NATIONAL HEALTH SERVICE

HC Deb 19 December 1963 vol 686 cc1465-579

4.25 p.m.

Mr. Kenneth Robinson (St. Pancras, North)

I beg to move, That this House regrets the failure of Her Majesty's Government to adopt, in relation to the National Health Service, policies which would secure improved standards of service to the patient and permit the abolition of health service charges. It is, in a sense, unfortunate, though inevitable, that our censure, for that is what this Motion is, should fall on the Minister after his being barely two months in office, because we are complaining, not of the failure of a few months or even of a year or two, but of a continuing failure over 12 years, and of an attitude of mind that has persisted throughout the whole period of Conservative Government. Indeed, I think that the right hon. Gentleman, during his short tenure of office, has shown himself unusually receptive to ideas that have come from this side, and if he only had time, which he obviously has not, and if he continued to adopt Labour policies, he might even end up with a better record than any of his predecessors.

I shall not dwell at length on the latter part of the Motion, because I am sure that my hon. Friend the Member for Cannock (Miss Lee)—who I am sure the whole House is glad to see sitting in her unaccustomed place—will wish to say rather more about it.

The National Health Service was conceived as essentially a free service to the patient at the time of need. That is how it began. That is the kind of service that we on this side believe in, and that is the kind of service we intend to restore when we take over the government of the country. I only ask the right hon. Gentleman: will he tell us why, amid the shower of pre-election blessings that we have witnessed during the last few weeks, the sick have been omitted? Is it because the Government do not think that the sick, too, have a case, particularly at this time of year, or is it, perhaps, because of this basic difference between the two sides of the House on the question of National Health Service charges—a difference in political philosophy—which is one of the reasons why we shall divide the House?

Nearly everyone associated with the National Health Service must know that all is far from well with it. Not only has the service to the patient failed to improve as it should have done, but, in certain respects, standards are deteriorating. Many of those who are working in the Service are getting steadily more disheartened, and we believe that, for this situation, much responsibility rests with the Government and successive Ministers of Health—right hon. Gentlemen who, in the past, have never seemed to see a critical situation approaching, and who have acted, when they have acted at all, only when the crisis was upon them, and usually toe late to make action really effective.

I have a fairly good idea of what the right hon. Gentleman and the Parliamentary Secretary will do, because Ministerial replies in Health Service debates have become almost common form. The Ministers will drench us in figures. They will produce a large number of statistics demonstrating that we now have more doctors, more nurses, more physiotherapists, and more dentists than we had 12 years ago.

It will be, as it always is, a calculated effort to lull the House into a sense of complacency and into a belief that there is nothing serious to worry about. I have no doubt that these statistics will be reasonably accurate, if, perhaps, somewhat selective, but they are really no answer to our charge. There is, of course, more of this and more that after 12 years I would remind the right hon. Gentleman and the House of the situation that existed when the Health Service came into being.

What did the Service inherit when the Bevan Act became operative in July, 1948? First, it inherited a network of largely out-of-date hospitals. I believe that their average age was between 60 and 70 years. They were hospitals upon which only the absolute minimum of maintenance had been carried out over the previous ten years. It inherited an acute shortage of almost every kind of staff needed to start a Health Service and a medical profession divided and bewildered and whose perhaps natural anxieties in the face of change had been systematically exploited by sections of the Conservative Party and a handful of medical politicians in an effort to strangle the Health Service at birth.

Indeed, that the Service was successfully launched at all was in my view, and that of most of my hon. Friends, due to the determination, the patience and the negotiating skill of one man, Aneurin Bevan. Would it not indeed be remarkable if we had not got more doctors, more nurses and more staff of every kind than we had in 1948? The first three years from 1948 were in the nature of a rescue operation carried out at a time when the national economy was still suffering from the ravages of the Second World War, at a time when we were still undergoing shortages of every kind. They were the years of make-do and mend, but despite the fact that very limited sums of capital were available to the Service it was a surprisingly successful operation.

When Labour left office in 1951 the Health Service was poised for a great push forward towards the full realisation of the ideals upon which it was founded. But the Government changed and that thrust never came. Never since that time has the Health Service enjoyed under Conservative Governments anything like the special priorities which were accorded to it by the Labour Government that set it up.

I expect that the Parliamentary Secretary or the Minister, who, I understand, is winding up the debate, will try to deny this and will point to the Hospital Plan, the 10-year building programme of which the Minister's predecessor was so proud and with which I think he hoped to wipe out all past sins of omission. We had our reservations about that plan which we expressed in debate on it in the House, but we welcomed it in principle. Indeed, we welcomed a number of reforms which the previous Minister, the right hon. Member for Wolverhampton, South-West (Mr. Powell), tried to bring in when we thought it was right. On those occasions, we supported him sometimes when political expediency might have dictated otherwise, but on the Hospital Plan we said, and I believe that it is no less true today, that the right hon. Gentleman always claimed too much for it. Somehow, he tried to oversell it.

I want to try and put the Hospital Plan and the capital development of the Health Service into some kind of perspective today. At first glance, the size of the programme is formidable—close to £700 million over 15 years. It is perfectly true that compared with the pitiful hospital building record of the previous 10 years the programmes for the next 10 years are substantial, but let us look closer at this matter. Ten years ago capital expenditures on the Health Service and on the roads were roughly the same—about £20 million a year. Next year the capital expenditure on the Health Service will have gone up four-and-a-half times over the 1955 figure and will be about £91 million, but the capital expenditure on the roads will have gone up more than nine times over 1955, to £186 million, and it will be seen from the Government White Paper on Public Expenditure in 1963–64 and 1967–68, which was published yesterday, that the same kind of relativity will be maintained over the next four years, to 1967–68.

The Post Office, next year, will get twice as much capital provided for it as will the Health Service. Education will get two-and-a-half times as much, and the electricity boards seven times as much. These figures, therefore, hardly suggest that the Health Service is receiving an over-generous share of the capital expansion that is taking place.

We were told by the Prime Minister on the opening day of this Session, at the beginning of the debate on the address, that …a new hospital is now being started every 19 days."—[Official Report, 12th November, 1963; Vol. 684, c. 41.] That statement, which is untrue, is now blazoned on Conservative posters all over the country. I am quite sure that the Prime Minister would not wish deliberately to mislead the House. I can only assume that either his arithmetic is a little rusty or that he failed fully to understand the brief with which he was provided.

