HC Deb 04 June 1962 vol 661 cc31-160

3.37 p.m.

The Secretary of State for Scotland (Mr. John Maclay)

I beg to move, That this House takes note of the White Papers on the Hospital Plans for England and Wales and for Scotland (Command Papers Nos. 1604 and 1602). In what I am to say, I shall be dealing mainly with the background against which the hospital proposals for the next ten years have been prepared; the thinking underlying the proposals; and the reasons underlying the general approach out of which the proposals have emerged. I do not propose to discuss individual hospitals or groups of hospitals, but rather the pattern which experience of past years and modern developments have indicated as that best calculated to serve the hospital community as a whole. By that I mean those who at some time or another in their lives will need the service of the hospitals and all those professional and other staff who work in them.

While talking largely of the material and planning aspects of the proposals, I would assure the House that I am more than aware that the buildings, the statistics and the estimates are significant only in relation to the human beings whom the end product is designed to serve—the patients, those who might well become patients but for the research and teaching which figures so largely in our proposals, and, of course, the physicians, the surgeons, the matrons, the sisters, the nurses, the auxiliaries, all those without whose devoted service these proposals would mean nothing.

If I may be allowed one personal note, I have the strongest personal reasons at this moment for profound gratitude to all those who go to make the greatness of one particular Scottish hospital, and if in what I have to say I do not talk much about people, they are at no time absent from my thoughts, nor, of course, have they ever been throughout the drawing up of these plans.

The Motion asks the House to approve the Hospital Plans for England and Wales and for Scotland. Both of these plans were published on the same day in January, this year. They provide for major changes in our hospital services, and we are glad that the House should have an opportunity to discuss them.

While my right hon. Friend the Minister of Health and I have each dealt with the separate problems of the hospital service in the two countries in our own ways, the two documents are basically very similar in that they accept the same underlying principles as to the planning of the future hospital service, and they provide for the expansion of the building programme, at more or less the same rate.

I should like first to say a word about the background, to explain the need for plans of this kind at this time. The hospital service, which was taken over with the National Health Service Acts in 1946 and 1947, consisted of a very large number of separate hospitals administered by separate authorities and voluntary bodies and functioning very often in isolated independence. Already in 1948, nearly 10 years had elapsed since hospital building in this country had come to a standstill with the war, apart from the war-time emergency hospitals. Many of the hospitals were already very old. Since 1948, the housing programme, the education programme, the capital investment required by industry, have meant that for rather longer than many of us would have wished it has not been possible to devote the very substantial resources that the large-scale rebuilding of existing hospitals and the construction of new ones require.

Even so, in Scotland alone some £30 million has been spent since 1948 on hospital building and equipment. The figure for England and Wales is about £200 million. But this expenditure had to be devoted very largely to extension of existing hospitals where some urgent new need had arisen. Equipment had to be renewed and hospitals upgraded to make them suitable for the purposes, often new purposes, they were trying to fulfil.

The demands on the hospital service have grown steadily since 1948. In Scotland out-patient attendances have increased by 60 per cent.; and the number of in-patients discharged by nearly 50 per cent. These demands have been met without any major new building—mainly because beds are being more effectively used—and that in turn is the result of better staffing and new methods of treatment.

The advance of medical science has not only created new needs—in the sense that much more can now be done for the patients—but it has often altered the whole pattern of working in many ways. It follows that even those buildings which are not very old are not really satisfactory as they stand, because they were designed for different conditions and different medical and nursing practice.

Quite obviously, a higher rate of capital investment in 'hospitals was desirable as soon as it was practicable. There is now enough experience of the hospital service as it has gradually been integrated since 1948 for it to be possible to work out, with same assurance, the basis of a long-term plan for hospital provision throughout the whole length of the country. The regional framework on which our hospitals are organised provides the opportunity to do this—to plan a service adequate to meet the needs and yet fully coordinated so that there is the minimum of overlapping and, therefore, a higher quality of service can be given in each of the separate units.

A plan of this kind must take a long view, because the hospitals are interdependent and one cannot take decisions about one without making assumptions about what is going to happen in others. There is a second factor which makes a longer view inevitable. It has emerged very clearly from the work which has already been done on new hospital buildings that the time factor in hospital planning has to be fully allowed for. There is, first, the determination of need for the area in which the new hospital is to be sited, with a great variety of factors of population, age structure, incidence of sickness and so on to be taken into account. It is only now that the basic statistical information for this purpose is becoming available.

Then, again, a modern hospital is a very complex affair—for its size it houses an exceptional number of skilled people performing a wide variety of tasks that have to be closely correlated to one another. Hospitals often use elaborate equipment which has to be carefully located and installed. That goes some way to explain the time taken by the preparations which have to be made before the hospital can be put on the ground. Decisions have to be taken as to how particular departments are to function, what staff and equipment they will need, what numbers of patients they should be designed to handle in a given time and so on.

These are not easy questions to settle in face of the rapid changes in methods of treatment—and to settle independently of the severe limits imposed on existing practice by old buildings and old equipment. People have to project themselves out of their existing surroundings. All this has to be settled and described in the detailed brief provided for the architect. A hospital is not simply a great office building where there is a large element of repetition throughout.

In a hospital, where every department will be devoted to a different speciality, the needs of the particular departments vary very greatly, and much thought has to be given in advance to each room in each department if the architect is to be properly instructed. At the building stage, too, there seems to be some evidence to show that hospitals with their heavy requirement for technical and engineering components rise more slowly than other types of building. I know that only too well.

Given this background, it seemed desirable to my right hon. Friend and myself that the hospital authorities should be given the maximum amount of advance notice of the projects which they might expect to be able to undertake, and that they should, from now on, always have this notice for about ten years ahead so that they would have adequate time to work out the requirements and prepare and have their projects ready to start at the right time.

The other advantage of the ten-year programme was that it enabled us, and, indeed, required us, along with the regional hospital boards, which are the major planning authorities, to lay down a framework of settled policy within which they could proceed. The boards had already done much to re-organise and improve the service, but in face of a great number of demands for new buildings and new services there was a risk of their being distracted from the true long-term objectives by their concentration on these pressing individual demands. There had to be a settled policy on a national scale on the future pattern of development and on the priorities. We have set out in the White Papers the considerations—and the calculations—that influenced us in determining that policy.

The first point that I wish to emphasise is that the hospital service cannot operate in isolation. In planning its future we have to allow for the fact that it is only a component part of the National Health Service, that it has to be closely co-ordinated with the other parts—the local authority service, health and welfare, and the family doctor services. We must always keep in mind that the hospital is only for the patients who need the special services that it alone can provide, that many people can be properly cared for, in some ways better cared for, in the community—either without going to hospital at all or going only for, say, diagnosis or one stage of their treatment.

So there must be complementary planning in the other services and increasingly close co-operation between them and the hospital service. Our plans assume this, and my right hon. Friend and I intend to follow them up by working with the other responsible authorities, both the statutory bodies and the voluntary agencies, to assure that this assumption is realised.

The other main consideration I would mention is that the pattern of the hospital service must provide suitable conditions for recruitment and training. It is essentially a personal service, and nearly everything depends on the quality and the numbers of skilled staff. We have therefore allowed for new training schools, either replacements or additional ones, where it seamed desirable.

There are also calculations of bed need, and so on, on which the actual scale of provision for particular hospitals has been based. I will not try to deal with these in detail, but they are worked out on the best information we have and they can be adjusted if experience shows this to be necessary. The amount of information on this subject is steadily growing. These ratios take account of the development of the community services to which I have already referred.

The plans as they were laid before the House represent a great deal of work on the part of the members and officers of boards, and I am sure that the House will wish to acknowledge the work that has been done by the hospital service, especially by board members in their own time.

I come now to the actual content of the plans. They specify the hospitals which will be built, renewed or extended during the next ten years. They are named because we believe that people should know in detail what is intended. I need hardly say that my right hon. Friend and I were aware of the risk of doing this, since for each hospital on the list there must be others that are not on it but which people in the localities concerned had hoped and even expected to see on it. Representations have already been made to us and will, no doubt, continue to be made. We have made it plain that the plans are not final and inflexible and that for the later years, in particular, there may have to be changes.

But I think that these would not have been reasons for shying away from putting down in as precise terms as possible what the intentions are and what the limitations even of this programme are. On present estimates, in the United Kingdom as a whole it will cost about £570 million—about £500 million in England and Wales and about £70 million in Scotland—to implement during the ten years, and some of the projects will run on thereafter, so that the total commitment is considerably larger. Although we have felt able to plan on the assumption that we can spend much more on hospital buildings in the next ten years than we have been doing, we must all recognise that there are still limits to a programme which is for one particular sector of the public services. The limitations are not only those of money but of the real resources of the country—the planners, the architects, the engineers, the capacity of the builders and the equipment manufacturers.

If all the programmes were raised until everybody was content, the net result—quite apart from the financial implications—would certainly be that no programme at all would be finished on time and that every item would take much longer. We believe that this programme is feasible, but it depends, like so much else, on the economic progress and financial stability of the country in the years ahead.

The plans also set out the future pattern on which the hospital service will be based, and it may help the House if I try to summarise it. We see two major kinds of hospital. The first is the teaching hospital, the other the district hospital. The teaching hospitals in each region, with their medical schools, act as the focus not only for medical education but as centres of advanced work and research; these are the places where the frontiers of medicine are steadily expanded. With their responsibility for training new generations of doctors, they hold a very important place in the whole structure of the future of medicine in this country. The whole health service benefits from their work. We have therefore, provided for a very substantial replacement programme of teaching hospitals. It has meant sacrifices elsewhere, but I am sure that this will prove to be wise in the long run.

The district hospital is not altogether a new concept, since some areas already have hospitals with fairly comprehensive facilities—most although not all of the services that we now think a district hospital should have. But there are many areas where the picture is very different and where these modern facilities are almost completely lacking. During the next ten years, therefore, we propose to provide many new or extended district hospitals—ten in Scotland.

In the district hospital most of the essential services ranging over the whole field of medicine and surgery will be available to patients. The services they will provide stop short only of what are called super-specialties, like neurosurgery, radiotherapy, and others, which can conveniently be provided only on a regional basis. The district hospital provides the patient with a single place where his needs can be dealt with without being shunted from one hospital to another. It also enables the doctors to work in closer touch with all the different branches of their profession.

With the advance of medical science, much more elaborate investigation is now possible, and there is a shift of emphasis in hospital to the diagnostic and outpatient services. A first-class laboratory service is an essential basis for this work, and only the work of a large district hospital can justify the facilities and the highly specialised staff which the laboratory service requires.

The new district hospitals should provide a standard of service that in these areas it has hitherto been impossible to achieve. They will be the fundamental part of the hospital structure, and it is by their performance that the general standard of the service will fall to be assessed, because that is where most acute illness will be treated.

But—and there is a but—a good many of our existing hospitals have been built as small units; many of them are the products of very fine voluntary effort and community spirit of small villages and towns in days when transport was limited and medicine was not so highly specialised. Many of these hospitals have still a valuable part to play. They are in areas where they are still needed, either because of the nature of the country or because the particular service they can provide—for example, for old people—can well be provided locally.

Some have changed their rôle already, and it may have to be changed further. But some will no longer be needed. We know only too well that the prospect of closing the small local hospital naturally causes dismay. People suspect that it is simply a case of administrative convenience; it may not be easy to understand the real reasons for it. I have some sympathy with this feeling, but I am afraid we cannot really have it both ways. We cannot have both a first-class service in the district hospitals and at the same time a second-class service in small and out-of-date local hospitals.

My right hon. Friend and I have followed what we believe to be the best medical information on this subject, and I hope that those who are associated with small hospitals which are going to be affected by the changes, or perhaps even closed over the next few years, will understand the reasons and the need for the changes. This is not a question of saving money, important as that may be. It is a matter of giving the patients the most favourable conditions in which the medical and nursing staff can exercise their skills.

I have mentioned the teaching hospitals and the district hospitals. I should like to mention three other important aspects of these plans. First, the provision for the specialties such as neurosurgery, radiotherapy, and plastic surgery. Facilities of this kind simply cannot effectively be provided in small units in scattered hospitals. The specialist doctors are very limited in numbers, the nursing staff are specialised, and the facilities are exceptionally costly to provide. These services are provided for on a regional basis.

Then there are the facilities for the treatment of the mentally ill. While there has not yet been any dramatic breakthrough in this field of the kind that we have known in other fields, much more can now be done to treat the mentally ill, and we can already see in being a service which is no longer characterised by the long-stay patient shut away from the community. We have to give this new service the facilities it needs. We want to see units with all the necessary accommodation and equipment for the diagnosis and treatment of the mentally ill forming part of the basic hospital service and often, in fact, a physical part of the district hospitals themselves.

Finally, a word about the hospital care of the aged sick. This problem has begun to identify itself in recent years as one of the major problems of the hospital service—how best to organise and provide care for those who cannot be nursed at home. The other part of the problem is to prevent, wherever possible, old people from reaching this stage. All the evidence suggests that if they are brought to an assessment unit at the right time, where the facilities exist for investigation and treatment, many of them are able to return to their homes and resume their life there.

Here again, while much of the accommodation which has gone out of commission for other uses can very profitably be used to advantage for the elderly sick, the geriatric services, as they are now called, should be carried on in association with the general hospitals, which enables them to use the special facilities available there and benefit from the outlook on treatment there—one of getting people well again and back home.

These plans were published in January and were in preparation for some time before that. When the effort has been made to produce plans of this sort, there may sometimes be a tendency to sit back and admire them without seeking to translate them into the reality which is the only reason for their existence. I hope that what I am going to say will reassure the House on this point.

We knew that one of the limiting factors would be the availability of the skilled people we need to carry out these plans. We have, therefore, over a period actively encouraged the hospital boards to increase their staffs, medical, technical and administrative, to keep pace with the work involved. My right hon. Friend's Department and my own are issuing hospital planning notes designed eventually to cover the whole range of hospital departments in order to avoid each separate board having to investigate the same problem for itself. Both our Departments have development units which are working together and seeking to demonstrate in experimental buildings the new kinds of structure and layout that might be used. Some of the projects in the plans are very big indeed and will approach £10 million. We are, therefore, proposing to discuss with the building industry how we may best experiment with methods of working which would ensure a higher degree of collaboration between all the professional men involved, and also achieve the much higher rate of building which some of the larger contracting firms have shown on other work is possible in the right conditions.

It is most important that these new hospitals should not be buildings modelled on past experience, buildings which are no more than modern reproductions of nineteenth century hospitals, designed for working conditions which are already quite out of date. The new hospitals should be so designed that they will be able to cope with needs which even now can only be forecast from a distance. Moreover, in the nineteen sixties, we must not simply reproduce the standards of amenity and comfort that seemed appropriate in 1900.

We are trying, therefore, to see that the various departments are designed not only for today, but that they also take into account the possibilities of change. We hope that the design will be flexible enough so that when future architects and hospital planners have to meet a new need they will not find themselves blocked at every turn by a structure or a layout which is too closely related to the particular needs of today. In the matter of amenity, there must be an element of caution. Sick patients must be readily supervised by nursing staff. The indiscriminate provision of rooms for small groups of patients or for single patients could create very serious difficulty for the nursing staff supervising the patients. The merit of a Florence Nightingale ward was that the sister with almost a single glance could see all of her patients and be aware of what was happening in her ward. Some of our experimental work at present is devoted to trying to find a satisfactory reconciliation of the two objectives, to give the patient the accommodation suited to the time we live in and yet to safeguard his medical care.

No two hospitals are ever likely to be exactly the same. But we are already taking steps to ensure that those who have more or less similar problems work together and exchange information at the planning stage. My right hon. Friend has set up a new branch in his Department to study the standardisation of equipment on a United Kingdom basis. There may be scope, too, for the use of common standards in the design of structures and in components, as has been done successfully in schools, and this is being actively examined.

We are trying to ensure, too, that, as we go along, the experience we gain is analysed and applied to the later projects. In Scotland, we are subjecting each new building in turn to a ruthless re-appraisal of its working in practice to see what we can learn that will be of benefit in the later plans. For example, only last Friday three officers of my Department spent the night studying the working of the new Kirkcaldy hospital under night duty conditions. With the smaller staff then on duty, any shortcomings there may be in the designs become much more obvious. We will continue this practice.

This brings me to the question of the staffing of the new hospitals. Undoubtedly the more intensive treatment and the wider range of care which the new hospitals of the future hold out involves a higher ratio of staffing generally to beds. This does not, however, necessarily mean a large addition to the total requirement of skilled staff, for two reasons. The first is that we are planning for an actual decrease in the number of general hospital beds available in the country. This may at first sight seem surprising when all of us know of waiting lists in various places for particular conditions. But, with the modern facilities of the new buildings, and greater efficiency in the organisation all round, there seems no doubt at all that we can expect improved rates of turnover and higher levels of occupancy. The available staff will work more effectively.

Secondly, we shall go on learning how to save the time and energy of skilled staff both by technical methods in the widest sense of the term and by devolving upon others many of the tasks which do not require special skills. Nevertheless, in retaining and, where necesesary, expanding our hospital staff, we can be confident that much better working conditions and the opportunity of giving a new standard of service which these new buildings and the new hospital pattern afford will be our greatest possible asset.

I have described the plans and the functions of the plans. Some hon. Members who follow me will no doubt try to show in what directions the plans fall short. But I must ask them to keep in mind that the plans themselves relate only to the first ten years. While they are the beginning, they are far from being the end of hospital planning. What we have in mind is a continuous ten-year plan. We shall carry it ahead every year or every two years as seems convenient, and this process has already begun. The plans may have weaknesses. Doubtless some hon. Members will say they have. But we have gone a long way further in hospital planning than has ever been done before, certainly here and probably in any other country in the world. Our job now is to translate the White Papers into reality, and a lot of work has already been done.

It therefore gives me great pleasure to commend the Hospital Plans to the House.

4.6 p.m.

Mr. Kenneth Robinson (St. Pancras, North)

I am sure that the House will be grateful to the Secretary of State for Scotland for his clear exposition of the Hospital Plan, or shall I say the Hospital Plan as it is conceived by the Government, and for telling us what the Government's intentions were in drawing it up and what lies behind it. The right hon. Gentleman told us that his speech would not be very much about people. I must warn the House that the same shortcoming will be found in my own speech. Therefore, at the outset, I should like to echo what the Secretary of State said about the essential importance of people, both staff and patients, when dealing with this service.

This is a plan for hospitals, and it is on that that we must concentrate. On the whole, the plan has had a good reception, in the Press and elsewhere. I think that it would be not unfair to say that the further away from the National Health Service one got the greater was the approbation. So far it has not had very much critical scrutiny. So we must try to redress the balance today.

It is a somewhat unusual White Paper in that it is 14 pages long with 265 pages of appendices. I propose to concentrate my attention this afternoon on the 14 pages, as the Secretary of State did. They deal with the general principles and the extent of the provision planned for 1975. I shall refer to the Appendix from time to time only by way of illustration. I do not propose to refer to the problems of Scotland. My hon. Friend the Member for Greenock (Dr. Dickson Mabon), if he is fortunate enough to catch your eye towards the end of the debate, Mr. Speaker, will deal with those, and he is far more competent to do so than I am.

Since I shall have many reservations about and criticisms of the White Paper, I want to say at the outset on behalf of my right hon. and hon. Friends that we welcome the decision, belated though it is, to try to plan and co-ordinate hospital development and modernisation over a period of 10 to 15 years. After all, for over 20 years we have hardly had any new hospitals in this country. As the White Paper makes clear, one out of every five of our hospitals was built before the Crimean War.

I understand that there are those who believe that in concentrating first on the hospitals the Minister of Health has got his priorities wrong. I venture to disagree with them. I think that he was right to tackle the modernisation of the hospital service, which must be at best very much a long-term operation. Indeed, the first complaint I have to make is that this plan is about ten years too late. Those ten years have been years of frustration for hospital planning authorities. During this period, they have been trying to plan their hospital developments on a year-to-year—one might almost say a hand-to-mouth—basis, without any picture of what they could hope to be aiming at. Indeed, what we should be enjoying today is not the satisfaction of being able to plan but the actual fruits of planning. These are still a very long way off.

Incidentally, I should like to say something about the delays in hospital building, to which the Secretary of State himself referred in passing. Must ten years always elapse between the decision to build a hospital, or even to extend a hospital, and the admission of the first patient? I know that we have a slow-moving machine. To some extent that is inevitable. However, I still believe that it could be speeded up very much more with a real effort by everyone concerned. I know that the right hon. Gentleman's Department is doing something towards this. I wish him well in his efforts, through his architectural section, to improve methods of hospital construction by standardisation and in other ways, but I think that still more could be done. I hope that he will also have a look at the procedure for dealing with approvals, because this has led to much delay in the past.

My second criticism of the plan is that it is inadequate. The scale of the plan embodied in the White Paper has been consistently exaggerated, not least by the two Ministers concerned. Therefore, it is very necessary that the plan should be put into perspective. First, the plan represents substantially less in terms of capital expenditure than the hospital boards—the planning authorities—asked for. As the House knows, the boards were invited to submit their own proposals, without any financial limit, for a ten-year development programme. For planning authorities, which have been continuously starved of capital funds, the very sinews of planning, to receive such an invitation looked rather like putting down a saucer of cream in front of a cat. But it was far too good to be true.

The plans which the boards submitted to the Minister, as he told us in reply to a Question, would have cost in the aggregate £800 million over ten years. The Minister has scaled those down very considerably, and what the boards have got is £500 million over ten years. That is a figure which is barely two-thirds of what the British Medical Association suggested was needed to modernise our hospitals. It is an average of £50 million per year. Such is the low base from which we start that we will not even reach the figure of £50 million a year before about 1965 or 1966.

Added to this, it is abundantly clear from the White Paper that there is no firm commitment to spend even these sums. Everything will depend on the economic state of the country and a number of other provisos. There is no commitment at all. Fifty million pounds a year is just about equivalent to what we were spending on hospital building in 1938, allowiing for the change in the value of moneys, or even taken as a proportion of our national income. Therefore, the programme is not all that colossal. I believe it could easily be twenty years before this ten-year plan is realised, at least if it rested with the right hon. Gentleman and this Government, which happily it will not.

In the first five years of the ten-year programme, some regional boards are given nothing at all which is not already in their programme and which has not already had from the Minister at least approval in principle. Some boards are bitterly disappointed with this plan—and they are the more progressive and more active boards. They will apparently get less under the plan than they are currently contracting to spend annually on projects which they had been able to push ahead even before the Hospital Plan was born. Indeed, the whole document shows every sign of being a kind of levelling operation; the more go-ahead boards are to be held back and the more sluggish boards are to be urged forward.

I can see the force of this, and I see that it is necessary to lift up the more backward areas. It is quite reasonable up to a point. But I think that this process has been carried too far. The stifling of initiative cannot be a good thing either for the morale of those concerned or for the standards of the hospital service as a whole. There must always be somebody going a little ahead in order to encourage the others.

I have a great anxiety that as a result of this very detailed plan drawn up in the Ministry some of the planning function which now rests with the boards is being usurped by the Minister. I hope that he will give a good deal of thought to this and watch the position, because the most important and, in a way, the most satisfying function of the regional board is the planning of its services. Already it is deprived of that satisfaction in respect of the very big developments, the large new hospitals, and I have a feeling that a detailed centralised plan like this may carry that process somewhat further.

My third criticism is that the whole operation has been far too rushed. Indeed, the entire plan has been evolved in twelve months dead from the date when the Minister first approached the boards. The boards were given a bare four months to produce their plans, and this has led to a good deal of resentment at hospital management committee level, because that made it quite impossible for boards to consult management committees in drawing up their proposals for the Minister. Even so, to produce any programme at all involved both officers and members of the boards in a great deal of hectic work which had to be done if any coherent proposals were to be put forward.

Why did the Minister rush it in this way? I can only speculate. I think that, very understandably, he wanted this to be his plan, and perhaps he reflected on his five predecessors and their average tenure of office of rather less than two years each. Six months had already gone by and twelve months was perhaps the maximum time which he could allow with any margin of safety for the plan to be produced during his tenure of office. We are paying the price of having at the Ministry a middle-aged man in a hurry. The whole plan suffers from the indecent haste with Which it has been concocted, and it bears many signs of inadequate preparation.

That brings me to my fourth criticism. I have already said that it is ten years too late, but even those ten years should not have been wasted in the way in which they have been wasted. During those previous ten years there should have been instituted by the Minister of Health and his predecessors a number of research studies into the present and future needs of the service in terms of hospital beds. In fact, practically nothing has been done, and what little has been done has been almost entirely carried out by bodies outside and independent of the Ministry of Health. So far as the Ministry is concerned, these have been the locust years. As it is, most of this plan is based on guesswork of future needs and future bed requirements. I know that statistical projection is a difficult and often a hazardous exercise, but it is at least important to see that the projection starts from a sound and solid base.

I want to give some examples. The first is the question of acute beds, which is perhaps the key to the whole plan. Surely there could have been a systematic series of surveys in different parts of the country about bed needs for acute illnesses—surveys, perhaps, in the Metropolitan area, in conurbations, in the smaller urban areas and in country areas. But we have had nothing of the kind. What we have had is surveys covering six medium-sized towns very similar in character. If hon. Members look at the White Paper, they will find that with one exception each constitutes a single Parliamentary constituency —Northampton, Norwich, Barrow, Reading, Salisbury and Cambridge.

