NATIONAL HEALTH SERVICE, ENGLAND AND WALES

HC Deb 11 July 1961 vol 644 cc219-350

3.42 p.m.

Mr. Kenneth Robinson (St. Pancras, North)

Apart from the series of debates we had arising from the decision of the Minister of Health last February to increase health charges and contributions, this is the first opportunity for very nearly a year that the House has had to debate the National Health Service. Last July, we had what was nominally half a Supply day; it actually turned out to be less than 2½ hours. Brief as that period was, however, it was sufficient to produce a quite remarkable result.

So cogent was the Opposition's case on that occasion, so persuasive were our speeches, that within an hour or so of the Division, the then Minister of Health, the right hon. and learned Gentleman the Member for Hertfordshire, East (Sir D. Walker-Smith), had announced his resignation from the Government. In case this recollection raises the hopes of my hon. Friends too high, I feel bound to tell them that there can be no certainty that the present Minister will be guided by that precedent.

During the last twelve months a number of important policy decisions have been made, and a number of important reports have been published, all of which deserve the attention of the House, and it is for that reason that we asked for a whole Supply day on this occasion. There are so very many topics to discuss that my greatest problem has been that of selection.

First, I should like to put on record that what we said when the right hon. Gentleman introduced his increased charges and contributions has been amply borne out by events. Indeed, the protest that we made has been reinforced by the decision of the Chancellor of the Exchequer to hand out to Surtax payers the money raised by the right hon. Gentleman by means of increased charges on the sick, and poll tax contributions. We now have figures for the three months since the prescription charges were increased on 1st March, and experience so far suggests that we were right when we said that some patients, at any rate, would suffer as a result of this step by not getting the medicines they needed.

In replies that the Minister has given to Questions, we have found that between February—that is, the last month of the old charges—and March, the first month of the double prescription charge, there was a fall of 2.7 million in the number of prescriptions dispensed. That is a fall of 21 per cent. between February and March. That, by itself, is perhaps not a significant figure, but it should be looked at in comparison with the fact that between February and March of the previous year there was a 3½ per cent. rise in prescriptions.

Very much more significant than those figures are the figures now available for March, April and May. In that period there has been a drop of 6.6 million prescriptions dispensed, compared with the similar period of last year, and that represents a fall of very nearly 12 per cent. We on this side believe that there is already ample evidence to justify a reconsideration of this double prescription charge.

Not all the evidence is of a statistical nature. Only about a week ago I was told by a doctor who is in general practice in a typical London area that, in his view, hardship is undoubtedly being caused by these charges, particularly amongst the lower wage earners with families. He gave one or two examples of the sort of thing that is happening.

If a patient gets a multiple prescription—one with several items on it—he is apt to say to the chemist "I'll just have the bottle," and perhaps forgo an antibotic that may be of real therapeutic value and need to him. Other patients ask the doctor to give them prescriptions with just one item on them; if the doctor wants to prescribe two or three items, they ask for two or three separate prescriptions so that their liability at the chemist's will be limited to 2s. each time. Worse still, perhaps, are those cases where the patients just do not get their prescriptions dispensed at all. Very naturally, feeling rather shamefaced, they do not mention that fact to the doctor who, again very naturally, thinks that the prescribed treatment has not been effective.

I agree that there are rather more people applying to the National Assistance Board for refunds on hardship grounds, but, even so, the total amount paid out by the Board for these refunds is still very small. It is equally a fact that the number of people whose applications are rejected is also increasing, so it can be said that the arrangements for meeting hardship have, at any rate, not been any more successful than we forecast from these benches.

The Minister of Health must surely have become aware, since our earlier debates, of how very objectionable almost everyone and, in particular, the doctors and pharmacists find his doubling of the prescription charge; and that more than 40 executive councils have protested to him about it. What worries us is that the right hon. Gentleman seems to see some positive virtue in these charges. We think that at any time the Treasury wants to cut public expenditure—and by all accounts that time may be very close at hand—or at any time the Chancellor wishes, once again, to ease the lot of the better-off section of the community, the Minister may again be tempted to impose further increases, and to try to justify them exactly as he did last time.

It is for this reason that we would like some assurances from the Minister about the future. Will the right hon. Gentleman undertake to introduce no new charges and to make no further increases in the existing charges while he holds his present office? Furthermore, will he agree to reduce at least the 2s. charge if the fall in prescriptions that the figures already reveal continues over, say, the next three to six months? My hon. Friends and I feel entitled, on the right hon. Gentleman's past record, to ask for these assurances. On his reply will largely depend our decision whether or not to vote against this token Estimate tonight.

I now turn to some matters which are less controversial, at any rate in the party political sense. In the debate a year ago I spoke about something which is often called, conveniently, if perhaps somewhat inelegantly, the humanisation of our hospitals. This is a subject in which I know the Minister has shown a commendable interest. The right hon. Gentleman described it in a recent debate as the … attitude of the hospital service to the individual man and woman in its care as a human being and not merely as a case."—[OFFICIAL REPORT, 8th February, 1961; Vol. 634, c. 428.] It is regrettable that this attitude is not always satisfactory. At least two recent Reports issued by the right hon. Gentleman's Department bear out this contention. The first of these Reports—and both of them came from the Central Health Services Council, which is doing admirable work in assessing the operations of the National Health Service—was called The Pattern of the In-Patient's Day".

It is a wholly admirable Report and it contains some sharp criticisms of the outmoded, one might almost say inhuman though unintentionally inhuman, practices which still prevail in some sections of the nursing profession; practices which seem to lead to the subjection of the patient to the hospital routine, rather than to what we would all hope to see, the moulding of the hospital routine to fit the needs and comfort of the patient.

I will merely mention, in this connection, such things as the time-honoured practice of waking patients at 6 a.m. or even earlier—considerably earlier in some maternity departments—the ritual that accompanies medical rounds in the morning and the total cessation of work while this is going on. These are one or two of the practices which this Report suggests are not necessary and could be brought to an end. This criticism is all the more welcome in that it comes from a committee which was composed entirely of nurses and which had the advantage of being chaired by one of the most dynamic and progressive members of the nursing profession.

The Minister commended this Report in a recent speech which he made to the Association of Hospital Matrons. I hope that this will be carefully pondered by all who are associated with hospital care, and even by those who are not necessarily associated with it, and that it will help to revolutionise the nursing routines and the in-patient's day in our less progressive hospitals.

The second of these Reports is entitled "Human Relations in Obstetrics". This is a similarly valuable contribution and it admits that in maternity departments it is not unknown for worried or frightened mothers to be met by an attitude of what the Report calls domination or even bullying on the part of those who are supposed to be caring for them. It is suggested that some midwives, perhaps through psychological difficulties of their own or through overwork, are developing a brusque and insensitive manner and the Report recommends that the most sympathetic attention should be given to the emotional needs of the expectant mother and, I am happy to add, to the expectant father.

The Report mentions, and many tributes have been justly paid to, the inaugural lecture by Professor Norman Morris, Professor of Obstetrics at Charing Cross Hospital, entitled "Human Relations in Obstetric Practice". I would like to pay my tribute to the pioneer work of Professor Nixon, of University College Hospital, with whom Professor Morris worked until he moved to Charing Cross, and who has done more than anyone in this country to bring humanity, intelligence and understanding to the practice of obstetrics in Britain. His ideas are gradually permeating to maternity departments, but there is still a long way to go and this Report will do much to stimulate progress.

I hope that the Minister and the Central Health Services Council will turn their attention to the out-patients who attend our hospitals, in some of which patients are treated with an appalling lack of consideration and are sometimes subjected even to indignity. Of course, most out-patient departments operate what they choose to call an "appointments system". Many of these systems work well and efficiently, but some are systems only in name. They are systems designed for one purpose only: to ensure that whatever happens—whatever accident occurs—the consultant in charge of the clinic shall never be kept waiting for one moment.

The corollary of this is that patients must often be kept waiting for a long time and the sort of thing that happens is this. A clinic is perhaps due to start at 2.30 p.m. so that five or six patients are summoned to attend at 2.15 p.m., just in case they should happen to arrive late. In fact, of course, hospitals should realise that patients nearly always arrive early for their appointments. Thus probably most of them would not arrive at 2.15 p.m. but at 2 p.m. I regret to say that, too often, the consultants are late. To take a very mild example, let us suggest that the consultant arrives at 2.45 p.m. This means that the first patient to be seen from the first batch will have waited three-quarters of an hour. It also means that the last patient will have waited about one-and-a-half hours and this will go on throughout the afternoon.

This type of appointments system—if one can dignify it with that name—is based on two assumptions: first, that the time of the doctor is priceless; and secondly, that the time of the patient is valueless. I submit that neither of these assumptions is necessarily true in all circumstances. Two incidents came to my notice in recent weeks. The first, of which I have close personal knowledge, was that a routine appointment was made for a post-surgical check-up and the appointment was made six weeks earlier. By the time the patient and her child got in—to see not the consultant, but the registrar, I believe, because one never knows who is the doctor one is seeing—an hour and forty minutes had elapsed. The patient said, very mildly, "Is this normal?" and received an extremely brusque reply, the doctor saying, "We are very busy today" and that there was nothing abnormal about it.

In the second case, a friend of mine was waiting in an out-patients' department where nearly all the patients were mothers and children, some of them with babes in arms. Not only did they have these long waits, but they all had to sit on long hard benches, and every time another patient was taken in to see the doctor everyone had to move one place along the benches, collecting all the children, the babies and all their traps in doing so. Nobody, apparently, has thought of giving out tickets, perhaps, with numbers on, and calling "No. 6 next".

This practice of treating patients rather like sheep is a bad hang-over from the old days of the Poor Law type of hospital. It is all easily avoidable and should be avoided. I hope that the Minister will encourage, or even instruct, the Central Health Services Council to carry out a full-scale inquiry into the functioning and organisation of outpatient clinics.

I turn now to the Report of the Platt Working Party on the Medical Staffing Structure in the Health Service. This is an important document, even if one does not accept all its conclusions. One of the most significant findings in the Report—it is in paragraph 41—is that the number of consultants in the Health Service is inadequate. Hon. Members need have only some knowledge of the length of waiting lists in our hospitals to agree with that finding. The Report speaks of excessive delegation of work by consultants to senior registrars and even to more junior grades of doctor. It suggests that in some cases the work of these junior doctors is done without supervision by the consultant.

This only confirms what many of us have for a long time suspected. It would be illuminating and, perhaps, even rather disturbing to know what proportion of, for instance, major surgery within the Health Service is carried out by doctors below consultant rank.

It is not only the shortage of consultants which lead to excessive delegation. There is, one regrets to say, a minority of consultants—I believe and hope that it is a very small minority— who are simply not doing the work for which they are paid on a sessional basis. They are apt to leave all out-patient work, for example, to their registrars, out-patient work for which they are allocated their own sessions. This is not exactly dealt with in the Working Party's Report, but it is something to which the Minister should turn his attention because the practice of this small minority is not only doing damage to the Health Service and to some extent mulcting the taxpayer, but it is also doing great disservice to the majority of consultants who do a good, conscientious day's work.

The Working Party gives several contributory reasons for the shortage of consultants. Some of the reasons are within the Minister's direct responsibility and some are not. In paragraph 42 the Working Party mentions that there has been a resistance to the creation of new consultant posts sometimes by hospital boards and sometimes by consultants". I have never heard of a regional hospital board resisting extra consultant posts, but I have heard—in one way I am glad to see this confirmed by the Report—that there has been resistance on the part of the consultants' advisory committees.

The Report having revealed that there has been such resistance, it seems somewhat contradictory that it should go on to say that the consultant establishments of the future should be decided by a similar, if not, identical kind of professional advisory committee to the one which advises the Minister now. I hope that, when we have the regional review of consultant posts which the Report recommends—I hope that the Minister does not waste much time about this but encourages regional boards to send it to him in six months or, at the outside, twelve months—the decision about future consultant establishments will be taken with complete objectivity and without any suspicion of a professional closed shop being allowed to enter into the consideration.

Perhaps the most controversial recommendation in the Report is for the establishment of a new grade of hospital doctor, the medical assistant. This has met with a good deal of criticism from the medical profession in its journals. I find it difficult to see how a grade which will embrace not only the failed registrar, but also the newly qualified doctor getting hospital experience before going into general practice and also the general practitioner himself doing hospital sessions, could ever be regarded as an alternative ladder to consultant status.

Whatever the merits or demerits of such a proposed new structure for the future, what it is not and emphatically cannot be is a solution to the problem of the existing time-expired senior registrar. These men, of whom there are, I think, rather more than 100, long ago completed their training as senior registrars, and at no time during that long period of training was it ever suggested to them that they were not entitled to expect a consultant appointment at the end of it or that they would not make the grade. Many of them are doing consultant work in fact if not in name, and they have been doing so for years. Many of them have higher post-graduate qualifications.

For a year or more before the Working Party was set up, we pressed the right hon. Gentleman's predecessor about these unfortunate men. We pointed out that, although limited in size, it was a problem which caused desperate anxiety to the individuals it affected. The Working Party was to be the answer. Three more years have gone by and no satisfactory solution is even now in sight. Will the Minister please settle the problem here and now without waiting for his ultimate policy decisions on all the rest of the recommendations in the Report? Will he put these unfortunate men out of their misery and give them, if not full consultant status, at any rate para-consultant status without waiting for the implementation of all the rest of the Report?

The Report suggests also that the general practitioner should be more closely associated with the hospital service. We all agree that that is desirable, but I wonder haw realistic it is. How many general practitioners, even those in partnership or in group practice, have the time to devote two or three sessions a week or even two or three hours a day, as the Report suggests, to hospital work? The lists of so many general practitioners are already so large that they find it difficult to give full attention to the patients who came to their surgeries, let alone to allocate many additional hours to the hospitals in their neighbourhood.

The reduction of general practitioners' lists ought to be one of the Minister's priorities. On these benches, we were very disappointed that, when the Royal Commission's award to the doctors was implemented, there were not, at the same time, parallel improvements in the method of distribution of the general pool, improvements in the interests of the patient. Some of us wondered whether there could not have been some weighting of the second thousand patients on the list in order to remove the great incentive to build up maximum lists at all costs, which cannot be in the interests of the patient.

I appreciate that this might well call for more general practitioners. I think that we do need more general practitioners and more doctors generally. There is already an overall shortage in both the hospital service and general practice, and I believe that the shortage is growing. In many hospitals it is almost impossible to fill junior medical posts except with doctors from overseas. I do not for a moment suggest that there is anything professionally inferior in these doctors, but they are all needed in their own countries and many of them will, in fact, return to their own countries to practice.

Only a week or two ago I was at a fairly large general hospital in the North of England. I think that every post below senior registrar was occupied by a doctor from overseas. This is not a healthy situation, and it brings us back to the notorious Willink Report. The Committee will remember that the Willink Committee recommended in, I think, 1956, that the intake of medical students should be reduced by 10 per cent. and that that would be adequate to meet the needs of the Health Service in future. I believe that this was a most unfortunate decision.

I do not know whether the Committee drew the wrong conclusion from the statistical data given to it or whether it was given the wrong statistical data, but I doubt whether anyone today would assert that that conclusion was anything but disastrous. The sad thing is that the effects of that fall in the intake have not yet been felt because of the six-year time lag which it takes to train a doctor. We are at least glad to know that the situation is being reconsidered. I wonder whether the Minister can tell us when he is likely to let us know the results of that reconsideration.

In March this year the Minister made an important statement about the future of our mental hospitals. We on these benches supported the general tenor of his speech, but it gave rise to very grave anxieties, particularly among mental nurses. If believe that their fears for the future and for the security of their jobs are exaggerated, but, nevertheless, they are very real. It is essential for the morale of the mental health services that these fears be dispelled, and only the right hon. Gentleman can do that.

What I understood the Minister to say was that recent statistical research about the mental hospital population has shown that, after a steady rise in the number of in-patients for very many years, in about 1955 this flattened out and began to decline and that that decline has continued ever since fairly steadily. This has been happening despite the fact that the number of patients admitted and re-admitted for treatment: every year has been increasing. I believe that this apparent anomaly is almost certainly due to the fact that people who make up the chronic population of our mental hospitals, many of whom went into hospital before there was any of the modern methods of treatment, are getting steadily older. As they get older they are dying in larger numbers and are not being replaced by anything like the same number of chronic patients because of the effectiveness of the treatment of new admissions.

The Minister therefore assumed that if that trend continued it meant that the number of beds needed for the mentally ill would steadily decline, and that calculation led him to the conclusion that we should need about half the number fifteen years from now. The favourable trend may not continue. It may even be reversed. No one can know. If it is reversed, no doubt there must be a reappraisal, but if it continues we can envisage emptying at some time during the next ten or fifteen years of at any rate some of the older, out-of-date mental hospitals and, of course, their eventual demolition, because, as the Minister said, few of them are really suitable for any other purpose.

I am sure that there was no implied criticism in this assumption, as there is not in anything that I say, of the excellent work being done in those hospitals today, only a criticism of the unsuitability of the buildings and, in many cases, of their location. If I understood the Minister's speech correctly, the calculations which he made do not in any way depend on the development of the local health authority community services which, if they take place, will do something to reduce the load on the mental hospitals. Nor do they depend on the development of psychiatric units in general hospitals. As I understand, these two things would, if anything, increase the trend of falling population in the existing mental hospitals.

I wish to say one or two things in parenthesis about these two new developments. I do not think that anything has happened since the Mental Health Bill was pissed to falsify the contention of us on this side that only a specific earmarked grant to local health authorities would ensure a rapid expansion of the community mental health services on the lines envisaged by the Royal Commission. The failure of the right hon. and learned Member for Hertfordshire, East to secure this, and his reliance on the block grant to do the job, undoubtedly means that very little will be done for a long time over the country as a whole to take the load off the mental hospitals and hospitals for the sub-normal and to care in the community for patients who do not really need full in-patient hospital facilities.

Equally with the difficulties over trained staff. At last we are to get a National Council of Social Work Training, but this time it is the Minister's refusal to allow central grants to students which will hamper the recruitment of the social worker students so desperately needed by the Service. I hope that the right hon. Gentleman has not finally closed his mind on that point.

On the question of psychiatric units in general hospitals, I believe that this is the most promsing line for the future. In a sense, I am sorry that the Minister appears to be putting all his eggs in this one basket. I should like to see the development of one or two small modern purpose-built psychiatric hospitals run side by side with psychiatric units in general hospitals so that a fair comparison can be made about the efficacy of the two forms of care and treatment. But if we are to concentrate on psychiatric units in general hospitals, it is essential that they should be properly planned and designed and purpose-built. It will not be enough to adapt one or two wards which happen to be empty. After all, the needs of patients who are mentally ill are very different from the needs of patients who are physically ill, most of whom spend all day in bed.

There are many ancillary services, such as recreational and occupational facilities, which the mental patient needs, and the unit must be large enough to permit these facilities to be provided. In my submission, it must also be large enough to provide a comprehensive psychiatric service for the area which the hospital serves. I do not think that these units should be less than sixty beds and perhaps should not be more than 120 beds, but what will be no good at all will be small, acute units of 20 or 30 beds which merely cream off the interesting and promising cases, leaving the rest of the difficult cases to be admitted to one of the existing older mental hospitals.

So long as the two types of care run side by side, as they will for a number of years, I suggest that there must be a close association between the staff of the existing mental hospital for the area and the staff of the general hospital unit, and that there must be a frequent interchange of staff between them. It is important that all the staff should have the experience of treating all types of mental disorder and not merely be limited to chronic cases, on the one hand, or acute cases, on the other. Finally, the staffing levels must be very high, far higher than they are in our existing mental hospitals. I suggest that this would be the answer to the anxiety of mental nurses, so cogently expressed, that as long as the staffing levels are high enough the fact that the units are smaller should not affect their career prospects.

I ask the Minister whether any progress has been made about getting rid of the ridiculous system whereby the grade of salary of nurses or administrators is tied to the number of beds in the hospital in which they are employed.

Lastly, I consider it essential that the teaching hospitals should be encouraged also to develop psychiatric units. I hope that the Minister will refuse to approve the development plans of any teaching hospital that do not include an adequate psychiatric unit in them, because without this there will be little or no chance that the medical student will get anything more than the very rudimentary knowledge of psychiatry that he gets in our medical schools today.

Before I leave the mental health services, I want briefly to call attention to one or two extremely serious gaps from which we suffer. The first is facilities for treating psychopaths, a duty which was firmly placed upon the hospitals by the Mental Health Act. We are already hearing too many cases of psychopaths who are having to go to prison because no proper facilities are available for treating them in hospital. Often, they are cases in which the court would like to make a hospital order. It is important that regional boards should be encouraged to develop units for treating psychopaths—of an experimental nature, possibly, but without delay

Secondly, we lack very much indeed in-patient units for psychotic children and, perhaps even more, for psychotic adolescents. These are two difficult categories to deal with, but the absence of these facilities causes untold misery to far too many families.

We do little or nothing about the treatment of alcoholism. This is something which properly forms, or should form, a part of our psychiatric services. A great deal is done about the treatment of alcoholism in several countries on the Continent of Europe in which, perhaps, the problem is not as serious as it is here. I hope that the Minister will give encouragement to the development of alcoholic units.

I want now to say a brief word about the salary negotiating machinery within the National Health Service. We have had about a dozen years' experience of the Health Service Whitley Councils. When they were set up, we all expected that there would be teething troubles, and we have certainly had them. The Civil Service Whitley Councils had their teething troubles when they were set up after the First World War, but they have now settled down and they work well. This has not happened in the National Health Service and the Minister is now faced with a widespread loss of confidence in the entire Whitley system.

At the moment, it is the physiotherapists and the occupational therapists who are demanding an independent committee of inquiry. Hon. Members who have consulted their mail in recent days and weeks will know that the physiotherapists are utterly fed up with the treatment they have had from their Whitley Council. The Confederation of Health Employees is demanding a Royal Commission on nursing. The medical laboratory technicians are complaining about the interminable delay in considering one of their salary claims.

All along the line, the groups within the Health Service are tending to look outside the Whitley system if they want the whole basis of their salary structure to be reviewed. Not so long ago, it was the administrative and clerical staffs who were complaining. They achieved their independent inquiry through Sir Noel Hall. As a result of it, their position was substantially improved, although it has been allowed to fall back again since then.

I repeat that the confidence in this system of negotiating machinery is at a very low ebb. It is not that the complaint is against the individual members of the committees. We all recognise that they work hard and long to achieve agreements. The complaints are against the system, which, the staffs allege, does not permit of genuine negotiation. There is what one might call sham negotiation between the staff side and the management side, and then along comes the Minister's representatives on the Whitley Council, under guidance, no doubt, from the Treasury, who make the decisions and seldom give their reasons for it. One of the results of this is that many Health Service salary scales are distinctly on the low side.

My hon. Friend the Member for Greenwich (Mr. Marsh), who hopes to speak towards the end of the debate, will deal with this matter in rather more detail. I content myself by saying that this loss of confidence is having a bad effect on the morale of the service and on recruiting. It has created a situation which the Minister must face and with which he must get to grips.

Now, a brief word on the question of drugs. We are glad that the Minister has at last adopted some of the advice that we and the Public Accounts Committee tendered to him about drug purchases. On his decision to purchase centrally patented drugs from unlicensed sources under Section 46 of the Patents Act, the Minister has so far told us very little. I hope that he will be able to say a little more about it today. Tenders should now be in for all three groups of drugs which the right hon. Gentleman mentioned. We would like to know what the response has been, whether any contracts have been let, whether any further tenders are to be invited and what saving he hopes to make in the drug bill as a result.

Then there were the recommendations of the Cohen Committee on prescribing, about which the right hon. Gentleman was so coy when he made his statement to the House. We would like to know how the doctors have responded to this, if there is any evidence so far. Certainly, more and more evidence is coming to us about the high prices of proprietary drugs and the excessive profits of certain drug manufacturers. We called some months ago for an independent inquiry into drug manufacturing costs. I would like to know whether the Minister has considered this suggestion.

I do not want to take up too much of the time of the Committee; I have already spoken too long. I propose to leave such important matters as the need for an occupational health service, about which the British Medical Association has just published an interesting report, the need to look at the whole of our geriatric services afresh and the general care of old people in hospitals. Perhaps one or other of my hon. Friends may deal with these aspects during the debate.

I want, finally, to say a word about the ten-year capital programme. Naturally, we all welcome the emergence at last of some forward planning from the right hon. Gentleman's Department. Boards have been delighted at being encouraged to plan development programmes for ten years ahead, although some of them would have liked a little more time to prepare them. Now that the Minister has these plans before him, it will take him time to digest them; he has said that it will be months before he can make a statement. He would not even state the aggregate capital implication of all these programmes. I do not know whether that means that he has not yet done his addition, or that he has done it and it has left him stunned, but we all realise that the total must be very large. These, however, are developments which hospital authorities regard as necessary to produce an efficient up-to-date service in ten or fifteen years' time.

We have a long way to go before that can be achieved. The Minister has raised high hopes, but this whole operation will be worth while only if he is determined to resist all attempts to cut down these programmes to fit the current levels of spending. If he now starts whittling down what boards have been encouraged to expect, he will create new and, perhaps, even greater frustration than before.

The Minister must know how desperately we need modern hospitals that are worthy of our National Health Service. Let him remember at all times that he is the custodian of what is still, despite the worst that three Conservative Governments could do, and despite the criticisms that I have made today, the finest Health Service in the world.

4.30 p.m.

The Minister of Health (Mr. Enoch Powell)

Like the hon. Member for St. Pancras, North (Mr. K. Robinson), I find myself with an embarrassment of material in this welcome whole day debate upon the National Health Service. Although I shall, in the course of my speech, touch upon most of the matters with which the hon. Gentleman dealt, there will be some that I shall leave to be covered in the winding-up speech of my hon. Friend the Parliamentary Secretary, notably, the issue of the negotiating machinery about which there will, no doubt, be further contributions in the course of the debate.

Much of our material in our discussions on the National Health Service is concerned with physical provision and administrative arrangements, but I should like to begin by speaking about an aspect which is neither physical nor administrative, namely, that of human relations within the hospital service, for it is very easy, especially for a vast organisation like the National Health Service, staffed and exercised by powerful professions, to forget at times that all of this exists for the sake of the patient. This, indeed, is a direction in which great improvements can be made quite simply and quite quickly by taking thought and by instilling a right feeling and a right attitude.

I am not denying that there is some connection, of course, between the human approach to the patient in hospital and the physical conditions under which the staff are working, but, preponderantly, this is a matter of attitude, of human being and human being. I have taken occasion in recent weeks, as the hon. Member has done this afternoon, to point to deficiencies in this respect which still have to be made good. I would hope that it was understood that there was inherent in this no criticism or denigration of a particular branch of the staff; no picking on this or that profession involved, but simply a recognition that here there is a challenge to all those who are concerned with the working of the National Health Service.