I have obtained from the Minister and the Secretary of State for Scotland the actual figures, and I am only helping the Prime Minister by including Scotland. The figures are that precisely 10 new hospitals have been or will be started during 1963. That is not one in every 19 days, but one in every 36½ days. I hope that the Prime Minister will apologise at some convenient moment for this inadvertent slip and, equally, that the Conservative Central Office will hastily cover up the posters which have been displayed and quietly pulp the rest of the stock.

But patients and the public in general are rather more interested in hospitals that are finished rather than hospitals that are starting. They want hospitals they can make use of, and I should like to look at the whole record of the Conservative Government in this respect.

If, in the 12 years 1951–63, they had been successful in starting one new hospital every 19 days we should be today better off by about 170 new hospitals. In fact, during those 12 years precisely four new hospitals and one dental hospital, without any beds, of course, have been completed in England and Wales. That is not even one in every 19 months. Scotland has done relatively better with four new hospitals, but they seem to be very small, because the total number of beds they represent is 475. I thought it worth putting the Prime Minister's statement in perspective and getting the facts on the record.

I should like to turn now from capital to revenue expenditure. I think that some hon. Members, and certainly some people outside the House, have the impression that the National Health Service is an enormously expensive service. In fact, it costs just about 4 per cent. of our national income, and, again looking at the White Paper on Public Expenditure, it seems likely to remain at about that figure of 4 per cent. One would expect a Service which is comprehensive in a sense which is not true of the health service of any other Western country to cost a good deal more than others, but we have some I.L.O. figures—I think that they are the most recent available—which show that New Zealand, Norway, Canada, the United States and France all spend a substantially higher proportion of their national income—about 4½ per cent—than we do.

The figures show, also, that Belgium spends slightly more than we do, and of the Western countries cited only Holland and Denmark spend less in terms of national income. One cannot see in those figures any justification for the financial straitjacket which was imposed on the Service about two years ago by the right hon. Member for Wolverhampton, South-West.

We told the right hon. Gentleman at the time, protesting about it, that the 2 per cent limit which he tried to impose on hospital development could result only in either reduced service to the patient or postponement of essential maintenance—or possibly both. Hon. Members will know that, at that time, many hospitals had to cease the recruiting of nurses, and some had to close down wards for lack of staff. But the right hon. Gentleman seemed not to be impressed by the warning which we gave.

Now, however, the chickens are coming home to roost. Official Ministry figures show that there was a fall last year in hospital maintenance of about 11 per cent. over the previous year, and figures which I have been able to obtain suggest that the fall in the current year will be nearer 15 per cent. over last year. What does this mean in actual terms? It means that there is no painting of the walls of hospital wards, the postponing of roof repairs, no replacement of defective window frames or worn-out flooring, and no replacement of worn equipment. For a hospital these are dangerous omissions or postponements.

At last, this desperate situation has been acknowledged by the Minister He is now making a special allocation of money for 1964–65 designed to cover these arrears of maintenance. Of course, the trouble is that it is a totally inadequate sum even to catch up with one year's arrears, let alone to cope with the accumulated arrears of two or more yean;. This is something which has been happening all over the country, and the Minister or his predecessor cannot say that he was not warned in terms by this side of the House.

I turn now to three Reports which have all been published in recent months, since our last debate on the Health Since. All are critical in tone, and all, I think, support, either directly or indirectly, the case which we are making against the Government and which is embodied in the Motion. The first is the AnnisGillie Report on the Field of Work of the Family Doctor, the Minister's own Report though, unhappily, not published as a Parliamentary Paper. The second is the Report of the Survey on Perinatal Mortality. The third is the Report on Food in Hospitals by the Nuffield Provincial Hospital Trust.

Each of these Reports bears out our assertion that standards of service to the patient are unsatisfactory and in some respects declining. Each Report deserves a debate to itself because of its importance. In the time which I have, I must be content to deal only with the main features of each, and I hope that some of my hon. Friends will be able to expand on the points which arise.

First, the Gillie Report on the general practitioner service. This is a remark able document. It discloses with unusual frankness for a Government report a picture of frustration, disillusion and depression among family doctors, feelings which are undoubtedly having the most serious effects on the Service and on patients. If the state of general practice is unhealthy, as all the indications show it to be at present, there will be repercussions on every branch of the Health Service because the general practitioner is the vital link between those branches.

The Gillie Report unfolds a sorry tale, and the tale is very much confirmed by another document which I and, I think, some other hon. Members received this morning from the Medical Practitioners' Union entitled "Blueprint for the Future". The fact is that, after 15 years of the National Health Service, the general practitioner finds that his traditional rôle is radically changing and his new rôle is somewhat uncomfortable and ill-defined. He finds that his relationship with the hospital service is generally rather unsatisfactory. He finds that he can offer the better facilities which he would like to offer to his patients only at a direct cost to his own pocket because of the ridiculous system we have of reimbursing practice expenses on a capitation basis.

In this connection, I am glad that the new Minister has, at last, come round to tackling the problem, after all the locust years during which his predecessor, to use his own words, found the problem a little baffling. It is early days yet, but I should like the Minister to tell us what progress has been made in the discusisons he has been having with the General Medical Services Committee of the B.M.A.

The Gillie Report shares our view, which we have urged from this side of the House for many years, that the most satisfactory form of general practice for both doctor and patient is group practice. The present Government or, perhaps, more likely, the next Government will have to do a great deal more than has been done in the past to encourage and facilitate the setting up of group practices in urban areas.

Above all, the Gillie Report echoes another charge which we have frequently made, that general practitioners are overworked, that they are too few in number and that their lists are too large. One inevitable result of this situation is that they cannot give the service which they want to give to their patients, and the other result is that recruitment in general practice is at a dangerously low level. It is alarming to compare the number of applications for practice vacancies now with what was happening ten or even five years ago. The Government's record on the whole subject of medical staffing throughout the Health Service during their term of office has been appalling. Far from trying to stimulate the training of more doctors, for a time they did the precise opposite and actually limited the entry of students into the medical schools. I think that the Minister will now admit that that was a very foolish action indeed from which we are now suffering.