These studies have used different definitions of the word acute and they are based on different premises. Three have been carried out by the Nuffield Provincial Hospital Trust, two by hospital boards and only one by the Ministry of Health. Very understandably, they produce most varying results—results which vary from two beds per thousand as the need for acute illness to 3¼ beds per thousand. The Minister sticks in his thumb and pulls out a figure marked 3.3, and that is to la; taken as the normal requirement foe acute beds. The present figure is 3.9r very much larger. It may well be their the need for acute beds can be met by is much smaller figure than that, but sure, such a vital figure, on which the whole ten-year programme of the country in based, should be the result of something more than guesswork. Why have no studies been made—or, if they have, why have we not been told about them?—into local variations in morbidity, which are considerable in this country?

In this connection, I want to mention the speech which the Minister made to the Institute of Hospital Administrators in which he complained about the inaccuracy of National Health Service statistics and mentioned hospital waiting lists. I agree with him that these are notoriously misleading, but why have we not had an analysis of waiting lists made long ago? I believe that one study is being carried out by the King Edward Hospital Fund for London in the London area. That is the only one about which I know. Perhaps the Minister will tell us of others.

Next, there is the problem of geriatric beds. The White Paper assumes, on very optimistic and inadequate data, that 1.4 beds per thousand of the population will be sufficient in 1975. The plan provides for only 1.3, and that is the same figure per thousand of the population as we have today, with a steadily ageing population. I do not know of anyone who considers that the existing geriatric services in this country are anything like adequate, nor can I see the local authorities taking any substantially increased share of the burden.

In addition, one hopes to see over the period covered by the plan fewer and fewer old people going into psychiatric hospitals when they do not need special psychiatric care but are sent there just because there is nowhere else for them to go. But some hospital provision will have to be made for some of these at least. I believe that some kind of re-assessment will be needed about the requirement of geriatric beds.

There has been virtually no research into future requirements in respect of mental subnormality, despite the fact that today we have long waiting lists. I remind the House that waiting lists in respect of mental subnormality are indices of avoidable human misery. despite these waiting lists and the tendency, which is acknowledged in the lan, for the subnormal to live longer, he plan aims to provide no greater number of beds per thousand of the population than we have today. and it is only at this moment that the Ministry are beginning to embark on studies which should have been done years ago, and to embark on them, if rumours are correct, on a very limited scale, too.

In respect of maternity beds, the Minister may be luckier. The figures which are given in the plan on the face of it do not look sufficient, but I believe that the development of short-stay hospitalisation for maternity cases may well come to his rescue. Nevertheless, surely the Metropolitan area, with its endemic housing problem and its other special circumstances, ought to have the highest provision for maternity beds in the whole country. So one would have thought. In fact, if one looks at the figures, the proposed figure for the Metropolitan regions is rather below the national average for 1975.

In the plan as a whole, there seems to have been inadequate co-ordination of the various proposals coming forward which to some extent no doubt, is the result of the haste with which they have been put together. I want to give one example to illustrate this. If one takes the southern half of the Metropolitan area—the South-West and South-East Metropolitan regions—one finds that by 1975 there will be roughly 3½ acute beds per thousand of the population, while in the other half of the Metropolitan area, the two northerly parts, there will be five acute beds per thousand of the population. This is after the appropriate allowance has been made to deduct teaching hospital beds which serve a population outside the region. If we take non-teaching hospital beds in the southern half of the Metropolitan area, we find that these are to be cut by nearly 50 per cent.—from 5,500 to 2,900. We all agree that the Metropolitan area has special features, but surely those features apply on both sides of the River Thames. It looks very much as if someone's arithmetic has gone wrong.

I have no doubt that the Minister will say, as the Secretary of State suggested, that this is a flexible plan and that it is subject to annual revision, when mistakes can be put right. I ask the Minister exactly what this means. We have heard about it being subject to annual review. Does it mean that the boards themselves will conduct an annual review of their part of the plan and make annual submissions to the Minister? Or does it mean that the review will be carried out by the Ministry? To what extent are the revisions to be made in the plan to be made known? Will the whole White Paper be republished periodically, and, if so, how often? Is it intended that some kind of submission should be published annually? We should like to know. After all, one favours flexibility; there is much to be said for it. But there is a great deal to be said for getting the plan basically right to start with. Once all the working drawings have been done on a project it is not very easy to make adjustments. We want buildings, too, which as far as possible are flexible, by which I mean adaptable to changing needs and purposes and changing techniques, which is not an easy thing to do, and I am glad to know that hospital architects are at last addressing themselves to this problem.

I want to turn to the basic concepts behind the plan and to say at once that I accept the main pivot, which is the district general hospital. I agree that a hospital of this kind which can offer a full range of hospital services to a population of 100,000 or 150,000 is right. I think the optimum size of 600 to 800 beds mentioned in the White Paper is also about right. We agree that broadly this is the best way to deploy the hospital services, but subject to certain things. The hospital must be correctly sited. Above all, it must have easy access by public transport. I am a Londoner and, like most Londoners, I am apt to take public transport very much for granted. We are extremely fortunate, but this is an absolutely vital consideration in country districts. We must consider the convenience of visitors and relatives of patients, and also of out patients.

It is an unhappy coincidence that the right hon. Gentleman should come forward with a project for fewer and larger hospitals at the moment when the Minister of Transport is busy dismantling rural transport services by both rail and road. The Secretary of State mentioned today the days when transport was limited; it looks very much as though those days are returning. I hope that the Minister will have a talk with his right hon. Friend the Minister of Transport to see that he does not whip away all the transport services to these district hospitals, because travelling quite considerable distances will be involved in some areas.

As the Secretary of State and the White Paper have made perfectly clear, the development of the idea of the district general hospital will inevitably involve the closure of a number of smaller hospitals. There will be many local objections to this. It is a matter in which local loyalities are bound to be touched and perhaps a few entrenched interests affected, but I think it inevitable. I hope, however, that before any hospital is closed the most careful scrutiny will be made to ensure that that hospital is not providing some absolutely vital local function and also to ensure that its services can be better provided by a district hospital, and provided without intolerable inconvenience to patients and their relatives.

The closure of these small hospitals is bound to include many small general practitioner hospitals. Unless something is done about it, that process will carry still further the divorce of the general practitioner from the hospital service. What is being done about that? There has been a great deal of talk and some brave words. The Platt Report made some recommendations, which are referred to in paragraph 26 of the White Paper, but there is no sign that they are being implemented. I hope the Minister will hurry up and settle his arguments with the medical profession about the nature of the intermediate grade of hospital medical staffing. That seems an essential preliminary before beginning to get the general practitioner back into the hospital.

The Central Health Services Council, we are told, is also examining the future work of the general practitioner. It will no doubt report on the question of access to hospitals. Here again we have the basic thinking following the publication of the plan instead of preceding it. I think we all agree that the relationship of the general practitioner to the hospital is vital to the whole future of the National Health Service. The Minister. must lay down some agreed general principles and then integrate them into h[...] Hospital Plan.

I turn to the problem of mental health As the right hon. Gentleman knows, have given my general support—I am sure that goes for my hon. Friends—to his policy of having psychiatric units in general hospitals and to the corollary of that policy, which is the closure over a period of many of the older mental hospitals and a fairly drastic reduction in the size of many others. This is a policy which has come in for a lot of serious criticism—some of it admittedly ill-informed, based on false premises, but some also worth very serious consideration. I commend to the Minister, if he has not already read it, the book recently published by Dr. Kathleen Jones of the University of Manchester, entitled Mental Hospitals at Work.

What is proposed here is a major revolution in psychiatric care. It would be wrong if something like this went through quite unchallenged. It is very important that we should get this policy right and start off on the right foot. It is also important that we should leave some room for experiment. One might have expected, in the light of the rather dramatic announcement of policy which we had from the Minister a year ago, that the Hospital Plan would have shown a great deal of boldness in this respect, but I find it rather tentative and in one respect badly misconceived.

There are hardly any new psychiatric units planned to start in the first five years of the programme. Quite clearly, some regional boards have shown a very obvious reluctance to plan psychiatric units in general hospitals at all. I do not know if anyone has totted up for the Minister the figures for the County of London. If we add up the figures for the four Metropolitan regions covering the County of London, we get a total of 650 psychiatric beds in general hospitals by 1975 for a population of just on 3 million. That is less than the national average, and I suggest that it is totally inadequate. London, above all, should have more than the average provision; indeed, probably it needs something like double the provision for the country as a whole. I hope that will be looked into. I do not know the reason for it. It might be that the teaching hospitals have shown some reluctance to harbour psychiatric units under their roofs. I notice that one Metropolitan hospital board does not plan for any psychiatric beds at all in general hospitals by 1975.

I come to my main point about the planning of these psychiatric services. Everywhere in the White Paper these general hospital units are referred to as short stay units". I suggest that that is the wrong concept altogether. If we are really moving towards treating mental illness in the general hospital, these units must aim not at just treating the multi-neurosis and acute cases with a very favourable prognosis. They should aim at providing a comprehensive psychiatric service for the population which is served by the hospital as a whole. If they are to do that it is essential that they should be of a certain minimum size, perhaps 60 to 120 beds. Some of them are planned on that basis, but in many more it is intended that there should be no more than 20 to 30 beds.

This type of unit can only cover short stay cases, and not very satisfactorily either. It is quite impossible to provide in a unit as small as that either the therapeutic atmosphere so important in psychiatric care or the ancillary services necessary to psychiatric patients—services such as occupational therapy and recreational space—and all the things needed by patients who generally are up and about all day, but which are not needed for general hospital patients who spend most of the day in bed.

There is another point about having purely short stay units. It is the psychological effect on the patient who finds that he has to be transferred to the mental hospital proper. Such a transfer, I should think, would be very depressing and possibly disastrous for many patients. What we want is a unit which will retain its patients as long as treatment is needed. If units do not do that, in my view they will not be carrying out their proper function.

If we have purely short-stay units, what will happen to the existing mental hospitals in the long term? Will not they become mere dumps and progressively more difficult to staff? I hope that the whole of this policy will be looked at very seriously. There are bound to be difficulties and problems in bringing psychiatry into the general hospital. But, in my view, it is a project which is practicable and thoroughly worthwhile. That is not only my view. It is also the conclusion reached in a most excellent editorial which appeared in the Lancet of 26th May—I commend it to the right hon. Gentleman—and in a paper in the same issue which promoted the editorial and was entitled In-patient Psychiatry in General Hospitals".

In passing, I wish to mention one horrible idea which seemed to have gained currency not long ago, even in the Ministry—of 300 or 400-bed medium-stay psychiatric hospitals placed somewhere between the short-stay unit and the long-stay chronic hospital. Such a project would give us the worst of all possible worlds. It has been condemned by every psychiatrist with whom I have discussed it, and I sincerely trust that it has been buried without trace.

Before leaving the subject of mental health, I must express disappointment that more has not been done in this plan to fill the yawning gaps in the Mental Health Service. So far as one can see, there are no special units planned for the treatment of alcoholics. There are hardly any units for psychotic children or adolescents, and—possibly the most important of all—there is only one psychopathic unit in the plan, with the possibility of a second one in the 1970s in one other region. These are all urgent priorities, and a ten-year plan which virtually ignores them is seriously deficient.

This brings me to the section entitled "Care in the Community". This section is full of pious hopes and unwarranted assumptions. For example, in paragraph 39 there is an assumption that the standard of services for the elderly outside hospital will be brought generally up to the level of the best current practice. Why should the right hon. Gentleman assume that and then proceed to base upon it the whole of his calculations for the hospital needs of the elderly? What sign is there that laggard local authorities are in the process of catching up?

Similarly with mental illness. Almost everyone, except possibly the Minister, is very disappointed at the slow progress being made in expanding community mental health services. I believe—I have said it before in this House—that so long as the Government remain determined that no Exchequer moneys are to be made available to local authorities specifically for the development of community services, or to social worker trainees in the form of grants; so long as they are determined to rely on the block grant, the expansion of these services in many areas will be almost imperceptible. Yet paragraph 41 refers to: All this expansion of local authority services…. I see that the local authorities, too, are to produce a ten-year plan. I wish I could think that it would be a plan to match the pressing demands soon to be made upon them to deal with the needs of the mentally disordered in the community, and, indeed, the needs of the elderly.

We all know that the provision of bricks and mortar does not heal sick people. That is done by the skilled and devoted staffs working in the hospitals. But only one of the 52 paragraphs in the White Paper deals with hospital staffs, and that has nothing new to say. I have no wish to repeat today what I have been saying in the recent debate in this House about the staffing problems of the National Health Service. I will just say that this plan will be still-born if we cannot get staff in the numbers and of the quality that we need.

As the Minister knows, there are problems at every level and in every category of staff, and the right hon. Gentleman has done a good deal in recent weeks and months to make those problems worse. Unless he adopts a very different approach, he will find himself with new hospitals and no staff left in the old ones. We are already facing shortages of doctors, nurses, and ancillary professional workers of all kinds, and something like a seachange is required in the attitude of the Government if we are to avoid a most serious crisis. I hope that the right hon. Gentleman will now turn his attention to this aspect of the problem.

I repeat that we welcome the fact that we now have a long-term plan at last. We agree with its general lines of advance. If I have spent more time on criticism than on approbation, it is partly because the Minister and the Secretary of State claim rather too much for their plans. In the preface to the White Paper, there is talk of …modernising the whole pattern and content of the hospital service and for integrating it still more closely with the great services which provide care and treatment outside the hospitals". The plan emphatically does not do that. We are prepared to give two cheers for what it is, a long-term, if somewhat tentative, hospital building programme. Even on these limited terms, it would be a better plan had the right hon. Gentleman and his predecessors started their homework earlier and done it a good deal more thoroughly. For a really comprehensive forward-looking plan the National Health Service must await a change of attitude, and that means not so much a change of Minister as a change of Government.

4.46 p.m.

Colonel Sir Malcolm Stoddart-Scott (Ripon)

Like the hon. Member for St. Pancras, North (Mr. K. Robinson), I should like to congratulate the Secretary of State and the Ministry of Health on bringing forward this comprehensive and visionary plan. The only way to bring a great hospital service such as we inherited in 1946 up to adequate standards was the provide an overall plan such as this. We must realise that 50 per cent. of the hospitals we have were built in the last century. Therefore, I wish to congratulate my right hon. Friend and thank him for having formulated this plan and presented it with such vigour.

In debates on the National Health Service, I have always maintained that the time must come when we should have to spend a vast amount of capital on hospitals. It was right and appropriate that immediately after the war we should make housing our priority in the spending of money, and I think it was equally appropriate that in the next decade we should spend a vast amount of capital upon schools, colleges and universities. I am glad that now we have arrived at a decade when, I hope, the first priority in the spending of capital will be hospital buildings. I hope that my right hon. Friends the Minister of Health and the Secretary of State will not allow their colleagues, or any crisis or any emergency, to budge them from the target which they have set themselves for hospital building by 1975.

This is a vast scheme, and I am sure that my right hon. Friends will realise that, like all great schemes, it is not always possible to get it right first time. It is not possible to get all the details correct. I was, therefore, glad to hear the Secretary of State say that to some extent this was not final and not inflexible but that the plan was fluid. In 1946 the National Health Service legislation was not final. We had three or four amending Acts before reaching the present state of perfection. I hope, therefore, that some of the things which are not very satisfactory in this plan will be put right before it comes to fruition.

In the Leeds regional board area, especially in my own constituency, there are the valleys of the Wharfe and the Aire, which will be completely devoid of hospitals if this plan is adopted. Therefore, we shall have a population of no fewer than 75,000 with no district hospital nearer than the City of Leeds, the City of Bradford or the County Borough of Keighley. This defeats what is laid down in the Cmnd. Paper—that the hospital should be— located in or near the centre or one of the centres of population of the area which it serves". Here we have a population of 75,000, with not very good rail facilities, where sometimes it would require changing on two or three buses in order to get into these cities and to the hospitals to visit sick relations if they are sent there.

The Minister has done much in encouraging and creating facilities for visiting patients, and I think it is a great pity if, by removing some of these small hospitals, he makes this visiting quite impossible. The view which I am expressing is not only my own view but that of every local authority, every doctor in the area and of the regional hospital board, which is that this area should not be left completely devoid of a district hospital. Therefore, I hope that my right hon. Friend will have another look at that part of Yorkshire, north-east of the City of Leeds.

There is no mention in the plan of the building of children's hospitals. I think that probably is a good thing. I believe that the treatment of children should be carried out in the comprehensive hospitals and that it is quite right and proper that it should so be done there, but when the Minister comes to the planning of these hospitals I hope he will plan them so that in the part of the hospital which is for the treatment of children accommodation shall be provided for the mothers to stay with the children when they are sick. Where this has been tried it has proved a tremendous advantage in the healing of children. A sick and fretful child is not likely to recover as quickly or as completely if it is separated from its mother. Therefore, I hope my right hon. Friend will see that at least a certain percentage of the accommodation for sick children will include also accommodation for their mothers. Where this has been tried in some hospitals, it has been found that no less than 60 per cent. of the mothers were able to take advantage of the accommodation when it was offered to them.

I realise that this will be an added expense in the building of these hospitals, but it has been found that where mothers stay with their sick children they are able to do the greater part of the nursing, the greater part of the feeding and the washing of children, and much of the work usually done not only by the nursing staff but by the domestic staff. Therefore, I think the Minister will find that probably he will be able to save a considerable amount of money, although he will have to spend an added amount of money in providing the accommodation in the first place.

I welcome this plan. I praise and thank the Minister for the enthusiasm, the vigour and the initiative which he has shown in putting it over to the country.

4.54 p.m.

Mr. Denis Howell (Birmingham, Small Heath)

I would not wish to follow the hon. and gallant Member for Ripon (Sir M. Stoddart-Scott) too far, except that I noticed the special plea which he made in respect of his constituency. I think it is quite true that there will be a considerable amount of constituency pressure, which the Secretary of State for Scotland, with commendable wisdom, I thought, foresaw in his opening speech. I was glad that the right hon. Gentleman and my hon. Friend the Member for St. Pancras, North (Mr. K. Robinson), who led from this side of the House, while recognising that it was legitimate for this pressure to be exercised and taken account of, agreed that the great matters of principle must be determined outside these rather narrow constituency points, and it is to some of these principles that I want to devote my speech.

First, I want to ask what is to happen in the interim period before this plan gets into operation. It is already apparent throughout the country that Treasury funds are drying up, and people with plans, even plans for essential maintenance, in district hospitals are having considerable difficulty in getting money to carry out repairs and maintenance. I think this is a bad thing. I share absolutely the view of my hon. Friend that the plan itself is quite inadequate to meet the needs of this day and age, and particularly to meet the needs, such as we can estimate them, for the next ten or fifteen years, but, in fact, it will be calamitous if in trying to build new hospitals which will not come into fruition much before ten years from now essential maintenance is neglected.

The Minister should tell us something about maintenance, because we must not get into the situation where existing hospitals will be allowed to decay. All of us with experience of regional hospital boards know that we are told that there is no money available except that which is to be reserved for the plan, and I d-o not quite know how we can expect these hospitals to carry on.

This brings me directly to my second point. If the plan is to be successful, we shall have to have a dynamic in the Health Service and in the Ministry such as we have certainly not seen since the war, with all due deference to every Minister of Health since the war, and we have had one or two rather dynamic characters. In order to get this plan carried through, we have to be told and shown that there are people in the Ministry who are forging ahead and who are prepared to forge ahead, and not only in the Ministry but also in the regional hospital boards. I think that unless we can see—and these people on the regional hospital boards are voluntary people—that there are on the regional hospital boards some dynamic personalities urging on all the time this plan will never come into fruition.

I am associated with what must be almost the largest hospital plan in the whole of the area covered by the new plan, and I congratulate the Ministry in agreeing to the proposals for a very large size indeed, because I think the curious circumstances there justify it. Already I can well understand that unless there are people who can give a lot of their time, and unless there is a tremendous dynamic, we shall not get that hospital to completion in 20 years.

In discussing the type of buildings that we are to have, I was very interested indeed in the remarks of the Secretary of State in respect of the building trade and architecture. I think that the first thing that the Minister has to decide is whether we are to build hospitals to last 100 years or to build hospitals to last 25 years, recognising that they should then be replaced. There is nothing whatever in this plan, or in any of the speeches which I have heard so far, to show that anybody has done any fundamental thinking about it. If we are to build hospitals to last 100 years, certainly we have no right to erect monstrosities. The danger, as the Secretary of State said, is that we shall build some magnificent new architectural monstrosities. While I recognise that that is not the most important factor, because the treatment provided in the hospital is the most important, we have no right to build architectural monstrosities which the citizens of our country will have to look at and be staggered by for the next 100 years.

I have been making a plea in connection with the hospital with which I am associated that we should have a first-class architect and a first-class layout and design. I see that it may well be that we shall have to build hospitals to last 100 years, and I do not know the answer. Certainly, on medical grounds, if somebody finds a cure for cancer over night most of these proposals, revolutionary as they are, would be absolutely hopeless because we should not want the present tremendous number of beds for acute cases. There is a pattern of social illness which keeps changing all the time. I certainly think that there is a lot to be said for not committing ourselves willy-nilly and wholesale to building these magnificent structures which we think will last one hundreds years.

Mr. Harry Randall (Gateshead, West)

Would my hon. Friend not agree that some attention might be given to the thought that has gone into the school-building programme in this respect in the last ten years in which the idea has been not to build the monstrosities that we have known in the past but buildings relevant to the present situation?

Mr. Howell

That is certainly appropriate, and I think that the Secretary of State for Scotland told us that account had been taken of that experience in the provision of both equipment and of buildings.

I was encouraged by what the right hon. Gentleman said today about some of the thinking on this subject that is now going on in the Ministry, and I congratulate the Government upon their intention to have consultations and discussions with the building industry. In most parts of the country, there are only a few buildings firms which can undertake this sort of work if we are to erect buildings to last a century. I thought that the Secretary of State contradicted himself. He started by saying that hospital buildings never seem to rise off the ground. We have all had that experience, but there is no reason why this should be so. If a private developer thought there was money to be made from erecting hospitals, they would be built at ten times the speed at which they are built today. The very large building firms, with their preplanning, recognise that they cannot afford not to be on time. If it is an office block or buildings of that sort, they are always on time whatever the vagaries of British weather.

I hope, therefore, that in future excuses will not be accepted. Far too often in the public service, and especially in the Health Service, we have accepted excuses that there is labour trouble and all sorts of difficulties preventing the work being finished. It is obvious from the operations of the large building firms that these excuses need not be accepted in future.

There is a tremendous difference between the standards of building set by the large building companies and the inefficiencies of many of the smaller firms. If I may ride one of my hobbyhorses, however, I hope that in accepting the lowest tender for hospital buildings we do not, as so often happens, accept inefficiency. If ever a system ought to be thrown out of the window in the public service it is the system of a ace p Ling the lowest tender. I see the evils of this system almost day in and day out in the hospital service.

We must also make sure that the regional hospital boards have the necessary staffs to cope with new building. I have paid tribute in the past to many of the regional architects who have done great work, but I doubt whether regional boards have the staff to do all the work that is now to be thrust upon them. There must be some system of farming out the work to other architects while retaining some sort of central control in the regions.

Why is it necessary that all these buildings throughout the country must show some variation from each other, as the Secretary of State led us to believe? If we can get the architecture of some units agreed, there is no reason why it should not be transplanted throughout the country. This would go far to ensure that programmes were finished on or ahead of schedule. Proud as I am of some of the good architects we have in the country, and eager as I am to allow them to have their freedom, I feel at the same time that we must not allow them to have their head entirely because if we do we should never have the programme completed on time.

One of the most serious implications of the Hospital Plan is the undoubted fact that if the programme is to succeed a further colossal amount of expenditure will be transferred by the Government from the taxpayer to the ratepayer. I am glad that my hon. Friend the Member for St. Pancras, North drew attention to the block grants system because in almost every section of the Report on the hospitals we find that the Minister can carry through his proposals only if the ratepayers take over a greater share of the burden.

If hon. Members opposite go round at local election times talking about the burden on the rates, I hope that they will accept their responsibilities and the logic of what they are agreeing to in the Report. For instance, on maternity beds, paragraph 15 of the Report states: The present trend towards a greater rate of hospital confinements may well raise the proportion above 70 per cent.; on the other hand, the effect of this factor may be off-set by the tendency to a reduced length of stay in selected cases. No allowance has therefore been made for either trend. If, as seems evident, births continue at the present high rates and the rate rises even further, there will be an added burden on the maternity services.

Paragraph 16 of the Report, dealing with geriatric beds states: With the further development of active treatment and rehabilitation and the wider and fuller provision of services for the elderly outside hospital, this ratio should be adequate or more than adequate generally and should cover the provision required for the elderly confused who do not need treatment in a psychiatric hospital. The logic of this paragraph clearly is that the local authority welfare services and health services must take greater responsibility for half-way houses—as I recognise they should do—and for nursing people in their own homes. This again must mean an increase in local rates.

Paragraph 17, deals with beds for mental illness. After discussing the ratio, the paragraph states it may well prove too high, even if re-admissions increase, because …it takes no account of any contribution from the expansion of community mental health services or from further advances in medical treatment. We hope that there will be advances in medical treatment, but any expansion of community mental health services must again mean placing greater responsibility on the local authorities.

