§ 3.47 p.m.
§ Dr. Edith Summerskill (Warrington)
We have thought it necessary to devote one of our Supply Days to debate important matters concerned with the health of the people, because there are many questions outstanding and we realise that the week after next the House will adjourn. It seems that, if we had not taken this opportunity, the Government would have failed to give us the time necessary to raise these matters of great social importance. I am very surprised that the Minister of Health has not used his influence with the Government to initiate this debate and that it has been necessary for us, at the end of July, to raise matters which cannot be left for many more weeks, and certainly not for months.
All the matters with which I propose to deal have been raised at Question Time, but have invariably invoked evasive Answers. I do not want to exaggerate on that point. I invite any hon. Member on either side of the House to examine HANSARD on a Tuesday and the Answers to Ministry of Health Questions. We have done everything 420 in our power to evoke Answers on matters which I shall raise this afternoon, and either the Minister or the Parliamentary Secretary has tried to evade us, has suggested that more Questions might be tabled and said that perhaps they may have something to say later. So the weeks have passed.
We have waited patiently for statements about the Hinchliffe Report, the Cranbrook Report and the Younghusband Report, but without success. When hon. Members on both sides of the House this afternoon learn the details of those Reports, they will agree that some announcement should have been made. The House should have been informed of the progress of discussions on those Reports. The recommendations contained in them are of great social significance, affecting the lives of large numbers of people. Indeed, some would affect savings, which might well be used for other purposes.
The other aspect of this serious omission to give Government time to discuss these Reports is the discourtesy involved in failing to give public recognition to the debt we owe to the many distinguished men and women who have served on these Committees. Whenever an important Committee is set up by this House, hon. Members on both sides are very anxious to know about those who are to serve on it.
We know that, very often, these Committees are not set up until there has been some pressure, and the Minister concerned has felt that the proper procedure would be to inquire into a matter. Men and women who serve on these Committees feel that a favour has been conferred on them, as it is recognition of their standing in the community and their distinguished services in a special sphere. Therefore, to allow the months to pass without recognising these services is extremely discourteous.
First, I propose to deal with the Committee on the Cost of Prescribing, presided over by Sir Henry Hinchliffe. The increasing size of the drug bill, which is now over £70 million, is attracting the attention of all hon. Members. The dubious methods used by the drug houses to increase sales have been criticised but, invariably, successive Ministers of Health—there have been five, I think, in this Parliament—have 421 assured us that they are only waiting for the Report of the Committee on the Cost of Prescribing for action to be taken.
On other occasions, I have drawn the attention of the House to the costly samples, extravagant literature and presents distributed by the drug firms to doctors in an attempt to increase sales. Last year, the House was called upon to endorse a Supplementary Estimate of nearly £2 million, all of which was for drugs, and the position has worsened.
The joke among doctors' wives today is that when they want to do shopping in town they leave their husbands to have lunch with a drug firm. The following invitation came to my notice last week. It says:Bayer Products Ltd. have pleasure in inviting Dr.—to the showing of a new film-strip on rheumatoid arthritis. Any medical colleagues will also be welcome. At the Green Dragon, N.21, on Wednesday and Thursday, 8th July and 9th July. Cocktails, 12.45; Film. 1 p.m., lunch, 1.20 p.m.A doctor whom I know, who went to one of these shows—rather a cynical man—said, "We were expecting some pep pills at cocktail time." But no, there was an adequate supply of gin. The film was not a film at all, but a few cheap lantern slides. The lunchers were well supplied with wine, and another cynical doctor said, "The most important things given out were leaflets telling us what drugs to prescribe"—all made by the firm, to recompense it for the lunch.
This is not a joke. I hear an hon. Member ask "Who pays for this?" It is not paid for by that firm. It does not come from the firm's private pocket. The cost is put on the price of the drugs and, in the end, the National Health Service pays. Is it surprising, when this is practised on a wholesale scale, that this House was asked last year to approve a Supplementary Estimate of £2 million for drugs, and that we are now spending £70 million a year on drugs?
I would say that because of the publicity that is being given to this abuse of the National Health Service—or, as one doctor said, this "milking" of the National Health Service—certain groups of British firms—the firm to which I have referred is a foreign firm—have now come together, and are trying to 422 establish an ethical code. We should congratulate them. I read the ethical code yesterday, and although I think that it could be improved a little it is, at least, the right approach. They recognise that the practices I have described are really outrageous, and an abuse of the hospitality of this country to some of these firms.
The Committee on the Cost of Prescribing was appointed in June, 1957. It made a very useful interim Report, but most of it was concerned with education of the doctor, and so on. The final Report is the important part, and the implementation of this Committee's recommendations is, in my opinion, extremely urgent.
Having regard to all that I have already said, I want to ask why the Minister, when the Report was published, did not tell the House that he intended to take action on it. The Committee emphasises the importance of expedition. It recommends that… a permanent expert body should advise the Minister expeditiously on all matters affecting the trend of costs in the pharmaceutical service.We want to know, before we adjourn for several months, whether this has been done. If it has been done, who are the members of the permanent expert body? If it has not been done, surely the Minister cannot argue here that there is ignorance of the matter. Surely he cannot argue that there is not a case for taking action. Why is there this delay?
The drug houses and their numerous interested friends have always justified their colossal profits on the ground that they spend a great deal on research. This has often been repeated from the Government Front Bench, and many people believe that it is so. What does the Report say? It shows the falsity of this argument by saying that not all firms are capable or willing to undertake research, and that, furthermore, certain firms make large pofits on new preparations which are not therapeutically superior to those already in existence, and devote no part of their profits to significant research.
On this subject, the Committee recommends that arrangements designed to make full allowance for genuine research and to discourage extravagant overheads or sales promotion—such as I have 423 described—should be made. The Minister has known this for many years. His predecessor has known it. There is nothing new in this. Here, then, is a recommendation that might meet many of our complaints. What is being done? What is the objection? Or has the Minister taken action? We should like to know.
We should also like to know what action is being taken about prescription charges. I notice that one Sunday newspaper said that it was proposed to remove these charges just before the General Election but, having regard to the evidence of the Committee, I am quite sure that the Minister could not be quite so immoral. The fact is—and this is revealed by the Committee—that financially, ethically and socially the Government made a colossal blunder. When the charges were imposed, we on this side gave in detail all the consequences that would militate against success. Many hon. Members present today were present on that occasion, because they take a great interest in this particular social service.
The Hinchliffe Report justifies all our warnings. We said that there would be gross over-prescribing. I myself described the huge bottles of medicine that would be prescribed, the thousands of tablets that would be wasted in the country's medicine cupboards, and the difficulty of disposing of all the drugs prescribed but which were no longer necessary. We warned the Minister, but, far from him taking our advice, he said that he was in favour of doctors over-prescribing because that would meet the difficulty.
Now the Hinchliffe Committee has reported, having investigated the whole question of over-prescribing. According to the Report, the Committee on Prescribing was told that 40 per cent. of the increased cost of drugs since 1956 was due to the prescription of larger quantities.
The Report goes on to say:This tendency is a matter of grave concern. … It will give grounds for constant agitation, and criticism … and may destroy confidence in the economic working of the pharmaceutical service as a whole.The Minister will agree, I think, that this is very strong criticism by an impartial Committee of the Government's 424 inept handling of the most important social service in the country.
Now let us see what the British Medical Association says about it. This body is not in any way affiliated to the Labour Party. The doctors, for the most part, are Conservative. The British Medical Association advises the Minister. It knows that the charges have failed in their objective, and it has urged their abolition. Why, in the face of all this evidence, has the Minister failed to abolish these iniquitous charges? I would say, at the risk of causing a laugh on the benches opposite, that this is one of the first things that the next Labour Government will do.
A question to which I should like an affirmative or negative answer is this, and it has been asked on many occasions. I want to know whether the Minister has agreed that free drugs can be supplied to private patients under the National Health Service. In the British Medical Journal of 11th April it was reported that
Agreement has now been reached with officials of the Ministry of Health that a scheme for the supply of drugs and appliances to private patients on Form EC.10 is administratively possible. The Minister of Health has agreed to meet representatives of the Council immediately following the final Report of the Hinchliffe Committee.
§ Is this one reason why there is all this delay? What has been the result of this meeting? Has the Minister, in fact, had that meeting? I cannot understand why this information has to be found in the British Medical Journal and why Parliament is not informed of these facts. These are very important matters which concern the whole future of the National Health Service. Yet we on this side of the Committee have to find this information in a medical journal when it should have been given at the Box at Question Time or in a statement. We want to know, before we adjourn for the Recess, what has been the result of that important meeting. We want to know what promise the Minister has given.
§ Members are entitled to know this, because in the opinion of hon. Members on this side of the Committee a concession of this nature, making two classes of National Health Service patients, would destroy confidence in the Service and harm the patient-practitioner relationship. I can think of no easier way to 425 destroy the whole basis of the Health Service. Therefore, I say that if the Minister has had this meeting which he promised the British Medical Association, if he has given an undertaking that this shall be done, we must know before the House adjourns.
§ There are other things, perhaps less controversial, but of a medical kind, which the Minister should undertake. The time has arrived when the general public should be enlightened about the hazards of the antibiotic era. We need a campaign to teach the people that the consumption of medicines and pills may not be the answer to their needs and, indeed, may be positively harmful to them. That is the real test of an efficient Health Service—not the amount of medicine and pills consumed, not the cost, not the buildings nor the number of staff, but how far it meets the medical needs of the people.
§ During the last twenty years, since the introduction of the sulphonamides, followed by the powerful bactericidal drugs, penicillin and streptomycin, and a whole series of other drugs, a tendency to indiscriminate use followed, and it soon became the custom to treat the mildest temperature with one or other of these drugs. I remember an hon. Member coming to me and saying, "I have got a sore throat. Do you happen to have a penicillin tablet on you?" It is a most dangerous habit, and now we are seeing what it has done.
§ While these antibiotics have been used, rightly, in cutting short the progress of many serious infections, we are now faced with two antibiotic hazards as a result of indiscriminate use, namely, the hospital cross-infection with resistant strains of staphylococci, and the alarming increase in the number of persons who are becoming sensitised to these drugs. This is not a party matter. Hon. Members opposite, like my hon. Friends here, are becoming sensitised to these drugs. It is a most serious position. I believe I am right in saying that staphylococcal infection in hospitals now constitutes the chief bacteriological problem of the day. It is clear now that the use of penicillin should be restricted to very serious infections, and the indiscriminate use among out-patients drastically limited.
§ I have raised this because these are matters about which statements should 426 have been made by the Government in the House. They are very serious matters. These are new hazards of the antibiotic era which only the Ministry of Health fully appreciates because it has the statistics and the reports and is in daily contact with the people who run the hospitals. The Ministry knows about staphylococcal infection. An hon. Member asked a Question about it on Monday. But it requires more than Questions in the House. It needs a campaign to direct attention to the risk to the people from the indiscriminate use of these antibiotics.
§ I have finished with the subject of drugs. There is a lot to say, but time is limited. I come to another Report, the Report of the Working Party on Social Workers which was presented by the chairman, Miss Eileen Younghusband. This Committee was convened as long ago as June, 1955—four years ago—to inquire into the proper field of work and the recruitment of social workers with regard, in particular, to the place of a general purpose social worker. There are many not familiar with the day-today working of the National Health Service who will say, "Surely there is no urgency about the implementation of these recommendations."
§ On the contrary. I have spoken again and again at this Box on the importance of community care and of co-ordinating the work of the general practitioners, the hospitals and the local authorities. Coordination is not only called for on medical grounds. If we try to direct the available funds into the right direction it is necessary for us to co-ordinate the whole Service. Here the welfare worker can play an important part in this coordination, and, therefore, the welfare worker today is an important part of the medical service.
§ It is very unpleasant to contemplate, but 10 per cent. of all illness is psychopathic, and the welfare worker can play a valuable rôle in this field. The mentally ill require help with all kinds of problems concerning themselves, their families and their employment. I would remind the Committee that the Royal Commission on the Law Relating to Mental Illness and Mental Deficiency felt so strongly about the importance of bringing welfare officers into the Service that it said that this was a matter of 427 real urgency. I stress that now. We are taking this Supply Day because these are matters of real urgency.
§ Dr. Summerskill
Not quite. The Lords' Amendments are to come next week.
The Minister and I, together with other right hon. and hon. Members, discussed the matter upstairs during, I think, 17 sittings of the Committee. When we considered the staffing of this new mental health service, we said that the service would not function properly unless there were welfare workers of all kinds. We reminded the Minister that there are only 500 psychiatric social workers in the country. It was quite clear to us that the whole Measure would prove abortive unless the new service could be adequately staffed.
Time after time, the right hon. and learned Gentleman said, in effect, "It will be quite all right. Let us wait for the Younghusband Report, which may point the way to a solution of the staffing problem." Here is the Report. These workers are needed in every section, not only for the mental health service. What has the Minister done? The weeks have dragged on. Two weeks from now, the House will rise.
These great services, starved of adequate workers, are waiting for a word from the centre. Everyone knows that training, co-ordination and the assimilation of new grades of welfare workers takes a long time. We have waited since 1955 for the Report. Before we rise, we ought to know which of the recommendations the Minister proposes to adopt. If he tells me that he has already done what is necessary, I shall be the first to congratulate him.
I come now to the Report of the Maternity Services Committee, which was presided over by Lord Canbrook. I do not think that anyone will say that maternity is not an important matter. The Committee was appointed in April, 1956, three years ago. The Report was published in February, 1959, six months ago. This was an extremely important 428 Committee, having as its terms of reference:To review the present organisation of the maternity services in England and Wales, to consider what should be their content and to make recommendations.I am sorry to be the first to do this publicly, but I wish to thank the chairman of the Committee, and to say, also, that our special thanks should go to Dr. Arthur Beauchamp. Dr. Beau-champ was taken to task by Dr. J. L. McCullum, in a letter to the British Medical Journal of 28th March, for signing the Cranbrook Report because it contains recommendations directly contrary to the policy of the representative body, particularly in regard to the obstetric list and its retention.
I do not know whether there is any precedent for this. It seems to me to be grossly improper. Dr. Arthur Beau-champ is a man of the highest integrity, highly respected. He sat on a Committee of great importance and did what he considered honestly to be his duty Then, in his professional journal, a colleague criticises him for signing the Report and, what is more, says that he should have signed a minority Report. I congratulate Dr. Beauchamp on his admirable reply. He wrote:Our guiding principle was to show how, in our view, the maternity services could be organised so that mothers and babies would be saferThat is the test which must be applied to the recommendations in the Report. Do those recommendations make mothers and babies safer?
The Minister must be following all this in the British Medical Journal, and I suspect that it is having some effect upon him. Is it responsible for his reluctance to implement the recommendations? What has happened? Does he recall that, on 4th May, he was asked what he proposed to do, and he said that he hoped soon to make a statement? It is now 15th July. On 15th June, the Minister was asked what he proposed to do, and he replied thatconsultations … are still in progress".—[OFFICIAL REPORT, 15th June, 1959; Vol. 607, c. 3.]No further time should be lost in making decisions on this Report, which is of inestimable value to mothers and babies. Why is the Minister adopting a "go-slow" policy?
429 In early May, the right hon. and learned Gentleman was prepared to take action. By the middle of July, he has done nothing. I hope that he will not say that he must have further discussions and these will take time. Years have passed, during which time we have had one Minister of Health after another. It is only right that we should now have an answer. I hope that the Minister is not aligning himself with those who gave evidence before the Cranbrook Committee and opposed an obstetric list of general practitioners.
This may bore the Minister, but he has never had a baby. I have always noted that obstetrics go over his head. But many women have babies, and the right hon. Gentleman himself would not be here if somebody had not had one. I must insist upon his taking seriously this whole matter of an obstetric list of general practitioners with special experience of midwifery. He may not know much about it. As I have already observed, when the Minister is asked Questions on these subjects he evades them and his Parliamentary Secretary evades them, too—I was going to say even more clumsily.
Unless he has only just learned about it, the Minister will know very well that there has been an obstetric list in operation before. He knows very well what was the evidence given before the Cranbrook Committee. This is a serious matter. There are many women who have babies, and they are extremely interested in the subject. It is not something about which the Minister should laugh or giggle. We want answers. We are challenging him today because we believe that he has not done his duty. This is an excellent example of the way he conducts himself. When he is asked for details about the new maternity service and the recommendations of the Cranbrook Committee, and the word "obstetrics" is mentioned, he feels that he should smile and not really pay serious heed.
§ Mr. Walker-Smith
The right hon. Lady keeps on saying that I smile at it and do not take the matter seriously. I am sure that the Committee appreciates, even if she does not as yet, that it is not the subject-matter which makes me smile but her treatment of it.
§ Dr. Summerskill
The maternity services and the obstetric list are not often discussed in the House, and, when they are, it is very difficult to treat the subject lightly. This, incidentally, is typical of the Minister's legalistic response. He should have given an understanding answer on the subject of the maternity services. He should have appreciated that these are important matters. They are not merely academic.
The work of the Cranbrook Committee took a very long time, and the men and women on the Committee took their task very seriously. They recognised the importance of the matter. When the Minister interjected, I hoped that he would say that he realised this. But not at all. We are used to this attitude at Question Time. This is the Minister's approach always. He thinks quickly, but what he thinks out is a snappy interjection. By doing that he thinks that can evade the issue, but the obstetric list to doctors and local authorities throughout the country is of great importance.
May I tell the Minister, in simple terms, what it means? It concerns general practitioners who, in the past, on qualification, felt that they were qualified to treat a confinement, but who, in these days, must have special knowledge. This matter is taken very seriously throughout the country. The Minister should know that in the debate on the Cranbrook Report all these questions were raised, and there were some, I am sorry to say, who held the nineteenth century view that a medical qualification itself, however recent, entitled a doctor to practise on a woman during her confinement at the expense of the mother and baby. Is that a laughing matter?
As the Minister well knows, there is now a movement to prevent the obstetric list operating, as the Cranbrook Committee recommended. I make no apology for dealing with this matter in an academic manner. It is of tremendous importance to helpless, inarticulate mothers throughout the country.
I want to congratulate the Cranbrook Committee. It has not adopted the Minister's attitude. It has not adopted an indifferent attitude; not a bit of it. The Committee having heard the evidence, rejected these outworn ideas. It said that it was of the opinion that the 431 practice of obstetrics required special skill and experience, and decided to recommend an obstetric list and that the criteria of admission should include a six months' resident appointment in an obstetric unit.
I ask why the recommendation—and I shall put it in simple terms, so that the Minister will appreciate it—that a young general practitioner, who perhaps qualifies at 23 or 24 years of age, should have experience of obstetrics and should spend six months in a hospital studying this specialty before practising, has not been implemented? Why has the Minister allowed two and a half months to pass since saying that he would make a statement? I am glad to see that the Minister is no longer laughing at the matter of the obstetric list. [HON. MEMBERS: "Oh."] Hon. Members have seen the Minister's attitude and have heard his interjection. This is a matter which concerns women in every constituency, whether it is held by a Labour or a Conservative Member. What has happened? How long does the Minister propose to wait? Will he give an answer today? I shall be the first to congratulate him if he does. It is said that he is dragging his feet, and he certainly will not get support from certain Conservative Members who oppose his point of view.
I now come to a point which has been raised by hon. Members on both sides of the House. It concerns maternity accommodation in hospitals. I want to ask the Minister what he proposes to do about the expansion of maternity accommodation in hospitals. Does not the right hon. and learned Gentleman regard this is an urgent matter? The right hon. and learned Gentleman answered on Monday a Question tabled by my hon. Friend the Member for Edmonton (Mr. Albu) about this matter. My hon. Friend the Member for Stoke-on-Trent, South (Mr. Ellis Smith) interjected and mentioned a hospital in Stoke and said that that, also, needed more accommodation. The Cranbrook Committee recommended that accommodation in maternity hospitals should be expanded. Can the right hon. and learned Gentleman give us an answer to this matter?
I should have liked to deal with other reports. There are reports which the 432 Minister may well say are not his, but there are reports which deal with the preventive aspect of medicine, such as the Gowers Report. However, I want to pass to another point. I want to turn to the question of the serious consequences which arise from the increasing pollution of the air associated with our modern way of life. I presume that the Minister has read the Lancet this week, in which he is accused of not paying sufficient attention to pollution of the atmosphere by smoke in the Manchester area.
This is a local matter for Mancunians, and I do not intend to join in the controversy, but, for my part, I am prepared to accept the provisions of the Clean Air Act which provide for the use of smokeless fuel and the control of industrialists. I think that we should congratulate the Lancet, however, on directing attention to the part which polluted air is playing in the causation and aggravation of chest complaints. The Lancet said:Last winter the hospitals were overwhelmed, and it must have been ironical to see their chimneys polluting the air of wards crowded by patients with pneumonia, asthma, bronchitis and emphysema.Many of my hon. Friends took part in the debates on the Clean Air Bill. In particular, my hon. Friend the Member for Barking (Mr. Hastings) asked that attention should be directed to the amount of sulphur in the atmosphere.
When we ask the Minister Questions about this matter, what are we told? I know the Minister's Answers off by heart. He rises at that Box and says that he is co-operating with the Minister of Housing and Local Government about the implementation——
§ Mr. Walker-Smith indicated assent.
§ Dr. Summerskill
The right hon. and learned Gentleman nods; I suppose that he must have said this twenty times—about the implementation of the Clean Air Act. May we know precisely what he means by co-operation? How is he helping local authorities to fulfil their functions? After all, it is the Minister's job to deal with bronchitis, asthma, cancer of the lung, and things of this sort. Surely he cannot ignore the fact that dust and dirt in the atmosphere are contributory factors to these diseases. We should like to know precisely what 433 he has done about co-operation, particularly in the provision of adequate staff.
The danger of smoke pollution is not only related to industrial processes. When we raise the question of cancer of the lung with the Minister, and remind him that the commonest form of fatal cancer, cancer of the lung, is today responsible for 20,000 deaths a year, predominantly among men in their prime of life, and ask him whether he is carrying out any propaganda among schoolboys, he says that he is co-operating——
§ Mr. Walker-Smith indicated assent.
§ Dr. Summerskill
Again the Minister nods; I know the answer—with the Minister of Education and local authorities. We know that for a man of 50 years of age to cut down his smoking is difficult, but I am sure that he would be willing that his son should be invited not to acquire the habit. Cancer of the lung is increasing by 1,000 cases per year, and we should like to know how the Minister is co-operating with local authorities about it.
My last point, and some may consider it to be the most important, concerns the pollution of the air by radioactive material. We have found ourselves in a very curious position in the House lately. Most eminent scientists have told the world of the danger to health of ionising radiations, yet the Prime Minister has taken it upon himself to answer all the Questions on this subject. The health hazards are so serious that I asked the Prime Minister whether he would set up a small group of specialists in the Ministry of Health to answer questions on this subject. On one occasion the Prime Minister said that he did not believe that conditions today called for immediate consideration and that the amount of strontium 90 in the air was not so serious that it called for immediate consideration. This is not very reassuring.
I should like the Minister to give me a specific reply, as far as possible, to these questions. Who is responsible for deciding the form of instruction in the event of immediate consideration becoming necessary? We are told time after time that immediate consideration is not necessary. What happens when it is necessary? We should like to know whether these instructions exist. Does 434 the Minister have overall protection of the health and safety of the people from ionising radiation? Is that the function of the Minister of Health, or is there a division of responsibility? These questions should be answered having regard to this new threat to health, to life and to future generations.
I have asked the Minister a number of questions. I told him that I would raise questions concerning the three Reports and I have mentioned pollution of the air. It should not have been necessary for the Opposition to have to use one of its Supply Days for this purpose at this late time in the Session. Shortly, the House will be adjourning. The Minister should have recognised that there were all these outstanding questions in which the whole country is interested. He should have come to us, answered us at Question Time and kept us well informed, but he has not done that, even though these topics are of paramount importance. Therefore, I give him this opportunity of showing the Committee that he is informed and that he has these subjects at heart.
§ 4.32 p.m.
§ The Minister of Health (Mr. Derek Walker-Smith)
I welcome the initiative of the Opposition in using one of their Supply Days to discuss these important matters of the nation's health. The right hon. Lady the Member for Warrington (Dr. Summerskill), as is her custom, has said a great deal of interest and value, but also, as is her custom, she has exhibited a curiously uneven pattern in the quality of her speech. The right hon. Lady has a genuine interest in these matters, but I could not confidently say that her comprehension necessarily keeps pace with her interest at all times.
We shall, however, have an amiable day, because the whole of the advocacy of the Front Bench opposite is given to the right hon. Lady and to her hon. Friend the Member for Lanarkshire, North (Miss Herbison). If any of my hon. Friends were rather disappointed in the speech of the right hon. Lady to which they have just listened, they must seek consolation in the philosophic words of Dr. Johnson:a woman's preaching is like a dog's walking on his hinder legs. It is not done well; but you are surprised to find it done at all.435 In the course of my speech, I shall be dealing with the Reports and other matters of interest which the right hon. Lady has raised. It would, however, be right for me to start by making clear the claim which I shall make to the Committee in this debate. I come here certainly in no complacent, still less in any vainglorious, spirit, but, equally, in no defensive spirit and still less in any apologetic vein. My claim is clear and categorical and it is this. We are making good and steady progress in the health field, in some respects striking progress, and in some even spectacular progress. That is the claim which I make to the Committee. As a lawyer, I shall be expected to produce evidence in substantiation of it, and this I shall gladly do. There is abundant evidence, both long-term and short-term, to substantiate the claim.
In a health debate ranging, at the wish of the Opposition, over the whole of the field of health, it is well to remind the Committee that we come to this debate against the background of a very good health record. After all, the basic test of how we are doing is the simple test of the health and well-being of the country as a whole. In that respect, whether judged on the long term or on the short term, the position is very good.
Let me take one or two examples. We can see it in the longer life of the people and in the healthier life they have at various ages and stages. The expectation of life today is twenty years greater than it was a hundred or so years ago. The expectation of life for boys at birth today is 68 years. I add, for the consolation of the right hon. Lady and of her hon. Friend the Member for Lanarkshire, North, in case what I said earlier may seem a little harsh, that for girls the expectation of life is six years longer.
§ Dr. Summerskill
The Minister knows perfectly well that the reason he is able to give those figures is that the maternity services have improved and the infantile mortality rate has dropped.
§ Mr. Walker-Smith
The right hon. Lady has referred to the maternal and infantile mortality rates. Certainly, the maternal mortality rate today is 0.43 per 1,000 births, the lowest on record—under a Conservative Government. The 436 infantile mortality rate is also the lowest on record, 22½ deaths of infants under one year of age per 1,000 live births, an all-time record for the country. To get the position in the long-term perspective, I once more quote Dr. Johnson, who wrote to Boswell in 1777, a good deal less than 200 years ago, in these terms to console him on the death of his infant son David:You must remember that to keep three out of four is more than your share. Mrs. Thrale has only four out of eleven.I am glad that the right hon. Lady raised the question of infant and maternal mortality, the figures for which give as striking evidence as any of the progress we have made.