Mr. Geoffrey Johnson Smith (Holborn and St. Pancras, South)

The hon. Gentleman is being a little less than fair in making that charge against the Government. After all, that policy was merely carrying out the recommendations of a Royal Commission, was it not?

Mr. Robinson

No, it was not carrying out the recommendations of a Royal Commission. It was carrying out the recommendations of a Departmental Committee under the chairmanship of Sir Henry Willink, but Sir Henry Willink and Lord Cohen of Birkenhead have claimed that the Committee gave the wrong answer because it was given the wrong statistical information by the Government. The hon. Gentleman can sort out the blame as best suits him. I like to place it on the shoulders of the Government.

In this connection, I was very interested to read an article in last Sunday's Sunday Times in which we were told that the new Minister was face to face with a crisis of medical staffing. The right hon. Gentleman is quoted as saying: This is one of the most urgent decisions which has to be taken. We have got to make jolly sure that we have sufficient doctors to staff the new hospitals". I think that we can endorse that. But it is no new crisis. For years, it has been obvious that we needed more doctors, and, for the last three years, at least, we have pressed time and again for action to deal with a situation which was already serious and was fast deteriorating.

The Sunday Times report goes on to say about the Minister: He is also ready to admit the profession relies far too heavily on young trainee doctors from overseas, mainly India and Pakistan, to man junior hospital posts. They fill 40 per cent, of such posts on the average and in provincial non-teaching hospitals the average is 52 per cent. I understand that in the Sheffield region it is about 60 per cent. Here again his predecessor was warned, and I do not recall that we ever got any admission from the right hon. Gentleman the Member for Wolverhampton, South-West that he found the situation at all worrying. Indeed, there has been an atmosphere of frightening complacency about this question of medical staffing from the very beginning.

I should like to ask why was nothing done long before this, and why have no new medical schools been planned yet. This is another issue that we have tried to raise, only to see it bounce from the Ministry of Health to the Treasury, to the University Grants Committee and even to the Robbins Committee. It is very difficult to see where responsibility can possibly be placed for the opening of a new medical school. There is a very real urgency about this because it will be more than ten years from the taking of a decision to expand medical education and establish new medical schools before the benefits accrue to the National Health Service in the shape of additional newly-trained doctors.

There is no shortage of candidates, as hon. Members who read the correspondence columns in The Times today will see. There is a letter which states that two London medical schools have between 2,000 and 2,500 applications each for place; when there are, in fact, approximately 100 places available in each of the two hospitals. In other words, for each vacancy in the medical school there are roughly 20 applicants.

Sir John Vaughan-Morgan (Reigate)

The hon. Gentleman is usually very fair. I think he will recognise that in some cases in the teaching hospitals people apply more than once.

Mr. Robinson

I think that is perfectly true, but all the indications are that there would be no difficulty in finding suitable candidates for something like double the present number of medical schools. I hope that the right hon. Gentleman will be in a position to make some announcement during the debate about the setting up of new medical schools.

I see in the Robbins Report, in a footnote, that the U.G.C. estimated that there would be a 25 per cent, increase in the number of medical students by 1980. We may well need more than that and need them sooner. I should like to know where these students are going to train.

I turn to the second Report—the Perinatal Mortality Survey. I hope that other hon. Members will deal with this very important Report more thoroughly than I can. Very briefly, it shows that, although maternal mortality in child birth has fallen very satisfactorily in recent years, infant perinatal mortality has declined far less speedily. In actual percentages, it has come down from 3–8 in 1948 to about 3–1 last year. Statistics of this kind are apt to be very impersonal, but this means that there are three dead babies for every 100 women in childbirth. Put in another way, it means that some 25,000 babies per year are either born dead or die within a week of birth.

According to the survey, a considerable proportion, perhaps 100 a week or more, of these infant deaths could be prevented. They could be prevented by better ante-natal care, by having more confinements in hospital, and, what is equally important, a better selection of high risk cases to go into hospital maternity beds. They could be prevented by closer consultant supervision, which means more consultant obstetricians, and, above all, they could be prevented if we had more midwives. If we are to avert these avoidable tragedies, we must have more hospital maternity beds.

The right hon. Gentleman knows that his predecessor's hospital plan slipped up rather badly in its calculations for maternity beds. A hasty reassessment was made at the end of the first year, and my own guess is that even the revised figures will prove seriously inadequate. We must do something to induce more nurses to take up midwifery. I do not know whether it is still true—I believe that it probably is, and it certainly was a year or two ago—that a State registered nurse taking her midwifery course after registration,—it is, of course, optional—had to revert to a student's rate of pay while she was on the course. If this is still true, as I believe it to be, it is difficult to devise any more powerful disincentive to nurses taking up midwifery, I hope that something can be done about it, and indeed about the remuneration of midwives. It seems that in this society which has emerged after twelve years of Conservative Government the least rewards go to the most socially valuable members of the community.

The last report that I want to refer to is the Nuffield Report on Food in Hospitals. I should like first to examine the credentials of this Report. It was a survey which was carried out by Professor Platt, who occupies the Chair of Human Nutrition at the London School of Hygiene, assisted by two lecturers in his Department. The method he used was to take a random sample of all types of hospitals in different areas of England and Wales. The total number of hospitals coming under survey was 152. Each hospital had one ward selected, also at random, and the catering arrangements were surveyed. In that ward a single patient's diet was studied for 24 hours and the survey team visited each hospital without prior notice. The findings of the Committee were endorsed by an advisory committee, comprising professors of biochemistry, epidemiology and medicine and a consultant who specialises in gastroenterology. It was presided over by a chairman of great experience in hospital work. I think no one can doubt the authenticity of this Report. What did they find?

First, they discovered that the best food and the best catering were to be found in the smaller hospitals, particularly those with 60 beds or less, and that, in general, the larger the hospital the lower the quality of food, the lower the efficiency of the catering administration and the higher the percentage of waste. Their criticisms fall under three broad headings. The first refers to a low standard of hygiene especially in the ward kitchens. This is quite unpardonable. It makes nonsense of the hospitals' efforts to control cross infection. After all, there is little point in maintaining a high standard of cleanliness in a ward if we get in an adjoining ward kitchen the kind of unhygienic conditions described in this Report.

The second criticism relates to the food itself. The members of this group found that there was an unsuitable choice of food of doubtful nutritional value. They found that there was poor preparation of it and poor cooking and that in most cases vegetables were overcooked to the point at which Vitamin C was lost to the extent of 75 or even 100 per cent.