If responsibility in these three categories is to be placed upon the local authorities, we are entitled to have from the Minister a statement of Government intention in the financing of local government and particularly of the local health services. I am not very optimistic that we shall have it, but we ought not to embark on a new trend in hospital services and on this Hospital Plan without knowing exactly where we are in this respect.

Like my hon. Friend the Member for St. Pancras, North I doubt the ratio of chronic sick cases and maternity cases as given in the Report. Hon. Members who are connected with the health services in the larger conurbations, where the more crowded housing conditions exist, know that very often when the general practitioner attends a confinement he throws up his hands in horror and says, "You must go to hospital." The result in Birmingham, for example, is that we have people going into hospital who on medical grounds ought never to be there at all. We must face the fact that this will happen for a long time yet. I wonder whether in respect of cases like that, or of people who ought not to be in hospitals for the chronic sick but are there because the local authorities cannot afford to build half-way houses, we could not have a survey made of the availability of temporary prefabricated structures. I know that there are some very excellent forms of prefabricated structures now being used in certain parts of the hospital service. "Terraplane" is one type which I am told is very good.

We must certainly face the fact that we must get out of our maternity hospitals and out of our chronic sick hospitals patients who ought not to be in them and who are occupying beds that should be reserved for medical cases. I think that this distinction between the need for hospital treatment on medical grounds and being sent to hospital on social grounds is not being met at all by the Minister in the plan, and that it is a matter which certain needs considerable attention.

I wish to deal with another pressing problem which is not mentioned at all in the Report. It is a problem which is causing great concern to many hon. Members on this side of the House. It is the increasing provision of pay-bed facilities in the hospitals. There can be no doubt at all that more and more the Ministry of Health is encouraging people to pay to go into hospital, to jump the queue—it is unfortunate that there is any queue—and to get some sort of priority. This means that a lot of people feel that there are two standards of service in the Health Service—one for those who can pay and one for everybody else. That is not good enough.

Let us take the case of a child who requires a tonsil operation. We all know that if its parents take it to see a doctor in a hospital it will be put on the waiting list and may have to wait six or nine months before having the operation. But if the parents take the child to see that same doctor in private practice that evening we find that in all probability the child can be operated on almost the next morning. On ethical grounds this sort of thing is indefensible and on social grounds dangerous. The people of the country ought to feel that the best possible treatment is available to everyone.

The Ministry of Health, unfortunately, issued an edict some years ago—before the present Minister was appointed—saying that any hospital consultant who did not wish to be whole-time had the automatic right to be put on maximum part-time. The result has been that there is now very great difficulty in getting consultants to be whole time. They want to do maximum part-time —to do nine-elevenths of their work in in hospital and two-elevenths in connection with private patients. Of course, the corollary of that is that when they have become maximum part-time they demand to have pay beds in hospital. They say, quite frankly, "What is the good if us exercising the right which the Minister gave us to be maximum part-time is we have no hospital beds for our private patients?" The result is that every hospital management committee is having pressure brought to bear upon it by consultants who wish to be maximum part-time.

I hope that when we on this side of the House return to power we shall put an end to this system with all its evils. In looking at the proposals, particularly for the Birmingham Regional Hospital Board, in respect of pay beds I find that the provision of Part V beds has become a hallowed matter. It is built in. I find that in the Birmingham region there is the provision of beds to cover every sort of speciality—gynaecology, dermatology, pediatrics and dentistry. These Part V beds are there as a right. They are not related to the various consultancies but are to be provided in hospitals where they have never been provided before, and this without any prior consultation with the members of the hospital management committees. There are to be 29 such beds at Dudley Road Hospital which has none at the moment, there are to be 29 of these beds at Selly Oak, on the new Rubery site, and 21 at Little Bromwich, Yardley Green, where they never had any before. This is a rather serious matter, the continual erosion of the comprehensive principle of the Health Service and the provision almost as of right of private beds for consultants.

There is another matter which I find even more serious. It is the threat with which we are faced by the provident societies and insurance companies which are now doing record business in the country establishing private hospitals in competition with those in the National Health Service. Can the Minister, for example, give us any information about what is going on in Shrewsbury? I am told that there the hospital management committee has unanimously agreed to sell a large area of land belonging to one of its hospitals to an insurance company which is going to build a private hospital within the precincts. It will try to attract nurses in the area by paying them higher rates of wages than the Minister is paying nurses at the moment. They could hardly be lower. The people concerned will be outside the normal negotiating machinery for nurses The people who have paid insurance companies in order to get into hospital will make their own arrangements with the consulatant surgeons or physicians. I hope that hon. Members on this side of the House will take a very serious view indeed of the matter if the Minister confirms that in any hospital grounds in this country a private hospital can be erected in competition with hospitals in the National Health Service. This is something which ought to be fought as vigorously as possible. Hon. Members should make no mistake about it, decisions in this connection have already been taken, certainly in Shrewsbury

We wish the Minister well m the general plan. We note that if we are faced with further economic difficulties we shall not get even the comparatively small amount of money proposed at the moment. I hope that there will be a new awareness of the need for the hospital service not just on health grounds but on social grounds. This has been highlighted in a very dramatic manner. One of the most fundamental problems facing the nation is that we cannot have an affluent private sector in industry unless the public sector proceeds at the same pace.

As an hon. Member said earlier in respect of housing and education, there has been some surge forward. But I think it would be agreed that in these fields we still have a long way to go before we can be at all complacent. As far as the national investment is concerned, we have to invest a greater proportion than even this plan allows for as otherwise we shall have a considerable surge of feeling in the country, and that surge of feeling, I hope, will be taken into account by the Labour Party at the next election. As I say, we wish the Minister well although we recognise the limitations of what he is going to do.

5.20 p.m.

Sir Gerald Wills (Bridgwater)

In common with other hon. Members who have spoken, I wish to commend this White Paper which my right hon. Friend has had prepared with the aid of the regional boards, although it may be that in certain minor, and possibly not so minor, ways I may wish to criticise it. The preface to the White Paper states that the groundwork of the plan is that of the regional boards and that it is their responsibility to work out the programmes and to put them into effect. It is emphasised in the preface that the hospital authorities will be alert to modify present proposals and to bring in new ones as events demand and as circumstances change. It is also quite clear that the programme as set out is not hard and fast but is one which will be reviewed possibly from year to year or perhaps at two-yearly intervals in the light of events as they occur.

In the last paragraph of that preface, we find the phrase "Hospitals are for people". I think that phrase sums up what many of us feel should be one of the chief functions of hospital service. There have been many references in this debate to good buildings, the type of architecture and design, and so forth. Those things are necessary in a hospital programme, but I do not think we can over-estimate the fact that it is the patient who matters in a health service.

When I was reading this White Paper, I wondered at times whether the convenience of any one group of people or the convenience of consultants alone had been given too much prominence when the White Paper was in course of preparation. The needs of the general practitioner and the feelings of the patient as an individual person should play just as large a part as anything else in preparing this White Paper. Neither do I think that the plan should be based too much on the experience and thinking of people who live mainly in the great conurbations or who think mainly in terms of great cities. We should have incorporated in this scheme the experience of people who know rural life and life in the smaller towns. I am sure that this is very important.

The problems of travel in the countryside and of communication in rural districts are very real and must be taken into account when White Papers and schemes of this nature are brought into being. In many parts of the country it is still not possible to hop on a bus and attend as an out-patient a hospital which is quite close. There may be only two buses a week. These things matter to people, and they must be considered.

I hope also that there will be a high degree of flexibility in the regional approach to this plan and in my right hon. Friend's acquiescence to any suggestions which are made by the regions as a result of suggestions which are made to them. I certainly feel that my right hon. Friend is of that mind and that in fact the plan is a framework for the future planning of our hospitals over the next ten to fifteen years.

I make no apology for being parochial in this part of my speech. It will not be any news to my right hon. Friend that my constituents and I attach great importance to the degree of flexibility which my right hon. Friend might be prepared to bring to bear on this plan in years to come. The proposals in the White Paper are admirable in many cases, but they have aroused in my constituency the greatest possible indignation. This is because it is proposed that in the next ten years or so the Bridgwater General Hospital and the Mary Stanley Nursing Home will cease to exist and all the patients who now attend them will have to journey to Taunton in order to receive medical treatment.

I appreciate that this is not the time for me to go into the details of the many objections which about 10,000 people have made to me and the Minister against these proposals. But there is no doubt that the objections are very real. It is relevant for me to point out that in 1960 there were some 87,000 attendances at the Bridgwater General Hospital. This number is obviously increasing as the town grows. I should not like to say how many attendances there will be in ten years' time, but even on the present basis if that hospital were to be closed at least 87,000 people would have to travel from Bridgwater and the surrounding area, which is of considerable size, to Taunton. That is not a prospect which any of them relish, and neither do I.

I sometimes wonder how precisely the plan was prepared at regional level. I find that no Bridgwater doctor was consulted about the regional preparation of the plan. Since, in addition, there is a complete lack of Bridgwater area representation on the regional board it is quite possible that some of the decisions made by the board and transmitted to the Minister were based on incomplete information. I do not like being parochial in a debate of this type, but I feel bound to say that Bridgwater is growing rapidly industrially. Taunton is the place where it is proposed to put the hospital, but the ratio of casualties to population is 35 per cent. in Taunton and 43 per cent. in Bridgwater. It is rather difficult—I put it no higher than that—to understand why it is proposed to close the Bridgwater Hospital.

I want to emphasise again the difficulties which occur in respect of transport from the villages and outlying parts in the country districts. The fare is quite considerable, and this has a bearing on the ability of people to visit their friends and relatives in a hospital if it is sited too far away from where they live. It may be difficult to believe, but in many places in my constituency trains are nonexistent. We have one little railway line to Minehead, but apart from that we have practically no trains. It is pos- sible to spend almost a whole day visiting a patient and getting back home again. These are personal difficulties, and I mention them in connection with my theme of treating people as people in hospital matters. I know that my right hon. Friend realises that there still are people without motor cars, and that it is quite an undertaking for them to travel long distances. This aspect of the plan—the difficulties of getting to and from the new general hospital—will need further consideration.

My right hon Friend, the British Medical Association and many other people of experience have spoken of the importance of visits to the patient and of the need for the human and friendly approach to the person in hospital. It is paramount. It is proper that patients should have visitors whenever possible, and perhaps more frequently than occurs in some cases. Many of these valuable things will be impossible in Bridgwater and the surrounding area if the plan is implemented in its present form, and I believe that the same considerations will apply in other places.

I should like also to refer to the proposal to close the Bridgwater Maternity Home. There are just as many babies born in the Bridgwater area as in the Taunton area—and the best of luck to them. What is more, it seems that this decision to close the maternity home is contrary to a number of points made in a report produced this year by the Royal College of Obstetricians and Gynaecologists who seem to think that it is a good practice to have maternity homes within reasonable reach of comparatively small districts. I should have thought that if my right hon. Friend saw any difficulty in changing his mind, paragraph 23 of the White Paper would give him some justification for having a comparatively small maternity home in Bridgwater.

I am sorry to have devoted so much of my time to domestic matters. but I feel that what is true of my constituency is true of many others. When a plan such as this proposes to close a relatively small hospital, but one which is efficient, is greatly loved and very well supported by local voluntary work, it is bound to cause considerable disquiet and unrest.

I urge my right hon. Friend to realise that in my view, and I do not think that I am alone in this, there is still room for small hospitals which could deal with the less serious surgical cases, and at the same time cope with casualties and outpatients. If a surgical case is serious, it will obviously have to go to one of the larger district hospitals, but I think that my right hon. Friend should think again about this part of the plan to allow this greater flexibility.

I am glad that the White Paper recognises the importance of the family doctor. It envisages providing maternity beds for a doctor's patients and proposes that the family doctor should have direct access to diagnostic facilities in district general hospitals, but, when we are thinking about these doctors in the more scattered rural districts, I wonder whether, because of the time and distance factors involved, they will be able to take advantage of those facilities. I do not believe that they will be able to get to their patients even if they are in such hospitals.

I turn now to the problem of staffing these new district general hospitals, especially those serving scattered rural areas. At present, in the Bridgwater Hospital, about 25 per cent. of the staff —those employed on domestic duties, cooking, keeping records and nursing itself—are married women living in the town or close by. This is true of many other hospitals. How will this percentage of the staff be obtained when a large district general hospital is built on the site of a smaller one? This again is something which must be taken into account.

Paragraph 49 of the White Paper states that the decision to build a new hospital or close an existing one will be taken only after the most detailed consideration and consultation. It will not be taken in isolation, and hospital authorities will welcome the opportunity to seek and take into consideration local opinion both professional and lay, and it goes on to refer to continuous collaboration between local authorities.

If all that happens. and if local lay opinion is taken fully into consideration as well as the views of local authorities, I do not think that the plan as at present drawn up will ever be implemented in my constituency, and I hope that when such representations are made from my area to my right hon. Friend he will take them into consideration.

What I have said does not in any way detract from my admiration of the broad concept of the plan put forward by my right hon. Friend. My only desire is that it should be more flexible and perhaps a little more human in the way it takes account of human wishes, human thoughts and desires with regard to visiting patients in hospital and so on. If this can be done, I think that the plan can be made to work for the benefit both of the patient and the medical profession which serves the patient so well.

5.35 p.m.

Mr. Llewelyn Williams (Abertillery)

The hon. Member for Bridgwater (Sir G. Wills) made a thoughtful speech. When he referred to some of the human aspects of this great plan, I think that he carried with him many hon. Members on both sides of the House, but I think that he must sooner or later realise that, regrettably, though perhaps inevitably, there are limitations on carrying out in full some of the aspirations and desires mentioned by him.

My hon. Friend the Member for St. Pancras, North (Mr. K. Robinson) made an admirable speech and, despite some criticisms, which I thought were valid, gave his approbation to the ambitiousness of this plan. I agree with the approval accorded by my hon. Friend. Within its limits, this plan is bold and imaginative and has many obvious merits.

The basic principle of the plan is the emphasis on the base or general, or district, hospital. I hope that the Minister, with his command of language, will be able to think of a more gripping word. Those are limpid words to describe what will be a focal point of the hospital service, and I am sure that there must be a better word to describe it.

Like the hon. Member for Bridgwater, I, too, have possibly some sentimental reservations about what will happen to our local hospitals in the valleys of South Wales. The building of many of these hospitals was made possible by genuine sacrifices by the miners in the years when things were very difficult for them. Nevertheless, I believe that there must be a limit to our sentimentality, or sentiment if that is a mare appropriate word, with regard to our local hospitals.

I agreed with the Secretary of State for Scotland when he said that we cannot have it bath ways. We cannot have a first-class medical and surgical service operating in both small local hospitals and large base or general hospitals, but I make the plea that so far as it can be done—and I am referring not only to what can be done in practical terms but what can be done in psychological terms —the closure of the small hospitals should be achieved as imaginatively and as sympathetically as possible because of the loyalties which so many people have to these small hospitals.

I believe that a case can be made for the continued use of these smaller hospitals as long-stay geriatric units, or as diagnostic centres or emergency hospitals, and I am sure that an imaginative Minister of Health could find some such use for them. There is hardly any need for me or for any other Member on either side of the House to refer to the paramount need for new hospitals in our country. The figure produced by my hon. Friend the Member for St. Pancras, North—that one in every five of the hospitals in this country was built before the Crimean War—really shook me, and I am sure it shook everyone else who heard it. We also know that over 50 per cent. of our existing hospitals are more than 70 years old. Such a state of affairs is, of course, intolerable, and that is why there is every justification for embarking on this new ambitious scheme.

I hope the Minister will see to it that in this new construction of an almost new hospital service in Britain the most modern ideas will be adopted about the suitability and size of wards and the creation of a new atmosphere in the wards. This was referred to by the hon. Member for Bridgwater as the human factors. I hope the Minister will see that these human factors will take their proper place. I think it would be terribly disappointing if we still have hospital wards with about 30 or 40 beds in them. That would be contrary to all modern development in hospital progress. I certainly hope that the absurdly anachronistic atmosphere which pervades so many hospitals, of treating the patients as so many morons, as though they would not understand even if things were explained to them, will be dissipated for all time. In making this appeal to the Minister, I do not think I am appealing to someone who is indifferent to these considerations, or that this appeal will fall on deaf ears. I am sure that the Minister, who has already expressed his view about this aspect of things, will see to it that these features will be developed parallel to the actual construction of the hospitals.

I read in the Western Mail some very interesting words which emanated from Mr. Arthur Keates, speaking at the annual conference of the Institute of Hospital Administrators in Cardiff on 3rd May. I believe the Minister was present at that conference. Mr. Keates says: The concept it introduces of concentration of services and facilities in large but, I hope, not too large district hospitals is sound. It represents a forward step in the organisation of our health and hospital services. If the programme is completed, nearly half the hospitals in the country will be replaced. Will the harsh realities of the national economy falsify the promised vision? That is the 64,000-dollar question, and everything really hinges upon that.

The Minister, very wisely, I suppose, from his point of view, has safeguarded himself by entering some caveats in the introduction to the White Paper. He has told us that these plans are not to be regarded as commitments because of these difficulties. He said: These figures do not represent commitments and the sums which will actually become available may he somewhat more or less. dependent on the state of the economy, the capacity of the building industry, and other claims on national resources. That, of course, creates a question mark in the minds of all of us who sit on the Opposition benches, because there has not been what we would describe as a very propitious start on some of the projects we have beard so much about in recent years.

I shall refer to two in the Principality of Wales. I think the building of the teaching hospital in Cardiff has been unconscionably delayed. My hon. Friends the Members far Pontypool (Mr. Abse) and Ebbw Vale (Mr. M. Foot) and I are very concerned about the Royal Ghent Hospital, and we have had our hopes damped somewhat by a letter received by Newport and East Monmouthshire Hospital Management Committee from Mr. A. E. Newall, the secretary to the Welsh Regional Hospital Board. These words are no encouragement for us to think that this plan will one day leave the blueprint stage and appear actually before us, and these are the words: The existing timetable for the Royal Ghent Hospital envisaged a starting date at the end of this calendar year. Because of the time taken to obtain the necessary approvals I am not prepared to say that this timetable can be adhered to. If the timetable is to be knocked out of gear at this stage, the outlook for the future is indeed a pretty gloomy one. Mr. Rice Edwards, who is the chief surgeon in the Royal Ghent Hospital and is chairman of the Ghent Hospital Management Committee, said: It is two years since we went to the Welsh Hospital Board and discussed the plan. So far as we can see we are no nearer to seeing any building work taking place than we were then. When we remember that the building of the new teaching hospital in Cardiff is only now proceeding on the basis of site development, then we can really understand why some of us are not so optimistic about seeing the actual realisation of these plans as, perhaps, the Minister would wish us to be and we are compelled to ask rather salient questions of the Minister. Will the first flush of enthusiasm wane? He did wax very eloquent, I suppose rightly, when the plan was announced. Can we be sure he will not weary in well doing? I put this point to him, and it is a very important one. Wild he employ his well-known pugnacity when he has to deal with the Treasury? Experience tells us that he will need to fight as no man has ever fought before if he wishes to see this imaginative plan in real terms.

He knows his Bible as well as I do, and if he turns up the warning of the Good Physician, as we sometimes call Our Lord, he will find in Luke, Chapter 14, verses 28, 29 and 30, words which he may possibly see have a particular relevance to him in the situation in which he now finds himself: For which of you, intending to build a tower, sitteth not down first, and counteth the cost, whether he have sufficient to finish it? Lest haply, after he hath laid the foundation, and is not able to finish it, all that behold it begin to mock him, saying, This man began to build, and was not able to finish. That is the real question for us in this debate today. Will this plan really be brought to fruition? If I may say so, the Government's record in slum clearance and in the five-year school building programme would not encourage us very much to think that this hospital plan is going to leave the blueprint stage. I know the Minister is painfully aware, of course, of the difficulties and obstacles. My hon. Friend the Member for St. Pancras, North had some words to say about the expenditure on hospitals. We remember the Guillebaud Committee and its recommendation, which we thought very modest indeed, for an expenditure of £30 million a year. The expenditure envisaged in this hospital plan is £50 million a year, in the first quinquennium, £200 million, in the second quinquennium £300 million. The case was made out—I do not need to repeat it—by my hon. Friend that this will not meet the burning, cogent needs of the existing situation in Britain today.

What about buildings? The Minister referred to possible limitations to his programme because of building capacity. There is any amount of building going on in Britain today. What sort of building? I pass a huge skyscraper every morning as I come from my place of residence in London to the House of Commons. I am told that it cost millions of pounds. There are similar skyscrapers all over London; but they are not hospitals. In many cases they are blocks of luxury flats and offices. We cannot build everything. We have to have a system of priority for constructive work.

I am told that the new work done by the contractors in 1961 was 10 per cent. higher than in 1960, but by far the largest proportion of that has been taken by private enterprise. That again is something which irks, which makes me uneasy, and which fills me with the foreboding that I shall not live to see some of these 90 new hospitals envisaged in this plan and the 134 remodelled hospitals which are also envisaged in the plan. These considerations make me feel very dubious. A more enlightened Government would insist on having their priorities much more equitably fixed because their social vision would be clear.

I come to a very important aspect of the hospital plan. I am referring to the question of the people who will staff the hospital. It is no good thinking in these Utopian terms, of these vast imaginative schemes, if they cannot function because we have not the staff necessary to man these hospitals. I do not think that the outlook is at all promising. I do not know what will be the consequences of the discontent which is so prevalent today in the nursing profession. I do not know if existing nurses will persuade their sisters or, if they are married, their daughters to enter the nursing profession which has been so shabbily treated in the last few months.

The Royal College of Nursing, in a memorandum, stated that in 1961, for the first time since the end of the war, the numbers both of student nurses and trained nurses fell. That is a very serious statement, especially in the light of an ambitious scheme such as this. I think that the Minister, if I may say so very pertinently to him, is rather complacent about the situation. He has been very touchy about this. In Cardiff, he said that some of the statistics about nursing shortages are obviously "phony". Mr. Rice Edwards said: If he would like to take statistics of the Royal Gwent. we can show him very reliable ones, which will prove to him beyond any doubt that this hospital is far too small. We have a shortage of nurses and certainly a shortage of beds. The Minister does not make one important distinction. It is a distinction that must be made if there is any sense to be brought into these calculations—the distinction between trained nurses and untrained nurses. The percentage of trained nurses is going down.

The Minister of Health (Mr. Enoch Powell)indicated dissent.

Mr. Williams

The Minister shakes his head, but the statistics and all the facts that I have been able to glean from different sources entitle me to say that the number of trained nurses is going down. The number of untrained nurses has increased over the last few years. I shall quote another valid authority if he refuses to accept my word. I quote from the periodical issued by the medical practitioners' union. This is what it has to say. It gives the figures for 1949 and 1961 of qualified nurses, student nurses, State enrolled nurses and other nurses. It comments: The most striking figure is the drop in the proportion of fully qualified and student nurses and the large increase in the number of unqualified nurses. During the same period the number of patients treated as in patients and out patients rose by 25 per cent. The number of hospital doctors rose by 33⅓ per cent. This means that there are relatively fewer nurses today, taking into consideration the number of patients treated, and not the number of hospital beds. The Secretary of State for Scotland tried to relate the number of nurses to the number of beds. We have a quicker turnover now, and the important thing is not the number of beds but the number of patients treated in the beds. According to the union A large part of the additional work is done by the unqualified staff". The Minister cannot be satisfied when the figure of wastage is 50 per cent. in mental hospitals and 30 per cent. in general hospitals.

With regard to doctors, we have lost five valuable years because of the absurd conclusion of the Willink Committee in which it advocated a cut of 10 per cent. in the intake of medical students. These were five very valuable years. We could have had more doctors available for our service. In the Sheffield Regional Hospital Board's area 58 per cent. are foreign doctors. I would not by any stretch of the imagination close the door in this country to anyone who wished to serve in this very fine and admirable way, but it is a pretty poor reflection on our medical schools that so many of the doctors in this area should be foreign born.

The actual number of dentists operating in Wales today was fewer in 1961 than in 1960 by nine. The situation in Wales today is that there is one dentist to every 6,353 people. That is a shocking state of affairs. One has only to be a parent, as I am, living in South Wales today, to know how impossible it is for youngsters to have the proper care to which they are entitled as growing children because of this absurd shortage of dentists.

My hon. Friend the Member for Birmingham, Small Heath (Mr. Denis Howell) referred to the issue of the local health services which the Minister will expect to be the instruments to reduce the number of beds required in his Hospital Plan. We all know, certainly those of us who served in Committee on the Mental Health Bill, of the possibility inherent in the local health services in future in connection with community care, domiciliary visits, home help, health visitors, social psychiatric workers, training centres for physically and mentally handicapped people and residential homes and the hospitals. That is right and proper. The Mental Health Act is one of the finest pieces of legislation which ever went through the House. But it will be absolutely useless unless the local authorities are provided with the wherewithal to implement it. The block grant will make it impossible in many instances for this great scheme to be carried out.

Let us be perfectly frank today. In any county council or other local health authority one has one's outstanding leaders, and they all have different orientations. For one person education is the be-all and end-all of existence. Another person will have a slant towards roads. These people, being perhaps dominant personalities, will ensure that a greater proportion of the block grant will go to their own special "pets". Health may well take a very subsidiary place in the final assessment of the resources of local authorities. That is why I ask the Minister to realise that his plan just cannot succeed unless the local authorities are given resources. Without those resources, they cannot possibly carry out their tasks.