Children not only have a greater chance of survival at birth, but they are born larger, grow more rapidly and mature earlier. In the realm of infectious diseases, we see the same progress. What Bunyan, in his graphic phrase, called "The men of death" are yielding ground. Smallpox is no longer endemic. Diphtheria has dropped to negligible proportions. Typhoid fever is a great rarity and bovine tuberculosis is now seldom seen. These things form an essential background to the assessment of the success of our health endeavour.
I do not want to multiply the evidence, because I gave a lot of it in the corresponding debate last year, when we discussed the first ten years of the Health Service, under three years of a Labour Administration and seven years of a Conservative Government. Progress is continually accelerating and I am glad to say that today we have many additional achievements to our credit in the year which has since passed.
Having said that, however, I think it right to strike this cautionary note, as I have done before. Although our progress is good, it does not remove our problems. That, indeed, is the paradox of the Health Service. The better the Health Service, the longer the life of the citizen. The longer his life, the greater the range of his vulnerability to disease, and the greater his vulnerability the bigger the potential burden on the Health Service. This being so, like Alice, we have to run pretty hard even to keep in the same place. Now, however, we are running just that extra bit harder so as to make good progress.
437 Not the least of our problems are the economic ones. Today, the gross cost of the National Health Service in Great Britain is £718 million and the Exchequer cost is £534 million, the Exchequer cost alone being about five times as great as the total Budgets which Mr. Gladstone introduced as Chancellor of the Exchequer only a hundred years ago.
It does not need much ingenuity for anybody to think of more things to be done given unlimited resources. With a service as deserving as the Health Service, it would be nice to be able to proceed regardless of cost. It would, however, be unrealistic to approach it on that basis. Therefore, the principles which should guide us are, first, to devote to the Health Service as much of our national resources as other deserving claims will allow, and secondly, to get out of that expenditure the maximum benefit for the patient and thereby for the community as a whole. And so our object is to get the highest common factor of efficiency and economy which can bring the best results in terms of the health and well-being of the people.
I think that there are five main lines of advance which we pursue and will continue to pursue to achieve that object: first, the development of preventive measures and the promotion of positive health so that we can reduce the volume of illness; secondly, the development of community care, to which the right hon. Lady referred, so that we can better arrest and treat illness without the necessity of recourse to hospital care; thirdly, the acceleration and modernisation of our hospital provision so that it is attuned to contemporary needs and can deal as quickly as possible with those who really do need hospital treatment; fourthly, the recruitment and training of the necessary personnel, with the improvement of career prospects necessary to stimulate and sustain recruitment, about which aspect of it, on which the right hon. Lady did not address us, I should like to say a word later; fifthly, other aspects of promoting the best use of our resources, research, improvement in our administrative procedures, and so on.
I believe that these five things, taken together, assist the promotion of health, and the prevention, cure and care of disease at all stages and from every angle. Though, in a sense, they are 438 separate aspects and activities they must, of course, he woven into a co-ordinated pattern by co-operation at all levels and between all levels. I agree with the right hon. Lady in attributing importance to co-operation. It is not merely a matter of providing administrative machinery. We have, in fact, done that, and nobody, I would say, would wish to multiply the administrative machinery beyond what is necessary. What is required is an attitude of mind, and there is a great deal of evidence that this attitude of mind is growing throughout the Health Service.
Certainly, we at the Ministry are conscious of the need to keep contact with and to consult all those who may be affected by the plans and proposals which we have under consideration. We try to make our consultations in the early stages and thus give effect in the final scheme to the views of those bodies and representative organisations whose work may be affected, and this sort of consultation has improved many of our schemes. The right hon. Lady mentioned mental health on which, it is true, we have spent many hours in the House this Session. There is the plan for building up community care in the field of mental health to which we attach such great importance and which has been embodied in recent circulars which I have sent out. Those are the product of an immense amount of prior consultation and have been greatly improved in the process.
Coming from the centre to the work of those in the field, I am happy to say that good examples of co-operation are becoming ever more frequent. Just to take a very few examples: the arrangements at Birmingham, Wigan, and the London Hospital to keep general practitioners in touch with hospital staff and their work; the co-operation of health visitors with particular general practitioners, again in Birmingham, and in Oxford and in Hampshire; the cooperation at the Nuffield Trust health centres at Harlow and the work at Sal-ford, to which the hon. Member for Salford, East (Mr. Frank Allaun) referred the other day.
We need co-operation between the various agencies both at the level of administration and at the level of case work, and this is the constantly recurring theme both in the reports of the advisory 439 committees, for example, the Cranbrook Report and also in Departmental guidance which we have given particularly in respect of the aged and disabled. Working together at the administrative level is helped by common membership of administrative bodies and voluntary organisations, and at case level by such means as case conferences for the dissemination of information, and so on.
I now come to prevention and community care. Of course, as the right hon. Lady said, prevention of illness and promotion of health is not exclusively a Health Service matter. It ranges much wider than that and through all aspects of public environmental health, housing, water, sewerage, all these things; but there is a big contribution in the strict context of the National Health Service. For example, the reduction in maternity mortality of which I spoke has been much helped by greater use of the facilities provided for antenatal supervision. On a wider scale the provision of dentures, hearing aids, glasses, artificial limbs, and so on, does a great deal to restore to health and active life people who would otherwise be a liability on the community.
§ Mr. Walker-Smith
I am just coming to the Hinchliffe Report, to which the right hon. Lady referred. In the debate of 12th March the Parliamentary Secretary dealt with the progress on the interim Report on which action has now been taken in all cases. On the final Report, the 11 recommendations dealing with medical training have been taken up with the appropriate medical schools. The trial recommendations are about to be discussed with the Royal Colleges, and the drug recommendations with the industry. On the important recommendation in respect of voluntary limitation of drugs, we are having consultations with the British Medical Association and the General College of Practitioners.
The right hon. Lady asked me about prescription charges in this and other contexts. I have already told the House that these charges are being continued at present and that I keep under consideration all relevant considerations relating to the financing of the National Health 440 Service. These circumstances are, of course, both economic and social, and we have recently had the advantage of their consideration by the Hinchliffe Committee.
The Committee advised me to seek an agreement with the medical profession on this matter, to which I have just referred, that the amount of drugs supplied on one prescription should be limited to that required for the patient's illness if it be expected to last less than seven days or to not more than one week's supply with exceptions for chronic or particular cases. It also recommended a trial period of two years at the end of which the use of this scheme could be reviewed. The Committee went on to say, in paragraph 301:If a voluntary scheme of the kind we have suggested proved successful in controlling expenditure on drugs, it might be expedient to consider the abolition of the prescription charge.The Douglas Committee, in its Report on Prescribing Costs in Scotland, did not make a similar recommendation but contemplated an experimental limiting of the quantity of drugs available at any one time.
The Government regard the Hinchcliffe Committee's recommendation as a constructive approach if it is possible to set up such a scheme. If such a scheme proves successful in controlling expenditure on drugs we would, naturally, consider whether the saving justified the abolition of the prescription charge at the end of the two-year period as suggested, in the context of the results of the scheme, the finances of the National Health Service, and all other relevant circumstances.
I have already initiated discussions with the British Medical Association about the recommendations of the Hinchcliffe Committee, including the recommendation for a scheme of voluntary limitation, and my right hon. Friend the Secretary of State for Scotland has initiated discussions on the recommendations of the Douglas Committee.
§ Dr. Summerskill
I gave the Minister specific questions to answer. There are two important recommendations in the Hinchcliffe Committee's Report which he has absolutely ignored. I read them out to him very carefully. I may have been 441 preaching, but at least I put them precisely, and I should like an answer. They are most important.
§ Mr. Walker-Smith
It was so precise that when the right hon. Lady was asked to identify the paragraph to which she was referring she was quite unable to do so. I have the Report here and I will deal with anything in it in answer to the right hon. Lady or any other hon. Member. If the right hon. Lady will identify the passage I will certainly deal with it. I appreciate that she is not fond of accuracy in debate.
§ Mrs. Harriet Slater (Stoke-on-Trent, North)
On a point of order. Is it in order for the Minister, just because my right hon. Friend the Member for Warrington (Dr. Summerskill) is a woman, to keep on with this sort of slanging match?
§ Dr. Summerskill
I thought that the right hon. and learned Gentleman was going back. I told him that I was asking a specific question. I read it out to him. As he knows, the Committee recommended that a group of experts should be called into being as permanent advisers to him and that on this question of the expense of the pharmaceutical services they should advise him expeditiously What has the right hon. and learned Gentleman done about it? Has he called the group into being? What are their names? The other point was on research.
§ Mr. Walker-Smith
Not at all. I have not called the body into being. The recommendation on the permanent body suggested by the Hinchliffe Committee is interesting. It raises practical and perhaps even constitutional problems. It is a matter which I am certainly ready to consider, and to consider further in the light of the reactions of the professional bodies and others whom we are consulting on the recommendations as a whole. The recommendations on research efforts 442 in the drug industry will form part of the subject matter of the discussions with the industry to which I have referred.
§ Dr. Summerskill
Why has the Minister not taken action? I feel that I am speaking not only for this side of the Committee. Why has he not taken action about this appalling waste of money and the terrific profits made by the drug firms? Why has he not taken action?
§ Mr. Walker-Smith
It may not commend itself to the right hon. Lady, but it is not right to take action on these recommendations until we have received the views of the bodies which we have consulted. I have not yet received the views of the British Medical Association.
On the important question of prevention and community care, I should like to give the Committee, in summary form, an account of the progress which we have made with poliomyelitis innoculations. At the end of June, the acceptance figures for Great Britain were: children 73 per cent. and young people 36 per cent.; and 4⅓ million third doses have been given. That, again, is very satisfactory progress.
As to matters of community care, we are here concerned, of course, with the work of the general practitioners, the local health authority services, the health visitors, the home nurses, the home helps, the welfare services, and the voluntary agencies to whose work we would all wish to pay a high tribute. The record of our advance in this respect is best and most simply and shortly told by the figures.
In 1951, we had 17,000 general practitioners, Last year we had 19,600, an increase of 2,600. Local health authority expenditure in 1950–51 was £33.2 million. In the last financial year it was £57.8 million, an increase of £24 million. Local authority welfare expenditure was under £10 million in 1950–51 and over £19 million last year. Expenditure on the mental health services was £1.4 million in 1951 and £4.1 million last year, an increase of £2.7 million.
Indeed, this forward movement is accelerating under the new general grant arrangements, because the amount taken into consideration in determining the aggregate of the general grants in respect of the local health authority services was £61.32 million for this financial year 443 and for the next financial year it is £63.48 million. The element within that with respect to mental health expenditure was £5 million in this financial year and will be £5.9 million next year.
I now come to capital expenditure. Here, in the welfare services we are concerned with the provision of old people's homes and, in the local health services, amongst other things, with mental health training centres and hospitals. Taking the value of building schemes approved for loan sanction, we have figures for 1950–51 of £1.6 million on health and £2.6 million on welfare, a total of £4.2 million. In 1958–59, the figures were, health £3.8 million, welfare £4.6 million, making a total of £8.4 million. This year there is an estimated total of £9 million, of which £4 million are in respect of health and £5 million in respect of welfare.
I give these figures and could give many others showing the gratifying growth in our community care services, but I do not want to retread all the ground so admirably covered by my hon. Friend the Parliamentary Secretary in our debate on these matters on 5th June. I could speak of the growing number of visits paid by home nurses, the increasing number of cases attended by home helps, the number of beds and homes provided under Part III of the National Assistance Act, and the increasing number of old people for whom local authorities provide accommodation.
These were 57,680 at the end of 1951 and 79,877 at the end of last year, an increase of over 22,000, or about 40 per cent. There were 195 training centres for the subnormal at the end of 1951 and 307 at the end of last year. I submit that these figures tell their own story and one of steady and gratifying growth which shows that we are practising what we preach in relation to the development of community care.
As to the Cranbrook Report, about which the right hon. Lady the Member for Warrington questioned me, the Committee reported on 19th February and we are most grateful for its labours. We immediately began to take appropriate action and to enter into the necessary consultations. After consultation with the appropriate organisations, memoranda 444 have now been prepared commending to hospital authorities, local health authorities, executive councils and general practitioners many of the recommendations of the Report. I hope to issue these memoranda by the end of this month unless, of course, printing difficulties supervene. These memoranda will put special emphasis on recommendations about co-ordination and co-operation, the more careful selection of patients for hospital and domiciliary confinements, and improvements in ante-natal care. They will also deal with the provision of hospital accommodation.
Some of these recommendations are necessarily reserved for further consideration and discussion with the medical profession, including those affecting the maternity medical services provided by general practitioners and especially the recommendations about the future of the obstetric list to which the right hon. Lady referred.
§ Dr. Summerskill
These are the two important recommendations, but, again, the right hon. and learned Gentleman says that he is not going to make a specific statement on them. Why is it that after all these months he is not prepared to tell us specifically, and without all this verbiage, what he is going to do?
§ Mr. Walker-Smith
It is because we have not finished our discussions and consultations with the professional bodies. Surely the right hon. Lady is not going to be so irresponsible as to suggest that a Minister of Health should issue a diktat to these professional people about these professional matters. Surely that is not her concept of democracy and of the appropriate way of conducting the business of Government. I am very shocked to hear it.
§ Dr. Summerskill
My concept of the right hon. and learned Gentleman's function is to protect the women and children and not to keep saying that he is putting off these important recommendations while he has further discussions. Months have passed. When is he going to make a decision? These are the two important recommendations about which I am speaking.
§ Mr. Walker-Smith
I shall make the decision as soon as I am satisfied that 445 the consultations have yielded all that they can. I am satisfied that it would be quite wrong, in order to get some cheap political credit from the right hon. Lady, to try to stampede the matter and take a decision before that. Equally, I do not propose to hold up the memoranda dealing with the other important points until the consultations are completed.
I want to say a word in respect of hospital building. I do not think the right hon. Lady said much about hospital building, but it is an important matter. I am glad to say that we are now vigorously engaged in an expanding programme of hospital building. After the war hospital building got off to a pretty slow start. Until 1951 the highest annual expenditure was £8½ million. Then, in 1955, my right hon. Friend the present Minister of Labour announced our plans for expanding hospital building. We are now doing that. Last year we allocated £20 million, this year we have allocated £22 million, and next year we are allocating £25½ million.
The increase in these allocations is being devoted mainly to the centrally financed programme of major projects which have been expanded each year and now includes more than 120 large projects in course of construction or planning, each costing over £250,000 The first parts of four new hospitals are already in use and ten more new hospitals are in progress in various parts of the country. In addition, we have large new units and major extensions, and, in all, 40 of the large building schemes in our programme have already started.
I should like to add that, in addition to the new hospital and major schemes, much capital and work goes into improvements at existing hospitals which are directed at getting increased and improved service from those hospitals. For example, new laboratories, operating theatres and X-ray departments have all led to a greater and more efficient use of beds. [HON. MEMBERS: "Oh."] Oh, yes, because with a 6 per cent. increase in the number of beds we have been able to treat one-third more patients. About one-fifth of the available capital has been spent on these ancillary departments to help produce this result.
446 We are also devoting much attention to out-patient provision because this, of course, reflects our policy of trying wherever possible to save people having to enter hospital, or, if they do have to enter hospital, to minimise the time they have to stay there. We have concentrated on out-patient clinics which can give diagnosis and treatment which formerly was thought to require inpatient treatment, and also provide follow-up care afterwards.
§ Mrs. Slater
Does that mean that Stoke is to have a very quick realisation of its out-patient clinic?
§ Mr. Walker-Smith
The hon. Lady has some interesting Questions on the Order Paper for Monday, when I think we can deal more efficiently with the mater in regard to Stoke.
Taking the general position, we have built new out-patient and casualty departments or improved existing ones at 100 hospitals at a cost of £7 million.
The other aspect I wish to mention is that of mental and mental deficiency hospitals where, in recent years, we have been able to increase the proportion of the allocation directed to them, which means that they are now getting a larger share of a larger total.
§ Mr. Kenneth Robinson (St. Pancras, North)
Will the right hon. and learned Gentleman say what is the percentage of the new share?
§ Mr. Walker-Smith
The latest figure for regional hospital boards is 31 per cent.
One other matter of hospital provision that I think the House will consider important is that of design and procedure. I am very anxious to improve design and accelerate procedure, and we shall now be assisted in all this by having our own chief architect at the Ministry and also by the expansion of our design unit. The unit has already done a great deal of good work, as hon. Members know, and what I now propose is that the unit should design some hospital departments which will be built in various parts of the country, the first being an out-patient department. I think that such building will illustrate our ideas about hospital design and will show in finished form the guidance which hitherto we have been giving in bulletins. 447 I am very anxious to simplify and streamline the ordinary procedures and to cut out any stages which it is possible to cut out, such as the previous examination of working drawings at the Ministry.
§ Mrs. E. M. Braddock (Liverpool, Exchange)
Does that mean that particularly in Liverpool, where a scheme has been waiting for a long time—I have here six batches of letters which have gone backwards and forwards to the Ministry since 1950 and the job is not yet completed—that sort of thing is going to be cut out? If I get an opportunity I shall make reference to the matter, because that is what is happening.
§ Mr. Walker-Smith
I am very anxious to accelerate those procedures and to reduce any delays. I am obviously not going to apportion responsibility for delay in any particular case in the course of my speech, but I think it would be relevant to point out that one can only hope to do this with co-operation, as it were, at both ends. I spent a good deal of my professional working life in the consideration of building contracts, and I know that unless one gets complete clarity from the building owner in regard to his requirements and unless those requirements are then adhered to nothing goes well with building work. Therefore, I am emphasising to hospital boards the importance of getting a clear and unambiguous schedule of their accommodation requirements before detailed planning is started. We shall give all the assistance we can through the design unit and otherwise.
In regard to these matters, we have a number of proposals aimed at putting the emphasis on scrutiny and correction at the earliest possible stage, and these are going to be discussed between my officers and the officers of the hospital boards. I very much hope that this will lead to an acceleration and improvement of these procedures which they would all desire.
If I may, I will conclude by saying a word about——
§ Mr. Walker-Smith
I am coming on to the Younghusband Report in this context. The right hon. Lady need not worry.
448 As I was saying, I should like to conclude by saying a word about the people engaged in the Health Services, which is a matter of great importance and one which is rightly of interest to the House. Our aim in this context is to get the right number of people properly trained and to offer them appropriate remuneration, conditions of service and attractive career prospects. We have been making good progress in that respect in the course of this year. In the hospital sphere we have the Working Party under Sir Robert Platt making good progress on the medical staffing structure. It has held many meetings and visited 40 hospitals and received 58 statements of evidence.
In the case of nurses, we have a steady expansion of staff. We have now got over 147,000 whole-time nurses, an increase of nearly 16 per cent. on the 1951 figure, and nearly 40,000 part-time nurses, an increase on the 1951 figure of no less than 61 per cent. As from 1st March this year we have substantially increased salaries for trained staff, particularly ward sisters and more senior grades. Compared with the salaries which resulted from the very first Whitley Review on 1st February, 1949, staff nurses in general hospitals now have a maximum of £625 as against £415, and ward sisters £800 as against £500, while in the mental health field the staff nurse maximum is now £675 as against £435, and the ward sister £850 as against £520.
Hospital midwives also received increases of the same order. With effect from 1st March, staff midwives now have a maximum of £655 and midwifery sisters one of £830 as compared with £435 and £520 in 1949. On a point in which hon. Members have taken some interest in the past, the position of nurses taking midwifery training has been improved. They are now paid as post-registration students instead of as new entrant pupil midwives.
Most of these salary increases are already in payment, and the details for the remaining hospital grades, which will also date from 1st March, will be issued to hospital authorities tomorrow week.
§ Dr. Horace King (Southampton, Itchen)
Would the Minister be good enough to add to the picture which has given the whole Committee pleasure by 449 telling us what he has done for domiciliary midwives?
§ Mr. Walker-Smith
I am much obliged to the hon. Gentleman for drawing attention to that important point. Discussions are now in progress about the salaries of nurses and midwives in the public health and domiciliary services, and the new salaries which will result from those discussions will also take effect as from 1st March this year.
We have an improving figure for hospital midwives, though I will not give the detailed figures to the House because time is getting on. It is also gratifying to record the remarkable advance in the number of student nurses in recent years in the mental and mental deficiency hospitals. All the figures I have given reflect the position before the new salary improvements have really had a chance to make their attraction felt, so they should provide a further impetus to this welcome forward movement.
Another good development is the 88-hour fortnight. I gave the figures of implementation in February. I am afraid I have not got the detailed, up-to-date figures, but I am confident that they would show a substantial improvement on the figures I then gave to the House. There were, of course, some hospitals, in particular mental hospitals, which could not do this without extra staff and cost, and so I included an additional sum in the allocation for regional boards for 1959–60 for the specific purpose of assisting hospitals to introduce the 88-hour fortnight for nurses and mid-wives.
Also there has been good development in regard to the administrative and clerical workers, where the new grading structure is in operation with improved new salaries, which should make a more attractive career prospect. The Whitley Council is now considering the question raised the other day by the hon. Member for St. Pancras, North (Mr. K. Robinson) about the designated grades, and I am sure it will get on with that important matter as soon as possible. In addition, radiographers are to have an increase and a circular will soon be issued to this effect. The salaries of hospital pharmacists and assistants in dispensing will also shortly be coming before the Whitley Council.
450 So in pay and conditions in the National Health Service I think we have a pretty general advance all along the line. This is appropriate in respect of employments which have not in the past been in the van of wage increases. I have used the term "career structure", but to many in the National Health Service, of course, their work is not so much a career as a calling, which evokes much that is noblest in human nature and which, while it is not susceptible to economic evaluation, should command a reward reasonably in keeping with their high responsibilities and zealous endeavour.
The right hon. Lady asked about the Younghusband Report. We have speedily got to work on this massive and valuable Report on the training of social workers, which was published two months ago. On this, again, I think nobody would wish us to act without appropriate consultation, and we have therefore sought the views of the local authority associations. We have not yet had their replies, but there is some evidence that the Report has had a favourable reception. While awaiting those views, I appreciate to the full the importance of the matter and the desirability of making our decisions as soon as possible, having regard to the importance of the work they do.
I have taken up a considerable amount of time. If I have not answered all the points made by the right hon. Lady, I will study her speech in HANSARD with the care which I always give to what she says and reply at some convenient moment, or I will get my right hon. Friend the Secretary of State for Scotland to do so when he speaks later in the debate. I am conscious that many hon. Members wish to contribute to it, and I have only taken up the time I have used because this is such a wide-ranging subject, of great and direct importance to the people of this country.
I submit, with I hope all proper humility, that on the evidence the claim I made at the beginning of the debate is substantiated, that we have made substantial and satisfactory progress. I do not know what is the intention of the Opposition, but I hope that this is not a matter on which hon. and right hon. Gentlemen opposite wish to divide the Committee, because a hostile vote on this Estimate would be a vote in face of the facts and in defiance of the merits.
§ Mr. Walker-Smith
If the Opposition divide the Committee, I say this to them in clear terms, that it will convict their political judgment and their sense of fairness. It cannot convict our administration, because the facts and the record speak so clearly and convincingly on our behalf.
§ Dr. Summerskill
Is the Minister aware that he has not answered one of my questions? [HON. MEMBERS: "Oh."] Not one, but perhaps he could answer at least this one. May I ask him again what decision has been reached on the question of free medicine to private patients? The Minister has asked us whether we are going to divide the Committee. He has convicted himself. He has given us a dreary recital of facts but has not answered one question. No wonder he has had to drink water three times. Will he answer at least the one question about free medicine, which is fundamental to the National Health Service?
§ Mr. Walker-Smith
I met the representatives of the British Medical Association at their request. Naturally, I shall consider all they have to say to me, but I can assure the right hon. Lady that I have not given them any promise in this matter.
§ 5.21 p.m.
§ Mr. Kenneth Robinson (St. Pancras, North)
I am sure the whole Committee is gratified to learn of the improvement in the nation's health and of the development of the National Health Service, which was illustrated by the figures the right hon. and learned Gentleman has given this afternoon.
If he had been content to leave it at that, so should I be, but he was at some pains to emphasise that all this had been achieved under a Conservative Government, that the record levels of maternal mortality and infant mortality had been reached under a Conservative Government, while the National Health Service was administered for only three years by the Labour Government. I must remind 452 the Committee and the country that it was the Tory Opposition which voted against the National Health Service Act in 1946 on both Second and Third Readings. I think it salutary that we should be reminded of that fact.
I do not think we can accept the Minister's statement as an adequate reply to the indictment made by my right hon. Friend the Member for Warrington (Dr. Summerskill). On these three Committees—to take one example—the Minister has told us that there are consultations going on or that discussions are about to begin. That applies to every recommendation of importance made by these three Committees.
The right hon. and learned Gentleman and his predecessors have been perhaps more prone than any other Ministers to set up working parties, departmental committees or Royal Commissions into this, that and the other problem affecting their Department. We make no complaint about that so long as the reports of those bodies lead to speedy action, but what so frequently happens is that they lead merely to protracted discussions and very often in the end not to action but to the setting up of another committee. I wish to emphasise what my right hon. Friend said about the main recommendation of the Cranbrook Committee's Report. It is vitally important that the Minister should not be deflected by pressure from any quarter from adopting the very important recommendation of an obstetrical list.
The subject of this debate is vast and one has to limit oneself very severely in the number of aspects to be dealt with. I want to discuss two trends in the hospital service which have been giving me concern for some time. I should emphasise at the outset that, although for about nine years I have been a member of a regional hospital board, the criticisms I make are not in any way directed to the hospitals in the region with which I am associated. I happen to think it is the best regional board in the country. The views I am about to express are the result of information I have received and impressions I have gathered over the whole country. The first matter I want to talk about is public relations, in the literal and widest sense. I do not use the phrase as a euphemism for advertising, which is what it usually 453 means, but literally as relations with the public which, in the context of a hospital, means the patient and the patient's relatives.
I readily admit that once a patient is received into a bed in a hospital he gets care and attention of a quality which probably is second to none in the world. There is nothing too good for him in the way of medical and nursing treatment, and, subject to one or two reservations to which I shall come later, he is treated as an individual human being. Most of the criticism I have to make relates to what happens to a patient before he gets into a hospital ward.
I first take the question of out-patient departments. Most of us remember the old system whereby masses of outpatients came to the department in the early morning, or early after lunch, and waited for hours like dumb oxen until their turn came—it might not come that day at all—to be seen by the doctor. They sat in draughty corridors, on uncomfortable benches, at considerable inconvenience and frequently some suffering. Most of us hoped that the introduction of an appointments system would bring all that to an end. Although probably it is true to say that here and there appointments systems are working extremely well, generally the way they are run has not altogether eliminated the bad features of the old system.
The main trouble is this. There is an over-insurance against the possibility that the doctor might be kept waiting occasionally for a minute or two. The system usually works rather like this. A batch of patients is asked to come at a certain time, probably a quarter of an hour and possibly half an hour, before the doctor is due to start seeing patients. The patient himself is nearly always over-anxious and comes to the department a quarter of an hour, or possibly half an hour, before he is required to come, while the doctor, I regret to say, is frequently a quarter of an hour and sometimes half an hour late. It means that probably the first patient must have been waiting three-quarters of an hour or an hour before he can be seen by the doctor and the remaining patients in the batch have to wait that much longer. The assumption behind this principle is a very simple one. It is that the doctor's time is priceless and the patient's is 454 valueless. Neither part of that proposition is necessarily always true. I think it time that a more civilised appointment system was adopted over the country as a whole.