Lastly, they criticised something which will be familiar to any hon. Member who is or has been an hospital in-patient—the unattractive presentation of the food to the patient.

These things, it was thought, were due to failures to make proper use of the dietitian in the hospital and to study a patient's normal food requirements and to cater for those and not some imaginary requirements that someone had thought up in an office. They attributed them to old-fashioned kitchens with out-of-date equipment and old, badly planned hospital buildings. Also, although this was not so much stressed in the Report, I think that they are largely due to the salaries and wages which the hospital authorities are allowed to pay to the catering officers and the cooks that they employ. On these wages it is impossible for the hospitals to compete with the catering trade or large scale industry.

The third broad category of criticism refers to waste. The Report found that only 55 to 60 per cent, of the food prepared for patients in the larger hospitals was eaten and that the bulk of the rest went into the pig swill. I should like to quote a remark which came to me in a letter from a correspondent about his experience in a London teaching hospital. He said: I suggested to Matron that she could save £1 a day —in one ward alone— by issuing out the food on an 'as required' basis. It was not well received. She said, 'We make money by selling the swill' ". He said that he could not contend further with that sort of economics. At Question Time the other day the Minister seemed to think that the Press rather exaggerated the extent of waste and the money it represented. I will make my own estimate, and I think that it is a fairly conservative one. On the evidence of this Report, I think that the overall waste is probably about 33⅓ per cent. I agree that some waste is inevitable, but I would estimate that, of that 33⅓ per cent., about 20 per cent, is unnecessary. The total amount spent on food in hospitals is roughly£50 million a year. Twenty per cent. of this represents a potential saving of £10 million.

The Minister of Health (Mr. Anthony Barber)

As the hon. Member has been very fair, and as I shall not be speaking until later, I should like to say that I agree entirely with him that if we could avoid most of the waste which is avoidable we would save a considerable amount of money. I will not trouble to quote what I said in an Answer the other day, but the point which I was seeking to make was that there are some very old hospitals with appalling kitchens—I have been round some of them myself—which, nevertheless, produce pretty good food. In fairness to that type of hospital, I did not want to fall into the error of lumping it with the others where there is not the slightest doubt that there is room for considerable improvement and very great savings.

Mr. Robinson

I am glad to hear the Minister say that, but I think that he will agree that the case is very fairly presented in this Report. It is acknowledged in the Report that some good catering is done even under very difficult circumstances. I ask the right hon. Gentleman to reflect on what he could do with £10 million to modernise these kitchens and even to increase the catering wages. In the past his Department has not paid enough attention to food, and I do not think it has been seized of the importance of this matter.

I wish to quote the experience of a hospital at Kingston-upon-Thames, where, in 1951, the management committee began to discuss the idea of an experimental kitchen and dining suite. Eight years later, in 1959, the Ministry of Health experimental team visited the hospital and put forward a precise proposal for siting within the hospital grounds a truly experimental unit where every modern technique of catering could be tried. The hospital management committee jumped at this proposal and accented it on the spot. That was in 1959.

In 1961, the Minister's predecessor made a public announcement to the effect that this experimental kitchen would be set up. Today, four years after the decision was taken to set it Up, the hospital management committee has not even seen the plans. However quickly people move now, this kitchen cannot be in operation for a further two years at best, which means that it will be about twelve years from the time that it was first mooted by the hospital management committee.

I have spent some time on this Report and I make no apology for that, because meals and visitors are about the only things which patients in hospital can look forward to in the course of the daily hospital routine.

I should like, in conclusion, to sum up our attitude. We believe that the National Health Service is still a great social service, although it has been damaged and diminished by Government policy over the last 10 years. We think that it is a service which has yet to realise its full potential for good. It is a service which is directed and staffed, in the main, by devoted men and women whose only wish is to see patients better served and better cared for, but their efforts have been met with frustration and disappointment over the years. The Minister, who is, I suppose, in a sense one of the largest, if not the largest, employers of skilled and unskilled labour in the land, should be a better employer than he is.

Despite the pre-election spurt about which we have heard recently, we do not believe that the Tory Government will ever nourish this Service as it needs to be nourished, because, basically, it runs counter to their political philosophy. It is no coincidence that two past Ministers of Health, who happened to leave the Front Bench for the back benches together a week or two ago, wrote a pamphlet some years ago from which I should like to quote the following brief passage: …the general presumption must be that they"— that is, the social services— will be rendered only on evidence of need, i.e. of financial inability to provide each particular service out of one's own or one's family's resources. The question which, therefore, poses itself, is not 'Should a means test be applied to social services?' but 'Should any social service be provided without a test of need?'. To those who believe that, the National Health Service will always bean extravagant waste of Government resources. They will, as successive Conservative Governments have done, quietly stimulate and encourage private medical practice to the detriment of the public Health Service because they believe in the two-class system of medical care.

We do not believe in that, and nor, I believe, do the vast majority of medical practitioners. This is why the National Health Service cannot be entrusted any longer to right hon. Members opposite, and this is why we shall go into the Lobby against them tonight.

5.9 p.m.

The Joint Parliamentary Secretary to the Ministry of Health (Mr. Bernard Braine)

I beg to move, to leave out from "House" to the end of the Question and to add instead thereof: welcomes both the considerable expansion of the National Health Service which has taken place in recent years and the further improve- ments which will be brought about by the policies of Her Majesty's Government". My right hon. Friend and I welcome this debate. It is right that attention should be focussed in this way upon our arrangements for promoting the nation's health. It is helpful to discuss freely and frankly the problems and difficulties which confront us in this field and to argue about the priorities which we should apply. We on our side are just as anxious as the hon. Member for St. Pancras, North (Mr. K. Robinson) to improve standards of service to the patient. Indeed, we can justly claim, as I hope to show, that not only have we been able to secure considerable improvements to the service in recent years, but we have for some time been engaged in a massive, comprehensive programme of development and expansion of which any country could be proud. It is unfortunate, to say the least, that the Motion makes no acknowledgment of the great improvement that recent years have seen in the nation's health, and it is unfair as well as wrong in its implication that the Government are failing to get their priorities right to the detriment of the patient.

