.
When I listened to my right hon. Friend the Member for Ebbw Vale (Mr. Bevan) open the debate—I am sorry he is not here—I hoped that something he said would go round the world. My right hon. Friend, who was Minister of Health responsible for introducing the National Health Service, stood here and said that, to him, one of the loveliest sights in the world today was the spectacle of British women and their children attending at the maternity and child welfare clinic. For that to come from my right hon. Friend, who represents this side of the House in foreign affairs, is a delightful contribution to the debate.
I assure the Minister that my contribution will not introduce any party spleen but will, I hope, be a contribution to the pool of information. The Parliamentary Secretary need not take notes or consult his advisers about how he should respond to me. He need not be on the defensive. My attitude tonight is that of one who is deeply interested in the Service and who is anxious only to improve it. If any suggestions that I make—most of them, I am sure, have been made already—do not accord with what the Minister thinks, I hope he will simply accept them without asking his advisers to try to defend the Ministry.
I was a little shocked at the way the Minister dealt with details. Sitting back listening to his speech, I thought to myself after he had dealt with a few details that he would then deal with the fundamental problems. As that thought occurred to me, however, the Minister said that he was about to conclude. I was, therefore, somewhat sympathetic 1470 with his hon. Friend the Member for Farnham (Sir G. Nicholson), who said that he had sent a report to the Minister asking him to deal with the fundamental problems of the Service. As far as I can, I will deal with what I consider to be some of the fundamental problems and look at the Service as a whole, bearing in mind some of the spectacular advances in medical science and the changing pattern of medical practice.
Already a great deal has been said about the new methods of diagnosis and treatment which were unknown ten or twenty years ago. Many of us know the names of the new antibiotics, and there are many new names which come on to the market which have to be learned by doctors; but nothing has been said about the nuclear age and its products. These are clearly related to medicine, and already we are making diagnostic and therapeutic use of radioactive isotopes. I assure the Minister that I am not trying to make a party point when I say that paradoxically, while we use the great discoveries of the nuclear age for curative purposes, at the same time at each test of an atom bomb we release into the upper atmosphere material of a lethal character and calculated to have horrifying genetic effects.
Consequently, posterity may not endorse all that we say today. Our successors may take an entirely different view of the past few years. They may look at the increase in leukaemia. They may regard the genetic effects—I am quoting an eminent scientist—and what we now talk about as the beneficial effects on the health of the people arising from the actions of the statesmen in the last few years with scepticism. Tonight, therefore, we are taking a rather short-term view of what has been done. I would like to live for another fifty years to find what our successors say about the effect upon our health of the nuclear age and its products.
Many hon. Members have mentioned the advance in the reduction of the incidence of tuberculosis. I must say something about that, because it is a disease which is distressing not only because of its symptoms but because of the stigma which it carried. Only a few years ago, the members of a family would not like to admit that they had a tubercular case amongst them because the disease was 1471 infectious and they were afraid that people would not come to their house. Now, all that is changing. The reduction in the morbidity and the mortality rate of tuberculosis is spectacular. That has occurred in the last few years. The reduction in the incidence of the other diseases of which the Minister spoke—for example, syphilis and diphtheria—began, of course, before the last decade.
I wish to say something about mental disease, to which many hon. Members have referred. While there has been a spectacular change with tuberculosis, so also in the mental field we have reason to congratulate ourselves. We have heard about the colossal mental hospitals, many of them 100 and 150 years old, but the astonishing thing is that the atmosphere in these hospitals has completely changed. The old padded cell, with which many of us were familiar when we were students and were taken to see that horrifying place, has practically disappeared. Eighty per cent. of the patients are voluntary boarders. That is a remarkable achievement. It means that the stigma which is attached to mental disease is disappearing. An individual who, perhaps, feels himself to be a little unstable is prepared to go to a mental hospital for treatment. That is remarkable. The shock treatment and tranquillisers—tranquillisers used in the best therapeutic sense—have given infinitely more freedom to these patients. There has been a dramatic change.
While nobody in the psychiatric world would dispute these great advances in the successful treatment of the insane, nevertheless this cannot be effective without an adequate nursing and medical staff. At the last mental hospital to which I went, I went into the big room, with which everybody who goes to these hospitals is familiar, and saw the rows of patients sitting round the room mute, inarticulate and deteriorating every week, every month and every year, because there were not enough nurses, doctors or other people to give them this treatment which we know has made such a tremendous change in the lives and minds of many people who have been fortunate enough to receive it. A large amount of money would be necessary to adapt existing mental hospitals or to provide new ones.
1472 I am greatly in sympathy with what my hon. Friend the Member for Batley and Morley (Dr. Broughton) said about the future of the treatment of mental health, but pending many of these changes the staff should be increased to enable individual treatment to be given. It is quite indefensible that beds should be empty in some of our mental institutions owing to lack of staff, considering the demand there is for accommodation. If nurses and others are not attracted to this work—and I can quite understand it if they are not, for it is uncongenial to many people—the rate of pay and conditions should be improved in order to provide an incentive. My right hon. Friend the Member for Ebbw Vale, when he became Minister, took an interest in the rate of pay of nurses and insisted that it should be increased. I know that nurses in mental hospitals get overtime. They are the only nurses in the Health Service who receive that pay. Nevertheless, they are undertaking work of such a mentally and physically arduous nature that their rate of pay should be increased.
Our whole approach to mental health should be altered. The present practice of keeping large numbers of patients in huge mental institutions is outmoded. I visualise the time when we shall have a large ward in a general hospital which will be used for mental patients. I visualise the time when we have our day hospitals and psychiatric hospitals as part of a big mental health service.
It is interesting, as was done by the Minister, to observe how the increased expectation of life has been accompanied by a change in the age structure of the population, and how that is reflected in the work of the general practitioner. While today chronic disease rather than acute takes a large portion of the general practitioner's available time, modern life and some element which has so far eluded us are responsible for other changes in the incidence of disease. Coronary heart disease, peptic ulcers and stress disorders are prevalent in this country, and I understand that they are even more prevalent in countries like the United States. Furthermore—and although this has been mentioned, I think, by the Minister, it must be again emphasised—nearly 45 per cent. of our hospital beds are occupied by patients suffering from some form 1473 of emotional instability. We must face the disturbing fact that the symptoms of more than 25 per cent. of the patients can be traced to some emotional rather than physical disturbance.
How are these patients being approached? I think it will be accepted that the patient's first consultation is with the general practitioner. I want to say quite a lot about the general practitioner, because the general practitioners comprise the largest single element in the Health Service. In my opinion, a patient suffering from some emotional disturbance should have the opportunity to unburden himself to some doctor in whom he has complete confidence, and I believe that the person best placed to give advice on the maintenance of general health is the general practitioner who knows all the patient's circumstances and his family background. However, the general practioner is faced with the fact that 25 per cent. of the patients have some instability which has a nervous cause, and the general practitioner unfortunately has inadequate training in psychiatry.
I am glad that other people have said some of these things before me, or hinted at them, otherwise people would believe that because I am a doctor I have some cranky notion about these things. This position is not only due to the fact that the medical student has an inadequate training in psychiatry, which is partly due to the limitation of the curriculum, but there are also prejudices on the part of many physicians and surgeons.
I am sure the Minister will agree with me that when at Question time the subject of psychiatry and the position of psychiatrists is raised here, very often, generally on the Minister's side of the House, there is a little laughter and the matter is treated as something of a joke. I am very pleased that whenever this subject has been raised in this civilised debate today hon. Members have accepted it seriously and have also made very important contributions to the debate.