Another feature of out-patients' departments which sometimes disturbs me is the attitude of the sister in charge to the patients waiting there. They are treated sometimes almost as if they were malingerers and certainly with less humanity than is due towards people who probably are nervous, worried and more than normally vulnerable. Some of the more famous teaching hospitals are among the worst offenders in this respect. There seems to be a different attitude on the part of some senior members of the nursing profession towards a patient who is in the ward as opposed to a patient who has not yet got there.
I think the admissions to hospital beds are sometimes rather thoughtlessly organised. I wish to quote an instance concerning a friend of mine which happened only a short time ago. He went into a very distinguished teaching hospital in London for observation. He was told that he was to have a serious operation but that facilities were not yet available. He was to go home and would be summoned when they were available. He went home and then one morning he was asked to come to the hospital at about 11 o'clock. He duly turned up, but when he got there he was told, "I am sorry, but the bed is not available". He was told to go away, have his lunch and come back in the afternoon. He was fortunate, because he had been brought there by his wife in a car.
My friend was able to go away, have a good lunch and come back in the afternoon, but I wonder what would have happened to many poor people who had not those advantages? This happened to be a sweltering hot day in the middle of the heat wave. Such patients might have come up from a country district and have been told to make their way around London and come back four hours later. That is not good enough. These things arise simply through lack of appreciation and understanding of the effect on the patient of the instructions given. It may not 455 be very common, but the point I am trying to make is that it should not ever happen.
I said I had one or two reservations about patients in the ward. The first of these concerns the ward rounds. The doctors' daily ward round is, of course, the focal point of the organisation of the ward. Frequently the time that the patients are called in the morning is dictated by the length of time it takes to get the ward ready for the doctor's rounds. The doctor sees the ward in apple-pie order—everything is excessively neat and tidy. Sometimes the beds of the patients are tidied so effectively that the patients are lying in a state of acute discomfort. It seems to me that the doctors do not want this; they ought not to want it anyway. I should have thought that a doctor wanted to see his patient in the ward in its normal state.
I am constantly reminded when I see this in hospitals of what used to be called the captain's rounds in the Navy, when the messdecks were "tiddlied-up" for the captain's inspection on Saturday mornings. The cutlery was polished with some obnoxious and lethal substance so that it gleamed, but it had to be washed in boiling water afterwards before it was fit to eat with. This is the same sort of attitude. I am afraid that it stems from the attitude of the nursing staff towards the medical profession. This is something which in this day and age needs serious reconsideration. We want to remember that the patient's getting well will be the result of a partnership between the doctor, the nurse and the patient himself. Unless the other two people are brought in on something like level terms with the doctor, I do not think that the public relations, in the sense in which I use the term, will be good.
Another thing is that the patient is seldom allowed to know anything about his own illness. He is not supposed to ask and it is not his business to know what his body is doing at that given moment. If patients are told little about their ailments, then relatives are told even less.
To quote another experience which happened to a friend of mine recently, he had his small daughter in hospital suffering from an obscure type of fever, 456 one of the features of which was a violently fluctuating temperature. My friend, although a layman, has quite an extensive knowledge of medical matters, and when he went to visit his daughter he asked what was her temperature. The nurse responded as if she had been affronted by such an improper request. This information had to be winkled out of the ward sister. It was his own daughter and he merely wanted to know what her temperature was and whether it had gone up or down.
This sort of thing is much too common. Too many hospitals give the impression that relatives and visitors are rather a nuisance, instead of recognising them as very often part of the treatment of the patient and as something of therapeutic value to the patient. I think that anyone who has been an in-patient in hospital must remember how much it means when visiting hours arrive and some fresh interest is introduced into the scene.
I ask myself—I do not want to exaggerate it, but I think it is important—why we have this comparative failure of public relations? I think it is partly because hospital management committees have become a little too remote from the patients. They have become too swamped with agenda papers, memoranda and administrative detail to have enough time to find out what is really happening in the hospitals which they are administering.
When my right hon. Friend the Member for Ebbw Vale (Mr. Bevan) introduced the National Health Service Act and designed the administrative structure of the hospital service, he was very careful to insure that there should be ultimate lay control of all but purely clinical matters, and control in the interest of the patient. I am afraid that concept has never in the event been fully realised.
That brings me to the question of doctors. Members of the medical profession have been given a very generous share in the management and detailed policy-making of the public service in which they earn their living. Possibly this is becoming a somewhat excessive share. I think it is essential that we should guard against anything in the nature of medical syndicalism in the health service. That is a danger which the Guillebaud Committee recognised 457 and to which certain of its recommendations were directed. I fully agree that it is very important that the medical view should be considered, but it is no less important that outside the clinical field the medical view should not automatically prevail.
There was one example of this which gave me some concern about two years ago when I discovered that in one region the chairman of a hospital management committee was also the medical superintendent of the largest hospital in that management committee's group. He was, I am quite sure, a most excellent medical superintendent and an admirable chairman, no doubt, of his committee, but this is a very dangerous precedent indeed. It should not have happened. On grounds of principle, I hope that the right hon. and learned Gentleman has seen that that situation has been brought to an end. I remember calling his predecessor's attention to it.
I want to say a word about the consultant service. I think that most hon. Members who are in any way associated with the hospital service will agree that far too much work which is appropriate to consultants is today done by senior registrars and even by registrars. This is partly due, but only partly due, to the fact that we have not enough consultants in the hospital service, a matter which no doubt very closely concerns the Working Party to which the right hon. and learned Gentleman referred at the end of his speech.
There is another aspect of this, and that is that none of us either at management committee level or regional board level or in the Ministry has any control whatever over how much or how little a consultant does. Of course, a few people may know. The hospital secretary or a group secretary might know, but he would seldom dare to report anything of this nature that he thought was improper to the management committee or to the regional board, perhaps because he knows the strength of the medical interest and the fact that there would be no protection for himself. Registrars and senior registrars who do work that should be done by consultants would be even less likely to let anyone know what is happening.
I do not want to exaggerate this, and I fully recognise that the majority of consultants 458 are highly skilled, hard working and conscientious, but there is a minority—I think almost entirely part-time; how big or how small a minority we do not not know and we cannot possibly find out—who are abusing the freedom that the service gives to them. There are some part-time consultants who seldom go near the hospital to which they are attached and for which they receive regular payments for services which are nominally, and only nominally, performed—consultants who are always too busy in their private practice.
Then there is the question of the domiciliary consultations. The Minister will remember there was some concern expressed in the Report of the Select Committee on Estimates about abuses in the domiciliary consultant service, on which the Committee received certain evidence. It is quite impossible to find out for certain whether the abuse exists because there is so little control. In my own region, after this Report came out, we wanted to be even more conscientious than in the past about certifying domiciliary visits for payment. The Minister placed an obligation on regional boards to satisfy themselves that consultations were necessary before agreeing to pay. Two consultants in the region refused to give information which would enable the board to decide whether the visits were necessary, and the board refused to pay. The board was threatened with litigation and so appealed to the Minister, who directed it to pay.
That is not good enough. I am all in favour of doctors and nurses being given the maximum clinical freedom, but I think that there must be some more control in order to see that the minority, who are prone to abuse the service for their own ends, do not prejudice the reputation and interests of the majority who do an admirable and a conscientious job.
The part-time consultant is probably the most extravagant part of the hospital service. These consultants are paid at a high rate and they are often paid for long periods when they are sitting in motor cars travelling from hospital to hospital. Furthermore, it is this factor which leads to abuses of pay-bed facilities. We have all from time to time had complaints about the pressure brought to bear upon patients by consultants who 459 are also in private practice. The patients are told that they can circumvent the waiting list if they will have the operation or treatment as a private patient. We all know the effectiveness of the persuasion which can be exercised over an anxious or worried patient. Not long ago in an Adjournment debate my hon. Friend the Member for Birmingham, All Saints (Mr. D. Howell) quoted from a letter written by a consultant who had exercised this pressure in a most overt way and, for once, was foolish enough to put it down on paper.
This sort of thing creates the illusion—I am happy to say that it is an illusion—of a kind of two-class health service; an idea which is also bolstered up by the proliferation of insurance schemes designed to encourage private treatment both inside and outside hospitals. Few such schemes, incidentally, reimburse the patient in full for the cost he incurs by this private treatment. I say, therefore, that the whole question of part-time consultants and pay beds should be objectively examined.
In the meantime, the Minister, in conjunction with the Chancellor of the Exchequer, should remove the special disincentives against whole-time practice in the hospital service, the disincentives to whole-time consultants who are the backbone of the service.
I have called attention, admittedly and perhaps inevitably in rather general terms, to certain aspects and trends in the hospital service which I, at any rate, regard as undesirable. I believe that these trends could be reversed by resolute action on the part of the Minister and his Department. Unfortunately—this point was made by the Select Committee on Estimates—there has not been that leadership and resolution from the Minister or his predecessors which the hospital service was entitled to expect. Because such qualities have been lacking, these tendencies have been allowed to grow, and I suggest that the time has come to do something about them.
§ 5.45 p.m.
§ Colonel Sir Malcolm Stoddart-Scott (Ripon)
It is now thirteen years since the National Health Service legislation passed through this House and it would have been extraordinary if, at one fell 460 swoop, we could have reorganised our hospitals, the general practitioner service, the dental service and our district nurses, as well as the other auxiliary services associated with the Health Service, and got the reorganisation right first time. Therefore, I think that after thirteen years it is not inappropriate that we should have a committee reviewing the different aspects of the Health Service. I should have liked to have seen the task given to a Royal Commission. I was not very impressed with the Guillebaud Committee, which found everything right in every direction. That was too good to be true. I cannot believe that every department of the Health Service was as good as the Guillebaud Committee said it was.
I was delighted to hear my right hon. and learned Friend speak about the rebuilding of hospitals and to be told that we are spending three times as much money in the coming year as was spent in 1951. In a Welfare State, where we have many welfare services, from time to time each service must get a greater amount of assistance than the others. Immediately after the war, hundreds of millions of pounds were poured into the building of houses. Since we have had to educate an increased number of our population, and while the bulge has been passing through our schools, hundreds of millions of pounds have been poured into the building of schools; and rightly so, I do not criticise it. But I believe that we are getting near the time when we shall have to spend, not just £25 million a year but hundreds of millions, upon the building of hospitals. Some of the hospitals in this country may truly be described as slum hospitals. Some have had to be closed down because of the bad accommodation which they provided.
I was also delighted when the Minister told us of the great increase in the number of general practitioners over the past year. I wish he had told us something about the numbers of dentists in the Health Service. I am anxious about the dental service. Members of the dental profession are retiring and dying at a greater rate than newcomers are entering the service. I foresee that in the near future we shall be desperately short of dentists and I hope that the Secretary of State for Scotland, when he replies to the debate, will be able to 461 tell us what steps the Government are taking to attract an increased number of students to our dental hospitals. Have we the facilities in the hospitals to provide an adequate number of students to replace the losses from the dental service? Has a dental hospital been established in Wales where there has been no dental hospital? That was recommended by one of the committees which examined the dental service.
I should like to hear a little more about midwives. The Minister told us that there was an increased number of midwives in our hospitals. I hear that some hospitals have closed down the maternity wards because of a shortage of midwives. Perhaps that shortage is in some regions only, but there is no doubt that the domiciliary service is short of midwives. I should like to hear more about what the Minister is doing to attract women in the nursing profession to acquire the extra midwifery qualifications and to practise on the midwifery side of their profession.
I hope that the Minister will take no notice of the sarcastic and cynical remarks of the hon. Lady the Member for Warrington (Dr. Summerskill) about drugs and dressings for private patients. I think this aspect of the National Health Service is most unjust. The House has permited people to have a private practitioner if they wish, and if they choose to do so they are not permitted to have free drugs and dressings although they are called on to pay their National Health contributions and taxes.
I hope that in the near future a little more justice will be done to those who pay rates and taxes like every other citizen but who are not permitted to have free drugs and dressings. If any hon. Member is not feeling very well and comes to me for advice, why should he have to pay for his drugs and dressings while if he goes to another practitioner who is in the Health Service the hon. Member will get them free? That is not fair to him nor to me.
I do not want to say much about doctors' pay, because the Royal Commission must be getting near the end of its work, although it has taken a very long time. When the Royal Commission was set up one heard of it making its findings within six months. It is probably reviewing very much more than 462 just the subject that was at first mentioned, which was the immediate claim of the doctors, but I hope that the Minister will tell us something about the general practitioner pension fund.
The 1955 National Health Insurance Superannuation Regulations laid down that 1½ per cent. of the total net remuneration that a doctor earned while he was in service would go towards his pension, and the Minister was authorised to keep this pension fund account which had to be submitted to an investigation by the Government Actuary every seven years. It was arranged that an investigation and report of the fund up to 31st May, 1955 would be made by the Actuary. Has that Report been made? Has it been published? If it has not, when will it be, and has the balance between the assets and liabilities of this fund been maintained?
This pension fund is very important to the general practitioner, because it is based on a different principle from most other Government service pension funds, where the pension is based on the average earnings over the last three years. This fund is based on the whole of a general practitioner's earnings over the years that he is in the Service, and inflation has affected the value of this pension fund very considerably. There is great anxiety amongst general practitioners about the fund.
The Minister's speech showed that there has been great development in the National Health Service. The hon. Member for St. Pancras, North (Mr. K. Robinson) criticised us on this side of the Committee for voting against the National Health Service Bill in 1946. We voted for reasoned Amendments. There were certain things in the original Bill which we did not like, and the amending Bills that followed in rapid annual succession show that we were right and that the Government of the day were not.
The administration of the Act has provided a service which is very popular in the country. Although the right hon. Lady the Member for Warrington had some bitter and sarcastic things to say about the Health Service, it is working well. It is popular throughout the country and I believe that it is very acceptable to the large number of people who benefit from it.
§ 5.55 p.m.
§ Mr. Somerville Hastings (Barking)
We have listened with great interest to a detailed speech from the Minister telling us what he is doing for the prevention and treatment of diseases. A good deal more can and ought to be done for the prevention of certain diseases, and I should like to consider chest diseases, particularly chronic bronchitis.
There is no doubt that chronic bronchitis is a dangerous and serious problem. The British are said to be chesty people and I think that is true, partly, perhaps, because of the moist atmosphere in which we live. But we have done a good deal for the prevention and cure of some chest diseases. Lobar-pneumonia is no longer the danger that it used to be. Some of our youngest and best people used to be carried off in the prime of life. Now, with the use of antibiotic drugs, the story is very different.
The story is very different also in the case of tuberculosis of the lung because by improved conditions of life it is much less common. There is much less infection and children are less frequently infected in early life—although the disease might become latent until later in life—I understand that in the London area only some 14 to 16 per cent. of children leaving school show indications of previous infection. We have done a great deal also for the treatment of tuberculosis by the use of new drugs.
Then there is cancer of the lung. We know the cause of at least 90 per cent. of the many deaths from this disease. If we do not make use of the knowledge which we as a nation have we cannot blame the Minister but we must blame ourselves.
Chronic bronchitis, however, presents a different story and I should like to stress how serious a disease it is. There are 30,000 deaths a year from chronic bronchitis and that does not include 20,000 deaths from broncho-pneumonia, in many or indeed most cases of which the disease was prepared for by chronic bronchitis. This death rate is twenty times higher than in the Scandinavian countries, but I would not stress these figures too much because it may be that the diagnostic criteria is different in different countries. At any rate the death rate from chronic bronchitis is very much higher than it ought to be. 464 The loss of working days amounts to approximately 20,000 per year amongst insured persons and the numbers suffering from chronic bronchitis among those not employed is also very great.
Some research was done in Newcastle-upon-Tyne a few years ago and probably the hon. Member for Newcastle-upon-Tyne, East (Mr. Blenkinsop) knows more about it than I do. Men and women over the age of 30 were examined and no less than 36 per cent. of men and 17 per cent. of women showed not symptoms but definite signs of chronic bronchitis. The Minister will know that of all diseases which have to be dealt with by general practitioners in the National Health Service chronic bronchitis comes first in numbers.
It is a very distressing disease. It does not kill quickly. People get attacks of it and go into hospital. When their condition improves they are sent home, but they get worse again when the weather becomes bad. They are kept awake for many hours at night. The complaint leads to other chest diseases such as bronchiectasis, asthma and bronchopneumonia, and it frequently affects the heart. The trouble does not end there, because coughing from infected lungs spreads disease. My right hon. Friend the Member for Warrington (Dr. Summer-skill) referred to the amount of staphylococcic infection in hospital. There is no doubt that the chronic bronchitics in hospital help to distribute these staphylococci. Not many weeks ago I was in hospital. I was exceedingly well treated, and they did everything they could for me. Unfortunately, I brought away with me some of these virulent staphylococci, and for the first time in my life I had a horrible carbuncle. There is no doubt that that was due to my stay in hospital, although I benefited enormously in other ways.
Chronic bronchitis gave a great deal of trouble in the early months of this year. There was an influenza epidemic, although it was not of a very virulent type, and there were fogs, in many parts of the country, although the fogs in London were not of the worst type. Only a few days ago, however, the Minister gave me figures which showed that in February of this year, in the country generally, there were nearly twice as many deaths from bronchitis, bronco-pneumonia and influenza—all chest diseases—as there were 465 in February last year. In the London area there were more than double the number of deaths from these diseases this year. This February there were 8,695 deaths per million, whereas in February, 1958, there were 3,254 per million. That is very serious in itself, and it is also so because these deaths and the exacerbation of chronic bronchitis take up many beds in our hospitals, keeping out other cases which need treatment and thereby increasing waiting lists.
I recently received figures relating to the North-East Metropolitan Regional Hospital Board, of which I was a member until two years ago. I understand that a warning to take in only acute cases existed in that region from 19th January to 9th March. It appears that in the whole London area the emergency bed service was at its wits' end to find places for the many cases referred to it. Usually it deals with about 1,200 cases a week, mostly successfully, and is able to find places for them in some hospital or other. Those of us who have seen its work will know what splendid work it is. However, I am told that in the week ending 24th February last, instead of about 1,200 cases there were more than double that number, namely, 2,420. Chronic bronchitis is not only a danger in itself, which causes great suffering, but it also blocks our hospital beds in the winter, when they are most needed.
I suggest that the time has arrived for the Minister to try to find out more about the causes of this disease and the way to prevent it. We know something about it already. We know that it is commoner in urban areas. The death rate in these areas is six times as high as in rural regions of England and Wales. Why is this? It is partly due to overcrowding, and the spread of catarrhal infections, which get down into the lungs and start up acute bronchitis, which develops into chronic bronchitis. I am sure that another cause is the amount of sulphur in the atmosphere. Smoke may also have something to do with it. I am talking not of tobacco smoke but of smoke from coal fires. The sulphur is the important ingredient. The fact that many smokeless fuels contain nearly as much sulphur as does coal or coke means that they are also a menace to health. Dust in factories is undoubtedly another cause, and there is 466 also smoking. Richard Doll and others have shown, by careful work, using doctors as guinea-pigs, that more doctors who are inveterate smokers die from chronic bronchitis than do doctors generally.
There are other possible causes that need investigation. I ask the Minister to investigate the causation and prevention of this very serious and troublesome disease. I should like to see either a departmental committee of inquiry or, better still, a Royal Commission, set up to inquire into the cause and prevention of this disease. It may be said that it is a medical problem, but intelligent laymen can understand medical problems quite well, especially if they are explained by intelligent doctors. Those of us who served with the Minister in Committee on the Mental Health Bill came to the conclusion that, though the right hon. and learned Gentleman is not a doctor, there was very little about mental health that he did not know, although whether the knowledge was recently acquired or not none of us could be quite sure.
I want to suggest that a Royal Commission of intelligent laymen might perhaps be even better than a Departmental Committee, but I appeal to the Minister to realise what a danger and disadvantage to so many people this disease is—not only the sufferers from it, but others as well—and how, in some countries, particularly the Scandinavian countries, it is much less prevalent than in this country. I hope he will give his mind to the matter and see whether he cannot have some form of inquiry into the causation of this disease which may lead to its prevention.
§ 6.11 p.m.
§ Mr. Anthony Kershaw (Stroud)
I wish to congratulate my right hon. and learned Friend the Minister on the review which he started and completed, in spite of interruptions from the right hon. Lady the Member for Warrington (Dr. Summerskill), on the progress of our National Health Service during the past year. I think that the extra resources which the nation has been able to devote to the Health Service in the past year because of the measure of our prosperity are a source of real gratification to the people of this country. The Health 467 Service is popular, and it is regarded with affection by the people. We are proud of it, we are glad we have got it, and we think it is rather better than anybody else's health service, although probably we do not, individually, know very much about anybody else's health service. That good opinion in which the Health Service is held is undoubtedly due to the devoted administration of those who take part in it and to the wise guidance which successive Governments have given to it since its inception.
I may say, in passing, that I was sorry that the hon. Member for St. Pancras, North (Mr. K. Robinson) revived that ancient red herring about the Tory Party having voted against the National Health Service. It would be just as logical to say, if the Opposition vote against these Estimates tonight, that they will be voting against the National Health Service. [HON. MEMBERS: "No."] It would have the same degree of logic, though I agree that it is completely untrue. I am very happy that the Opposition say that is absolute nonsense, because, by the same token, it is absolute nonsense for them to say that we voted against the Health Service, when we were trying to get the very best Health Service at the very start.
§ Miss Herbison
I do not think the hon. Member for Stroud (Mr. Kershaw) was in the House when the National Health Service Bill was going through. Perhaps he does not know that his party voted against it not only on Second Reading but also on Third Reading, which meant that it voted in principle against the National Health Service.
§ Mr. Kershaw
I think that the hon. Lady, who has been longer in this House than I have, will know that that is a Parliamentary device and that we are not deceived by it.
I was particularly gratified to hear of the progress made with the construction of new hospital buildings and to learn that four are already in use and ten are building. We all know the vital importance of new buildings to hospitals in this regard, and it is very gratifying, that—I was going to say almost at long last—the financial position of the country has made it possible for us to embark upon this ambitious programme.
468 The pay and conditions of those taking part in the Health Service are also a vital link in our Health Service which, up to fairly recently, was rather weak. As I understood the figures which my right hon. and learned Friend gave in his résumé, the pay and conditions have risen about one-third in value since 1951, and that must be a source of gratification to all of us.
I had the opportunity the other day, through the kindness of my hon. Friend the Member for Epping (Mr. Finlay) and the noble Lord, Lord Taylor, to visit the Harlow Industrial Health Centre. As I believe my right hon. and learned Friend also went there later, I am not telling him anything he does not know, but I was extremely impressed with this industrial experiment, which fills a gap in our arrangements. It is an aspect of the Health Service in an area in which mostly small businesses or small factories are situated. The very large industries, employing many hundreds of people, can afford—and it is financially to their benefit to afford—a health service of their own inside the factories, but in the case of smaller ones employing up to 200 people or so, it would be a waste of their resources, and a waste of medical resources, to have to spend money in this way in the confines of their own factories. It seems to me that this could fill a need in some parts of the country where the factories are of the right size and sufficiently concentrated to provide a sufficient number of patients, and that such provision should be made in such areas.
A centre like this needs a certain amount of money and a certain amount of guidance. In the first place, it needs organisation. It means bringing the general practitioners in, and they should be willing to work it, because they are the doctors who must work it in with their own private practices. All this means a certain amount of organisation and give and take between the parties, and that has to be organised by somebody in the position of Lord Taylor. The best thing would be a whole-time organiser, and, to settle these very difficult questions, he must be a medical organiser as well. A person of that status and calibre must be fairly highly paid. Besides that, we have to have the buildings, we have to pay the staff and we have to acquire the equipment, and 469 all these things need a certain amount of money.
I wonder whether or not—and I think this is a matter for debate—the Government should help in the foundation of health centres of this sort. I know it can be said, and I think with force, that the Government should confine themselves to providing the minimum that is absolutely necessary, and that if private enterprise, industrial enterprise or anybody else wants to provide something a little better, it should raise the money to do so itself. A thing like this needs so much money to start and is so valuable to the community when it really gets going that any loans which the Government were able to make, in the way that the Nuffield Foundation did to Harlow, would soon be repaid, and the saving in industrial health and disease would be very great. I think the Committee is aware of the enormous number of days lost through industrial disease, far outstripping the number of days lost by strikes, which the public generally do not realise. It would be very valuable if that could be dealt with.
In going round the Centre, I was struck by the ingenuity by which X-ray machines had been acquired, often for a very small outlay, and that is illustrative of two things. One is the lavish equipment in the public service which causes these machines, which have many years of life in them, to be cast out so that they can be acquired by an enterprising person at almost derisory prices. Secondly, it illustrates what may become the merit of the block grant by which it is possible to make savings by intelligent buying, if the will to do so is there.
I welcome very much the announcement about salaries, because I had intended to say something about midwives who, as my right hon. and learned Friend knows, have been rather disturbed by their position until recently. In common with other hon. Members, I imagine, I have had a memorandum from the midwives asking that certain things should be done to improve their status and salaries. As I listened to my right hon. and learned Friend, I realised that every point that I had intended to make had been granted in the new arrangements that have been made, with the possible exception of one which my 470 right hon. and learned Friend did not mention. I think that, too, might well have been dealt with. Up to now, the promotion opportunities in the midwifery service have been rather small, and it has been suggested that in each unit of, say, fifty beds in large hospitals there should be a matron's job, so that there would be a little more opportunity of promotion in that service and thus provide an opportunity to those anxious to get on to do so.
I want next to deal with the Young-husband Report. I know that no conclusion about it has yet been reached and that there have to be consultations about it in the profession. However, I think that the House will welcome the largely sensible proposals in the Report and that, in general, it will in due course receive the commendation of the House.
However, it raises two broad questions about which I should like to ask at this early stage. In these days of increasing specialisation leading people to concentrate on isolated points, so to speak, rather than on the whole sphere of their profession, it becomes increasingly the case that some sections of medical or social science are almost left out of account because nobody is particularly-interested in them. That is particularly the field which the social workers cover and which the Younghusband Report says they should be more adequately trained to cover.
However, the Younghusband Report expects that social workers will have far more specialist training than has been the case hitherto. I am sure we welcome that, but I hope that those workers will not become so specialist that in a few years we find that some of their functions are left out and we have to appoint another committee to tell us that specialist training for social work has left some branches of this work uncovered.
Secondly, the Younghusband Report says that the work which will face these trained social workers is constantly expanding. I should like some explanation of what is meant by that. If it means that the work in connection with old people is constantly expanding, then it is easy to understand, because more people are reaching retiring age than has been the case before. But if it means 471 that people other than retirement pensioners will provide increasing work for the social workers which it is desired to train, then I am a little doubtful about it.
Is the assumption that as our bodily needs are met more adequately and as we live longer because of the better medicine which we have today, our moral and spiritual needs will become so great that we shall all have to have psychiatric treatment and call in the public service to help us when we have private difficulties? If that is the assumption, and if it is thought that as a nation we are becoming more juvenile and less adult and less able to manage our private affairs, then my right hon. and learned Friend should study the Report with a certain amount of caution, because that is not an assumption which should be accepted.