The plan is excellent in so far as it deals with the problems of those who are some times referred to as the mentally afflicted. This part of the plan based on the Mental Health Act will do away with the large, segregated, soulless communities that we sometimes see. We have had some in Wales, one with over 2,000 patients and two with 1,500 patients. I more whole heartedly support the Minister on this than on any other point. Those places should be done away with altogether. Let us have our acute psychiatric units in our base general hospitals, and if we must have special hospitals, let them be much smaller than these huge impersonal establishments.

I agree that the responsibility in this respect should be shifted more and more on to the community so that we can really be brothers to one another and offer our shoulders to ease the burden of those who are afflicted. Goodness knows, the line between those who are afflicted and those of us who think we are not is a very thin one. Just a little extra pressure or problem makes all the difference. But if we are to have this community care attitude towards this problem, the Minister must provide the wherewithal.

Some very frightening words were uttered by my hon. Friend the Member for Small Heath when he referred to the increase of private beds in the hospital service. The idea of what is likely to happen in Shrewsbury frightened me. I read some days ago some words by Dr. Horace Joules, a very eminent physician, who referred to this trend—it is an increasing one—of undue concern for the private patient. He said that in the Central Middlesex Hospital, some beds were used in shifts. Are we going back to the Middle Ages? There are 1,000 people waiting for beds in one small hospital in Harrow, and the board has approved an increase in the number of private beds. There is no waiting list for private beds. In our constituencies we find how easy it is for one to get into a hospital if one is a private patient. We also know about the insurance schemes run by some of the large firms. All this is in line with Conservative philosophy, but it is definitely opposed to Socialist thinking

I am a Welshman and represent a constituency in Wales, and as a member of a conquered race I am full of suspicions and little jealousies. I have been through the tables at the end of the White Paper scrutinising the lists of percentages to see whether Wales is faring worse than England. Although I am a suspicious and jealous Welshman, I try to be an honest one, and I must confess that Wales has done fairly well.

Mr. K. Robinson

My hon. Friend has a Welsh Minister.

Mr. Williams

It may well be, of course, that we start from a worse position than the rest of England. The only exception I can find is with regard to mentally subnormal people. It is specifically stated on page 272 of the White Paper that there is a shortage of beds for subnormal and severely subnormal patients in Wales. That is why I cannot understand why we should be below the national average in beds per 1,000 population.

I do not want to be facetious just as I finish, because I think that I am dealing with a very serious subject. Obviously, I cannot suggest, and I would not, that the rate of mental subnormality or abnormality is higher in England than it is in Wales. I do not think that would be true. Of course, the English people are politically very subnormal vis-à-vis the Welsh. From 1922 onwards if the English had been like the Welsh we should have had a Socialist Government continuously. But that is a political reflection.

I hope the Minister will look again at the consideration which I have mentioned. He has a wonderful chance' think he knows it—to be associated with probably the most ambitious hospital building programme ever known in this country and possibly in the whole world. But it will be a terrible pity if it is said of him, in words that I have quoted before, that people will mock at him because he started something which he could not finish.

6.7 p.m.

Sir Henry Studholme (Tavistock)

It is tempting to follow some of the arguments used by the hon. Member for Abertillery (Mr. Ll. Williams), but I know he will understand if I do not do so, because I want to touch on a rather different aspect of the problem.

Like other hon. Members who have spoken, I congratulate the Government and my right hon. Friend on the new Hospital Plan. I think that on broad lines it is excellent. We all want to see the best possible hospital service, and I am sure that the Government are determined to ensure that we get it.

Obviously, because of the enormous cost of the most up-to-date specialist equipment and because of the need to save the time of specialists, we cannot have the most modern specialist treatment in every small local hospital and it has to be concentrated largely in the bigger hospitals in the big centres. It may also be possible that a number of small hospitals can be closed down because a big modern hospital is easily accessible to the patients and no undue hardship will be caused to them and their relatives. In fact, there may be cases where the disadvantages of closure will be outweighed by the advantages of the new service provided.

On the other hand, there are in many country districts hospitals which on no account ought to be closed. I was interested in what my hon. Friend the Member for Bridgwater (Sir G. Wills) said. Plans which may look tidy and plausible on paper may be far from sensible in reality. All sorts of things have to be taken into account, such as the weather, the state of the roads in winter, the distances, the availability of public transport, and so on. If I may, without repeating the remarks of my hon. Friend the Member for Bridgwater, who apologised for being parochial, may I extend a similar apology, for I wish to take my constituency of Tavistock, a scattered rural area, as a case in point.

The White Paper contains a list of hospitals in West Devon which might be closed. On reading the White Paper, it was not clear when, if at all, these hospitals would be closed, although some people did jump to the conclusion that they would be closed down in 1971. I took the matter up with my hon. Friend the Parliamentary Secretary who, as always, was kind and helpful and assured me that the plan was not a cast-iron one but merely a broad outline, and that if any hospital was eventually closed that would not take place until after 1975. She informed me that such a step would not be taken until after the most careful consideration and discussion of the matter with the local interests and the regional hospital board. I was assured that, in the first instance, any representations should be made to the regional hospital board.

So far so good—but that is not quite good enough. My constituents, understandably, would like to be assured that under the new plan there will continue to be a hospital and maternity home at Tavistock, that Holsworthy will not be left without a hospital and that Plympton will not be without an old people's hospital. Some people think that the whole of Devonshire has a Riviera climate and while that may be true of Torquay and some other places, it is certainly not true of all of Devon. Inland we have some high, exposed country. That applies to Holsworthy and to Tavistock which is situated on the edge of Dartmoor, and much of the hinterland there is high and bleak, particularly in the winter.

In winter the roads are not only dangerous but sometimes impassable because of snow, ice and dense mist. I cannot see that it would be sensible therefore, to close a hospital like Holsworthy. Then take Tavistock. It may be only eleven miles from the proposed new hospital at Derriford but the hospital and the maternity home at Tavistock serve a wide catchment area. People would have to travel thirty miles or more in a return journey to get to the new hospital on the outskirts of Plymouth. Some would also be coming from places where public transport is virtually non-existent.

If the hospital in Tavistock were closed, apart from the dangers resulting from treacherous roads, there would be questions of inconvenience and expenditure for out-patients who would have to go further afield for treatment. The question of accidents and delay in getting people to hospital arises. This delay might be fatal in certain circumstances. It is worth remembering that the maternity home was built at Tavistock because babies were being born in ambulances on their way to Plymouth. It was as a result of great pressure that the maternity home at Tavistock was established.

Vital human questions must also be considered; for instance, the loss in wages for people who must attend for treatment. A day's pay might be lost if they have to travel so far afield. There is the difficulty for young mothers who must find someone to mind their young children, perhaps for the whole day. There is is also the additional expense of relatives and friends having to travel great distances to visit in-patients and if, God forbid, there were ever a war, the hospitals away from the vulnerable large centres would play a vital rôle.

It is for these reasons that my constituents seek an assurance from the Minister that local councils will be consulted not only before any action is taken before a definite decision is made concerning the future of these hospitals. I realise that much of what I have said is parochial. I do not think I need apologise for that because these problems are of great importance to my constituents and I have no doubt that many hon. Members who represent country constituencies are facing problems of exactly the same nature.

6.16 p.m.

Mr. Harry Randall (Gateshead)

I shall resist the temptation mentioned by the hon. Member for Tavistock (Sir H. Studholme) and will try not to be parochial. It is a somewhat sad reflection that at least the last two hon. Members to have spoken from the benches opposite have dealt largely with the parochial aspects of a plan which affects the whole country. I could easily be parochial and speak on behalf of my constituency and its hospital management committee. I could indeed argue a good local case. At another time and in the appropriate way I propose to do that, but today I shall concentrate on the plan as a Whole.

While I welcome the Government's decision to place their plan before us, there are certain shortcomings and difficulties contained in it which should not be ignored, especially in view of the considerable enthusiasm which was created when the plan was first issued. I wish to confine my remarks to four main points: the district general hospital, about which I shall make a plea for more humanity; the provision of geriatric facilities; the question of whether the displaced staffs will be prepared to travel—an item which has not so far been raised—and the related problem of redundancy which may face some of the existing staffs.

The concept or corner-stone of the plan is the district hospital which will provide all the services. Because of its size it will serve a large population and, it is hoped, will provide the very best medical attention. That is a virtue with which I wholeheartedly agree and one which cannot lightly be dismissed. Indeed, I think that it is because of that concept that the plan has been so widely accepted.

However, there are some shortcomings, if not dangers. For example, some areas are to have two or three district hospitals and this would seem an admission that one large hospital is too large. It is already admitted that a unit must not be too large and I am given to understand that it must not contain more than about 800 beds. A unit of even that size must have adequate communications It all levels within the hospital unless the homeliness and friendliness of a hospital as we now know it are to b lost. This is an important aspect when considering the work of a modern hospital. It is not only the medical care and the skill of the doctors that matter. The general atmosphere is important to the recovery of the patient.

In the suggested unit of not more than 800 beds, I hope that every effort will be made to see that the communications at all levels are the best possible. The problem of distance and isolation has been mentioned, and this is important not only for visitors and for in-patients, but for out-patients, and it is something which should be considered very carefully. I agree with the theory of the district hospital, but special attention must be paid to the problems of communication, personal relations and attitudes.

The ratio of beds for geriatric patients is 1.3 per 1,000 of the population. To put it mildly, that is not a universally accepted ratio and has many critics. Has the ratio deliberately been fixed too low? Are we being told that the best medical and nursing care for the elderly is available not in hospitals, but at home, and that it is a problem to be tackled by the local authorities? I suspect that local authorities are to be asked to bear a greater burden. I know that it is said in the White Paper that this matter will be subject to continual review, but this is not something on which we can take a gamble. We ought not to take the risk when the consequences, if the ratio is too low, are so great.

Where are geriatric patients to be cared for? Am I to understand that it is to be in the district hospitals? I am not sure that that is right for the elderly. I was recently reading an international report which dealt with the subject of elderly patients in district hospitals under the constant searchlight of the specialists and other doctors. I do not want to be misunderstood when I say that we have to he satisfied that when folk get older they do not want to be worried too much by doctors and specialists and others running about the ward. Have not old people largely learned to live with their ailments and sometimes to come to peace with them? Is it always wise to try to do more than we should be doing?

The report which I have mentioned refers to the patient who, it was obvious to everyone, was going to die. He was surrounded by desperate doctors and nurses rushing about with oxygen, syringes and tubes, while the family, waiting to take a last farewell of its dying member, was kept outside in the corridor. Where are we to cope with geriatric patients? I know that we have to make an estimate of their needs and decide what sort of treatment they should have, but the best place for them might be not in the district hospital itself, but rather in what is called the long-term stay annexe. I should prefer an approach towards the problem of the elderly to be made in that way.

How are we to staff the district hospital? This is already one of the most pressing problems. Despite the shaking heads on the Government Front Bench, there is a widespread and firm feeling that the wastage of nurses is far more than it should be. The true extent of the problem is hidden by the sterling efforts of the staff and by resort to local part-time labour. When we have district hospitals, what is to happen to local part-time and local full-time labour?

I know of one senior regional official who, off his own bat, found a solution to this problem by suggesting that nurses and other staff should provide their own conveyances. In that case, the distances involved are not great, but what happens when the district hospital is ten or twenty miles away? Are the part-time staff, upon whom we rely a great deal, or the full-time staff to have to use their own motor cars?

We have been told that a good deal of consideration has been given to personal relationships, but I wish that there were as much excitement about trying to humanise our hospitals as there is about the bricks and mortar. This is a problem which should be tackled much more energetically if we are to ensure that we keep our staff.

I want finally to refer to redundancy. The implementation of the plan must not be bought at the cost of individual hardship, and the staffs of hospitals which are to close are likely to face individual hardship. This problem has not been sufficiently appreciated and in the first flush of enthusiasm we ought not to overlook, it. We have to remember those to be displaced and provide for them adequately. There must be no loss of status and there ought not to be even loss of post.

I think that I know hospital staffs well enough to believe that they may be reluctant to press their own case strongly. They may see their own problems dwarfed by the overall plan. But I ask the Minister to consider this aspect most carefully. The Treasury has dealt with redundancy throughout the Civil Service very generously, indeed—that is an over-statement; let me say that it has been generous. I want the Minister to be just as generous with hospital staffs who are displaced.

6.27 p.m.

Commander C. E. M. Donaldson (Roxburgh, Selkirk and Peebles)

The hon. Member for Gateshead, West (Mr. Randall) has spoken, as he always does, with fervour, interest and sincerity. I shall endeavour to do the same. We are dealing with two White Papers, Cmnd. 1602 and Cmnd. 1604, and I wish to refer to the former which refers to the ten-year Hospital Plan for Scotland. In an Adjournment debate I had to complain about something which is not in the new plan and some things Which were, particularly in relation to a hospital serving a general purpose in my constituency of three counties, and also serving the County of Berwick, which is next-door to my constituency. I refer to the matter again because on the Adjournment debate I did not have the time or opportunity to say several things which I want now to say.

As with the plan for England and Wales, there is a goad deal in the Scottish plan to be commended and I have to praise both my right hon. Friends for the time and effort which they and their Departments and all the regional boards have put into the thinking out and creation of these ten-year plans. It was said in the Adjournment debate that this was a continuing process and that the hospital plan was not conceived just as a ten-year plan so that it would not be until ten years from now that another plan was introduced. I hope that I am right in assuming that the ten-year plan is the "kick-off" for a continuing process which is constantly under review and subject to suggestion and improvements by recommendations from regional hospital boards, which in turn are supported by management committees, as is the case in my own area. A great deal more good will come from the application of this original ten-year plan than the public generally has so far appreciated.

I do not want to go into a great deal of constituency detail. Indeed, the hon. Member for Gateshead, West twitted one or two of my hon. Friends for having been parochial. However, that criticism does not apply only to this side of the House. The hon. Member for Abertillery (Mr. Ll. Williams) made a most interesting speech and spoke with great knowledge and exactitude when he quoted St. Luke's Gospel, but he went on to make a number of provocative points which were parochial. Perhaps we should not follow that too much. The great temptation in following the hon. Member for Abertillery is to quote chapter and verse, but I quote merely the Lord's Prayer, which says: And lead us not into temptation". I do not want to be tempted from the general tenor of the debate and the acceptance of the plan combined with some criticism of the possibilities of its application. I think that no one, including the hon. Member for Abertillery, wishes to make it a matter of party politics.

My right hon. Friend the Secretary of State for Scotland and my hon. Friend the Member for Glasgow, Hillhead (Mr. Galbraith), the Under-Secretary, with whom I have conferred many times about local matters. would not wish me to speak for too long about a regional hospital, but I have to refer to a hospital which serves four counties, three of them forming my constituency and the fourth the constituency of the right hon. Member for Berwick and East Lothian (Sir W. Anstruther-Gray), Mr. Deputy-Speaker, for whom I also speak on this occasion.

This is a very well conducted hospital. The hon. Member for St. Pancras, North (Mr. K. Robinson) spoke of the siting of hospitals and the transport required. The hospital with which I am concerned is the Peel Hospital in Selkirkshire which is acknowledged as being extremely badly sited. We all know that it was an emergency hospital taken over under the National Health Service, and that no finer surgeons and medical practitioners, nor more highly dedicated sisters and nurses, are to be found anywhere. But it is badly sited. Accessibility is bad and we all know the great part which visits to patients play in medical treatment.

I have suggested that if the ten-year plan is to go on and on, so that we are always looking ten years' ahead and not breaking the long-term plan into ten-year disjointed limbs, that hospital should be replaced and that we should look for a properly located site for a new hospital. I do not press for an answer now. I understand that representations from the Border Hospitals Board of Management were recently made to the Secretary of State. I was not privy to that meeting nor do I know its results, but I hope that this centrally located district hospital, serving four Scottish counties and 75.000 people, will be sited somewhere else. I understand that a site is available. It is for the regional hospital board to say where it should be, no doubt prompted by the Border Hospitals Board of Management. But the acquisition of a site, either by purchase or by auction, would go a long way to allay the anxieties of my constituents and of those of the constituency next door about the proper application of the beginning of this ten-year hospital plan.

6.35 p.m.

Mr. Eric Lubbock (Orpington)

As the hon. and gallant Member for Roxburgh, Selkirk and Peebles (Cammander Donaldson) said, this is not a party political matter. Particularly is this true, as we now see that the Conservatives have accepted planning. As Mr. Mark Arnold Foster said in the Observer yesterday, planning is no longer a dirty word in the Tory vocabulary. It must be obvious to all hon. Members that planning is especially essential for hospitals, when it takes so long from the moment of their conception to the moment when they are built and ready for use

I congratulate the Government on their Hospital Plan, and I hope that they will pay careful attention to my remarks, because in the many years that I expect to remain in the House I do not suppose that the occasions upon which I shall feel able to congratulate the Tories will be numerous.

The first question we must ask ourselves about the hospital programme is whether it is large enough. We have already heard that, some years ago, the British Medical Association said that we should be spending £75 million a year on our hospital building. That compares with the £50 million a year spread over the 'ten years of this programme. This takes into account the 90 new hospitals which it is proposed to build, the 134 Which are to be modernised, and the several hundred schemes of a smaller size.

If this could be achieved with the sums which are now earmarked, in fifteen years' time our hospitals should be very much superior to those that are in use today. No one can argue about that. But there is a very important question to which we must know the answer before we can say what likelihood there is of the plan's being fulfilled. We need to know whether the estimates are being calculated in terms of January, 1962, pounds or in money terms. It is important to know this, because otherwise the expenditure in the second quinquennium might be no larger than that in the first quinquennium. As this is such a vital point I hope that we shall have an answer from the Minister.

We must also bear in mind the fact that the plan has been hedged round with all sorts of qualifications. I believe it was the hon. Member for Abertillery (Mr. Ll. Williams) who referred to paragraph 46 of the White Paper, which outlines the restrictions. It refers to the possible factors which may inhibit the success of the plan, and, remembering what happened to the capital expenditure programmes of local authorities towards the end of last year, as part of the measures to meet the economic crisis, we may be forgiven for thinking that the remarks contained in paragraph 46 may be in the form of an apology for the non-fulfilment of the plan even before its first stage has been executed.

But let us assume that we succeed in building new hospitals and in modernising others. Several hon. Members have asked the very important question of where the staff to run these new hospitals is to come from. It has been pointed out that this subject is dismissed in one paragraph of the White Paper, although it is perhaps the most important feature of the lot. The Willink Committee estimated that 350 doctors were emigrating to the Commonwealth every year. Indeed, Dr. J. Seale, in a letter to the Guardian on 23rd January, put the figure at 500. Nobody has bothered to collect accurate statistics, and there is still room for disagreement. But all the authorities agree that this rate of emigration cannot be tolerated. This is mainly because of the miscalculations of the Willink Committee, which have now been generally admitted. It is known that we have not been training enough doctors to meet the increase in population and the growing demand of the hospitals.

If this is true of doctors it is even more true of the nursing staff. Here the problem has been aggravated by the very high wastage rates which have occurred in recent months, and which have been referred to in two recent debates. This morning I received a letter from the matron of a hospital, telling me about a nurse who had emigrated to Australia and who had written to her from there telling her that on the boat in which she travelled to Australia there were no less than forty trained nurses. I do not know whether that was coincidental, but if forty trained nurses are leaving on every boat to Australia it is clear that we are dealing with a problem of some size.

The Minister knows that the situation can be corrected only by offering the nursing profession pay and conditions which will stand the test of comparison with other occupations open to young men and women of intelligence. Yet he has refused to listen to the unanimous advice offered by the Royal College of Nursing, the Royal College of Midwives, the Confederation of Health Service Employees, N.A.L.G.O. and hon. Members from all three parties.

I now turn to a feature of the plan which must be examined with the greatest scepticism. I refer to paragraphs 31 to 44 of the White Paper, under the general heading of "Care in the Community". The hon. Member for St. Pancras, North (Mr. K. Robinson), in referring to this section of the White Paper, said that it was full of pious hopes and unwarranted assumptions. I do not know whether paragraph 31 is a pious hope or an unwarranted assumption when it says: the aim will be to provide care at home and in the community for all who do not require the special types of diagnosis and treatment which only a hospital can provide. That is all very weld, but can it be done? The Medical World Newsletter of March, 1962, says: The Local Authorities can produce schemes on paper to deal with these new domiciliary services, but who is to pay for them and who is to staff them? Paragraph 37 of the White Paper refers to the number of health visitors, home nurses and home helps and says: The numbers may be expected to increase further: the national figures are made up of local figures which show wide variations, and nowhere have the services yet attained their full development. As they expand both generally and in particular localities, the hospital provision forecast in the plan will require review. What specific grounds are there for believing that these services can be expanded? I ask this question particularly because it is fundamental to the success of the Hospital Plan and also because it seems to conflict with the letter that I received from the Parliamentary Secretary, dated 15th May, in which she said: Demands on the home help service in Kent are increasing but the availability of work in light industries in the area has reduced considerably the number of suitable women willing to work as home helps. The Council have as a result had to reduce the service provided for a number of people … often in the face of a real need for it. I am sorry that the hon. Lady is not here at the moment. I wrote to her and told her that I would refer to this letter.

There is an obvious case for transferring some of the health functions of local authorities either to regional hospital boards or to a new regional health board which would be responsible both for the hospitals and for some of the local authority aspects of personal health.

There are three arguments. First, the home help is concerned primarily with keeping people out of hospital in the first place and with helping them to stay out once they have been released. Secondly, the services which home helps provide would be financed by taxation and no: through the rates, which are becoming very burdensome. If the regional boards were responsible for services such as home helps, there would be every incentive for them to provide an adequate service, because any amount of home help is still cheaper than hospitalisation. Local authorities have not this incentive, because if someone has to go into hospital in the end, the money comes out of another pocket, as it were. Thirdly, if the services were under unified control, there could be an improvement in co-ordination.

I had a letter from a well-known doctor about lack of co-ordination among the three elements of the structure of health service, and he pointed out to me that it often militates against the best interests of the patient who, after all, is the most important person in this discussion. I gave an example in speaking about home helps, but the same remarks apply with equal force to such matters as Part III accommodation and inoculation. There is room for much greater integration between the various aspects of the health service, and this must be considered if the Hospital Plan is to succeed.

At the risk of being accused of being parochial. I want to refer to some details of the plan as it affects my constituency. 'We are told that the old hutted unit at Sidcup is to be replaced by a new district general hospital, which will include a new major accident centre and will cover the whole of the Sidcup and Orpington district. Does this mean that casualties which occur on the A.21, which is an extremely dangerous road, must be taken all the way to Sidcup for treatment? If so, it seems to be a retrograde step.

The White Paper says that the ultimate closure of Orpington Hospital is envisaged as a result of schemes starting after 1970–71 but that it will still be in existence in 1975, with a reduced number of beds. That is all very well, unless it serves as an excuse for doing nothing about Orpington Hospital which, like the old St. Mary's, is an old hutted unit built in the First World War and totally unsuited to modern thought. A hospital such as this must be much more expensive to run than a properly planned modern unit. To take one example, the heating costs much be very much greater than those of a correctly insulated building.

Next, where is it intended that we should put the 234 geriatric beds, which at present arc in Orpington Hospital, once the hospital is closed? If these patients are to be accommodated in the new district hospital in Sidcup, it will be very much more difficult for friends and relatives to visit them. This is not a problem which is particular to Orpington, because several hon. Members have raised it with reference to their constituencies, but it is a matter which needs the closest attention. The same comment would be true about acute cases, but I infer from the White Paper that once Orpington Hospital is closed, these would be accommodated in Farnborough Hospital, although that fact is not specifically stated.

In conclusion, I say that the plan is some improvement on anything which we have had before, although that would hardly be difficult considering the very low priority which has been given to spending on hospitals ever since the war. I express the hope that the reservations to which I referred at the beginning of my speech will turn out to have been unnecessary and that over the years we shall build hospitals of which we can be justly proud.

6.48 p.m.

Lord Balniel (Hertford)

It is a pleasure for me to follow the hon. Member for Orpington (Mr. Lubbock). I was interested to hear one who might be described as the arch-apostle of laissez-fairelecturing the Conservative Party on their inadequate planning, and I was also interested—although I do not wish to follow many aspects of his speech—when he suggested that the home help service, which surely is one of the finest functions of local democracy, should be taken out of the hands of the locally elected people and placed in the hands of Ministerial appointments in the shape of the regional hospital board. As a strong believer in the part which local democracy can play in the running of the health service, I would regard this as a very retrograde step.

For a short time I served with the hon. Member for St. Pancras, North (Mr. K. Robinson) on a regional hospital board, and I was interested to see that only the other day our then mutual chairman described the responsibilities of that particular regional board as containing 150 hospitals and a complement of 36.000 beds. He pointed out that these hospitals were of all shapes, sizes and ages. Some had been built in the days of the Battle of Waterloo and others had been built in the Victorian days. There were also the cottage hospitals of the Edwardian era, institutions which had originally been built as Poor Law institutions and even a few hospitals which had been built in the inter-war years. But he said that they all have one feature in common—none of them had been built during the past twenty years.

The merit of this plan is that when it is translated into practice it will completely transform the picture of these various regional boards. The plan envisages the building of ninety entirely new hospitals during the next ten years. It envisages the extensive rebuilding of a further 134 new hospitals during the next ten years, and there will also be a large measure of improvement, upgrading and modernisation.