I welcome enormously the two reports to which the hon. Member referred at length on the in-patient day, and on human relations in obstetrics. He referred to them so fully that I need do so only cursorily, but I would emphasise as he did, their origin, that these were reports coming from Committees consisting of outstanding members of the professions concerned and responsible. They were not outside criticisms; this was opinion of the most valid and well-founded character, and I am determined that these reports shall not lie idly upon the table, but shall be followed up by all concerned.

This can be done in part, I know, by calling for returns from hospital boards and hospital authorities, but there is a limit to the utility of calling for returns about how much has been done about this and that, and in the last resort this is a matter of individuals taking note of individuals reacting to the climate of opinion which it is sought to create. That is why I have been particularly grateful in this for the co-operation of the matrons, nurses and midwives and for the wholehearted way in which these professions, their organisations and the journals which serve these professions have taken up these reports, and how an attitude of mind has been spread where people throughout the service are asking themselves: "Does this criticism apply to us? Can that be said of this hospital? If so, let us put it right as soon as; possible."

I believe that we cannot be satisfied even with these two important reports, wide though the field is that they cover. There are at least three further respects in which I believe attention to the humanising of the service is urgently necessary. These do not include the matter of the out-patient departments, which the hon. Member mentioned, and I should like to consider, in the light of the advice which has been given in the past, whether the time is ripe for another look at this aspect, too, of the relations between the hospital service and the patient.

The three matters that I have in mind are, in the first place, noise. Noise is one of the most disturbing factors in the relation between man and man and certainly in the relation between the hospital service and the patient in hospital. There is, of course, always reference to this in any report on the subject and a special study of it has been made for the Central Health Services Council which I hope to publish and commend next month, together with the recent studies made by the King Edward VII Hospital Fund. Noise is something which I believe everyone in and concerned with hospitals would do well to watch and regard as an index of the attention paid to the welfare of the patient.

The second matter is visiting hours. There has been a tremendous improvement so far as children are concerned following upon the Platt Committee's Report and there are now few hospitals left in which, in spirit at any rate, the recommendations of the Platt Committee's Report on visiting hours for children are not being complied with. The Report on in-patients touched on this question of visiting hours and made a useful suggestion of an alternative half-hour period in the latter part of the day. I believe myself that we have to consider whether we ought not to go much further, whether to accept the half-hour visiting period, even if it is daily, and there are a good many hospitals in which it is still not daily.

The half-hour visiting period is, if anything, a relic from a former age, from the age of the infirmary, from the age of the horse and buggy. It does not belong to a period in which people may have to travel considerable distances to visit their relatives in hospital, when the hospital services by their very nature are increasingly centralised and serving larger areas and when the whole social habits and behaviour of people have become increasingly unfavourable to the cramming of visits into 30 minutes of the day. I believe that this 30-minute period imposes on hospitals and hospital staff far more of a burden than it removes, and that it would be found that a mare liberal policy in visiting hours would, in fact, bring relief to the staffs rather than the reverse. I know that much experiment is going on in this direction, but I think that this is something to which a further impulse should now be given.

The third matter I had in mind, which is by far the most important of them all, is what I believe, in publicists' jargon, called "communications"—the way in which the patient, the patient's relatives and the people who will be concerned with the patient when he comes out of hospital are given information about what is going on. There seems to me to be often a real failure of communications in this sense in our hospital service, through no on the part of anyone, but simply from the existence of a blind spot in this respect. The patient, the patient's relatives and all those concerned with him expect and have a right to be treated as intelligent persons.

I know that this impinges on one of the most delicate and important professional aspects of the doctor's duty and it is not in my mind to offer advice on that or to offer criticism, but I do say that there should be a much more general 'understanding of how important it is that the patient, his relatives and those concerned with him should never be left in ignorance about what is going on, what is intended to be done with him, why he is Where he is, and all the obvious questions which any sentient human being will want to know about himself and those for whom he cares.

I notice over and over again in the complaints which come to me, not least from hon. Members of this Committee, how it is the fact of a failure of communications, sometimes the failure to speak two sentences at the right moment to a patient, which has been the cause of deep-seated antagonism arising between the individual or his family and the service. I think that the time has come when we ought to give deliberate study to this problem of communications between the hospital service and the patient's relatives and all concerned with him.

Mr. Llywelyn Williams (Abertillery)

The Minister has spoken some profound truths and made some constructive suggestions. Could he help the Committee by suggesting what exactly are his powers in these matters, other than the power of appeal? Can he in any way interfere with a local hospital in the way in which it is carrying out some of his excellent suggestions?

Mr. Powell

I do not really think that powers come into this matter, because I do not believe that in any of these matters the hospital authorities or any of those working in hospitals have any desire but to give the best service to the patients. It is, therefore, not a matter of enforcing behaviour upon reluctant authorities and people, but of ensuring that the attention of those concerned is consistently drawn to good standards of practice and to the advice which is made available, distilled from experience, and diffused through the Service.

Mr. Norman Dodds (Erith and Crayford)

Who is to do that?

Mr. Powell

We have before us, for example, the way this has been done in the case of the two Reports which the hon. Member for St. Pancras, North mentioned. I do not think that there can be any doubt that the publication of those Reports, the publicity which they have obtained, the discussions which they have undergone both in the professions and in the hospital service, have in themselves already begun to produce results.

I cannot really believe that this is the kind of matter in which we ought to seek to proceed by direction. I believe that people will respond here to leadership, and the leadership, not least, of the professions, taking advantage of experience as it is made available. But it is a field, as I say, in which, I believe, we have really only started on some of the more urgent aspects, and where not only those aspects must be kept in view but new ones must be urgently studied and similarly dealt with.

I turn from this theme to another which the hon. Member mentioned and one which has bulked large in public discussion—not only party political discussion—in recent months, and that is the drug bill, the cost of drugs and dressings as an item of the total cost of the Health Service. The Committee may care to have a review of the measures which have bean taken in this field in recent months.

There are two preliminary remarks which I would make. The first is on the relationship of the prescription charge to this matter of the drug bill. I do not regard, and I have never recommended the prescription charge as a means of appreciably reducing the gross cost of the drug bill in the National Health Service, and, as I have told the House on an earlier occasion, the Estimates for this year, which are before the Committee, were not framed on the assumption that when we had full working experience of the prescription charge there would be any important fall in the volume of prescribing. I recommended it to the House and the House has accepted it as an additional source of finance which can be used to good effect elsewhere in the Health Service.

If any hon. Member would ask where it has been used I would remind him that the gross cost of the Health Service rose by 11 per cent. this year as compared with last, and this year it is taking a higher proportion of the national income than it has ever before been recorded to take. It is that sort of development which has been safeguarded by the prescription charge, but, as I say, I do not regard it as relevant to any important extent to the problem of the control and magnitude of the drug bill in the sense of the gross cost of drugs and dressings in the Service.

The second preliminary observation I would make is that to be concerned about the gross cost and about the control—if one can use that word—of the cost of drugs in the Service implies no underestimation of the importance of modern drugs in modern medicine or of the immense blessings which some of the most expensive modern drugs have brought, the dramatic effects and changes in the prospect of various sicknesses which they have wrought. It implies no disregard of that fact at all.

What it implies is simply this, that when an element of the Service is costing in England and Wales alone practically £100 million a year it is the duty of those responsible to this Committee for the expenditure to be as certain as they can that any waste involved in that figure is minimised and that the patient is getting maximum benefit from the very appreciable sum which is involved.

It is from that point of view that a number of measures have been taken, which I should now like to summarise, to the end of controlling the drug bill. There are really two aspects of this subject. There is the price of the article, and there is the decision to buy an article by prescribing it.

Looking first at prices the Committee will recall that the Voluntary Price Regulation Scheme was renewed in an improved form at the beginning of this year and in its improved form it made possible much closer discussion and negotiation between my Department and the industry over a wider field than had been possible previously. Reductions in price which have been made following the introduction of the scheme have been worth £1¾ million in a full year's usage. That is, I think, a useful beginning, but I regard it only as a beginning, and I regard this as a constant activity which has got to be the continuing preoccupation of my Department.

The hon. Member has referred to the decision announced to the House in the middle of May to use the provisions of the Patents Act for the purchase of certain widely used drugs by the hospital service to which the Patents Act is applicable. The thought behind this decision was that where there is a prima facie possibility of obtaining a drug for the National Health Service at substantially lower cost than had been paid for it, by use of the powers which Parliament has placed in the hands of the Government, it would be wrong not to explore any way in which that result can be obtained in practice.

Tenders have, as the Committee knows, been called for for three groups of drugs, and the response has been such that new contracts covering all those drugs will be in force by 1st September. I cannot at this stage indicate to the Committee what the scale of saving will be since final prices are not fixed, and, of course, there will also have to be negotiations, in which my right hon. Friend the Minister of Aviation acts on my behalf, over the relevant royalty payments. It will be necessary to be guided by experience in these initial stages as to the further development of this policy.

On the side of prescribing I would agree with the hon. Member in the outstanding importance of the recommendation of the Cohen Committee on prescribing in the Report which was published in March of this year and distributed to doctors in April, and perhaps I could trouble the Committee by reminding it of what the terms of that recommendation were. The Committee recommended that while there should be no absolute restriction on the prescribing of any drug which in the general practitioner's view is necessary for the treatment of his patient … the general practitioner need not normally go outside the drugs and preparations described in the"— three official books— together with drugs in categories N and P. Before he decides to prescribe any other preparation he should satisfy himself that the one chosen is better for his particular patient and that it is the only reasonable choice to make, as he may be called upon to justify his action if the cost of his prescribing is being formally investigated. In those last words of that quotation from the Cohen Report we are reminded of the ultimate sanction against excessive prescribing which is agreed between the profession and my Department, but of course it is not by use of the ultimate sanction that this important recommendation of the Cohen Committee will produce its effect. It is by a growing acceptance by the profession itself of the wisdom and rightness of that recommendation as a guide to good prescribing. I believe that this can be assisted by contact between my regional medical officers and general practitioners throughout the country. That is why I have attached importance to the strengthening of the team of regional medical officers and to making more time available for them to meet and discuss prescribing problems with the doctors in an entirely informal atmosphere.

It is worth emphasising that the Cohen Committee recommendation eliminates no effective drug from the armament of the general practitioner. What it recommends, nevertheless, could result in true economy in prescribing. The Ministry places one of the official handbooks gratis at the disposal of all doctors in the Service, and it also provides them with a flow of material designed to assist in their prescribing. I believe, in particular, that the new bi-monthly publication the Prescribers' Journal will find a place among the means on which the general practitioners rely for assistance in their prescribing work.

Finally, I should like to refer to a group of measures which are concerned with the cost of drugs in hospitals. The hospital sector of the drug bill represents only about one-eighth of the total. Nevertheless, its importance is quite out of proportion to that ratio, for it is in hospitals that a good deal of the pattern of prescribing is fixed both by the influence of hospital practice on the future general practitioner and by the fact that prescribing for a patient is often shared by the hospital and the general practitioner.

The analysis of cost in the hospital service, which has been greatly elaborated and improved in recent years, has now made it possible to compare with some accuracy the cost of drugs in similar hospitals and groups of hospitals within regions and throughout the country. Regional hospital boards have been active in drawing the attention of hospitals to apparently unexplained excesses. In a number of cases this has resulted in real improvements in the control and economy of hospital prescribing. I believe that the use of these cost statistics and. indeed, of other cost statistics should be pushed much further and harder.

I have said that this is a field in which the co-operation of the medical profession is absolutely vital, for the clinical judgment of the medical profession must remain sovereign. I should like to generalise that by saying that since the era which was marked by the publication and acceptance of the Pilkington Report—and I cannot myself as Minister of Health speak of any earlier period—the relations between the Government and the professions have been extremely cordial and co-operative. I should like personally to express my gratitude for the co-operation which I and my Department have received both from officers and officials of the British Medical Association and the British Dental Association.

While on the subject of the Pilkington Report, I might refer to a couple of points which the hon. Member for St. Pancras, North made. I think that his memory played him false when he suggested that the Pilkington settlement, as applied by the working party, had not contributed to improving the distribution of general practitioners. On the contrary, there were a number of important improvements in the financial inducements to the better distribution of general practitioners. In particular, the initial practice allowances were very substantially increased and extended from three to four years. The inducement payments paid in difficult areas were increased and the loadings to which the hon. Member referred were substantially improved.

On the second point which the hon. Member made in relation to general practice, it is true that the calculations of the Willink Committee have been proved by experience to require reexamination. As I told the Committee earlier, my right hon. Friend the Secretary of State for Scotland and I are re-examining urgently the statistical bases on which these conclusions were worked out. However, little practical result flowed from those recommendations because the intake of medical students this year is higher than it was during.the last year before the Willink Committee reported.

The Government and the medical profession are now engaged together on a study of the Platt Report to which the hon. Member for St. Pancras, North very rightly devoted a considerable part of his speech. Good progress has been made in the study of that Report by the Government and the profession, but I am sorry that the stage has not been reached when a general statement upon it can yet be made. I need hardly say that the Government attach great importance to as early a decision on these matters as is consistent with their being properly considered by the profession.

I hope, however, that it will not be thought inconsistent with what I have just said if I follow the hon. Member to some extent in referring to the recommendations of the Platt Report, to place emphasis on one special aspect. I do not think that anyone who has given attention to the problem of the future of the general practitioner doubts that a closer link between the hospitals and the general practitioner is integral to its solution. The proposal which the Platt Committee makes for fuller hospital experience before entering into general practice would undoubtedly be one means of promoting lasting and close connection between hospital and doctor.

Another recommendation of the Platt Report is relevant—that the,hospital of the,future should be able to "absorb part-time services from suitably qualified general,practitioners in specified kinds of work" to a far greater extent than happens at present. The hon. Member for St. Pancras, North expressed some scepticism about the practicability of this, but it is a fact that, for example, in the Birmingham region no fewer than one general practitioner out of every four has a part-time appointment in a hospital.

Here surely is one of the guide-lines for the future. To quote the Report again, there should be … more openings … for suitably qualified general practitioners … to continue to work in hospital for part of their time in a responsible capacity. This reference to the intimate, and I hope in future the more intimate, link between the general medical service and the hospital service is only a reminder that one cannot plan for any single part of the whole Health Service in isolation.

This brings me to the long-term hospital planning operation on which the Committee would perhaps welcome a brief progress report.

Mr. K. Robinson

Before the right hon. Gentleman leaves the Platt Report, can he not give one word of hope to the time-expired senior registrar?

Mr. Powell

I am not at all sure how far it is practicable to separate that question from the recommendations of the Report, and for that reason I should be reluctant to give the hon. Member an answer off the cuff. I have noted, however, what he has said.

As the hon. Member said, the boards have now completed their marathon of turning in by 31st May, as they were asked, their pictures of the hospital service in their regions as it should be in 1975. I thank the boards and all who were concerned for the immense amount of work and effort which went into that part of the operation. One realises, of course, that it was possible only because so much study, research and planning had been going on in previous years; but I am sure that boards welcomed the challenge to bring all this to a head and make a definite and concrete statement which would sum up their planning and their practical aspirations for the next fifteen years.

Those individual reports from 15 regional hospital boards and 36 boards of governors will now have to be welded together into something which will deserve the name of a national plan for the hospital service. That cannot be done by simply binding them up together; for if this be a national plan, it must imply the application of national standards and a consistent policy. Indeed, it is through the standards of provision, which we write into the hospital Plan, that the aims of the hospital service over the next ten or fifteen years can be expressed in a form in which they can eventually come to reality.

Mr. Ll. Williams

As the right hon. Gentleman will know, Members of Parliament have shown a real concern about this final decision. As he knows, there is a very great element of secrecy about the master plan. Will it be possible for Members of Parliament to be consulted or informed about his ultimate proposals in this matter?

Mr. Powell

I am obliged to the hon. Member for Abertillery (Mr. Ll. Williams) for his intervention. Perhaps I might break off at this point to say that when the hospital service, if I might put it in that way—for I regard the hospital committees, boards and myself not as separate entities but as parts of one service—has worked out its view of the next ten or fifteen years, then that must, in whatever form may be best suited, be put before the public, not as a diktat, not as something which settles and fixes all the details, but as a framework within which individual decisions can be taken, not as hitherto, ad hoc and in isolation but against the background of the plan as a whale. In other words, the hospital plan will not prejudice any individual decision which has not yet been taken.

I would hope that both in its generality, in the principles embodied in it and in its local details the plan would be the object of lively discussion both on a national and on a local scale. Indeed, I would hope that it would continue to be so as the years go by and as the plan itself is revised. But what it will provide is a background of general intention, a shape which makes sense, against which the details as well as the policy of the whole can be discussed.

Something else which has got to be built on to the raw material provided by the regional hospital boards is the part to be played by the other parts of the National Health Service. This is perhaps one of the most important aspects of the planning operation as a whole. We have got to see, so far as we can, where the general medical services will fit into this, and we must see how the complementary organisation of the local health and welfare authorities corresponds with the provision which it is proposed that the hospital service should make.

As regards the general medical services, the Standing Medical Advisory Committee has, at my request, agreed to study, through a sub-committee, the scope of the services which general practioners should be providing in the future. I hope that that study will provide a starting point for clearer thinking about the rôle of the general medical services within the framework of the National Health Service as a whole over the next ten or fifteen years.

As regards the local authorities, it seems to me quite essential that one should try to spell out—the hon. Member touched on this in relation to mental health—the implications for provision outside the hospital which are implicit in the provision which is being made in the hospital service. I have already brought the local authority associations into consultation on this, and I shall hope to have their assistance in working out what I might call the local authority component of the plan for the hospital service, for here the functions of the hospital service and the local authorities are, in the truest sense, complementary. I would hope, too, that the clearer delineation of the field for services outside the hospitals would also be a help and an inspiration to the many voluntary bodies which are doing much but could do a great deal more in this field.

As the hon. Member mentioned specially the policy in regard to mental health and mental provision, perhaps I might take mental health as an example of the way in which national standards and co-operation between the hospitals and the rest of the National Health Service ought to be worked into the plan. He referred to the forecast of a decline of 50 per cent. over the next fifteen years in the requirements of beds for mental illness. I emphasise "for mental illness", for, unfortunately, there is no reason to anticipate any similar decline in the places which are required in hospital for mental sub-normality. Rather, at present, we shall be planning on the basis of a certain increase.

This forecast is based purely upon the continuation of trends which are in existence at the present time. It takes no credit for any further advances in treatment or medical knowledge or any break-through in medical research. I think it would be fair, therefore—as I think the hon. Gentleman does—to regard it rather as a cautious than as a bold estimate.

Nevertheless, there is real flexibility here. The boards in their plans, I am glad to say, have thought it right to adopt broadly this policy of a 50 per cent. rundown of beds for mental illness over the next ten to fifteen years. But since much of the new provision is being made in units in general hospitals of the kind about which the hon. Member was talking, we have the situation thoroughly within our control during this period, since if more rapid progress is made, as we hope, then we shall be able to close more of the old hospitals faster, whereas if, unhappily, and, I believe, quite improbably, there should be some reversal of the trend, it will still be possible to maintain beds which would otherwise be closed. So, although what I would claim is a very modest and cautious forecast of the future will be embodied in the hospital plan, there will be sufficient safeguard and flexibility for account to be taken of favourable or adverse developments.

The future pattern of provision for the mentally ill and the mentally sub-normal must depend to a very large extent upon the provision which is made outside the hospitals by the local health authorities. Here the local authorities are, in fact, showing great keenness. The number of places, for example, in training centres for the mentally sub-normal is rising at a rapid rate. So we shall be able in this sector of the hospital service to see both the working out in the plan of a national policy for the development of the hospital service and also the co-ordination of that development with the provision made outside the hospitals by the local authorities.

If I might add one word about staffs, I am entirely at one with the hon. Member for St. Pancras, North in saying that there is no reason in all this why the staffs of mental hospitals should regard theirs as a dying part of the profession. Very much the contrary. It is a part of the profession to which life, hope and vigour are now coming, for the first time, where opportunities of movement, of variety and of taking part in stirring developments are opening up all the time. And with the more intensive staffing ratio which the new mental hospitals will demand, I should not have thought that, even numerically judged over the whole period, one could regard this as a diminishing element in the National Health Service.

I hope that this planning operation, on which the whole of the National Health Service and not only the hospital service is thus engaged, will, of itself, contribute to greater co-operation and coordination between the various parts, and that it will be an encouragement to all who work in all parts of the National Health Service to know that we are taking a long view, and that we shall set before us the objectives towards which we are striving. But I believe that there is another even more important aspect. I believe that this can be the means of securing the understanding, and thus the interest and support, of the general public for what is being done.

It is on this support of the public—I would go further and say, the affection of the public—that the success of the National Health Service must depend.

5.12 p.m.

Mr. James Boyden (Bishop Auckland)

Many Members on both sides of the Committee will be grateful for the right hon. Gentleman's description of his efforts, both current and future, to humanise the hospital service. As someone who represents a constituency which is already suffering from great transport difficulties, I can say that my constituents will welcome very much his interest in visiting hours and appointments, and in making it easier for patients to be visited and, indeed, to get to hospital. Many of us will also be grateful for further information about the hospital capital programme.

It is a pity, though, that this plan was not announced ten years earlier. That may not be the fault of the right hon. Gentleman personally, but it is certainly the fault of the Government of which he is a member. The backlog of hospital improvements, particularly in the north of England, is very considerable. I suppose that my constituency has more of the Poor Law hospitals and the emergency service hospital buildings than most, and we are, therefore, most interested in the speed and momentum which the right hon. Gentleman's plans are to have.

We have a sinister feeling, however, that he is not master of his own fate but that decisions are being taken in another Department in relation not to the medical needs of the country but to the lack of momentum in the economy as a whole. I hope that the right hon. Gentleman, when he announces his major programme, will give a clear indication of how the programme is related to the medical needs of the nation. As I read the plan which has been submitted to the Newcastle Regional Hospital Board—

Mr. W. A. Wilkins (Bristol, South)

On a point of order, Sir Samuel. May I ask whether the only way in which to take part in this debate is to give one's name in at the Table?

The Temporary Chairman (Sir Samuel Storey)

That is not a point of order. It is a question of who catches the Chairman's eye.

Mr. Wilkins

I appreciate that.

Mr. Boyden

As I was saying, it is the momentum of the hospital building scheme which will be of most importance to areas like the north of England. In studying the Newcastle Regional Hospital Board's programme, it seems to me that a great many of these unfortunate buildings are not likely to come into the scheme for regrading and demolition until towards the end of the period. I hope for an assurance from the right hon. Gentleman that the momentum of hospital building will become greater and greater.

Members opposite are always praising I.C.I. and its efforts in building up its industry, but this is based very much on a continuous momentum through the investment of capital, so that recruitment of staff and planning can go steadily ahead. This, through its own momentum, generates economies. I look forward to a considerable rise in development through the hospital service.

Recently I asked the Minister of Works about the percentage of building resources devoted to the hospital service. I was told that only 1 per cent. of our current building resources are going into hospital work. I am sure that the future plan will naturally increase that percentage, and I should like to know what it is likely to be.

I also want to know what steps the Government propose to take to see that adequate building resources are devoted to hospitals in those areas which are particularly deficient. I know that my own board is very concerned about whether it will be able to get enough resources from the building industry to fulfil its plans. This has been particularly marked recently in changes in the architectural and civil engineering staffs. The Government must take some responsibility for this because, as my hon. Friend the Member for St. Pancras, North (Mr. K. Robinson) said, there have been considerable delays in pay awards to architects and engineers.

In the case of the Newcastle Board, I suggest that some of the illness among the architectural staff has been due to pressure caused by shortage of staff, which, in turn, was caused by dilatory methods in connection with pay and awards. This, as my hon. Friend said, runs right through the hospital service. The laboratory technicians have been lobbying many of us over their circumstances. I hope, particularly in relation to the building and planning side of hospital development, that the Minister will be able to give an assurance that we shall not, in this development, have the merry-go-round of one branch of the building industry getting architects and engineers from another branch, like the local government service, so that other worthy public building is not dealt with.

Time and time again, Ministers responsible for social services have refused to say much about the recruitment of new staff. This has been so in relation to doctors, and we have had some discussion about that. The right hon. Gentleman has said that he is considering revising Willink, and I hope that he will do this urgently, with particular reference to areas in the North, where there is considerable need for more medical students and more medical training.

Here, I put in a special plea for the Durham end of the University of Durham. As the right hon. Gentleman probably knows, shortly—perhaps eighteen months or two years—it is likely that new universities, one in Durham and one in Newcastle, will be formed. A long time ago the Durham division of Durham University carefully considered the facilities it might offer for a medical school. I ask the right hon. Gentleman carefully to consider the facilities which exist there—the splendid university site itself and the pleasant opportunities for housing medical students—and also the good effect that it would have on the north of England—particularly the area which my hon. Friend the Member for Durham (Mr. Grey) and I represent—together with its effect in improving the quality of the intellectual life of the university as well as improving medical facilities generally. If the university should make proposals of this sort I hope that the right hon. Gentleman will support them.

That there is a considerable need for much greater hospital and medical facilities there can be no doubt. I want to refer to some of the hospital conditions in my constituency. In Bishop Auckland General Hospital—the major hospital of the area—no joint medical planning committee has yet been appointed to consider future plans. The hospital's ad hoc committee has been under way for only a short time, so that none of the medical planning has been carried out that has gone on in other parts of the region. The hospital is made up half of E.M.S. hutted buildings and half of workhouse buildings. Under those conditions the staff manage remarkably well. As the Minister said in relation to other sections of the medical services, great devotion is shown by the staff, who work in incredibly difficult conditions. When they are allowed to, they turn some of these horrible buildings into most attractive buildings for patients. I urge the Minister to give early attention to the problems of areas like mine.

I now want to refer to the general picture to be painted of the small hospitals under the control of the general hospital. These hospitals are dotted about the area, and have been described as small hospitals which do not provide a very high standard of accommodation and are not easy to run efficiently. The maternity hospital offers poor accommodation in a converted house and should he abandoned as soon as the department at the main hospital can be enlarged. Two hospitals in the area of my hon. Friend the Member for Durham, North-West (Mr. Ainsley) are both converted houses and their standard of accommodation is not of the best. I am sure that my hon. Friend the Mem-Member for Durham, West could give similar details about hospitals in his constituency which my wife knows well.

The real gem is the "geriatric hospital" at Barnard Castle. It is called Cambridge House. I do not know whether the Minister had the opportunity of visiting it when he came to the North, but it is a disgrace. It offers such a poor standard of accommodation, with a complete lack of any ancillary services, that it should be shut as soon as other accommodation can be provided. I am sure that all the inhabitants of Barnard Castle would echo those wards. Barnard Castle contains a convalescent home which is about to be taken into the National Health Service. I believe that the legal formalities are almost complete. A fairly large sum of money goes with this hospital. There are plans by the regional hospital board ultimately to transfer the geriatric unit from Cambridge Noise to the Richardson Home, and there is planning intention to make it a small general hospital.