Lastly, I wish to refer to the position of the general practitioner who, after material construction, represents the most important factor in the National Health Service today. I hope that it will not be misunderstood if I say that the G.P. is not the man he was. He used to be more respected than he is now. He used to be a very good confident and mentor. [HON. MEMBERS: "He still is."] I say that he used to be more so. That is my point. He had a higher status in the past.
Perhaps I exaggerate in order to make my point, but I think that there is some danger of the G.P. becoming almost a medical mechanic, the chap one telephones to give one a certain note or to renew a prescription for mum's favourite medicine. His influence on personal matters is not exactly what it was. I believe that the mutual trust between the public and the G.P. has been somewhat damaged of recent years. [HON. MEMBERS: "How?"] I will not attempt to answer that, but I will put one or two facts to show why that is so.
At the beginning of the National Health Service, when many doctors suddenly had to look after longer lists of patients than before, there was bound to be a certain amount of dislocation, but I believe that those long lists have lasted too long and that they should now be reduced. I cannot but come to the conclusion that the basic reason why the lists have remained long is that G.P.s 472 are not paid enough and have to keep long lists in order to earn a living commensurate with their professional status. I know that it would be very difficult to work out, but that is my belief.
I understand that the G.P. is paid approximately £1 per patient per year. In the rural areas, such as that which I represent, making four or five journeys in a motor car, ten miles each way, and making five or six telephone calls to local hospitals to find whether there is a bed available for a patient, can soon eat up £1. That patient, if the doctor is being economic, is thereafter a dead loss to him—[Laughter.]—from a financial point of view. Perhaps that was not a happy phrase.
However, we cannot blame the doctor if sometimes he is slow to turn out when he thinks that he knows what the condition of the patient is and when he knows that the patient is a little fussy about wanting to be visited. There was a letter in the Daily Telegraph this morning which was headed, "Crying Wolf Too Often", or words to that effect, in which there was discussed the case of a doctor who had been disciplined for refusing to make a visit. The writer rightly said that doctors so often get called out on errands which are not emergencies, that if they occasionally make a mistake, that is understandable, although it is very damaging to the relationship between doctor and patient and damaging to the public estimation of the medical profession, which is a great pity.
§ Mr. A. Blenkinsop (Newcastle-upon-Tyne, East)
Would not the hon. Gentleman agree that all the investigations by the many committees which have studied this point have suggested that there is less calling out of doctors at night or at other inconvenient hours than used to be the case?
§ Mr. Kershaw
But it still exists. I am talking about how we can get rid of that in order to banish the feeling that the G.P. is not quite the chap he used to be.
Doctors are under pressure to keep their lists long and there are a few patients who abuse the position which they think they have under the Health Service. Many people consider, and I do not disagree with them, that they 473 have paid for their National Health Service and they are therefore determined to get the service which they think they ought to have. Of course, anyone who studies it knows that, in fact, that is not the case. Individually, we get the Health Service on the cheap, although as taxpayers we have to put on another hat and come to a somewhat different conclusion. As individuals we do not pay very much towards our Health Service benefits.
If the patient is unreasonable he can and, I am informed, sometimes does, indicate to the doctor that he will leave his list unless he gets the ambulance or other service which he requires. That does not make for good medicine or for that trust between doctor and patient which I should like to see.
§ Mr. John Diamond (Gloucester)
Would the hon. Gentleman explain how an increase in the salaries or emoluments of doctors will prevent certain types of patients making excessive calls on their time?
§ Mr. Kershaw
My point is that at the moment there is a severe discipline on doctors to behave in a correct manner medically. No one disagrees with that, although whether as professional people they need such discipline is another matter.
Secondly, there is a financial discipline on the doctor in that, because he has to have a very long list to earn a proper living, his status and medical performance are reduced and he cannot afford to permit a patient to leave his list. If his list were shorter, or if he had a larger income, he would be much freer to behave entirely as the medical position of his patient warranted.
I am not saying that doctors should not give every possible medical attention. No one would suggest that for a moment. But, after all, doctors are professional men with long training and may be expected to know their duties to their profession and to their patients. It is a bad thing if a doctor has to have his eyes deflected, so to speak, from this by financial considerations which at the moment, I am certain, cause him a certain amount of anxiety.
It is said that doctors are guilty of over-prescribing. I wonder whether that 474 is so. One must reflect that the provision of an expensive drug may get a man back to work much quicker than if he went on with a less modern drug and less modern attention. This complaint of over-prescribing by doctors has been greatly exaggerated. I once ploughed through a book which set out to show that there was over-prescribing by doctors. It was a big, monumental sort of work, but in the end the only thing I could understand was that the price of prescriptions in Bournemouth was higher than the price of prescriptions in Wigan, which was not very surprising.
Any pettifogging control over the price of prescriptions is something which a professional man of the status of a doctor really ought not to be subjected to. If we could have the status of the doctor restored to a greater extent to what it used to be before the National Health Service came in, that would be to the great advantage of the Health Service, with which we and most doctors are very satisfied.
The status of the general practitioner is slightly reduced by the achievements of modern medicine because the G.P. cannot possibly know all the things that are going on in research and at the same time keep abreast of his practice. Many of his patients are taken away to the large hospitals where he cannot possibly follow them. In country districts that situation is very much better. For example, in my part of the world, where we have the advantage of cottage hospitals, the liaison between hospitals and G.P.s is excellent. In towns where the hospitals are necessarily very much bigger the hospitals cannot have the G.P.s milling around trying to find their patients all the time. It might be possible to make better arrangements for liaison between the G.P.s and the big hospitals. The status of the G.P. is very important. This is one of the growing pains of the National Health Service which can be overcome. One way of overcoming it is by giving to the G.P. a higher financial status than he has at present.
§ 6.33 p.m.
§ Dr. J. Dickson Mabon (Greenock)
I am very pleased to follow the hon. Member for Stroud (Mr. Kershaw). Since his area got the new British Nylon Spinners factory some months ago, I have always 475 felt a little resentful towards him, but on this occasion I am very pleased to follow him in the debate because he said many pleasant things about my own profession.
I entirely agree that many doctors are so overstretched at work that they cannot give the kind of service that they would like to give, so the relationship between doctor and patient has to that extent been adversely affected and is not as good as it ought to be. Whether that adverse effect is because of the National Health Service is another argument. One has to look at conditions as they were before the Service was introduced, and then one finds that many medical men made very little money, especially if they were practising in industrial and slum districts. The very book to which the hon. Member for Stroud referred—I think it is called Social Aspects of Prescribing—illustrates that situation. Again, the pre-war figures of the number of patients per head of doctors show how lucrative it was to practise in a place like Bournemouth and how different it was in a place like Jarrow. Consequently, there were substantially far more doctors in Bournemouth than in Jarrow per head of the population before the war. It is hardly fair to say that the actual standard of practice has gone down throughout the whole of the profession.
The attitude of people towards doctors has changed, as it has to teachers and to many other professional people. We have become a less distinctive and stratified society since the war. People joined together more readily during the war and began to realise that people in other classes were not quite as snobbish, and on the other hand not quite as vulgar, as had previously been the belief. Social attitudes have changed a lot in twenty years. Doctors also have changed in their attitude to life. The striped trousers and the black jacket are no longer the fashion for doctors, and the tall hat in which—according to legend—one kept one's stethoscope has gone completely out of fashion. But today in many ways the doctors are more familiar with the lives of their patients. Whether that is a good thing or not is probably a subject for a social treatise.
I am grateful to the hon. Gentleman for mentioning these matters. I hope 476 that the Royal Commission will bring in a formidable award for the doctors, especially those who have the very difficult task of managing a practice single-handed where group practice is not possible. Then there are doctors in difficult areas, for instance working in slum areas, and there should be some increase in their standard of living as well as some incentive to them to try to reduce their lists. My hon. Friend the Member for Deptford (Sir L. Plummer) made a comment to me during the speech of the hon. Member for Stroud about the logic of his argument when he spoke of patients ringing up the doctor in the middle of the night. I believe it was said that, somehow or other, the doctor when shortening his list, would try to get rid of them.
§ Dr. Mabon
Perhaps. But I believe that there would then be an increasing tendency for doctors to report patients when large lists were no longer a primary aim. At the present time doctors do not, save in rare cases, report patients; it is the patients who report the doctors. Logically, doctors are entitled to report patients who lodge, falsely or maliciously, what they call an "emergency" call. There are some patients, one has to admit, who in their own minds regard every call as an emergency one, and the calls may not be regarded by the doctor as false or malicious even then. There are some patients, a minority I am glad to say, who would drag their doctors out of bed on quite ridiculous matters. It is wiser never to quarrel beforehand with those patients, but to fume after the event. Otherwise, as the hon. Gentleman said, we might end up with a dead loss.
I want to base my remarks on the question of waiting lists. I do not want the debate to degenerate into one of those marginal, statistical arguments, but I would argue that the next Government, whether it is constituted by my own party or by the party now in power, should look at the problem of waiting lists and try to do something about it. When we compare one waiting list with another, we find that the lists vary largely from district to district and from 477 hospital to hospital. Trying to link up the waiting lists with the number of consultants and staff employed in hospitals is a very obvious line of country to pursue, but it does not always follow that we can compare the services of the available part-time consultants and equate them with so many full-time consultants.
This is a question for the Ministry of Health and the Department of Health for Scotland. I am sorry to have to put them in that order, but I am afraid that in our administration in this country the Department of Health for Scotland usually trails behind the Ministry of Health in England. I hope that the Ministry will start a national survey of waiting lists and will try to persuade the Department of Health to follow. This should be a national survey based on common criteria to determine exactly what the waiting lists are and what steps are necessary to have them reduced.
I believe that one of the answers to the problem of reducing the waiting lists lies in the problem of the registrars, those much-neglected men of medicine, men of my own age or perhaps ten years older. If they are over forty and are still registrars, I am sorry for them. A number of them have left or are leaving the country because of the complete blockage in the higher reaches of the profession, not because of the intrinsic wickedness of the National Health Service as is often claimed, but because the Government have been unwilling to increase the number of consultant posts. It is ridiculous that we should have large lists of people waiting for important, serious operations, and yet do not provide more consultants. Unless we can make more consultant posts available, and especially more full-time consultant posts, we shall not make up the present back-log. At present many young men of medicine are completely frustrated in their medical careers and may end up by becoming embittered consultants for just a few years of their lives. That would be regrettable, but it will come about unless we do something.
The curious paradox is that if we do nothing about it we shall end up in twenty years with a tremendous gap because many people are being turned away from the specialities of medicine by reason of the blockage ahead of the 478 registrars. The young student tramping the wards with the registrar and the young houseman working alongside the registrar are influenced by the disappointed registrars who say, "It will be many years before I can get promotion. It will be another twenty years before so-and-so dies and I am able to step into a dead man's shoes."
This attitude is very bad. In twenty years' time we may not have the registrars to take the place of those who will then be moving up in the normal process of time.
I know that the Minister will reply that there is a committee inquiring into this subject. As long as I have been a Member of Parliament—and longer—there has been a committee going into this matter. We have been protesting for a long time, but we are getting nowhere. Since 1955 nothing in fact has been done about this. I remember an excellent article by a Scottish registrar in the British Medical Journal as early as 1956 asking for such a committee to be set up. I believe—we have had our Health Estimate debates in the Scottish Grand Commitee—that committee is still meeting on a United Kingdom basis, but we still have no report and I do not know when it will come. Is is tactically dependent on the Royal Commission? Perhaps the Secretary of State will give the doctors some news about that if there is some connection between one and the other and if there is some monetary link.
I turn now from the questions of the staff to deal with those who are waiting for medical attention to the actual facilities. The Tory Party, probably justifiably from its political point of view, takes great pride in its claims about the money being spent on the Health Service. I am glad that it is not substantially less in proportion compared with what the Labour Government spent, but I would point out that the Guillebaud Committee was most unhappy about the amount of money devoted to capital investment in the Service and about the proportion of the national product being put aside for the Service. This is a matter on which hon. Gentlemen opposite are blinding themselves with their own propaganda. They take a delight in saying that so many millions will be spent on hospital development in a certain time. However, the British Medical Association, hardly the 479 most Socialist and radical organisation in the country, has called for an expenditure of £750 million over ten years. That is an average of £75 million a year, which knocks the Government's present programme into a cocked hat. But these are realists. They are not men speaking with a vested interest or with a political return in mind. They are talking about actual need. I wish at times that in our political debates we talked about needs rather than the comparative endeavours of one party and another. That is a barren and sterile field. It may be of some use on the hustings, but it is no use in the House of Commons.
The hon. Member for Stroud—I am surprised that he does himself this injustice—tried to defend the actions of the Conservative Party in the House between 1945 and 1950. Why should he do so? He was not in the House at that time. Why should he take upon himself the sins of his predecessors in the Tory Party? All parties make mistakes. Why should the hon. Member, who was not in the House at the time, take upon himself the mistake then made by the Tory Party? It was an awful mistake, and the Tory Party has bitterly regretted it ever since. The posters which went up at the time of the 1950 General Election caused many a Labour supporter to smile. The Conservative and Unionist Party said, "We fought for the social services." The obvious reply was, "Methinks it doth protest too much." Politically, the National Health Service was a most popular Measure, and medically it was a wonderful step forward that had to come in some form or another when the war was over. To align one-self with the inevitable is a simple prerequisite of any sensible politician.
§ Mr. Kershaw
My point was not that the Tory Party never makes mistakes but that it did not make that mistake.
§ Dr. Mabon
I will not answer that point. The hon. Gentleman has not managed to capture his full tone of conviction. In other words, I do not think he really believes that.
On the subject of drugs, I want to say a word about the two Reports. I am glad that we are voting against the Government tonight to chop £10 off the Votes of the Ministry of Health and the Department of Health, for they have been most 480 remiss in respect of the Hinchliffe and Douglas Committees' Reports. Those are very valuable Reports. In a way they provide an answer to many of the charges made by politicians of all parties about the misuse of and extravagance in the use of drugs and so on. In other words, it is a most important part of our discussion politically, and I am surprised that the Government did not provide time of their own much earlier in which we could discuss these Reports.
The debate is, of course, a little ridiculous when one considers that we are trying to cover not only the Hinchliffe and Douglas Reports—and they have interesting variants in recommendations which are themselves worthy of discussion—but also the Cranbrook Committee's Report, the Montgomery Committee's Report—the Scottish equivalent—and the Younghusband Committee's Report. It is silly that the Government have not found more time to enable us to discuss these essential health matters.
Having read the Hinchliffe and Douglas Reports, I think we might be able now to proclaim that a rising drug bill does not necessarily mean wasteful use of drugs. It is high time we agreed on both sides not to talk about a rising drug bill as being evidence of extravagance. We are living in an era of improved medicines, and medicines which are in the initial stages expensive. We ought to recognise that there is a lot of work done in the financing of many of these new drugs which is valid expenditure and should be carried in the initial stages of the drug. What we should not allow to follow from that is that the manufacturer or discoverer should be able to fleece the community for longer than a reasonable period of time to enable him to recompense himself for his initial effort.
The greatest drug discovered since the end of the war is probably penicillin. The discoverer is dead, but it is worth while recalling that Sir Alexander Fleming gave the drug to humanity without patent and without seeking any recompense for himself. It would be a wonderful thing if others would follow suit and if the drug companies were willing to hand over advantages of that kind. That is, after all, the great conflict in medicine. We find it in many of the arguments that we hear.
481 Medicine is primarily a social service, and there should be no place in it for commercialism. It is probably one of the hard facts of life that there must be some private enterprise, some seeking after money, in some way or another, but we in the Committee must try to temper that commercial aspect with what are the fundamental objectives of medicine. I suggest that the fundamental aim is to provide the best drugs and the best treatment possible to the patient at the right time. I hope that the rising drug bill will be accepted by the Committee, that this will mean that we are on the way to better medicine and that this, in turn, may stop the carping about the expense of drugs.
Perhaps I might mention one useful recommendation in the Report to which the Minister referred this afternoon and which may cause a great deal of trouble. The Minister said that there would be discussion with the appropriate authorities on this subject. I refer to the recommended central expert body to decide on the therapeutic value of certain drugs. Several of my hon. Friends and myself met some representatives of the pharmaceutical industry yesterday and had a very long discussion with them. I think that the drug companies have a reasonable point of view in many ways and that their new code, to which my right hon. Friend the Member for Warrington (Dr. Summerskill) referred, is commendable. What a pity that not all drug companies so far are observing this code. I look forward to the time when they do.
It seems to me, however, that we have here a most important question as to how we are to obtain any objective assessment of the merits of one drug as against another without the manufacturers becoming most annoyed at this independent assessment. If the expert body is considering the therapeutic value of drugs, it is bound to have to say at one time or another, "Drug A is therapeutically better than drug B." If these are proprietary drugs, then obviously the firm selling the apparently inferior drug will make a great protest. I suggest that every access to information and every method of communication should be possible between the company concerned and the central committee to make sure that there is no possible misrepresentation.
482 Nevertheless, we should not run away from the idea of a central body. We ought not to decide, simply because it will cause some embarrassment, that we should not have such a body. I remember an excellent article in the British Medical Journal not long ago by two Scottish doctors. It is amazing how the best doctors are so often Scottish doctors; I have to say that, because I should not be allowed back home if I did not. After going through all the various iron preparations these two doctors ended by saying that if doctors continued to prescribe tab. ferrous sulphate, grains three, t.i.d. the matter would be settled and there was no added therapeutic advantage in the other preparations. That is perhaps a little dogmatic, but it is a jolt, when we think of the great number of iron products available, to be told in a medical paper that this was so. It shows that this central body has a very wide field of opportunity open to it.
I remember as a student hearing one professor open his medical lecture by reading the B.M.A. pamphlets of 1909–10 exposing the drug rackets of that time. The B.M.A. has changed much since those early days. These were wonderful pamphlets to listen to as a student, and it was interesting to realise how much quackery went into drug advertising and selling. I do not say that by any means the majority of companies are like that today. Not at all. But there is a fringe which has to be exposed, and we must keep drugs under review to make sure that expensive substitutes are not foisted on the innocent people of this country.
I regard the Minister as one of the best debaters in the Committee, and I mean no disrespect to him when I say that, with the present Minister and the Joint Under-Secretary at the Scottish Office, I feel that we are not getting quite the kind of administration which we need at present. It may be competent. Ministers may tell themselves that that is so. It is not imaginative. So many opportunities are open to the Minister and to the Under-Secretary in medicine which offer a great challenge.
I hope that the positions of Minister of Health and of the Scottish Minister responsible for the Department will not be regarded merely as political posts which M.P.s of one party or another 483 pass through, but rather that the occupants of those offices will become imbued with the ideals of the professions within the ambit of the Ministry of Health and the Department, and that these offices themselves will become vocations. After the battle about wages, salaries and conditions has ended, we have to remember that doctors, nurses and midwives are not in the health professions to make money. I hope that the political heads of this Ministry and the Department, too, will work for the Service with imagination and will not regard their offices as merely timeserving posts in the Administration.
§ 6.57 p.m.
§ Mr. Patrick Wolrige-Gordon (Aberdeenshire, East)
My brief to speak in the debate must be simply as a member of the general public, because I have little knowledge either of the administration or the practice of the National Health Service and can claim only general interest in the whole Service and particular interest in those parts of it which affect my own area.
In that connection I should like to pay a tribute to the National Health Service as it has been and is being administered in my part of the country. Country areas, with the distances involved and the variety of needs for different districts, often present greater problems to a central administration than do urban areas. In addition, the more individual qualities demanded in country practice tend to make uniformity more difficult to apply. In spite of these factors, the National Health Service in Aberdeenshire is extremely successful, although I do not say that there are not quarrels; in fact, there are.
At the moment a controversy is raging there about the projected closure of two small country hospitals. I am very much in favour of these hospitals and this kind of hospitals being kept open, if humanly possible. Every community, however distant, is equally important, those small and far away no less so than the larger and perhaps more compulsive ones nearer the centre. In the country areas, these tiny hospital units, which may look so unimportant on the books of the gleaming, starched frontages of the regional hospital boards, render an incalculable service to the community in 484 which they are situated. They therefore merit preservation in these communities for that reason alone and without necessarily raising consideration of the wider issues which must be involved in connection with larger units.
There has been considerable feeling in the past that certain types of hospital should be transferred to local health authorities. This has been denied, so far, and to my mind convincingly denied, but I think that there might be a case for transferring such small country hospitals to local authorities if in this way they should prove easier to administer and thus to maintain. I am certain that at least when they can preserve themselves they should be allowed to do so. I will go further. In this age of increasing paternalistic Government there is a case for that old function of patronage, under which those distant country areas used to be endowed locally by the leading families. This function of patronage should be transferred, if possible, to the central authority. It might be a little more expensive, but not very much more expensive, particularly when we consider the great contributions, including often large financial contributions, which these hospitals have made already to the National Health Service.
There is another case at Peterhead where a magnificent local effort is producing a large sum of money to contribute towards the building of a maternity home. This is being supported sympathetically by the regional hospital board. I hope that we shall continue to see that kind of co-operation between the central authority and the local community.
In my part of the world the incidence of G.P. beds in the hospitals is very high. That is very satisfactory, and I am glad that it continues to be still further encouraged. Obviously, it is desirable that the closest possible contact should be maintained between doctor and patient, and it is more than ever desirable that it should be maintained throughout the latter's stay in hospital, with the addition of specialist treatment on call should that prove necessary. After the reduction in general practitioner beds which resulted when the National Health Service was introduced, I am glad that the number should have been increasing slowly but steadily over the last five years. I am especially glad that it should be so high in my own area.
485 As a layman, it seems to me a pity that this practice should not extend to district nurses, particularly as regards midwifery. I understand that in the same way as sometimes concerns doctors this would represent considerable administrative and even psychological difficulties, but it might be worth while if those obstacles could be surmounted.
The great benefit we have in Scotland is that our teaching hospitals are, in nearly every case, grouped with ordinary hospitals and come under their direction. There is no question but that this method of administration is highly satisfactory.
There is one feature about the Health Service which tends to annoy people like me who do not know very much about it. It seems to us that foreigners receive just as much benefit from the Health Service as we do, without contributing anything towards it in any way. I have been making inquiries about this and I find that this annoyance is based, to a certain extent, upon misconceptions which I do not think are widely enough known outside. First, the direct contribution towards the Health Service is very small, because most of its expense is met by taxation. Secondly, those people who are supposed to come to this country in order to benefit from the Health Service have to pay. Finally, it has been made clear to me that to find out who are the people who fall sick while visiting this country, and who therefore profit from the Health Service, and to get their bills paid would require extremely complicated and expensive administrative machinery. In addition, the numbers are fairly small.
Provided that these visitors do not receive priority treatment to the detriment of our own countrymen, I think that we should accept the position with more equanimity than we do at present. Obviously, the way to solve this problem is to try wherever possible to make reciprocal agreements with other countries. I hope that everything possible is being done in that respect.
§ 7.3 p.m.
§ Mr. A. Blenkinsop (Newcastle-upon-Tyne, East)
I am glad at least to be able to congratulate the hon. Member for Aberdeenshire, East (Mr. Wolrige-Gordon) on some of his last comments 486 It is true that many rather foolish things are said about foreigners coming to this country and gaining enormous advantages from our Health Service, but they make some contribution to it themselves in our general taxation, and the numbers are certainly small. Administratively it would be very complicated to recover the money. It is a good advertisement for our National Health Service that we should be doing this. Our attitude should rather be to try to extend this type of facility to other countries. There are already some agreements. I wish that there were none. I believe that it is possible that as time goes by more will realise with shame that they do not provide the kind of facilities which I hope we are proud of in this country. After all, we are only following the practice of some hospitals and monasteries of the Middle Ages. In this case, it is a good tradition to follow.
I wish, chiefly, to concentrate my remarks upon certain points which I felt that the Minister rode away on rather too easily. We are all delighted at and immensely proud of some of the excellent work being done by the National Health Service. We were delighted to hear some of the figures given by the Minister. We are over-joyed that there should be so many receiving such very real and tangible benefits from the service. What annoys us and makes us sometimes rather bitter is the fact that we feel that we have a tool which is not being properly and fully used. We believe that the Health Service is capable of far fuller service to the people and that opportunity is not being taken. We believe that there is a lack of drive, energy and determination on the part of the Ministry. It is not wholly the fault of the Minister. No doubt some of the complaints could fairly be laid at the doors of other Ministers than the Minister of Health, but as head of the Department he must accept responsibility for the disappointment felt by many people at the lack of development over these years.
The account given by the right hon. Gentleman, pleasing though it was, is not encouraging to anyone who thinks about the possibilities and potentialities of the Service, which are not being properly and fully utilised. I will start by examining what the Minister said, for example, about capital expenditure. 487 He can rightly comment on the figures for capital expenditure in the early years at the end of the war when the Health Service was being established. Relatively, those figures were small. How could they be anything else? It is not a criticism to bring those into the argument. In any case, if the right hon. Gentleman cares to examine the figures quoted by Professor Titmuss and Dr. Abel-Smith in their report to the Guillebaud Committee he will see a much more careful analysis of the proper expenditure in terms of assets on the capital side in the Health Service in the years of the Labour administration and the years immediately following in the Conservative administration. That gives a rather different picture. One must look at these figures very critically.
At this moment when the Government are congratulating themselves upon their ability to encourage all kinds of building to take place—it is a rather different picture from a year ago—it is most extraordinary that we are seeing these faceless blocks of office buildings going up all over London. They have no architectural merit. They are built without any architect knowing for what he is building or designing in nearly every case. There are some very despicable efforts to be seen in London. All this is going on at the same time as we are being told that we should be proud that we are to spend on capital account in the current financial year about £25 million, taking into account the capital expenditure in Scotland. That is to be set against the figure which the Guillebaud Committee at the beginning of 1956 recommended for seven years of £30 million per year. In present-day terms of money values that figure would be higher. Probably it would be 10 or 11 per cent. higher.
I am wholly unimpressed by the Minister saying to us that we should be delighted to learn that £25 million will be spent on capital expenditure in the current year. That should be set against some of the facts given in the British Medical Journal of 4th April in the excellent report that it produced on hospital building. The Minister should study the report very carefully. It is a very carefully prepared report. It comments on the position and age of our hospital buildings. On take-over in 488 1948 two-thirds of the hospitals were built before 1891 and one-quarter were built before 1861. That means that a quarter of them were 100 years old.
In such a situation, while it was obviously essential at the immediate outset of the Service to make do and mend in every way we could—and we did miracles in that way considering our resources—it is no longer a sensible policy to adopt. Today, it is a very uneconomic policy to adopt. One is worried by some of the examples still to be seen of the continuation of this policy. As I say, it was inevitable in the early years after the war, but when one looks around and sees the other use made of material and manpower today it is obvious that it is inevitable no longer.