It might be helpful, therefore, if I begin by putting this matter in perspective. The truth is that whatever the imperfections of our arrangements, the British people are fitter and longer-living than ever before. [Interruption.] Many of the diseases which used to carry off young children and men and women in their prime have been checked or mastered, and I claim that our medical services are the envy of the world. [Interruption.]

Before hon. Members starting interrupting on the subject, let us consider some of the facts. In the decade between 1951 and 1961, the average expectation of life at infancy rose from 66 to 69 years for a man and from 71 to 74 for a woman. Infant mortality has steadily declined, and in this we overtook the United States in the1950s. Similarly, there has been a striking fall in maternal mortality. I would be the first to say that none of us can be satisfied with the present figures. It is the fact that the number of mothers who die through child-bearing is little more than one-third of what it was only ten years ago.

Mr. Richard Marsh (Greenwich)

In fairness, since the hon. Gentleman has raised this argument, could not one make the same comparison and show the same improvements in comparison in almost every African State? Is it not a fact that Britain pays a smaller proportion of its national income on health than most other European countries?

Mr. Braine

I listened with close attention and, I hope, courtesy to what the hon. Member for St. Pancras, North said from the Opposition. There were many moments when I could have risen to check some of his statements. I did not do so because I was anxious to hear what he said, whereas the hon. Member for Greenwich (Mr. Marsh) is not anxious to hear the case which I am deploying. [Interruption.]

I want, first, to get the facts on the record. During the same ten years—and I do not know why hon. Members opposite should seek to denigrate—[Hon. Members: "Nobody is denigrating."]—these figures, because improvements in health, measured in terms of human happiness, are very substantial things—our children grew taller, sturdier and heavier. By 1961, the average boy of 14 was nearly 1 in. taller and 5 lb. heavier in weight and the average girl was ½ in. taller and 3 lb. heavier. Both of them were far less prone to illness than were their counterparts only ten years previously.

Diphtheria and tuberculosis, once killers, have been brought under control. Deaths from diphtheria are now rare. Between 1951 and 1961, deaths from respiratory tuberculosis dropped by over 75 per cent. Deaths from polio have fallen from a yearly average of 481 in 1946–51 to 126 in 1956–61 and to a total this year of only 45. While only ten years ago absence from work due to tuberculosis caused a loss of 23 million days, this has been reduced to 9½ million days by 1961. These are all marked improvements. They are a reflection in part of a continuously rising standard of living. Better housing, better nutrition, better clothing and speedier educational advance have all combined to improve the nation's health and well-being. There have been striking advances in the diagnosis and treatment of disease, in the use of new and powerful drugs and in the application of new surgical techniques.

The most exciting advances of all have been in the treatment of the mentally ill and the chronic sick. Perhaps I may be permitted to say that progress has come as much from attention to social factors and a growing awareness of needs as from the use of new drugs.

I would not wish to suggest—and this is the answer to the hon. Member for Greenwich—that all these improvements are due solely to the National Health Service, and I would be perfectly ready to concede that other countries have registered marked improvements in their health standards over a comparable period. It is, however, the case, and I hope that hon. Members will agree with me, that the National Health Service has been the instrument whereby the benefits of modern medical science have been brought to bear more quickly, more effectively and more fairly to the whole nation and not just to one section of it.

It is not surprising that Professor Almont Lindsay, an American social historian who made an eight-year study of the Service, has described it as one of the notable achievements of the twentieth century, magnificent in scope and almost breathtaking in its implications". [Interruption.]

Mr. John Hynd (Sheffield, Attercliffe)

Who opposed the National Health Service?

Mr. Braine

Hon Members opposite must make up their minds what they are cheering. I reject, therefore, the suggestion of the hon. Member for St. Pancras, North that standards have not improved. Anyone who has had anything to do with our hospitals over the last ten years could not subscribe to that view.

There have been substantial improvements in the scale of the services provided. In the last decade, the number of family doctors has increased and they have become more evenly distributed. Similarly, for every four hospital doctors, there are now five and there are 25,000 more full-time nursing staff and 32,000 more part-timers as well as 3,000 more full-time midwives and 1,100 more part-time midwives.

Having said that, I recognise that although a great deal has been achieved, much remains to be done. The reason for this, as the House will recognise, is that there is no finality, and there never can be, in the war against ill-health. Both medical men and lay administrators must constantly seek to devise ways of waging that war more effectively by doing things better and more humanely and doing new things that previously lay beyond their powers.

Moreover, it should be recognised that we have to plan in the knowledge that the population pattern is changing. The nation is growing at both ends. More babies are being born and the elderly are living longer. In the last five years, more than ½ million more babies were born in Britain than might have been expected from the birthrate in the early 1950s, and it is by no means certain that this trend has reached its peak. In addition, over the next twenty years the number of those aged 65 and over will be at least 30 per cent, greater than it is today, while the number of those aged 75 and over will be 40 per cent. greater. This, of course, is obliging us to make greater quantitative provision in our health and welfare services for both young and old, and our other social services, too. It is spurring us on to raise standards as well. Indeed, as national prosperity increases, it is inevitable that the exceptional provision of today will become the commonplace of tomorrow. Since one or two things have been said, quite unjustifiably, about the philosophy of my right hon. Friends and hon. Friends on this side of the House, let me say that in our view that is as it should be.

It is surely one of the marks of a civilised community that human beings matter, that the strong should be glad to help the weak, that we should strive to do all we can to reduce suffering and mitigate physical handicap and so to improve the quality of life and thereby enlarge the sum of human happiness. That is why it is so essential to get the priorities right now.

As to whether we have been devoting adequate resources to health and welfare, I can only say that the proportion of the gross national product devoted to the National Health Service has risen from 3.8 per cent.—where it was when the hon. Gentleman's party left office in 1951—to 4.1 per cent. of a very much larger national income last year.

Mr. K. Robinson

Would the hon. Gentleman also tell the House that after the Conservative Government came into power the percentage dropped to reach an all-time low of 3½ per cent. in 1955?

Mr. Braine

That was a higher proportion and a higher figure in absolute terms than was the case when the Labour Party left office. In money terms we are spending more than twice as much today as when the hon. Gentleman and his party last had responsibility for the Service.

As the House knows, we have embarked upon two massive long-term programmes—one for the development of the hospitals and the other for health and welfare services in the community.