I thought that the hon. Member for St. Pancras, North poured cold water rather excessively on the scale of the plan. In very rough terms, it means that between a quarter and a third of all existing hospitals will be replaced by new buildings started during the next ten years. If one looks slightly further ahead, it means that almost half of the existing hospital buildings in the country will have been replaced by new buildings started before 1975. We are referring to what the hon. Member for Orpington described as the Cinderella of the social services. She may not yet be exactly ensconced in her glass coach, but she has a fairly glamorous vision before her eyes. We ourselves might not look upon this entirely as being a vision, but what we have, and what the hospital authorities have, in this plan for the first time is a picture which sets out the hospital structure of the next ten years. For the first time we have something tangible which we can discuss and which the hospital authorities can study.

It is a credit to my right hon. Friend that although quite a number of months have passed since his plan was first published, although every opportunity has been given for criticism, and although there have been two debates on the plan in another place, there has materialised only a very smell amount of criticism of the main structure. I agree with the recent review undertaken by the Hospital and Social Services Journal of this Hospital Plan which concluded that On the whole, as a grand design, its stature is undiminished. I should like to join other hon. Members in congratulating the members of the regional hospital boards on the fine work which they have undertaken with a sense of great urgency in the preparation of this plan. I also congratulate my right hon. Friend. He specifically disclaimed that this is his plan, but most of us on both sides of the House will agree that his leadership and initiative have contributed powerfully to the formulation of the plan.

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

The hon. Gentleman said that there had been very little criticism. That is true, except for the fears now expressed—and I ask him whether he has noted them—by the local authorities, through the A.M.C., for example, who wrote to me on this matter yesterday, pointing out that much of the success of this plan, when it is carried out, will depend on co-operation from local authorities and on the part which they will have to play and the work which they will have to do in rescuing people from hospitals and treating them in the community. Their criticism is financial: will they have enough money to be able to do it?

Lord Balniel

I accept that there are worries, among persons associated with the plan, whether it will be translated into fact, and obviously finance lies at the basis of their worries. We look to my right hon. Friend to implement the promise contained in the plan, and we shall hold him and his successors responsible for any failure to implement it.

I welcome, however, the hon. Member's comments on the work of local authorities, because this is an element which I should like to discuss. My right hon. Friend has emphasised that this is not his plan and that it is a corporate plan, and he has also stressed his desire and that of the hospital service to welcome comments and suggestions from the public. I believe that in emphasising this my right hon. Friend is touching on something which is of fundamental importance, not only for the Hospital Plan but for the health service in general. The hospital service is saying, "This is our plan. This is the best that we can do. We want your help by improvements and suggestions."

In February my right hon. Friend convened a conference on the scope of voluntary work in the Hospital Plan, and the report rightly emphasised that the voluntary contribution, particularly in community care—the local authority field—has not yet reached its full potential. I find this completely true, and I find it a rather sad reflection on the service. Wonderful work is being done by a fairly limited number of people with a strong sense of social mission. May I give an example from my own constituency? There we are building the first of the new district general hospitals referred to in the plan. The wards will not be open to receive patients until some time towards the end of next year, but already a League of Hospital Friends has been formed, and it is willing and able to provide amenities the moment that the patients and the staff begin to fill the hospital.

While great work is being done, I believe that it is in the public interest, as a means of providing a sense of social purpose and as a focus for idealism, and also in the interests of the health service itself, that there should be a much wider sense of partnership. By this I do not mean only a partnership between the hospital service, the local authority service and the general practitioner. I mean a much greater sense of partnership between the hospital service, the local authority service and ordinary members of the public. I should like to see the ordinary members of the public feel that they were playing a part in the building up of the hospital service.

I have very recently returned from journeying in Israel. There I saw something which I found extremely moving. Although it is not directly connected with this Hospital Plan, it incorporated a sense of purpose which I should like to see in our plan. In that country all girls of the ages of 17, 18 or 19 do two years' military service. As part of their military service, and as an honour, they are allowed just once in their lives to give a welcome to immigrants coming to their country by ship or by air. These young girls welcome the immigrants and, as an honour, for a short time they are allowed to look after those families when they come into the country.

The reason they do this is that it is felt that the smile of a girl doing this social task just once in her lifetime makes an infinitely greater welcome than would the same task performed hundreds of times by an official. These girls feel a strong sense of being partners in the creation of their country. What I want to see is the young people of this country feeling that they are partners in helping the sick and the enfeebled.

I very much welcome the circulars which my right hon. Friend has recently addressed to hospital authorities and local authorities urging them to provide opportunities for voluntary service in the hospital service. The voluntary organisations to which he was referring and of which he was thinking, however, embrace almost only the adult section of the community. I should like to see my right hon. Friend undertake a profound and serious study in conjunction with the Ministry of Education and those charged with responsibilities of youth organisations to see what part young people can play in this field.

Of course we should not turn all our Teddy boys into boy scouts overnight. That is impossible, but I find that so many boys and girls are without a social purpose simply because they cannot find a constructive channel through which to express their idealism and enthusiasm. If my right hon. Friend could somehow incorporate their energy and idealism in the hospital service I believe that he would be serving a very wide and urgent social need and also breathing some life into a service which too often tends to be bureaucratic.

There are one or two other aspects of the Hospital Plan to which I wish to refer. The core of the plan deals with the district general hospital, a hospital of between 600 and 800 beds and a catchment area of 100,000 to 150,000 parsons. Medical opinion seems to be fairly generally agreed that that is about the right size of hospital for this country and that we should certainly try to avoid having large hospitals of the Scandinavian type. The Report says in paragraph 20 that: The district general hospital offers the most practicable method of placing the full range of hospital facilities at the disposal of patients and this consideration far outweighs the disadvantage of longer travel for some patients and their visitors. I accept that statement, but only if there is a major improvement made by many hospitals in their visiting hours. Many hospitals do not yet seem to appreciate the generosity of visiting hours already allowed by the best hospitals without any impairment of service to patients. I believe that there are very few hours of the day when the wards could not be open to visitors. At the very least, all hospitals ought to open their wards to visitors twice a day.

Mr. Denis Howell

The hon. Member is on a fascinating point about visiting hours, but while all of us would have considerable sympathy with the underlying motive of what he had said, I hope it will not be forgotten—as some of us think the Minister sometimes forgets—that often a patient wants to get rid of visitors. A person who is convalescing is harassed by the fact that the family think they should be with him for the whole day.

Lord Balniel

The hon. Member makes a perfectly valid point. I think we must leave a large measure of discretion to the sisters in the various wards. The hon. Member, however, has an urban constituency. I think that he slightly underestimates the incredible difficulty in rural areas of getting to the hospital in order to fit in with the rigidly fixed and very limited visiting hours.

I should like to refer to another feature of these district hospitals. A matter which is rather surprising is the variety in the cost of building. Welwyn Garden City and Hatfield Hospital which is being built in my constituency will be a fairly typical new general hospital with a clinical ward, a maternity ward, general wards and children's wards. It will consist of 330 beds and will cost in the region of £2 million. A similar hos- pital is being built in Harlow with a similar bed-cost relationship. There are a great number of these hospitals where the costs per bed amount to between £5,000 and £7,500. There are also hospitals, fairly similar in character, where the costs are totally different. For instance, the West Cumberland Hospital has 260 beds and is costing £2.6 million, the Hillingdon reconstruction, which has 210 beds, is costing £2.9 million and the Huddersfield General Hospital, with 520 beds, is costing £4.8 million.

This is a group of hospitals in which the cost per bed is £10,000. There is yet another group, not very dissimilar, where the cost per bed falls below £2,500. I realise that one cannot make an exactly strict comparison among these different hospitals. I realise that my right hon. Friend will be laying down cost limits and encouraging standardisation, but is anything being devised to give inducement to regional hospital boards to reduce the costs below even his cost limits? The variation between £2,500 and £10,000 per bed seems very large.

I wish to refer to a point made by the hon. Member for St. Pancras, North. The machine we need for mastering a capital programme of this size needs to be highly efficient. I hope that my right hon. Friend will be able to create such a machine. During the next ten years, every fortnight we shall be starting a new hospital. During every month in the next ten years, five or six extensive rebuildings, costing more than £100,000, will be started. Unless there is to be wastefulness, this will mean having a highly efficient administrative machine. This is capital investment on the scale of the world's largest industries.

I cannot see that the administrative machine will be efficient unless there is a wide measure of devolution. My fear is that the Ministry will take too much into its own hands. I agree with the hon. Member for St. Pancras, North in his fear that the planning function is being usurped by the Ministry. I ask that the great importance of devolution be borne in mind. The first of the new hospitals was built in my constituency and the detailed interference, restrictions and quite unnecessary control which the Ministry exercised over the building of that hospital should be taken as an example of what not to do during the next ten years. While expressing that hope, I should also like once again to welcome this most imaginative plan.

7.10 p.m.

Mr. William Hamilton (Fife, West)

The noble Lord the Member for Hertford (Lord Balniel) constantly puts before the House a curious mixture of progressive and extremely reactionary views. Today he has treated us to rather more of the progressive views, although his speech was streaked here and there with a little of the reaction with which we associate the party to which he belongs. I wish briefly to comment on his remarks about cost limits and the possibilities of standardisation, because I think that one of the most startling developments in this country in recent years has been the remarkable economies effected in the school building programme by the kind of action suggested by the noble Lord. I refer to cost per place and building control.

I had the honour to be Chairman of a Sub-committee of the Estimates Committee which went into this subject. The Committee was very impressed by the achievements in the school building programme. The Secretary of State for Scotland hinted that this was very much in the minds of the Government, and I hope that we shall hear something more on the subject from the Government. This is a considerable programme of capital investment and we want to make sure that we are getting full value for the money we are spending.

Hon. Members who have spoken have been relatively unanimous in approving the general plan both for Scotland and England. I found myself in the rather unusual and not altogether comfortable position of agreeing with a large proportion of what was said by the Secretary of State for Scotland about the Scottish programme. I began to ask myself exactly what was meant. The right hon. Gentleman remarked, quite properly, that a great deal of the success of the programme would depend on the co-operation between the three partners in this matter—the G.P. services, the local authorities and the hospital services. We shall not get the kind of co-operation which is essential unless and until the financing of the local authority services is completely modernised and altered. There is a feeling among hon. Members on both sides of the House that this must be done very soon in order that we may derive full benefit from this programme and fulfil the aspirations which were revealed during the passage through this House some time ago of the legislation relating to mental health both for England and Scotland.

I do not give a wholehearted welcome to this programme, and I will try to explain why. The Secretary of State for Scotland talked about the overall size of the programme and gave a figure for Scotland of £70 million to be spent in ten years. That is a very large sum, but it is a little less than the amount of farm subsidies for Scotland over two years, and so it is not all that big. Of course, it is substantially higher than any figure which has been attained hitherto, but that is a reflection on past inadequacies rather than on the sufficiency of the present programme.

As has been said by almost every hon. Member who has spoken, this is not a firm commitment. There are a number of "ifs" and "buts" and there are loopholes through which the Government may escape. We have seen this technique operated before. The nearer a General Election comes the more extravagant are the Government with such proposals, and we may expect that in the next 12 or 18 months there will be a progression of promises from the Government in an attempt to retrieve their political fortunes.

As is said in the White Paper, a good deal depends on economic growth, on financial stability and on the adequacy of staff recruitment, and I should like to deal with each of those things in turn. The Government's record in relation to economic growth is dismal. That is something which I think even the Government would admit. It seems to pep up only about 12 months before a general election. This stop-go economy does not provide the best situation in which to embark on long-term financial commitments such as are expounded in this programme. Reference has been made to school building and house building, but the achievements in neither of those things gives us grounds for optimism or for thinking that this programme will be fulfilled in toto.

The same argument applies to financial stability. The hon. Member for Orpington (Mr. Lubbock), who having addressed the House has disappeared from the Chamber, made a valid point when he asked the Government to make clear whether the figures in the White Papers took into account the falling value of money which has been a consistent feature of the ten years of misGovernment by the present Government. Compared with 1951 the present-day purchasing value of the £ is 15s., and if its purchasing power continues to be reduced over the next ten years this programme will lose a considerable amount of its value.

To turn to the recruitment of staff, I recall that some years ago when I was in West Africa I asked questions of Nigerians and others about enthusiasm for education. I asked teachers whether they would rather have—were they given the choice of priority—fine school buildings or good, well-paid and highly qualified teachers. Invariably, and to me rather surprisingly, I was told that they would rather have nice fine buildings. I tried to point out to them that it seemed to me that they had got their priorities wrong; that a good teacher would get his message across in a barn but a bad teacher could never get his message across no matter how good the building in which he taught. The same argument applies to this programme. We may put up the finest buildings, but if we have dissatisfied, discontented and untrained personnel the fine buildings will count for nought.

It is true to say—it has been said by the Royal College of Nursing and other organisations in the Health Service—that relations between hospital staffs and the Government have never been worse than at this moment and that unless and until this relationship is improved we may as well stop thinking about implementing this programme. The gross unfairness of the Government's pay policy hits these people with undue ferocity, undue harshness and with great iniquity. It is as well to remember these things and we must make sure that these people get a fair deal.

I want to turn to another aspect of the programme not yet touched on. I have heard most of the debate and I think I have missed only one speech. I want to know how the Government are to get the money to finance it. In 1960 we had a National Health Service Bill, and at that time the Minister of Health and the Secretary of State for Scotland said that the only way in which they could get the money to finance hospital building was by increasing the Health Service charges. They said that in the course of the debate, and the Bill came immediately after the 1959 Election, which the party opposite won. The Health Service contributions that were imposed in that National Health Service Bill, including the insurance stamp increase, the welfare foods increase and the prescription charges, amounted to about £66 million a year, which is more than this programme visualises over the course of ten years.

In other words, the Government are taking very much more out of the old, the sick and the lame than they will be paying for under this plan, so that the grand design which the noble Lord the Member for Hertford talked about is a grand design which is being paid for by the sick and the old and those who are paying 2s. per item for their prescriptions. That is where the money is coming from, and let us not be mealymouthed about it.

There are pressures on the Government to increases these charges still further. There are many hon. Members on the Government side of the House who are constantly saying that patients in hospitals must pay for their food.

Mr. James Boyden (Bishop Auckland)

And the Liberals.

Mr. Hamilton

Yes, and the Liberals, too. All the absentees. Lord Hailsham has said exactly the same—that patients in hospital ought to pay for their food, and I think we shall get this kind of charge if the people are foolish enough to return the Tories after the next election.

Almost every speech has been devoted, in the main, to the general proposition, but has ended with a constituency complaint. I shall be no exception to that, because the right hon. Gentleman must know that the doctors, the local authorities and everybody concerned in Fife-shire, and in West Fife in particular, are not at all satisfied about the provision, or the lack of provision, for them in this plan. The right hon. Gentleman knows very well about the scandal that exists in the Dunfermline Maternity Hospital and the Northern Hospital, both in Dunfermline. He knows the views of the general practitioners in the area, because they wrote to him last October. There is no need for me to go into that, except to say that they are very far from accepting these proposals as the last word. From that point of view, I welcome the remark of the Secretary of State that this programme is a flexible one, that it is not the last word, but that pressures can be brought to bear—and he can rest assured that they will be—on what we regard as an inadequate programme.

One of the big problems quite properly referred to in the Command Paper is the increasingly serious one of the old people. Here, perhaps, in this field more than in any other, the local authorities have an extremely vital part to play. I am wondering whether the Government have made any attempt to assess the economy of trying to get more and more old people out of hospital and into their own homes by more generous financial provision for the local authorities, not only in building many more old people's homes for 40 or 50 people, along the lines of the model old people's homes belonging to the Fife County Council in Dunfermline, but also individual cottages in which the old people can spend the rest of their days. I am certain that the more people we can get into their own homes or into local authority homes, the more economical, as well as the more humane, it will be.

My last point relates to a remark by the Secretary of State about the standardisation of components and some provision along the lines of the school building programme. Last week, I sought the leave of this House to introduce a Bill to provide State-owned factories in Scotland, and one idea which I put forward was that the National Health Service ought to set up its own establishment, or work through appropriate public authority agencies, to provide many of the components and many of the things required in the National Health Service. I think that this would not only result in great economies in the Service, but that it could be used as an instrument for solving the most impor- tant problem in Scotland today—that of unemployment. The Government could combine the two aims in one policy, and I hope that the Under-Secretary of State for Scotland will not dismiss this idea as a kind of dogmatic Socialist, half-baked idea. This is an idea, which is more than the hon. Gentleman has got, and it will bear some consideration.

I welcome the programme as a belated recognition of a very long neglected problem, but we shall watch with some doubt the Government's progress towards its final achievement. The Government may be quite sure that we shall particularly watch how they finance it, and from whose pockets the money is corning.

7.28 p.m.

Miss Joan Vickers (Plymouth, Devon-port)

I will try to comment on the speech of the hon. Member for Fife, West (Mr. W. Hamilton), though I will not go into detail about Scotland. I should like to say, in regard to the African illustration which he gave, that probably good buildings attract people, and that if we have good building in which to work we may attract the right type of people. Probably, that is why the people in Africa are keen to have new buildings, in order to attract the right type of personnel. I think that is one great advantage of new buildings, because it is so much easier and so much more pleasant to work in a modern building than in an old one. I am sure that this will be one of the attractions to the nurses.

Mr. W. Hamilton

I hope that the hon. Lady is not using this as an excuse for keeping the salaries at their present inadequate level.

Miss Vickers

That does not seem to me to arise. Recruitment is going on extremely well, but I will explain a little later how I think one can attract more nurses when dealing with the plan.

The hon. Member for St. Pancras, North (Mr. K. Robinson), who opened the debate for the Opposition, said that this plan was ten years too late, and that it was now being rushed. I think that we are very fortunate to have the plan, and I am delighted that the regional boards have worked so quickly to enable it to be produced. One of the things we are always complaining about—and I have myself complained about several—is that we receive Reports and even after one or two years, they are never discussed or acted upon, and this seems to me to be most undesirable. Therefore, I am delighted that this plan has so quickly been put into print and submitted to the House.

I was interested to hear what the hon. Member for Birmingham, Small Heath (Mr. Denis Howell), who I regret is not now in his place, had to say in regard to pay beds. This must be a new policy for the party opposite, because they brought in the pay beds and the part-time consultants. Furthermore, they seem to like hospitals outside the National Health Service, when we remember that the Manor Park Hospital, which I notice has recently increased the nurses' wages, is run on completely independent lines from the rest of the National Health Service.

Dr. J. Dickson Mabon (Greenock)

The hon. Lady may be aware, from the manifesto "Members One of Another" which the Labour Party published, that we are on record as saying that we wish to see the abolition of pay beds. We accepted the case for the present amenity beds, but we are certainly on record as being against the concept of pay beds.

Miss Vickers

This is a new policy, and we shall be interested to see if the party opposite will implement it. Perhaps they will also let us know What is to be their policy in regard to hospitals such as the Manor Park Hospital.

The hon. Member for St. Pancras, North spoke about the possibility of mental hospitals being "dumps" in the future, but I think that we shall always need them far long stay patients. There will always be long-term illnesses which, like tuberculosis, are quite curable, but not in a short stay in hospital, and I am sure that the mental hospitals will still have a great part to play in the health service.

The hon. Member for Orpington (Mr. Lubbock) mentioned forty nurses who were going to Australia and he seemed to think that they could not have received sufficient pay in this country. I am sure that that was not why they were going, but probably all those nurses were going on contract service, they were nod migrants. We have a continual flow of nurses to and from the United Kingdom and Australia. This is of great benefit to the Commonwealth, and I hope that it will continue.

My hon. Friends the Member for Tavistock (Sir H. Studholme) and the Member for Bridgwater (Sir G. Wills) spoke on local paints. I suggest to them that it is very necessary to have the best surgeons, doctors and nurses, and they will be provided at district hospitals and that it is perfectly possible to have an adequate bus service to hospitals. These are being provided already. There are many mental hospitals and other hospitals which people visit by taking a train to a certain point and then boarding a bus. In other cases, such as in Plymouth, bus services are provided for visitors for a journey of fifteen miles to a hospital on certain days of the week. I hope that these services will be continued and augmented when the district hospitals are provided. Some hon. Members have said that they do not like the title "district hospital", but the hospitals will be given individual names. Meanwhile I suggest that they might be called "community hospitals" because they will serve large communities.

I congratulate my right hon. Friend on the Hospital Plan, he has given a lead to many other Government Departments. The plan should be tied up with a plan for slum clearance if we are to have a healthier population. I hope that we shall have a ten-year plan for this. I hope that my right hon. Friend will remain in office for many years. Hon. Members opposite have said that we have had five Ministers of Health in too short a time. Now we have one who has an excellent plan and I hope that he will remain the Minister for many years to Come.

I was a member of the Hospitals Committee of the London County Council for nine years. At the end of the war the Report of the Topping-Grey Committee under the chairmanship of Mr. Somerville Hastings, an honoured former Member of the Opposition in this House, was published. I know from experience the immense amount of work that is done by officials in the Ministry of Health in producing a report of this kind. We can read these reports quickly, but they involve enormous work and an almost endless amount of visiting of hospitals in preparing the details. Too little has been said in the debate today about this background of the Hospital Plan and of the work of the regional boards, the local planners and those employed in the Ministry.

The hon. Member for Abertillery (Mr. Ll. Williams) quoted the Bible. I have a quotation from Elizabeth Barrett Browning, who knew more about illness than most people. She wrote: I think it frets the souls in Heaven to see how many desolate creatures on this earth have learnt the simple dues of fellowship and social comfort in a hospital. I hope this which has been so true in the past will be true also of the future, and how much more it should be when this plan has been put in operation. I understand that the Lancet has approved the plan, which must be a great encouragement to the Minister. That journal has said that the plan is "immediately welcome" and "heart-warming", which is praise indeed!

To make the plan work there must be co-operation between the planners. I suggest that there should be a certain number of plans in the Ministry which could suit different sites, particularly when it comes to the provision for example of operating theatres which are very similar in any hospital. I know the length of time that it takes to prepare plans of this kind. It took four years to prepare one for a hospital in my constituency. It would be a good policy to have plans which could be put together to fit any area concerned. When the plans are produced I hope that we may have meetings between the architects, local doctors, staffs and all grades and the local authorities, because if we are to have good work done in the hospitals those who are to do the work should be consulted.

I agree that hospital buildings should not be too permanent. I should like to see the exterior walls of the buildings made permanent but the interiors so built that they could be changed according to need and the type of ward wanted at any particular time. This has been done with offices and has proved beneficial. For instance, if fewer beds were needed for tuberculosis cases a ward could be adapted immediately to meet other needs. Hospitals were too solidly built a hundred years ago. I can think of one which would cost £30,000 to pull down because it is so massive a construction. It needs to be pulled down, but that is not feasible at present and it will have to be converted as it is into a fairly modern unit.

I understand that the Minister has sent a circular to local authorities inviting them to contribute a ten-year plan for their own health and welfare services. I hope that he can tell the House what progress has been made, how many authorities have submitted plans and what is the estimated cost for the future.

The Hospital Plan is particularly impressive in that it has not overlooked the local authorities or the voluntary organisations and it is stated in paragraph 52 that It is intended that the programme shall be reviewed and carried forward annually … I should like to know whether this will include a review not only of the work of the Ministry but of the local authorities and the voluntary organisations. Is it to be a joint enterprise?

I was heartened to note from one paragraph the increase in the number of health visitors, district nurses and home helps. The hon. Member for Orpington referred to this and, had he been here, I should have liked to have drawn his attention to the fact that since 1959 450 health visitors, 359 district nurses and over 5,000 home helps have come into the service. These figures show the tendency of more and more people to take up work which will help the Ministry to fulfil his programme.

In the matter of obtaining the help of voluntary organisations, I should like to make the simple suggestion that home helps should be given a uniform coat to wear. I understand that people who live alone often send for the district nurse to do minor jobs such as washing their feet. I have made inquiries as to why this is so, and apparently, if someone in uniform comes to the door the neighbours take more interest and see that help is needed. I suggest, therefore, that home helps might be given a uniform. They might also be given some form of home nursing certificate. This might lead to more people calling upon them instead of on the district nurses who have such a great deal of work to do.

Community services have been mentioned in the debate and reference has been made to costs falling on the ratepayers. I should like the Minister to say how he visualises the furthering of the domiciliary services without causing the ratepayers too much expense, for that will be the only thing to prevent them falling in with his plans.

I suggest that, as far as possible, in hospitals all the cleaning should go out to contract in future. I do not think that nurses should do the chores in hospitals. Far more will be keen on their training and on becoming qualified if they do not have to do these chores. I also suggest that such matters as sterile dressings should go out to contract. In addition, all hospitals should have modern equipment for their cleaning, and it should be as silent as possible—far too much equipment is noisy at present.

My next point concerns accommodation for the staff. If we are going to have these more centralised hospitals we shall have to think of the question of the domicile of the nurses in particular, and I hope that provision will be made for hostels to accommodate student nurses. It is preferable for student nurses to live in, but once they become staff nurses, and particularly as many of them are married by the time they reach that position, accommodation should be provided, perhaps in conjunction with the local authority, in the form of houses fairly near the hospital. This is already done in the case of some mental hospitals, and I do not see why this practice should not be followed in the case of district hospitals.

As for the matron, in future accommodation should be provided for her away from her hospital. She should not have to live in the hospital, however good may be her flat, because she has no privacy, everybody knows who visits her. She is the one person in the hospital who has no independent life. Therefore, in building these hospitals I hope that consideration will be given to the fact that these women need to lead their separate lives and need homes of their own, especially as many of them may be married.