I hope that this will be fairly well advanced in the schemes that the Minister finally approves. South-west and northwest Durham, with difficult communications and heavy industry, need rather more consideration than some of the more prosperous parts of the country which have developed their hospitals by means of voluntary contributions more easily than has been possible in Durham. I urge upon the Minister earnestly that the Newcastle Regional Hospital Board and my own area in particular, should receive careful consideration.

Finally, I want to refer to the difficulties that have resulted from the Willink Report. The right hon. Gentleman tended to brush this aside and to say that its effect has not been important, but it has had a bad effect on the University Grants Committee. That Committee has been very timid about making recommendations for new medical schools in new universities. That is one reason why I pressed the claim of Durham, which, to some extent, will rank as a new university under the new arrangements. In some of the special fields, such as psychiatry and psychological medicine, there is such a time lag and such a backlog to be made up in order to produce an adequate service that it is imperative far the Minister to consider that aspect of the Problem very generously.

On many occasions I have asked him questions about the number of Commonwealth and colonial doctors in the National Health Service. He has told me that he does not have the figures. I have not asked him this question because I wish those doctors to return to their own countries. I have asked it because we need to make a proper assessment of the number of doctors we require, and the number required by the Commonwealth and the under-developed countries. We take far too limited a view of our obligations to the Commonwealth. Not only should a very careful study be made of the expansion we need in our own medical services, in regard to the provision of doctors, but a much more generous attitude and a determination to help wherever we can should be adopted in regard to the countries of our own Commonwealth and Colonies.

5.25 p.m.

Mr. Ian Fraser (Plymouth, Sutton)

The hon. Member for Bishop Auckland (Mr. Boyden) laid particular stress on hospital building. I was glad to hear that because, if I understand my right hon. Friend's mind aright, in the developments of the National Health Service he has laid particular stress—both in the ten-year capital programme and in other ways—on the development of the hospital services in the next ten or fifteen years. I am sure that that is the department on which we ought to keep our eyes firmly fixed if, during the course of the next ten years, we have to choose between desirable priorities. Above all else, it is important to try to find a /pattern of the Health Service which will suit our life in this decade.

If we look outside the improvement of the hospital services, one of the services which needs more attention than most is that which deals with incipient and mild mental disorder in the population. From such observations as I have been able to make while working in my constituency—and I am sure that other hon. Members have had the same experience—it is clear that there is a particular need to concentrate upon the problem of dealing in time with this incipient and mild form of mental disorder.

I was glad to hear my right hon. Friend lay stress on the desirability of close cooperation between the Health Service and local authorities in matters of that kind. The desirability for co-operation goes still further than that; it must extend from the local authority health and welfare services through the whole range of local authority social services.

I wonder whether it has been the experience of other hon. Members, as it has been mine, that in many instances it is the housing problem which lies at the back of these cases of incipient and mild mental disorder. If it is possible, through co-operation over the whole range of local authority services, to isolate and deal with problems of that kind, the medical problems can be more easily cleared up.

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

I agree absolutely with what the hon. Member has said, but does not he also agree that it follows that it is the general mental practitioner—the family doctor—who must be able first to recognise the symptoms, and that he must, therefore, have specific training, and also have time both for diagnosis and, at least, to advise where treatment can be taken?

Mr. Fraser

I thank the hon. Gentleman for that intervention. I think that that is very important, but I would add to it further by saying that it is not only a case of the family doctor. I think that people like ourselves come into the matter, too. The wider this is disseminated, the more easily we shall be able to deal with it. What I am quite certain is a very serious and growing problem is this wide dispersal throughout the population of forms of very mild and perhaps incipient mental disorders. This problem is far greater than one would like to think.

The main thing that I want to put before the Committee for a few minutes is something different from that and something in which I have a close personal concern. I hope that the Committee will forgive me for dealing for a few minutes with the question of artificial limbs, their provision and, in particular, their design. I have a compunction about wearying the Committee, as I must for a few moments, with the details of my own artificial anatomy, but I want to take as an example the actual limb that I happen to be wearing—it is a Government artificial leg for above-knee amputation—as the text for what I want to say.

The artificial leg which I am wearing is a 1946 model and it has been maintained in all the years since in perfect order by the right hon. Gentleman's Ministry and its predecessor, when another Ministry was responsible. There is no doubt at all that this limb and others like it are very good limbs indeed. I say this with absolutely no question of any vainglory, and were I tempted to be vainglorious the example of my right hon. Friend the Minister of Power would shut my mouth immediately, because he really knows about these sorts of things.

Since 1946, when this limb was issued to me, it has climbed mountains in Baluchistan, it has been exposed in the Sind Desert and other places to heat of the order that is turned on in Kuwait at the moment, it has mounted guard on ceremonial parades, it has ridden horses and been thrown from them and it has motored thousands of miles during which time it has had to perform the same functions as does a human leg in operating a clutch.

As far as these limbs go, I think that for the first and only time in my life I regret the absence, as hon. Members opposite so often do, of the Secretary of State for Scotland, for what I am going to say is unfair to Scotland. The only thing, I believe, that one cannot do with one of these limbs—I am sorry about it, because I used to be particularly keen on it before I lost a leg—is Highland country dancing. Although I can still screech, I cannot, I regret to say, cavort with this leg.

The point I wish to make is that despite the extraordinary strength both in design and construction of these limbs—and that is amply proved—there is no doubt that we are falling behind in this matter. It so happens that in addition to a 1946 artificial leg I happen to have a 1946 car, which is still running. Cars have improved enormously since 1946. I cannot believe that no improvement can be made in the design of artificial limbs. I do not think that very much general improvement has been made in that direction.

I had the good fortune, through the very kind co-operation of the Ministry of Health, to see in my constituency last autumn an exhibition of modern artificial limbs. They seemed to be remarkably similar to the limb which I was wearing. There has been a great deal of talk in recent days of the desirability in our national life to set ourselves aims of one sort or another. I would venture to commend to my right hon. Friend a minor though, I think, a worthy target which, perhaps, the Health Service might care to set itself. That target would be to lead the world, to the extent that we do not do so already, in the design and provision of artificial limbs. Such a target seems to me to have all the characteristics of a good challenge. It is a humanitarian one. Though it is rather challenging and difficult, I think that it is probably well within our scope.

The two main problems which have to be solved in that sort of enterprise are, first, the problem of the method of seating and of ventilation of these limbs, be they legs or arms, and, secondly, the problem of their action, the way in which they are to work, with particular reference to the possible application to them of power in some form or another. It need not, of course, be direct power or of a gyroscopic type, but power of one form or another.

Let me deal with one argument which might arise, because I think that my right hon. Friend might well say to me, "But surely in this sort of development, which will be expensive, is there not a place for private enterprise to come in and start it off? Are we morally required to do more than provide a thoroughly sound piece of equipment?" I think that the answer to that must surely be that our obligations to our ex-Service disabled population probably preclude that view being taken and that we ought, in fact, to regard the development even of a much more complex and expensive type of artificial limb than we now have as a genuine obligation on the part of the Government.

There has been much talk in this debate about the next ten or fifteen years. I hope that during the next ten or fifteen years I may, perhaps, have the pleasure of taking off from the Terrace on one engine, on my left leg. I am looking forward to that very much.

Because the disabled population is not all that large or all that important it can never take a very prominent place in the counsels of the Health Service as a whole, but I hope that it will have its appropriate place, and that we may consider the advantages, both human and moral—and very real advantages I think they are—in making a special concentration in the Health Service on a matter in which we already have so good a reputation but one in which, I fear, we are tending to fall somewhat behind.

5.40 p.m.

Mr. William Whitlock (Nottingham, North)

It has been said already in the debate that we are covering a very wide field today. I want, first, to speak about dental health. If I may, I will follow the example of the hon. Member for Plymouth, Sutton (Mr. I. Fraser) by drawing on a personal experience. During last week I suffered considerably from the pain which one normally associates with dental decay. I visited a dentist at the weekend. He told me that he could find no signs of decay in my teeth, but, after considerable tapping and probing, he considered that one of my teeth was causing trouble and that the only way to deal with it was to pull it out.

I suggested that there was a need for a more precise diagnosis. After all, if he pulled out this tooth, I would, in effect, be losing two teeth since its opposite number, would have nothing to bite on. Further, as he was not sure that this was the offending tooth, it might be necessary to pull out another one, and I would then have lost the effective use of four teeth. His reply was, "There are always dentures". I took the risk and had the tooth extracted. Within an hour and a half the pain returned and endured until yesterday, and prevented me from taking part in the debate on science.

We are on the verge of space travel to other planets, yet we have not yet learned how to determine the cause of so many of a comparatively minor ills to which flesh is heir. Dental health is of enormous importance to us all. We all have to eat, and our general fitness, and perhaps even how long we live, can be determined by the efficient manner in which our teeth do their job and help our long-suffering stomachs.

The British Dental Association has recently decided to set up a Dental Health Bureau, to counter what its president described as the Government's failure in duty. He went on to say that the McNair Committee's recommendation that the Government should foster dental health education, though accepted by the Government, had been allowed to become another example of a pious hope warmly applauded by politicians, proudly exhibited as showing progressive thought, and quietly suffocated by inaction and lack of imagination. So often reports and recommendations receive that kind of treatment in this place.

He then said: That any Government should sponsor a health service and not take over and support financially health education is an abnegation of public duty which is disgraceful. So far, this debate has been nonpartisan. I therefore hesitate to say as strongly as I might otherwise do how I feel about some of the aspects of health in which the Government's performance leaves much to be desired. Incalculable harm is being done to our physical and industrial well-being by the Government's approach to the Health Service. Production lost by strike action is spotlighted almost daily, but we read practically nothing about the infinitely greater loss of production which stems from the incidence of chest complaints, rheumatism, and similar ailments, and the fact that the Health Service is starved of the necessary funds for research into preventive medicine.

There is one field of research which, has been promised by the Government, and in which I have a constituency interest. In a short debate on 3rd February of this year the House debated the difficulties of diagnosing pneumoconiosis, and the fact that pulmonary disability as shown in asthma, bronchial spasms, and emphysema appears to be more prevalent amongst those who have to endure occupational hazards, such as miners and pottery workers, than among those in other occupations. It was stressed that there was great difficulty in diagnosing pneumoconiosis, or in finding a clear-cut industrial causation for other respiratory conditions which are common to other sections of the public. We were promised that research would be carried out. Has that research been commenced, and, if it has, how far has it proceeded?

There is widespread discontent in my constituency about the method of diagnosing pneumoconiosis in particular. No one who has any knowledge of the distress which is caused by this disease can possibly be satisfied until that research produces a much more satisfactory and definite method of diagnosis. Research will undoubtedly show that the incidence of bronchitis and emphysema is more prevalent amongst miners than among the rest of the population, and that there is an industrial causation.

That brings me to the need for an industrial health service, a need which the British Medical Association is urging at the moment. Last summer, I spent a short period in Eastern Germany. I saw many things which disturbed me, but I saw many things which greatly impressed me. Amongst the latter was the system of polyclinics. I visited a polyclinic in a dockyard employing about 6,000 people and found it to be in effect a small hospital excellently equipped and staffed by specialists, doctors, and nurses, available to treat not only the 6,000 workers employed there, but their families. I should like to see such polyclinics set up in this country as part of an industrial health service. It would be of enormous value in reducing the loss of production caused by illness.

Another gap in our Health Service is the lack of a chiropody service for old people. Anyone who has any contact with old people must realise what a boon such a service would be to them. To be confined to one's home by any kind of foot ailment is hardship enough, particularly among people who live on their own, but to be made immobile by a foot ailment which can easily be cured or eased by some simple treatment is intensely frustrating and annoying. Many of them hobble around in agony which is easily preventable and we ought to do all we can to introduce such a chiropody service, and I hope that the Government will consider it.

Mrs. Harriet Slater (Stoke-on-Trent, North)

Is it not essential that the Ministry should do something, along with the Ministry of Education, about facilities for training chiropodists, because local authorities which have these services have great difficulty in getting chiropodists to fill the posts?

Mr. Whitlock

I agree, and I hope that the Parliamentary Secretary will take note of what my hon. Friend has said.

Enoch Powell, the poet, has penned the line: I hate the old, I hate the sick. I know that many old-age pensioners believe that the Government hate them. They believe that the introduction of the 2s. prescription charge—

Mr. T. L. Iremonger (Ilford, North)

I imagined that the hon. Member for Nottingham, North (Mr. Whitlock) intended to quote the context, the poem, in which my right hon. Friend penned that line. I am astounded that he should imagine that in this Committee he can get away with a quotation of that kind, implying that those are the sentiments of my right hon. Friend. I call upon him to withdraw.

Mr. Whitlock

I said that those lines were penned by Enoch Powell, the poet, and they most certainly were.

The Deputy-Chairman (Major Sir William Anstruther-Gray)

Order. If the hon. Member for Nottingham, North (Mr. Whitlock) is referring to an hon. Member, he should not do so by name; but perhaps he is not.

Mr. Whitlock

I am sorry, Sir William, that such exception should have been taken to this quotation. I did not mean to imply that the right hon. Gentleman the Minister of Health hated the sick and hated the old. No doubt the full quotation would clear him of that accusation in every way. But those lines have been quoted on a number of occasions.

I want to make it clear that old-age pensioners who have approached me feel that the Government do hate them, having introduced this 2s. prescription charge, which they have to pay out of their all too inadequate pension. I do not suggest for a moment that the Minister of Health or any hon. Member opposite is callously indifferent to the old people or to others who are suffering in any way, but all too often hon. Members opposite show a lack of understanding about conditions at the lower end of the income scale. They show a complete understanding of the miserable plight of the man on £10,000 a year, to whom they propose to give £10 a week in tax remission, but they do not appear to understand that many old people are going without medical benefit because they cannot afford the items on their prescriptions.

At the last election, hon. Members opposite promised our old people a share of the nation's prosperity. Instead they are reducing the health standards of the old people and the sick in order that those earning more that £2,000 a year may be even better off. That action seems to be indicative of the Government's whole approach to the social services. It is an approach which becomes more and more evident to the electorate every day and at the next election they will pay the price for it.

5.55 p.m.

Lord Balniel (Hertford)

There were certain sections of the speech of the hon. Member for Nottingham, North (Mr. Whitlock) which I regarded as rather unhappy, and I will not be tempted into referring to them. On the other hand, I would like later to take up his remarks about the chiropody service for old people, a part of his speech with which I found myself in considerable agreement.

Mr. Richard Marsh (Greenwich)

In common with many of his hon. Friends, the noble Lord seems to have taken exception to the quotation made by my hon. Friend the Member for Nottingham, North (Mr. Whitlock) of a poem written by the Minister of Health. That is the first I have heard of any objection being taken to this quotation. Perhaps the noble Lord can enlighten us about the context in which this line was written and why the matter has not been raised before.

Mr. Dodds

Before the noble Lord replies—

Lord Balniel

May I be permitted to reply to the hon. Member for Greenwich (Mr. Marsh)? My frank opinion of that section of the speech of the hon. Member for Nottingham, North is that it was a cheap gibe about my right hon. Friend in clear contrast with the sentiments of my right hon. Friend and his work in improving the standard of life and the happiness of those who are sick. It is for the reason that I thought that it fell below the standard of debate that I was reluctant to refer to it in any more detail.

The hon. Member for St. Pancras, North (Mr. K. Robinson) made a constructive speech and rightly referred to the shortage of those who are classified as auxiliary workers in the medical service. He referred also to the difficulties of recruiting those people because of the unsatisfactory state of Whitley machinery negotiations. Although he commented on that matter, my right hon. Friend did not reply to the case made by the hon. Member.

I entirely agree with the hon. Member for St. Pancras, North that there is a considerable shortage of auxiliary workers in the hospital service. Hon. Members may have seen the figures which were published as a result of the questionnaire circulated by the Associa- tion of Hospital Management Committees. The replies to that questionnaire indicated that there was a shortage of radiographers of about 15 per cent., of physiotherapists of about 20 per cent., of occupational therapists of 23 per cent., of speech therapists of 17 per cent. and of therapeutic dieticians of 43 per cent.

Any of my hon. Friends who are assiduous collectors of Press cuttings can produce a whole galaxy of cuttings on this shortage of auxiliary workers. The other day I was told of the closing down of the physiotherapy clinic in Grosvenor Road, Watford, as a result of the shortage of physiotherapy workers.

However, the hon. Member for St. Pancras, North failed to paint the whole picture in that he did not indicate, no doubt unwittingly, that there has been a tremendous expansion of the services rendered by these auxiliary assistants. There has been a substantial increase in recruiting to these services. The figures were given by Lord Newton in another place in a debate on the hospital services, indicating that during the past ten years the number of dietitians has increased by 23 per cent., the number of radiographers by 55 per cent., remedial gymnasts by 53 per cent., occupational therapists by 93 per cent, and physiotherapists by 23 per cent. That is partly the answer to the case made by the hon. Member. While there is a shortage, it is a shortage caused by the tremendous expansion of these services, and recruiting is not as unhappy as he indicated.

I accept that there has been an erosion of good will towards the Whitley machinery. We hear that the nurses want a Royal Commission on their salary scales. We know that the Society of Occupational Therapists, the Society of Physiotherapists and the Association of Hospital Management Committees all want an independent inquiry into their salary negotiations system. Personally, I have no particular objection to an independent inquiry, but I think that one of the interesting things is that although this matter has been debated very fully in another place, and although the hon. Gentleman referred to it in his speech, no suggestion which I have heard so far has put forward a more satisfactory machinery than the Whitley machinery which was introduced by hon. and right hon. Gentlemen opposite after the war. There may be a more satisfactory system, but, so far, those who have criticised the present one have not put forward any constructive suggestions.

I should have thought that the problem here was of a much wider context. The problem is surely that we are short, in the Health Service, in the public services and indeed in private industry, of persons with university degrees, of persons with professional qualifications and of persons with technical qualifications. I should have thought that the hospital service was getting a fair and reasonable share of the very limited pool of such persons which is available. We should direct our minds, though perhaps not in this debate, to the widening of the pool of such people from which the hospital service could draw a larger share, and that I think completes the picture on the point made in the opening speech today.

I should have liked also to have referred in this debate to the hospital building programme, but, like other hon. Members, I find myself in some difficulty, partly because the development plans of the regional boards have been called in to the Minister and we have not yet had an opportunity of studying them in detail, and partly because the mere collection of development plans from different parts of the country is nothing approaching a national plan of hospital building. That has still to be formed, sculpted and moulded out of the various development plans for the various regional boards.

When referring to hospital building, I should like to say that as a result of the tremendous increase in capital investment in hospital building, and as a result of my right hon. Friend's decision to call the hospital management committees and regional boards to lift their eyes a little beyond the annual plodding allocations which they have, and to call upon them to play their part in visualising and planning the hospitals structure we shall have in the 1970s, my right hon. Friend has introduced into the hospital service a sense of exhilaration and hope which has been notably absent for many years. Indeed, I should like to congratulate him on the effort he is making in humanising the service.

It is important, if we are to gain the good will of the public, that hospitals throughout the country should do away with those irritants such as fantastically early wakening hours in the morning. We should do away with the irritant of short visiting hours, to which my right hon. Friend referred, which are such a source of annoyance in rural areas, where people have to travel up to an hour and a half or two hours to arrive at the hospital and are then able to visit a relative for only half an hour.

It is a source of annoyance that the recommendations of the Platt Committee on the Welfare of Children in Hospital, namely, that there should be totally unrestricted visiting hours, subject only to the discretion of the sisters in charge of wards for children, have not yet been fully implemented, and it is a source of annoyance to the public that the failure to introduce the appointments system, particularly in ante-natal clinics, has resulted in long waiting hours for many patients.

It is not only the good will of the patients and the public which is at stake here. My right hon. Friend referred to noise and to the effects of bad nursing, noisy nursing, and also of badly designed equipment in hospitals, which result in noise which is harmful to the health of the patients. He also referred to human relationships in obstetrics, and this is a matter of considerable importance to parents. It is quite wrong, however busy nurses might be, that mothers in labour should be left for hours on end utterly alone with no one to talk to. I feel also that the interests of other patients concerned should be borne very firmly in mind. My right hon. Friend has said that it is the patients for whom the services are being provided and not the administration, and it seems to me right, even if it is a cause of annoyance in hospitals, that if a father wishes to be present at the birth of his child he should at least have the right to be.

I do not want to make any hostile, sweeping criticisms of the hospital service, because anyone who has had any work to do with the hospital service knows of the touching devotion shown by matrons, doctors and nurses towards their patients, but I feel that just as in the physical buildings we have been left with a legacy of outmoded barrack-like hospitals, some of this rigid administrative pattern is also a legacy of the past. It is a legacy from the time when patients were grateful merely for the right of being allowed in hospital and being given treatment.

Today, the attitude of mind has changed. People have a higher standard of living and they are used to better services, and, incidentally, as a result of "Emergency Ward 10", they expect an exceedingly high standard of service when they go into hospital, and also have a greater understanding of general medical practice. I believe that patients actively resent being told blindly to follow the advice given by doctors and nurses. They want to know, especially mothers in labour and the parents of children, the reasons for the instructions which they are receiving, and it is simply not good enough for doctors and nurses to turn to them when they ask questions and say, "Oh, do not worry; you are in very good hands indeed."

I would merely add to what my right hon. Friend said on this subject that the pamphlet "s Human Relations in Obstetrics" is a wholly admirable and compassionate document. I should like to see it made obligatory reading for every doctor, matron and nurse coming in contact with maternity wards, but I should also like to ask my right hon. Friend whether he will consider, as there are so many aspects of humanising the service, whether a simple document covering children's wards, visiting hours, maternity wards and the appointments system could not be sent out to all the lay members of hospital management committees. To expect them to read "Human Relations in Obstetrics" as well as the Platt Committee's Report or the Report on in-patients is expecting too much of people who are serving the hospital service in a voluntary capacity.

I should like to turn to another aspect of the service. It is difficult for us to talk about the hospital building programme, but we can talk about the importance of ensuring that those who are in the hospitals are only those in real need of hospital treatment.

We talk about the importance of ensuring that services outside the hospital are of an extremely high standard. It seems to me that there are three facets of the problem. One was mentioned by the hon. Member for Nottingham, North, namely, the need to provide a good occupational health system for those in employment. That has been the subject of a recent report to the B.M.A. and I do not wish to elaborate upon it. There is also the need to ensure that old people, many of whom are in hospital quite unnecessarily, are provided with an efficient domiciliary service to keep them in the community and out of hospital. There is the third facet, that those mentally ill should be looked after in the community by the local authority rather than be unnecessarily in the wards of mental hospitals. I wish to comment on the last two facets.

Nowhere is the shift from hospital care to care within the community likely to be more marked than in the case of mental health. But if we are to break down the attitude of segregation which for so long has blighted all progress in this sphere, I think that the public will need some reassurance on the question of security. Although there is a lot of free public discussion about mental health, although this may give the impression that the attitude of the public has changed, I have a feeling that just below the surface all the old fears and prejudices lie waiting, and that if there is any clumsy move or unfortunateccident—such as the very tragic case which occurred recently these fears and prejudices could easily come to the surface.

I hope that my right hon. Friend will look upon the question of reassuring the public about security as a matter of substantial importance, not only because intrinsically it is important, even with the advent of tranquillisers, but because the success or failure of our mental health programme depends on our gaining the good will of the public. Will my right hon. Friend make clear—I think that there is doubt about it—whether all patients with aggressive personalities will be sent to Broadmoor, to Rampton or to Moss Side? Or is it the intention, as a result of new developments, to continue with high security wards in various mental hospitals? I think it part of our task in reconciling public opinion on this matter to make clear that it is not, as many people believe, our intention to scatter mentally ill people out into the community before adequate provision has been made to receive them. Of course, such a course would be medically disastrous. It would be financially disastrous. We should have to strengthen the police services—

Mr. Dodds

The hon. Member has mentioned an important point, the fear of the public. Has he, as a responsible person, any evidence whatsoever that since the introduction of the Mental Health Act there has been an indiscriminate scattering of violent patients about the country? Has he reason to believe that any lack of security has resulted from the introduction of that Act?

Lord Balniel

I think that the hon. Member for Erith and Crayford (Mr. Dodds) must have utterly misheard what I was saying. I was saying that there is a danger, because the old fears and prejudices still exist—of course they do—that if the impression is created that we are scattering the mentally sick into the community before adequate provision has been made for them, these prejudices may come to the surface and hamper the mental health programme which we are trying to implement.

Mr. Dodds

I should like to reassure the hon. Member. I heard every word which he said as well the second time as the first. I should like to ask him, because of his reference to this fear, whether he has any evidence that as a result of the working of the new Mental Health Act there is any lack of security which might worry the public. If he has, he should mention it.

Lord Balniel

Most certainly I have no such evidence. Of course, misjudgments are made about the security risks which could be taken. That is inevitable, and they will be made in.the future. Inevitably that will occur at some stage, but I have no evidence that they have occurred to date. I am merely saying that I think it an important part of the responsibility of my right hon. Friend for the implementation of the mental health programme to see that the public receive very full reassurance at this stage.

In indicating in his circular that there is in the next fifteen years to be a reduction in the number of beds devoted to mental patients by 50 per cent., my right hon. Friend has given great hope to those who work in mental hospitals. I realise that to some extent his remarks have been misinterpreted, but I think that the necessity to diminish the number of beds in hospitals provided for patients suffering from mental illness may be gauged from the figures which I obtained when I visited an important hospital recently.

In this hospital there is scandalous overcrowding and scandalous under-staffing. The establishment of this hospital, one of the greatest mental hospitals in the country, was 190 for male staff. The actual number engaged is 102. This hospital cannot advertise for more staff because accommodation is not available. In the female wing the establishment for nurses is 251. The actual number engaged is 120, of which only 26 are trained. These nurses have the care of 639 female patients and one can realise the hope which the proposals of my right hon. Friend have given to those interested in this matter.

The figures given by my right hon. Friend indicate that local authorities are making substantial progress in the building of training centres and of new hostels. This is essential. We must tackle this problem with dynamism if we are to achieve success. But I have the impression that while the general figures are pretty good, progress is patchy. There is confusion about who has the responsibility, whether it is the hospital or the local authority, for the building of these hospitals. I have an uncomfortable feeling that the general statistics which my right hon. Friend has given may hide the fact that in some areas little progress is being made.

The other matter about which I believe that more progress should be made is in the care of old people. I recognise that much still remains to be done in the hospitals. Any hon. Member who has read the report of Dr. Sheldon, the medical adviser on the care of old people in the Birmingham Region, must realise what a tremendous amount needs to be done. He speaks of the large number of geriatric units in his area which are totally unsuited for modern usage and unfit for repair. They are suited only for the bulldozer. In view of the scale of geriatric rebuilding, I wish to know whether it is the intention of my right hon. Friend to introduce standardised designs for new geriatric units. Standardised designs made the tackling of the building programme possible, and I am sure that standardised designs for geriatric building are also necessary.