I am sure that it was right in the earlier part of the last decade to concentrate, as we did, on improving and staffing the existing hospitals. But by 1955 we felt able to embark upon the first post-war hospital building programme. In 1962 we launched the ten year plan which envisages the spending of some £670 million over the next ten years. This includes the building of no less than 151 completely new hospitals, the rebuilding of 138 others and the carrying out of nearly 400 major schemes of improvement.

Already this great programme is well under way. So far, including those built before the plan was launched, eight completely new hospitals have been put into commission. A further 76 entirely new or substantially remodelled hospitals are now under construction. The pace is accelerating.

Each year the plan is reviewed; where necessary new instalments are added. The first review took place last April and another £100 million worth of work was added. As the plan takes shape, its momentum grows. Many of our older hospitals are in the wrong places to serve existing populations. Some are ill-designed for the practice of modern medicine. Others are too small to carry all the specialist staff and services now required. Indeed, in recent years there has been not only a trend towards greater interdependence of the various branches of medicine but, happily, there are now many more specific remedies for a whole range of illnesses for which previously little could be done. Quick and accurate diagnosis is essential if these new treatments are to be used to the best advantage.

That is why it becomes increasingly important to bring together in a single hospital the full range of facilities for diagnosis and specialist treatment. That is why we are aiming to provide large new general hospitals so sited that every part of the country will be served on a basis of 600 to 800 beds per 100,000 to 150,000 population.

Admittedly, we should be on guard against making too many assumptions about the way in which the hospital service will develop, for if we look back over the last decade we can see that the pattern of hospital care has been changing quietly but continuously. Some of our hospitals, for example, have changed in use. Many more patients are being examined and investigated as out-patients rather than as in-patients. The average length of stay in hospital is decreasing due to changes in medical techniques such as the use of new drugs and the practice of getting patients on their feet earlier and also to increased facilities such as new X-ray departments and operating theatres. In the psychiatric and geriatric fields we have seen the establishment of day hospitals which are proving to be a most valuable development.

However the service may develop in the years ahead we are faced, as the hon. Gentleman rightly reminded us, with certain immediate problems. In regard to these it might be helpful if I made known the Government's views and intentions.

First, there is the general concern about the running costs of an expanding hospital service and the need to ensure adequate maintenance of existing buildings.

Second, there is the special problem of maternity accommodation which has arisen, at least in part, from the somewhat unexpected but continuing rise in the birth rate.

Third—the hon. Gentleman did not mention this, but it is of major impor- tance—there is the pressing need to reduce over-long waiting lists.

As regards running costs, I want to make it plain that the Government are determined to see that the hospital service develops at the maximum rate consistent with the availability of resources.

For some time we have been increasing our allocation of funds to the hospital authorities at the rate of about 2 per cent. per annum in real terms, and over the years this adds up to a substantial total increase. This is exclusive, of course, of the funds to meet increases in wages and salaries and certain other costs. Even that is not the full measure of the additional help available since, as might be expected, the hospital service itself is steadily improving the efficiency with which it uses its resources, and we should take this opportunity to give credit to it for its achievements.

We are anxious to encourage this progress. I am glad to tell the House, therefore, that my right hon. Friends propose to assist the service still further next year by supplementing the additional funds which would ordinarily be available to the extent of a further £4½ million.

We are, of course, well aware that a great deal needs to be done to improve the state of maintenance of many of our existing buildings. Accommodation is still in use which should be upgraded to a standard which patients today are entitled to expect. Some equipment, both medical and non-medical, needs to be replaced. We hope to get very shortly the hospital boards' proposals for the use of the additional funds in tackling these important tasks.

I do not suggest for one moment that the money we shall be providing next year will be sufficient to meet all the needs that might be presented to us, but I expect it to make an appreciable impact and my right hon. Friend will certainly keep in mind what remains to be done when. considering his plans for the future. At this point I would like to make it plain that additional money will be allotted to hospital authorities to meet the cost of extra staff that may be required to permit shortening of hours of work.

I now turn to the special problem facing the maternity services. Our policy on this can be stated quite simply. It is that sufficient maternity beds should be available to enable every mother whose age or health involves a risk to her or her child at birth, to have the baby delivered in hospital.

In drawing up the Hospital Plan we accepted the recommendations of the Cranbrook Committee on Maternity Services which, the House may recollect, calls for the provision of a sufficient number of beds to permit a national average of 70 per cent. of confinements to take place in hospital with a stay of 10 days after a normal confinement. In doing so, we were aware, of course, of two imponderables, which might tend to cancel one another out—the trends towards a greater rate of hospital confinements and to a reduced length of stay in selected cases.

Nevertheless, as I have already said, flexibility is of the essence of the Hospital Plan and when we came to make the first annual revision last April, we were able to increase the additional 6,500 maternity beds by a further 1,200. With each bed able to deal with 30 or more births a year, these are substantial additions to the programme. We also have in reserve several thousand beds in hospitals due to be replaced and which, if the need should arise, could be kept in use.

Besides the actual addition to the number of beds to be provided, boards have been asked to bring forward the starting dates of building schemes, to consider the temporary use of other beds in hospitals for maternity purposes (for example, for ante-natal patients), and to consider the provision of additional labour accommodation where this is a limiting factor in the maximum use of beds.

My right hon. Friend is also about to send to hospital authorities, local health authorities and local medical committees a note which emphasises the need for local co-operation to ensure the best use of available resources and the planning of the arrangements to be made where, in particular areas, the services are working under strain.

I feel, therefore, that the House will see that we have already taken urgent steps to help resolve this problem, and I can give an assurance that my right hon. Friend is determined to watch the situation closely and consider what more should be done.

Mr. Maurice Edelman (Coventry, North)

The hon. Gentleman has just said that it is intended to make beds available for every maternity case for which they are suitable. But did not the Minister say to a maternal and child welfare conference this year that it was the Government's intention to provide beds for 70 per cent. of the potential mothers by 1972? Does that not contradict what the hon. Gentleman has just said?

Mr. Braine

I think not. This is a very important subject and my right hon. Friend will be going further into it. He will be able to explain what was said on that occasion. I do not wish to sound complacent in the least. Like so many other problems in our Health Service, this situation must be watched closely. The arrangements we are making will bring a great easement.