The turnover of beds is so much quicker than it used to be that I do not think the question of visiting patients is so important as it was previously. I agree that relatives should be able to visit, but when a patient is in hospital for only a week or ten days it does not have the same importance. Visiting should be made easy when a patient is very sick, but I do not think we should worry too much about friends and relatives having to travel long distances if they do not need to visit more than once a week. In any case, as I have already mentioned, frequently special bus services can be organised.

On the question of upgrading some hospitals, which is referred to in paragraph 29. The teaching hospitals attract the pick of the girls for training and if these district hospitals could be upgraded to teaching hospitals, the pick of the nurses could be spread more evenly over the country. This would enable them to go to the various local hospitals and acquire some knowledge of the people living in the area, instead of, as so many do now, coming to London for their training after which they are not too willing to go back to places such as Plymouth, for example.

I now wish to refer to the question of general practitioners. This is an extremely important point, and I am very glad that there is to be more cooperation. General practitioners have facilities for visiting, they usually have a car, and I feel that if general practitioners can see their patients this will eliminate the difficulties of relatives making visits. They will make the contacts, and they can then tell the relatives how the patients are getting on.

With regard to voluntary organisations, I understand that my right hon. Friend had a conference at national level which was very well received. I feel that a much greater part can be played in the future by such organisations as the League of Friends, the Red Cross, the St. John Ambulance Brigade, the W.V.S. and such services. They can also help in the matter of visiting if relatives cannot get to the hospital. I am sure they will have a much greater part to play in the future.

Finally, I come to a point which is not mentioned in the Report, namely, whether there is going to be any cooperation with the Service hospitals. My right hon. Friend may know that in Devonport the Royal Naval Hospital has for some time taken civilian patients because there are so few naval patients. I should like to see in this plan provision for co-operation with the Service hospitals. They have the staff and the surgeons, and in many cases I am sure they would welcome more patients because few of the beds are occupied. Perhaps it will be possible to integrate these hospitals in the final plan.

I thank my right hon. Friend for producing this Report and I give it every support.

7.47 p.m.

Mr. James Boyden (Bishop Auckland)

I confess that I do not share the enthusiasm of the hon. Lady the Member for Plymouth, Devonport (Miss Vickers) for the Minister and his plan. The Newcastle Regional Board's draft plan was studded with this kind of statement: Both East Haven, Darlington, and Cambridge House, Barnard Castle (especially the latter) afford such a poor standard of accommodation, with complete lack of any ancillary services, that it is hoped to terminate their user agreements as soon as other accommodation can be provided. One sees at the top a note "Not before 1971."

I cannot understand why hon. Members opposite, including the Minister, are so daunted by the sums of money involved. After all, £50 million a year of capital expenditure is the equivalent of only £1 per head of the population, and even at the extortionate rate of 7 per cent. interest it runs out at only a few pence interest in the course of the year. The hospital provision per head the nation is being asked to make is less than building a short length of garden path or erecting a strip of fencing in the course of a year. If it is put fairly to the electorate that this is a relatively small sum for a rich nation, they will respond very well.

The hon. and gallant Member for Ripon (Sir M. Stoddart-Scott) was very near the mark when he said that he was afraid that economic crises would upset these fairly modest capital sums being spent, and that little local difficulties would arise. Indeed, paragraph 46 of the plan puts forward three barriers to fulfilment of the plan, three escape lines to enable the Government to escape from their promises. It says: There is still a scarcity of doctors, architects and engineers expert in hospital planning, and their numbers can only slowly be increased. Whose fault is that? I remember that two or three years ago there were serious discussions on the Newcastle Regional Hospital Board as to where these people were to come from in view of the pay claim pending for architects and engineers. It is only fairly recently that their pay has been brought into line with that of other architects and engineers. Four years ago, getting an architect or an engineer probably meant getting him from a local government post into a more senior post in the hospital service. In any case, these shortages of professional people have been known for at least ten years, and it ill-becomes the Government to plead this as an excuse for not being able to implement the scheme.

In the same way, another sentence in this paragraph says that the building up of the hospitals will be dependent on the state of the economy and the capacity of the building industry. If the capacity of the building industry is a serious criterion for getting on with the job, then Scotland ought to have twice as much capital building as the rest of the country. I hardly advocate this on grounds of principle, but Scotland has twice as much unemployment in the building industry as the rest of the country, and if, therefore, the Government are anxious to get on with the plan they should give Scotland twice as much hospital building for the time being and then, when they had pushed on with the plan and had taken steps to increase the capacity of the building industry elsewhere, they could come to the north-east of England. But I would not advocate this as a principle.

Mr. W. Hamilton

Why not?

Mr. E. G. Willis (Edinburgh, East)

The hon. Member will soon find himself on the Scottish Grand Committee.

Mr. Boyden

My hon. Friend says that I will find myself on the Scottish Grand Committee for being so enthusiastic about Scotland. I hope that nobody will take notice of that warning.

The Government have good remedies to hand if the capacity of the building industry is not there. They can limit luxurious office building and so increase the capacity of the building industry. It never seems to dawn on the Government that industrial capacity can be increased, and if the organisation of the building industry and its capacity are really so limited, it is up to the Government to do something about them.

I know that the Government have Sir Harold Emmerson's Report on some of the detailed organisation, but these things have been here for a long time and the Government ought to have devoted more time to them a long time ago. This defensive attitude inhibits the Government from doing something they ought to be doing. They ought to be stimulating the public demand for a better hospital service, and asking the public to pay for it.

To go back to 1944, this is what a Coalition Government said about the health service in a small document published in that year. Under the heading, "Need for a new attitude" they said: Perhaps the most important point of all is the need for a new attitude towards health care. Personal health still tends to be regarded as something to be treated when at fault, or perhaps to be preserved from getting at fault, but seldom as something to be positively improved and promoted and made full and robust. Much of present custom and habit still centres on the idea that the doctor and the hospital and the clinic are the means of mending ill-health rather than of increasing good health and the sense of well-being. There is nothing in the plan that points to some of these constructive things—for example the constructive use of convalescent homes. There has been a report on the method of using convalescent homes to build people up for operations. There is no reference to this in the plan. We have not reached the stage of being able to regard health as a positive matter, and we are still in the curative stage and grumbling about the expenditure of £50 million. I criticise the Ministers responsible for not going to the country and emphasising that these things have to be paid for—that a modern country like Britain needs a modern health service, and modern hospitals in large numbers.

One reads in the American Press that the American hospital system has expanded and developed much more than the British hospital system. At one time under the present Government there was a good deal of bureaucratic slowing down of the National Health Service. Projects were being put forward for improvements and buildings, and the Ministry of Health was criticising details and putting details back to the board, which if it had been anxious to push the thing forward it would never have done. Even now one has doubts about whether there is the right control in the Ministry to keep the plan moving as it should.

I have a report from a Newcastle regional architect who says: A further factor which prohibits the Board's officers from arriving at a reliable programme is their inability to obtain an indication from the Ministry as to the official policy which is to be adopted.… There then follows a couple of alternatives. I will not read the whole of this. but he goes on to say: So far, however, the only indication received from the Ministry as to the timing of the resubmission of a 10-years programme which must now also include a further year (1971–72) is that this should be done 'towards the end of the year '. The Minister has been pressing the hospital authorities to do this work as rapidly as possible. Where is the reciprocal drive and enthusiasm from the Ministry of Health? So much for the building programme.

I criticise the plan for not devoting more thought to the staffing side. As other hon. Members have said, the staff are much more important than buildings. Not only has very little been said about the staff shortages in medical specialities, in auxiliary staffs, and so on, but, as has also been said, staff relations in the health service are about as bad as they have ever been.

If the hon. Lady, the Parliamentary Secretary to the Ministry of Health, can come to the House and say that there is little point in the staff side being so angry about the redundancy plan because there is practically nothing between us, why do not the Government bridge the gap and make concessions which the staff side want and thus produce a better atmosphere? This is pure bureaucratic intransigence, or something worse which we cannot discuss here.

Consider, for example, the difficulties with overseas doctors. The Minister has given some figures. Many times I have asked the Questions and on some technicality the right hon. Gentleman has been able to avoid answering the particular point, but then it comes out that 40 per cent. of our junior hospital doctors are from overseas. I recently found that the acclimatisation of these doctors, which is extremely important because of the difficulty of language and understanding of our medical practices, is being considered to be done—it is not even being done—by the Nuffield Foundation. Must we really wait for charitable organisations to do something which it ought to be the job of the Government to do? For instance, the Technical Assistance Department, the Commonwealth Relations Department, the Colonial Office, all have responsibilities in this field. These are things which would make for better relations, and things which ought to be done in the interest of our country, our patients and the overseas countries concerned.

At the last hospital board meeting I learnt that the Nuffield Foundation is having to step in to deal with postgraduate education. The University Grants Committee is not making adequate grants to establish a proper system of medical post-graduate education, and the regional hospital boards have not the money to do this. How can it be that in 1962, with a plan of this description, post-graduate medical education is still being financed by an individual foundation? It is a good job that we have that foundation, but it is a comment on the miserliness and a lack of inspiration in the Ministry of Health.

The Secretary of State for Scotland made some reference to the reason why the plan might be coming forward at this moment. He said that it was only now that the basic statistical material was coming to hand. Really, after fourteen years of the health service, the basic statistical material is only just coming to hand! I think that there is a little basic statistical material which the Minister of Aviation could have provided but which he refused, about the amount of emigration by air going on. I asked a Question of the Minister of Aviation and he refused point blank to provide the remedy. Perhaps it would be unpopular, but knowledge of these facts would be useful. It would not solve the problem, but at least it would provide accurate data for attacking the problem.

I asked a Question about the amount of money which is being spent by regional hospital boards on their own research, a matter which is very much linked with the careers and the interests of junior medical staff, and I found that in the case of the Newcastle board it was coming from free moneys; in other words the amount for clinical research being done by the regional hospital board is coming out of the money of the old charitable endowments. When I got the figure for the whole country I found that the total for the boards was less than £300,000, and most of it came from the same sources. When one looks at the spread of the money one finds it varies from East Anglia, whose board spends £1,000, to Manchester, which spends £108,000; or perhaps to give a more comparable set of figures, one finds that Manchester spends £108,000 and Liverpool £6,000. There is something wrong there.

If one produces a plan one expects to be able to produce a plan in relation to research which affects very much the doctors and the local clinical improvements. I can tell the hon. Lady that in the Newcastle area research undertaken by Dr. Blowers on cross-infection has been most valuable. The Minister hides behind the fact that this sort of thing is tolerated and that great efforts are made, and he does not provide adequate funds for really getting on with the job adequately.

The Secretary of State for Scotland said that the Ministry was actively encouraging regional hospital boards to increase their staffs and to cope with their planning, and only now at this stage, all these years after the inception of the hospital scheme, has the Ministry of Health got round to some of the planning and some of the other research which the Ministry of Education has had now for some years. Although the Minister of Education very often claims credit for this, the actual basis of this was largely the work of the Labour Minister of Education, and actually much of the detailed work was done by a consortium of local authorities, most of them Labour controlled.

The plans for the advance of and maximum utilisation of the staff are lacking in this document. Reference has already been made to the Willink Report. The Secretary of State was referring to new statistical material. It is really quite laughable that the Government set up a committee, the Willink Committee, which goes through all the motions and takes a lot of evidence and finds a wrong figure for the number of doctors, and the right hon. Gentleman the Minister of Health believes it to be wrong and adds 10 per cent. Is that an accurate way to find the doctor-need of the country? It is a ridiculous way of going on. Therefore, one begins to have very grave doubts whether the actual figures in this plan, which are more complicated and rather more subtle and need a great deal more research even than the figures of doctors, are going to be reliable.

Mr. Maclay

The hon. Member is trying to have his argument both ways. He says that we ought to have got the statistics a long time ago and now he says that it is almost impossible to get accurate satistics. He cannot have it both ways.

Mr. Boyden

I am pointing out that the statistics can only be accumulated slowly over a period, but the Government have been in office for ten or eleven years and ought to have been working on this for a long time.

I could point out to the right hon. Gentleman the facts in relation to population research. A good many of these things depend on the latest accurate information in population research. The Royal Commission on Population produced a series of recommendations most of them in relation to fertility and marriage rates, and they have been neglected. That is one of the things the Government ignored, and this is the responsibility of the Ministry of Health. There has been an improvement in relation to research in some aspects of medical statistics, but there has been practically no improvement at all in the findings of research in relation to a thing which is the key to all expansion in this field, in educational expansion, in the provision of all staffing facilities, and that is intelligent anticipation of fertility rates and marriage. If the Secretary of State wants to take this thing further, he should consult some of the professors in demographic research and see how satisfied they are with the facilities the Government provided, and with the actual research going on.

Even at this stage, even if the Minister's figures are right—and, as I say, I have grave doubts whether they are—it is a notorious fact that the medical schools are still overcrowded, that places for women are particularly difficult to get, and that there is no suggestion at all that we are going to use our facilities properly, or that we are going to find enough places for women either in the dental schools or medical schools. This is really quite scandalous. The only scientific subject adequately covered at girls' grammar schools these days is biology. There ought to be a continuing flow within our existing resources to the dental and medical schools. Although the position is very much better than it was, it is still woefully deficient.

The situation in regard to auxiliary professions and auxiliary uses is not much better. I was astonished a week or so ago when the Minister of Education came to this House and talked about cheap assistants in schools and short-service commissions. I wonder the Minister of Defence did not kick him on the shins. I have never known of officers in the Royal Air Force or anywhere else who were appointed with inferior qualifications; they were short-Service commissions; they were not inferior Service commissions. The use of auxiliaries in this sense we are talking about, in the medical sense, demands severe training, and also the finding of places.

I will quote again the minutes of a certain board, but I shall not quote names or places. The heading in this report is, "Shortage of Radiographers", and the paragraph says this: With reference to the suggestion made at the last meeting that the Minister might be asked to approve the employment of an unqualified but experienced radiographer Dr.… stated that he had interviewed the man in question, who was at present employed as an unqualified laboratory technician at … However, as the man was being paid more in his present job than he could be paid as an unqualified radiographer he was not interested in employment in the radiography department … Is it not a bit thick that one has to go round the country to try to get unqualified people only to find that it is not worth their while to take on the employment in the auxiliary services?

One could spend a lot of time in analysing the deficiencies, and I have not that time, and also in asking why there is no section in this document explaining what is to happen in relation to improving the dental service and so on. The number of dental places in the dental schools has been increasing, but the last Report of the Minister of Health is full of criticisms of the present organisation of dental facilities. For example: Most of the dental research carried on in this country is in dental teaching schools or in the appropriate departments of the universities with which the dental schools are associated. By comparison with the United States of America the numbers engaged in dental research in England are small. There is a paragraph in the Report on the hospital dental service which criticises the provision of dental services in hospitals, and it is stated that Chest and chronic sick hospitals are also far below an adequate staffing standard. and I could give a dozen quotations from the same source.

A think like the accident service has been very badly provided for. I asked a Question of the Minister on 26th February as to which areas in Great Britain were without a special accident service. I thought that was a reasonable Question and I expected a reasonable answer. I expected to be told that there were certain places which had got a special service while others had not. I got this answer: All areas have arrangements for dealing with accidents."—[OFFICIAL REPORT, 26th February, 1962; Vol. 654, c. 932] Even the Liberals know that.

The fact remains that this is a building plan and not a hospital plan. It offers us something better than in the past, but the past was not very good. There are very large holes in this plan and they relate to the things that most concern the service. One of them is the staffing provisions. These buildings will not be utilised to the full unless real attention is given to that problem. I suggest that it is up to the right hon. Gentleman to produce another plan to supplement this one on the staffing side. Without this, we are discussing only one side of the problem.

8.11 p.m.

Mr. Donald Box (Cardiff, North)

I was most interested to hear what the hon. Member for Bishop Auckland (Mr. Boyden) said, particularly about hospital costs and the problems of dental training. I hope to say something about these particular aspects later in my speech.

Despite the inevitable reservations contained in paragraphs 46, 49 and 52 and the Appendices, I believe that speeches from both sides of the House today have indicated that most hon. Members welcome this plan as a realistic attempt to provide the country with a hospital and medical service that is in some way appropriate to the space age.

The hon. Member for St. Pancras, North (Mr. K. Robinson) referred to the fact that in his opinion the planning was ten years too late. I go a little further and suggest that the planning is 15 years too late. If the planning under review today is starting rather later than we hoped, I think that hon. Members opposite have to bear some share in the blame for not providing a better foundation for planning during their period in office.

The hon. Member for Abertillery (Mr. Ll. Williams) referred to the fact that in the financial summary to Appendix C, expenditure per head of the population, Wales came only second to Liverpool. That is welcome news indeed, because it indicates to us in Wales that before many years are out we are likely to have a hospital service which is worthy of our dynamic industrial growth in recent years. In Cardiff, we count ourselves fortunate that Cardiff has been chosen as the site for the University Hospital of Wales, and when I passed the site recently I was pleased to see that work on that £8 million project had been started. I have seen the scale model on several occasions, and if that is in any way indicative of what the final building will be, I think that this will be a fine example of the sort of hospital to be provided under this plan.

This new teaching hospital in Cardiff has been the subject of a good deal of uninformed criticism from time to time. It will provide 800 beds and, in addition, a medical and dental school which will supply the much needed doctors and dentists. It is gratifying to us that to supply this urgent need for dentists the dental school part of the hospital will be completed first. We have heard the figures quoted already—one dentist to every 3,353 people in Wales. To get an appointment with a dentist in Wales is rather like seeking an appointment with the Chancellor of the Exchequer on the morning of Budget day.

Mr. Leo Abse (Pontypool)

While the hon. Member is giving his eulogies about the position in Wales, perhaps he will tell the House when he anticipates the first dentists will emerge from the dental school and how many there will be?

Mr. Box

I understand that the dental section is intended to be completed by 1964 and that the first intake of dental students will be then. What we have to ensure is that when these periods of training are completed we have sufficient attractive opportunities for them to make them want to stay in the area.

If I may fly a small kite on dentistry, the dentists are the end products of the good 'proportion of this hospital plan. We all know that there is a chronic shortage of school dentists at the present time and 'that newly qualified dentists can finish their training and start work almost immediately at a salary Which compares very favourably with that of an M.P. Is it unreasonable, therefore, that this expensive training should to some extent be repaid by a compulsory period of initial service of one or two years to the school dental service. After a similar period of training, doctors have to put in a year's post-graduate training often on a salary of some hundreds of pounds before they receive their diploma. If this applies to doctors why should it not also apply to dentists? It could have the dual purpose of not only supplying the grave shortage of school dentists but also enable the local authorities to get something back for the expensive outlay on education grants, and at the same time it would not deprive young dentists of starting work at a very handsome salary.

Apart from the university hospital to which I have referred, there are a number of new hospitals and alterations and extensions of existing hospitals which I think have been generally wel- corned throughout Wales. The governing factor that decides where the base or district hospital should be sited can be defined as those areas which are convenient and natural gathering grounds for the population which they have to serve, having due regard to the geography, communications and social habits of the people. Such a far-reaching scheme, whatever form it took, is bound to receive a mixed reception. We have heard something today of the agony of mind where small hospitals are closed down. Often these hospitals have built up a strong bond of service and affection in the communities which they serve. It is very difficult to see how some of these small hospitals will not have to be sacrificed if wastage and duplication are to be avoided. It is true that the patients may have to travel further in the future, but they will surely be compensated by the fact that they will receive much better treatment in return. Visitors will obviously have to travel further, too, and there may even be some opposition from general practitioners who have perhaps became too accustomed to past arrangements.

But while initially none of these arrangements is likely to commend itself particularly to the people on the fringe of the district hospital areas, I believe that the ultimate advantages will greatly outweigh the disadvantages. After all, the first objective is to provide a comprehensive team of specialist consultants at every district hospital. This means that a far more effective service for the sick will be provided and that there will be a far greater likelihood of an accurate and quick diagnosis when they are sick, followed in urgent cases by suitable surgical or medical treatment.

As medical science evolves, some centralisation is inevitable, indeed desirable. But the plain truth today is that the specialist needs the backing of a fully-trained staff and a fully equipped laboratory. The days when he could depend on his stethoscope alone have long since gone. While centralisation is bound to mean that those who are to be patients in the hospitals will have to travel further, they should be, as I said, rewarded by getting far better treatment in the future.

I am glad to read that in Wales as the plan develops most patients will not have to travel more than 25 miles to a district hospital. In the rural areas, where the population are more scattered, obviously these conditions cannot apply. I was pleased to read, I think in the Report. that in those cases some of the smaller hospitals will be kept open during the transition stage.

It is natural that such a far-sighted and, I think, in many respects controversial plan as the one before us should call for the closest co-operation from all the parties concerned. In Wales, we enjoy normally an excellent relationship between the Ministry of Health, the Welsh Board of Health, the regional hospital board and the hospital management committees. I believe those good relations will continue despite the rather deplorable efforts of some hon. Members opposite to widen a minor difference of opinion into a major disagreement between the chairman of the regional hospital board and one of the hospital management committees. They have done so through the medium of a rather clumsily worded Motion on the Order Paper.

This is not the first time that hon. Members opposite have attacked the chairman of the regional hospital board, Sir Godfrey Llewellyn, but I think their methods suggest that they are indulging in a rather spiteful vendetta against a man because he is a well known member of the Conservative Party. All that the chairman of a regional hospital board requires is that the negotiations between his board and the management committees should be conducted smoothly in partnership and without political bias. I think there is every indication that the chairman in this instance has done that during his term of office.

Mr. Abse

Will the hon. Gentleman give way?

Mr. Box

In a moment.

The chairman welcomes healthy and constructive criticism, but he does not expect to be attacked by his own hospital management committees, particularly on matters which are largely beyond his control. If hon. Members opposite want to attack delays in the rebuilding or reconstruction of hospitals in Wales or in other areas, they know perfectly well what they should do. They should attack my right hon. Friend the Minister of Health, because he has broad shoulders in matters of this sort.

Mr. Abse

Does not the hon. Gentleman appreciate that in a place like Wales, where there are passionate attachments to local hospitals, it is essential that in a scheme of this kind, which all of us wish to put through in some form or other, delicate relationships between management committees and the regional hospital board must not be so altered so that the chairman of the regional hospital board can attempt bureaucratically to intimidate hospital management committees making legitimate protests, by saying that they are agents' representatives and must be silent? That is precisely the sort of treatment and behaviour which will prevent the scheme being the success that we all want it to be.

Mr. Box

I do not believe there has been any intimidation whatever in this case. The operative word is "partnership". After all, if difficulties are to be ironed out and avoided in the future, the closer the partnership between all the bodies concerned, the better. It is common knowledge that in the case with which we are particularly concerned the delay stems from the fact that the hospital was rephased from a 600-bed to an 800-bed hospital, and the costs involved are now to be three times greater—about £1,800,000 instead of the £600,000 under the original plan. I should have thought that that would have been a very good reason indeed for exercising a little extra patience in the matter, although I do not under-estimate the difficulties of the medical and surgical staff at the hospital concerned.

I turn now to the question of costs as summarised in paragraphs 45 to 52 in the chapter of the Report headed "The Hospital Programme". This shows the figure we already know so well—the expenditure of £500 million on the building of now hospitals and extending and modernising old ones. What is less readily understood is that during the same period of ten years a further approximate sum of £500 million will be spent running existing and new hospitals; in other words, maintaining them and heating, lighting and servicing them as well.

This financial commitment is very large indeed. Its sheer size demands that we should get the best possible value for the vast sum of taxpayers' money that is to be expended in this way. It is estimated that even at the present rate of building it may take as long as 60 years to replace the existing hospitals and their equipment. Some buildings being created today will, therefore, be quite old by the time the present scheme is completed. For that reason, it is essential that we should take extra care not only to see that we get value for our money at the planning stage but also to ensure that false economies are not made in the initial stages, because false economies might in due course add considerably to the cost of maintenance, replacement and alteration.

What I suppose we have to do is to weigh up the pros and cons of the situation. If one takes long-term rates of interest into account and allows for even a slight inflation in the future, it may prove much cheaper to spend an extra £1,000 on some item now than to spend a much larger sum in fifteen or twenty years' time. For example, if a stoker or liftman will entail wages of about £500 a year during the life of a hospital of, say, 60 years, it is obviously worth considering at the initial planning stage whether it would not be better to spend £10,000 on putting in an automatically stoked boiler or an automatic lift rather than spend about £30,000 in wages over the 60 years—always assuming, of course, that one can get the man to stoke the boiler or conduct the lift.

On the other hand, if the life of the building is to be extended by only 10–15 years, obviously that heavy capital outlay would hardly be justified. In the same way, such a simple thing as a grass covering may ultimately prove twice as expensive as paving stones, because, as we all know to our cost, grass has to be mown and requires other attention as well, whereas paving stones require require very little, if any, attention at all. Decoration is important, too. Some types of wall surface not only have a better appearance than others but cost less to clean and redecorate aver the years. Glazing is often a very complex problem. Although initially it is very expensive to install, the extra natural light that it allows in may result in a considerable saving in artificial light over the years. Against that must be set the fact that the flow of heat through glass is rather more rapid than it is through other cladding materials, and that in its turn may add to the cost of heating.