I wish to refer to what was said by the hon. Member for Nottingham, North about chiropody services. It is trite to say that if we are to keep old people healthy we must keep their minds occupied and keep them on their feet. As long ago as 1956 the Guillebaud Committee recommended that as soon as more resources were available there should be a further development of the local authority chiropody services. It was not until April, 1959, that the Government circular was issued calling on local authorities to extend the service. They were advised to co-operate with local voluntary organisations and to submit proposals. It would be interesting to know what progress has been made regarding chiropody services.

More important, I think, is for us to know on what principles we are working in relation to the chiropody service. If one is in need of serious treatment one can obtain such treatement free of charge in hospitals. If one is in need only of preventive treatment, under some local authorities one has to pay for chiropody treatment in accordance with one's needs. If one is living in the area of other local authorities one obtains such treatment free of charge. In Scotland local authorities do not have power to charge for this treatment.

Here we have a situation in which in some areas preventive services are free while in others it is forbidden for local authorities to charge and in others they can charge according to means. This seems quite illogical. If preventive treatment is as important as treatment in hospitals—as I am quite certain it is—I should have thought it only logical and reasonable that this chiropody service should be made available free of charge to those who need it. I do not believe that the cost would be very considerable. Largely, the service would be used by old persons. One in every four or five old people are in any case on National Assistance, so it would be paid for them by the National Assistance Board.

If we look at the matter in a wider context, it seems a false economy to deter persons from having preventive treatment so that ultimately they have to go to hospital to get treatment free of charge, whereas in the meantime they are deprived of serving the community through a failure to obtain preventive chiropody treatment. I hope that my right hon. Friend will take note of the remarks of the hon. Member for Nottingham, North and see if an improvement can be made in this matter.

6.22 p.m.

Mr. Laurence Pavitt (Willesden, West)

This is the third time that I have had the honour of following the noble Lord the Member for Hertford (Lord Balniel) in a health debate. I hope that the occasion may arise when he will follow me. I welcomed, in particular, the last comments he made. I can assure him that from this side of the Committee we shall continue to press the Minister to give free chiropody services for old people. I am sure that, in his turn, the noble Lord will bring all the pressure he can on the Minister to that end.

I also welcomed his comments on the auxiliary services, which were highlighted by my hon. Friend the Member for St. Pancras, North (Mr. K. Robinson). The noble Lord perhaps did not sufficiently emphasise that these are so much an integral part of the other services and that if there is a shortage of physiotherapists and radiographers and other auxiliaries that affects all the other kinds of service being given in those hospitals.

There was a pleasant aspect about the opening speech by the Minister today. We have become so used to hearing him in the rôle of Mr. Hyde that when he came forward as Dr. Jekyll with a far more comprehensive approach, there were a number of things which we welcomed. We welcomed particularly his views on humanising the service. I feel that in the first three months of this year he was solely animated by the question of £ s. d., but perhaps now some balance is being restored. We get an opportunity of debating health only once a year. We all sympathised with the Minister when he said that he had too much material. We are all precisely in that situation, trying to get a lot into a very short time.

The prelude to this debate took place before Easter and mainly concerned ways and means of economising. We on this side of the Committee spent a great deal of time bringing the utmost condemnation of the Government's policy. We felt that it was very bad and was harming the Health Service. We felt that it ought to be opposed to the utmost extent. There will be no let-up on that front, for not only have the actual measures taken by the Government been harmful, but, until now, the Minister's attention has been diverted from the constructive kind of things he should be doing to pursuing economies. The purpose of this debate, with the lead given by my hon. Friend the Member for St. Pancras, North from the Opposition Front Bench, was to see in what kind of directions we can make suggestions which will give some positive leadership in the Health Service.

The Minister will need to fight very hard for the retention of his hospital building programme, of which so much has been said in this debate and previously. The Guardian said yesterday: Mr. Powell's economies in the Health Service have been well received by some supporters of the Government, and more retreats from the social service standard would be welcomed. We have to be aware that in the present economic state of the country the Minister of Health will be under fire from many quarters, not only to find further economy but, in his hospital building programme, to discover that the time is not yet opportune to proceed. Will he assure the Committee that he has now made the maximum economies and reached the limit and that there will be no further inroads on the present programme?

One of the worries about the hospital building programme, which was mentioned by my hon. Friend the Member for Bishop Auckland (Mr. Boyden), is that plans may be held up for physical reasons. There is the need to find architects and other matters which go to the preparing of a huge building programme. Previous building programmes have shown that there has been delay between the first idea of building a hospital and the actual time when the hospital was started. So far as I can see, although we have an ambitious long-range programme, we shall not see anything practical in the form of bricks and mortar until at least 1966. I hope that the Minister will give attention to any possible delays in his Department. Is he quite sure that the machinery he has for approving plans of regional hospital boards, hospital management committees and teaching hospitals is adequate to ensure the flow of building which he envisages?

Recently, I read a report of a planning committee of a hospital which showed that on one major scheme there had to be seven separate approvals given by the Minister. If that is to go on with every major scheme it is obvious that, apart from technical problems involved, there will be considerable delay in getting necessary permissions and authority to proceed. My hon. Friend the Member for St. Pancras, North and others on this side of the Committee have spoken of the desire for the planning of this building to be carefully thought out especially in relation to the services to be provided in the sector of mental ill-health and mental illness. It is important if we are to build on the right kind of ideas—which I believe the Minister now has—to be careful that building should be done in the right places. There has been a change in the pattern of hospitalisation and in the pattern of medicine.

The Minister's plan to eliminate the huge quantity of beds for mental illness in the next fifteen years is, I believe, based on the right kind of motives. I welcome very much his approach by which to get away from the idea of the Rampton and Colney Hatch type of institution and to bring people with mental disorders more and more into the mainstream of ordinary hospital service. I want this to be successful. There are enormous dangers if it is done in the wrong way. For sixty years in psychiatric medicine we have had the benefit of Freud, Adler and Jung, yet still there are 44 per cent. readmissions of mental health cases.

I can accept the fact that the present trend is in the right direction. I am concerned, however, that we should not have in the ordinary hospital open wards, a kind of shop window for those who are neurotic, psychosomatic or well-behaved borderline cases, and separate long-stay institutions for acute cases which will still remain part and parcel of the old institutional system, and have the same effect on public opinion as the closed hospitals of the past. If we are to integrate mental health services with hospitals, it may mean building not inside, but alongside. In that respect, we need a good deal of very proper research with specially organised pilot schemes. We might well have a special committee composed of men of vision and practical experience of modern forms of mental treatment who would be able to advise the Minister on long-term planning.

One of my main concerns in the hospital field is the emergencies which are taking place at present in obstetrics. In spite of the Cranbrook Report, the number of maternity beds is woefully inadequate in many parts. The number of monthly admissions on an emergency basis in Central Middlesex has doubled since last year. It was 15 in January of last year and 29 in January of this year. The situation is becoming extremely acute. When young mothers try to register for hospitalisation for their first babies, as Cranbrook recommends, they are told that there just is not a bed available. They are told that when their labour pains start they should telephone their general practitioner and that it may be all right; the hospital will do its best for them at the time.

What a situation for a young mother to be in—she has to embark on bringing a child into the world without any knowledge of just how and when it is to take place. Yesterday, I received a letter from a general practitioner in my area. The letter says: As you know, … overcrowding and the rising birth rate are giving us many more patients who have to have their children in hospital on social and other grounds. There are far too few beds, and many mothers-to-be have to make emergency bed service arrangements. This means that they do not know which hospital will take them until they enter labour, the general practitioner has to phone around to try for a bed, time passes and not only does the mother have the psychological upset, but her child's life is jeopardised by the delay. In the hospitals deliveries take place in labour rooms, in rooms pressed freshly into this service, and also in the corridors on many occasions. The conditions can only get worse". Does the Minister know how many mothers are giving birth to children in hospital corridors? How many of his hon. Friends' wives are faced with that kind of situation? Is it right that this situation should exist in 1961 when we claim to have a comprehensive Health Service? This is an appalling anxiety for a young woman expecting her first child. This is one of the matters to which the Minister should be giving urgent attention. He talked about humanising the hospital service, and he was quite right to point out the importance of human relations in obstetrics. He should give priority attention to this problem. I hope that he will devote as much energy to solving this problem as he devoted to saving 1s. 1d. on each bottle of orange juice for the same mother.

Just as important as hospital buildings and the provision of an adequate number of beds is the question of the people serving inside the hospitals. It is disastrous that the House of Commons will not have the opportunity of a full day's debate on the Platt Report. What happens about the Platt Report and about the medical staff will to a great extent shape the hospital service in the next ten years. My hon. Friend the Member for St. Pancras, North made out a cogent case for making haste and not delaying the review of consultant posts.

The recommendations of the Platt Committee should be complied with. The Minister is still waiting for the profession. He could well assemble the necessary facts from regional hospital boards and this would enable him to make quick decisions on this subject rather than awaiting the outcome of what appears to be quite a long-drawn-out debate between the Ministry and the profession.

I want to draw attention to a problem which has not been grasped either in the Platt Report, or in the discussion which has gone on around it. That is the system of the allocation of beds to consultants. A consultant gets a number of beds and the size of that number is regarded as a status symbol. This system is antiquated and has very little place in modern medicine. It acts as a barrier to healthy team work between consultants. The whole trend of modern medicine is to get away from the individuality of the "star" who does marvellous operations single-handed. There is team work between teams of doctors. The question of the allocation of beds should receive the Minister's urgent attention. There should be a now system of organisation in this respect.

The question of the organisation of consultants' and specialists' salaries has been mentioned in relation to Whitley Councils. Like my hon. Friend the Member for St. Pancras, North, I doubt very much whether the establishing of the new grade of medical assistant will help solve some of the major problems of frustration which are occurring amongst the medical staff in hospitals. This new grade could still be a backwater. It could be the S.H.M.O.s under another name. It could mean that the vexed problem of the time-expired registrars will be shelved by calling them all medical assistants.

It is a scandal that we have well over 140 time-expired registrars and nobody seems to worry very much about it. Some of them have higher qualifications. Some of them have for some years been doing consultant work with very little supervision, yet they still remain the forgotten men of medicine. In answer to a Question of mine the other day the Minister showed that the cost of upgrading them to consultants would be relatively small. I can see no reason whatever why the Minister cannot take a step in this direction without awaiting his long negotiation on the Platt Report.

We should very carefully examine the case being made out this afternoon by my hon. Friends for the adaptation of the Whitley Council machinery to the real needs of the Health Service. I only want to deal with the Whitley B Committee and its total failure to deal with medical staff in hospitals. It is appalling that Mr. Holmes Sellors, a member of the Platt Committee and chairman of the Joint Consultants Committee, should have said, of Committee B: … it was a perfectly appalling body to sit in. Each side spoke; each side knew what it would accept. To try, in such circumstances, to get agreement just did not add up. It simply meant that each side stated its case, a move was made, and then each side went away to consider the next move. All that led to the most regrettable length of time needed for the solution of any major problem. That was said by Mr. Holmes Sellors and reported in the British Medical Journal on 17th December. When the chairman of the Joint Consultants Committee makes such a statement, it is time for the Minister to see whether we should not have some other form of arrangement in order to reach a solution on conditions of service and pay.

The failure of the Whitley Council was one of the reasons which led to so much unhappiness which, as the Minister rightly said, has been a thing of the past since the Pilkington Report. However, the very fact that that kind of thing can go on is indicative of the need for a fresh approach to the problem. The Government should not just rest on the laurels of Pilkington and say, "We are out of the wood now. We will wait for something else to blow up". The Government should consider whether fresh machinery more geared to Health Service needs is desirable.

Any discussion of hospital service personnel must include mention of the terrific shortage of nurses. Last year's Ministry of Labour Gazette showed the following vacancies: trained nurses, 6,750; student nurses, 7,468; midwives, 929; pupil midwives, 558; assistant nurses, 2,609; pupil assistant nurses, 1,744: total, 20,058 vacancies in nursing staffs of hospitals. Recently, at Leicester, wards had to be closed merely because of lack of staff. It is not just a question of pay and conditions.

There is something wrong with morale. There is something lacking in leadership. Those in the nursing profession are very loyal people who give devoted time and energy to the service but, for some reason, we cannot inspire them and make them feel content. The result is a high turnover of those not finishing their training. There is need for radical action here.

The general practitioner side of the service gets scant attention in this House, and I hope that the Minister's fresh approach today, when he showed himself more aware of the service as a whole and less lopsided on the hospital side, means that more attention will be given to the general practitioner sector.

By many of the nation's leaders, the family doctor service is called the key to the whole Health Service; the basis on which we build. These are the men who have to deal, day in and day out, with every family in the land. Yet, surprisingly enough, the Ministry gives them no leadership at all. That is not to be wondered at, because although there is at the Ministry headquarters a staff of 2,320, the department looking after general practice numbers only 14. What a miserable proportion.

At its head the Ministry has five under-secretaries and with 24 assistant secretaries. The general medical services are allotted half an under-secretary and half an assistant secretary to look after them—they do not even have the full-time services of one person in the major grades. Of the Ministry's 38 principals, the general practitioners are fortunate in having the services of one principal and the part-services of another. Is this the driving force that is to revolutionise general practice? Is that the leadership that is to be given to the 23,000 doctors who look after a population of 52 million? If the Minister is serious about having an integrated and balanced service, he should make direct and radical changes here.

I hope that the Minister appreciates, as do most hon. Members, that the general practitioners have been prepared not to take £1 million of the pay due to them in order to get the ways and means of improving general practice. That is all to their credit, but what is the Minister doing? Does he intend to offer incentives for an appointments system? Does he not think that for people to have to wait for hours in doctors' waiting-rooms is out of date, when it is possible to have an appointments system?

Will the right hon. Gentleman help doctors to redesign their waiting-rooms and surgeries? Can we have a design unit for doctors as we have for hospitals to provide patients with a more efficient service? What is wanted is a permanent standing committee. The family doctors know what they want to improve, but there is nobody with responsibility to ensure action. There is no leadership, but only a polite game of ping pong between the Ministry and the B.M.A. until the ball falls on one side or the other, when vague action, usually too little and too late, results.

The greatest need is for training in psychiatry far general practitioners, as has been mentioned on both sides of the Committee. Very many patients entering a general practitioner's surgery could be considerably helped if there was some development on these lines. It is not generally known, but there is no recognised training in the whole country for short-term psychotherapy and social psychiatry, which includes social and community treatment.

I hope that I have been constructive—I have tried to be—and I suggest that the Minister has a ready-made instrument with which to deal with this problem. During the last ten years, 70 day hospitals have been started, and they have been doing marvellous experimental work. Here we have ready-made the centres where this kind of training for general practitioners could be given.

Concern has been expressed among general practitioners about the high-pressure salesmanship used to persuade them to prescribe proprietaries. Their waste-paper baskets are the daily witness to the "glossies" that come in, and their desks a tribute to the give-away gimmicks like desk diaries, by means of which the drug houses seek to persuade them to prescribe proprietary articles.

We think of the flow of such literature and gimmicks, and then we look at the Prescriber's Notes. In competition with the high-pressure salesmenship of the drug houses, all the television advertising and the rest, all the general practitioner is given is this drab little booklet once every two months. Is the Minister satisfied that by this means he is able to get over to the general practitioner the kind of approach he wants? Would it not pay him to spend £50,000 on a good editor and good public relations to ensure that the general practitioner is helped to dispense economically?

We do not know what effect this barrage of advertising has on the general practitioner, or whether it affects him. Why not sponsor research in order to find out? The payment of a few research assistants at a university would yield a lot of information. It need only be a short-term project, but it would result in knowledge rather than propaganda. More positive steps to ensure that doctors use the British National Formulary, and not proprietaries, would do more than pious exhortations in the way of helping doctors, patients and taxpayers.

The last sector I wish to deal with is the health of workers in commerce and industry. The B.M.A. has recently published a pamphlet on the occupational health service, and this follows on twenty years of activity. The first report of the Committee on Industrial Health was published in 1941. We had the Gowers Report in 1949, and the Dale Report in 1951. In 1959, we had the I.L.O. recommendation to all its member nations. What has happened? The Government have taken a decision. They took that decision in March, 1961, and published it in Cmnd. 1318. The decision was to do nothing. The Government in publishing their decision to reject the I.L.O. recommendation have also decided that there shall be no occupational health service.

The Health Service should be a quadrangle but, so far, only three sides have been filled. The fourth side is an occupational health service. We need special facilities for training doctors in industrial hygiene and occupational pathology and, most important of all in these days of stress, some training in the problems of assessing working capacity in relation to the job. I do not know what the result of such a medical assessment would be on hon. Members—I suspect that many of us would apply for the Chiltern Hundreds—but with all the modern nervous strain in industry and commerce medical care is needed to make sure that the man at work does not have a nervous breakdown because he is in the wrong job at the wrong time in the wrong place. Such a service would save the nation millions of pounds of hospital expenditure.

I pay tribute to the excellent work done by the Ministry of Labour, especially through its factory inspectorate which has done so much in the prevention of accidents, but the time has come for the Government to accept a central occupational health services council to combine the efforts of the two Ministries. A Department of Technical Co-operation has recently been established to take over from the Colonial Office and the Commonwealth Relations Office certain functions that tend to fall between the two Departments. Occupational health tends to fall between the Ministry of Labour and the Ministry of Health, so let the Government take the initiative to establish a fresh council that can make sure that nothing slips through the gap between them. We should never forget that 262 million days are lost through sickness, as against 3.7 million through strikes. This is a field in which the Minister could take some action without incurring great expenditure and the increased productivity would help the nation's economy.

Previously during the year I have spent a good deal of time attacking the right hon. Gentleman, but today I am not attacking him. Today I charge the Government with complete incompetence and utter lack of vision in looking after the health of the nation. Instead of bringing to these problems the professional standards of the good doctor, the Government behave like a cheapjack. Instead of making the Minister responsible for the health of the nation a senior member of the Cabinet, it uses him as an office boy of the Treasury.

I stress the importance of changing the emphasis from curative to preventive medicine, but the Government appear incapable of placing the health of the family, the worker, the young and the old above the squalid values of a profiteering society. My diagnosis is that the Government are worn out and senile and the best treatment that I can recommend is that they should go into permanent retirement a long way from Westminster.

6.52 p.m.

Mr. Robert Cooke (Bristol, West)

I will not follow the hon. Member for Willesden, West (Mr. Pavitt) in reading out a long screed of praise or abuse about my right hon. Friend.

I felt, when my right hon. Friend spoke today, that it was clear from his speech that he takes nothing for granted in this new job of his and that a most human man exists behind that somewhat severe exterior. Since taking office my right hon. Friend has obviously made a thorough investigation of all sides of the National Health Service, and I am glad that he has come to the conclusion that the patient must be the focal point around which all else should revolve. It follows from that that the family doctor is also of prime importance.

The National Health Service has improved the overall picture with regard to general practitioners. We have more of them and they are more evenly distributed. Undoubtedly, the prestige of the G.P. suffered when the scheme came in. His surgery tended to be just a clearing house on the way to hospital. More patients continued to come to see him as a result of the facilities offered by the Service and, gradually, he tended to become what some people have described as nothing more than a rubber stamper of prescription forms. [HON. MEMBERS: "No."] There was that tendency, but if that existed then it is less so today, because better cooperation now exists between the G.P.s and the hospital services with which they are trying to work and I welcome any move towards getting G.P.s closer associated with hospitals.

But there are areas, especially country areas, where the central facilities in the big towns are a long way off and here is where some of our cottage hospitals—and I know that some of them are to be closed eventually—will have to continue to back up the work of the G.P.s in the surrounding areas. There are also today many of the smaller hospitals which have absolutely first-rate honorary staffs attached to them—surgeons and consulting physicians—who give their services without payment from the National Health Service. I realise that that is objected to by many people who want an all-embracing scheme. But I urge hon. Members to remember that these people do this work in an honorary capacity and that we would lose much if we dispensed with their services.

I also believe that the doctor should be rather like the clergyman, a person of influence and importance in his locality, and not just a mere technician. I hope that even in these changing times the doctor's education and training will fit him to take that place in the community. I think that the Minister could use his influence in this sphere. I know that it must be technical and very complicated and more complicated than in my grandfather's day when he trained to be a doctor, and I also appreciate that we have not got time for the Latin and Greek that had to be learned before one started in those days. But much remains to be done in order to make the young doctor fit for his position in the community.

Many hon. Members have said that the public attitude to medicine is changing. It was not the National Health Service which started that, for it has been going on throughout the century. Certainly the Service speeded it up and the means of mass communication, of course, have gradually hurried the process along. The secrets of the operating theatre and of the consulting room are now available for all to see through the medium of television, to hear on the radio and to read about in magazines and newspapers. Whether we like it or not, that has happened, but I am wondering how much my right hon. Friend and his Department have been able to co-operate with the producers, particularly of television, but also of the other media, in the production of their programmes.

Although many of them are good, some of them are very bad indeed, and I consider that they would not be so bad if the producers were in closer touch with people who could give them the expert information that they require. Medicine is no longer the mystic science it used to be. Hon. Members have said that it is right and proper that the patient should know what is going on and what is happening to him. Once again, whether we like it or not, that has happened and I hope that the Minister will bear it in mind in the reforms which he is undoubtedly going to bring about in the Service.

Mental health has also been raised today and we have seen a gradual improvement in the public attitude towards it and in the treatment given to patients. But unless we get the old institutions pulled down and get rid of them altogether, I have a feeling that we shall go on filling them with cases of one sort and another. When the facilities are there, there is bound to be a tendency to say that if there is something wrong with this or that person, he or she should be put in an institution. The old idea that if someone is funny in the head one should lock him up still persists, and as long as we have these old buildings standing I am afraid that we shall find them filled.

It is obvious that there is still not enough understanding about mental illness on the part of members of the public. For example, in Bristol the other day we had a first-rate exhibition put on by the director of our best mental institution in the city—at the Royal West of England Academy—and the exhibition concerned many aspects of the subject, including the treatment of mental patients today as compared with earlier times. The exhibition received some publicity and a good number of people went to see it, but I was distressed to find no official present from the regional hospital board headquarters, which is situated just up the road from where the exhibition was being held. I do not know whether an official did go to see it or even if the regional board knew about it. However, I sent a message to the meeting of the board and urged the officials to see it. It was an exhibition which did not receive the proper attention from those connected with the service. The Minister sent his good wishes to the organisers of the exhtibition and that action on the part of my right hon. Friend was much appreciated, but obviously his officials were not fully aware of what was going on, and they should have been.

Much more still remains to be done to get the mentally ill people back into the community. I have visited certain institutions, day hospitals and clubs for the mentally affected, and many of these people, with a little help and encouragement and treatment, can live in their own homes and can go along for an hour or two a day and meet other people who have similar problems to face and, thus, can benefit by that and eventually become perfectly normal members of the community. There are always difficulties when one tries to set up a new club or a clinic or something on those lines. People nearby often object and we must exert all our influence to persuade people to accept these new ideas.

I turn now to a group of people who ought not to be in hospital at all. My noble Friend the Member for Hertford (Lord Balniel) spoke of them in the course of his speech. Many old folk are in hospital because they have nowhere else to go. We know that. What is the solution to their problem? Should we build new homes or institutions of one kind or another for them? That can help but, of course, nothing is so good as bringing them back into their own home circle or some home circle or other, even if we cannot stop them going into hospital in the first place. Certainly, we should do all we can to prevent their having to stay in hospital. By skilled geriatric treatment in the first instance, many elderly people could be brought back into the community again.

There are, for instance, many pieces of apparatus—some of them are rather expensive—which could help old people to live normal lives if only they had access to them. One knows of old people whose only infirmity is that they cannot get in and out of a bathtub. There are many inventions which could help them, but I have found that not enough is known about such things. I only discovered them myself because, when walking down Wigmore Street, I saw them in a shop window. I hope that my right hon. Friend will bear that matter in mind.

Mrs. Slater

Is the hon. Member suggesting that the Minister should give financial help to old people to buy such apparatus, or is he hoping that they will be able to buy it for themselves out of their present old-age pension?

Mr. Cooke

I think I made it perfectly clear that I wanted my right hon. Friend to bear that in mind when trying to distribute the available money over all the matters which hon. Members have raised. I said that such apparatus was often expensive. We are talking about the National Health Service, and I think it is obvious that those guiding the Service should try to deal with these problems.

I read in the most recent Report of the Ministry of Health that some local authorities have thought up the revolutionary idea that, within their home help organisation, they could arrange for one home help to look after a group of old people. This seemed a revolutionary idea to the person who wrote the Report. At any rate, it had not been tried very often before. Surely, that is the way to go about tackling this problem.

In my constituency, I have, I am sure, more almshouses than are to be found in the constituency of any other hon. Member. While I do not suggest that all old people should be put into almshouses, I believe that the functions of a matron in charge of an almshouse who looks after the needs of several old people could very often be carried out by a home help in people's own homes in a small area. If a person were looking after a small group of elderly people, she or he—I assume that it would usually be she—would get to know them extremely well and would be able to care for them in much the same way as old folk are cared for in almshouses.

Many old people find themselves, so to speak, at the mercy of the State, having to be dealt with by some form of Government action, because their own families, their own relations and their own friends have failed them. I believe that there is a growing tendency for people to think that, because we have the Welfare State, we can shirk our responsibilities to our own families, to our parents, to our grandparents and to old people generally. If, in this bingo-playing age, half the people who waste their time on that ridiculous sport gave a few hours of thought and care to some of the older members of their families, many of our problems would be solved. Lest any hon. Member should think that I am singling out a particular sport, there are quite a lot—

Mr. Denis Howell (Birmingham, Small Heath)

On behalf of all sportsmen, I very much object to the hon. Member including bingo in that category.

Mr. Cooke

I withdraw anything to which the hon. Member takes exception because I know that he represents a particularly sporting community, and I should not include any of his friends in that category.

Even if the family has failed, and even if the State cannot do all that is necessary to help old people, there are several voluntary services willing and able to help, but often people do not know about them. Again, I am sure that my right hon. Friend, with the human approach he is adopting in going about all these things, will do what he can to bring to the attention of all who may need them the services which are available, whether they are connected directly with the National Health Service or are part of the work of some voluntary organisation.

At the beginning of this year, I spent sixty days in the United States of America. I found that there were three great issues in the minds of most Americans. One was the prospect of "socialised medicine"—that was the name they used to describe it—which worried them very much. The second was what we would do in regard to the Common Market. The third, I think, was nuclear weapons.

Mr. Wilkins

And the next was how to pay their medical bills.