Mrs. Judith Hart (Lanark)

Clarification on this matter is very necessary. Did not we understand from the perinatal survey that a little under 50 per cent, of mothers had their babies in hospital? Did not the survey recommend that, in order to avoid avoidable perinatal deaths, the proportion should go up to 70 to 80 per cent.? Does not this mean that half as many beds again should be provided? Is that what the hon. Gentleman is undertaking to do?

Mr. Braine

I think that the figure is higher than 50 per cent. I am anxious that the House should be satisfied that the arrangements we are making are adequate. My right hon. Friend when he comes to wind up the debate will deal with that point.

Now I come to the question of waiting lists. These are regularly, and rightly, the source of criticism in the House and in the country. They must be reduced. There are bound to be waiting lists for less urgent cases, since truly urgent cases must be admitted without delay and hospital authorities must be able to determine the proper order of need when allocating their beds.

It is only right that I should say here that my right hon. Friend the Member for Wolverhampton, South-West (Mr. Powell) made a determined effort to get waiting lists reduced. The House may be interested to know what action has been taken. Last year we advised hospital authorities on the best ways of using, reviewing and preparing waiting lists. Last March we issued further advice on reducing surgical and general waiting lists and called for a concentrated attack. We suggested a variety of methods, all of which had been endorsed by the Joint Consultants Committee.

These included more use of theatres at present partly idle by means of co operation between hospitals; transfer of patients, with their consent, to surgeons with shorter waiting lists; keeping patients in hospital for shorter periods; dealing with more as out patients and properly organising the call system so that substitutes are found for patients who, for one reason or another, cannot enter hospital when a bed has been found for them.

Mr. H. Hynd

Is the Minister doing something to deal with the well-known habit of people jumping the queue by offering a 5 guineas fee?

Mr. Braine

That sounds to me a highly improper practice. All I can say is that we are not neglecting any opportunity to bring home to hospital authorities our view of how waiting lists can be reduced. In fact, we urged hospitals to make reductions in waiting lists a major objective in the current year.

Mr. James Dempsey (Coatbridge and Airdrie)

Are the Government taking effective action to deal with the problem caused by paying patients? In Lanarkshire, where there is a nine months' wait for certain operations, one can be dealt with within weeks if one is willing to pay. Is the Minister dealing with that situation?

Mr. Braine

If the hon. Gentleman has evidence of something taking place which he regards as improper, I hope that he will send the details to me or to my Scottish colleague. As I say, we urged hospitals to make the reduction of waiting lists a major objective during the current year. How far these efforts have been successful we shall not know until the returns showing the figures of waiting lists at the end of this month are available and have been analysed. But I can assure the House that on every possible opportunity, particularly through professional channels, hospitals are being stimulated to reduce their waiting lists.

I am sensitive to the feeling of the House on this subject. In all these matters, both now and in the future, we must never for one moment allow ourselves to forget that we are providing a service for people, for sick and worried people at that. I think that it is true to say that in recent years we have seen a growing and welcome recognition that the hospital service must cater not only for the purely medical needs of the patient but for his welfare generally, for clearly this has an important bearing on his recovery.

Increasing attention, therefore, has been paid to all aspects of human relations in hospitals. Three examples spring to mind. First, the introduction of more liberal visiting arrangements, secondly, the provision of accommodation where mothers can be admitted with their sick children, and, thirdly, efforts to raise standards of hospital catering.

The hon Member for St. Pancras, North was quite right to focus attention upon tie Nuffield Report on hospital catering, This is a most useful document. It sets out the difficulties fairly, it covers nothing up, it offers valuable advice as to how improvements can be effected, and it should provide, as my right hon. Friend said earlier this month, …a further stimulus to hospital authorities to secure universally high standards". In fairness, however, it should be said that the Report was based on a survey carried out; between 1960 and 1962. Considerable improvements have been made since then and are continuing to be made. Indeed, the vital importance of improving hospital catering was yet another matter to which my right hon. Friend the Member for Wolverhampton, South-West gave his vigorous personal attention, in his address to the annual meeting of the Hospital Caterers' Association last April, he said that hospital food is an integral part of the patient's treatment. As he put it: There is no more telling way of indicating to a person one's respect…for his personality than the manner in which one invites him to eat, and there are few matters in which people can be so sensitive or susceptible. The hospital service owes to its patients the same consideration that a host owes to his guest. 'Respect me, respect my food' is the silent injunction of the patient to the service. I think that the House would agree with that.

Part of the difficulty has been the poor layout of kitchen accommodation in so many of our older hospitals. We fully recognise this. But at the time my right hon. Friend was speaking, no fewer than 12 schemes for the provision of new catering facilities in hospitals, amounting to over £800,000 and ranging in cost between £30,000 and £200,000 were in progress and many smaller adaptations and improvements were in hand.

As to what is being done to raise the standard of hospital meals—the hon. Member for St. Pancras, North seemed to suggest that nothing was being done—the House might like to know that my Department attaches the highest importance to proper qualifications and training of hospital catering staff, and in this we have been greatly helped by the training courses provided by the King Edward VII's Hospital Fund for London. We provide hospital authorities with expert advice on all aspects of catering, and in January, last year, we published a handbook, which some hon. Members will have seen, providing up-to-date information and guidance on hospital diets, preparation and cooking of meals, costing, staffing, food hygiene and, above all, service to patients. I am sure that the hon. Member has seen it and equally sure that he approves its content.

In the hospital building programme we are paying particular attention to the design and layout of kitchens and dining rooms. Our own Ministry design team is working at present at the hospital in Kingston-upon-Thames, to which the hon. Member referred, planning a model kitchen, dining room and store. This is a scheme which will reflect all that is best in modern thinking and practice on the subject and which will provide a practical example for hospital authorities of the standard at which they should aim.

I should like now to turn to the equally important subject of the health and welfare services outside the hospitals, important because these are aimed at the prevention of illness or, if prevention is impossible, at care in the home and within the community. In planning an improved hospital service, we took into account the need for care being provided for all who did not require the specialised treatment which a hospital could give. We were concerned not merely to modernise the whole pattern and content of the hospital service, but to integrate it more closely with the general services which provide care and treatment outside the hospitals.