I hope I have given hon. Members some idea of the complexity of the enormous problems, which are fascinating even to a layman like myself. But I am encouraged by the fact that no one is better qualified than my right hon. Friend the Minister of Health to juggle with such involved considerations. I believe that the next two years will see big strides towards a revolutionary improvement in our hospital services, and I look forward to the early implementation of the plan before us.

8.30 p.m.

Mr. Laurence Pavitt (Willesden, West)

One of the difficulties about speaking so late in a debate is that there are so many interesting points to which one would like to reply that one does not have sufficient time in which to do so. The hon. Member for Cardiff, North (Mr. Box) raised a number of such points, but I shall deal with only one of them; his interesting suggestion about the dental services in relation to the new hospital being built in Cardiff. I hope that this matter will be pursued further both by the hon. Member for Cardiff, North and the Minister.

At present we have an entirely wrong set of priorities in dentistry. We should be making an adequate number of dentists available to the school dental service and for children so that they are able to deal with the prevention of dental decay rather than having to cope with the situation after the decay has gone too far. The suggestion of the hon. Member for Cardiff, North in this context deserves more comment than time permits me to give it.

I do not quite agree with his suggestion that the plan is a realistic attempt to deal with our present problems. This seems to be the point which has divided hon. Members on the opposite sides of the House. However, I am grateful to the Minister for having initiated the debate in this way, merely to note, because, frankly, had he invited the House to give its approval I would have felt that at this stage I could not have approved the plan, despite its many ramifications.

Like all plans, it is a statement of intentions, and until those intentions are turned into action one's judgment on it must be reserved. I thought that the noble Lord the Member for Hertford (Lord Balniel) certainly tapped our subconscious when he made an analogy involving Cinderella and the fairy coach. There is more than a little of the fairytale element in our discussion, and it is that element which gives many of my hon. Friends a number of reservations concerning this matter.

The plan has been born today with a certain amount of smoothness, but, as my hon. Friend the Member for Fife, West (Mr. W. Hamilton) pointed out, its conception was in very different and stormy circumstances. We spent three months arguing about the £65 million that must be raised from the sick, the mothers and children, and so on, so that this plan can be financially possible. We are now faced with the next five years' expenditure at the rate of £40 million a year when our present annual rate is estimated at about £32 million. I agree that there is to be some increase, but when we consider the plan as being something tremendous or such a great step forward, would the additional amount of expenditure lead one to normally consider that lit is such a great amount. considering the economic strides forward that Britain anticipates?

As some of my hon. Friends have pointed out, there are many caveats and provisos to be considered. Paragraphs 46 to 52 of the White Paper reveal that despite this beautiful dream we may wake up to find very little of it actually happening. The hon. Lady the Member for Plymouth, Devonport (Miss Vickers) expressed the wish that the Minister would be in office long enough to see the fruition of this dream. I do not know whether the hon. Lady wishes him well or ill. Is she aware that the Minister of Health is considered to be a very small fry in the hierarchy of Government. If she wishes him to retain this lowly place for so long she should consider this aspect of Parliamentary thought. I gather, however, that she actually means that she hopes that her right hon. Friend, if he has the courage and remains in office long enough, will see these intentions carried through.

Ministers—especially Ministers of Health—come and go and by the time this 15-year plan—for it is not really a ten-year one—really gets into its stride we shall, no doubt, have seen a number of new Ministers holding that office. I hope that they will have the same strength of purpose as the present Minister apparently has. When one looks at the provisos and caveats about which I spoke one discovers that although there are to be 90 new and 134 remodelled hospitals, all to be started by 1970 or 1971. The White Paper makes it clear that it is the Government's aim to have as much as possible completed by 1975 because the document contains the words "or later". It is for that reason that I am suggesting that this is by no means a ten-year plan but a 15-year one at least, and probably a 20-year plan.

The accent has been on buildings and I should like to know if the number of people in the development unit at the Ministry of Health is to be increased. At present that unit consists of 13 full-time and eight part-time officers; yet we are dealing with a scheme large enough to cover the whole country. Is it to be worked out with less than one full-time officer for each region, apart from the teaching hospitals? This has been one of the most important sections in the Ministry, it has done a good job of work and if given the strength it can successfully overcome some of the difficulties with which it is and will be faced. But, if the section is to be cheesepared, then I am afraid that the development unit will be absolutely inadequate.

A number of hon. Gentlemen opposite have referred to the elimination of about 750 hospitals by 1971 and a further 500 after that date. That involves more than 1,200 hospitals going out of existence. I agree with my hon. Friends who have said that we must look at this as a large-scale planning scheme and, providing the services can be given in the district hospitals, there should be no question of the smaller units, which cannot command so much the first-class skill and attention, not being eliminated in the course of time.

It is interesting to note that no existing hospitals will go until replacements are established. Hon. Members need not fear that their hospitals will be just wiped cut overnight, because, as I say, until an alternative service is available the plan provides that they should remain in existence. Several hon. Members have apologised for being parochial in their attitudes towards this, but I too must express disappointment in my own area. The Central Middlesex Hospital has received some publicity recently and Dr. Horace Joules, the medical superintendent, has indeed been in the news.

The House will be aware that this hospital is one of the finest in the country and, despite the difficulties, has succeeded in giving a standard of care and attention which is second to none and which equals even the teaching hospitals. That is saying something. The Minister visited the hospital and saw for himself mothers in beds in corridors waiting to deliver their babies because there was no room for them in the wards. The Minister knows that this is no sensational journalistic matter. He saw it for himself.

We are worried because, under the plan, these problems will not be tackled until after 1970 or 1971 because it is stated that nothing at all is to be done about the Central Middlesex Hospital for another ten years. We try not to be parochial, but we shall be obliged to continue to press the Ministry to do something in cases such as this.

The problem of staffing is inadequately dealt with and inadequate research has been done into the question of how this hospital service is to be staffed. Buildings he has, but people are the Minister's weak point. It always has been. I have no confidence that, in the light of Willink and Lord Taylor's comment in another place that staffing presented an awful and ghastly picture, that the buildings will be adequately staffed. I have no confidence in the Minister because of the basis of his approach to the nursing problem. The right hon. Gentleman said recently: … all branches of nursing and midwifery showed and continued to show a strong upward trend, marked and continuous, a trend which had characterised the whole period of the preceding five years or more."—[OFFICIAL REPORT, 14th May, 1962; Vol. 659, c. 947.] That is a categorical statement which shows the basis on which the Minister plans. However, when one considers the General Nursing Council's Report for the year 1st April, 1960, to 1st March, 1961, one finds it stated on page 9: It will be seen that the total number of students in training for all parts of the register"— and I emphasise "all parts of the register"— at 31st March 1961 was 860 less than the total on the same date in 1960. The number of those admitted to training for the first time shows a decrease of 791 …". If this is the basis of the Minister's planning for nurses, then either the Nursing Council Report is wrong or the Minister's information is wrong.

By 1975 the plan will give us 50,000 fewer beds and, as my hon. Friend the Member for Gateshead, West (Mr. Randall) pointed out, this means more domiciliary care—more midwives, more home helps, more district nurses and more social workers. What are we doing about recruitment? Recruitment is a heartbreaking task for local authorities for the simple reason that all the professional branches of the Health Service have pay claims waiting to be settled.

I hope that the Minister will tell us what he intends to do about redundancy. The annual conference of the Association of Hospital Management Committees is taking place this week and tonight we need a categorical statement from the Government on his policy for redundancy when these 1,250 hospitals are closed so that on Thursday or Friday their annual conference will be able to take a competent decision in full knowledge of the Government's intentions.

The question of costs is always preeminent in the minds of hon. Members opposite, while hon. Members on this side of the House always give costs second place to people. Nevertheless, we have to bear costs in mind. When the Conservatives are saying that we must cut down public expenditure and when hon. Members opposite are putting pressure on the Chancellor of the Exchequer to cut down public expenditure, the transfer of the care of the aged and the mentally sick and mentally handicapped to residential homes will be an increasing burden and therefore more public expenditure. Who is to pay? At the moment these services are paid for by the Treasury out of taxation, but in future the burden will be passed to the ratepayer. Even if, in spite of the block grant and as an extra grant, the Government are prepared to make a grant towards meeting these costs, local authorities will still have to find the other 50 per cent.

If we are to transfer old people from institutional care to domiciliary care—and I think that the transfer is right—then the general practitioner will have to bear a greater weight. At present, the general practitioner's list is an average 2,300 with a maximum of 3,600, patients, but every general practitioner knows that he gives twice as many items of service to the old and the young as to the middle-aged. The corollary of transferring geniatrics to domiciliary care is to reduce the list of the general practitioner. What action is the Minister to take in this respect? Similarly, the work load represented by 60,000 psychiatric beds will have to go to the general practitioner if the plan is successful. What kind of consideration has the Minister given to that? Has the morbidity in various areas been accounted for? For instance, in South Wales the morbidity rate is three times that of Surrey. We are looking at global figures and I appreciate that the figures are given by the regional boards, but I submit that research into these matters has been inadequate.

I am far less optimistic than the Minister about the way in which general practitioners can be integrated into the new district hospitals, as mentioned in paragraph 26 of the White Paper. I predict that unless something definite is done to integrate them, they will find themselves only having some faint contact with the diagnostic and peripheral clinics, less than they now have and having nothing to do with the main body of curative work in the new district general hospitals.

I agree that a hospital of 600 or 800 beds is the right size of unit, but, as so frequently in his period of office, the Minister has missed a unique opportunity. This is half a plan about half a subject. Had the Minister taken it in its wider context, he could have planned effectively for the whole of the National Health Service and not just a part of it, which he is doing. He is trying to take hold of one part of a tripartite entity and do something with it when the over- riding need in the next decade is integration of the three services—local authority, general practice and hospital.

Has the Minister considered that the district hospitals might be the place where that integration could occur? If that were tried I should like to find another name for these hospitals. The word "hospital" would no longer fit and "health centre" is already used in another connection. I should like the work of the local health executive, the local health authority and the curative side of the hospital work to meet under the one roof. That might give a local unit where, instead of water-tight compartments administered separately, the three subjects would be integrated together in the one building. The Minister might consider the possibility of naming the new health service building, district health community centres, or health supervisory centres, or comprehensive health centres. Some kind of physical expression would be given to the integration of the tripartite system.

I charge the Minister with inadequate planning. By trying to deal with one section he has missed the opportunity of making a plan which could be comprehensive. He is trying to plan in a vacuum. Questions of population, economics and sociology have not been scientifically considered. He has proved that a Conservative Government can plan only piece-meal. The Conservatives do not believe in planning and can do so only hesitantly in small sections, even when the priority and need is for a comprehensive approach so that one can see just where each part fits into the other instead of merely ticking over on its own. Even so it will take all the Minister's courage and expertise to get this plan past some of his friends in the Treasury, even though we think that it is inadequate for the task facing us in the next fifteen years.

8.46 p.m.

Mr. Percy Browne (Torrington)

There are three or four points that I want to pick up from the speech made by the hon. Member for Willesden, West (Mr. Pavitt). If we are to plan something it is surely sensible to decide upon something around which we are going to build, and I suggest that that is exactly what the plan is. It makes provision for hospitals in the right centres of population, and for the use of certain areas. It is round this that the triumvirate of which the hon. Member speaks will be built. He said that nothing was happening yet, but we have a plan and, like my noble Friend the Member for Hertford (Lord Balniel), who talked about Cinderella and her coach, he must be aware that land has been bought and earmarked for hospitals, and that plans are well forward. They certainly are in my part of the world.

I accept some of the things that the hon. Member said. First, the problem of redundancy is likely to arise. Many people in my area are worried not so much about compensation as about whether they will be paid off and will be unable to find jobs in other parts of the country. The hon. Member also advocated what many of us feel strongly, namely, the necessity for the general practitioner to be brought into the hospital work which will be going on in the new district hospitals.

The hon. Member said that the plan did not represent a huge step forward. I believe that it does, and I congratulate my right hon. Friend, as many of my hon. Friends have done, upon his breadth of vision and upon the fact that the plan is now before us. It is a comprehensive plan—not before time. It is the hospitals' turn—and over the next ten years we shall be spending a large sum of money on them. It is not a myth. I can take the hon. Member to places where land has already been bought, where plans are in being, and the phasing of the building of hospitals is about to take place.

By bringing our hospital service up to date in this way and building these ninety new hospitals we shall be making a true economy in the expenditure of capital. We shall also economise by virtue of the fact that we shall have an overall plan for the whole country, based upon area needs. A further economy will also be possible, because area hospital boards and local management committees will now be able to plan with certainty for their minor works, knowing how long the hospital in respect of which they want to make improvements will remain in being—a matter of the greatest importance.

In my part of the world we have found that a village school is bound to be closed after we have spent money on building a canteen on the end of it. This sort of thing also happens in the hospital world. The plan will therefore make possible a real economy. It will enable local management committees and area hospital boards to know for what length of time each hospital must remain open.

I found the Blue Book of great interest, if only because it shows the increased importance of home help, and the change in requirements in that we shall have an increased need for geriatric and maternity beds in place of the many beds formerly needed for chest diseases. Many of us have constituency problems —I certainly have—and if we look at the preface to the Blue Book we find that: The hospital authorities will be alert to modify present proposals or bring forward new ones, as the needs of their areas change or new methods are developed. I trust that this means exactly what it says, but many of us feel a sense of erosion when we find that some of our local hospitals are to be closed. We have the same feeling over the closing of a village school, or a local railway station, or whatever it may be.

I will not bore the House with these matters again, because I have spoken of them so often before. But this is yet another example of the loss of something which we have always treated as part of the locality—something which those of us who have lived in the area were only too ready to help if we could. These hospitals have provided us with treatment when we have gone to them to be treated and to be put together after an injury.

In North Devon our new hospital is to be started in 1965–66. We understand the necessity to concentrate the essential part of the very important hospital service in one place. In other words, as we build new hospitals we must have in them resident surgeons and E.N.T. specialists—and these facilities cannot be provided by means of a lot of small hospitals dotted around the periphery of a large town. But we also want to see general practitioners being allowed to use beds for maternity and geriatric cases.

It is in this respect that I—and I know that my hon. Friend the Member for Tiverton (Mr. Maxwell-Hyslop) agrees with me—would like to see the plan altered to some extent. Many people retire to the South-West, and our ratio of elderly to young is therefore very high. In fact, I feel that there is a miscalculation in the Blue Book in respect of the number of geriatric beds that ought to be allowed for. I hope that the local hospital management committee's suggestion that Bideford Hospital and Torridge Hospital should be kept open for geriatric cases, general practitioner maternity beds and G.P. beds will find favour not only with the South-Western Regional Management Committee but also with the Minister.

This is not merely a matter of tradition, and the feeling that one is losing a friend. It is concerned with the difficulty of transport. It was very sensible of my right hon. Friend to encourage hospitals to allow visitors every day, and twice a day if possible—even though the hon. Member for Birmingham, Small Heath (Mr. Denis Howell) suggested that they might not always be glad to see the visitors. In cases of emergency there ought to be a local centre nearby, so that one need not travel 15 or 20 miles before one can have a finger put in a splint.

I apologise for the parochial reference at the end of my speech. I congratulate my right hon. Friend on his breadth of vision and on what I feel to be a very good plan. No doubt we shall get in due course the amendments which some of us feel necessary. These new hospitals which will be built in the next 10 or 15 years will serve the people of this nation as they are intended to do and will enable those who are dedicated to the service to work in the up-to-date surroundings which they fully deserve.

8.56 p.m.

Mr. Leo Abse (Pontypool)

May I make some hasty remarks, bearing in mind the lateness of the hour. I want to say a few things about the mental health service in the Principality and to make a few comments on medical education relating to the mental health service.

At present, in Wales, we have only one bed per thousand of population for the mentally retarded, and in this respect we are as badly served as any other region in the country. So grimly over- crowded are many of these hospitals for the mentally subnormal that, quite wrongly, hundreds of patients have been forced to overspill into mental hospitals, where they are placed cheek by jowl with mentally sick patients. In the last published report of the Welsh Regional Hospital Board, it was shown that more than 500 of these mental deficients were in mental hospitals. The board frankly acknowledged that they had been compelled to export 400 patients to English hospitals who would benefit by being transferred nearer home.

Nearly 700 patients, many of them urgent cases, are on the waiting lists recommended by local authorities. On the regional board's report and figures, there is no less than a need for beds at a rate of 1.4 per thousand to be provided. I am sure that the Minister is aware of the apparent inadequacy of the number of beds allocated under the plan, and I ask him to take another look at that in order that we shall not be in the position which the plan indicates—that by 1975 there will be no other region with fewer beds for the mentally subnormal per thousand of the population than Wales.

In the minute or so which remains to me, I wish to say a few words too about the dramatic cut which the Minister has indicated that he intends to make in the number of beds in mental hospitals. We all hope that the plan will come into effect, but at the same time if one looks at the projections which are based upon the national figure and compares them with the past performances of mental hospitals in Wales, one sees that there are huge gaps. If one looks at one of our largest mental hospitals, Morgannwg Hospital, Bridgend, and takes account of the intended reduction in beds which will be provided and then relates the proposals to what has happened over the last few years and to what is likely to happen over the next few years until 1970–75, one discovers that on the basis of past performance. we could not reach by half the cut in beds the target set.

The reason why these laudable intentions cannot be fulfilled on the basis of past performance is that we have not the staff in Wales to bring it about. We require psychiatrists of quality, and in these days of competition for such personnel the Welsh Region is bound to be short of psychiatrists as long as the Welsh Medical College shrinks from its duty to turn out psychiatrists to man our mental hospitals.

I know how interested the Minister is in the question of mental health. Is he aware that three times in the last decade the Welsh Regional Hospital Board has asked for a chair and a department of psychiatry to be established at the Welsh College of Medicine? The Minister for Welsh Affairs has expressed that hope and the Parliamentary Secretary has indicated that views have been given on the matter to the University Grants Committee. Now we are dismayed to hear rumours that the possibility is that this chair and department will not be established until the Welsh teaching hospital is completed. I urge the Minister to look at this question because our mental health services are so primitive in some respects. For example, we have only one full-time psychiatric worker in the health service in South Wales and not one child psychiatrist in the capital city or in the whole of Monmouthshire.

Until psychiatry is given some status there is no hope of gathering a nucleus of psychiatric social workers. Even the hospital used for the perfunctory psychiatric training given to Welsh medical students has no psychiatric social worker. The medical department is not turning out psychiatrists and has not got a chair of mental health, such as the neighbouring City of Bristol has: nor has it a chair and department of psychiatry as in Edinburgh. It would be fair to say that the Welsh medical college is failing in its duty to Wales despite its great past glory and great past tradition.

If we are to achieve this objective of cutting down our mental health problems we shall require the establishment of such Departments. In the Welsh mental hospitals there are more than 500 men and women wrongly detained. A study recently carried out by a Medical Research Council unit at Morgannwg Hospital, Bridgend—a hospital whose standards are no worse nor better than anywhere else in Wales—revealed that more than 6 per cent. of the patients according to the medical staff, were fit to live at home and their families were ready and able to receive them. These patients are forgotten people. For the most part they have been in hospital for more than two years.

Our mental hospitals are so short of psychiatrists, trained staff and social workers that the bulk of medical and social work has to be concentrated upon short stay groups of patients and the harassed and over-stretched staffs cannot give adequate time to the long stay patients. These 500 patients, although now fit to leave, have been abandoned because a shortage of staff, in particular social workers, has prevented contact being re-established between the outside families and the patient. They are left as flotsam in the mental hospitals because an overworked staff cannot manage to arrange to identify the receptive families, supervise the discharge process and smooth out the social complications.

I sincerely hope that if we are serious in our intention to bring about a state of affairs in which the large mental hospitals in Wales will disappear and that we have smaller well staffed hospitals and acute psychiatric units the Minister, despite the respect he must have for the academic freedom of the medical college, will make his voice heard so that we can be sure that the money which is to be spent on the new plan coming into existence will ensure that there are men and women to staff it. Only when we have departments of the type established in Bristol, where there is a chair of mental health and when we have a chair of psychiatry in our University of Cardiff will it be possible to bring about what at the moment is stated in the plan as being desirable for the Welsh mental health services.

9.4 p.m.

Dr. J. Dickson Mabon (Greenock)

I was very pleased to surrender a few minutes more for my hon. Friend the Member for Pontypool (Mr. Abse) to put his point of view so vigorously. With a name like mine it would be wrong for me to stand in the way of a Welsh protest and argument of that kind. I am glad that there have been a number of vigorous speeches from both sides of the House in this debate.

I particularly commend that of my hon. Friend the Member for Fife,West (Mr. W. Hamilton) in which he suggested that the genesis of all this was in what the Minister said on 1st February, 1961. That was where the plan started. It was on the day when the National Health Service charges were introduced, to quote the Minister, …to carry through a long-term programme of modernising our hospitals."—[OFFICIAL REPORT, 1st February, 1961; Vol. 633, c. 988.] The consequence of the health charges, as we know, was to reduce the present Estimate by £50 million in the current year 1961–62 and by £65 million in a full year. We reflect that since that announcement was made, the building programme from the point of view of capital expenditure has actually increased by only £6 million in the whole of the United Kingdom and is running at £38 million in the present year. According to the value of money at 1938 prices that is actually less than £10 million, which was the sum spent by a rather stodgy and unspectacular Tory Government in the financial year 1938–39. Yet hon. Gentlemen opposite have been worrying about whether we are, in a Welfare State, pampering people. What a commentary that all these years later the Tories should be spending less than was spent in 1938–39.

We are invited to approve this programme, but we are not quite sure what it is that we are approving. We do not know the size of the programme. We are told that it is £500 million in ten years, and the Tory "tabloids" published screaming banner headlines to that effect. But the Minister says it "might be £500 million" in ten years—it might be. In another place Lord Newton was more precise. He went so far as to say that the total cost of building to be started within ten years is to be £707,500,000. That is an incredible prognostication. While the Minister of Health can say only that it might be, one of their Lordships in another place, speaking officially, was able to say that in fact the figure would be £707,500,000 in the ten years. May we have an explanation of this? Is it the case that he means that buildings will be started, as was said earlier by the hon. Lady the Member for Plymouth, Devonport (Miss Vickers) and that the Minister will be laying foundation stones representing £707,500,000 in the next ten years; and that probably we shall have more foundation stones than psychiatric social workers in Wales—or in Scotland either for that matter?

We may be given an explanation of all this, but it is a little unreal when we go into the question of the size of the programme and think of the past record of the present Administration. Earlier in the debate the Secretary of State for Scotland boasted that about £230 million had been spent in the past ten years on hospitals. May I remind the right hon. Gentleman that that represents an expenditure at 1938 valuations of £5 million a year which is half of what was spent pre-war. When we look at the old arguments about the high cost of the health service and the rest of it we reflect that the percentage of the national income spent at present, either net or gross, is no higher than it was before the war.

We must remove from our eyes some of the cotton-wool arguments about the Welfare State. We should not congratulate ourselves on this matter, that we are spending no more on the Welfare State than was spent in pre-war circumstances. It is high time that the economists and particularly—and here the Minister is involved the Treasury Ministers, realised that the National Health Service is a first-class priority and is deserving of far better treatment than it has had. It ought not to be treated in the meagre and niggardly way in which it has been.

My hon. Friend the Member for St. Pancras, North (Mr. K. Robinson) said that this was not a plan but an expres. lion of pious hopes and unwarranted assumptions—and how I agree with him. At the best—not that I would ever accord that the Minister has given the best in relation to health matters—it is a declaration of good intentions. It is hardly a plan at all. The proposals reveal some "familiar faces". Admittedly, my hon. Friend the Member for Willesden, West (Mr. Pavitt) is disappointed at the absence of one "familiar face" in the form of the Central Middlesex Hospital and at the fact that what was hoped for five or six years' hence will not now happen until more than ten years' hence. In Scotland that is not quite the case.

I am glad that my hon. Friend the Member for Pontypool did not apologise, as have many hon. Members including some of my hon. Friends, for expressing a constituency point of view. My own opinion is that we ought not to accept the philosophy of Edmund Burke; that we should reject his view. The constituencies represented here tonight are represented by the best M.P.s they have—to paraphrase the Home Secretary—and I cannot see why Members of Parliament should not express constituency interests from time to time, or should ever fail to voice the interests of their own constituents. Edmund Burke is on the way out, though the Minister may not realise it. I am glad that my hon. Friend did not apologise, because he had every right to express his constituency point of view.

Accordingly, I have a word or two to say in relation to Scotland. I was talking about the presence of some familiar faces in the programme. I look at the programme for Scotland, and no doubt other hon. Members can find the equivalents in their own areas, and I see the Bellshill Maternity Hospital, the Victoria Hospital, in Kirkcaldy, the replacement for the Dundee Royal Infirmary, the radio-therapy unit at the Western Infirmary, Glasgow, and the admission unit at the Royal Edinburgh Mental Hospital. These are familiar names to those of us who concern ourselves with these matters. If I recollect rightly, these are the ones that were promised on 5th February, 1955, by a gentleman called Commander Galbraith, now Lord Strathclyde, who was then Under-Secretary of State at the Scottish Office. So the sins of the fathers are visited upon the children —or is it their promises? I think the quotation goes on: unto the third and fourth generation". but heaven preserve us from having to wait that long for these matters to materialise. These particular items, solemnly announced in this new plan, are promised for the 1961–65 period. Yet the Commander later was apologising to my hon. Friend the Member for Dundee, East (Mr. G. M. Thomson) for having promised, rather prematurely, he said, that the Dundee Royal Infirmary would be built on time. And this was some nine years after it had been promised, because it was originally promised in 1952 by the Scottish Minister at that time.