Here is the general practitioner, sitting in his overcrowded surgery, faced with the fact that in our modern life he has this large number of patients coming to see him without symptoms of organic disease. The pressure, of course, under which he works deprives him of the 1474 chance to sit back alone—such a wonderful thing in life—and few politicians have the opportunity of sitting back alone—and think about the very nature of man and his behaviour in society.
§ Dr. Summerskill
So the general practitioner has a harried and harassed life. His job from early in the morning till late at night is to see that his patients have the right number of tablets, the right size bottle of medicine and enough powder to get on with. His opportunities of contemplation, of thought and of sitting back and considering social problems are almost nil.
This is the background against which he has to face these problems. Yet the facts speak for themselves. A large amount of drugs are given to soothe and placate those who have no organic symptoms. The cost to the country of the drug bill is £74 million, and I understand that one-third of that is used for these drugs which are consumed by those who have either a minor degree of neurosis or suffer from some psychosis. The prescriptions are often written solely to terminate a protracted but necessary interview in a busy surgery with a patient suffering from some form of neurosis. That is the picture throughout the country.
We must ask ourselves whether the system that we have evolved encourages a doctor to be frank and, furthermore, to refrain whenever possible from sending a patient to hospital. The Minister gave us the figures this afternoon about the increased number of in-patients and out-patients. He said that between 1949 and 1956 new out-patients had increased by 12 per cent. He may have given different years, but that is the official figure. Surely he is not testing the Health Service on those figures which he prided himself on this afternoon. Is his test of an efficient health service the number who go as out-patients? Surely we should look for the reasons why the out-patients' departments of our hospitals are crowded at a time when public health, food and the general conditions of life have been immeasurably improved.
In the same period, new in-patients increased by 27 per cent. and the population by only 4 per cent. I think that 1475 when I ask the Minister to discuss fundamentals he should examine more deeply why this may be. May I bring this to his attention? The general practitioner's remuneration is based on a capitation system which, in some cases, is not calculated to improve the quality of the Service. I am very glad that my hon. Friend the Member for Loughborough (Mr. Cronin) said something of this nature. This capitation system for some people only serves as an incentive to achieve the maximum list of patients.
It may be said that the general practitioner should not be concerned with such material considerations. That, of course, would be the ideal approach to medicine, but, unfortunately for him, the doctor has his financial commitments like the rest of the community. If a general practitioner were completely frank with a patient and refused to prescribe tablets and medicine when requested to do so his list would dwindle and his income correspondingly diminish. That cannot be disputed. That is the financial position of the general practitioner under this system. If he refuses a request from a patient and proves difficult about prescribing one of these proprietary, expensive drugs, not only can the patient remove himself from the doctor's list but the whole family goes with him, with a resultant tremendous financial loss to the individual doctor.
Let us consider also the part-time consultants. Many people have raised this matter on other occasions. Is it economical for us to use the services of part-time consultants rather than of full-time consultants? Figures have been put to the Minister today and the case has been presented, but I should like to draw another point to his attention. I have discussed this matter with many people. The opinion of well-informed circles is that the payment of a consultant by the session encourages him to keep his outpatients' department fully occupied and his beds full.
A consultant has had the courage to say in the debate today, though perhaps in a different way, that it paid the part-time consultant to ensure that next time his clinic would be full. If he treated patients in such a way that they would not come back for another consultation then, quite understandably, his employers 1476 would say, "There is no reason why you should come here. Nobody came for that session". Therefore, there is that incentive applied to the part-time consultant to keep his clinic and his beds full.
In view of this background, is it surprising that the hospital service accounts for 50 per cent. of the total cost of the Health Service and the general practitioner service accounts for 10 per cent.? It should be remembered also that the 50 per cent. is spent mainly on food and accommodation and not on medical services. As to remuneration, the Spens Committee thought that when the competitive stimulus of private practice was removed it was necessary to give consultants an extra award to ensure their best work. Therefore, the merit award was designed. The merit award is a secret grant given to between one-third and one-half of the consultants in this country. I am not advocating this method of rewarding merit, but why medical officers of health and general practitioners were excluded has never been revealed. I should think that this is the only secret grant of public money the destination of which is not revealed to the taxpayer.
One can only speculate on future trends in medicine. No doubt my speculations may prove wrong. I can only ruminate, read and talk to many doctors, but broadly the picture is that while there has been a reduction in demand for thoracic surgical facilities for tuberculosis there is arising a new problem in cancer of the lung. This matter has been raised so often at Question Time that I would press the Minister to see that some propaganda is done in schools. It is the only way to remove the smoking addiction. It is an addiction. It cannot be removed in middle and old age. The only way is by education of the young.
I presume that the reduction in the number of tuberculosis cases will enable cases in future to be treated in special wards of general hospitals. It seems to me that the general hospital of the future will have a ward for mental cases and a ward for tubercular cases. This will be of tremendous benefit not only to the patients but also to the staff. No longer will there be revealed a reluctance to serve in our mental hospitals or in our tuberculosis hospitals. This may sound ideal, it may sound Utopian, but I believe 1477 that in the days of our grandchildren, or of our great grandchildren, we shall see general hospitals which will cater for all types of disease.
Cardiac surgery has increased rapidly and in another ten years' time, when I hope we shall have a debate on the same subject, I think there will be dramatic developments in this respect. I believe that special units for neuro-surgery and plastic surgery are needed, but, on the other hand, I believe there is no necessity to increase the paediatric departments.
It has been said already that one of the great achievements of the National Health Service has been the distribution of the consultants. Now that the Service provides economic security for consultants, of course they are prepared to work in the smaller towns. In consequence, the country is served not only by consultants in various branches, but by a greater number of them. Furthermore—this has not been mentioned and I regard it as a great improvement on the old days—the general practitioner can arrange a consultation at the house of the patient as part of the service to which the patient is entitled.
Of course, we have a long way to go before we overtake our need for new hospitals. Of the 3,000 hospitals which were taken over in 1948, the most modern was a sanatorium completed in 1944. The most modern general hospital in England was opened in 1940 and I believe the only entirely new hospital opened since that date is a dental teaching hospital at Sheffield. I am not blaming the Minister for this. I realise that money has been very tight and that hospitals are expensive, but it is clear that we have a long way to go before we can provide the number of hospitals necessary for the whole population.
I believe that a hospital service, like a school service, depends primarily on the people who serve in it. It has been possible, therefore, to make successful changes in the quantity and quality of service without new hospitals, and the Minister has told us something about this. I think we should congratulate the medical services on the advance in thoracic surgery. It seems to me not very long ago that I went to see my first operation on a lung and I thought it was miraculous. Now it is accepted all over the world.
1478 Thoracic surgery, neuro-surgery, plastic surgery and radiotherapy have developed to such an extent that now they are within reach of everybody who needs them. I agree with my right hon. Friend who said, in opening the debate, that the great difference is that today all these things are within the reach of everybody. Without the service I might have come to this House and been very pleased at the progress in these forms of surgery, but I would have been conscious of the fact that only those who could afford the fees of a small group of specialists would have been able to avail themselves of it.
Unfortunately, too many applications have been received for available posts, especially in general medicine, surgery, obstetrics and orthopaedics. Those specialties are the favourites of most young doctors, and the result is that very large numbers apply for posts and many are disappointed, while the other specialties are deprived of some first-class people.