Mr. Cooke

We could do much to help our great friends and allies in bringing about some form of national health service as, undoubtedly, they are deter- mined to do. My right hon. Friend has much to do in this country, but I am sure that he will offer what help he can to our friends across the Atlantic who are desperately anxious about all these things and who desperately need our help.

Mr. Wilkins

I was in America about three years ago and I had the issue of socialised medicine raised with me. Medical men in America said to me, "It is a damned good scheme, but we hope that it never comes here". Why?

Mr. Cooke

I shall not follow the hon. Member for Bristol, South (Mr. Wilkins) in quite the language he used.

Mr. Wilkins

That was what was said to me.

Mr. Cooke

It was not the language which my friends in America used about our National Health Service. Many of them thought that it had good qualities, but they were worried lest they should have something exactly like it over there. What they were really afraid of was the sort of National Health Service which we had at the beginning, ten years ago.

Mr. W. Griffiths (Manchester, Exchange)

What is wrong with that?

Mr. Cooke

We have improved it a great deal since. I think that my right hon. Friend could do a good deal to help our American friends by explaining to them the sort of difficulties we have discovered and some of the problems which we still have. We could well work together on that.

I receive letters on a great number of subjects, but the only complaint about the National Health Service I received during the whole of last year came from a man who said that he had sent a copy of his complaint to Her Majesty the Queen, the Lord Mayor of Bristol, the chief constable, the Speaker of the House of Commons and the Prime Minister. I assure the Committee that his complaint was completely frivolous.

The hon. Member for St. Pancras North (Mr. K. Robinson) said that we had the best health service in the world. I do not quarrel with that, but I think that hon. Members will realise from what they have heard already this afternoon that, even if we have the best health service in the world, my right hon. Friend and his hon. Friends on this side of the Committee are determined to have a yet better one.

7.8 p.m.

Mr. W. A. Wilkins (Bristol, South)

I was very interested to hear the hon. Member for Bristol, West (Mr. Robert Cooke) relate his experiences in the United States. I am prompted to tell the Committee that, during the course of a few weeks in the United States myself, I had the opportunity of talking about what he quite correctly said that Americans call our socialised health services.

I was amazed at the amount of interest shown in our National Health Service, and I was left in no doubt, either by private individuals or by the profession itself, that people regarded our scheme as an excellent one. But, of course, medical men in America are desperately afraid that such a scheme may come there as a result of what Americans discover when they visit this country, as they are doing now in their thousands, with the consequence that one of the most lucrative porfessions, if not the most lucrative profession, in the whole of the United States may lose its present position of advantage.

It is a fact that the mortician's, or undertaker's, profession and the medical profession are the two wealthiest professions in America. Doctors in America are not likely readily to forgo their present position if they can possibly prevent a national health service being instituted there.

I also met a number of people connected in one form or another with American Government departments. They were the equivalent of civil servants in this country. Even they expressed the gravest apprehension to me that, although they took out insurance policies for which they paid huge sums—I think that Blue Cross is one—they were still fearful of having to go into hospital for an operation because of the sum of money which they would have to pay in addition to that for which they were covered by their insurance policy in the event of their choosing the surgeon who should carry out the operation. In other words, there was a general surgeon who carried out operations on people insured under a Blue Cross policy, but if a person wished to have someone else for whom he had a particular fancy he had to pay an additional fee. I do not think that that is the kind of medical service which the people of this country wish to have.

I sat through almost all of the earlier speeches in this debate—at least six, I believe—before I was forced to go and get a cup of tea.

Mr. Dodds

I have not had a cup of tea yet.

Mr. Wilkins

Judging from the tenor of today's speeches, I thought that I was attending a tea party of the Primrose League. I was amazed at the tolerance, to use a very mild word, of all that has happened in this country in the last twelve months. I am sorry to say that my hon. Friend the Member for St. Pancras, North (Mr. K. Robinson), who reminded us that it is twelve months since we last had the opportunity to debate the National Health Service as a whole, did not take advantage of the opportunity today to launch what I think would have been a completely justified attack on the disastrous effects of the policies of the Minister of Health.

In making that criticism, I am not forgetting that the right hon. Gentleman has made some good proposals, but, after our experience in Committee on the Bill imposing the increased dental charges, and after our dicussions on the Regulations imposing the increased prescription charges, I can never forget the typical Tory reactionary attack on the fundamental basis of the Service. I can understand attacks being made on what I would call the sidelines, the incidentals, but when the Government start attacking the source from which people hope to be made well by their doctors—that is, the medicine which is prescribed for them after diagnosis—then they attack the fundamental basis of the Service. I cannot and shall not forget the attack which the Minister and his supporters have made on the Service, and I intend to remind them of it wherever they may be.

I am not trying to be churlish. I would much rather feel that I was in a position to congratulate the Minister on what he has done for the Service over which he presides, but I could not do that. On the contrary, I believe that he has brought irretrievable disaster to the National Health Service since he has been Minister. There has been a sequence of attacks on the Service designed ultimately completely to undermine it. It is true that there has been many wonderful improvements, particularly in the hospital services. One can go into quite a few hospitals in Britain of the type to which the hon. Member for Bristol, West referred.

I wish to tell the Committee about what has happened in the oldest building being used for medical purposes in Bristol. I refer to the building at Stapleton which was built to accommodate French prisoners of war. It was a Poor Law institution. Then it was used for mentally defective people, whose illness was of a not too serious character. It has been converted, more or less, into a general hospital to accommodate chronic cases and elderly people. Anyone who goes to that building is able to see what can be accomplished by a committee or board determined to make a success of the job which it has been given. It is a worth institution. It is true that the architecture is not all that could be desired, but I do not think that many people would be unduly disturbed if they found themselves in this building being cared for by a very able and willing staff of nurses and doctors.

As I say, there have been great improvements in a number of our hospitals, but I do not think that much of the credit for them necessarily falls to the Minister of Health. I think that they are largely due to the ingenuity and enthusiasm, not only of the members of the hospital committees, but especially of the staff, particularly the maintenance staff.

I should like to ask the Minister whether he is in a position to promise us that the Chancellor of the Exchequer will not attack his proposals for new or improved hospital accommodation in the near future. We have so often heard expounded in this Chamber wonderful plans for new roads and new schools and for great advances in the social services. I could not help but think when I heard the Minister announce his ten-year plan that, as usual, his proposals were for the very dim and distant future. I hope that that is not the case.

When the Minister considered the formulation of a plan for the development of the hospital services, I do not believe that he intended anything other than to bring it into being. However, I doubt very much whether he will be permitted to carry out many of the proposals which he has briefly outlined to the House of Commons. It seems obvious to me that there will be cuts in many of our social services. Since the Chancellor of the Exchequer exhorted, encouraged or instructed the Minister of Health to make cuts in the welfare foods and services and to increase the prescription charges, and so on, one can have but very little faith that, if he is driven to drastic action, he will not ask the Minister of Health to come to his assistance, and, if not to cut out things in the right hon. Gentleman's programme, to slow them down.

The part of the Minister's speech which appealed to some of my hon. Friends and to me was his reference to the human considerations that we have to bring to bear when considering the services which we provide for the people. I took particular note of his reference to the trouble of noise in our hospitals. What I did not understand was whether he was referring to internal noise in the hospitals, such as the noise of trolleys being wheeled about, or to the noise from which patients suffer due to the location of the hospital.

I suppose that in almost all our great cities, certainly in the older cities, the larger general hospitals were as a rule located in the centre, at the heart of the cities. One can understand that, of course. The hon. Member for Bristol, West will know that we have a clear example of that in Bristol, in the Royal Infirmary and Bristol General Hospital, part of the Royal Hospital group, built many years ago, especially the older part of Bristol Royal Infirmary which is almost in the heart of the city. Now today, with the areas around built up and a massive flow of traffic, there is created all manner of noises, of course. Cars have to change gear going up a bit of a slope just outside the institution, and one can well understand how this must cause considerable disturbance and to some extent annoyance to the patients. The remedy for a situation like that is, undoubtedly, to build new hospitals and to locate them in some part of the city where they will be more or less noise free or trouble free.

I should like to make a suggestion to the Minister about this on behalf of Bristol. This is something which has been talked about in our city for a good many years, and it is really two suggestions in one. There was a time when we were talking about a transfer of Bristol Royal Infirmary or adding to it and having it as a teaching hospital on an admirable site known as Ashton Court where there is any amount of ground that could be used. It is almost completely secluded, a wonderful place to build a hospital, if anyone has the will to do it.

I make a plea for my own constituency on a matter about which I have already had communication with the Minister. As far back as 1936 we had planned a hospital on the south side of the city. This would be right on the outskirts and literally noise free. The site accepted for development was an old airport site with plenty of land around, ideal for the building of a general hospital. I say that as an addition to what I have already said in representations I have made to the Minister about it. I hope very sincerely that in due course the Minister may find it possible to say "Yes" to the requests of my constituents who number a good many thousands.

I hope that the Minister will listen to this because it is a very important point. On the housing estates in my constituency—there are three or four of them now, I believe, so the position is pretty well impregnable from our point of view—

Mr. Iremonger

Famous last words.

Mr. Wilkins

But not because I am defeated.

In those housing estates there are more residents than there are in the town of Taunton. I am not talking about electors, but there are more people resident in those estates than there are in the population of Taunton. I did know how many general practitioners there were practising in Taunton. I believe there are forty-one. For many years on the housing estates I am referring to we had difficulty in getting even one general practitioner to go to live there. We had to provide a service of student doctors from Bristol General Hospital whereby they could be called upon from the hospital to go to the estates to attend people in desperate need—people perhaps taken suddenly ill.

I must make one or two other points, but only one or two. One was raised by the Minister when he referred to the drug bill. I think he said that in England and Wales alone the cost was £100,000 a year and that some steps must be taken—

Mr. Powell

£100 million.

Mr. Wilkins

Yes, of course. I had a note of £100 million, but I did not notice the last three noughts.

The right hon. Gentleman said that some steps must be taken to recover some of the waste which arises. I think that is what the Minister said.

Mr. Powell

I said that in dealing with so large a sum as that it was the duty of anyone asking this Committee to provide it to ensure that waste in that total was kept to the minimum and the best value obtained for the sum.

Mr. Wilkins

I thank the Minister for elucidating that. I appreciate the point. My general comment on that, the comment I intended to make about it, is that I believe that if the Government had spent one half of their time planning the productive effort of this country, to increase the production of this country rather than see it decline, as we know it has declined by 1 per cent. per head, if they had increased the productive capacity of this country comparable at all with that of the 12 per cent. of the European Common Market countries with whom we are now flirting, we should have had no need whatever to introduce those cuts, no need whatsoever to impose the increase in prescription and dental charges. There would have been no need for that if we had increased the national income.

But this doctrinaire Government, who never seem to see an inch beyond their nose, do not think in terms of this sort. All they think about is ruthless cutting back. We know what happened in 1929. They did precisely the same thing. They have never changed. I do not believe they ever will. It is not in their political nature to change their ideals and policies in this connection.

The Minister of Health is probably one of the keenest brains in the Government, especially when it comes to finance. Look how he used to treat us when he was at the Exchequer. We always used to know that if anything ruthless was to be done about anything they would put up the right hon. Gentleman, then the Financial Secretary, to do it. He has got this keen brain, and I wonder that he himself does not try to compel the Government to think in terms of improving the economic position, improving the productive capacity of this country, so that we could meet the growing charges.

These charges will always go on growing. We must not shut our eyes to the fact. These charges will mount year by year. We shall have to go on increasing charges for prescriptions, dentures, spectacles, and so on, unless we take other steps to reinforce the economy of the country.

Mr. John Hall (Wycombe)

Do I understand from what the hon. Gentleman is saying that if the figure of £100 million, which is now the amount of the drug bill, were to fall as a percentage of the whole and of the national income, we need no longer then be concerned with waste which might be in the net figure, wastage with which my right hon. Friend is very rightly concerned?

Mr. Wilkins

No. I was not suggesting anything of the sort. That was not in my mind at all. I was thinking only of the fact that to meet or partially to meet the drug bill the Minister of Health has increased the prescription charges to 2s. per item. What I said was that if we had increased the productivity capacity of this country at the same speed as we were doing up to 1951 there would have been no need to increase the charges. The Conservative Government allege that the Labour Party is a doctrinaire party, but the Conservative Party is far more doctrinaire than the Labour Party has been over the years.

I think that that is all I shall say, all that I ought to say. There are some things I wanted to say about prescription charges, but I will skip them so that other hon. Members may have a chance to speak. There were some quite important points I believe I could have made on the prescription charges, but I finish with these words to let someone else have a chance to take part in the debate.

7.30 p.m.

Dr. Donald Johnson (Carlisle)

Although this is not exactly the first day in Parliament that we have debated the National Health Service since my right hon. Friend the Minister took up his present office, I hoped that I would have been able to say that it was the first day that we had been able to discuss it without party polemics, but I am afraid that I cannot do so after listening to the speech of the hon. Member for Bristol. South (Mr. Wilkins).

It is, however, the first formal debate that we have had and I think that it would be out of place not to congratulate my right hon. Friend on the grasp and vision he has shown in the past year of the problems of the National Health Service. We welcome, in particular, the direct action he is taking concerning the hospitals and the way in which he is cutting through the jungle of reports of working party committees, Royal Commissions and so forth, which have tended to encumber the scene up to date and which have become somewhat discredited over the past ten years by their lack of constructive suggestion.

As there are many hon. Members who want to speak in this debate and who have only a short time to do so, I shall try to concentrate my remarks on one point and to follow the hon. Member for Willesden, West (Mr. Pavitt) in what he said about general practice. I hope that my right hon. Friend when he has finished his immediate plans for the hospitals will direct his live mind towards the problems of general practice.

We have heard in previous debates—my hon. Friend the Member for Stroud (Mr. Kershaw) referred to it a couple of years ago—of the alleged drop in status of the general practitioner. There is a large element of truth in that and it is no consolation to know that this is not exclusive to this country and is happening in the whole of the democratic world.

In looking at the position of the general practitioner, the first thing that we tend to hear of, and have heard of in recent years, is the legend of the overworked doctor, to which the hon. Member for St. Pancras, North (Mr. K. Robinson) referred in his opening speech. That is something that we have to dispel, to take with a grain of salt, because it is actually belied by the statements of doctors themselves. I recommend my right hon. Friend and also the hon. Member for St. Pancras, North, to read in the issue of 5th July, 1958, of the supplement of the British Medical Journal, an "American Report on the National Health Service", by Professor Gemmill of the University of Pennsylvania. It is typical of the beaver-like reports which we get from Americans when they investigate things.

Professor Gemmill spent a year in this country calling on doctors and asking them and their patients various questions. He took as a sample 372 doctors in 139 practices whose lists had a general average of 2,283 patients, 53 per cent. having fewer than the average and 47 per cent. more, so that it was a very general sample of doctors. He put the following question to them all: "With your present list of patients do you find it easy or difficult, or almost impossible, to give them what you regard as adequate medical care?"

As he said in his article, the answers surprised him, as possibly they will surprise the Committee, for 54.8 per cent. of those doctors said that they found it reasonably easy to manage, 37.8 per cent. said that they found it difficult, and only 3.4 per cent.—a very small percentage indeed—said that they found it almost impossible to do an adequate job.

Going further, Professor Gemmill found that in a considerable number of cases that the answers did not even correspond to the size of the practices. He said that 13 per cent. of the doctors who answered "difficult" had fewer than the average, and in two cases fewer than 1,000 patients, while 18½ per cent. of those who had more than the average replied that it was "reasonably easy". This question of the overwork among doctors is not quite the problem that it is represented to be. In particular, it depends on the idiosyncracy of the doctor how he works his practice, and so on. There are almost as many dif- ferent ways of organising a practice, as there are doctors in practice today.

Whereas we can perhaps dismiss for the sake of the argument the idea that doctors as a whole are an overworked profession, what is a fact today is that their work is, under present conditions, dull, dreary and to a large extent disheartening. It consists not in coping with the difficult and interesting problems of medicine which they have seen in hospitals and have been trained to deal with, but largely in dealing with certificates, repeat prescriptions, specialists' letters and pharmaceutical circulars. I think that I can say with truth that during the time I was in general practice, immediately before I came to this House, a great deal more paper passed through my hands daily than has passed through my hands while I have been a Member of Parliament, and that is really saying something.

It is also beyond doubt that the work of the general practitioner is over-weighted in dealing with minor maladies at the expense of what the doctor feels is his real work, which is tending to drift into the hands of the hospitals. He inevitably has the feeling that his status and his work as a whole are being reduced almost to that of a medical orderly, while circumstances do not allow him under present conditions, particularly in general practices in the towns, to do the work for which he was trained.

The Platt Committee's Report has already been mentioned during the course of the debate and has something to say about this. We have the following position owing to the outstanding lack of integration of the Service which I personally have mentioned previously in these debates. On the one hand, we have the general practitioner very conscious of his deprived position in the respect that I have mentioned, and, on the other, we have the hospitals, short of assistant staff, having to employ staff from overseas and so on. Up to date, except in one or two places—I think that it has been done to a small extent in Birmingham and probably in some of the country districts where integration is much closer—we have had these two problems side by side without any serious attempt to marry them. This is a condemnation of the three divisions of the Service which I and many other hon. Members have talked about in the House. I hope that my right hon. Friend will direct his attention as a matter of urgency towards this particular recommendation of the Pratt Report.

When my right hon. Friend does that, I hope that he will not entirely visualise the position as concentrating the doctors' help as clinical assistants, and so on, as is recommended, in large centralised hospitals. I hope that he will not entirely eliminate the cottage hospitals, which have done such splendid work, even though they may in some respects have to change their function. There is no question that the integration of these small hospitals with the general practitioner, which does not occur in the towns, is responsible for the fact, which we have to face—and I say this as a townsman—that the standard of general practice and doctoring as a whole is considerably better in the country than in the towns.

I hope that my right hon. Friend will still regard the cottage hospitals and the smaller hospitals as places and centres where general practitioners can find a great deal of interesting work without having to travel many miles into the towns. Nowadays, with the use of motor vehicles, distances are not great, but it still eats up a doctor's time if he has to travel twenty or thirty miles to do part of his day's work. Even when it comes to surgery, a well-trained general practitioner can take out an appendix every bit as well as a newly qualified house officer in hospital, who is frequently the man who has to do this type of operation.

Mr. Arthur Holt (Bolton, West)

The hon. Member extols the work of the cottage hospitals. Has he ever had experience of one as a patient?

Dr. Johnson

No, I cannot say that I have, although I have had some acquaintance with them. I am not defending cottage hospitals as places for major surgery. I merely make the plea that they should not be eliminated and that they should be able to carry on in, perhaps, a modified form.

Mr. Holt

Unless I misunderstood the hon. Member, he has been suggesting that the cottage hospitals are better than the hospitals in the towns.

Dr. Johnson

No. I said that the standard of general practice was, on the whole, better in the country than in the town. I am sorry if I gave the wrong impression. Nobody can seriously pretend that cottage hospitals are places for major and complicated surgery. One does not want to see them eliminated entirely, however.

Rather than that, one would like to see health centres—about which we do not talk very much in the House of Commons nowadays; we have rather lost sight of them—extended to the towns, where general practitioners could do more advanced work than they can at present, although not as multiple surgeries. The whole idea of health centres has tended to degenerate. To use health centres as multiple surgeries, with four of five doctors and the patients collected in a joint waiting room is not the proper idea.

In my view, they should be places where general practitioners can do minor surgery and pathological examination and have X-ray and other facilities available which enable them to do a proper standard of work which in so many places today they are quite unable to do, even with the best will in the world. It is towards these ideas that I wish to direct my right hon. Friend's attention.

A great many of our debates this year on the National Health Service have centred around the financial aspect in a rather unconstructive fashion. It is far more to the point if we can look at the points where the financial equilibrium of the service is threatened and if we can see whether in the development of the Service we cannot pay attention to these points.

There are two conspicuous ways in which the financial equilibrium of the Service is threatened. One is the load of elderly people that the Service has to carry. That is not to suggest that we should avoid dealing with the problem, but we have to deal with it by establishing an efficient geriatric service. One has only to go to places, of which Oxford and Winchester are examples, which deal with these problems at an early stage and efficiently to see not only how much better the work is dealt with but how much more economically it is handled.

In talking about the Service, it is the greatest error to think that the spending of money automatically brings efficiency, whereas very often the reverse is the case. This is particularly true in the medical service when dealing with elderly people. If it is possible to get the elderly people at an early stage, to keep them mobile and to nurse them at home, one not only treats them more efficiently but saves a great deal of money.

The second threatening factor is the load of minor illness which the Service has to carry, and which, of course, has to be handled, too. One of the fundamental objects of the Service is that people should be able to come to the doctor at an early stage with minor symptoms to get their illnesses properly diagnosed, in case it is the one case in 500 of cancer or serious heart disease, for example.

There has to be a stage in doing that where the minor illness must be separated from the major illness. One of the faults of the Service—it is a fundamental fault as well as a fault of expenditure—is that this stage of separation between minor and major illness has gone beyond the general practitioner. There are a large number of factors in this. The general practitioner may have the urge from the patient to go to hospital or to see a specialist. He lacks the financial incentive to see his patient too often. A cumulative number of reasons of this kind has tended to pass this stage of segregation from the general practitioner, where it should be and where it always has been traditionally until recent years, on to the hospital. That again is not only inefficient but it is infinitely more expensive.

According to recent figures, the average cost of a single out-patient attendance at hospital is about 17s. 6d., but a general practitioner attends a patient for a whole year for practically that sum. That is the difference in cost between dealing with the minor illness at the general practitioner stage and dealing with it at the hospital stage.

The hon. Member for St. Pancras, North talked about crowded and inefficient out-patient departments, and he was quite right to do so. The reason is the number of people who are being sent to the hospital out-patient departments. The hon. Member talked about the shortage of consultants, and he was quite right. The reason for the shortage is the number of people who are sent to consultants.

One of the cures, as the hon. Member said, is to provide more consultants. The other is to make certain that facilities are provided to enable these people to be dealt with at an early stage. We must give general practitioners facilities in the manner which I have urged. We must also give back to the general practitioner his self-confidence, the incentive and the general verve which he has lost since the beginning of the Health Service and also as a result of factors which have nothing to do with the development of that Service.

I hope that my right hon. Friend will look at these things and also at the method of remuneration of general practitioners. We missed a big chance when the Pilkington Committee was appointed in not giving it the opportunity to pay greater attention to and consider a wider basis for the method of remuneration for general practitioners as well as the actual amount. As is perhaps well known by now, I am a deadly enemy of the capitation fee. I think it is quite the worst possible way of paying doctors. There is an interesting suggestion in the correspondence columns of the British Medical Journal that doctors might be offered an item for service for special work on top of the capitation fee. Unfortunately, my right hon. Friend has only a million £s to play with, at the moment, but I hope that he will direct his attention to these matters.

I was pleased to hear my right hon. Friend talk about the problem of communication between patient and doctor. I congratulate him on the initiative that he has shown in this respect. I talk as a member of the medical profession when I say that there is no question that the profession in this country is too aloof in its attitude towards the patient. One does not always find this elsewhere and it is extraordinary how one finds different manners in the most unexpected places.

We think of the Germans as an authoritarian people, yet during the war, when I was stationed at a hospital in this country where we were dealing with repatriated prisoners, we found that they all said that before German doctors operated or did anything to a patient they always explained everything carefully. It is apparently the custom of German doctors to do that and to draw diagrams and ask the patient's permission to cut this or that bit away.

It is quite different in this country, where one hears stories, not entirely apocryphal, of ladies going into a hospital and losing vital organs before they realise exactly what is happening to them. This aloofness or lack of communication is not the custom of the medical profession as a whole, but it appears to be something of a peculiarity of the profession in this country, and I am glad that my right hon. Friend had something to say on the subject.

I was also glad to hear what he and other hon. Members had to say about mental illness and to think that the mental health revolution about which we have been talking for some years in the House of Commons is at last coming to fruition in the provinces and in places where it really matters that local authorities should be putting it into effect. I hope that my right hon. Friend will give these enthusiastic people, as most of them are, some guidance and show them a model plan of what they are expected to do. A number of them are quite vague on the subject.

In some cases one finds hospitals putting these ideas into effect, in other places local authorities, whilst in other cases little is happening. It would be a good thing if my right hon. Friend could promulgate a model plan showing people what is expected of each body concerned and what can be done by integrated action. Here again we are up against the question of the division of services and it will require intensive leadership from my right hon. Friend before this problem of division is overcome.

I wish again to express the appreciation not only of all hon. Members—because we have had it expressed from hon. Members opposite as well as on this side of the Committee—but of the people of the country as a whole of what my right hon. Friend has done since his inception to his present office.

7.56 p.m.

Mr. Norman Dodds (Erith and Crayford)

As I listened to the Minister's speech I could not help thinking what a remarkable man and personality he is. Over the months he has appeared to me to be a sort of Jekyll and Hyde. I cannot help thinking what a different man he has shown himself to be today from the man who dealt with National Health prescription charges. There was not an atom of humanity in his eyes or in his speech when he dealt with that subject which means so much to the people of this country, but today he presented an entirely different picture. He stood at the Dispatch Box, with his eyes blazing and his arms apart, talking about humanising the hospital service. I liked him better that way and I hope to see him again many times as Minister of Health in that pose.

I think, however, that that beautiful picture was somewhat spoilt when my hon. Friend the Member for Abertillery (Mr. LI. Williams) intervened in the right hon. Gentleman's speech and asked him what powers he had in connection with this wonderful business of communication, of father and mother and relatives being told what was happening to the patient, of in-patients and out-patients being treated as people, and of remembering that the hospitals are there for the patients.

My hon. Friend asked the right hon. Gentleman what powers he had to ensure that these things were introduced into many hospitals which are still a long way short of the picture which he painted. The right hon. Gentleman replied, as we expected, that there were no powers of compulsion. He said that we had no need of them; that we had had committees sitting and publicity had been given to their reports and that, sooner or later, all this would percolate to the backwoods. What hard luck it would be for the Bell or Brown family to hear about Aunt Clara living in a progressive part of the country when their hospital services are in the backwoods.

It is up to the Minister of Health to pool all these ideas and to see that as far as possible they are introduced even in the backwoods. My hon. Friend the Member for Willesden, West (Mr. Pavitt) spoke about the need for some action and a dynamic personality. Is this the response to that appeal? My hon. Friend the Member for St. Pancras, North (Mr. K. Robinson) gave us a good picture of the people who attend some hospitals as out-patients. The doctor's time is valuable, but not that of the patient. He spoke of hospitals introducing an appointments system, but for the benefit of the doctor, not that of the patient.

My hon. Friend spoke of people sitting waiting on hard benches. The benches in this Chamber are hard enough but patients, who are sick people, have to sit on wooden benches. These people are not in full health, as I am. Can we not provide something better for them than wooden benches? My hon. Friend mentioned an instance where each patient has to move up one place as the other is called in by the doctor. He appealed for the introduction of a system of numbers that could be called out so that patients do not wear their trousers out through moving up on wooden benches.