The report in the British Medical Journal gives three examples. I shall not weary the Committee by reciting them all, but I will quote only one, which, incidentally, is similar to a case of which I have personal knowledge. This report speaks of:A special hospital where £1 million will be spent on extensions to an already obsolete building because money is not forthcoming for a completely new hospital But after this there will still not be an efficient hospital commensurate with the work to be done.What we have to ask ourselves is whether, in many cases, we are putting highly expensive equipment into old buildings that are not worthy of that equipment, or of all the other inside alterations that are thereby made necessary.
I could quote many cases where such things are still being done. It seems utterly foolish. If the Minister was facing his problems at all actively, he ought to have got the support of the Chancellor of the Exchequer for a programme much more ambitious than that announced. I am very disappointed that the right hon. and learned Gentleman has not been able to say any more than we know of the programmes for next year, with a small advance in the succeeding year.
It makes very poor reading as against either the recommendation of the Guillebaud Committee—and that, I think, was too modest, anyhow—or the rather more ambitious but much more realistic programme set before us by the writers of the article in the British Medical Journal. 489 I hope that we shall soon have a Minister ambitious enough to see the importance of a real new programme of hospital building phased over a number of years; realising that this cannot be done in a moment, but realising, too, that we could probably gain great economies from full exploitation of modern architectural designs truly adaptable to changing uses.
We want no more of the old form of traditional hospital building that forces us, long after its use has passed, to make expensive alterations in a large and heavy structure. Today, we must think in terms of much lighter and adaptable construction, and excellent work has been done in this regard by the Nuffield Trust. That cannot be done unless the resources are made available. The ten years that have passed will not have been utterly wasted if we now have a really ambitious programme to make use of the fresh ideas that have developed in those years. But I see very little evidence of that at present, and I am very sorry that more has not been done.
My hon. Friend the Member for Greenock (Dr. Dickson Mabon) said that it was not easy to judge waiting lists, as different factors operate in different areas, but he invited the Minister to get on with a national inquiry into this subject so that we could judge it more fairly. I have been urging on the Minister for some time now a fuller examination of the whole question of waiting lists. The same issue of the British Medical Journal points out some quite pertinent facts. It says:The waiting-lists should be also considered with reference to the need for more hospital buildingThe writers point out that while there has been a great improvement in the treatment of the more urgent medical cases there is a great list of patients with what are, perhaps, less serious conditions, but conditions that enforce a very great deal of hardship on the patient, and possibly upon the whole economy.
They point out, for example, that the hospital service… should also consider any other conditions which affect health and efficiency, such as hernia, haemorrhoids, varicose veins and genito-urinary conditions.In this connection, one could add conditions arising from industrial injuries. They say: 490The waiting-list for these complaints is often two years or more, and from the point of view of the country's economy earlier treatment of these less urgent problems should be a major aim.I cannot detect in the Minister any appreciation of the urgency of this. He passes it off with a good-humoured quip as if it were of less significance. The Health Service should now be in a position to deal with these matters, and it is shocking that after the passage of all these years we should read in the official records that over the last two years the waiting lists have been growing.
That is tragic, of course, and it should give us all great anxiety. While action is probably being taken in some areas to improve the position, it is very unsatisfactory to know that more and more people—and the country, too—are being put to the loss involved in these very heavy waiting lists. In England and Wales alone there were about 440,000 patients on the lists at the end of last year. That is a tragic state of affairs, and not one of which the Minister can for a moment pretend to be proud.
Those waiting lists must be tackled by tackling the problem of the shortage of fully-qualified consultants. There is undoubtedly a need to break this jam in the hospitals. There are far too many junior and senior registrars having to take up work that should be done at the consultant level. That results from a lack of sufficient appointments. If we look at the figures, we can see that the great expansion that took place in appointments in the early years of the National Health Service has flattened out, and there has been relatively little increase in the last few years. This has stultified the whole position, and has frustrated numbers of young and able men who have not been able to advance in the Service.
The position also results partly from the lack of some proper form of self-discipline among senior consultants. Even if it hurts some of my hon. Friends to hear it, one has to face the fact that the members of the medical profession sometimes look upon themselves a little too much as gods. One must try to get a more rational, modern view of the position of the doctor and the specialist. It is fair criticism to say that in some respects the National Health Service, so far from imposing too strict conditions 491 upon the medical profession, has allowed the profession unduly to dominate the National Health Service.
I agree with my hon. Friends who have said that we should ensure that the doctor has proper freedom in his work, but if that freedom is to be assured to the medical profession, the profession must look to the actions of a minority of their number who impose an unfair burden upon the rest of their colleagues, quite apart from anybody else.
We have 56,000 building trade and constructional workers out of work in England and Wales. Why are we not using them to get on with the really imaginative hospital building programme that is needed to deal with these waiting lists? We have idle resources, and surely there is no reason for not utilising them properly.
The Minister dealt too lightly with the question of prescription charges and the recommendations of the Hinchliffe Committee. I notice, as did my right hon. Friend the Member for Warrington (Dr. Summerskill), that the Hinchliffe Committee argues strongly that the effect of the prescription charges has been to stimulate the wrong incentives. The Committee states that these charges have twisted the Service and have given it a wrong direction. The Committee goes on with suggestions for easing the change-over, to make it as smooth as possible, and indeed it would be surprising if a a body like the Hinchliffe Committee did not take this modest view of the matter.
Nevertheless, the Committee goes on to say in firm terms in paragraph 288:We consider that the present charge is a tax which stimulates avoiding action and is resented by patients and doctors as a tax on illness.Then the Report goes on to discuss the position of dispensing doctors and so on, and states:We conclude therefore that, besides stimulating the wrong incentives, the charge per prescription has proved disappointing financially.That is in paragraph 289, if the right hon. Gentleman is following the Report closely.
It seems to me that, faced with a recommendation of that kind with those rather worrying words, and backed up 492 by the other Reports of which we have heard dealing with the effect of prescription charges, besides the investigation that was made and reported in the British Medical Journal and the Lancet not long ago, as well as the recommendations of the British Medical Association, we have a right to expect more from the Minister than the mere statement that he is prepared to consult with the medical profession about the proposal for limiting the quantities of drugs.
In view of that expression of opinion about the serious effect of prescription charges, we have a right to expect the Minister to be more forthcoming instead of merely saying that he is prepared to discuss the quantities prescribed. I recognise that we have a Conservative Government and we cannot expect everything straight away, but we do at least expect a temporary review of the present charges and some sort of undertaking that the Government are prepared to make this kind of gesture——
§ Mr. Walker-Smith
The hon. Gentleman has referred to several paragraphs of the Hinchliffe Report, but if he wants the Committee to know precisely what the Hinchliffe Committee suggested he must refer to paragraphs 299 and 301, of which he stopped short. If he will read those paragraphs and then read my speech in the OFFICIAL REPORT tomorrow, which I am sure he will do in any case, he will see that we have recognised the constructive approach suggested in the Report and he will also see how far we have gone.
§ Mr. Blenkinsop
Yes, but what I am complaining about is that the Minister is following the very modest view expressed in the Hinchliffe Report and has not gone any further. I believe that the Minister, faced with these worrying comments in the Report, should have gone much further and should have said, "In order to prove to the medical profession that we are really sincere in being prepared to withdraw the charge, we will at least take some interim action in this matter." That surely would have been a reasonable approach. I know the recommendations which the Hinchliffe Committee has made. They have been referred to on several occasions and, indeed, the right hon. and learned Gentleman read them out. I am not 493 trying to dodge them. They are very well known. What I am saying is that they do not satisfy us and they are not sufficient. If the Minister were really concerned about the matter I feel that he should have gone much further than he has done.
My right hon. Friend and, indeed, the right hon. and learned Gentleman referred to the question of the preventive services and called attention to the need for a more vigorous attitude to prevention. Although the Minister fairly quoted the figures relating to the expansion that has taken place—and I do not blame him for doing so—I feel that anyone with knowledge of any of these services, such as the mental health service, will know how little those figures actually cover. The Minister may say that there has been an expansion, or even a doubling of the expenditure, in the local authority mental health service, but in fact every expert with knowledge of this work knows how minute is the work at the moment. They know, and the Minister recognises, that there are certain cities which have made considerable efforts in this field, and we are all full of admiration for them, but over the country as a whole there has been a lack of action.
I have recently addressed members of hospital management committees and local authority health committees, and I have been disturbed by their apparent willingness to "pass the buck" to somebody else to get on with this work. This will not do. The Minister's weakness in allowing the Government and the Treasury to get away with the block grant has shackled him and has made it unlikely that this important work will be properly carried out.
If the Minister really had the drive that we expect from a Minister of Health, there ought now to be a great effort at developing an industrial health service which is now vital to Britain. It could save us an enormous amount of money. We are losing a great deal in terms of economic effort because of the colossal rate of preventable illness and accident in industry.
The Minister has been far too complacent. The need today is for a Minister with real energy, who is prepared to challenge the Treasury and the country, and to reveal the great opportunities which He before us in our National 494 Health Service, of which we are proud but which at the moment, I feel, are not being taken to the full.
§ 7.28 p.m.
§ Sir Keith Joseph (Leeds, North-East)
It is a pleasure to follow the hon. Member for Newcastle-upon-Tyne, East (Mr. Blenkinsop) who has delivered a well-informed speech, but I suggest that in two respects he has omitted to mention some of the hopeful elements.
He talked of the hospital building programme. I should think that every hon. Member would like the capital programme to be even larger than it is today, but we must recognise that there is keen competition for many alternative uses of our resources, and I congratulate my right hon. and learned Friend the Minister of Health on the slice that he has got for the hospital building programme.
I should like to congratulate my right hon. and learned Friend also on the fact that he has taken a leaf out of the very successful book of the Minister of Education and his predecessors in both parties. The building development unit of the Ministry of Education has succeeded, ever since the war, in steadily reducing the cost of even better schools each year, despite the rise in the costs of building. If the development unit in the Ministry of Health can, over the years—it will not be a quick job—produce a revolution in the cost of hospital building much the same as has been produced in school building, the hon. Member for Newcastle-upon-Tyne, East will find that the money available for the hospital building programme will go very much further than it seems likely to go today.
I particularly congratulate my right hon. and learned Friend on his decision to use this building development unit in producing prototypes which, when suitable may be built by his Ministry. This is the way to try out the ideas, see to what extent they are successful, and, when they are successful, persuade the regional hospital boards to copy them. I feel that the hon. Gentleman missed a very hopeful point in the capital programme which he criticised when he did not mention that.
It was interesting to hear the hon. Gentleman stress, once again, as the right hon. Lady the Member for Warrington (Dr. Summerskill) did, that the 495 removal of the prescription charge has first place in the Opposition's list of priorities for the Health Service. I have seen very little evidence—hon. Members opposite will give me credit for reading almost everything which comes out on the subject—that, bearing in mind the work of the National Assistance Board, people are, or need be, inhibited by the charge as it is now from using medicines, if they take advantage of the resources available from the taxpayer through the National Assistance Board. If we found that people were inhibited from using medicine, this would be a most persuasive argument against the charge in its present form.
§ Mr. Blenkinsop
Does the hon. Gentleman deny the point made very clearly in the Hinchliffe Report and other Reports which have been published?
§ Sir K. Joseph
No. I admit readily that the quantities seem to have grown with the present form of prescription charge; but my right hon. and learned Friend has said clearly that he is having consultations with a view to meeting the recommendations of the Hinchliffe Committee on this point.
Turning to the general subject of the debate, I will start by saying that the Committee as a whole should welcome the speech of my right hon. and learned Friend for the indications it gave of very remarkable progress. This progress, of course, has been brought about not only by the administrators, and still less by the politicians, but by the scientists, doctors, nurses and everyone working in this vast field of health. There has been most remarkable progress on a score of fronts.
I particularly welcome the creation of the hospital efficiency service, which gives a good start to the expansion of the organisation and methods service which many of us hope will relieve the burden on the manual and nursing workers in hospitals, while improving the service to the public and increasing the value for money.
I wish to concentrate not on the work which falls exclusively within the province of my right hon. and learned Friend the Minister of Health. I believe that the subject mooted today in the columns of The Times by a letter from 496 Sir George Schuster—a subject which has been referred to by the right hon. Lady and spoken about also at length and with feeling by my right hon. and learned Friend—the theme of coordination—is something to which we here should pay more attention. It is, as it were, the twilight area in which the citizen often finds himself. With the best will in the world, with all our different organs dealing with health, the citizen who does fall ill often does not derive the best value from the health and welfare services simply because the co-ordination is not as good as it might be.
New Reports tend to steal the limelight from the old. I have here a dogeared copy of the Boucher Report on the Services Available to the Chronic Sick and Elderly, and I feel that this Report has been far too little discussed in the House of Commons. I congratulate my right hon. and learned Friend on publishing it. I congratulate his predecessor on conceiving it. I congratulate Dr. Boucher and all concerned on preparing it. The question now is, what on earth can be done to propagate what it has to teach? Within the pages of the Boucher Report there is an answer to almost every problem. Somewhere in the country, someone has the solution to every difficulty in coordination. There is good practice in every complex situation. How are we to spread the good practice in a field where everyone is either a professional worker or, at any rate, not under the command of my right hon. and learned Friend?
There are four particular obstacles in the way of co-ordination: the problems of direction, the problems of planning and research, the problems of staffing, and the problems of finance. With a blush, I confess that, at one time, I was one who thought that all welfare activities should be tidily packed under one super-Minister. After examination, I have realised the error of my ways. It would be utterly beyond the power of anyone responsible to the House to cover the whole range of welfare activities. Any analogy with defence which I or anyone at one time propounded does not give the right answer in this case.
There is no need to be too ambitious in order to achieve some partial success. 497 My right hon. and learned Friend will realise that it is no reflection on him personally—anything but—when I say that the pattern in Scotland is one which we in England could learn from. In Scotland, there is the conjunction of housing, health and local government. There is no reason, therefore, why it should not, at least, be considered in England.
It would bring under one political control those activities which, we know, most directly affect the citizen, the local authority preventive services, the hospital services and the medical services. To those it would add the vital service of housing, particularly important in preparation for the increasing proportion of the old in our population. It would mean one Minister fewer, but it would, after all, merely restore the arrangement under which this country was governed until fairly recently, and I believe that much good would come out of it.
Only in this way, perhaps, could the lessons of the Boucher Report be really driven home by one man at the top of the local government, executive council and hospital pyramid. Only then would one stream of circulars be sent out, and only then would all the officers concerned, the planning and executive officers, have their place in the same pyramid and be answerable to the same Minister.
A Minister with power but without research or planning staff is almost valueless, just as a planning and research staff without a unifying Ministry is impotent. There is much to be learnt from Sir George Schuster's excellent pamphlet, "Creative Leadership in the Health Service". He drew attention there, as many others have done, to the need for more research.
I speak diffidently here because I am, obviously, not claiming that we need a great research staff in order to discover several things which commonsense tells us should be done today, if we have the money and the staff. I do suggest, however, that there are subjects whose solution might baffle the most conscientious civil servants, who are, after all, kept very busy. The civil servants are not free to roam away from their immediate preoccupations, and they are not, usually, equipped with statistical or 498 other such specialised research knowledge. Besides, it cannot always be easy for people in the Departments to criticise policy.
The sort of research I have in mind has been pleaded for by Younghusband, by Hinchliffe, by the National Corporation for the Care of Old People, by Lady Wootton in her book, and by many other pundits. Might it not be that this kind of research could be done best outside the Government machine altogether? I know that the Ministry of Health, in its Part II Report this year, pleads for more research through the local authorities, outside its own door. But might it not be that there is a place in the social services for, as it were, a Chatham House, an independent body, supported, perhaps, as Chatham House is, partly by subscriptions from corporate bodies and individuals and partly by Government grant?
Such an establishment could fill out the work at present being done by the Nuffield Foundation and the King Edward Foundation, for instance. It would not only be able to initiate new research and, perhaps, experiments, but it would be able, also, to absorb and digest the countless disparate ideas about the social services which are flooding forth from so many different sources today. I am sure they cannot properly be absorbed by Ministries which are separate and concerned with health, on the one hand, and local government, on the other. The civil servants in the Ministries are desperately busy with the myriad activities for which they are responsible daily in their separate Departments. I very much feel, therefore, that there is room for more research.
It is with even more diffidence that I mention a relatively new type, namely, operational research. This is the study of the cost and service resulting from different combinations of variable factors. It is a new technique used in plenty by Government Departments, particularly by the Service Ministries. It is used by the nationalised boards, particularly the National Coal Board, and it is used ever more progressively and increasingly by private industry. All of these—public bodies, the nationalised boards and private enterprise—find that operational research pays. May it not be—and I say this very humbly—that 499 the social services might find that it would pay also?
I realise that in private enterprise and public enterprise profit is a motive which lends itself to easy measurement. If the question is "Shall we have a coal mine here, or a coal mine there?" then, "Which will be cheaper in cost?" gives a starting point for comparison. It is not possible to do the same with welfare, because so many social factors are involved. If we are to make use of operational research we should start now by setting up a small unit, either within the Government or encouraged by the Government, in a sort of Chatham House outside the Government which will begin to formulate the criteria which one day will permit us to use these new and remarkable techniques for the more effective service of the public in the social services.
If I were asked to give examples of what sort of work such a body would do if it were in action, I would ask where study is being given to the comparative results and costs of the normal mental health service in comparison with the Health Service being provided at Worthing, Oldham, York and Nottingham. I would ask where consideration is being given to the remarkable work of Martin in his book called "The Social Aspects of Prescribing ". I would ask which Ministry or Department is conducting research into the question whether it is better in an ageing population to expand our domiciliary services—that would involve higher wages for more home helps and possibly constant attendance allowances—or whether it is better to expand Part III accommodation or geriatric wards in hospitals.
I do not believe that the Ministry as at present constituted can handle academically—and there is some academic work to be done before a practical policy can be arrived at—these issues which span the frontiers of several Ministries and which often involve the accumulation of detailed information which no Ministry is equipped to obtain. I therefore plead for more research to help the Ministry.
Thirdly, I want to deal with the question of staff. I realise that the Young-husband Report was so recently published 500 that very few of us can have had time to arrive at a clear view. I believe after one reading that it is a splendid Report, taken as a coherent whole. I am disappointed only that in its panoply of social work it has not made provision for the training of people at a policy level. How does the Committee think that in future we shall get the heads of local authority welfare departments? These are people who would benefit possibly from university courses after they have had some experience in the field. I believe that that is the only omission in the Report.
I very much welcome the idea of a national council for social work training and I hope that the staff college, which would be of infinite value in spreading good ideas as well as in teaching and carrying out the functions which the Report suggests, will get a favourable wind from any voluntary bodies which it is hoped may support it.
I now turn to the most obdurate problem of all, namely, finance. As we all know, even with the best will in the world, bodies required to co-operate and which draw their finances from different sources often find that they have contradictory interests. As we all know, the running cost of the Health Service is paid for by the taxpayer above the line in the Budget, while the Health Service capital cost is borne below the line in the Budget. Local authority preventive services are borne by the grant-aided rates and the preventive service capital costs are at the moment paid for through the normal money market. These are different sources and it must mean that any problem that falls to be decided for the benefit of a whole area or region is often decided by parochial considerations. These are not unnatural considerations to be taken into account.
How can this problem be overcome? The suggestion of coalescing the services under one Ministry will not overcome it. It is true that Professor Chester, of Manchester, suggested that the Health Service should be run on similar lines to the National Assistance Board, as a quite separate executive body looking to a political Minister purely for political policy and, within that, carrying on as separately from politics as possible. I do not think that Professor Chester deals with the delicate financial issue, namely, 501 from where would this supposed board get its money? I believe that one day it might be possible to set up a board in each area which would draw its income partly from the taxpayer and partly from the ratepayer but spend it impartially. That is a far cry from where we are today and would have the gravest implications for local authorities. I put the suggestion forward very tentatively.
I put forward these structural comments on the Health Service, particularly these remarks about the Ministry, research and finance, so that the common purpose of co-ordination may be achieved without damaging any other factor. I do not believe that there is need for a dramatic jump. If there had to be a dramatic jump, I think that there would be far less chance of making progress.
We should move forward stage by stage, leaving the big financial hurdle until last, because the previous stage of coalescing Ministerial control, if it were considered practicable, and serving that Ministry with either internal or external research facilities, may possibly avoid the need to tackle the financial obstacle altogether. The obstacle may disappear, but I am certain that, if we do not take a step towards the structural changes soon, we shall still be considering the problem of co-ordination in ten years' time. Even if we start making these changes soon, it will still be some years before we begin to bring the benefit of this sort of combined operation to the people for whom the Health Service is designed, namely, the citizens of this country.
§ 7.48 p.m.
§ Mrs. Mary McAlister (Glasgow, Kelvingrove)
We have heard a lot today about the improvement in public health since the advent of the National Health Service. I am sorry that the Minister is going away.
§ Mr. Walker-Smith
I think that the hon. Lady will be fair and realise that I have been here all day, except for about five minutes, and, much as I would like to listen to her speech, I am sure that my hon. Friend the Parliamentary Secretary will listen to her with great care. I shall certainly give myself the pleasure of reading her speech tomorrow.
§ Mrs. McAlister
As I was saying, we have heard a lot about the revolutionary changes in public health since the advent of the National Health Service. Even if I sat on the Government benches—which heaven forbid—I could not deny a word of that. There is no doubt about it. It is not long since I told the Scottish Standing Committee of the revolutionary changes which I have seen in my lifetime, such as the virtual disappearance of diphtheria and the changes in the treatment of tuberculosis, pneumonia, and so on.
I was also interested to hear the Minister of Health refer to nursing as a calling when he was dealing with the improvement in the recruitment of nurses. There is no doubt that nursing is a calling. Unfortunately, however, this fact has been used as the basis for exploitation of the profession over a large number of years and ultimately it did the profession a great deal of damage. Because service cannot fully be paid for in money, it does not follow automatically that the minimum of money need be paid for it. We are glad that there is now at least a step in the right direction concerning the remuneration of nurses and midwives. Those are the comments that I particularly wanted the Minister to hear me say.
Although I have always had a great aversion to repetition and to saying anything that has been said over and over again, I am unable to make any apology for returning to the serious matters affecting public health in my own city of Glasgow. Year after year, in the annual reports of the medical officer of health, attention has been drawn to the serious—indeed, tragic—shortage of maternity beds in Glasgow. "Tragic" is not too strong a word to use—it certainly is not an unfair word to use—if we take account of the infant mortality figures of Glasgow. In the natural order of things, these figures should be falling. Far from showing any decline, however, last year they were actually up. They stood then as the highest in Scotland and by far the highest among comparable cities in Britain.
The serious disadvantages that Glasgow suffers have been frequently referred to and are clearly reflected in the percentage figures of mothers who are unable to have their babies in hospital. 503 Only 63.5 per cent. of Glasgow mothers have this facility, as against no less than 91.4 per cent. in Aberdeen. There is room for difference of opinion as to the advisability of all mothers having their children in hospital. Not even obstetricians and gynaecologists are agreed about this, as was made clear to me when giving evidence before the maternity committee about a couple of years ago.
Other things being equal, or anything like equal, I do not say that all mothers should have their children in hospital—I am not qualified to do so. I am dealing not with a medical matter, but with a social question. Housing conditions over large areas of Glasgow are such that there could not possibly be any two opinions as to where mothers from certain areas of Glasgow should have their babies.
It is only a few weeks ago that the Minister agreed with me that housing in certain areas of Glasgow constituted a public scandal. He was widely quoted to that effect in several Glasgow papers. The Report on maternity services drew attention to another result of bed shortage in the city, that is, the necessity to discharge patients much earlier than they should be discharged. The Report stated that while a ten-day period was desirable, indeed, was necessary, discharge in seven or eight days was fairly common. To be fair, however, the Report stated that some gynaecologists and obstetricians think that with the present shortage of beds, more admissions and shorter stays would be preferable. The witnesses from the Royal College of Nursing, however, who probably know more about social conditions than anybody else, said that the discharge of mothers before the tenth day made it much more difficult to establish good feeding habits and to get mothers into the right routine, and, in addition, placed a terrible strain upon the domiciliary services.
The Secretary of State for Scotland said in answer to a Question only the other day that it was not within his knowledge that there was a general shortage of domiciliary midwives. That is not my information, and I am in fairly close touch with those who should know. I know that the Royal College of Mid-wives is presently engaged in compiling 504 evidence on the whole question of mid-wives in Scotland and hopes shortly to meet the Minister on this very matter and to put before him the state of affairs regarding domiciliary midwives in Scotland.
What kind of response have we had so far to Questions on this subject? We have been told in a vague sort of way that progress is being made in Glasgow. I do not blame the Minister for being vague, because things are not progressing at all, or, if they are, the progress is so slow that nobody in Glasgow seems to notice it.
As I have said before, I do not want to harass the Minister or anyone else, but what are the facts? The proposed increases in maternity accommodation in Glasgow are fifteen additional beds in Redlands, twenty additional beds in Robroyston and the conversion of pavilions at Belvedere Fever Hospital to give fifty beds. This additional accommodation, however, will not be ready until the end of 1960. With regard to Yorkhill Hospital, at which it is proposed to build a maternity hospital, the piling of the site begins this autumn, and, according to somebody who ought to know, it would appear that the hospital will be ready in about five years from now.
The new hospital is to accommodate 112 patients, but the accommodation at Lennox Castle, which has approximately 80 ante-natal and lying-in beds, must be offset against this because, we understand in Glasgow, the beds at present being used for maternity purposes in Lennox Castle are to revert to their original purposes for mental defectives. I do not say that this is correct. I simply put it to the Minister. I understand that these units will be closed. There is one gynaecological unit there which, I presume, will also be given back for the accommodation of the mentally handicapped.
I want the Minister seriously to consider these figures which I have given. The medical officer of health for Glasgow and everybody connected with child welfare and maternity in Glasgow are seriously concerned about the position. I know that the Minister has a great deal to do and that he cannot know everything. I do not know who is 505 advising him on the question of maternity services in Glasgow, but he has certainly been ill-advised. I implore him to look at these figures and to find out whether what I am saying is correct. I am positive that it is correct. I have a fairly long experience of maternity services in Glasgow. I served on the Health Committee for a great number of years and was its chairman for three years and I know something about the conditions in the city.
I have already drawn the attention of the House of Commons to the housing conditions in the constituency which I represent. I tried not to be dramatic, but I pointed out that in some of the houses the people had become so accustomed to rats on the premises that they did not complain unless the rats got really cheeky, such as facing up to the cat, as, in one case, they are said to have done. That illustrates the condition of housing in some parts of my constituency. I implore the Minister to look into this matter, if only because I am continually being harassed by officials, by mothers and by all sorts of persons in the constituency and throughout Glasgow on account of the state of affairs in the Glasgow maternity services.
The same degree of complacency, I am sorry to say, seems to exist in regard to geriatric beds. When the famous X-ray drives were in the offing, we were told over and over again that when the beds were evacuated by tuberculosis patients they would be available for other purposes. We have been told over and over again that this, that and the other place is not suitable as a hospital for old people.
Nobody will tell me that any hospital bed or any hospital ward in the City of Glasgow, or even in the precincts of the City of Glasgow, however primitive, is less suitable for old people than some of the places in which they are presently living in Glasgow. Nobody will tell me that, because I simply will not take it in. Apart from that, a geriatric specialist told me only about four months ago that the closing of any beds at this time was quite unjustified.