More advice should be given to students regarding those fields of medicine and surgery which offer great opportunities for rewarding work. A student is a sensitive individual. He is very often influenced by his chief. He may be working under a great physician or great surgeon. He may watch that man or woman and decide that that shall be his speciality. Unfortunately, nobody is there to remind him that that field is already overcrowded. Here we are in the position of having brilliant young men and women anxious to work in surgery and medicine, but left to their own devices. They should be told of those fields of medicine and surgery which offer great opportunities for rewarding work.
We can expect that early ambulation after surgery and a shorter stay in hospital will reduce the number of beds required. However, I now come to something about which I feel very strongly. The surgical waiting lists are so long and are falling so slowly that more facilities are needed. At Question Time, the Minister is more than usually evasive on this subject. I am astonished that when my hon. Friends ask him about the waiting lists in their towns and he says that a waiting list is 1,000 or 2,000, he does not supplement his Answer and say what is to be done.
1479 Without pressing the Parliamentary Secretary and while giving him time to digest the matter and possibly write to me about it later, I want to know what he thinks about the suggestion of territorial redistribution for the long waiting lists. It seems that greater flexibility is needed. Beds should be available for medical cases in the first three months of the year, when respiratory disease is at its height, being returned to surgical beds later in the year. I know that the medical profession holds on to its cases and that where there is a long waiting list at one hospital in one town and in another town not far away there is a surgeon who can perform an operation needed by somebody who has been on the waiting list for a long time, professional reasons make it difficult to readjust the situation. Nevertheless, there should be territorial readjustment, and I strongly believe that the needs of the patient should always be put first.
I have formed the opinion that the consultant is well content with the Health Service and would be very reluctant to return to the old system. He has a secure income which he can, if he likes, supplement with private practice. However, the senior registrar certainly has a grievance because of the limited number of consultant posts. Of course, hon. Members must consider the whole position and must remember that a subsidy was given to demobilised doctors after the war to enable them to take higher degrees. No doubt the consultants will complain if another junior grade of consultant is established, but it should not be forgotten that there are some consultants who tend to exploit the services of the registrar, who does his work without the recognition which is his due and who, consequently, has a grievance.
I believe that the general medical service is the most important element. The other branches are essentially supporting services. Consequently, I believe that the future of the Health Service will be in the expansion and co-ordination of home care, and I think that many hon. Members will support that view.
It is the general practitioner who is a witness of the difficulties and stresses of the family and it is he, together with the medical officer of health, who can make the biggest contribution to preventive 1480 medicine. General practice organised in health centres or group practices should be the very pivot of a whole series of outside domiciliary services, for health centres and group practices will undoubtedly foster higher standards of general practice.
I was very pleased to hear from the Minister that there are now so many geriatric clinics. The geriatric service, including the integration of home nurses and home helps and the meals service and chiropody services, will help to resolve the main problems of our aged population. Home nursing is the most important contribution made by the local authorities to family practice.
On this important occasion I pay a tribute to the modest, hard-working home help whose service for the aged is particularly praiseworthy. She not only cleans and cares for the old people, but she relieves the tragic plight of the lonely. Solitary people will agree that an increased allowance is no substitute for companionship. Thinking in terms of social problems, it is interesting to discover that the suicide rate in Kensington is much higher than it is in Poplar. If we could inject the healthy comradeship of the East End into the lonely little bed-sitting rooms of Kensington, we might have a healthier picture. This fact emphasises that in order to promote the health of the community we must provide supervision of the environment and occupation of the people. We have ignored that too much.
I must refer to the cost of prescribing, since I have raised the matter on several occasions. We have waited with some impatience for the interim Report of the Hinchliffe Committee on the cost of prescribing. Since our drug bill this year is £74 million and the average prescription costs 6s. 7d., I was astonished that the Minister did not mention it. The Report is a curious document. In its introduction it says:Our first comment is that so far we have found no evidence of serious irresponsibility on the part of doctors in prescribing.It then proceeds to recommend ways by which doctors can be effectively checked from over-prescribing and by which rather dubious advertising methods of the drug houses can be scotched. I know that this is an interim Report, but, nevertheless, the publicity which was 1481 given to it on the radio and in the newspapers quoted the first comment only and so vindicated the guilty with the innocent and encouraged the drug firms to renewed efforts to sell expensive proprietary drugs at the expense of the National Health Service.
Apart altogether from the high cost of the drug bill, the time is long overdue for people in a mature society such as ours to be weaned away from the medicine bottle. This may be difficult with the aged who have acquired the habit, like smoking, but the young should be taught that the recuperative powers of nature are often more potent than the most widely advertised drugs.
I have had an opportunity of examining the health services in many countries, and I am convinced that we have the best Service in the world. But we must now strive to integrate its various elements and take the preventive and curative services right into the homes of the people, for physically sound and mentally well-balanced people provide the real wealth of a nation.
§ Mr. Leslie Hale (Oldham, West)
On a point of order, Mr. Speaker. The Minister of Health already having spoken, he will have already exhausted his right of reply, and those of us who have been here throughout the debate, who wish to exercise the cherished right to continue the discussion, who have given notice to you of our desire to do so and have given notice to the Minister of the matters that we wish to raise—in my case urgent constituency matters—will have no opportunity of having an answer before the Adjournment. With respect, that is a right which has been exercised to my knowledge for the last fifteen years.
As the hon. Member knows, it is the usual custom to call a Member on each side of the House alternately. I think that if the Minister replies now, there might be an opportunity, if the hon. Member wishes to speak, of being called later.
§ Mr. Baird
Further to that point of order, Mr. Speaker. I have been sitting in the Chamber since half-past three this afternoon. I have wanted to raise an important matter concerning the dental 1482 profession. There are important questions before the country on this issue, and I should like to hear the Minister's reply to the points that I make. How can I get a reply from the Minister if he speaks now?
It is very difficult. If the hon. Member can compress his points to a small compass, we could hear him now if the Minister agrees. Mr. Hale.
§ 9.37 p.m.
§ Mr. Hale
I am much obliged, Sir. Because of the courtesy which has been extended to me, I will confine myself to the one special matter which I regard as extremely urgent, and I will not develop a considerable number of matters concerning the National Health Service which I would have developed had I been called earlier in the debate.
I will limit myself very readily, though personally with some reluctance, to the particular question of which I gave the Minister notice. Mr. A. H. Barber has been employed since 1937 as a distinguished gynaecologist in the County Borough of Oldham. There is no question about the very high regard which the great majority of his patients have for him or, indeed, which the local authority have had for him for many years. That regard has been expressed to the Minister in many forms. Mr. Barber is a man of distinction, against whose reputation no reasonable allegation has ever been made except in so far as I shall refer to it in the course of these proceedings. He is a man of the utmost repute, but if he has in some ways a fault it is that he is an individualist. He is a person who might cause a certain amount of worry to party Whips on either side of the House.
There was some disagreement when the Manchester Regional Hospital Board was formed as to the nature and terms of the agreement that he was asked to sign. There was a good deal of delay on both sides. When the end of 1951 came, the agreement had not been signed and negotiations were going on. There is no question that there were persons on the Board who had taken a good deal of personal dislike to this very distinguished gynaecologist, who was also the obstetrician of the Oldham Corporation. He was told by the Manchester Regional Board that it was giving him three 1483 months' notice so that he could exercise his right of appeal.