I can tell the Minister that if he is to be humanitarian, he must do a lot more than he did this afternoon. I, for one, shall be watching what happens. There are no party politics in the matter of sick people. The Minister would find in me a supporter if he were trying to carry out the things that he said this afternoon. But we are "fed up" with fine speeches. What we want is some action.

The question of communications has arisen. The noble Lord the Member for Hertford (Lord Balniel) said that it would be a marvellous thing for the father to know what was happening about the mother, and he went so far as to say that he would even have the father present at the birth of his child.

Lord Balniel

I said that the father should have the right if he so wished, but I did not necessarily advocate it.

Mr. Dodds

If the father had the right, that would be good enough; he would be at the birth if he insisted. But he would not be there now because he is not allowed; he can be told to keep out. However, judging by the trembling which I have seen on the part of fathers-to-be, I hardly think that they would be much assistance if present at a birth. I would hesitate about giving a father the right to be present at the birth of his child. Probably the noble Lord knows more about this than I do. I have only two children. Probably the noble Lord speaks from greater experience.

Lord Balniel

I have four children.

Mr. Dodds

There have been references to matters of security and to people being in danger from persons who have suffered from mental illness. The Minister has been asked about Rampton. Will the violent people be sent there, or are they to be in secure places in local hospitals?

There is another aspect of this to be considered. We have to bear in mind the parents of the patient. I know of an old lady who travelled every month for eighteen years from Bristol to Rampton—fourteen hours there and back—just to see her son. This raises the matter of the length of visits. That old lady, travelling for fourteen hours from Bristol to Rampton and back, could see her son for one and a half hours probably once a month. That is where we need some humanity.

The Minister told us that a high-powered committee had said that Rampton, with its 1,200 patients, should be broken up into smaller units so that patients might be within reasonable distance from their homes and their relatives would have an opportunity to see them. The present position is ghastly for 1961. There is a greater need in this respect than there is for a father to be present at the occasional birth of a child. I should like to hear more about what is to happen to Rampton. Not every patient there is violent. I believe that half the patients there are not. The reason why many are there is that they kept running away from their local mental hospital and made themselves a nuisance. Rampton and Moss Side are the only institutions which have the requisite security to prevent such patients from being a nuisance.

We must have regard to the position of parents, most of whom are middle-aged or elderly, who have to travel long distances, year in and year out, to see their sons or daughters who are undergoing, in effect, not a five-year, ten-year or fifteen-year, but an endless sentence. We have to bear in mind the situation of poor parents, including those who have retired and have little money to spare. It sounds good when one talks about getting National Assistance, but one ought to try to get it and find out how difficult it is. We need some more humanity in this respect, and it can easily be provided.

The other day I asked the Minister how many patients up to the latest convenient date had been reclassified under the Sixth Schedule of the new Act as informal patients and haw many of them had subsequently been discharged. The Minister replied that comprehensive statistics would be available only from the end of the six months' transitional period, but he said that a small sample relating to sub-normal patients suggested that rather more than half the patients detained on 1st November last were reclassified as informal. Yet there are tens of thousands of them. The Minister also said that about one in twenty of them had left hospital by the end of April.

I was delighted to hear from the Minister that it was expected that in the near future there would be 50 per cent. fewer beds for the mentally sick. I make no apology for devoting some time to this, because it is a fact that nearly half the hospital beds in Britain for all illnesses are occupied by people who are mentally sick or mentally sub-normal. Consequently, it is one of the most important aspects of the Health Service.

What the Minister told us was wonderful news, but I was staggered to hear him say—I cannot understand it even now, and I should like some further explanation—that the need in respect of the mentally defective and mentally sub-normal is likely to increase. Why? The Minister said that he may need even more beds. I should like to have this cleared up.

Mr. Powell

I said that the future requirement of places in hospital for the sub-normal cannot at present be expected to decrease in the way that the beds for the mentally ill can for the simple reason that the population of the subnormal is continuing to increase as a result of the increase in the expectation of life, and until there is some dramatic medical change, we must make that calculation.

Mr. Dodds

I can understand that, but what about the other more than compensating calculation in respect of the mental defectives or the sub-normal? Before the passing of the new Act, many mentally sick patients were informal patients and could leave at will, but all mental defectives were certified and compulsorily detained. In the mental defective hospitals there have been, and are today, many who have no need to be there. They are not there because they are medical cases. According to evidence placed before the Royal Commission, there are many there because of social rather than medical needs. They could be released if there were homes for them to go to.

There is a mental defective hospital near my home, and there are patients there who for many years have been going out daily and working in the district. Nobody would know that they were different from anybody else in the district. Some of them are earning good wages. But because nobody will give them a home they have to go back at night into the mental hospital. There could be a great clearing out of such people. A large percentage of patients in mental defective hospitals are getting no treatment at all and have not had any for years. They are there simply because they have no place to go to and nobody will have them.

The public would rather have someone from a prison than someone who has been in a mental hospital. Their attitude is that a person who has been in a mental defective hospital may look all right, but one never knows whether, when the moon is full, he may pick up a knife and stick it in one's back. When I had two mental defectives with me for Christmas, two years ago, some neighbours were worried; they were worried that they would get killed—never mind me. That seems to be the general feeling.

The noble Lord raised a very important point. He spoke about the local authorities playing a very big part, and said that their job was to provide hostels and half-way houses for these people rather than that they should have to live in hospitals. They need a bed to go to at night, and probably a warden and his wife to keep an eye on them, deal with their problems and communicate with the hospital if they see some signs that these people need looking after.

The Minister may say that there has been some development. In my inquiries I have talked to many county councillors. I am appalled at the number of county councillors who feel so lightly about the problem. As my hon. Friend said, the money is not there. The block grant system will never get down to that. Many local authorities would like to do this job. I have heard about some money which will be given to them, but let us think of what the Minister could save in other ways and about the human happiness which he could create by doing this. Unless there is dynamic action in providing half-way houses and hostels the whole thing will fail. I feel that that is why he believes that he will need more beds in the hospitals for these people.

I was delighted, two weeks ago, when the right hon. Gentleman was asked a Question about a patient having been let out of hospital. He had my support, and that of many hon. Members, when he said that, in the humanising experience of getting these people back into the community, there would be need to take reasonable risks. He will have to be a brave man, but if he carries this through he will give one of the greatest services a man can give. But in conjunction with this scheme we must have homes for these people.

Reference has been made to educating the public. Most of the newspapers will have to put up a better show than they have been doing, because they can "put the wind up" the public. I will read a few lines from a recent copy of the News of the World, which goes into millions of homes. Speaking of a patient, the Report said: He was automatically given his liberty by the new Act after a lifetime in mental hospitals. It is getting abroad that the new Act will open the floodgates to these people who are turned out into the community. If that idea takes hold, then the people will call those who fought for reforms irresponsible. The Act gives all the necessary protection. No patient over the age of 25 can go out automatically under the Act. There are safeguards, if he is a danger to himself and to others, which allow the doctors to keep him inside. When an incident does occur, someone will have to tell the public of the great successes which have accompanied this scheme.

I conclude on this matter because, too often, hon. Members are not close enough to know of the successes, but they can read in the newspapers about the failures. Some time ago, I asked that, as an experiment, two young men who had been sixteen years in Rampton should be told that their endless sentence could come to an end if they would cooperate with the staff for six months. They would not co-operate—but who would? There seemed no end to their sentence. I was asked to go along and tell them that if they would co-operate for six months there would be a recommendation for transfer to an ordinary hospital near my home so that I could see them. From that time onwards there was a remarkable transformation.

So well did they behave that they were allowed to go out of Rampton four and a half months later. These were the two who spent Christmas at my home. One boy was a good case. He spent his 36th birthday at my home, but there were only six candles on his cake—for the six years he had spent in freedom. He had spent thirty years in institutions. We got him a job in the local "co-op" two weeks later and he became a marvellous craftsman. He not only repaired ladies' shoes, but made miniature sets of shoes as well. In a short while, he was back at home in the bed which his mother, a widow, had kept for him for sixteen years. What joy and happiness there is in that family now. He is now earning between £17 and £20 a week at a plastic factory in Birmingham.

The other boy was not such a good case. He was an only child. From middle age until they were so elderly that they were unable to do so any longer, his mother and father travelled to Rampton to see him. I had my doubts about him, but he wanted a chance for their sake. But when he came out of Rampton and went to another place he kept climbing over the wall and getting drunk. It was to him such a wonderful change from being in Rampton. But, of course, he had to go back there. A year or two ago he would have had to stay there, but there has been a great change, and I pay great tribute to the doctors who have led this change. They are leading the public in this liberalisation, although they get "kicked in the pants". They are brave men who are trying to carry out this plan.

When this young man went back to Rampton for the second time I thought, "That is too bad." However, I asked if he could be given a second chance, and he was. Again, when he was transferred to Darenth Park Hospital, he went over the wall and got drunk, and fell asleep in a bus and was found incapable. I thought that that really was the end, but the medical superintendent decided to give him another chance. He talked to the boy's mother and she said that the boy would be happy if he could only come home. She said that his father and she would look after him.

Dr. Tucker, of Darenth Park, took the risk and found a winner. The chap is happy and he has a job. He earns £10 4s. a week at his work in Battersea. He gets up at 5.30 a.m. and makes a cup of tea for his mother before he goes to work. He often walks to work. He goes home in the evenings, and puts on his bedroom slippers and after dinner plays cards with his parents and then plays his accordion before going to bed. He is a model example and the happiness of his parents is quite remarkable.

Let us set all this happiness against the mistakes which happen on the other side. Let us count up the balance sheet, and I have no doubt that we will find that great work has been done, and that the right hon. Gentleman, whatever his faults, can go down into history as a great humanitarian. I wish him well.

8.16 p.m.

Mr. T. L. Iremonger (Ilford, North)

I am glad to follow the hon. Member for Erith and Crayford (Mr. Dodds), because I think that the whole Committee admires his doggedness and enthusiasm. He may sometimes be wrong, but he is often stimulating and he has put his finger on an extremely important point, on which I shall comment later. I found that part of his speech much more stimulating and worth following than his conscientious flogging of the dead horse of the prescription charges.

I do not intend to pursue this, but all too often I notice that hon. Members opposite—many of them making thoughtful and interesting speeches—suddenly think, "We must get in something about prescription charges", and go through their notes to read out statements which they hope will appear in their local papers to show that they are really ardent opponents of the Government. But, with respect to them, this does not cut any ice. All that water has gone over the dam. It is much more important to follow the example set in the latter part of the speech of the hon. Member for St. Pancras, North (Mr. K. Robinson) and to concentrate on the National Health Service today.

Perhaps this is not a bad day for the Committee to be considering the Service. It is no small tribute to the Service that the most highly paid and highly regarded artists of the Socialist fatherland should come here and spend most of their time at the dentist's getting new teeth. We can take some gratification from the fact that Russian dancers think that our National Health Service is so splendid that they have the repairs of a lifetime done to their teeth.

Mr. Denis Howell

Will the hon. Member take the comparison a little further? It is true that visitors from the Soviet Union flock to the dentist's to have free treatment, but so do visitors from the United States.

Mr. Iremonger

The treatment is much better than in Russia and cheaper than in the United States.

I want to direct the attention of the Committee to one part of the National Health Service, mental health. There are in my constituency two of the very best mental hospitals, Claybury and Goodmayes. I was a member of the Standing Committee which considered the Mental Health Act which has revolutionised our approach to mental health. We have an enormous responsibility for how it works out, especially those of us who were members of that Standing Committee. I want to raise four points.

First, about staffing. Leaving aside the whole question of problems in connection with the shortages of psychiatrists and psychiatric nurses and psychiatric social workers and psychotherapists, from time to time I am approached by deputations from my local branch of the Confederation of Health Service Employees, asking for my support in obtaining more pay for psychiatric nurses.

I always tell them that it is a matter for negotiation through the Whitley Council. Then they always tell me that the Whitley Council which considers their claims is constituted in favour of other branches of the nursing profession and that psychiatric nurses are left at a disadvantage. I then always tell them that the constitution of the various committees of the Whitley Council are such that it is possible to change their constitution, and there the discussion usually peters out.

I still feel at the end of the day that is a little unsatisfactory and I think that those hon. Members have been right who have suggested that among Health Service employees generally there is a fundamental lack of confidence in the Whitley machinery. That is regrettable and I am not sure whether it is avoidable. Has the Minister received responsible representations expressing dissatisfaction about the Whitley machinery, especially as it affects mental hospitals, or is it merely that any section of any profession always feels that any negotiating body is loaded in favour of some other section of that profession? Is there real justification for the C.O.H.S.E. grievance, or is it merely that it represents so many non-nursing staff that it adopts a rather belligerent attitude which those nursing members or members who do not belong to C.O.H.S.E. do not wholly support? I do not know and it would be interesting to have the Minister's views.

Perhaps the best test is the relative shortage of psychiatric nurses as compared with the shortage of nurses in other branches of the profession. It would be enlightening to have some indication of how serious the position is. I think that it was the hon. Member for Willesden, West (Mr. Pavitt) who said that morale among mental nurses was very low. I think that he is right and wrong.

From my friends in the psychiatric nursing profession I do not get the impression that morale is low in the sense that they have a low feeling about the importance of their calling, or its worth-whileness, but I do get the impression that morale is low in that they feel that they are not properly rewarded and that the structure of the Service is somehow out of gear. That is extremely unfortunate and perhaps my right hon. Friend will be able to bring to bear some of his talent for communication, as he called it, in this sphere.

Secondly, can my right hon. Friend give us a rather more precise assessment of the progress being made by local authorities in planning to discharge their new functions under the Mental Health Act? Broadly speaking, the main theme of the Act was to get mental patients out of hospital and into the community, in suitable circumstances and subject to arrangements being made for their care.

The local authorities were the instruments chosen to make those arrangements, and the main point on which the Standing Committee which considered the Bill was divided was on whether it could properly be left to local authorities to make those arrangements, upon which the working of the Act depended, or whether it should be mandatory upon them to do so.

In the end, a compromise was reached. My right hon. Friend's predecessor preferred not to make it mandatory in the Act, but he issued an administrative directive requiring action by local authorities, and he called for reports from local authorities to inform him exactly what each proposed to do and how and when.

We are now at the stage when we should be taking stock of the progress and asking exactly how we are getting on. From the information given from the Dispatch Box, I found it difficult to get a sharp picture of what the progress was. Is my right hon. Friend satisfied with the reports that he is getting from local authorities? What pace of progress is envisaged by the best authorities, and what by the least responsive and least satisfactory? How much pioneering is going on? To what extent do smaller authorities expect to share these services among themselves? It may be that some authorities will find that some of what is required is beyond their resources, and that in any case they would not be able to supply the clients, as it were. Is it not possible that smaller county boroughs will find it convenient to pool their resources? Is that being done?

Can my right hon. Friend tell us when and where we shall see the actual functioning of a sort of prototype hostel and training centre and how soon it will be possible to say that this is the sort of operation which we can regard as obviously successful, so that it could then be adopted elsewhere? What are the limiting factors? Is shortage of staff one of them? Are authorities finding difficulty about getting loan sanctions? Are they expecting financial difficulties arising out of the method of financing local government, the block grant about which hon. Members opposite do not agree? Personally, I am inclined to doubt that now.

Mr. Denis Howell

Oh.

Mr. Iremonger

It is all very well to say "Oh", but I said that it was my personal opinion. I give this to hon. Members opposite—I am not sure that in the long run, with the expansion of the social services which is to come, the rating system will be able to stand the burden. I am all for the burden being met locally, but I am not sure that we can meet it locally while we have a rating system. But that is a fundamental difference of approach and I do not think that the method of local government finance is what is holding us up yet. Can my right hon. Friend hazard a date on which he will be able to say that the Mental Health Act, 1959, is now being worked in England and Wales broadly speaking as we envisaged it when it was conceived? To a very large extent that will depend on the performances of the local authorities.

The third point I wish to make—I am sorry to be burdening my right hon. Friend with this but he is quick of hearing and at writing—concerns the major revolutionary innovation in the Mental Health Act, the introduction into the field of mental health of the patient suffering from psychopathic disorder who is now liable to compulsory detention provided that his condition requires it and he is susceptible to medical treatment—which begs the whole question. We recognised that these patients would be hard to accommodate within the tolerance of the National Health Service. We recognised that no hospital would want them and that they would be universal pariahs.

The Committee will have noted the setting up by my right hon. Friend of the working party on special hospitals—Broadmoor, Rampton, Moss Side and so on—and no doubt hon. Members have studied its recommendations. I am sure the Committee would like to hear something from my right hon. Friend about whether he accepts the approach and recommendations of the working party and what sort of progress he envisages in the setting up regionally of diagnostic and treatment centres. If this is not an unfair question to raise—perhaps it is too much to ask my right hon. Friend to answer it—I wonder what is the extent of the liaison between my right hon. Friend's Department and the National Health Service as a whole, on the one hand, and the Home Secretary and the Home Office, on the other, in connection with the proposed psychiatric prison at Grendon Underwood.

The working party on special hospitals suggests that there is a mere academic distinction between a psychopath whose behaviour has brought him before the court and one whose behaviour, though precisely of the same nature, has not. It suggests for both that the degree of security should be the same and for both the treatment will be equally questionable and difficult and equally likely to be the same. Therefore one might ask why should one secure diagnostic treatment centre be called a psychiatric prison and another one a diagnostic treatment centre, when the only difference between the patients, clients or inmates is that one lot of them have broken the "eleventh Commandment" as well as all the others. In the conception of the psychiatric prison the classification of the psychopath as being detainable outside prison was not envisaged at all. Perhaps this ought to be thought about again. Perhaps it might be well to put the thought into the minds of the Government.

I wonder how far the courts are being served by the facilities which already exist. The hon. Member for St. Pancras, North, raised this point and I shall not elaborate it further. But one cannot help feeling that it must be very difficult for a court, which feels, or is advised, that an offender is suffering from a psychopathic disorder, to make the right order for him, if it feels that it cannot get him medically treated. The result is very much worse for the public because if an offender suffering from a psychopathic disorder is sent to prison, he comes out soon. If he is sent to a psychiatric hospital for treatment, he may never come out. He can be kept even over the age of 25 if his condition does not warrant him coming out. So from the point of view of security, it is an important point.

My final point, which is perhaps the most important of all, relates to security. Reference was first made to this by my hon. Friend the Member for Hertford (Lord Balniel) and it was also mentioned by the hon. Member for Erith and Cray-ford (Mr. Dodds). It is my submission that the whole purpose of the Mental Health Act is in jeopardy at the present time through a possible lack of public confidence. I should like to read to the Committee a letter which reached me a few days ago. My correspondent writes: I hope I may say how glad I was to see that you had asked a question in the House some ten days ago about the number of discharged or imperfectly diagnosed psychiatric patients who have committed murders in recent months. It is so exactly what I have prophesied would happen that it is quite uncanny! These disasters were inevitable once this extraordinary revulsion against institutional care irrespective of the mental state or needs of the patient began to sweep the country. What I am writing to you to point out is that the Press and the societies concerned with mental health are quite definitely concealing the true facts. A lady very prominent and influential in this campaign said to me quite seriously that the truth should not be made known as it would be deplorable to do anything to discourage medical superintendents from discharging patients! People like many I could name literally do not care how many wretched victims are murdered or how many families are broken up so long as their fanatical craze for emptying the mental hospitals is gratified. This correspondent mentions at least four cases of discharged mental patients who have committed violent crimes of a most objectionable nature, of which hon. Members in this Committee are well aware. The letter expresses the misgivings of thousands of humble, obscure and inarticulate constituents of mine but the point is that the writer is not by any means an uninformed or obscure person. In fact the writer is not a constituent of mine. The writer, whose name I shall not mention although I have permission to mention it, is a medical doctor, renowned and highly respected, and a past President of the Medico-Legal Society.

It is a great pity that the whole purpose of the Act should be put in jeopardy because of ill-considered medical decisions in the reclassification of patients. I stand by the Act and accept responsibility for it. I am proud of it. I do not want to see it discredited. I want our doctors in the mental health field to follow their current, wise, humane and constructive policy, and to continue to restore life and hope and purpose to their patients, but I implore my right hon. Friend to impress on these people that we conceived this Act with a twin duty in mind—a duty to the patient and also a duty to protect the public, especially little children and women to whom we owe the maximum possible protection.

The medical profession must be sensitive to this or the public will say, "If this is the price of our compassion and co-operation, we would rather not give it, and we curse and renounce those who forced this Act upon us". I for my part would regard that as a tragedy. I hope, therefore, that those concerned with mental health will be warned, whilst being mindful of their patients, not to forget the rest of the community.

8.37 p.m.

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

This has been a most interesting debate. I am very sorry that men of influence and power in the United States were not able to be here to listen to it for, as many hon. Members have mentioned, there is a growing interest in the United States in the need for a health service of some type which will give comfort and succour to those who need it most in that great continent. Had they been here to listen to us, knowing what they have felt about our Health Service in the past, they would have been as amazed as I have been to note the chancre that has occurred in this honourable House as the years have gone by since this piece of Socialist legislation was brought forward.

I am sorry that the hon. Member for Carlisle (Dr. D. Johnson) is not now in his seat. I understand why he has left the Chamber. He has sat here, as I have done, virtually all day long, perhaps a little longer because I went out to eat. He has now gone out to do so and he has every right to do so. He and I have spoken on these matters in debates in recent years. Before he came to this House I remember once debating against him in Rugby. I noticed with very great pleasure today how much he has changed tin his views, for we heard from him of the need to establish health centres in every city in the country.

The hon. Member defined what he felt a health centre should be like, and it was exactly as we intended it to be when the original Bill was introduced in the House. The hon. Gentleman pleaded for health centres. He told us that in this way men would have greater interest in their patients; they would not wish to transfer them unnecessarily from their care, their own education would be improved and they would do better work than they do now working in isolation. We agree with all of this.

Another fascinating thing, which was so agreeable to my hon. Friends and I, was to hear the present Minister speak in terms of comprehensive and long-term planning for the whole Service. To have a Tory Minister preach planning to us and to have hon. Members opposite as the long years have passed speak with the same mind and voice as we did in 1946 and previously is pleasurable to us. If the House of Commons is thus joined together who am I not to say, "So be it"? I wish everybody in the world would listen to us and realise that this piece of Socialist planning has not failed but has won adherents, some of whom I admit are still rather lukewarm, on all parts of the benches opposite, including the Minister. By speaking like this I am paying the right hon. Gentleman the highest possible tribute. When men become converted to a good Socialist principle and accept it, I do not care what they call themselves so long as the principle is carried out.

I want to speak briefly about the things which will help the Minister and the Service from the long-term point of view. The Minister told us that he expects with some confidence that in about fifteen years' time he will need only about half the number of beds in mental hospitals that he has available today. I am speaking now of the general service and not of that part dealing with the sub-normal mental conditions. I hope that the Minister is right. I am fairly sure that he is right. I ask him to direct his attention to the possibility that the life sciences, the biological sciences, may well get a break-through in the next ten, fifteen or twenty years, comparable to the break-through achieved by the physicists in recent years. If that should happen, we can look forward equally to the emptying of beds in general hospitals.

I am sure that we must. We are only beginning to understand what fundamental science, well worked out and well applied, can do for humanity. If the life sciences are well supported and if there is such a break-through, we should be able, as a very great scientist said to me in the House of Commons last Friday, to influence life in the cell itself and in the germ plasm itself and thus remedy genetic faults. The scientist spoke to me as the originator—the discoverer—of insulin, together with Banting. He spoke to me of the possibility within fifty years of interfering in the cell itself so that genetic faults can be remedied and we shall not have to have mere substitutional therapy like the taking of insulin, but shall be able to cure the child before it is born.

This is going off into the stratosphere, but who, twenty or thirty years ago, would have dared to think that we should be closing down our sanatoria at the rate we have been doing in the last few years? They are being closed down because of the work scientists have been able to do in providing antibiotics and chemical drugs which allow us to do, for instance, all that has been done on behalf of the tubercular.

Therefore, we should look upon the future of the Service not only as a curative service but in real terms of prevention. If we look upon it in that light, we must give every assistance to the man who today is in the front line of defence but who ought to be in the front line of attack, namely, the family doctor, the general practitioner. As I have already said, he will not do this working alone in isolation in his own surgery, with no one to consult and no one to talk to, and with every temptation to get rid of difficult cases by shifting them on to the hospital.

The right hon. Gentleman should also bear in mind that anything he can do to foster fundamental medical research, applied research and clinical trials through the very great instrument that he has at his disposal, the Medical Research Council, is bound to be of the very greatest value to the Service and, ultimately, prove most economical.

The Medical Research Council has proved conclusively that its views and opinions, as a result of the care it gives to research and clinical trials when it tests and evaluates the new drugs that are pouring out and which are at the service of everyone, are such that the whole world will pay it respect and tribute. It is as reliable as any section of research workers in the world—indeed, I would say that, by and large, it is the most reliable. The Minister will therefore be doing only his duty if he listens most carefully to the Council and gives it—as I am sure he would say that he does—the very fullest support. I should like to have talked further on this point, but it might be going rather wide of the debate.

Having listened to the fascinating speech of my hon. Friend the Member for St. Pancras, North (Mr. K. Robinson) on the problem of humanising the Service, and having heard the Minister himself wholeheartedly endorse what my hon. Friend said, perhaps as a former practitioner I may be allowed to say how important that is. From the time that they are students, and ever afterwards, there is a tendency on the part of medical men when walking the wards and working in hospitals to take for granted the environment in which they were trained and not to regard it with the eyes and attitude of the patient.

The attitude of the medical student, of the physician and the surgeon is quite different from that of the Service's consumer—the patient. I think that the hon. and gallant Member for Ripon (Sir M. Stoddart-Scott) would agree that it is tremendously useful for a doctor to be a patient in a hospital. He can take advantage of being in an open ward and really learn what it means from both sides. It is an interesting experience, and one that I have had twice.

There is so much that can be done, but which never will be done unless an attack is made on the problem fairly quickly. All the things of which the Minister and my hon. Friend the Member for St. Pancras, North spoke are simply matters of good sense and a little forethought. It is a question of bringing in the experts. The expert on noise will see that doors do not crash when they close—such an easy matter. If lifts make a horrible noise they should be pulled out and modern ones put in. Trolleys should not go bang, bang, bang along the floors. They should have pneumatic tyres and be fitted with ball-bearings so that they cannot be heard. Hospital porters ought to be taught not to shout at the top of their voices first thing in the morning, or late at night.

These are all simple, small matters that can be so easily rectified. One notices them when lying in hospital, especially in an open ward where there are thirty beds. The open ward is an anachronism, if ever there was one. It is a shocking thing, because to go to hospital is a crisis not only for the patient, if he is very sick, but very often for the family, too.