We have been told today by the Minister—I do not know whether it applies to Scotland or not—that nursing recruitment has been speeded up. I am very glad to hear that. I gather that that 506 cannot be put forward as an excuse for closing beds. It may have been a legitimate excuse at one time that we could not find the staff, but that is no excuse at this moment.
I implore the Secretary of State to look at these figures and to find out for himself whether what I am saying about the City of Glasgow is true.
§ 8.1 p.m.
§ Dr. Donald Johnson (Carlisle)
Anyone who has had the honour to participate in this debate has been offered scope for a wide variety of comments in the multifarious activities of the National Health Service at the present time, and one is tempted accordingly to offer one's opinion on this wide variety of activities. However, it is my intention to resist this temptation in what I have to say tonight and to concentrate on an aspect which has figured prominently in the speeches of one or two of the previous speakers, an aspect which is, perhaps, in the most critical state of any part of the National Health Service at present, and an aspect also on which I think I can claim some right to comment. I refer to general practice and my own position as a former general practitioner. I am only sorry, in the light of what the hon. Member for Greenock (Dr. Dickson Mabon) said a little earlier, that I appear to be improperly dressed for the occasion—in the light of what he had to say about modern doctors' garb.
General practice can be rightly said to be in a turmoil at present. On the one hand, as we know, the Royal Commission on doctors' pay is sitting. On the other hand, in the background there is the rumble of threats from the doctors that they are making preparations to withdraw their services from the National Health Service. In my remarks I am glad to support what was said by my hon. Friend the Member for Stroud (Mr. Kershaw). I think that that is mistakenly put. I should have said it the other way round. I am sorry to say that I have to support the remarks of my hon. Friend the Member for Stroud when he spoke about the present general decline in the position of the general practitioner.
In the light of the various comments which that provoked from the other side, I hope I can be excused for putting my 507 exact credentials, even though the numbers left to interrupt on the opposite benches have rather dwindled in the meantime. I was not only brought up in a general practitioner's home, for my father was a general practitioner in the town of Bury in Lancashire for forty years, but I was myself trained as a general practitioner and practised for some seven years wholetime when I started doctoring. Then I had the unique experience some fourteen years later to return to the same area of practice on a part-time basis, in which capacity I helped my former colleagues. I was doing that right up to the time I entered the House of Commons in 1955. In view of what I have to say, I think I must make it clear that my experience was confined to the most successful practices in the district, though I have to admit that it was confined almost to urban practice and I have very little experience of country practice in which the circumstances are different and, I think, perhaps a little happier at the present time.
As one who has spent a substantial part of his life in the practice of medicine, I share the aspirations that realised themselves in the National Health Service, but I consider that the National Health Service in this respect of general practice is an imperfect vehicle in its present shape for those aspirations.
We have had scrutiny of the Service from time to time in recent years, particularly in the Guillebaud Report. I regard the Guillebaud Report—I think I am repeating what I have said before—as a generally unhappy document, in that it encouraged a mood of complacency towards the structure and the organisation of the Service. It tended to make us relax into a mood of complacency, a feeling that all was well in the organisation of the Service, when in fact, in this respect of general practice on which I am concentrating my remarks, one cannot but feel that things are far from well.
I have to emphasise my qualification of what I have just said in using the word "generally", because I think there is immense value within the pages of this Report, even if that value is concentrated at the end in the few pages of Reservations which were signed by Sir John Maude. Indeed, it is my intention in the first place, rather than base the opinions which I am expressing on my 508 own still limited experience, to draw on the authority of what Sir John Maude said and on the other authorities he quotes. He concentrates his remarks in particular on the tripartite division of the Service. We have heard in these debates on the Service a great deal about that. We have discussed it generally. I have myself made general remarks on the subject of the tripartite division. Of course, it is a thing which is permanently under discussion. Therefore, it is not my intention in this debate to indulge in any general comments on the subject. I merely want to concentrate my remarks through the medium of what Sir John Maude says on the question of general practice.
In paragraph 13 he says:The mischiefs to which the division of the Service gives rise fall broadly under two heads (a) the administrative divorce of curative from preventive medicine and of general medical practice from hospital practice and the overlaps, gaps and confusion caused thereby and (b) the predominant position of the hospital service and consequent danger of general practice and preventive and social medicine falling into the background.He goes on from there to make some extremely pertinent and able extracts from various evidence given to the Committee which, if time allowed, I should like to read out in full, but I know that there are other hon. Members waiting to speak in the debate, and I shall therefore merely commend those passages to hon. Members opposite, who were sceptical of the remarks which have been made on this subject. I will read only one, and that is from the evidence of that austere and very distinguished body, the Royal College of Physicians, in which it suggests that the general practitioner is in danger of becoming a mere "disposal agent". Three or four lines of the most pertinent paragraph read:In the technical revolution of medicine general practice has lagged behind. With the rise of specialism, the scope of the work undertaken by the average practitioner has steadily narrowed, and the public has come to believe that all but the most trivial ailments need the attention of a specialist.In those few lines we have the key to the situation, and they are remarks which I can endorse thoroughly and wholeheartedly from the depths of my own experience.
The position of the general practitioner today is that on one hand he is being inundated with compliments. Even on 509 Monday my right hon. and learned Friend the Minister was kind enough to use some of his most flowery phrases with reference to the work of the doctor, but there has been little talk and still less action devoted to improving his position. In the absence of such action, the internal stresses and strains have built up inside the Service with the present somewhat threatening result.
We anticipate, I hope not wrongly or prematurely, that the Royal Commission may recommend some form of increase in doctors' pay. The question is what form it will take. It is rumoured or mooted that it might possibly take the form of merit awards for general practitioners. I say straight away that I am against merit awards for general practitioners, and I ask my right hon. and learned Friend that when, as I hope, he reads my remarks he will view any suggestion of that kind with the greatest reserve. I put my reasons forward in a letter in the Daily Telegraph as far back as last autumn, and I hope that I may be excused for repeating them now in brief.
When we consider merit awards, the question arises of how the good practitioner is to be judged against the other general practitioner who is not so good. Who is to judge him and what form is his remuneration to take? What will be the criteria of judgment? Will he be judged by his seniors? If so, the danger will be that the Service will be still more weighted in favour of the seniors than it is at present.
Will he be judged by the administrators? The visiting regional medical officers seem the most likely people to be familiar with the general practitioner's work. But are we to say that excellence in administration, the filling in of cards, the making of returns and the writing out of certificates in better handwriting and without making mistakes in dates are to be considered more desirable qualities and more deserving of merit awards than attention to patients?
There is a great deal in this point. I should like to give an instance of a doctor who got into trouble with his senior administrators. It is the custom in general practice—and this is inevitable and I am not criticising it—that in order to check drugs a doctor is sent a blank 510 prescription form to fill in and send back to the Ministry. The Ministry's representatives then go to the chemist, draw out the drug on the prescription and test it to see whether the chemist gives the right weight and that sort of thing. Now and then, there are doctors who do not co-operate in this, for good reasons of conscience of their own, and they get into a good deal of trouble as a result. Will that sort of thing count in making merit awards. How much will it count if the administrators are to be the judges in these matters?
If the merit award system is introduced, what can be said generally is that the general practitioner will be even less independent than he is at present and even more subservient to the adminitration of the Health Service, which I personally would regard as an extremely undesirable thing to happen. Another alternative put forward is the making of seniority payments. That has been put forward in good faith, but some of those who favour it are not aware that any system of that kind will be going half-way to having a State medical service which, whatever hon. Members opposite may think of it, is extremely undesirable in the view of the doctors themselves.
The general practitioner has two needs. One is to retain his independence in the interests of himself and his patients and the other is to widen the scope of his work and regain public confidence in so doing. At the moment, the general practitioner has neither the incentive nor the opportunity to do this, in face of the very considerable public pressures which those of us who are familiar with the general practitioner service know quite well. I would say to my right hon. and learned Friend that unless he uses funds available to increase general practitioners' remuneration in order to break somehow this vicious circle, he will be virtually throwing money down the drain as far as improving the quality of the general practitioner service is concerned.
If we are to have an all-round increase of payment, such as has been advocated in the debate today, there will still remain problems which may be pacified for the moment but which will recur in new forms in the future. Perhaps it may 511 be permissible for me, in making suggestions of my own on the subject, first to reminisce briefly on general practice as I knew it twenty-five years ago. Even though our scope was even then very limited, we tackled many things which it is not the custom of general practitioners, particularly in the urban areas, to tackle today. We tackled accident cases, we stitched up quite extensive cuts, we did minor operations, we removed sebaceous cysts, and we removed tonsils under what probably would be regarded today as deplorable conditions. The child was put on the kitchen table. One doctor gave him the anæsthetic and the other yanked the tonsils out. It was a pleasant and indeed profitable occupation for a Sunday morning. But we did the job and we had no long waiting lists for the removal of tonsils. One realises, of course, that the days for that sort of thing are gone and that a better standard of treatment is expected today.
If I may say so in parentheses, it is worth reminding the Committee that in those days we dispensed our own medicine and, while service was our main aim, we learned the need for economy in drugs because we had to buy them ourselves. I have taken the occasion in previous debates here to mention the benefits of sodium bicarbonate, epsom salts and so on, which are frequently forgotten in these days. If I may add to my advice in this connection, I remember that the doctor from whom I took my practice, who was trained in the 1890s, was a great man for rhubarb powder. He got most remarkable cures from administering it, but I imagine that rhubarb powder is hardly ever dispensed nowadays in the National Health Service, although I can recommend it. That was the state of general practice twenty-five years ago, and it has, of course, altered considerably since that time.
Now I turn from rhubarb powder to my main argument, which is the scope of the work which in urban practice in large areas of the country the general practitioner has lost. This needs to be restored to him if we are to restore heart into the general practice. A little while ago I had the pleasure of sending to my right hon. and learned Friend the 512 Minister of Health a rather lengthy letter from a doctor who had emigrated to Australia. The point he made, and the reason why I sent the letter to my right hon. and learned Friend, was that he was more happy in his practice in Australia than he had been in this country because he was regaining skills which he had lost in general practice here. This is the primary need in the general practitioner health service today.
In this connection, the idea of the health centre comes to mind. In recent years, it is one which has caught the imagination. I think it is on the right lines, provided that the health centre does not become merely a multiple surgery, which has been the tendency where any have been established in recent years. If the health centres become multiple surgeries, where doctors are doing the same type of work as I have described—writing certificates and referring people to hospitals—we shall get the worst of both worlds. We must try to arrest that unfortunate trend.
Although I admire the criticisms of Sir John Maude, I do not agree with his recommendation that general practitioners should be put under and become a branch of local authorities. It will be the patient more than anybody else who will be in danger if general practitioners work in local authority health centres. For instance, a patient will find that if he offends one doctor in the health centre all the rest will gang up against him. We know that there are awkward patients and that perhaps members of the profession should defend themselves against such people, but sometimes the awkward patient in the end is found to have something seriously wrong, and it is only by going from one doctor to the other that at last he finds a doctor who has the specific cure for his complaint.
What is far more important is that we should have a link, even if it has to be created, between the general practitioner and the hospital, because a closer link is needed than we have now. Perhaps the health centres could be halfway houses, where general practitioners could perform minor operations, pathological examinations, and even tonsil operations under more desirable conditions than are available in their individual surgeries, at the same time retaining their main practice in their own home surroundings.
513 It seems to me that the extra payments which might be available could well be used to encourage this type of work in such cases, even if it means some reorganisation and revolutionary thinking about the organisation of the National Health Service. I am sure we must think of the Service in that way. I must say quite unashamedly that, although I was not in the House at the time, I am a 1946 man as regards the National Health Service. I am sorry I was not in the House then, but I was going about the country putting the doctors' point of view on the Service and criticising the propositions that were being put forward. Already I have seen my criticisms about general practice amply fulfilled. I say it now, and I will say it again, that we need a fundamental examination of general practice in the National Health Service.
In conclusion, I think we make the mistake on both sides of the Committee in thinking of the National Health Service as a kind of sacred cow in our new secular religion of the Welfare State instead of regarding it as a fluid, dynamic and changing thing, as it should be, ready to be adjusted from every point of view. I am glad to be the first publicly to congratulate my hon. Friend the Member for Leeds, North-East (Sir K. Joseph) on his admirable speech. The suggestion he has made about having a social service research centre may meet the need felt by many of us to develop our opportunities in this connection, and for the lack of which many of us who are interested in these matters feel extremely frustrated now. There ought to be a sorting house for ideas such as was suggested by my hon. Friend. That cannot always be done in the House, and it cannot be done in the Ministries. If we can achieve this we shall make big strides forward in the Health Service.
§ 8.28 p.m.
§ Mr. R. W. Sorensen (Leyton)
I am sure that the hon. Member for Carlisle (Dr. D. Johnson) will not mind if I do not follow him in his interesting reminiscences except to say that I gathered that he was somewhat critical in many respects of the Guillebaud Report. He seemed to be disappointed that it was more eulogistic than critical, and he seemed to have a certain amount of nostalgic desire to return to the good old 514 days when, apparently, he operated on children's tonsils with a carving knife on the kitchen table. That may be a slight exaggeration, but it was the impression that I got.
§ Mr. Sorensen
I listened to every word of it, unfortunately in one sense, because I would rather have been elsewhere obtaining nourishment for my body. The hon. Gentleman's speech was most interesting, though I must say that I detected a certain regret that he was compelled by force of circumstances to recognise that the National Health Service was a great British institution. One of his hon. Friends earlier had more openly praised the institution.
I shall be much more generous to the Minister and say that I appreciate the record which he has registered today of still further progress in our public health Few people, perhaps, realise what a remarkable silent revolution has taken place in the last fifty years or so. One of the criteria that I frequently use to illustrate this progress arises from the very simple fact that when I was born the infant mortality rate was 145 per thousand whereas it is now generally 23 per thousand and in some districts 18 per thousand. This contrasts with the situation in other parts of the world. I remember visiting a part of Borneo where the rate was 400 to 500 per thousand, and when I visited the Yemen some months ago I estimated that possibly half the children born there died before reaching their first birthday. That reminds us of what conditions were like here years ago. We must have had the same conditions as still obtain in certain parts of the world.
We can register advance in public health standards in another respect, and that is longevity. It is estimated that a boy born today has an expectation of life of about 68 years and a girl about 74 years. In other parts of the world it is very much lower than that. In India, it is 30 years. Ten years ago it was only 27 years, and so in ten years India has added three years to the expectation of life of her inhabitants. In the last 100 years we ourselves have added 30 years to the expectation of life of our children 515 compared with that of their great-grandfathers.
This striking improvement has arisen in two ways. First, there has been a striking increase in medical knowledge, skill and treatment. The curative side has been mentioned more than once. In a variety of ways we are tackling the incidence of disease. On the other hand, the remedial side has made just as much advance. Undoubtedly a great deal of disease, both psychological and physiological, is due directly or indirectly to lack of proper hygiene or sanitation, to the stresses and strains of modern life, to bad housing and to bad industrial conditions. I am persuaded that it is just as much in the latter category that we have helped to reduce so strikingly the incidence of human mortality as in the first category. That surely explains why the numbers in children's wards in hospitals are diminishing. The fact that the number of children in hospital is far fewer now than it was years ago is due not merely to improvements in medical knowledge and treatment but to improvements in social conditions.
The National Health Service is concerned with both these aspects, but I would urge that far more attention should be given to the remedial than the curative side. More time and money should be devoted to research in that direction. Take, for example, the sphere of diet. It is not many years since our hospitals and doctors almost scorned the subject of diet and the effect that diet had on human health. Nowadays the effect of diet is accepted, and all hospitals now have dieticians carefully trained in that subject.
I should like something much more than that to be done. I should like more efforts made to inform the general public about the right kind of foods and balanced diets. I should like the general public to be told what foodstuffs are deleterious and what foodstuffs are healthy and lifegiving. Although there has been a very great improvement in this matter in hospitals, there is still much room for improvement. It is not enough to have a theoretical knowledge of how to produce the right balance of vitamins, calories, carbo-hydrates and so on. The way food is cooked and served is equally important. There are some 516 hospitals where there is still a great deal to be desired in that direction.
Besides that, I should like to see much more research into the inter-action between the mind and the body. I am not a Christian Scientist and I believe that a certain amount of nonsense is attached to that theory, but there is a certain truth beneath all the accretions and the dross, and that is that the mental attitude of people does have a profound and comprehensive effect upon the physiology of health. Here is where much more should be done than is being done at present. I know that a great deal of negative research is proceeding, but I want positive research to be performed and for it to be made public.
I am not inferring that I am inclined to believe that natural primitive man was more healthy. Rousseau's "healthy savage" was merely a fiction in his own mind. I would say, on the other hand, that man is born in chains pathologically and sociologically and struggling to be free, rather than the other way round as we have often heard. Nevertheless, I agree that there are certain by-products of modern conditions peculiar to our own age. In particular—and reference has been made to this already—there is the effect on human health of smoke, dust the fumes. To that extent, I welcome the advent of the Clean Air Act which. I believe, has done some good already.
But what of the increasing effect on health of diesel-engine exhaust fumes? Nothing has been said about that today. Nor has it been sufficiently recognised that the streets of our great cities are becoming increasingly polluted by the filthy mess emitted by diesel-engined traffic. In my own district, we have a gas works, which was privately owned but which has now become part of a great national service, from which was emitted a good deal of this nuisance of fumes, grit and dust to the wretchedness of the people in the neighbourhood. We had an alkali inspector down and conferences and, in the end, some amelioration was effected. Even though that was so, nothing was said and nothing was done about the fact that 200 yards away from that gasworks, up and down the Lea Bridge Road go these heavy vehicles emitting this nuisance and danger to health.
517 I beg the Government to take further action along these lines. This nuisance has a direct physical and mental effect. There is not only the effect on the lungs in the way in which my hon. Friend the Member for Barking (Mr. Hastings) described but the effect on the nervous system as well. I ask the Minister to do what he can to concentrate more thought upon this particular aspect of the abomination of smoke pollution, and not merely to assume that all the danger and nuisance is derived from factory chimneys and the like.
On the remedial side, the National Health Service has already proved an example to the world. All of us ought to be proud of that fact. It is significant that 97 per cent. of the people of this country now patronise our National Health Service. It is as much a boon to the middle class—in fact even more of a boon to the middle class—as it is to the working class, and we are now coming to realise that. Whatever may have been the open or secret enmity and hostility on the part of some Members of this House years ago when the National Health Service was first introduced, I am certain that there is not a Member today who would dare to come out openly to advocate scrapping the National Health Service without fear of being scrapped himself in the process. There is a great difference between now and not so many years ago.
Those of us who have been to America know full well how interests from this country have fed the American Medical Association and similar bodies with a perfect travesty and unscrupulous misrepresentation of our National Health Service. Many times when I have been lecturing in America I have been asked questions about our "socialised medicine", sometimes, though not generally, with a curl of the lip. On one occasion I was very glad to be able to say that if the questioner would kindly read a report on one of his own newspapers, he would find it there stated that a Conservative Member, still a Member, was openly saying in the United States that all parties in Britain now supported the National Health Service.
Of course they do, and I am glad, because it is a nationalised service. The Institute of Directors would be hard put to it to discover anything like 60 per cent. of the people of this country 518 opposed to that kind of nationalisation. It is a pity that the Institute does not make that more clear.
Equally, it is now coming home to us that, according to the Guillebaud Report which seemed to receive a certain amount of indirect criticism, we are today spending proportionately less on the Service than was the case ten years ago. I remind the Committee that, according to that Report, in 1948–49 the cost of the Service was 3.51 per cent of the gross national product and that when the Report was issued it had fallen to 3.24 per cent. So it has been a good investment and it is costing the country rather less than it did. That should help to disabuse critics of a certain amount of bias and prejudice on financial grounds.
Of course, the Service has had its defects and difficulties. Until recently, one of the difficulties has been the shortage of nursing staff—and to some extent that difficulty still exists. I am very glad to know that there has been some improvement, and I hope that that improvement will continue, thanks partly to the services of West Indian and other girls from overseas who have come to this country, but also thanks to the response of British girls to the better pay and conditions which fortunately now exist.
I agree that we can no longer exploit a noble vocation as we once did. Many girls who have entered the nursing service have done so conscientiously as an avocation, but not necessarily as a vocation. We cannot make people have a vocation, and I am not disparaging people who have merely an avocation and who do a job well, but without putting their whole heart in it. However, I make the plea that every effort should be made to increase the number of girls and women in nursing to take up the work not merely as an avocation, a job to be well done, but a vocation, to which to devote their lives.
One matter I wish briefly to mention is this: why it is that there is such a gross overstaffing of the London teaching hospitals as compared with the general hospitals? I understand that the ratio of nurses to patients in a teaching hospital is about one to one, while in many general hospitals in other parts of the country the ratio is one nurse to two or three or even more patients. According to the Guillebaud 519 Report, that partly explains, perhaps, why the cost of treating patients in a teaching hospital is £23 18s. 7d. while in the general hospital it is £13 13s. 4d. Apart from that, something should be done to balance things up so that there is not this gross and unfair disparity in nurse-staffing between the teaching and general hospitals.
Is it not a question of assuming that there is a social prestige in being trained in a teaching hospital? If that is the case, I appeal to those thinking of getting their daughters into teaching hospitals and those responsible for teaching hospitals to try to draft into the general hospitals an increasing number of girls who would like to go to teaching hospitals. I would not use so harsh a term as snobbishness, but there does seem to be a discrimination between the different types of trainees in the nursing profession, and I hope that the Minister will carefully consider that matter.
I support the pleas for more attention to be paid to our industrial health service. Although much is being done in that direction, it should be part of the whole National Health Service. Where there is a large factory owned by a wealthy firm, a fine health unit may be set up, but the smaller factories cannot afford to do that. Why should the smaller factories be at a disadvantage compared with the larger ones? I make my plea for the integration of an industrial health service into the National Health Service so that all industries shall be able to have the service in their factories, workshops, and similar places.
Had I more time, I, too, would support the pleas that have been made for the abolition of the charges on prescriptions. It is all very well to say that if the people concerned are poor and old they can go to the National Assistance Board to get relief. One knows that, but those who do not or cannot get that relief have to pay relatively more for their prescriptions than those people who belong to the higher-paid classes. Because this is an anomaly, and virtually a waste, because it is a fiddling interference with the general principle, I make my plea that these charges should be abolished at the earliest possible date.
As usual, many of the things that one would have said have been said by 520 others. It is now recognised that we can proudly face the world with an example of a National Health Service of which we can be proud. When we go abroad we ought to claim it to be one of our great British institutions. Though it requires constructive criticism at times, do not let that criticism be of the mean, erosive type which, while we offer external praise, nevertheless tends to undermine a splendid national service.
§ 8.47 p.m.
§ Mr. J. C. George (Glasgow, Pollok)
Minister after Minister has been able to come to the Box from this side of the House and make a first-class progress report, and no Minister has more progress to report than my right hon. and learned Friend. The advance in medicine has been massive. Why should my right hon. and learned Friend not claim credit for the Government? If the progress had been bad the Governmentwould have been blamed. If the progress is good, why not say so? We want to give credit not entirely to the Government, but in large measure to the researchers, doctors and those in the National Health Service who have brought the tools to bear on the problems of effecting cures which have spread happiness throughout the length and breadth of the land.
In our time we have seen many diseases almost defeated. Fever, diphtheria, and other diseases are being defeated one by one. Prevention was the fundamental purpose of the National Health Service. If there had been no prevention the Service would have been a failure, because Lord Beveridge said that the fundamental purpose of the Service was prevention. In the short time that I have available I want to deal entirely with that aspect.
I go to America every year and I am impressed with the tendency amongst American businessmen—and men not very high up in business—to have a full check-up by doctors twice a year. That is a fundamental step towards prevention. It may be impossible to think about a nation-wide check-up twice a year, or once a year, but I wonder if my right hon. Friend would comment on the position. If a member of the National Health Service went to his doctor with nothing obviously wrong and said: "I want a check-up from top 521 to toe", how would he be received? Is that a service he can claim? If we could have a systematic check-up once a year we would be taking the first real step towards prevention.
If one studies the present killers, one is impressed by the fact that a great deal of the prevention in the future lies in our own hands. A great deal can be done without the doctors. We have lung cancer and bronchitis as two vicious killer, and we know, in the main, why they are killers. It does not need the doctors to tell us to stop smoking. I read yesterday that last year we spent £1,000 million on tobacco in this country, although all the time we know that lung cancer is being caused among thousands and thousands of persons. Are the Government doing enough to bring the facts home to the people and to tell them that this is the cause of a killing disease? I wonder whether more publicity should not be given to the effect of this continual smoking. I wonder whether there is not a tendency to respect the revenue more than the prevention of disease. I think that a campaign, almost as important as the X-ray campaign, should be conducted about the prevention of lung cancer.
Bronchitis is also a killing disease. We had a bad winter in Scotland as well as in England; we have had fog off and on for three months, and in Scotland there have been many more deaths than usual. One hon. Member said this afternoon that twice as many people died in this country this winter as died last winter. The Report of the Department tells us that in 1957, 10,747 people died from cancer, and of these 2,078 died from cancer of the lung and bronchus. We are told that in the four weeks January-February twice as many people died from bronchitis in the seventeen largest cities as died last year.
I want to deal with Glasgow. In Glasgow 468 people died this year compared with 197 during the same period last year. It was the worst year for many years. This could be reduced, as we know. Smoking could be reduced if a campaign were conducted against it. The other aids to bronchitis are fog and smog. I wonder whether we are moving fast enough in Scotland in dealing with these problems. I wonder whether my 522 hon. Friend is satisfied with the progress made by local authorities in applying the Clean Air Act. A great deal could be done. I remember seeing a great city like Pittsburgh, when it was a black city, and I visited it after it had been cleaned, when the sun shone through to places where it had never shone before. We could do the same in Scotland, but we are not doing it nearly fast enough.
In the Report we are told that the incidence of bronchitis is "the highest anywhere." Does that mean anywhere in the world or anywhere in the country? If it is the highest anywhere in the world, surely we need to spur on local authorities to deal with the Clean Air Act as it ought to be dealt with.
Another killer disease in recent years has been coronary thrombosis. Again, we are told by the authorities that the cure for this lies in large measure in our own hands. The hon. Member for Leyton (Mr. Sorensen) mentioned that. We are told that diet plays a tremendous part in the prevention of coronary thrombosis, especially among males.
In paragraph 33 we are told that the experts consider thata sedentary life coupled with over-indulgence in food and the excessive consumption of certain types of fat has an influenceon the incidence of this disease. The hon. Member for Leyton suggested that more publicity should be given and that people should be better informed about these matters. I wonder whether we can devise ways and means of bringing the facts about these killers home to people to tell them that they can help to reduce the death rate and to keep people out of hospitals, which was the original idea of the Service.
In America television is used widely by the insurance companies. They have found it a good investment to put the facts to the people about cancer, bronchitis and thrombosis by means of television. The people in America hear these facts on the radio and see programmes about them on the television, all bringing the facts into the home. I know that it has had a good effect. I know of one lady who was listening to a radio programme one morning which asked, "Have you recently checked for lung cancer?" She thought that this was a good idea and obtained an interview that day. It was found that she had 523 cancer in its early stages. She has been cured and is still alive. It pays the insurance companies, and I wish that our insurance companies would use television for that purpose.