We are now told that the Minister had at that stage told the Manchester Regional Board that, in his view, there was no right of appeal, on the somewhat technical ground that one cannot appeal against an agreement if there is no agreement and that there must be an agreement signed before there can be an appeal against it. This argument sounds one of the least happy ever put forward, because if one signs an agreement there is nothing to appeal about. The Minister says, "I have got him either way. If he signs there is no right of appeal, and if he does not sign there is no right of appeal because there is no agreement."
When the three months came to an end, Mr. Barber was advised by highly reputable solicitors and intimated to the Minister that he desired to exercise his right of appeal. He was told that he had got none. He was told that he was out of the Service; that, under the local rules, he would have no further access to the gynaecological wards in the borough where he had worked for twenty years; that, continuing as obstetrician of the Oldham Corporation, he would be able to give pre-natal advice—without having access to the very organisation from which he would gain his continuing experience in this sphere.
Let me say here that I do not make a personal attack on the Minister at all. I regard him as rather above the average of his colleagues on the Treasury Bench—and now that he knows those colleagues so well, he cannot accept that as much of a compliment. However, all the relevant events happen before he was Minister of Health. On 23rd June last I asked him a Question on this matter, and he gave a reply that was, at that time, satisfactory, and I was very grateful for it. I raise this matter now because of what has happened since—and about which I may, possibly, not be fully informed.
I presented to the House a petition, signed by 11,000 inhabitants within the Borough of Oldham. I should have raised the matter fully in debate but, at the time that I wanted to do so, it had become sub judice as the result of an issue of a writ. I brought to London a very representative and distinguished 1484 collection of gentlemen associated with the Oldham Hospital and its committee to urge on the Minister the necessity to revoke his decision and do justice to Mr. Barber. The Minister said that he would consider it. He did consider it, and came to the conclusion, as he so often did during his term of office, that no further action was called for.
Mr. Barber was, therefore, left with the rather miserable remedy of legal proceedings. The case came on in December, and lasted a number of days. It was heard by Mr. Justice Barry, but the difficulty that any judge faces in any sort of legal proceedings having to do with contractual obligations is that the judge can only assess the loss up to the date of his decision. The court awarded Mr. Barber very substantial damages. Although the Manchester Regional Hospital Board had the assistance of a distinguished Member who sits on the opposite side of the House, and one whom we always respect at the Bar, I am sure that he would not feel that I am being unjust if I say that the Ministry made very little effort to substantiate the case carried on against Mr. Barber all those years.
Mr. Justice Barry decided that Mr. Barber was entitled to a declaration that he had been entitled, and still was entitled, to the procedure prescribed by Section 16 of the rules relating to the terms and conditions of employment of consultants, specialists and others. Those terms and conditions have two clauses. The first says that there shall be a right of appeal to the Minister, who shall consider what proper steps to take in regard to reinstatement, or otherwise. The second says that the regional board concerned shall make every proper effort in an appropriate case to find alternative employment.
The court granted a declaration that Section 16 applied and awarded about £7,000 to Mr. Barber. I think I am correct in saying that the damages and costs to be paid by the Health Service by this act of folly on the part of the Minister totals about £13,000, and that the case has left a good deal of resentment in its wake. In the meantime, the Boundary Park Hospital remains the only gynaecological and maternity hospital in Oldham. I make no criticism of the hospital—it is an excellent institution—nor do I criticise the staff, who are all excellent people, but 1485 the position is that we have had one gynaecologist doing nine sessions a week at the hospital, and another doing four sessions a week there, four at Ashton-under-Lyne and, quite possibly—although I am not quite sure—private practice as well.
For that gynæcological ward there is a waiting list of 1,000 and, of course, each and every one of those patients is liable to be displaced by a more urgent case coming in, and there appears to be no machinery whatever for checking the urgency of a case. I am told that once a doctor has certified that a gynæcological operation is necessary, he must put in a form, and wait for a summons.
I suggest that there may be very grave conditions of urgency that cannot be checked by a registrar or clerk at the hospital. If a woman has a prolapsed womb, and has to go back to work in an engineering factory or heavy work in the cotton industry, her operation is, to that extent, more urgent. If a woman is suffering from a gynæcological condition associated with any neurological or neurasthenic condition, the operation, again, is more urgent than it would be in other circumstances.
In Oldham, therefore, we are facing a very serious situation, but all this time one of the most distinguished gynæcologists in the North is kept out by the petty spite and ill-feeling that this case has left in its train. The Minister told me on 23rd June that he would write to the Manchester Regional Hospital Board drawing attention in proper terms to its moral obligation to take steps to help this gynæcologist, who has been out of employment for seven years and who is no longer a young man. This he did. Seven years' lack of experience is of itself something of a disqualification for obtaining a post.
The Minister wrote on 9th July and was courteous enough to send me a copy of the letter. I have no quarrel with the terms of his letter, which seemed to me to be an eminently proper letter. I have no right to know what the Board replied, but there are Strong rumours in Oldham that the reply of the Board to the Minister was something that could be vulgarly called "a raspberry."
I am told that in one paragraph the Board asked him why he has only just been told this after so many years of 1486 waiting and why he called the Board's attention to this several months after the case. I am told that the Minister, in many words but of not much meaning, spoke about referring the matter to another sub-committee, but added so many qualifications as to make it clear that the sub-committee was not expected to come to a decision.
This is the reason why it seemed to me I ought to raise this matter today. I apologise to the House for intervening. I am grateful to the Minister for his personal courtesy in facilitating this interjection and for your consideration, Mr. Speaker. The Minister has power to act under paragraph 16 of the "Terms and Conditions of Service of Hospital Medical Staff." Furthermore, twelve months ago the Minister wrote to the Manchester Regional Board, and presumably to all the other boards, suggesting that it should accept the proposition that a consultant who had been in employment and who was for any reason out of employment temporarily might be replaced through the usual procedure of advertisement. The Board, not then thinking of Mr. Barber, agreed and expressed its approval of that procedure.
It is clear that the Minister can deal with this matter if he wishes. I believe that he wants to deal with it. I appreciate that he means no discourtesy to the Board. When I called his attention to the matter he acted with reasonable speed. But I suggest to him that the time has come when he should put an end to this matter. There should be a little bit of cutting Gordian knots or turning a blind eye to the regulations, or, indeed, simply acting in accordance with the regulations. The Minister should exercise his power under paragraph 16 to appoint a professional committee to investigate the matter. He knows what the result will be. Already it has been investigated, and that has proved almost a waste of time.
In conclusion, may I say that, knowing the Minister as I do, and respecting him as I do, I am sure that we shall not have any of this silly business of offering an Oldham specialist a job in a remote village which one could be reasonably confident would not be accepted. As a man who has lived in Oldham for thirty-seven years, has his home there and his own little private practice there and has 1487 an appointment as obstetrician to the corporation there, I am sure that Mr. Barber would accept an appointment as consultant in other towns in the vicinity of North-East Lancashire with reasonable access of Oldham by car. I hope that we shall not have any sort of gesture of offering an appointment which will not satisfy him or the sense of justice in the community that a fair deal has been given to a distinguished public servant.
§ 9.49 p.m.
§ The Parliamentary Secretary, to the Ministry of Health (Mr. Richard Thompson)
I should like to say how much I welcome the extremely constructive tone of the debate, which has been well worthwhile, marking as it does the tenth anniversary of this great Service. I suppose that we in this House shall always have differences on political lines about how this Service should be run, but I think that today has shown that, however much we may differ on means, we are fairly broadly united about the end, which is to provide a comprehensive Health Service for all in need, the cost being borne by the community as a whole. Within this aim, it is surely right to debate from time to time whether we have our priorities right, whether we are trying to do first things first. Much of the debate today has centred on the question whether the priorities are right inside the Service and between the Service and other forms of expenditure.