It is not a very good thing to have to lie in a bed of pain and have to be drugged at night because one would not sleep because of the noise if one were not drugged. It is intolerable that we should still put up with conditions such as that today. To be awakened in the morning with a bed pan is an abomination of desolation. People, especially men, are so shy that they can make themselves ill because they cannot properly function under those conditions.

We know that plans are available and that in the new hospitals this sort of thing will be remedied. There has been very little priority given to hospital building since the war. Now, we are told, building will take place, and I am sure that whatever plans are available the things about which I have been complaining will not occur ultimately in the future.

The Parliamentary Secretary and her right hon. Friend the Minister should bear in mind that they have, as it were, assistance at their disposal for saving mankind much pain and suffering if they will themselves take an interest and assist in what I will call the adjuvants and accessories of medicine. If we had a nutritional policy of an optimum nature, and knew what that really was in this country, it is possible that many forms of preventable diseases from which we now suffer would soon disappear. I have in mind diseases like gall bladder infection, stones in the gall bladder, possibly arterial degenerations. I do not say any of this with certainty, but it is possible that these will disappear from our community.

I notice that in the Chester Beatty Research Institute's annual report for 1960, mention is made of carcinogenesis or cancer tendency, with a sentence or two describing how their work on nutrition is a promising line and leads them to believe that they might be on to something more than promising and that in the coming year emphasis will be placed on the nutritional aspects of preventing carcinogenesis.

We are living in an exciting age. It is a time when almost anything is possible if mankind does not destroy itself. Given fifty years of peace and enough money—and peace itself would contribute a vast amount of money to all the powers of the world—and the vast number of scientists now engaged solely in defence, we could say with confidence that the quality of our Health Service today, of which we boast and say is as good as any in the world, would appear as only the beginning of what we could achieve in the future, when it could become a creative service, preventing disease and teaching man how to live in the way that he should live.

8.54 p.m.

Mr. Percy Browne (Torrington)

I have always welcomed the opportunity of listening to and following speeches made by the hon. Gentleman the Member for Stoke-on-Trent, Central (Dr. Stross). It makes a mockery of a debate to say at the beginning of one's speech "I hope that the hon. Gentleman will forgive me if I do not follow him" but, owing to the time factor, and seeing that I must sit down at nine o'clock, I must say, for the first time, exactly that.

I understand that the hon. Gentleman the Member for Greenwich (Mr. Marsh), who will wind up the debate, will say something about the Whitley Council. That is the subject to which I shall address my remarks. Whatever the Government does, and whatever this House may recommend or do, the Health Service stands or falls by the skill of the consultants, surgeons and general practitioners who are the hub of the wheel of the Service, and by the skill and devotion of the people in the ancillary services.

If we want people of the right quality to come forward in the numbers we need, then, I suggest, those who do come forward should have better pay and conditions. We want people able to take responsibility. We want people with ability. Sufficient encouragement should be given to these skilled people to stay in their posts. Setting aside consultants for the moment, the men and women who are doctors and nurses are paid a rate for the job, yet there does not seem to be any system whereby anyone is paid a better rate for doing the job better. This problem is not confined to the National Health Service, of course. It is to be found in any non-competitive profession.

I will illustrate the point by saying that a midwifery sister can, after seven years, earn a maximum salary of £872. That is the limit. If she wants to go on, she probably has to become a matron and her skill may well be lost to the profession. That is not to say that some people must not go on, but, equally, it does not follow necessarily that a back bencher makes a good Minister.

Again, to illustrate the point, in my part of the country the North Devon Hospital Management Committee conducted an inquiry to find out how many of its registered midwives were practising. It found that, of the 40, 16 were practising and four, for various domestic reasons, were not. The remaining 20 had moved into the higher realms of nursing and were, therefore, lost to a particularly scarce profession.

Consultants have a merit award. They recognise the problem. General practitioners have tried to find some way of rewarding skill. As far as I can gather, no attempt at all has been made in the ancillary services, with the result that a sister in charge of 12 patients in a convalescent ward draws exactly the same money as a sister in charge of an acute surgical ward with, let us say, 30 beds.

There should be a differential. There should be some sort of "responsibility allowance." It is surely not beyond the ingenuity of either the Whitley Council or the Minister to create a guild of master craftsmen. Perhaps that is not the right expression to use, but it serves to illustrate the point I make. In some way, there should be an opportunity for a skilled person to earn an extra reward instead of seeing his or her limit reached at the end of so many years.

I should have liked to mention the anomalies to be found in the present rates of salary in the nursing services. I have nothing against a health visitor, but, if one sets her salary, which is, I think, £872 at the maximum, against some of the salaries paid to hospital sisters or to midwives, who are district nurses-cum-health visitors, it seems very strange that the health visitor should be paid so much.

I congratulate my right hon. Friend on his attack on the drug firms, a thing about which I have been particularly keen, and upon the wind of continental competition he has allowed to blow through the industry. I hope that the President of the Board of Trade will take note of what he has done.

My right hon. Friend has his priorities right. He is now trying to cut out waste and concentrate our resources on bricks and mortar and equipment. I suggest that there are two further essentials. The first I have mentioned, better pay and conditions and what I have called a guild of master craftsmen or some system for special remuneration for skill and/or responsibility. The second is an inquiry into the method of financing the Health Service in the future both in fairness to the contributor and so that the Service shall continually be improved for the benefit of all who use it.

9.0 p.m.

Mr. Richard Marsh (Greenwich)

The speech of the hon. Member for Torrington (Mr. P. Browne) was typical of a number of speeches that we have heard in this debate from hon. Members opposite. There was little in what he said with which many of us on this side would find ourselves in any great degree of disagreement. There have been times today when listening to the speeches of hon. Members opposite was rather like being at a Labour Party conference during a discussion on the National Health Service: hon. Members opposite believe in the same things as those in which we believe. The hon. Member for Torrington says that there is something of a crisis in the National Health Service concerning staff and staff salaries. We have heard hon. Members opposite speak of the need for the introduction of an occupational health service. We are not at issue on this. We agree with hon. Members opposite all the way.

The hon. Member for Carlisle (Dr. D. Johnson) drew attention to the need for the establishment of health centres if the Health Service is ever to be a comprehensive service. There must be something wrong somewhere, because we have hon. Members opposite fighting for and believing passionately in these things, but no one trying to help them to achieve them. I cannot help wondering whether it is cynical or whether something has gone wrong somewhere that hon. Members opposite make speeches in support of the things in which we believe after elections but never make similar speeches before elections. If during the last General Election campaign members of the Conservative Party had demanded more health centres, if hon. Members opposite had made speeches in their constituencies calling on the Government to introduce without delay an occupational health service, the result of the General Election might have given them even a bigger majority. There would have been only one flaw—they would then have had to do something about it.

It is asking too much that the Opposition should be fighting year in and year out for certain policies within the Health Service and occasionally pressing issues to debate and Division but never getting hon. Members opposite to support us—or very seldom. We know that they are with us in spirit and that it is only the fact that their feet are not going in the right direction which prevents them from supporting us.

We heard from the Minister some of the points in favour of paying more attention to human relationships in the Health Service. This is a very important issue. It is unfortunate, however, that some of the major points seem to be missed. We all agree with the Minister that there is a need to cut down unnecessary noise in hospitals. We agree that one of the big problems with the sick is that they cannot rest because of the perpetual noise. While it is true that much of this can be avoided merely by persuading nurses on night duty to wear flat-heeled shoes and by having wirelesses at a lower level or special types of wireless receiver, a great deal more would be avoided if employing authorities and hospital management committees had sufficient funds to carry out the structural alterations to enable noise to be abated.

We have heard about delays in outpatient departments. My hon. Friend the Member for Erith and Crayford (Mr. Dodds) painted a terrifying picture of people sitting on hard, wooden benches.

This is not only a problem of discomfort to the sick and to patients. It is a cost to this country of millions of pounds each year on people who could be at work but who spend their time sitting in hospital out-patient departments waiting for treatment which could be provided much quicker if it were properly organised. It is not fair to blame the organising staffs or the administrations. We cannot have an effective out-patient appointments system unless there is a staff to operate it. One of the big problems is a short-age of medical records officers. It is difficult to obtain and to train people for this job.

It is no good the Minister coming to the Box and saying, "I want all these things. We all believe in less noise and better appointments systems in outpatient departments, but if anybody wants any money to enable us to achieve those difficult things, we will deal with them at some other stage."

My hon. Friend the Member for Erith and Crayford voiced what was in the minds of many hon. Members on this side of the Committee. He said that he could not understand this changed Minister of Health who addressed us this afternoon. This was a different man from the one who had introduced the charges on the Health Service. Here was a man who was saying things that were deeply human, with which we all agreed. Many people have been intrigued by this Jekyll and Hyde personality which the Minister exhibits from time to time.

The answer is simple. The right hon. Gentleman has a human approach to the problems of individuals. He has some progressive ideas and is sympathetic—provided that none of these things costs the Exchequer anything. We cannot have an effective Health Service, however, unless we are prepared to give it priority in terms of its calls upon the nation's wealth.

The Minister does not act as a Minister of Health. I do not think he realises that his prime purpose is the growth and extension of the Health Service. It is no secret that the right hon. Gentleman was introduced to his office as a Treasury Minister to curb the expenditure upon the Health Service. When he speaks as a Minister as distinct from a man, he speaks as a Treasury Minister whose prime concern is to cut the costs in this essential service.

I should like now to refer to the occupational health services, which several hon. Members have mentioned, and the admirable report recently published by the British Medical Association. The Health Service has to be comprehensive. It was a great disappointment during the latter part of the war years that ill health should not at any time receive the very best treatment that science could provide for it, that no person should be unnecessarily sick and that no person should suffer any lack of treatment that could be provided. For that reason, we wanted not simply a hospital service and not merely a series of services hung together; we wanted a complete, all-embracing, comprehensive service covering every person, wherever he was and whatever he was doing. We can never provide that, and we can never say that we have achieved the objective, until the National Health Service contains an effective industrial health service and until there is provision for the worker at his work.

The hon. Member for Bristol, West (Mr. Robert Cooke), speaking from the Government benches, spoke in favour of an occupational health service, but when one of my hon. Friends pressed him about the matter he added one or two qualifications. The hon. Member considered the idea a good one and he was asking the Minister to consider it. I have no doubt that the Minister will consider a lot of things. One of the troubles very often is that he says "No" when he has considered them. We on this side make no qualification at all: an industrial occupational health service is essential.

Less than one in three of the people are covered by any legislation in terms of health and welfare at their place of employment. A service such as this should be concerned primarily with a field of medicine which has been very much neglected—preventive medicine. We spend a little too much time talking about curing complaints from which large sections of the population should never suffer because, frequently, they can be prevented. Therefore, I should like to see an industrial occupational health service which concerned itself with preventive medicine.

In purely economic terms, the time lost through industrial accidents is infinitely greater than the time lost through strikes. The cost to the economy of this sort of problem is fantastic. In addition, there is need for a link between the workplace and the hospital. A man who is absent from work because of serious illness or accident should have contact between the hospital and his workplace, so that he may be reintegrated into his former employment. Hon. Members opposite who support what we support in this field miss one point. There is only one thing that prevents them having an occupational health service and that is their Government and their own Front Bench. No one on this side of the Committee will oppose them or place any obstacle in their way.

I want primarily to deal with a rather particular field that we have not often discussed in the past and which it would probably be bad if we discussed too frequently. None the less, I think that we have reached a stage in the National Health Service when we must pause to consider the position of staff employment within the Service and the general standard of the staffing of the Service. The hon. Member for Torrington and other hon. Members on both sides of the Committee have been made very much aware that, whether they agree or disagree with the criticisms, there is a lot of criticism being made by the staff within the Service and a lot of problems which arise from shortage of staff and the inability to get the right type of employee.

The Minister in the course of his duties has been called many things. I cannot list them because you, Mr. MacPherson, would not allow me to, but he appears in many different guises. We have seen him as the ice-cold intellectual, a sort of poor man's Roy Harrod, as the ruthless administrator, more recently known as "two-bob Powell", the terror of the sick. But it is often forgotten that one of his most important functions is that he is in fact one of the biggest employers of labour in this country.

Over 500,000 people are engaged within the National Health Service. In the salary levels there is an enormous range from £350 a year to £4,000 or £5,000 a year. There is almost every conceivable occupation. Too often people think of the Service as being concerned only with doctors and nurses. These are important people, they are good people, but the Service is dependent upon hundreds of different occupations, every one of which is essential to the running of the Service. There are butchers, laundry staff, shoemakers, scientists and labourers. There is virtually no limit to the type of people employed.

There are hundreds of different occupations, different social levels and different salary levels, and the only thing in common is that all are working in their different ways to the best of their ability to alleviate suffering. That is an aim which it would be difficult to improve upon. Their contribution to the nation is enormous. Quite apart from the social considerations, which never carry quite the same amount of weight on the other side of the Committee as they do on this side, the Service makes a major contribution to the nation's economic wellbeing and, if it were properly staffed and able to do as much as it should, it would make a much greater contribution.

My hon. Friend the Member for Nottingham, North (Mr. Whitlock) and other hon. Members have mentioned the emphasis that has been placed on strikes. We should never forget that more time is lost from rheumatic complaints or every time there is an epidemic of Asian flu than is ever lost by strikes. Attacks on the Service do as much damage to the economy of this country as irresponsible strike action. The party opposite is so selective in its condemnation of the people who are affecting the national economy. We hear them talk about the irresponsible strikes of labour but we seldom hear many of them who have the courage to attack both sides. These attacks on the Health Service are certainly no less irresponsible in their effect on the national economy.

The Service contributes an enormous amount to the prestige of the nation. We have all heard of recent events—we have got Major Gagarin with us nowadays—which may be matters for pride, but there was never an advance in rocketry, and there never will be, which engendered or will engender in the nation the pride which the establishment of the National Health Service in this country engendered in our people—[An HON. MEMBER: "And the world."]—and it was the finest National Health Service in the world. I say "it was", in the past tense.

For all those reasons, the staff are entitled to good salaries and it is essential that they should have good salaries, because the organisation cannot be efficient unless it is able to attract sufficient people of the right calibre. On this side of the Committee our case is that the policies of the Government in so far as they relate to staffing are fast turning the National Health Service into an industrial slum.

This organisation which has this enormous moral appeal to people has no economic appeal to them at all today. There are widespread discontent and serious shortages in many sections of employment in the Service. Hon. Gentlemen opposite from time to time talk about the control of immigration. If immigration were controlled the National Health Service might not continue, because it is a Service which cannot attract English people to work in it in sufficient numbers. I have shown before recruiting leaflets from my own union—in Polish, in Germany, in Spanish, in Hungarian, in Italian, because the people cannot speak English. I only hope that the Minister never finds himself on an operating table in an operating theatre where the people cannot speak English. He might find it inconvenient as well as undesirable. All this obviously is bound to have and has had a serious effect upon the service which can be provided to the patient.

There has been a fantastic rate of turnover in the Service. In one large teaching hospital alone in the London area there was an establishment for 88 domestics. Last year it took on 91, a turnover of 106 per cent. In the laundry there was an establishment of 25; it took on 39 staff, a turnover of 156 per cent. in one year. I do not know what hon. Members opposite who have responsibilities in industry would feel if this were the turnover in their own industries. I do not know whether they would consider this something to be looked at with complacency. For waitresses and domestics in the kitchen there was an establishment of 20; it employed 64; 320 per cent. turnover in one year, in an essential London teaching hospital. For porters—a humble grade, but an essential one in the National Health Service—there was an establishment of 23; it employed 79; a total turnover of 344 per cent. in one year.

Do we really have to make a particularly detailed case to argue that there is need for some inquiry into what is wrong in this Service? I suggest that turnovers of this kind are excessive and that they are indicative of something which is seriously wrong.

There is also the complete breakdown of confidence in the whole of the Whitley machine. There are disgracefully low rates of pay and there is a considerable amount of incompetence on the part of the Minister's administration in dealing with staff questions. Dissatisfaction with the Whitley Councils exists among all sections of staff in the National Health Service, among all Staff Side organisations, and among employing organisations, the hospital management committees. There has always been a suspicion that the real decisions in negotiations were taken by the Treasury and loft by the people with whom the staff were talking, and in 1957 they had proof. The staff reached agreement with the Management Side on a salary increase, a freely entered into agreement, and then the Minister of Health said, "Sorry, you are not going to get it." We have heard a lot in this Chamber and we have heard a lot elsewhere about the sanctity of agreements and the need for respecting them, and there is a lot of truth in that. If that agreement had not been thrown overboard in that way the dissatisfaction which exists today might perhaps have not been so strong, but from that day forward confidence in this machinery as a negotiating body vanished.

Another factor which made it worse was the repeal of the Industrial Disputes Order in 1958. There is no built-in arbitration machinery in the National Health Service, and with the repeal of the Industrial Disputes Order the staff can go to arbitration only by the agreement of the management side. That agreement is often withheld by the Minister. The staff cannot go to arbitration now, because the Minister would not let them go to arbitration on many issues. There was a case not long ago in the national blood transfusion service, a key service where the staff tried everything in their power to settle a dispute peacefully. They wanted to go to arbitration. They were refused arbitration by the Minister of Health and it was only because of the hard work of union officials and the loyalty of the staff concerned that there was not a strike in a key section of the Health Service. But what right has an employer to expect men to refrain from using the ultimate weapon if he denies them reference to arbitration?

An employee can go to a local committee and, if that fails to agree, to a national committee. But if the national committee fails to agree, the matter cannot now go to arbitration. That employee goes back to work having been to committees each of which tells him that he has a good case but the committee cannot agree on the outcome. During the rest of his working life there is no machinery whereby that position can be resolved, because he cannot go to an outside body. There is need for a built-in arbitration procedure in the Service, and there is no argument about the need for an inquiry.

We hear nowadays about the enormous purchasing power of the people of this country. We hear about yachts galore and wealth unlimited and astronomical salaries. In the Ministry's Department, after a recent increase, the basic rate of pay for an employee is £9 4s. 8d. a week gross. This is not some wicked private employer. These are the nation's employees, employed by the Minister of Health and taking home less than £8 10s. a week. It will be said that these are the lowest grades, but a head porter responsible for seventy men earns £12 18s. a week gross. A head male cook responsible for 3,000 main meals a day earns £13 10s. a week gross. What about technical staff? There is a shortage of darkroom technicians, the men who are responsible for developing X-ray plates and seeing that there are no flaws in them.

Lord Balniel

They are very few short.

Mr. Marsh

We are now entering a stage where there are degrees of shortages. Surely this is rather dialectical.

Lord Balniel

The hon. Member has selected a field where there is a very slight shortage. In answer to a questionnaire, the hospital management committees said that there was a shortage of only 4 per cent. of dark-room technicians.

Mr. Marsh

I should have thought that a shortage of 4 per cent. in a key sector of a national service was worth looking into at least.

Let us see why there is a shortage. I am sure that the noble Lord would agree that these people are doing a responsible and important job.

Lord Balniel indicated assent.

Mr. Marsh

At 25 years of age they are paid £445 a year for doing this work; that is, less than £8 a week take-home pay. Their absolute maximum at 29 is £535 a year.

Mr. H. Hynd (Accrington)

Less than a traffic warden's pay.

Mr. Marsh

Occupational therapists and physiotherapists after three years' training may remain in the same basic grade for twenty years and at the end of that time their maximum is £650 a year. These staff shortages are producing Gilbertian situations. The taxpayer spends hundreds of thousands of pounds on advertising. The Minister does not even know how much it costs to advertise for staff in the Service. I have been trying to far two days to find out from the Ministry how much is spent on advertising. Most hospitals have a regular advertisement in the local paper and in periodicals. They do not expect to get many applications, but it shows that they are doing their best, which is more than the Minister can say. The Minister does not know how much of the taxpayers' money is spent on this advertising. Yet one hospital in London last year spent more than £4,000 in advertising for staff which it could not get because it did not have the £4,000 to spend on staff salaries.

We now have a new feature—specialised employment agencies to provide staff which the Service cannot provide. There are two firms in London which exist to provide a 24-hour radiography service because of the shortage of radiographers in the Service The Service cannot provide radiographers, and so private firms have to do so. Those firms are very lucky. The Service trains the radiographers and then they go to private firms because the Minister will not pay them a decent rate of ray. The result is that the hospitals have to pay twice as much money to get the job done by private enterprise. The maximum basic grade for a radiographer is £630 a year. It is a career grade for many people.

Last year one hospital in London spent just over £2,000 in having X-ray work done by a private firm. If it had not been done by private enterprise, State enterprise could not have done it. This is an appalling situation. There are now medical secretarial agencies which supply staff at rates more than 50 per cent. above those applicable in the Health Service. Is it any wonder that we have an economic crisis if this is the way the Government run nationalised industries? We hear a lot of criticism of the nationalised industries. A quick glance at the National Health Service shows that what is wrong is not the nationalised industries but those who are running them. One hospital spent £5,000 last year in securing hospital secretaries from a specialised agency. Would it not have been better if it had been able to spend that money in ensuring that its staff had a reasonable rate of pay so that their services could be retained?

I mentioned earlier—it is an important point—the question of the incompetence in this field in the Minister's Department and the difficulty of getting into operation agreements which have been reached. The staff have a great feeling about this. I will give some typical examples. A.C. circular No. 93, a clerical circular, was agreed by both sides on 10th May this year, but it was 20th July, before it could be published and after that before it found its way into the pay packets. P.T.A. circular No. 88 was agreed on 2nd May, but it was 29th June before it could be published. M.C. Circular for nurses, No. 94, was agreed on 10th January this year, but it was 3rd March before the Minister could issue it. After staff have been waiting twelve months for a salary increase and agreement has been reached, one cannot tell them that they have to wait another two or three months while one prints the circulars and puts the increase into operation.

This is the position that we have arrived at today. We can make many suggestions about what could be done with the Whitley Councils and how they should be changed. I think that it would be much better from all points of view if the negotiations were direct between the Treasury officials and the staff side officials Witch management side representatives in an advisory capacity. But that is purely a personal point of view It is essential that there should be built-in arbitration machinery in the National Health Service.

All of this is just indicative of a deep-seated difference of attitude between us. Some hon. Members opposite have tried to have a non-partisan approach because we are talking about the National Health Service. That really will not wash. We want to see improvements in the Service, but we are obstructed at every corner by the Government. The whole question is full of political controversy because it involves the basic difference of approach between the two political parties in the country. Hon. Members opposite will never understand why I and my hon. Friends feel so strongly about the National Health Service.

I agree with the views expressed by my hon. Friend the Member for Bristol, South (Mr. Wilkins) on this issue. The National Health Service represents the fundamental division between the two sides of the Committee. We do not believe that this world or this country should be a jungle, with the strongest grabbing what they can and those who cannot grab doing without. [Interruption.] If the hon. and gallant Member for Ripon (Sir M. Stoddart-Scott) has eaten his dinner too quickly, he should avoid making revolting noises as a result of it.

We do not believe that the sole aim of parties in this country is the acquisition of particular things for a particular political group. What we want is a National Health Service of which everyone can be proud. We have seen the steady whittling away of the National Health Service in a nation which boasts of its affluence. This attitude betrays the inherent callousness of the approach of Members opposite. We believe that the civilisation of a nation is not measured by the number of television aerials, nor by the size or opulence of its bingo haunts, but by the extent to which it is prepared to defend the education of its children, the living standards of its old people, and the health of the nation as a whole.

In our opinion, the Government, by their approach to the National Health Service—indeed, to social activity as a whole and to social intervention by the Government—abrogate their responsibilities, and pursue a policy which is not only inefficient but which we regard as basically anti-social. For that reason, we will go through the Lobby against the Government tonight.

9.31 p.m.

The Parliamentary Secretary to the Ministry of Health (Miss Edith Pitt)

This has been an extraordinarily thoughtful debate and although, not having attended a Labour Party Conference, I was unable to agree with the hon. Member for Greenwich (Mr. Marsh) when he said that the debate was like a Labour Party conference, I disagreed with him when he went on lo say that there must be something wrong. I feel that there is nothing wrong when both sides of the Committee can make thoughtful contribitions to the National Health Service which they desire, and stress their own particular views on the developments that are taking place.

A number of hon. Members have referred to the Whitley Council machinery and the hon. Gentleman himself devoted a large part of his speech to it. The Whitley machinery under the National Health Service—which, of course, was started in 1948—followed discussions with all the interested associations, staff organisations, professional organisations, and employers—and it was established by agreement. The constitutions were drawn up embodying these agreements. This means, of course, that the machinery was acceptable to the interests concerned.

The Whitley machinery is part of the pattern obtaining through the public services generally, and, except for the presence of Ministry representatives on the management side, the Whitley machinery in the National Health Service follows the normal pattern. I believe that it has worked satisfactorily and proof of that statement is surely that, despite considerable competition, we have over the years been able to obtain increased staffs in almost every branch of the service.

The main function of the Whitley Council is to determine the pay and conditions of service of staff of the National Health Service bodies in Great Britain—that is, the hospitals and the executive councils. The set-up is the General Council and nine functional councils.

The General Council determines the conditions of service and matters other than pay which are of general application for all National Health Service staff, for example, the appeals machinery and travelling and subsistence expenses. The nine functional councils determine the rates of pay of grades with which they are concerned and any conditions of service peculiar to those grades.

The management sides of the councils represent the hospital authorities, that is, the regional hospital boards, the boards of governors, the hospital management committees and the boards of management, and also include the local authority associations, that is, the County Councils Association, the Association of Municipal Corporations, and the corresponding Scottish bodies, and the Health Departments, and, where they have an interest, the executive councils. The staff side membership includes both trade unions and professional associations.

Quite early on, the hon. Member for Greenwich made the point that the agreements of the Whitley Council should automatically become operative. He was critical of the requirement that the Minister's approval was needed. Automatic approval is prevented by the National Health Service (Remuneration and Conditions of Service) Regulations, 1951, which require two steps to be taken. Agreement on the Whitley Council is only the first step, and is followed by Ministerial consideration of that agreement with a view to approval or otherwise. It is an express statutory duty laid on the Health Ministers by the 1951 Regulations.

Mr. Marsh

We accept that there is a statutory requirement. It is that which the right hon. and learned Member for. Hertfordshire, East (Sir D. Walker-Smith) exercised. The point we are making is that the Minister's representations should be made during the negotiations. We should not have a situation in which both sides reach agreement and subsequently someone steps in to say that the agreement is invalid. He should negotiate first and agreement should be based on his representations.

Miss Pitt

The short reply to the hon. Member is that the Regulations were made by his own party when it was in power. They ensure, as the Guillebaud Committee recognised to be essential, that only those Whitley agreements which are acceptable to the Government are allowed to become effective. The provision is beneficial to the staff side, because it ensures that all employers pay the agreed rates. I assure the House that the Minister would normally withhold approval only in exceptional circumstances.