What progress is being made towards certification of physiotherapists and chiropodists? The physiotherapist has come to stay and is doing marvellous work. There is much disappointment in the profession that nothing is being done towards certification. Chiropodists feel the same way. These two branches, which have come to stay and are very important, should be put on a basis of certification at the earliest possible moment.
I should like to have had time to say more on prevention. We are not driving nearly fast enough towards prevention. I spent some years on a health committee. I have great admiration for health visitors. I believe, rightly or wrongly, that the main purpose of the health visitor is to spread the gospel of prevention of illness. These ladies are well trained and intelligent. They can disseminate the basic fundamental purpose of the Health Service by spreading the gospel of prevention. I read a report recently that in Scotland the Service is seriously short of personnel. The Scotsman of 6th April said:… there is a shortage of 490 full-time visitors in Scotland ".At the Scottish Health Visitors' Conference, where that statement was made, it was further stated:In recent years the preventive services in general and health visiting in particular have not received their due share of attention or of funds.I believe that health visitors can play a tremendously important part in the prevention of illness by spreading the knowledge which we have about what causes certain diseases and how they can be prevented. I urge my right hon. and learned Friend to look into the position of the health visiting service. I see that it is stated in the Department's Report that it is up to strength. That conflicts with the statement I have just read. In any case, I believe that this service should be expanded, with the fundamental purpose of preventing illness by taking knowledge of how it can be prevented into every home visited.
I welcome my right hon. and learned Friend's action in setting up three 524 industrial chest disease centres in Scotland. We in the mining areas have all our life had the dread disease of pneumoconiosis all around us. We have seen fine men shrivel up and die from this terrible and painful disease. We should spare neither effort nor expense. If anything can be done, by spending money or bringing in expert technicians, to tackle this subject and to cut down the misery that we have seen in mining areas, a great debt of gratitude will be owed to my right hon. and learned Friend.
We have heard a lot today about Reports. I wish to say something about the Piercy Report on rehabilitation, which is a very important Report. I know that my right hon. and learned Friend has taken certain action. A suggestion was made in that Report for resettlement clinics. It would be a fine thing if members of hospital staffs would get together when a patient is nearing discharge to do all they can to find him another job and advise him, so that the period when he leaves hospital will be free from worry, with the beneficial effect that that will have. What has been done about the creation of this resettlement service?
I want to say a word about the Report on Hospital and Community by Professor Ferguson and Dr. McPhail of the Department of Public Health of the University of Glasgow. They checked 548 unselected patients. They saw them at the hospital. They saw them three months later and two years afterwards. They wanted to check what happened to the patients after they left hospital. Three months later they found that 55 per cent. were working; 10.8 per cent. were aged and beyond the possibility of working; 33.7 per cent., or 183, had not returned to work and were still idle. After two years they went to see them again. They found that 106, or 22 per cent. of the total, were still not working; 129, or 27 per cent., had gone back to hospital for further treatment as in-patients. That emphasises that a great deal can be done to prevent patients returning to hospital. I should like my right hon. and learned Friend to say what he thinks about that Report and about rehabilitation.
§ 9.0 p.m.
§ Mr. Sydney Irving (Dartford)
I appreciate that I have only two or three minutes in which to speak, but I want to make two points from my own constituency experience which, I think, have 525 relevance in the wider field. On 7th November, the South-East Metropolitan Regional Hospital Board announced to local authorities and other organisations that it was proposed to carry out fairly soon a comprehensive reorganisation of the Dartford Hospital Group.
By 2nd March the board was saying to a local authority that wanted to consult it that there was no useful purpose to be served by a meeting between the board and the local authority. That authority had been seeking for some weeks an opportunity to meet the board. Although the four months between November and March may seem a long time, Christmas had intervened, the Parliamentary Recess had intervened and so had the local government Christmas recess. My point is that when there is a major reorganisation of this kind, involving the closing of a general hospital, public relations could be much better than that.
The bald statement of intention is not good enough, and I hope that when such major reorganisations as this are contemplated the board—for whose efficiency I have the greatest admiration—will invite the much closed co-operation of the local authorities and other bodies, without whose support we cannot get proper administration or that support for the hospital service that the work of those in the hospitals deserves. This could be done by meetings and special conferences.
It would be wrong if I did not tell the Committee that there is much dissatisfaction among local authorities about the way in which members are appointed to the hospital boards. The public does not know the method of nomination and many people regard the boards as self-perpetuating organisations. I would urge the Minister to examine relations between local authorities and hospital services generally, and to find ways of improving them. We have no argument now with the regional board. With the help of the Minister, relations with it have been much improved, and I hope that this will continue.
My second point is one that was touched on in general terms by my hon. Friend the Member for Newcastle-upon-Tyne, East (Mr. Blenkinsop) and relates to the piecemeal development of the hospital service, particularly in relation 526 to building. This proposal in Dartford involves the closing of one general hospital, and the improvement and upgrading of two others. A sum of £½ million is involved. What disturbed people locally was that there seemed no clear indication that the building of a new hospital had been considered as an alternative. The local people appreciate that the money may not be immediately available or, if it is available, that there may be others with higher priority.
In Dartford, however, when we have spent the £½ million, our two main general hospitals will still consist of one that was built as a workhouse over 100 years ago, and another, which is built by the London County Council on the marshes as an isolation hospital. That £½ million will be well spent. I have no criticism whatever to make of the work of those in the hospitals—for whose work I have the greatest admiration—but there can be no doubt that their work would be even better if it were done in first-class surroundings instead of in the difficult circumstances existing in these two outdated buildings.
I therefore urge the Minister to allow regional boards to plan more for the future than has been the case so far. The money may not be available to carry out that policy immediately, but in my constituency we have eight hospitals—two general, one maternity, one T.B., three mental hospitals, and a mental deficiency hospital, and the local hospital authority owns about 650 acres of land there.
We know that with the new knowledge, the new approach and the new medicines, the whole concept of the service will change, and I would like to think that forward planning was taking into consideration all aspects of the service, and that each area had a blueprint for the future so that, while we could not expect an immediate improvement and a first-class new hospital in every area, the money put into the service, and all the efforts made would be with that ultimate goal in view.
As the decision has been taken to close the Southern Hospital in Dartford, I ask the Minister to invite co-operation and consultation with the local authorities and local bodies concerned so that the 527 hospital buildings do not become derelict but are put to the best use at the earliest possible moment.
§ 9.5 p.m.
§ Miss Margaret Herbison (Lanarkshire, North)
Today we have had an excellent debate. From both sides of the Committee we have had contributions which in almost every instance have been constructive. The speech which I thought the least constructive was that of the Minister of Health himself. He apparently found that he had such a poor case to make that he began it with a personal attack on my right hon. Friend the Member for Warrington (Dr. Summerskill). He enlarged that attack to an attack on women in general. Does the Minister not realise that at least 85 per cent. of all the workers in this wonderful National Health Service are women? Quite a part of the Minister's speech was an insult not only to the intelligence of hon. Members but to the country as a whole.
I listened carefully to the right hon. and learned Gentleman's speech, and to me it seemed that it showed a great degree of complacency. Much of it dealt with what the Government were going to do, what they were planning to do in the future, particularly as regards hospital building. In other words, it was "pie in the sky". He talked about the Ministry having set up its own architects' department and about the streamlining of procedure for the building of hospitals. This was going to happen in the future. But the present Government were not returned last year. They were returned in October, 1951, and they have had almost eight years in which to carry out the things that the Minister now tells us they are about to do. That is what he now tells us on the eve of another General Election. It is so typical of so many of the speeches that we have had in the last few months from Ministers.
My right hon. Friend the Member for Warrington put a number of very pertinent questions to the Minister, the majority of which he did not answer at all. He did not even touch on them. It seems to me that in a debate such as this—a debate, I would remind the Minister, which we would not have had at all unless the Opposition had been ready to give one of its precious Supply Days—the Minister ought to have been 528 in a position to answer the pertinent questions that were asked. The Minister is a lawyer. He tries to give "smart-Alec" replies. Indeed, his whole speech reminded me very much of the old university debates that we used to have in our union. I hope that when the Secretary of State for Scotland replies we shall get an answer to some of the questions that have been asked.
I go on to deal first of all with this question of hospital building, which affects the whole of the United Kingdom. Much has been said today about the long waiting lists for hospital accommodation. In some parts of the United Kingdom these waiting lists are much longer than in other parts. I wish to deal particularly with accommodation in maternity hospitals.
My right hon. Friend the Member for Warrington spoke about the Report which has been issued for England and Wales. In Scotland, we have our own report, from a Committee appointed by the Scottish Health Services Council. The Minister spoke about the infant mortality rate and the maternal mortality rate and told us that they were the lowest ever. So they are, and we are very glad indeed for that. But, as my hon. Friend the Member for Glasgow, Kelvingrove (Mrs. McAlister) showed, this does not apply to the great City of Glasgow.
Many factors account for both these rates being lower. In many instances, people have better housing. Many young mothers today have had throughout their lives the chance of better nutrition than their mothers. All these factors go towards the improvement in the mortality rates. I earnestly hope that as the years go on the improvement will become greater and greater.
In this matter also, however, the Minister showed great complacency. The figures, particularly in respect of infant mortality, are still too high. No one should be complacent about them.
In paragraph 82 of the Report on Maternity Services in Scotland, it is said:As to overcrowding"—that is to say, overcrowding in maternity hospitals—and length of stay in hospital, the average length of stay in obstetric units in the Western Region is again markedly shorter than in the 529 other Regions, and it is obvious that there is very little margin for the occasional emergencies, great or small, which are bound to arise in maternity units, from the closing of an entire unit because of infection, to the closing of one ward while it is paintedThose words from that high-powered Committee present a serious and, I would almost say, a frightening picture for mothers and babies in the thickly populated part of Scotland. In the region covered by the Western Region Hospital Board there is about half the population of Scotland, and this is the region referred to by the Committee.
In paragraph 28, the Committee recommended that the time in hospital should be ten days. Yesterday, in answer to a Question, the Secretary of State told me that, in the County of Lanark—again, a very thickly populated part of Scotland—the average length of stay for mothers in maternity hospitals is seven days, three less than the number recommended by the Committee. If that is the average time, are some mothers being sent out in under seven days, or is it that seven days is the absolute minimum, and, on the seventh day, they are sent out?
My hon. Friend the Member for Coatbridge and Airdrie (Mrs. Mann) has time and again raised in the House the need for better maternity provision in Lanarkshire. I have discussed this matter with members of a committee representing the maternity service interests in Lanarkshire. What I say applies to many places in Scotland and to many thickly populated places in England and Wales. I have been told that the staffs in the maternity hospitals are seriously overworked. I have been told by the matron of one of the big hospitals that the staff has not time to talk to mothers in hospital, has not time to train them in the care of their babies when they leave hospital or in the handling of their babies, even for the mother having her first child. That is a very serious matter.
The Committee recommended that there should be what it terms "lying-in beds" for between 70 to 80 per cent. of the total births, but what do we find? In Lanarkshire there is provision for only 58.5 per cent. In Glasgow, where housing conditions are shocking, the figure is only 63.8 per cent. One of the bright spots is Aberdeen, where there is 530 provision for 91.4 per cent. I have a suspicion that a great deal of the credit for the situation in Aberdeen must go to Professor Dugald Baird, Professor of Midwifery in the University there. He knows very well the importance of proper maternity services for our women.
My hon. Friend the Member for Kelvingrove, in a very good speech, raised the question of maternity provision in Glasgow. She spoke about the Yorkhill Hospital. In March this year, in reply to a Question, the Minister said that plans for a new hospital had been cleared and that building would start in 1960. It seems to me that, knowing the conditions which prevail in that part of Scotland, building of the hospital should have commenced immediately the plans were cleared; but that did not happen.
My hon. Friend the Member for Fife, West (Mr. Hamilton) tabled a Question in the House about the Dunfermline Maternity Hospital. As the hon. Member for Glasgow, Pollok (Mr. George) will know, there has been a great increase in population in Fifeshire. The families of many displaced Lanarkshire miners have gone to Fifeshire. They have been provided with work in the mines and with houses, but, under the Government, little or no provision has been made for community services and there has been no new provisions for hospital services to meet the needs of the growing population. The wives of many of the young miners who have gone from Lanarkshire are having their families in Fifeshire. There was an article in the Sunday Pictorial on this point.
As I have said, on 9th June, my hon. Friend the Member for Fife, West, in a Question, alleged that the conditions in the Dunfermline Maternity Hospital were shocking. In answer, the Joint Under-Secretary of State said:I agree with the hon. Member to some extent"—meaning that conditions there were difficult—… we must concentrate on areas like Glasgow where facilities are below average."—[OFFICIAL REPORT, 9th June, 1959; Vol. 606, c. 785.]What is the state of the hospital about which my hon. Friend spoke? In the corridors of it women are in labour waiting to be delivered of their babies. What could be more shocking that that? The 531 Joint Under-Secretary, however, in his own language, said that these conditions were better than those in Glasgow. Is it any wonder that we accuse the Government of great complacency in the matter of hospital building? They cannot say that they do not have the material or the building labour with which to build hospitals.
I have looked at the figures and I find that, on 11th May, 64,500 building and contracting workers were unemployed in the United Kingdom. For Scotland, the latest figure shows that 11,020 building trade workers were unemployed. During the six years from 1953, the lowest number of unemployed building trade workers in Scotland has been 6,140. If the Government had used their resources in Lanarkshire, in Glasgow, in places like Liverpool and in all the congested, thickly-populated areas, we might have had proper maternity provision for our people ere this.
We are told that many of our domiciliary midwives are trained. They are trained in the hospitals, but when they finish their training they prefer to choose other work. As one matron said to me, "No wonder, because it is indeed a dog's life that they have." Why did that matron describe it as a "dog's life"? Again, in some of the overcrowded areas, I find that these domiciliary midwives are working 55 hours a week. Very often they are called out two or three nights a week. They get one day off a week, but when a midwife has her day off there is no replacement for her. Her work has to be done by another harassed midwife, who has to do two jobs and both of them very difficult indeed.
Although the salaries of these mid-wives are at present being considered by the Whitley Council, there is no doubt that if the employers' side of the Whitley Council realised that the Government were ready to grant more money for better salaries for these people more money would be forthcoming in the negotiations.
Before I leave the question of the overcrowded areas in the whole of the United Kingdom, I must condemn the Government on yet another score. In Liverpool, in London, in Glasgow and, indeed, in all the big cities, we have the 532 most serious overcrowding, and in insanitary properties. My hon. Friend the Member for Kelvingrove reminded the Minister of conditions. I shall not weary the Committee tonight with the number of one-roomed and two-roomed houses in Glasgow. I would, however, remind the Minister that yesterday my hon. Friend the Member for Glasgow, Central (Mr. McInnes) had a number of Questions concerning Glasgow's overspill. Glasgow has an overspill problem of about 300,000 people. It is the most serious in Britain. And what did he find? The Government passed a Bill which was supposed to take care of overspill, and in two years and two months since the passing of that Bill thirty-eight families have been removed under overspill agreements.
We had a Budget not so very long ago in which the Government found they had about £400 million to distribute. It seems to me that if we were at all concerned with the health of our people—and again I stress particularly those who are in the overcrowded areas—the Government would have decided in England and Wales to give again a subsidy for general need housing, because in England and Wales there is no subsidy at all for general need housing, and in Scotland they would have decided to give an increased subsidy for that type of housing.
One hon. Member opposite, the hon. Member for Leeds, North-East (Sir K. Joseph), spoke about the need for housing. He felt that it would be much better if in England and Wales there were one Minister responsible for local authorities, for housing and for health. It has not turned out so in Scotland. I hope that the hon. Member for Leeds, North-East, who made, I felt, a most constructive speech, will examine the set-up in Scotland before he tries to have it imposed on England.
Whether it is the supply of maternity beds or of beds to take care of these great waiting lists, it seems to me that during the years of the Tory Government ever so much more could have been done in hospital building. There is no need for the Secretary of State to ask, what did the Labour Government do in hospital building? We had the National Health Service from 1948 to 1951, and if one examines what was done during 533 that time one sees that by the time the Tory Party came to power almost all the teething troubles had passed—[HON. MEMBERS: "Oh."]—and then they had the chance. [HON. MEMBERS: "Oh."] Indeed they had. The hon. Members interrupting now from the Government benches are people who had not spent a minute on those benches all day until we came to the winding up speeches. If they had, they would have heard even some of their hon. Friends giving praise to this wonderful National Health Service.
§ Miss Herbison
I turn to another point, the care of the aged. I was interested in the speech made by the hon. Member for Aberdeenshire, East (Mr. Wolrige-Gordon). He said there was a great controversy in his part of Scotland about the closing of small hospitals. This is a matter which we on this side have raised time and time again, and yet this Government have closed hospitals, and if we look at the number of staffed beds at the end of 1958 we find that there were fewer than there were at the end of 1957.
I say to the Government, how wrong it was to close one single hospital in Scotland. When we find that so many of our old people, not those who can benefit from geriatric treatment, those who have got beyond any hope of benefiting from geriatric treatment, spend their last few days and their last few weeks in mental institutions, those hospitals ought to have been used for that type of old person instead of being closed. It seems to me that it was one of the most disgraceful actions of the Government, particularly when we look at the figures in 1956 to 1957, when 40 per cent. of certified admissions to mental hospitals were of old people over 65 years of age. That seems to me to be a very great indictment.
My last point concerns the prescription charges. Reports have been submitted by some high-powered Committees from which it will be seen that the increase in the pharmaceutical bill since 1956 has been 40 per cent. and has been due to over-prescribing. The Committees say that the reason for over-prescription is that doctors are providing on one prescription for much more than is really 534 needed. That seems to be a further indictment.
The hon. Member for Leeds, North-East said that there was little evidence that people were not getting the medicine they needed and, after all, there was always the National Assistance Board. There is a cat and mouse game going on at present. I give one instance which could be multiplied by similar instances from other parts of the country. Before the last increase in pensions, a couple in my constituency were receiving 1s. from the National Assistance Board. They accepted it not because it helped them but because the wife was chronically sick and by accepting the 1s. they were able to have prescriptions paid for by the Board. When pensions were increased they lost their 1s., and whatever increase in pension they received had to go on prescriptions instead of helping them generally in their livelihood. I took the matter up with the area officer of the National Assistance Board. Inquiries were made and I was told that after 7th September the couple would be again within the range of National Assistance and would again have their prescriptions free. That is a cat and mouse way of dealing with ordinary, decent, fine people.
In this matter of health, neither the Minister nor the Secretary of State for Scotland has shown energy or enthusiasm or given the direction which ought to be given, and the sooner we have a Labour Government, with Labour Ministers, the better for the country.
§ 9.33 p.m.
§ The Secretary of State for Scotland (Mr. John Maclay)
On the whole, we have had a very constructive debate, though I also would make an exception of two speeches, the first being the opening speech by the right hon. Lady the Member for Warrington (Dr. Summer-skill). I listened with interest to certain parts of the speech of the hon. Lady the Member for Lanarkshire, North (Miss Herbison). I know that she feels strongly on the subject of maternity beds, and I also hold strong views on the subject, but there were parts of her speech which were not constructive.
It is true to say, however, that generally, speeches from the back benches have been interesting and have properly drawn attention to matters which cause 535 hon. Members concern, either in their constituencies or in more general terms, in certain parts of the National Health Service. This is the value of a debate like this. We have, of course, listened to most of the speeches but reports of debates of this kind are also studied carefully and we make progress through considering both what has been said in debate and what is said in follow-up letters.
I am puzzled by the fact that, as I understand, there is an intention to divide the Committee. Why? What about? Interesting detailed suggestions have been made and there has been a general recognition that the health of the country as a whole has improved admirably. We know, of course, that there are flaws—[HON. MEMBERS: "Serious flaws."]—but the sum total of attack, which will mean a Division, and of the fury of the opposition of the right hon. Lady the Member for Warrington, seems to be derived from the fact that the Minister in England has failed to implement immediately a number of Reports, all of which have been received this year.
The right hon. Lady was quite right to want speed, but it would be unbelievable to think that the Reports, which have taken years to produce, could be fully implemented in a matter of weeks or months, particularly as it would be utterly irresponsible to try to impose on the people who will have to implement them the recommendations in the Reports without proper consultation. I listened with the greatest interest to the right hon. Lady's opening speech to see what the Committee could be divided upon. That was all I could discover, and it does not justify a Division.
The hon. Lady the Member for Lanarkshire, North, in winding up the debate, dealt with one point which concerns us all, the provision of new hospital beds, which can never go on as quickly as we would like. Without making a party point of this—[Interruption.]—if hon. and right hon. Gentlemen opposite accept it as a party point then the blame lies on them for not doing more when they were in power—let us see what has happened. The period between 1948 and 1954 was undoubtedly one in which, whoever had been in power, we had to catch up with the years of war and the 536 shortage that followed. I admit that there was lack of planning. It does not matter whether we or the party opposite were in power, because we would each have been forced to do precisely the same thing, namely, to do our best to catch up with the years of war and shortage.
Then we entered the second phase, in which we are now. About half the capital expenditure is on minor schemes of improvement and the other half is on large new schemes of hospital development. I will give the Committee the Scottish figures. We are providing 1,750 new beds for mentally defective patients, maternity services, radiotherapy services and other purposes. The third stage will start in 1960–61 and it will be improvement by rebuilding or by major additions to hospitals.
§ Mr. Blenkinsop
Will the right hon. Gentleman say why he did not accept the recommendations of the Guillebaud Committee to carry out capital expansion to the extent of £30 million a year?
§ Mr. Maclay
The hon. Gentleman knows well from his own experience that at any given moment only a certain proportion of our national resources can quickly be diverted to any one purpose.
Another difficulty common to whichever party is in power is that, when we are planning new hospitals and hospital extensions, there is a continual desire to have the building as up to date as possible. Indeed, sometimes I feel that the desire for perfection is the enemy of the good, and that time can be lost at the critical moment by trying to incorporate everything of the newest, thereby slowing down what might have been done earlier. I have seen that happen in my work in dealing with regional hospital boards. The only part of the speech of the hon. Lady the Member for Lanarkshire, North which sounded as if it might justify a Division was that dealing with hospital building, with which I have dealt. I do not believe for a minute that the party opposite could have moved into any phase other than that into which we have moved, and moved extremely effectively.
Now I come to the hon. Lady's questtion about maternity services. If the Committee will forgive me, I will give Scottish figures but they also bear on 537 the question of the right hon. Lady about what is happening with regard to the Montgomery and Cranbrook Reports. This is the Scottish side of the Cranbrook Report. Of course my right hon. Friend and I are extremely grateful to the members of those Committees, and especially to the Chairmen, for the contribution they have made to the development of maternity services. I emphasise that both Reports were received in February, 1959. There has not been much time to deal with the Reports.
However, a great deal has happened. I will explain what has happened in Scotland. Circumstances differ on the two sides of the Border. The recommendations of the two Committees show a considerable measure of agreement about the type and scale of the provision considered necessary for the maternity services. I will not go into too much detail now, but perhaps I may speak briefly of the progress that we have been able to make—I am speaking for Scotland for the moment—towards implementing the recommendations of the Scottish Committee.
The Western Regional Hospital Board, in whose area the shortage of maternity beds is greatest, already has plans for additional accommodation which will bring by far the greater part of the region up to the level recommended by the Committee. The hon. Member for Glasgow, Kelvingrove (Mrs. McAlister) made a moving speech on this subject. I know her intense interest in it, and I want to give some figures to show what is happening. Of course, if we could have had this years ago it would have been far better, but we are going as fast as we can at the moment.
§ Mr. James McInnes (Glasgow, Central) rose——
§ Mr. Maclay
I cannot give way. I have very little time and want to answer as many questions as I can.
On the basis recommended by the Maternity Services Review Committee, about 850 maternity and ante-natal beds would be needed in Glasgow to reach the 75 per cent. figure. There are at present 693 beds. Plans have been completed for the building of a new maternity unit of 112 beds at Yorkhill and for a 53-bed unit at Belvidere Hospital, and 538 work is expected to begin on these projects about the end of this year. The regional board is now preparing schedules of accommodation for a 90-bed unit, with 30 additional beds for abortion cases, at the David Elder Hospital to serve the south-western part of the city, and a 70-bed unit at the Royal Samaritan Hospital to serve the south-eastern part of the city. This is even more than we need to provide the additional beds to attain the 75 per cent. figure. These developments will enable the board to replace 91 beds in accommodation at the Lennox Castle Maternity Hospital which is needed for mentally deficient patients. That will be not a subtraction but an addition.
§ Mrs. McAlister
Is it not a fact that it will be five years before Yorkhill is available? The right hon. Gentleman has now admitted that we shall lose the maternity beds at Lennox Castle. They must obviously be put against the beds that we are getting in other places.
§ Mr. Maclay
I have been trying to make this point clear. This balanced programme will secure the balance that we need and we shall be able to release the beds at Lennox Castle.
Perhaps the hon. Lady the Member for Lanarkshire, North will forgive me if I do not give detailed figures to show what is happening in North Lanarkshire, but I will send them to her. I referred to the Bellshill proposals and the other additions in that part of the country.
I should like to move—[HON. MEMBERS: "Hear, hear."] The trouble is that when hon. Members are given facts which refute their charges they always want to get out of it and try diversionary activities. That is understandable on the part of hon. Members who are in Opposition, but it is not good for a National Health Service debate.
I want to say a little more about the Committee to which I have referred. On reading its Report—[Interruption.] I wish the right hon. Lady would not mutter. If she wishes to interrupt, would she care to rise to do so?
§ Dr. Summerskill
I would tell the right hon. Gentleman not to get excited about maternity questions. We understand that he cannot possibly know what he is talking about.
§ Mr. Maclay
That is the kind of abuse which brings the House into disrepute when it comes from the Front Bench. That is the sort of thing to which I am used occasionally otherwise, but when it comes from the Front Bench it is not good.
§ Dr. Summerskill rose——
§ Mr. Maclay
I am sorry, but the right hon. Lady cannot expect me to give way again after making a remark like she did. I shall have to leave some of the points with which I was going to deal because my time has been wasted by that interruption. [Interruption.] I will keep my present temperature; it suits me very well.
My hon. and gallant Friend the Member for Ripon (Sir M. Stoddart-Scott) made a very interesting speech. He asked what was happening about dentists. I feel that he was thinking back to the McNair Committee's Report. He raised the problem of whether there was a crisis developing and what we were doing to meet it. As he probably knows, the McNair Committee reported in 1957. It was appointed to consider the reasons for the shortage of dental students. The Committee recommended the expansion of the output of dental schools so as to produce an annual output of 800 for Great Britain as a whole. This recommendation has, of course, been accepted by the Government. The necessary expansion of the schools is at present being planned. The expansion includes plans for a dental school at Cardiff as part of the new hospital and university centre, which is at present the subject of an architectural competition and which has had some publicity. The expansion also includes extra places at Glasgow and Dundee.