I do not propose to dwell now on whether the total amount spent on the National Health Service is precisely right or is provided in the right way. All this we discussed at considerable length in our debates on the National Health Service Contributions Bill. We on this side think that the Service receives its fair share of national resources and that the present sharing of the burden by general taxation, contributions and charges is about right. Of course, there is no magic formula here or accurate means of establishing the ideal balance between the claims of health and other social services within the economic capacity of the country to finance them. But, as I say, I do not propose to spend time tonight on that. I feel that my most useful contribution to the debate could be made by picking up some of the points which hon. Members have made.
1488 Although he is not here at the moment, I should like to reply to a point made by the right hon. Gentleman the Member for Ebbw Vale (Mr. Bevan), to which he obviously attached considerable importance. He complained that the Tutor Midwives College at Kingston was in danger of closing down for lack of support. We have been subsidising this college on a diminishing scale, and the arrangement was to have ended in 1961, when, according to our understanding, it would be self-supporting. However, the college has just told us that it will need £3,500 per year permanently. We are considering this. No decision in the matter has been reached, and my right hon. Friend recognises fully the value of the work which is being done there.
Much attention has been devoted to the mental health services, and I think that, perhaps, the most notable contribution to the discussion was made by the hon. Member for Batley and Morley (Dr. Broughton), whose speech, thoughtful and humane—like the hon. Gentleman himself, if I may say so—impressed the House very much. I very much agree with most of the points which he made, some of which were repeated by other hon. Members later. The hon. Gentleman spoke of the necessity for a completely new approach to the problems of mental health. Indeed, he might have been repeating much of the message which emerges from the Report of the Royal Commission.
I am sure that the hon. Member for Batley and Morley is in step with modern enlightened thought on the subject, and I assure him that the kind of objectives which he has in mind—that fewer people should go into hospital at all, that more should be treated in the community, that we should make more use of day hospitals, that we should try to treat people more at appropriate outpatient clinics—are desirable objectives which we have at heart and which we intend to pursue.
The hon. Gentleman asked whether proper use was being made of the considerable number of tuberculosis beds which have become available as a result of the closing of tuberculosis hospitals and wards. He suggested that very good use could be made of these beds in the mental hospitals. This is actually being done. I have not any national figures 1489 for the precise number of former tuberculosis beds allocated to the mental hospitals but a substantial allocation is being made.
But, of course, not all these tuberculosis beds are suitable for the purpose the hon. Gentleman has in mind. Many of them date from the days shortly after the war when there was a desperate shortage of every kind of accommodation and all sorts of rather unsuitable accommodation had to be pressed into service. Some of these beds are located out in the country where it is difficult to recruit staff, and they would not really convert to the purpose very well. I can also assure the hon. Gentleman that we have gone right away from the conception of custodial care, to put it in that way, which was for many years the accepted way to treat these unfortunate people.
I want to say a word now in reply to the hon. Member for Abertillery (The Rev. Ll. Williams), who made a number of interesting points. He, in particular, spoke of a national chiropody service, as did the hon. Member for Tottenham (Sir F. Messer) later during the debate. We recognise fully the requirements that exist in this respect. We know the arguments in favour of it very well, but it is really a question of what it would cost to institute a service of this kind under the National Health Service on a comprehensive basis, and whether that would be the wisest way of employing that amount of resources at this time. The actual cost, it is thought, would be in the region of £1¼ million. This may not sound a great sum in relation to total expenditure in the Service, but nevertheless, with so many demands on our resources, we have to consider very carefully whether that really is a way in which we should launch out, and to that extent.
My hon. Friend the Member for Barry (Mr. Gower) raised a question concerning the provision of multiple packs to ease the incidence of the prescription charge on chronic patients. I refer my hon. Friend to a reply on this subject given by my right hon. and learned Friend to the hon. Member for Holborn and St. Pancras, South (Mrs. L. Jeger) on 10th February. My hon. Friend was concerned with the question of the borderline and people who fell just the wrong side of it. 1490 Since the Answer given by my right hon. and learned Friend on 10th February, there has been further discussion with the British Medical Association about the needs of the chronic sick, but so far the B.M.A. has been unable to suggest any further packs which satisfy the necessary condition that they should consist of items which are suitable for supply as one composite article and are in sufficient demand for manufacturers to market in that way. A new, larger multiple dressings pack designed for injuries and the like, needing rather more dressings than were available in the existing small pack, was made available on 1st June.
The hon. Member for Tottenham, to whose contributions to these debates we always listen with the respect that is due to one who has spent the greater part of his adult life in the Health Service and in local authority work, made an excellent speech. The hon. Member stressed the need to try to keep people out of hospital and laid the emphasis on the development of local authority health services and the building up of the general practitioner service.
We regard the general practitioner as the key man in the non-hospital medical services for which we are responsible. Through the executive councils and in every other way possible, we want to try to build up his position in the Health Service and ensure that it is one of proper status and importance, because we recognise that he is the key to the treating of people before it becomes necessary to make hospital cases of them.
My hon. Friend the Member for Farnham (Sir G. Nicholson) spoke about the joint purchasing of supplies, to which the hon. Member for Tottenham also referred. Since December, 1954, the organisation of all forms of hospital supplies, including purchase, storage and issue, has been under the consideration of a committee whose chairman was the hon. Member for Tottenham. I am glad to pay tribute to the work performed by the hon. Member in this connection as well as in his capacity as Chairman of the Central Health Services Council from its inception until June, 1957.
That Committee has brought forward both an interim and a final report, which my right hon. and learned Friend is at present considering. The interim report was concerned mainly with the 1491 development of joint contracting schemes, the desirability of which had been brought to the notice of the hospital authorities by the right hon. Member for Ebbw Vale when Minister of Health. The Committee and my advisers at the Ministry considered that the wider adoption of these schemes, by which two or more hospital groups would negotiate joint contracts for agreed ranges of articles, would generally be in the interests of economy and efficiency. Since the publication of the interim report, hospitals have been asked to review their purchasing arrangements and the results of the review are very encouraging.
A wide variety of goods is already the subject of joint contracting, and it is likely that these schemes could be extended to types of supply which individual groups, or even individual hospitals, have previously purchased for themselves. I hope that we shall see useful savings as a result of these developments. We are not asking hospital management committees to adopt these schemes irrespective of the merits of each case; I know that they would not do that. The aim, surely, should be to consider each type of supply on its merits and the advantages or disadvantages of joint contracting in any particular instance should be kept under constant review.
Then, we had a valuable contribution from the hon. Member for St. Pancras, North (Mr. K. Robinson). There are two points to which he attached great importance. The first, which was referred to also by the hon. Member for Newcastle-upon-Tyne, East (Mr. Blenkinsop), to whom it is familiar, was how the development of local authority community care services, which, it is generally agreed, should be extended and enlarged, can be secured under the general grant system, which is to operate from next year.
In the debates on the Local Government Bill, which set up the general grant—I was a member of the Standing Committee and, therefore, have an acute memory of the debates—the Government made it clear that they did not consider that the introduction of the general grant would lead to local authorities not discharging their functions as efficiently and as effectively as before. This, in my view, applies to mental health no less than to other services. The local authorities' 1492 associations have, however, suggested that it would be preferable that some special financial provision should be made for these services, and a meeting on this very subject took place as recently as this morning. We shall consider their views very carefully, and obviously I cannot at this stage say any final word on the subject.