The hon. Member referred to the fact that there is no arbitration machinery. In the absence of any special internal arrangements, and there is none in the National Health Service, this is the normal position. As in other matters, recourse may be had to the Industrial Court, with the agreement of both sides to the dispute. Contrary to what the hon. Member thought and stated, it is the practice that the management side does not refuse consent to arbitration on general issues, unless public policy is involved, and the awards of the court are given effect in Whitley agreements.

He spoke about delay in settlement of claims. The length of time which elapses between lodgment of a claim and its settlement depends on a number of factors, including the nature of the claim, its magnitude and its possible repercussions. In all centralised pay negotiation, both in industry and the public service, the national employers, or representatives of the employing bodies, require time to consider all the implications of a claim and to undertake such consultation as may be necessary.

I assure the Committee that there is no unnecessary delay in the Health Service, but the process of printing the agreement—the hon. Member anticipated me—and issuing it to the employing bodies, and the Minister's covering approval, mean some deferment of the date when the agreement can be implemented, but, and this is the important point, it makes no difference to the date of the operation of the award.

My hon. Friend the Member for Torrington (Mr. P. Browne) also referred to Whitley agreements and spoke of lack of flexibility under the Whitley system. In any national service there must be central determination of the salaries and gradings of the staff employed, since it is important that those who enter the service should be assured of a particular salary for doing a particular job, wherever in the service they may be employed.

As the Guillebaud Committee put it: The loss of the local autonomy formerly employed by hospital authorities in this field is an inescapable result of the introduction of a National Health Service. It is not the case that the Whitley agreements are always rigidly enforceable. By their terms provision has been made in a number of agreements for a certain amount of flexibility in their application where this is considered to be desirable and practicable, for instance in the matter of commencing salary. This means that in certain grades power is available to start people at a minimum above their scale according to their experience. There is also provision for the Health Minister to agree to variation in grades of Whitley rates and conditions where it is considered justified.

Finally, on this point, the hon. Gentleman contended that Whitley pay and conditions were not enough to attract recruits to the Service. I think this ignores, or at least minimises, the difficulties with which any public service is faced in competing with industry at the present time, particularly for young people. There are so many opportunities and so many jobs that the National Health Service, like all other employers, must compete for the available labour.

Since 1948 the Health Service has been staffing an expanding service at a time when other services and industry have also been expanding and when there has been a national shortage of professional and technical staff. The Health Service cannot hope to do more than attract a fair share of the available pool of recruits, and, in fact, there has been a steady increase in staff numbers over the years. I should like to give some examples. Since 1949 hospital engineers have increased by 19 per cent., medical laboratory technicians by 71 per cent., radiographers by 58 per cent. and physiotherapists by 23 per cent. I think this confirms my point about the expanding service.

While not all hospitals can recruit as many nurses as they would like—this was referred to in several speeches—recruitment is satisfactory over the country as a whole. The number of whole-time nurses and midwives has increased by 29 per cent. and the number of part-timers has doubled since 1949. The total number of nursing and midwifery staff on 31st March, 1961, was the highest ever recorded.

I have brought with me a list of the latest awards under the various Whitley Councils. I shall not take up the time of the Committee in giving them in detail, but they represent increases dating from the end of December, from April, 1961, and so on, in the various grades. I should like to say also that these pay increases are the latest since the National Health Service started and to some tsaffs there have been eight or nine increases over the last six years—in particular cases even more.

The hon. Member for Willesden, West (Mr. Pavitt) criticised the Medical Whitley Council B dealing with hospital doctors. The Royal Commission thought this body adequate for considering minor matters—major matters will be left to the new review body—but that did not work as efficiently as it might, and it was recommended that the two sides should jointly consider what might be done to improve this procedure. This joint consideration was undertaken after the agreed acceptance of the Royal Commission's Report and a revised procedure agreed to facilitate the Committee's work. So far it seems to have worked well, but it will be kept under review in the light of experience.

The hon. Member for Greenwich raised a question of blood transfusion centre bottle washers. I am advised that the management side refused arbitration because the staff side claim related to bottle washers at one centre only and the case really affected bottle washers at all centres. When the staff side amended its claim to cover bottle washers at all centres agreement to arbitration was given and there has been a recent award—

Hon. Members

Hear, hear.

Mr. Marsh

Who washes the bottles now?

Miss Pitt

The hon. Gentleman also referred to the terms of recruitment for technicians and radiographers. Although he was critical that the pay was insufficient to recruit them, I should like to point out that the scales of pay were awarded by the Industrial Court.

The hon. Member for St. Pancras, North (Mr. K. Robinson) suggested that as physiotherapists had asked for an inquiry, and nurses have been asking through their union for a Royal Commission on nursing pay and conditions, we ought to consider these matters. But I think that general recourse to special arrangements of this or any other kind throw doubts on the value of the negotiating machinery, not only in the National Health Service but throughout the whole of the public service, and even more generally. There can be no reasonable dispute that the existing machinery is fully adequate for the purpose it is intended to fulfil. The results which have been achieved, the increases in pay parallel with the increase in staff, I think provide clear proof on this point.

Mr. Marsh

Could the hon. Lady tell us, if we have a negotiating machine which the staff side thinks is unsatisfactory and needs revising and the management side thinks is unsatisfactory and needs revising, how it can continue to be satisfactory?

Miss Pitt

I have heard of no representations from the management side. I have quoted the two representations I know of from the staff side, but that in general does not disprove the point I have made about the increases in pay and increased staff which we have been able to recruit.

I want to mention as many points as I can. If I do not succeed I hope that hon. Members will forgive me, particularly for leaving out constituency points, because I want to keep to policy issues. My hon. Friend the Member for Plymouth, Sutton (Mr. I. Fraser) asked about artificial limbs. Although he paid tribute to the one which has served him so well, he questioned whether we were falling out of date in this work. The design of artificial limbs throughout the world is constantly changing and the design of artificial limbs under the National Health Service is no exception. It is necessary to embody new ideas which are continually coming forward and to make the best possible use of new materials.

The Ministry's research department is always striving to improve the design of artificial limbs provided under the National Health Service and several major developments in this matter are in the trial stage. In addition, a number of pilot trials of new fittings and devices are being carried out. All of them are intended to add to the efficiency of the limbs and the comfort of their users.

In the furtherance of their work, Ministry research officers maintain close contact with university departments carrying out investigation in related fields of engineering, bio-mechanics and orthopaedic surgery and with limb-makers who themselves carry out research. Our research workers are in touch with similar or related kinds of research in all parts of the world and there is a constant interchange of ideas, a process to which Great Britain makes a quite significant contribution.

My noble Friend the Member for Hertford (Lord Balniel), the hon. Member for Erith and Crayford (Mr. Dodds) and my hon. Friend the Member for Ilford, North (Mr. Iremonger) all asked about security in mental hospitals. A report by a working party on the special hospitals published in April deals generally with security at mental hospitals. It recommended that security arrangements should continue to be provided in National Health Service hospitals for those patients not requiring the maximum security of the special hospitals. My right hon. Friend announced his general acceptance of the recommendations at the time. He proposes very shortly to ask regional hospital boards to provide the necessary accommodation at one or more hospitals in their regions and to inform him where these will be.

While the open door policy adopted by many mental hospitals has therapeutic advantages, it is fully accepted that there will always be patients who must be treated in secure accommodation for the protection of the public. My right hon. Friend is also proposing as a pilot scheme to ask for the setting up of special diagnostic units in one or two regions. This has obvious relevance to the reference made by my hon. Friend the Member for Ilford, North to the problem of the psychopath in the mental hospital.

The hon. Member for St. Pancras, North and my hon. Friend the Member for Hertford both asked if we could say what was happening about local authority developments for the care of the mentally ill. In 1960 53 training centres for the mentally sub-normal, which is one part of the duties of local authorities, were opened and plans were agreed for a further 37. By the end of December last year, 84 per cent. of the children and 67 per cent. of the adults suitable for training were receiving it. There is the related point of hostels for the mentally disordered of various kinds. The provision under the National Health Service of special hostels is only just starting. I am sorry that I have no figures to give, but a good start is being made in providing hostels, including places for the mentally sub-normal who are attending training centres but live too far away for daily travelling.

In addition, residential homes under the National Assistance Act powers for the aged and infirm contain very many people suffering from mild degrees of mental confusion. Again, at 31st December, 1960 the following classified as "mentally handicapped" were in residential accommodation provided under National Assistance Act powers—1,708 aged males and 4,208 aged females. Of those people who were not aged and not at retirement age there were 1,422 males and 1,484 females, so there are 8,822 people in such accommodation already.

My hon. Friend the Member for Hertford said that he thought that perhaps the accommodation being provided by local authorities was patchy. I agree with him. Some authorities are doing better than others, but we believe that the ten-year development plan which regional boards have now provided for us showing their hospital developments will tie up and show the patchy areas of local authorities which are not yet planning to fulfil their part of the care.

The hon. Member for Willesden, West asked me particularly about maternity accommodation. I assure him that major schemes have already been announced for new maternity departments at North Middlesex, Watford, Margate, Stoke-on-Trent, Nuneaton, Burnley and Shrewsbury. In many of the schemes now before us as part of the ten-year development plan the maternity unit is the earliest, or one of the earliest, phases recommended to us. I hope that the hon. Gentleman finds that reassuring.

The hon. Member for Nottingham, North (Mr. Whitlock) referred to a gap in not having chiropody services for old people. My hon. Friend the Member for Hertford also referred to this. It is not quite true to refer to a gap, because local authorities have been asked to provide a chiropody service and at the end of December 108 schemes had been approved. Local authorities have discretion to recover such charges, if any, as they consider reasonable having regard to needs. In many cases—such as necessitous old people—no charge will be made.

The hon. Member for St. Pancras, North mentioned prescriptions and quoted the figures. I do not want to engage in a controversial argument on this. I only want to tell him that, having given him and his hon. Friends the figures for May in the Adjournment debate on 23rd June, I now have the provisional figures for June, 1961, showing 16 million prescriptions dispensed. This is very much in the same neighbourhood as the month of June on previous occasions.

I want to say something about the hospital capital programme, because the hon. Member for Bishop Auckland (Mr. Boyden) said that it was a great pity that the capital programme was not announced ten years ago. Ten years ago, we on this side were just getting down to this job and it is the case—[interruption.]—the figures will prove it—that up to 1954–55 never more than £10 million was available for the hospital building programme.

Since then, the programme has more than trebled. In recent years the amounts expended have been: 1957–58, £17 million; 1958–59, £19½ million; 1959–60, £20½ million. Last year, 1960–61, the capital available was £24½ million, and this year the programme has been further expanded, and it is expected that £31 million will be spent on hospital building.

There are now over 200 major schemes in the course of planning and construction. In addition, 28 major schemes have already been completed, and this number includes 11 new hospitals, partly completed and in use. The present programme includes a further six hospitals under construction, and 26 new hospitals at various stages of planning. One new dental hospital, at Sheffield, was completed in 1953 at a cost of £200,000, and a further six new dental hospitals are in the course of construction or planning. The hospital development programme is under way.

The hon. Member for Bishop Auckland asked whether we had adequate building resources. Of course, the programme must be phased, and room must be found for it in the Government's general programme, but all these changes, together with others designed to speed up building—the fact that boards have been told that the method of control of the building programme has been altered so that the approval of capital projects will be accompanied by the authorisation of starting dates; the fact that we are revising the whole handbook of hospital building proceedings with the object of speeding up approvals, and the fact that my right hon. Friend is publishing a series of building notes—show, I hope, that we are in earnest with this building programme.

I prepared myself another note of the developments which will be shown in a few days' time when the 1961 figures are available. They show more hospital patients accommodated, a reduction in waiting lists, an increase in the total numbers in out-patient and casualty departments, an increase in consultant staff and in nursing staff, an increase in the number of general practitioners, an increase in local authority expenditure. All this adds up to the fact that we have not only maintained the National Health Service but have improved it. We intend to go on still further to improve it.

Mr. K. Robinson

In view of the total failure of the Minister to give any of the assurances for which we have asked, I beg to move, That Item Class V, Vote 4, Ministry of Health, be reduced by £5.

Question put:—

The Committee divided: Ayes 193, Noes 255.

Division No. 248.]	AYES	[9.58 p.m.
Ainsley, William	Hamilton, William (West Fife)	Parkin, B. T.
Albu, Austen	Hannan, William	Pavitt, Laurence
Awbery, Stan	Hayman, F. H.	Pearson, Arthur (Pontypridd)
Bacon, Miss Alice	Healey, Denis	Peart, Frederick
Baxter, William (Stirlingshire, W.)	Henderson, Rt. Hn. Arthur (Rwly Regis)	Pentland, Norman
Bence, Cyril	Herbison, Miss Margaret	Plummer, Sir Leslie
Benson, Sir George	Hill, J. (Midlothian)	Prentice, R. E.
Blyton, William	Hilton, A. V.	Probert, Arthur
Boardman, H.	Holman, Percy	Pursey, Cmdr. Harry
Bowden, Herbert W. (Leics, S.W.)	Hott, Arthur	Randall, Harry
	Houghton, Douglas	Rankin, John
Bowen, Roderic (Cardigan)	Howell, Denis (Small Heath)	Redhead, E. C.
Bowles, Frank	Hughes, Cledwyn (Anglesey)	Roberts, Albert (Normanton)
Boyden, James	Hughes, Emrys (S. Ayrshire)	Roberts, Goronwy (Caernarvon)
Braddock, Mrs. E. M.	Hughes, Hector (Aberdeen, N.)	Robertson, John (Paisley)
Brockway, A. Fenner	Hynd, H. (Accrington)	Robinson, Kenneth (St. Pancras, N.)
Broughton, Dr. A. D. D	Hynd, John (Attercliffe)	Ross, William
Brown, Alan (Tottenham)	Irving, Sydney (Dartford)	Royte, Charles (Salford, West)
Brown, Rt. Hon. George (Belper)	Janner, Sir Barnett	Silverman, Julius (Aston)
Butler, Herbert (Hackney, C.)	Jay, Rt. Hon. Douglas	Silverman Syndey (Nelson)
Butler, Mrs. Joyce (Wood Green)	Jeger, George	Skeffington, Arthur
Callaghan, James	Jenkins, Roy (Stechford)	Slater, Mrs. Harriet (Stoke, N.)
Castle, Mrs. Barbara	Johnson, Carol (Lewisham, S.)	Slater, Joseph (Sedgefield)
Chapman, Donald	Jones, Dan (Burnley)	Small, William
Chetwynd, George	Jones, Jack (Rotherham)	Snow, Julian
Cliffe, Michael	Jones, J. Idwal (Wrexham)	Sorensen, R. W.
Collick, Percy	Jones, T. W. (Merioneth)	Soskice, Rt. Hon. Sir Frank
Corbet, Mrs. Freda	Kelley, Richard	Spriggs, Leslie
Craddock, George (Bradford, S.)	Kenyon, Clifford	Steele, Thomas
Cronin, John	Key, Rt. Hon. c. W.	Stewart, Michael (Fulham)
Crosland, Anthony	King, Dr. Horace	Stonehouse, John
Cullen, Mrs. Alice	Lawson, George	Stones, William
Davies, G. Elfed (Rhondda, E)	Ledger, Ron	Strachey, Rt. Hon. John
Davies, Harold (Leek)	Lee, Frederick (Newton)	Stross, Dr. Barnett (Stoke-on-Trent, C.)
Davies, Ifor (Cower)	Lee, Miss Jennie (Cannock)	Swain, Thomas
Davies, S. O. (Merthyr)	Lewis, Arthur (West Ham, N.)	Swingler, Stephen
Deer, George	Linton, Marcus	Sylvester, George
Delargy, Hugh	Logan, David	Taylor, Bernard (Mansfield)
Diamond, John	Loughlin, Charles	Taylor, John (West Lothian)
Dodds, Norman	Mabon, Dr. J. Dickson	Thomas, George (Cardiff, W.)
Donnelly, Desmond	MacColl, James	Thompson, Dr. Alan (Dunfermline)
Driberg, Tom	Mclnnes, James	Thomson, G. M. (Dundee, E.)
Dugdale, Rt. Hon, John	McKay, John (Walisend)	Thornton, Ernest
Ede, Rt. Hon. C.	Mackie, John (Enfield, East)	Thorpe, Jeremy
Edelman, Maurice	MacMillan, Malcolm (Western Isles)	Tomney, Frank
Edwards, Rt. Hon. Ness (Caerphilly)	Mallallieu, J.P.W. (Huddersfield, E.)	Ungoed-Thomas, Sir Lynn
Edwards, Walter (Stepney)	Manuel, A. C.	Wainwright, Edwin
Evans, Albert	Marquand, Rt. Hon. H. A.	Warbey, William
Finoh, Harold	Marsh, Richard	Weltzman, David
Fitch, Alan	Mason, Roy	White, Mrs. Eirene
Foot, Michael (Ebbw Vale)	Mayttew, Christopher	Whitlock, William
Forman, J. C.	Mendelson, J. J.	Wlgg, George
Fraser, Thomas (Hamilton)	Mitchison, G. R.	Wilkins, W. A.
Gaitskell, Rt. Hon. Hugh	Moody, A. S.	Williams, D. J. (Neath)
Calpern, Sir Myer	Morris, John	Williams, Ll. (Abertillery)
George, Lady Megan Lloyd(Crmrthn)	Mort, D. L.	Williams, W. R. (Openshaw)
Ginsburg, David	Moyle, Arthur	Williams, W. T. (Warrington)
Gooch, E. G.	Mulley, Frederick	Willis, E. G. (Edinburgh, E.)
Gordon Walker, Rt. Hon. P. C.	Neal, Harold	Wilson, Rt. Hon. Harold (Huyton)
Gourlay, Harry	Noel-Baker, Francis (Swindon)	Woof, Robert
Gray, Charles	Noel-Baker, Rt. Hn. Philip (Derby, S.)	Wyatt, Woodrow
Griffiths, Rt. Hon. James (Llanelly)	Oliver, G. H.	Yates, Victor (Ladywood)
Griffiths, W. (Exchange)	Oram, A. E.
Grimond, J.	Owen, Will	TELLERS FOR THE AYES
Hale, Leslie (Oldham, W.)	Padley, W. E.	Mr. Charles A. Howell and
Hall, Rt. Hn. Glenvil (Colne Valley)	Pannell, Charles (Leeds, w.)	Mr. McCann.
NOES
Agnew, Sir Peter	Batsford, Brian	Black, Sir Cyril
Aitken, W. T.	Baxter, Sir Beverley (Southgate)	Bourne-Arton, A.
Allan, Robert (Paddington, S.)	Beamish, Col. Sir Tufton	Box, Donald
Allason, James	Bennett, F. M. (Torquay)	Boyd-Carpenter, Rt. Hon. John
Arbuthnot, John	Berkeley, Humphry	Boyle, Sir Edward
Atkins, Humphrey	Bevins, Rt. Hon. Reginald	Braine, Bernard
Balniel, Lord	Biggs-Davison, John	Brewis, John
Barlow, Sir John	Birch, Rt. Hon. Nigel	Bromley-Davenport, Lt.-Col. Sir Walter
Barter, John	Bishop, F. P.	Brooke, Rt. Hon. Henry
Browne, Percy (Torrington)	Hill, Mrs. Eveline (Wythenshawe)	Peyton, John
Buck, Antony	Hill, J. E. B. (S. Norfolk)	Pickthorn, Sir Kenneth
Bullard, Denys	Hinchingbrooke, Viscount	Pilkimgton, Sir Richard
Bullus, Wing Commander Eric	Hirst, Geoffrey	Pitman, Sir James
Burden, F. A.	Hobson, John	Pitt, Miss Edith
Butcher, Sir Herbert	Holland, Philip	Pott, Percivall
Butler, Rt. Hn. R. A. (Saffron Walden)	Hollingworth, John	Powell, Rt. Hon. J. Enoch
Campbell, Sir David (Belfast, S.)	Hope, Rt. Hon. Lord John	Price, David (Eastleigh)
Campbell, Gordon (Moray & Nairn)	Hopkins, Alan	Prior, J. M. L.
Carr, Compton (Barons Court)	Hornby, R. P.	Profumo, Rt. Hon. John
Carr, Robert (Mitcham)	Hornsby-Smith, Rt. Hon. Patricia	Proudfoot, Wilfred
Channon, H. P. G.	Howard, John (Southampton, Test)	Pym, Francis
Chataway, Christopher	Hughes Hallett, Vice-Admiral John	Quennell, Miss J. M.
Chichester-Clark, R.	Hughes-Young, Michael	Rawlinson, Peter
Clark, Henry (Antrim, N.)	Hulbert, Sir Norman	Redmayne, Rt. Hon. Martin
Clark, William (Nottingham, S.)	Hurd, Sir Anthony	Rees, Hugh
Clarke, Brig. Terence (Portsmth, W.)	Hutchison, Michael Clark	Renton, David
Cleaver, Leonard	Iremonger, T. L.	Ridsdale, Julian
Cole, Norman	Irvine, Bryant Godman (Rye)	Rippon, Geoffrey
Cooper, A. E.	Jackson, John	Robinson, Sir Roland (Blackpool, S.)
Cordeax, Lt.-Col. J. K.	James, David	Roots, William
Corfield, F. V.	Jennings, J. C.	Royle, Anthony (Richmond, Surrey)
Costain, A. P.	Johnson, Dr. Donald (Carlisle)	Scott-Hopkins, James
Coulson, J. M.	Johnson, Eric (Blackley)	Sharples, Richard
Courtney, Cdr. Anthony	Johnson Smith, Geoffrey	Shaw, M.
Craddock, Sir Beresford	Kaberry, Sir Donald	Shepherd, William
Critchley, Julian	Kerans, Cdr. J. S.	Skeet, T. H. H.
Currie, G. B. H.	Kerr, Sir Hamilton	Smith, Dudley (Br'ntf'rd & Chiswick
Dalkeith, Earl of	Kershaw, Anthony	Smithere, Peter
Dance, James	Kirk, Peter	Smyth, Brig. Sir John (Norwood)
d'Avlgdor-Goldsmid, Sir Henry	Lagden, Godfrey	Spearman, Sir Alexander
Deedes, W. F.	Lanoaster, Col. C. G.	Spelr, Rupert
	Langford-Holt, J.	Stanley, Hon. Richard
de Ferranti, Basil	Leather, E. H. C.	Stevens, Geoffrey
Donaldson, Cmdr. C. E. M.	Leavey, J. A.	Steward, Harold (Stockport, S.)
Doughty, Charles	Leburn, Gilmour	Stoddart-Scott, Col. Sir Malcolm
Drayson, G. B.	Legge-Bourke, Sir Harry	Studholme, Sir Henry
Duncan, Sir James	Lewis, Kenneth (Rutland)	Summers, Sir Spencer (Aylesbury)
Eden, John	Lilley, F. J. P.	Sumner, Donald (Orpington)
Elliot, Capt. Walter (Canshalton)	Lindsay, Martin	Talbot, John E.
Emmet, Hon. Mrs. Evelyn	Linstead, Sir Hugh	Tapsell, Peter
Errington, Sir Eric	Litchfield, Capt. John	Taylor, Sir Charles (Eastbourne)
Farey-Jones, F. W.	Lloyd, Rt. Hn. Geoffrey (Sut'nC'dfield)	Taylor, Edwin (Bolton, E.)
Farr, John	Longbottom, Charles	Taylor, W. J. (Bradford, N.)
Fell, Anthony	Longden, Gilbert	Teeling, William
Finlay, Graeme	Loveys, Walter H.	Thatcher, Mrs. Margaret
Fisher, Nigel	Low, Rt. Hon. Sir Toby	Thomas, Leslie (Canterbury)
Frater, Hn. Hugh (Stafford & Stone)	Lucas-Tooth, Sir Hugh	Thompson, Kenneth (Walton)
Fraser, Ian (Plymouth, Sutton)	MacArthur, Ian	Thompson, Richard (Croydon, S.)
Gammans, Lady	McLaren, Martin	Thornton-Kemsley, Sir Colin
Gardner, Edward	Maclean, SirFitzroy (Bute & N. Ayrs.)	Tiley, Arthur (Bradford, W.)
George, J. C. (Pollok)	McLean, Neil (Inverness)	Turner, Colin
Glover, Sir Douglas	Macphergon, Niall (Dumfries)	Turton, Rt. Hon. R. H.
		Tweedsmuir, Lady
Glyn, Dr. Alan (Clapham)	Maddan, Martin	Vane, W. M. F.
Goodhart, Philip	Maitland, Sir John	Vaughan-Morgan, Rt. Hon. Sir John
Goodhew, Victor	Markham, Major Sir Frank	Vickers, Miss Joan
Gower, Raymond	Marshall, Douglas	Vosper, Rt. Hon. Dennis
Grant, Rt. Hon. William	Marten, Neil	Wakefield, Edward (Derbyshire, W.)
Grant-Ferris, Wg. Cdr. R.	Mathew, Robert (Honiton)	Wakefield, Sir Waved (St. M'lebone)
Green, Alan	Matthews, Gordon (Meriden)	Walder, David
Grimston, Sir Robert	Maxwell-Hystop, R. J.	Walker, Peter
Gurden, Harold	Montgomery, Fergus	Wall, Patrick
Hall, John (Wycombe)	More, Jasper (Ludlow)	Ward, Dame Irene
Hamilton, Michael (Wellingborough)	Morgan, William	Wells, John (Maidstone)
Hare, Rt. Hon John	Nabarro, Gerald	Whitelaw, William
Harrison, Brian (Maldon)	Nicholson, Sir Godfrey	Williams, Dudley (Exeter)
Harrison, Col. Sir Harwood (Eye)	Noble, Michael	Williams, Paul (Sunderland, S.)
Harvey, Sir Arthur Vere (Macclesf'd)	Oakthott, Sir Hendrie	Wills, Sir Gerald (Bridgwater)
Harvey, John (Walthamstow, E.)	Orr-Ewing, C. Ian	Wise, A. R.
Harvie Anderson, Miss	Osborn, John (Hallam)	Wood, Rt. Hon. Richard
Hastings, Stephen	Osborne, Sir Cyril (Louth)	Woodhouse, C. M.
Hay, John	Page, John (Harrow, West)	Woodnutt, Mark
Heald, Rt. Hon. Sir Lionel	Page, Graham (Crosby)	Woollam, John
Henderson-Stewart, Sir James	Panned, Norman (Kirkdale)	Worsley, Marcus
Hendry, Forbes	Partridge, E.
Hicks Beach, Maj. W.	Pearson, Frank (Clitheroe)	TELLERS FOR THE NOES:
Hiley, Joseph	Percival, Ian	Mr. Gibson-Watt and Mr. Peel.

Original Question again proposed.

Mr. Robert Mathew (Honiton) 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.