In regard to Scotland, there is something in which perhaps English hon. Members might interest themselves. In April, 1961, when the Minister was trying to recover some of his popularity—and he has a long way to go, despite the pogo sticks and all that—he gave a party political broadcast on television, no doubt to help the English elections along. He was seen pointing to the achievements—still to come, of course—of the Conservative Party. One of them, quickly passing across the television screen, was the Vale of Leven Hospital in Dunbartonshire. How apposite this was to an English election I am not sure, but perhaps it was because he was unable to argue that there had been a similar hospital built in England since the war, and because not even Swindon came in that category.

May I remind the right hon. Gentleman, when he singles out this Scottish hospital at the Vale of Leven as a triumph of Tory endeavour, that it is the only one that has been built since the end of the war, and that it was conceived initially by the Labour Government during the Korean War? As the right hon. Gentleman and the father of the present Under-Secretary of State publicly admitted, because he is an honest man in that regard, this hospital was conceived by a Labour Government. It took twice as long to build as was estimated because of the procrastinating Tory midwives who were constantly postponing delivery. They interfered with the capital building programme from time to time so often that the hospital took twice as long to build.

It was finally built in 1955, but the Minister could not open it for a year because the Government would not provide the money for the Western Regional Hospital Board to pay the staff and meet the running costs. He was, however, under public pressure, finally compelled to open it, but even today this social enterprise which the hon. Gentleman tried to claim in the English elections as a Tory Party achievement, still has not got an out-patients' department. It is a make-shift one. The actual new one, which is to make this a complete hospital is in this so-called marvellous plan. Is it any wonder that we are a little cynical about all this, and that we question if we are under the Tories ever to achieve it?

Perhaps the most heartrending cry of all was that uttered by my hon. and gallant Friend the Member for Ripon (Sir M. Stoddart-Scott)—if I may call him my hon. Friend, not in a legal sense, but in a medical sense—when he said: "Let no emergency or crisis budge him from fulfilling these figures." I wish that were, true, but the Secretary of State has given himself so many escape trapdoors. I have never known of anyone making so many political trap-doors for himself as the Secretary of State for Scotland, and that is saying something, for if anybody has trap-doors concealed in every speech, it is the Secretary of State for Scotland.

My hon. Friend the Member for Abertillery (Mr. Ll. Williams) mentiond slum clearance and the English schools programme, and hon. Members who are acquanited with these things in England know that they are well behind the original schedule. I would go further and say that there is not a single programme of capital expenditure in any category in England and Wales or in Scotland which is up to date. The Secretary of State for Scotland knows, for example, that the Scottish technical college programme is well behind time and at the present rate will not be completed by 1980 when it is supposed to be completed by 1966. The programme for overspill housing will not be completed before 1992 at the present rate instead of by 1967. There is not a single Government programme for capital expenditure that is not running years behind time.

Is there any reason to believe that this programme of hospital building will not suffer the same fate? Is there any reason to be genuinely convinced that it will go through on time? I admit that this is no reason for saying that therefore the programme in itself ought to be disregarded but I cannot help feeling that in a sense it is not meant to be fulfilled on time. I credit the right hon. Gentleman opposite with the intelligence to realise that unless luck goes their way constantly it cannot be done. Therefore, they are prepared to have flexibility, but this flexibility is primarily not based on any consideration other than finance.

Let us consider how this programme is conceived. It seems to me more like a propaganda exercise than anything else. It rests on three major pillars and if any one of those pillars cracks the whole edifice comes down. Those pillars are beds, staff, and local authority services. Let me begin with beds—how many, what kind and where.

When we want to know how many beds are involved, the Minister says, "Fewer than at present" and we are expected to be content with that. What kind of beds, and where are they to be? Hon. Members ask about rural district hospitals and speak about people who have to trek from Bridgwater to Taunton to visit people in these hospitals. his, of course, is a serious problem. We wonder how the Minister will tackle it and we study the Report to find how it is to be done.

Most hon. Members have been less fortunate than I have been in that I have had to read both the Scottish and English Reports. I am astonished to find that even in these Reports there is no agreement on how the number of beds is to be calculated. If hon. Members will compare the Scottish and English Reports they will find that for most categories referred to in the English Report there is a different category in the Scottish Report.

The caveat in the Scottish Report says: This table omits convalescent and general Practitioner beds, and unclassified unstaffed beds. This is a wonderful manœuvre. I congratulate both Ministers on this splendid political dodge, but, even accepting that, there are other differences. In Scotland and in England, apparently, we have acute cases, maternity cases, and mental deficiency cases. There are no chronic cases in England but in Scotland there are chronic sick. There are geriatric cases in England but not in Scotland. There are infectious diseases in Scotland and respiratory tuberculosis, but in England there are "other" cases. And all this is in a solemn programme presented to Parliament in two Reports in which the number of beds is supposed to be carefully calculated and in which Ministers say they can reduce the numbers of beds.

I must confess that if I were the Minister I should be frightened to reduce the number of beds. I should not be sure of myself unless I had substantial evidence to show that I could do this without any fear of being unable to face an epidemic or a catastrophe of one kind or another or even to face the new patterns of morbidity which a rapidly ageing society such as ours is creating. I do not know whether the Secretary of State for Scotland is fully informed on this; if not, that is nothing unusual. But we should like to know how the Minister can make this decision.

Apparently in Scotland there is to be a national morbidity survey. I wonder whether this is true of England. Is there to be a national morbidity survey in England? Is there to be a follow-up of all these things in relation to England? I remember when the hon. Lady the Parliamentary Secretary was being questioned by my hon. Friend the Member for Bishop Auckland (Mr. Boyden), who incidentally made an excellent speech tonight, about the follow-up of cancer cases. She could not tell us. I tried to help, no doubt feebly, at Question Time to get some response from her but I got very little. Yet the follow-up of cases is very important, as this national morbidity survey tells us. It tells us how many are likely to be going back into hospital in the different illness categories.

I have here an excellent report written by an old professor of mine, Professor Ferguson, who is Professor of Public Health and Social Medicine at Glasgow University. In addition to publishing his first report in 1954, he has now brought out a second one published by the Nuffield Provincial Hospital Trust which does most of the good research work for the National Health Service—not the Ministry of Health nor the Department of Health for Scotland. It is high time that the Minister shook up his ideas and realised that he has got to be able to put each research project, Government and Nuffield trust, side by side. He has got to match them pound for pound. He is not doing it at the moment.

I read that this revealing report, which I hope will be the sort of thing that we shall see in the national morbidity survey, referring to 1961, notes emphatically the poor facilities for terminal care of incurable disease in the West of Scotland and states that some patients die 'in conditions that were an affront to human dignity'. Professor Ferguson is, as I say, an old professor of mine. If ever there were a man anxious to get at the truth and to confine comment to that which was objective, it is he. Certainly in this report he has been emphatic about what he has found. It is on this kind of experience that a plan like this has to be founded. We have already had from the Minister what he admits is a plan not based on any concrete findings other than the sporadic surveys revealed by my hon. Friend the Member for St. Pancras, North.

My hon. Friend the Member for Birmingham, Small Heath (Mr. Denis Howell) raised an important point on the subject of pay beds. Is it true that we are going to have a higher proportion of pay beds in the National Health Service as a consequence of this plan? Is that the Minister's intention? Is he going to allow the regional board at Shrewsbury to sell the land there so that insurance companies may speculate on the medical care of people? Will the Minister tell us that there will be no increase in the proportion of pay beds in the National Health Service as a consequence of his plan?

My hon. Friend the Member for Abertillery mentioned small hospitals and asked that their closure should be phased. I agree with him. Here the Secretary or State for Scotland has been very negligent. He may recall our earlier debates in 1957 and 1958 on this matter, and that many of these small hospitals can lend themselves to other purposes. They could be used for such things as geriatrics. Many of them could be used as long-stay, or half way houses as they are called, for old people. I do not say that they could all be used in this way, but certainly many of them could.

What has happened to our beloved health centres? Have they gone for ever under this Government? Is it not possible that some of these hospitals might be able to provide health centres? I ask that because we have to think again about the general practitioner. It is not good enough merely to regard him as the family doctor working under difficult circumstances in an industrial town, able only to call on the hospital facilities in relation to diagnostic matters or to visit his patients who are occupying maternity beds. What has happened to the Standing Medical Advisory Committee on the future of general practitioners? When will this Committee report? It has been sitting for over a year, and we are most anxious to know what it will recommend. We are anxious to know whether its recommendations will be fitted into this plan.

My hon. Friends were quite right to ask the Minister to substantiate his claims about staffs. Is he satisfied that the present rate of recruitment will be adequate to meet this problem? The Minister is obviously an intelligent man, and when we are talking about staffs it is important to reflect on the kind of staff required. The right hon. Gentleman is thinking of hospitals which will be willing to lend themselves to the training of different kinds of specialists, hospitals which will be capable of changing their facilities in conformity with the changing pattern of medical treatment. Surely he must apply these considerations to the staffs as well?

Does not the right hon. Gentleman realise that the professions ancillary to medicine have grown in importance therapeutically? In the last twenty years these professions have grown to a substantial degree, and if the medical profession is to develop as we hope it will, clearly more and more specialists will be needed to help the medical personnel in the discharge of their duties. We will have to train more of these ancillary people to enable us to provide far better facilities than we do at the moment.

My hon. Friend the Member for Pontypool remarked that in Wales they did not have a school to teach social workers, whereas we have now one in Scotland. I have no doubt that ought to be grateful for small mercies, but I assure my hon. Friend that it is a very small mercy indeed. There must be a different attitude to the question of training social workers and many other categories of people whom we have discussed on various occasions—physiotherapists and so so—who as we sadly reflect are at present concerned in a pay dispute with the Ministry.

My last point is about community services. There is no need for me to substantiate or garnish the arguments put forward by my hon. Friends. A few months ago I asked the Secretary of State for Scotland how much money he estimated local authorities needed to meet the rising costs of community care and after care for the mentally ill and mentally deficient. The right hon. Gentleman did not know. He had not the faintest idea. Then I asked what was the estimate of running costs of these facilities. Again he did not know. The fact is that this programme cannot work unless we look after the people who are discharged from mental hospitals.

The plan continually emphasises that point. Nearly a quarter of the introductory remarks of that plan is devoted to repeating the incantation that community services must play their part otherwise the plan will not work. Very few of us are impressed by what the Minister or his colleagues have said about community care or the development of it. The hon. Lady the Member for Devonport asked the right hon. Gentleman to give an assurance that the burden of rates which would result from an extension of these local authority facilities would not be too great. I am only sorry that the Secretary of State for Scotland is not winding up. Perhaps he would have told us what his response might have been to what the president of the Institute of Municipal Treasurers in Scotland had to say in his argument about rating.

But it all adds up to the same thing. However well disposed hon. Gentlemen opposite are to this programme and to this plan, and however anxious they are —and it is obvious that they must be anxious, in their own areas at least, for electoral reasons—that they should have a good hospital service developing, nevertheless, this cannot be developed fundamentally unless there is the money and unless there is the will. I am quite convinced that the Government have neither, and in fact if this programme is to go through in any shape or form to reach its proper culmination, which it must, if we are to have a proper hospital service in this country, the right hon. Gentleman and his hon. and right hon. Friends must make way for a new Administration which can do the job for them.

9.30 p.m.

The Minister of Health (Mr. J. Enoch Powell)

Although we are tonight discussing a new Hospital Plan of great scale and scope, it would be quite wrong to leave the impression, which I think may have been given by some of the speeches in this debate, that little or nothing has been achieved in hospital development since the inception of the National Health Service. In fact, the progress report to date, which was issued at the same time as the Hospital Plan, showed that there had been a great volume of hospital development over the previous 13 years. Putting it in simple terms of crude quantification, it is the equivalent of some 50 new district general hospitals which have been added to our hospital service during these past 13 years.

It was right that that development in those years should not take the form primarily of new hospitals but of urgent additions to the existing hospitals to which little or nothing could be done during the war years. Now, of course, we come to a new phase, in which plans for the service can be made on a much greater scale.

Reference has been made during this debate to an estimate made by the British Medical Association of the sum of money which might be required to modernise the hospitals of this country. It thought, broadly speaking, that £750 million might be the figure required. Now this plan embodies the commencement during this first ten years of schemes in Great Britain of a value of more than that already, of a value of some £800 million, and looks forward to a considerable further extension beyond that. The estimate of the British Medical Association is, therefore, less than the work to which this plan looks forward.

It is, in fact, an illustration of the creative use of the long-term forecasting of expenditure. I think it is right that we should recognise the importance of the decision taken by my hon. and learned Friend the Chancellor of the Exchequer, a decision which is matched in many other fields of Government policy and expenditure, to lay down a long-term forecast of expenditure within which planning could proceed. The two great benefits of this, which were brought out by my hon. Friend the Member for Torrington (Mr. P. Browne), are that we secure true economy, economy in the application of resources, and economy in the interim expenditure which is necessary as the plan unfolds itself. We shall be sure from now onwards that the great sums of money which are applied to new hospital developments are expended within the framework of a general conception of the development of the hospital service as a whole, within the framework of the Health Service as a whole; and where we shall spend the still considerable sums which will be required upon the improvement of, and additions to, existing hospitals, we shall be able to select those schemes with the knowledge of the prospective life and future function of the hospitals which are being improved and maintained.

This plan is based upon the thinking and the work of the regional boards. The hon. Gentleman the Member for St. Pancras, North (Mr. K. Robinson) chided me for the haste with which it was produced in the space of a year, and he referred to the "locust" years in which, so he alleged, no thinking or planning had been done. Of course, the fact is that it was only possible for this plan to be produced in the space of 1961 because it rested upon years of detailed work and thought which the regional boards had been doing throughout the country. They had made good use of these years of planning and now the psychological moment had come, and was taken, to sum up all this planning, all this devising, within the comprehensive framework of a national plan. This has meant giving to it consistency of policy as well as financial practicability, and applying national standards; for we could not claim that it was a national plan for our hospitals which was merely content to place side by side, however matured, the plans of the individual regional boards.

Again I make no apology for the fact that the regional boards were invited to take a wide view of financial possibilities in putting forward their plan. It would, indeed, have been absurd if one had not invited them to take a comprehensive view of the development which they conceived necessary for the hospitals of their areas before one came to weld the result together within the national framework of finance and policy.

This plan, therefore, is put forward by and for the hospital service as a whole. It is a plan, as has been said often during the debate, not of myself, not of the Ministry—it is a plan of the hospital service. That this achievement has been possible has been due, above all, to the leadership given by the regional hospital boards and by their chairmen. I should like to thank here those 15 men, who give their service voluntarily and who bear the responsibility, perhaps only less than my own, for the hospital service of the country, for the teamwork and leadership which has gone into this achievement on their part.

Such a plan as this was bound to be drastic and to express nothing less than a new pattern for the hospitals of this country. It would be miraculous indeed if hospitals, half of which are 70 years old, and a hospital pattern which derives from the period of the horse and trap, were suitable either as buildings or as an organisation for the second half of the twentieth century. So it is that 'this plan envisages the replacement physically of almost half of the existing hospitals in this country, and the complete re-formation of the pattern and organisation of those hospitals.

It has sometimes pleased hon. Members opposite to describe me as Jekyll and Hyde, and I am prepared to offer them an example for their case in this instance. I admit that I yield to no one in antiquarian enthusiasm for old buildings in every other capacity than that of Minister of Health. As Minister of Health, I plead guilty to being an iconoclast. Worship of an old pattern, worship of old buildings in Which so much good has been done and to which so much loyalty attaches must not stand in the way of the welfare of the patients of the future. I believe that we shall find that the loyalties that were attached to that old pattern and those old buildings will be transferred, I hope in greater force, to the new buildings and to the new pattern Which this plan will bring forth.

Now that we have it we must see that it lives. As I have said before, it is a plan which has hands and feet. It walks and it works. It is not a static conception, stated once and for all, but something which is intended to live and to be dynamic. That is why the regional boards and my Ministry will constantly be carrying this review forward, so that there will always be ten years' work definitely projected ahead before the hospital service. That is why in these constant reviews which carry the plan forward the developments of modern medicine and treatment and their implications will be taken into account, for it would indeed be surprising if those changes in medicine, in morbidity and, perhaps, in our approach to hospital treatment, were less drastic in the next 15 years than they have been in the last. We must be on our watch for the implications of the coming changes to be reflected quickly and sensitively in the revisions of this plan.

The plan makes it clear that, except where specific decisions have already been announced, it does not finally commit the individual details of closure, or of new building on this or that site; but as and when the time comes when each executive decision has to be taken, the regional boards will be anxious to ensure—indeed, for the most part they will take the initiative—that opinion, lay and medical, is most fully consulted and taken into account before that final executive decision is taken, from which we shall not look back but shall go forward to the physical work of construction.

It is in this review of the details that the local points, many of which have been raised in the course of this debate, will find their due. I am sure that it is right that this work should primarily be that of the hospital boards. I entirely agree with the hon. Member for St. Pancras, North and my noble Friend the Member for Hertford (Lord Balniel) that nothing should be allowed to derogate from the planning responsibility of the hospital boards upon whom will rest the 'executive responsibility to realise the plan, although I and my Department will always be at their disposal, especially where major issues come forward for decision.

But while the plan is thus revised and carried forward so as to embody progressively the results of change, experience and, perhaps, better wisdom, the plan itself must be put into effect. I take very much to heart the warning which the hon. Member for Abertillery (Mr. Williams) quoted to me from Luke, the beloved physician. We must indeed ensure that the plan moves inexorably into effect. A number of steps to this purpose have been taken in the few months since it has been published.

Throughout most of the country there is already an agreed timetable settled between the board concerned and my Department for every named scheme in the ten-year plan, so that the progress of each scheme can be policed from stage to stage. Where there is a risk of a scheme falling behind, this will be known to those concerned and remedial action can be taken, or, where necessary, one scheme can be substituted for another, so that the full resources available may be used year by year in the hospital service. So we shall have a constant progressing and policing of the implementation of the plan.

The stages of each programme which the timetable will show are, I believe, themselves capable of acceleration. For most parts of a hospital, cost limits and guidance on design are now available in the Building Notes of the health departments and from now onwards the Ministry's examination of schemes will be confined to departures from the cost limits and from the guidance in the Building Notes. This decision will greatly lessen the area of detailed discussion between the boards and my Ministry, and therefore the time consumed, and I think that it will go far to meet the point of my noble Friend the Member for Hertford.

From now onwards, moreover, it is my intention that once a sketch plan has been approved by me, then, unless the approved cost is exceeded or unless the scheme itself is altered, no further examination will be required by my Department. The working drawings will not have to be submitted or tenders required to go to the Ministry for approval. This should result in a considerable acceleration of the stages before a scheme goes into actual execution, so that the timetables will be shorter and we shall have greater assurance of being able to carry through these schemes within those timetables.

Standardisation is a word which has been mentioned many times in the debate, and in whatever sense it is used I believe that standardisation can contribute to economy, efficiency and speed in hospital building. One development which is going ahead is that of modular co-ordination. I am sorry about the expression, but it means, as most hon. Members will be aware, the planning of hospital buildings in terms of multiples of basic sizes or dimensions. In every region some schemes are already being planned on this basis, and I foresee from it a considerable saving in time and a considerable economy, in due course, as it becomes possible to fabricate parts of these buildings away from the sites. That is standardisation in one sense: modular co-ordination.

But a great deal can be done by the standardisation of the interior and equipment, ranging from cupboards to floor coverings. There is no reason why a great degree of standardisation, with corresponding simplification of planning, and economy in cost should not be achieved in the contents of our hospitals. Indeed, there is hardly a limit to the exploration which is still possible and which is going on into the potentialities of standardisation in the widest sense in the planning and building of hospitals.

My Ministry's development unit, which has two schemes in hand and is about to start as a third the planning of an entire new hospital on an existing site, will be used to illustrate and further to explore these possibilities, and the results, as they accrue, will be placed at the disposal of the hospital service as a whole in a new series of publications. This week there begins the issue of a new series of technical memoranda, and the first, those issued this week, will relate to protection against static electricity and fire risk in kitchens. A series of new equipment notes will also Shortly begin, the first of which will deal with diagnostic X-ray departments.

I believe, therefore, that there are immense possibilities here of improvement, economy and speed which we can build into our system for policing and ensuring the execution of the plan.

These studies are only one example of the impetus which this plan will give to the study and investigation of every element and every aspect of the hospital. I totally disagree with the hon. Member for St. Pancras, North when he says that we ought to have carried out all these studies first and arrived at a final view of bed ratios and so on and that we should have investigated this and investigated that before the plan was drawn up. The drawing up of some framework such as this for the future development of the service was the necessary frame of reference for all these studies, whether of bed ratios, staffing, or of the physical items such as those which we have been discussing.

Of course, the estimates which have been made in this plan, the bed ratios and so on—and, by the way, there is no reason why the substantially different conditions, in some respects, in Scotland compared with those in England and Wales should not result in a somewhat different scale of provision being made for the two countries—will be progressively refined and studied and modified as the years go on, but that work could not be done effectively if we did not begin with the framework of the general intention which is expressed in the Hospital Plan.

Important though this plan is, it is only part of a greater whole, to which it belongs and in which it must be firmly set. On the day—and this was no accident—on which this plan was published, I asked all the local health and welfare authorities to prepare their own ten-year plans for the development of their own health and welfare services for community care. Those plans will be coming in during the latter part of this year and will find their place in a plan for the development of community care which will be the counterpart, and I believe the worthy counterpart, of this Hospital Plan.

It may have been noticed that no less than one quarter of the text of this plan is devoted to community care, to care outside the hospital. That is right, be cause the provision which is made inside the hospital is complementary to that made outside. The principle upon which we approach this is that the prevention of illness and the care of illness should take place in the community, except where the specialised services of the hospital are necessary.

The hon. Member for St. Pancras, North expressed the hope that local authority plans would measure up, for instance, to the needs of the mentally ill and the aged. In the ten-year plans for the development of community care, we shall be able to see and judge and, if necessary, to adjust the provision which is to be made outside the hospitals, in the community, and I have been happy as I have gone round local health and welfare authorities to see the impetus and the enthusiasm which the work of preparing the ten-year plan has generated.

This work of planning ahead for the community services provides for the first time the means of systematically extending the scope of the voluntary contribution to health and welfare.

Mr. Pavitt

The right hon. Gentleman has mentioned two parts; is he considering a ten-year plan for the general medical service?

Mr. Powell

I have not finished yet.

Mention has been made of the conference earlier this year of representatives of hospital authorities, local authorities and voluntary bodies, from which it emerged that a new impetus had been given to the exploitation of the resources of voluntary effort and service for the benefit both of the hospitals and of the local authority services.

I was interested in the suggestion of my noble Friend the Member for Hertford as to the scope for the work of youth in this development of voluntary effort, and I hope that all these matters will be carried forward in a further meeting which is to take place on a wider basis next month and at which a large number of the voluntary bodies will be represented.

Even so—and this is the point which the hon. Member for Willesden, West (Mr. Pavitt) had in mind—when we have these two great elements of the Health Service, the Hospital Plan and the plan for community care before us, there is still a third, the keystone of the whole structure, because it is through general practice, the family doctor, that the aid of both the hospital service and community care is brought to the service of the patient as an individual and as a member of his family and social environment.

It is, therefore, no accident that at the time when this planning is going forward in the hospitals and in the community, more active attention than for many years past is being given to the scope and the future rôle of the general practitioner. An important contribution to that will be the report of the committee, under the chairmanship of Dr. Gillie of the Standing Medical Advisory Committee.

Mr. K. Robinson

When will it report?

Mr. Powell

I think that it will be some little time yet. It is engaged on a very big work.

Not until we can be sure that the future relationship of the general practitioner with the hospital service on the one hand and with the services of community care on the other is the right one—the one which gives him, as the person who commands the view of the patient as a human being in his environment, the means to secure the right treatment in the right circumstances—can we be fully satisfied that our plans for the hospital and our plans for community care will achieve their purpose.

Mr. Robinson

I loath interrupting the right hon. Gentleman, but among the many questions which he has not answered is that of my hon. Friend the Member for Birmingham, Small Heath (Mr. Denis Howell) about the provision of Section 5 beds and the extraordinary story about the private enterprise hospital in Shrewsbury.

Mr. Powell

The extraordinary story certainly is not correct as suggested by the hon. Member. The number of Section 5 beds has substantially diminished over past years, and there is no indication and no implication in the plan as to an increase in the number of those beds.

Mr. Denis Howell

What about Shrewsbury?

Mr. Powell

As I said, the statement which the hon. Member made about Shrewsbury is not correct.

Mr. Howell

Then give us the correct statement.

Mr. Powell

I am now concluding, and I want to refer to the thread which has run through the debate—the consciousness in almost every speech that although we were discussing the physical equipment of the hospital service we dare not, at our peril, forget the human purpose behind it. That is why it is only an apparent and not a real paradox that my last words in this debate are concerned with general practice and with the patient as an individual and a human being. But if that is held fast through the development of all three pants of the National Health Service, we may be satisfied that this plan, in its conception, in its development, and in its execution, will provide for hospital patients in this country in years to come an environment which will challenge comparison with that available anywhere in the world.

Question put and agreed to.

Resolved, That this House takes note of the White Papers on the Hospital Plans for England and Wales and for Scotland (Command Papers Nos. 1604 and 1602).