§ Mr. Blenkinsop
The hon. Gentleman is aware, of course, that the Royal Commission recommended that there should be special financial provision to local authorities to carry out this work.
§ Mr. Thompson
I have no doubt that the hon. Gentleman has in mind the 75 per cent. capital provision which was recommended. To be fair, however, I think that I should say that the Royal Commission also accepted that in conditions of a general grant a specific grant might not be appropriate. I can say this, that I am quite sure that the local authorities will whole-heartedly co-operate in discharging their responsibilities on the lines recommended by the Royal Commission, whatever arrangements may be finally settled.
The hon. Member for St. Pancras, North returned to a favourite theme of his in connection with the working party and consultants. He felt that this would not serve any useful purpose on account of what he thought was its unsuitable composition—
§ Mr. Thompson
—which, he felt, was overloaded by too much talent from the teaching hospitals. The point which my right hon. and learned Friend has tried to put to the hon. Gentleman at Question Time is that if we are to include in this body all the representatives of all the specialties who can reasonably claim to be represented we shall get an unwieldy body which cannot easily or quickly be called together, because, after all, all these people are busy people with many other things to do.
In so far as the composition of the body was for my right hon. and learned Friend, his six appointees all have experience of non-teaching hospitals. That is the bone which particularly sticks in the hon. Gentleman's throat, but these all have that experience; the other 1493 members were the appointments of the profession.
I do not share the hon. Gentleman's pessimism about this. What I feel is that this matter has been dragging on so long, as he has often said, and that the important thing is to try to ensure that this body, which, I think, is sufficiently representative, will produce some answers in a reasonably short time. I have no doubt that it is already setting about its work with that end in view.
§ Mr. K. Robinson
I did not suggest for a moment that every interest, every specialty in the service, should be represpented, but merely that those interests who are particularly concerned with the problem which gave rise to the setting up of the committee should have more representation. My second complaint was not with the composition, but with the terms of reference.
§ Mr. Thompson
I accept that from the hon. Gentleman. Of course, I would not wish to misrepresent him in any way, but, certainly, the impression I formed was that he said that the composition of the committee was inappropriate to the work which it had to do.
The hon. Member for Newcastle-upon-Tyne, East made a very interesting speech indeed when he stressed, as I would hope to do, the forward-looking aspect of the whole of this operation. He felt that there was insufficient co-operation between the various arms of the Health Service in the job which they have to do, the local authorities, the hospitals, the general practitioners, and the members of the health team. I do not think that it is true that general practitioners are working in isolation, which was rather the impression I had from his remarks, and that they are not being encouraged to work with others. Every effort is being made to improve the liaison with hospitals and local authority services.
The increase in partnership, which helps to produce the effective co-operation which I think the hon. Gentleman supports, has been quite notable. In 1948, there were 50 per cent. practitioners in partnership. Now that figure is about 68 per cent., which is, I think, a desirable trend. Group practices also, have been encouraged, as the hon. Member would wish, with the aid of interest-free loans. These have generally proved more popular with the 1494 medical profession than health centres, which is another possible line of development.
I turn to the speech of my hon. Friend the Member for Putney (Sir H. Linstead). He had words to say on the subject of the drugs bill, and as the right hon. Lady the Member for Warrington (Dr. Summerskill) also had something to say about drugs at the end of her speech, it might be appropriate if I replied to that part of the debate now. The drug bill we debated at considerable length on the National Health Service Contributions Bill and on the Supplementary Estimates. We are familiar with the main criticisms, over-prescribing by practitioners, excessive and costly advertising campaigns, the unreasonableness of drug prices generally and the effectiveness of the arrangement with manufacturers on the regulation of their prices. That is one side of the picture.
On the other side, we have to reflect on the very costly nature of the new drugs and also on the immense savings in the hospital bill when patients can be treated at home, and also the fact that research, wherever it may be carried out, is a costly process and has to be paid for. On the whole, we are dealing with a responsible and reputable industry. Of the £74 million estimated cost of the drug bill this year, 40 per cent. will go to chemists for overheads and the services which they provide and 60 per cent. for reimbursing the chemists for the wholesale cost of the drugs and dressings which they supply. On that basis, the manufacturers get a little more than half the final cost.
The reasons for the rise is, first, the general rise in costs and, secondly, the cost of new drugs, the new antibiotics, cortisone and its derivatives and substances of that kind. We have taken measures to restrain manufacturers' prices. So far as standard drugs are concerned, an inquiry in 1955 revealed no evidence of excessive prices, but we are quite prepared to renew that inquiry if we judge it necessary.
Over 90 per cent. of proprietary preparations are covered by the scheme. The scheme was accepted by the Government in 1957 for a three-year period, under which manufacturers voluntarily accepted regulation of their prices. For the first three years a preparation is free 1495 from price restraint to enable the manufacturer to recoup his initial research and development charges. Subsequently, the reasonableness of the price is decided on this kind of basis: first, that the United Kingdom price shall not exceed the export price in oversee markets. We do not want the export market subsidised at the expense of the consumer here. Where exports are negligible the cost of a proprietary shall not exceed the cost of an identical non-proprietary standard drug available in the United Kingdom, and if neither of these two considerations apply, a fair and reasonable price may be negotiated with the Health Department.
This scheme started in June, 1957. It was applied to 3,250 preparations and 200 manufacturers and it resulted in 285 price reductions, giving an estimated saving of £400,000 per annum. It is not an enormous sum of money, but it is not a derisory sum, either. It is a little early to pass final judgment on the scheme, but it is at least a welcome development that the industry should accept the need for price restraint.
As hon. Members know, the Hinchliffe Committee on the Cost of Prescribing is sitting. Although it has produced an interim Report there is another and no doubt much more substantial final report on the way. We shall pay the closest attention to the recommendations it contains, because we recognise that with a drug bill running at roughly 10 per cent. of the total cost of the Service, and tending to go up all the time because of the nature of the new drugs, their expensive character and more wide application, obviously we cannot let this thing get out of hand. We must study every angle to keep it within bounds.
The right hon. Lady the Member for Warrington was gracious enough to say, in winding up the debate for the Opposition, that she was not asking me to reply in detail to the many points which she raised, so very properly, from her professional experience and her experience in the House and in the administration of the Health Service. I am sure, however, that she will not mind if I refer to one subject which she took up—the question of lung cancer and whether there really was sufficient sense of drive and urgency behind the propaganda which is being put out on this subject.
1496 I know that the right hon. Lady feels very strongly about this and I think that she knows that my right hon. and learned Friend proposes to obtain from the local health authorities, almost straight away, all the reports of the action which they have taken since we alerted them in June, 1957. When we have that information, and the circular requesting it is now ready, we shall be able to consider how far the efforts so far made have been effective, whether they need stepping up, and, if so, what other measures should be taken.
§ Mr. Thompson
That is a solution of classical simplicity which undoubtedly would have that effect, but before I have heard all the story of how our measures have gone so far I should not like to say whether it is the best step to take in the circumstances.
Perhaps I could say a few words to the hon. Member for Oldham, West (Mr. Hale) himself. He raised the case of Dr. Barber, about which he has tabled some Questions recently and some of which he put today to which he received replies. I do not know whether what I shall say to him will be acceptable or not. At any rate, we are agreed on one thing—that he and I are the only people here to pronounce gynaecology in the right way with a soft "g".