I say to the hon. Gentleman the Member for Greenock (Dr. Dickson Mabon), who in his speech said that the Department of Health was always behind the South, that I profoundly disagree. Sometimes it is in front and sometimes behind. Scotland already has had more than its proportional share of dental places and we intend to maintain our lead.
The hon. Gentleman the Member for Greenock raised one other point with which I should like to deal briefly. He asked specifically whether the working party on hospital medical staffs under the chairmanship of Sir Robert Platt had 540 any close connection with the Royal Commission. They are entirely separate bodies and will make separate reports.
§ Dr. Dickson Mabon
When does the right hon. Gentleman expect the Royal Commission's report to be presented? We have now waited many years for it. When will it come?
§ Mr. Maclay
I cannot make a definite forecast, but I would expect it to be before the end of the year. I cannot be certain about that now.
Turning back for a comparatively short time to some of the things which have been happening and which, I think, can be regarded as part of the progress we are making, my hon. Friend the Member for Glasgow, Pollok (Mr. George), in a most interesting speech, raised the question of rehabilitation. I should like to say something which I do not think has previously been announced. It does not precisely deal with what my hon. Friend asked but it is, I think, of very considerable interest.
This is the first time that I have been able to announce it. It has been decided with the approval of the National Advisory Committee on the Employment of the Disabled to begin detailed planning work for the building and equipment of an experimental comprehensive rehabilitation and assessment centre at the Belvidere Hospital in Glasgow. This combined medical and industrial establishment is the first of its kind to be set up in Great Britain, and it is being planned on lines suggested by the Piercy Committee to provide the advantages of having both medical and industrial rehabilitation facilities on one site in close proximity to an existing hospital. The new centre will be planned jointly by the Ministry of Labour and the hospital authorities and it is hoped to begin building on the site in 1961–62.
That is yet another sign of extremely interesting and constructive progress. [Interruption.] If I report what is to happen, hon. and right hon. Gentlemen opposite say that it will never happen. That is nonsense, because an enormous amount does happen. It is equally interesting that if I report on what has happened, hon. Gentlemen opposite ask what is to happen, so that they do their best to get it both ways. Tonight I am dealing with some of the things which 541 are to happen and with some of the things which have happened and that seems to provide a nice balance.
I will give the reasons why it is absurd for hon. Members opposite to dream of voting against us on this matter tonight and I shall take my illustrations from Scotland rather than from the United Kingdom as a whole. Do not let hon. Members opposite say that this is too small: the number of staff beds in Scotland has risen from 58,000 in 1948 to 64,000 at the end of 1958. I do not say that those are dramatic figures, but we must realise that the acute problem is to get the best beds at the right place properly used. [Laughter.] The hon. Lady the Member for Lanarkshire, North laughs, but to judge from the debate it sounded very much as though hon. Members opposite thought that absolute figures were all that mattered. That is not so and progress has been very reasonable.
The number of medical staff engaged in the hospital service in Scotland rose from 1,900 in 1948 to 2,800 by the end of 1958, a very big increase. The number of in-patients treated increased by 40 per cent. and the number of new out-patient attendances more than doubled.
Expressed in purely quantitative terms, we can claim that that is all good progress and that many people, not only the Government, deserve a great deal of credit for it. Before there is all this talk of things going badly, it should be appreciated that the number of doctors in the National Health Service in Scotland increased from 4,460 in 1948 to 5,700 by the end of 1958.
Of themselves, those figures do not amount to a great deal. What matters is the quality of the accommodation and the services we provide. I accept that it is our obligation to make certain that the quality is in accordance with the highest standards of modern medicine. I agree that we have been able to do things which hon. Members opposite were not able to do in the earlier years of the Service, even if they wanted to do them.
§ Mr. A. Woodburn (Clackmannan and East Stirlingshire) rose——542
§ Mr. Woodburn
We appreciate many of the things which the right hon. Gentleman is saying. A number of problems have been raised, including pollution and the question of prescription charges. It would be interesting to know whether the Government tonight intend to announce the abolition of prescription charges.
§ Mr. Maclay
I think that the right hon. Gentleman was present when my right hon. and learned Friend dealt with that matter and I do not propose to repeat what my right hon. and learned Friend said. The right hon. Gentleman will find precisely what was said if he reads HANSARD tomorrow. If I had not been interrupted so much, I would have been able to deal with pollution and many other things.
If I may continue with my own speech and conclude by dealing with other speeches, another piece of progress mentioned by the hon. Lady for Lanarkshire, North was that connected with infant mortality. She seemed to think that our figures were bad and that Scotland was relatively very much worse off than England. I agree that our figures are still worse than those of England. The comparisons between 1948 and 1958 are that the infant mortality rate for 1,000 births was 44.7 in Scotland against 32 in England, while at the end of the period it was 27.7 in Scotland against 23 in England. That shows a remarkable improvement. The figures are not good enough, but nothing is ever good enough in the National Health Service. The hon. Lady must agree that that is more evidence of genuine progress.
I should have liked to deal in much more detail with many of the topics which have been raised. Pollution has been mentioned by several hon. Members and obviously it has a relationship with various illnesses which have been mentioned. I confess that I am not very happy about the speed with which Scottish local authorities are getting on with making smoke clearance schemes. I have recently been in touch with them pressing them for more schemes. Everybody knows that this is a difficult problem.
§ Mr. Thomas Steele (Dunbartonshire, West) rose——543
§ Mr. Maclay
This is very important. I have given way a good deal and there is not more more time for me to deal with the points which have been raised.
§ Mr. Steele rose ——
§ Mr. Steele
Is the Minister aware that the Dunbarton Town Council made an order on 1st January, 1958, and it still has not been confirmed?
§ Mr. Maclay
There are technical reasons for that. That is clearly a constituency point and it has prevented me dealing with other points that have been raised.
It must be remembered that the party opposite are going to divide the Committee. They have not made their case, but let us look at what is happening apart from building and in addition to the improved figures that I have given. There has been a remarkable achievement in dealing with tuberculosis in Scotland. I do not claim full credit for the Government. I claim credit for the medical profession and all those working on the problem, but I also claim that this Government have made possible and encouraged the greatest anti-tuberculosis campaign conducted in any country at any time. The work that we have to do must be a combination of work by the Government, the medical profession, voluntary workers, staffs of the National Health Service, research workers and all those involved in this very great service.
Hon. Members opposite do not like the figures that I have given. Let us consider
§ what is happening, because this is an interesting and relevant reflection of the high standard of health that exists. The high birthrate may well be regarded as an index of a very healthy community, provided it is associated with a declining infant mortality rate and stillbirth rate. I have already given the figures for the declining infant mortality rate, but the birthrate figure in Scotland in 1958 at 19.2 per thousand was as high as it was in 1948 towards the end of the post-war bulge.
§ Why do hon. Members opposite intend to divide the Committee? The right hon. Lady the Member for Warrington, accused my right hon. Friend of laughing and smiling. She has sat there completely irresponsible throughout my speech, muttering to herself and unable to give any justification for dividing the Committee. I used to have some respect for the right hon. Lady, but she has lost it all today. Her charge against the Government was that they had failed to implement Reports which had been introduced so recently that it was physically impossible for them to be implemented. I deplore the fact that she made a personal attack on my right hon. Friend in the course of his absolutely first-rate speech.
§ Dr. Summerskill
I beg to move, That Item Class V, Vote 5 (National Health Service, England and Wales), be reduced by £5.
§ Question put:—
§ The Committee divided: Ayes 240, Noes 301.547
|Division No. 168.]||AYES||[9.58 p.m.|
|Abse, Leo||Burton, Miss F. E.||Donnelly, D. L.|
|Ainsley, J. W.||Butler, Herbert (Hackney, C.)||Dugdale, Rt. Hn. John (W. Brmwch)|
|Albu, A. H.||Butler, Mrs. Joyce (Wood Green)||Ede, Rt. Hon. J. C.|
|Allaun, Frank (Salford, E.)||Callaghan, L. J.||Edelman, M.|
|Allen, Arthur (Bosworth)||Carmichael, J.||Edwards, Rt. Hon. John (Brighouse)|
|Awbery, S. S.||Champion, A. J.||Edwards, Rt. Hon. Ness (Caerphilly)|
|Baird, J.||Chapman, W. D.||Edwards, W. J. (Stepney)|
|Balfour, A.||Chetwynd, G. R.||Evans, Albert (Islington, S. W.)|
|Bellenger, Rt. Hon. F. J.||Cliffe, Michael||Evans, Edward (Lowestoft)|
|Bence, C. R. (Dunbartonshire, E.)||Coldrick, W.||Fernyhough, E.|
|Benson, Sir George||Collick, P. H. (Birkenhead)||Finch, H. J. (Bedwellty)|
|Beswick, Frank||Corbet, Mrs. Freda||Fitch, A. E. (Wigan)|
|Blenkinsop, A.||Craddock, George (Bradford, S.)||Fletcher, Eric|
|Blyton, W. R.||Cronin, J. D.||Foot, D. M.|
|Boardman, H.||Crossman, R. H. S.||Forman, J. C.|
|Bottomley, Rt. Hon. A. G.||Cullen, Mrs. A.||Fraser Thomas (Hamilton)|
|Bowden, H. W. (Leicester, S. W.)||Dalton, Rt. Hon. H.||George, Lady Megan Lloyd (Car'then)|
|Bowles, F. G.||Darling, George (Hillsborough)||Gibson, C. W.|
|Boyd, T. C.||Davies, Ernest (Enfield, E.)||Gooch, E. G.|
|Braddock, Mrs. Elizabeth||Davies, Harold (Leek)||Gordon Walker, Rt. Hon. P. C.|
|Brockway, A. F.||Davies, S. O. (Merthyr)||Greenwood, Anthony|
|Broughton, Dr. A. D. D.||Deer, G.||Grenfell, Rt. Hon. D. R.|
|Brown, Rt. Hon. George (Belper)||Diamond, John||Grey, C. F.|
|Brown, Thomas (Ince)||Dodds, N. N.||Griffiths, David (Rother Valley)|
|Griffiths, Rt. Hon. James (Llanelly)||MacDermot, Niall||Ross, William|
|Griffiths, William (Exchange)||McInnes, J.||Royle, C.|
|Hale, Leslie||McKay, John (Wallsend)||Shinwell, Rt. Hon. E.|
|Hall Rt. Hn. Glenvil (Colne Valley)||McLeavy, Frank||Short, E. W.|
|Hamilton, W. W.||MacPherson, Malcolm (Stirling)||Silverman, Julius (Aston)|
|Hannan, W.||Mahon, Simon||Silverman, Sydney (Nelson)|
|Hastings, S.||Mallalieu, J. P. W. (Huddersfd, E.)||Simmons, C. J. (Brierley Hill)|
|Hayman, F. H.||Mann, Mrs. Jean||Skeffington, A. M.|
|Healey, Denis||Mason, Roy||Slater, Mrs. H. (Stoke, N.)|
|Henderson, Rt. Hn. A. (Rwly Regis)||Mayhew, C. P.||Slater, J. (Sedgefield)|
|Herbison, Miss M.||Mendelson, J. J.||Smith, Ellis (Stoke, S.)|
|Hewitson, Capt. M.||Mikardo, Ian||Snow, J. W,|
|Hilton, A. V.||Mitchison, G. R.||Sorensen, R, W.|
|Hohson, C. R. (Keighley)||Monslow, W.||Sparks, J. A.|
|Holman, P.||Moody, A. S.||Spriggs, Leslie|
|Holmes, Horace||Morris, Percy (Swansea W.)||Steele, T.|
|Houghton, Douglas||Morrison, Rt. Hn. Herbert (Lewis'm, S.)||Stewart, Michael (Fulham)|
|Howell, Charles (Perry Barr)||Mort, D. L.||Stonehouse, John|
|Howell, Denis (All Saints)||Moyle, A.||Stones, W. (Consett)|
|Hughes, Cledwyn (Anglesey)||Mulley, F. W.||Strauss, Rt. Hon. George (Vauxhall)|
|Hughes, Emrys (S. Ayrshire)||Neal, Harold (Bolsover)||Stross, Dr. Barnett (Stoke-on-Trent, C.)|
|Hughes, Hector (Aberdeen, N.)||Noel-Baker, Francis (Swindon)||Summerskill, Rt. Hon. E.|
|Hunter, A. E.||Noel-Baker, Rt. Hon. P. (Derby, S.)||Swingler, S. T.|
|Hynd, H. (Accrington)||Oliver, G. H.||Sylvester, G. O.|
|Hynd, J. B. (Attercliffe)||Oram, A. E.||Symonds, J. B.|
|Irvine, A. J. (Edge Hill)||Orbach, M.||Taylor, Bernard (Mansfield)|
|Irving, Sydney (Dartford)||Oswald, T.||Taylor, John (West Lothian)|
|Isaacs, Rt. Hon. G. A.||Owen, W. J.||Thomas, lorwerth (Rhondda, W.)|
|Janner, B.||Padley, W. E.||Thomson, George (Dundee, E.)|
|Jay, Rt. Hon. D. P. T.||Paget, R. T.||Thornton, E.|
|Jeger, George (Goole)||Paling, Rt. Hon. W. (Dearne Valley)||Tomney, F.|
|Jeger, Mrs. Lena (Holbn & St. Pncs, S.)||Paling, Will T. (Dewsbury)||Ungoed-Thomas, Sir Lynn|
|Jenkins, Roy (Stechford)||Palmer, A. M. F.||Usborne, H. C.|
|Johnson, James (Rugby)||Pannell, Charles (Leeds, W.)||Viant, S. P.|
|Johnston Douglas (Paisley)||Pargiter, G. A.||Warbey, W. N.|
|Jones, Rt. Hon. A. Creech (Wakefield)||Parker, J.||Watkins, T. E.|
|Jones, David (The Hartlepools)||Parkin, B. T.||Weitzman, D.|
|Jones, Elwyn (W. Ham, S.)||Paton, John||Wells, Percy (Faversham)|
|Jones, Jack (Rotherham)||Peart, T. F.||Wells, William (Walsall, N.)|
|Jones, J. Idwal (Wrexham)||Pentland, N.||White, Henry (Derbyshire, N. E.)|
|Jones, T. W. (Merioneth)||Plummer, Sir Leslie||Wigg, George|
|Kenyon, C.||Price, J. T. (Westhoughton)||Wilcock, Group Capt. C. A. B.|
|Key, Rt. Hon. C. W.||Price, Philips (Gloucestershire, W.)||Wilkins, W. A.|
|King, Dr. H. M.||Probert, A. R.||Willey, Frederick|
|Lawson, G. M.||Proctor, W. T.||Williams, David (Neath)|
|Ledger, R. J.||Pursey, Cmdr. H.||Williams, Rev. Llywelyn (Ab'tillery)|
|Lee, Frederick (Newton)||Randall, H. E.||Williams Rt. Hon. T. (Don Valley)|
|Lee, Miss Jennie (Cannock)||Rankin, John||Williams, W. R. (Openshaw)|
|Lever, Harold (Cheetham)||Redhead, E. C.||Willis, Eustace (Edinburgh, E.)|
|Lever, Leslie (Ardwick)||Reid, William||Wilson, Rt. Hon. Harold (Huyton)|
|Lewis, Arthur||Reynolds, G. W.||Woodburn, Rt. Hon. A.|
|Lindgren, G. S.||Rhodes, H.||Woof, R. E.|
|Lipton, Marcus||Robens, Rt. Hon. A.||Yates, V. (Ladywood)|
|Mabon, Dr. J. Dickson||Roberts, Albert (Normanton)||Zilliacus, K.|
|McAlister, Mrs. Mary||Roberts, Goronwy (Caernarvon)|
|McCann, J.||Robinson, Kenneth (St. Pancras, N.)||TELLERS FOR THE AYES:|
|MacColl, J. E.||Rogers, George (Kensington, N.)||Mr. Popplewell and Mr. Pearson.|
|Agnew, Sir Peter||Bevins, J. R. (Toxteth)||Cary, Sir Robert|
|Aitken, W. T.||Bidgood, J. C.||Channon, H. P. G.|
|Allan, R. A. (Paddington, S.)||Biggs-Davison, J, A.||Chichester-Clark, R.|
|Amery, Julian (Preston, N.)||Bingham, R. M.||Churchill, Rt. Hon. Sir Winston|
|Amory, Rt. Hn. Heathcoat (Tiverton)||Birch, Rt. Hon. Nigel||Clarke, Brig. Terence (Portsmth, W.)|
|Anstruther-Gray, Major Sir William||Bishop, F. P.||Cole, Norman|
|Arbuthnot, John||Black, Sir Cyril||Conant, Maj. Sir Roger|
|Armstrong, C. W.||Body, R. F.||Cooke, Robert|
|Ashton, Sir Hubert||Bonham Carter, Mark||Cooper, A. E.|
|Astor, Hon. J, J.||Bossom, Sir Alfred||Cooper-Key, E. M.|
|Atkins, H. E.||Bowen, E. R. (Cardigan)||Cordeaux, Lt.-Col. J. K.|
|Baldock, Lt.-Cmdr. J. M.||Boyd-Carpenter, Rt. Hon. J. A.||Corfield, F. V.|
|Baldwin, Sir Archer||Boyle, Sir Edward||Courtney, Cdr. Anthony|
|Balniel, Lord||Braine, B. R.||Craddock, Beresford (Spelthorne)|
|Banks, Col. C.||Braithwaite, Sir Albert (Harrow, W.)||Crosthwaite-Eyre, Col. O. E.|
|Barber, Anthony||Brewis, John||Crowder, Sir John (Finchley)|
|Barlow, Sir John||Bromley-Davenport, Lt.-Col, W. H.||Crowder, Petre (Ruislip—Northwood)|
|Barter, John||Brooke, Rt. Hon. Henry||Cunningham, Knox|
|Batsford, Brian||Brooman-White, R. C.||Currie, G. B. H.|
|Baxter, Sir Beverley||Browne, J. Nixon (Cralgton)||Dance, J. C. G.|
|Beamish, Col. Tufton||Bryan, P.||Davidson, Viscountess|
|Bell, Philip (Bolton, E.)||Bullus, Wing Commander E. E.||D'Avigdor-Goldsmid, Sir Henry|
|Bell, Ronald (Bucks, S.)||Butcher, Sir Herbert||Deedes, W. F.|
|Bennett, F. M. (Torquay)||Campbell, Sir David||de Ferranti, Basil|
|Bennett, Dr. Reginald||Carr, Robert||Dodds-Parker, A. D.|
|Donaldson, Cmdr. C. E. McA.||Johnson Dr. Donald (Carlisle)||Pitt, Miss E. M.|
|Doughty C. J. A.||Johnson, Eric (Blackley)||Pott, H. P.|
|Drayson, G. B.||Johnson, Howard (Kemptown)||Powell, J. Enoch|
|du Cann, E. D. L.||Jones, Rt. Hon. Aubrey (Hall Green)||Price, David (Eastleigh)|
|Duncan, Sir James||Joseph, Sir Keith||Price, Henry (Lewisham, W.)|
|Duthie, Sir William||Kaberry, D.||Prior-Palmer, Brig. Sir Otho|
|Eden, J. B. (Bournemouth, West)||Keegan, D.||Profumo, J. D.|
|Elliot, R. W. (Ne'castle upon Tyne, N.)||Kerby, Capt. H. B.||Ramsden, J. E.|
|Emmet Hon. Mrs. Evelyn||Kerr, Sir Hamilton||Rawlinson, Peter|
|Errington, Sir Eric||Kershaw, J. A.||Redmayne, M.|
|Erroll F. J.||Kimball, M.||Rees-Davies, W. R.|
|Farey-Jones, F. W.||Kirk, P. M.||Remnant, Hon. P.|
|Fell, A.||Lagden, G. W.||Renton, D. L. M.|
|Finlay, Graeme||Lambton, Viscount||Ridsdale, J. E.|
|Fisher, Nigel||Lancaster, Col. C. G.||Rippon, A. G. F.|
|Fletcher-Cooke, C.||Langford-Holt, J. A.||Roberts, Sir Peter (Heeley)|
|Fraser, Hon. Hugh (Stone)||Leavey, J. A.||Robinson, Sir Roland (Blackpool, S.)|
|Freeth, Denzil||Leburn, W. G.||Robson Brown, Sir William|
|Galbraith, Hon. T. G. D.||Legge-Bourke, Maj. E. A. H.||Rodgers, John (Sevenoaks)|
|Gammans, Lady||Lindsay, Hon. James (Devon, N.)||Roper, Sir Harold|
|Garner-Evans, E. H.||Lindsay, Martin (Solihull)||Ropner, Col. Sir Leonard|
|George, J. C. (Pollok)||Liewellyn, D. T.||Russell, R. S.|
|Gibson-Watt, D.||Lloyd, Maj. Sir Guy (Renfrew, E.)||Scott-Miller, Cmdr. R|
|Glover, D.||Longden, Gilbert||Sharples, R. C.|
|Glyn, Col. Richard H.||Loveys, Walter H.||Shepherd, William|
|Godber, J. B.||Low, Rt. Hon. Sir Toby||Simon, J. E. S. (Middlesbrough, W.)|
|Goodhart Philip||Lucas, Sir Jocelyn (Portsmouth, S.)||Smithers, Peter (Winchester)|
|Gough, C. F. H.||Lucas, P. B. (Brentford & Chiswick)||Smyth, Brig. Sir John (Norwood)|
|Gower H. R.||Lucas-Tooth, Sir Hugh||Soames, Rt. Hon. Christopher|
|Graham, Sir Fergus||McAdden, S. J.||Speir, R. M.|
|Grant-Ferris, Wg Cdr. R. (Nantwich)||Macdonald, Sir Peter||Spence, H. R. (Aberdeen, W.)|
|Green, A.||McLaughlin, Mrs. P.||Stanley, Capt. Hon. Richard|
|Gresham Cooke, R.||Maclay, Rt. Hon. John||Stevens, Geoffrey|
|Grimston, Hon. John (St. Albans)||Maclean, Sir Fitzroy (Lancaster)||Steward, Harold (Stockport, S.)|
|Grimston, Sir Robert (Westbury)||McLean, Neil (Inverness)||Steward, Sir William (Woolwich W.)|
|Grosvenor Lt.-Col. R. G.||MacLeod, John (Ross & Cromarty)||Stoddart-Scott, Col. Sir Malcolm|
|Gurden, Harold||McMaster, Stanley||Stuart, Rt. Hon. James (Moray)|
|Hall, John (Wycombe)||Macmillan, Maurice (Hallfax)||Studholme, Sir Henry|
|Harris, Frederic (Croydon, N. W.)||Maddan, Martin||Summers, Sir Spencer|
|Harris, Reader (Heston)||Maitland, Cdr. J. F. W. (Horncastle)||Sumner, W. D. M. (Orpington)|
|Harrison, A. B. C. (Maldon)||Maitland, Hon. Patrick (Lanark)||Taylor, William (Bradford, N.)|
|Harvey, Sir Arthur Vere (Macclesf'd)||Markham, Major Sir Frank||Teeling, W.|
|Harvey, John (Walthamstow, E.)||Marlowe, A. A. H.||Temple, John M.|
|Harvie-Watt, Sir George||Marples, Rt. Hon. A. E.||Thomas, Leslie (Canterbury)|
|Hay, John||Marshall, Douglas||Thomas, P. J. M. (Conway)|
|Head Rt. Hon. A. H.||Mathew, R.||Thompson, Kenneth (Walton)|
|Heald, Rt. Hon. Sir Lionel||Maudling, Rt. Hon. R.||Thompson, R. (Croydon, S.)|
|Heath, Rt. Hon. E. R. G.||Mawby, R. L.||Thorneycroft, Rt. Hon. P.|
|Henderson, John (Cathcart)||Maydon, Lt.-Comdr. S. L. C.||Thornton-Kemsley, Sir Colin|
|Henderson-Stewart, Sir James||Medlicott, Sir Frank||Tiley, A. (Bradford, W.)|
|Hesketh, R. F.||Milligan, Rt. Hon. W. R.||Tilney, John (Wavertree)|
|Hicks-Beach, Maj. W. W.||Molson, Rt. Hon. Hugh||Turton, Rt. Hon. R. H.|
|Hill, Rt. Hon. Charles (Luton)||Moore, Sir Thomas||Tweedsmuir, Lady|
|Hill, John (S. Norfolk)||Morrison, John (Salisbury)||Vane, W. M. F.|
|Hirst, Geoffrey||Mott-Radclyffe, Sir Charles||Vaughan-Morgan, J. K.|
|Hobson, John (Warwick & Leam'gt'n)||Nabarro, G. D. N.||Vickers, Miss Joan|
|Holland-Martin, C. J.||Nairn, D. L. S.||Vosper, Rt. Hon. D. F.|
|Holt, A. F.||Nicholls, Harmar||Wade, D. W.|
|Hope, Lord John||Nicholson, Sir Godfrey (Farnham)||Wakefield, Sir Wavell (St. M'lebone)|
|Hornby, R. P.||Nicolson, N. (B'n'm'th, E. & Chr'ch)||Walker-Smith, Rt. Hon. Derek|
|Hornshy-Smith, Miss M. P.||Noble, Comdr. Rt. Hon. Sir Allan||Wall, Patrick|
|Horobin, Sir Ian||Noble, Michael (Argyll)||Ward, Rt. Hon. G. R. (Worcester)|
|Horsbrugh, Rt. Hon. Dame Florence||Nugent, Richard||Watkinson, Rt. Hon. Harold|
|Howard, Gerald (Cambridgeshire)||Oakshott, Sir Hendrie||Webbe, Sir H.|
|Howard, Hon. Greville (St. Ives)||O'Neill, Hn. Phellm (Co. Antrim, N.)||Webster, David|
|Howard, John (Test)||Ormsby-Gore, Rt. Hon. W. D.||Whitelaw, W. S. I.|
|Hughes Hallett, Vice-Admiral J.||Orr, Capt. L. P. S.||Williams, Paul (Sunderland, S.)|
|Hughes-Young, M. H. C.||Orr-Ewing, C. Ian (Hendon N.)||Williams, R. Dudley (Exeter)|
|Hurd, Sir Anthony||Page, R. G.||Wilson, Geoffrey (Truro)|
|Hutchison, Michael Clark (E'b'gh, S.)||Pannell, N. A. (Kirkdale)||Wolrige-Gordon, Patrick|
|Hutchison, Sir James (Scotstoun)||Partridge, E.||Wood, Hon. R.|
|Hyde, Montgomery||Peel, W. J.||Yates, William (The Wrekin)|
|Hylton-Foster, Rt. Hon. Sir Harry||Peyton, J. W. W.|
|Irvine, Bryant Godman (Rye)||Pickthorn, Sir Kenneth||TELLERS FOR THE NOES:|
|Jenkins, Robert (Dulwich)||Pike, Miss Mervyn||Mr. Legh and|
|Jennings, J. C. (Burton)||Pilkington, Capt. R. A.||Colonel J. H. Harrison.|
|Jennings, Sir Roland (Hallam)||Pitman, I. J.|
§ Original Question again proposed.
§ Mr. Ray Mawby (Totnes) rose——
§ It being after Ten o'clock, The CHAIRMAN left the Chair to report Progress and ask leave to sit again.
§ Committee report Progress; to sit again Tomorrow.