§ Mr. Thompson
I think that the hon. Member will feel, on reflection, that it is not a soft answer. The court found Dr. Barber wrongfully dismissed and awarded him damages. There is no argument about that. It is not possible for the court or my right hon. and learned Friend to order his reinstatement. The best that my right hon. and learned Friend can do is to classify this case as what is called a moral obligation case, under paragraph 16, with which the hon. Member is quite familiar. This means that the Board must give every reasonable assistance to Dr. Barber to find new employment. Of course, it is a statutory requirement that every appointment must be advertised, 1497 and it is, therefore, for the Board to operate the moral obligation principle within the framework of the statutory procedure.
The position at present is that my right hon. and learned Friend drew the attention of the Board to this moral obligation principle and he has received a reply from the Board which does not seem to him to be wholly satisfactory. He is, therefore, communicating with the Board again to emphasise what he feels, namely, that the question of moral obligation requires more positive consideration on its part in this case.
This has been a useful debate because, after ten years, it has given us the opportunity of comparing the original conception of the Service with the actual form it has taken after a decade of progress. Nobody would claim that the progress has been uniform, or that there is not a great deal more to be done. Nevertheless, the experience we have had in ruining the scheme ought to enable us to approach the problems of the next decade with what we lacked in 1948, experience of the scheme in action and of the problems, expected and unexpected, which it has thrown up.
Here, may I identify myself with the hon. Member for Newcastle-upon-Tyne, East. The vital point in all this to me is the objective of producing a healthier population. That aspect seems to me even more important than the side of the Service, which aims at curing infirmity and disease. It is on this positive side that I am convinced emphasis should be laid in future.
If a healthy population is due to years of better nutrition, better housing, earlier and more accurate diagnosis and treatment of illness, better sanitation and standards of public cleanliness, timely immunisation where appropriate—if that is so—then the prospects for the Service at the start of the next decade must be incomparably brighter than they were ten years ago. We ought to get a substantial dividend from ten years' work in the form of a healthier rising generation by the application of the great advances which have taken place in medical science in the treatment of disease. Indeed, if we cannot assume that we have overcome at least some of the major difficulties, we might well ask ourselves whether this great effort was 1498 really worth while. Its justification lies in a healthier population, both physically and mentally, and in my view all progress must be judged by that yardstick.
There is no doubt from the speech of my right hon. and learned Friend that very solid achievements have been made, and although much remains to be done we can, with these ten years of experience behind us, see much more clearly our main objectives and the point at which the existing organisation needs strengthening or perhaps reshaping. The debate we have had has been exceptionally valuable in that respect.
Many matters are pending because we have a number of expert inquiries in progress—including, of course, the Royal Commission—on many of the most sensitive problems which must be solved if the Service is to prosper. I sincerely trust that as a result of the Royal Commission on doctors' and dentists' remuneration it will be possible to place remuneration for doctors and dentists in the National Health Service on a proper basis with satisfactory arrangements for keeping it under review. I recognise that it is not only a matter of remuneration by itself, but that it is a question of, among other things, status and restoring to the general practitioner the position he used to occupy vis-à-vis the consultant and the Hospital Service.
I referred to the Hinchliffe Committee on the Costs of Prescribing. We are taking some immediate administrative steps and are consulting the appropriate organisations on further action on the interim Report; we shall consider our ultimate approach in the light of the final advice given. I regard the Younghusband Working Party on the recruitment, training and field of work of social workers as exceptionally important. We expect that those recommendations will be of great help, especially in the care of the mentally ill, which will dominate so much of our future thinking about the health of the community. The Cranbrook Committee, studying the organisation and content of the maternity services, will, no doubt, produce a report to which we shall also pay the closest attention.
The Royal Commission on the Law Relating to Mental Illness and Mental Deficiency has reported and the Government have studied the Report with the interested bodies, concerned for some 1499 time. I think that it is generally understood that it is the intention to legislate as soon as practicable. Action here is absolutely vital for the future of the Health Service, when one reflects on the figure quoted by the right hon. Lady and other speakers, that two-fifths of all our available beds are filled with mental cases. It will be the first major change in the law on this matter since 1890, and one has only to think of the enormous changes which have taken place in that time, not only in the treatment of mental disorder, but also in the attitude of the public towards it, to appreciate the importance of such legislation.
Finally, there has been some mention of the problems of the ageing population, which have come about largely from the very successes of medical science and the increased scope of our services to the elderly. Much has been said about this, but our general aim must be to try to keep those not in actual need of hospital care and treatment out of hospital and in the community leading a useful life for as long as possible. To this end, local authority services have been considerably expanded in recent years and we plan to continue this expansion which, in the long run, will save money and free hospital beds for those who need them more urgently.
Of all our public services, the National Health Service probably depends most on voluntary help on its administrative side. I refer, of course, to the hospital management committees, the regional boards, the house committees, executive councils, and so on, who give their services freely in this worthwhile national cause. We can imagine the saving in administrative costs which the work of these bodies so freely given involves. We are deeply grateful to them for their help. They keep alive the voluntary spirit which must always permeate a service so human and personal as the National Health Service. It is in this spirit of co-operation and dedication to a great cause that we can face the future with a confidence which I have and in which I hope the House will join.
§ 10.29 p.m.
§ Mr. John Baird (Wolverhampton, North-East)
I am doubly happy to catch your eye, Mr. Deputy-Speaker, even at 1500 this late hour. I thought that I had become the invisible man. I am doubly happy to speak, since I am one of the few who took part in all the debates when the National Health Service Bill was before the House in 1946 and who sat through all the Committee stage proceedings and also because I am certainly one of the very few, if not the only hon. Member, who entered the Health Service as a dental practitioner or doctor on 5th July, 1948—and here I should declare my interest. I had hoped to speak earlier, because I have one or two important matters to raise and to which I hope to get a reply.
I am a dental surgeon, and, as far as I can recollect, this is the first debate on the National Health Service when dental surgery, a most important branch of the medical services, has not been mentioned, apart from the Minister saying that he accepted the McNair Report. It is a reflection on the debate that nothing has been said about the dental profession.
Before going on to talk about dentistry, I want to make one preliminary observation. As I said a minute ago, I took part in all the debates on the Second Reading, Committee, Report and Third Reading stages of the National Health Service Bill. When I studied the OFFICIAL REPORT of the Committee stage in the Library this afternoon, and looked up the names of the Members who then took part in the proceedings, I was surprised to find how few of us are left. Less than half of the original Members who discussed the Bill in Committee are now in the House. The three leading members of the Opposition are no longer with us. Therefore, it is not surprising that some hon. Members opposite seem to think that this was an agreed Measure when it was passed, because there are few people now who can tell them the facts of life.
I hope that the House and the country will always remember that the Tory Party attacked the Bill most viciously in the country and in the House at every stage, with wrecking Amendments of all kinds. If they had had their way there would be no National Health Service as we know it today. Therefore, it is humbug for anyone to talk now as if the Tories were ever in favour of the National Health Service at that time. Of course, now it is a different matter; it has been a success.
1501 There are one or two serious problems facing the dental profession today. It is now ten years since the Health Service was introduced, and for the first time dentists can now claim pension rights. A large number of dentists will be leaving the dental service and going into retirement, and we are facing a grave shortage of dental surgeons. The bogy has been raised time and time again that when we introduced the National Health Service we attracted dentists out of an efficient school dental service into general practice, and that the school dental service was almost destroyed. Of course, that is simply not true. There never was an efficient school dental service in this country.
Before the war, under the local authorities, dentists who did work in the school dental service were often working under terrible conditions, without water and proper equipment, and the result was that it was not possible to recruit many good dentists into the school dental service. At the end of the war we had a skeleton service, and when we introduced the National Health Service the numbers fell from 900 to 700. The argument is now put forward that by imposing charges on the Health Service we have forced the dentists back into the school dental service. The figure has now gone up from 700 to 1,000.
Everyone who knows any thing about this problem knows that we cannot have an efficient school dental service without 2,000, and more likely 3,000, dentists. So that the charges have not given us an efficient school dental service. I believe it is true that the figures are diminishing once again, and that there are not so many dental surgeons in the school dental service as there were a short time ago. It is a pity that we cannot get a reply to that point tonight.
However, I do not want to be too critical. I want to put forward some suggestions. First, I should like to say that under the Health Service, even although we have an inefficient school dental service, our children's teeth are better today than ever they have been. Most of the children go with their mothers and fathers and have their teeth seen to by the general dental practitioner instead of using the school dental service. I, as a practising dentist, know that children's teeth today are healthier than I have ever seen them in thirty years of practice.
1502 I am wondering whether something cannot be done to divide up the work between the school dental service and the dental practitioners. I suggest that if we cannot get enough dentists into the school dental service we should use that service as an inspection service where the dentist would inspect the children's teeth, find out what treatment was needed, advise the parents to this effect and then send the children to a dentist inside the general dental service. That, I think, is a compromise which might work quite efficiently.
There are other points, also. If we want more dentists in the school dental service we must give them a better status. What happens at present? In a large authority, such as London—I think it happens in London, also; it certainly happens in most large local authorities—if the senior dental officer, who is, perhaps, controlling a large number of dentists, wants to put a point to his medical committee he cannot do so himself. He can only make his case by referring the matter to the senior medical officer, who has access to the committee. Very often the senior medical officer knows little about dentistry.
I have raised this point before, and I must raise it again. Why is it not possible for senior dental officers in local authorities to have direct access to the local health committee so that they personally can put their points forward? It is a simple procedure. I do not see why it should not be done. If it were done, it would give a better status to dentists in local health services.
The Minister should look even beyond that. The different conditions under which dentists work in different local authorities lead to all sorts of trouble and chaos. The time has now come when we should have a national dental service in which dentists should work directly under the Minister of Health. I think that if we are to get an efficient dental service that is the only way in which we shall ever get it. It cannot be done immediately, but the Ministry of Health should be looking into the problem now.
The second point I wish to raise is one which the Minister promised earlier today that his Parliamentary Secretary would reply to, but to which he did not. It is the very important question of fluoridation. As the House knows, it 1503 was discovered some years ago that if there was a very small proportion of fluorides in water children's teeth were protected from decay. Experiments were carried out first in America, where there was no fluoride in the water. A very small proportion was added and, as a result, after some years it was found that the children's teeth were protected and were much healthier than they had been before.
Some years ago we in this country, under my right hon. Friend the Member for Ebbw Vale (Mr. Bevan), agreed to start an experiment. We impregnated the water in Watford, Andover and one or two other towns with a very small proportion of fluorides. This experiment is going on and we shall not get any results until about 1961 or 1962. During this time various cranks and cranky organisations will be putting up all sorts of opposition to the experiment, saying that we are making the water imperfect, and so on.
Even tonight I notice in one London newspaper a reference to the matter. As the House knows, Andover turned down the scheme. Indeed, it fought the last Election on the question of putting fluorides into the water. The leader of the campaign was a Mrs. Harvey, who defeated the mayor of the town. She has gone to the extent of sinking a well in her garden so that she will not have to drink water with fluorides in it. The newspaper says:She supplied others who claimed that the water supply with fluorides added caused nausea, stomach disorders, rashes and listlessness.There is, of course, no shadow of medical evidence for that at all, but the point is that in these areas it is very easy to exploit this kind of thing, and the people are stampeded by this type of propaganda and say that they do not want to have anything to do with the idea.
What is the Ministry doing to educate the people of the value of this work? The fact is that, in many of our towns, there is a greater percentage of natural fluorides in the water than is now suggested. There are towns like South Shields and Slough, for instance. If we examine the teeth of the children in South Shields and Slough we find that 1504 they have a higher and healthier standard than have the children in most of our other towns.
The Ministry must either counteract the kind of propaganda that is being put out in Andover or, more sensibly, accept the evidence coming from Slough, South Shields and America, and go ahead with a national scheme now. The Government must have courage, and tell the people what is happening, and not allow cranks to get away with what they are getting away with at present.
Another point about which I wanted to ask the Minister—but, again, I was "invisible"—was what progress there had been in the matter of dental ancillaries—a very important question that faces both the dental profession and the public. However, I had not the chance to raise it. I do want, however, to refer to the shortage of dentists. It is ten years since the Health Service was started, but there will now be a large departure of dentists, because, after ten years, they can draw a pension. It is estimated that in the next six months 1,000 dentists will leave the Service, but even if only 500 do so it will present a very serious problem.
What are we to do about it? I believe that the British Dental Association has suggested to the Minister that a scheme might be evolved whereby older dentists might be paid a higher rate for the job. A dentist, when he becomes old, may become more skillful, but he may not be able to work as fast as he once did; but skill is very often much more important than speed when working in the very small workshop which is the human mouth. I hope that the Minister will consider that, and see whether a scheme can be evolved whereby, as the dentist gets older, his scale of fees might be raised slightly. That would encourage the older dentists to carry on.
The other aspect of the dental shortage is dental places in the teaching hospitals. At present, the intake to the dental schools is 650 students. According to the McNair Committee, we want 900. We had a statement from the Minister the other day that he is now to take action, or has agreed that some of our dental schools—the U.C.H. in London, a new school in Wales, and so on—will be expanded. The Minister and the Parliamentary Secretary 1505 have been in the job for only a short time, but I have now been talking on this subject in this House for thirteen years, and for nearly all that time we have had this question of the expansion of dental schools on paper, but nothing has ever been done about it.
It is now not enough for the Minister to say, "We have plans to do this." He really must put pressure on the appropriate authorities to see that the extensions are carried out—and carried out very quickly, otherwise this country will be faced with a very great shortage of dental manpower, not within ten years but in the next two or three.
That is all I want to say. I apologise to the House for keeping it at this late hour. I also wanted to speak about the general medical service, in which I am also interested, and had some criticism to make of the Health Service. However, I will conclude by saying that I am delighted that my right hon. Friend the Member for Ebbw Vale opened this debate. I remember that long before the principal Act was first introduced as a Bill to this House, some of us on this side had discussions about its structure.
I was one of my right hon. Friend's chief critics, because I thought that we should have a fully-salaried service. Someone said earlier this evening that my right hon. Friend was not the right man to have introduced that Bill, because he offended too many people. As far as I remember, he was one of the most conciliatory Health Ministers I have ever met. In fact, I think that he gave way far too much to the doctors. He certainly had tremendous vision and tremendous vigour in pushing the thing through. I am certain that, for many years, when we look back on this great social experiment, we shall always associate it with the name of my right hon. Friend the Member for Ebbw Vale.
§ Mr. Walter Edwards (Stepney)
On a point of order. May I speak on the National Health Service, Mr. Deputy-Speaker?
§ Mr. Deputy-Speaker
Order. I called Mr. Parkin. It is the Consolidated Fund (Appropriation) Bill that we are taking.