Here the importance of the family doctor is self-evident. For the greater part of the population, the family doctor is the Health Service, providing, as he does, the patient's first line of defence against ill-health. My right hon. Friend will be saying something about general practice and the Gillie Report, but at this stage I want to say that it is of the utmost importance that hospitals should provide the family doctor with access for his patients to diagnostic facilities, especially in pathology and radiology. Our aim must be to ensure that, as need dictates, the doctor can call to his aid the supporting services—the home nurses, home helps, meals-on-wheels, health visitors—which it is the function of the local authorities and the voluntary organisations to provide.

It is true that the Plan for Health and Welfare, which we published last April, is uniquely comprehensive, embodying as it does for the first time the proposals of all the local health and welfare authorities in England and Wales and setting out the aims and standards which should govern their development. But I doubt whether it is sufficiently realised to what extent the local authority services for the elderly, for mothers and young children, for the physically handicapped and the mentally disordered, have developed in recent years. Revenue expenditure on these services in England and Wales alone increased from £48 million in 1951–52 to £103 million last year, an increase of nearly 115 per cent. The rate of capital expenditure has been rising even faster. In the last four or five years, it has almost doubled. It will be about £19 million this year and next year is expected to rise to £23 million.

This is the other side of the Health Service to which the hon. Gentleman did not refer, but this massive investment and expansion is part of the same picture, because the objective of a good health service should be to keep the sick person out of hospital or, if he has come out of hospital, to ensure that supporting services are so adequate that he does not go back into hospital.

The first revision of the local authorities' long-term plans, covering the decade 1964–75 will soon be coming forward. That revision is now in progress and I hope that it will not be long before detailed proposals are in our hands.

In the plan as it now stands, an increase of 45 per cent. in the numbers of trained staff is envisaged. We hope to increase the number of health visitors, social workers and home nurses by about 2,000 in each category, training staff for sub-normals by about 3,000, staff for residential establishments by about 10,000, and home-helps by more than 11,000. [Hon. Members: "When?"] This is over a ten-year period. [Interruption.] Hon. Members should wait. There is nothing terribly dramatic in these figures. It is true that they are large increases, but they should be capable of attainment because not only are the absolute numbers themselves not great, but the increases are in line with experience. There has been an increase of about 20 per cent. in the last five years. Training facilities are being rapidly developed. I am not surprised that the hon. Member for St. Pancras, North made no mention of these matters, but this is where progress is taking place at an extremely rapid rate.

The Council for the Training of Health Visitors—[Interruption.] These are matters of the greatest importance to those people who need the supporting services outside the hospitals, and I hope that hon. Members will allow me to go on without interruption. The Council for the Training of Health Visitors and the Council for Training in Social Work, which were set up just over a year ago, are making good progress. A training council for the staff of training centres for the mentally sub-normal is in process of being constituted and will shortly begin work. The staffing of residential establishments is being studied by it committee, set up by the National Council of Social Service, under the chairmanship of Professor Lady Williams.

The plans of the local authorities provide for capital expenditure over the ten years of some 4,000 new buildings, some of which, of course, will be replacements for existing buildings, costing altogether £220 million. In addition, new needs are likely to emerge, especially as local authorities press on with the closing of ex-Public Assistance institutions and provide more suitable and home-like accommodation for the elderly.

Up to 1958–59, the figure for loan sanctions was averaging about £4 million a year. In the last three years, it has risen to an average of £15 million a year. As in the case of hospital building, the programme is already well under way. Last year, some 76 new old people's homes and similar residential accommodation, 64 clinics, 67 training centres and 21 hostels for the mentally disordered were opened. This year the same momentum has been maintained.

In the last year, I myself have opened a number of these new buildings, and I want to tell the House what an inspiration it has been to see the encouragement that new purpose-built accommodation has given to devoted staffs and the pleasure and delight of old folk, whom one meets in the new homes, in the degree of comfort and privacy which they find there. On average, over the next ten years we shall be opening two to three new old people's homes, the same number of clinics, and one new training centre every week, and one new hostel for the mentally sub-normal and one new ambulance station nearly every week.

Mr. Eric Lubbock (Orpington)

I am sure that we would all like to congratulate the progressive local authorities on improving facilities in the way the hon. Gentleman has described. Can he tell the House how the Government are to ensure that the improvements in Part III accommodation, home helps and home visitors and so on, are uniform all over the country? Is it not true that in some areas much better improvements than in others are being made?

Mr. Braine

Of course, local authorities are carrying out these works—with Government help and approval. A substantial part of the money comes from the Government. [Interruption.] I sometimes wonder whether hon. Members are really interested in the subject. The hon. Member for Orpington (Mr. Lubbock) asked a question, to which I am endeavouring to reply. It is true that when we came to look at the plans submitted by 146 local health and welfare authorities there was disparity. The whole object of publishing their plans in juxtaposition was to bring home to them the fact that disparity in their provision existed. The first revision is now coming forward. We have no reason to believe that local authorities will be backward in revising their plans on a realistic basis to provide for their people in the years ahead a standard of service of which they can be proud. In the last year I have been engaged in many talks with local authorities on this subject, and I found them extremely alive to the need to raise their standards.

Finally, I come to the key question raised by the hon. Gentleman, the future supply of doctors. Concern about this was voiced in last week's debate in another place on the Robbins Report, and again today by hon. Gentlemen. In 1957 the Willink Report recommended that the annual intake of British medical students to British medical schools should be 1,760. It was soon recognised that this figure was too low and should be increased, and in the last few years the number has risen substantially. In 1960 it was 1,788. In 1961–62 it was 1,896. In 1962–63 it was 2,047, and the improvement is continuing. Last October the entry was 2,153. Thus we can see, on this basis at any rate, a steadily increasing supply of doctors.

We have been reviewing what more needs to be done and in this we have taken account of many factors. These have included the recommendations in the Gillie Report on the future of general practice, and on the larger part which family doctors should play in the hospital service. They have included the reports of hospital medical staffing which hospital boards have made in the light of the Platt Report, and these Reports are being studied with representatives of the profession.

In the light of our review, the University Grants Committee has been asked to advise my right hon. and learned Friend the Lord President of the Council and Minister for Science, as the Minister responsible for university grants, what provision should be made. The Committee has recommended that at least one new medical school should be planned, and that at the same time the possibilities of further expansion of existing medical schools should be examined. My righthon. and learned Friend has authorised me to say that he has accepted that advice, and that the University Grants Committee is considering the question of location.

As the House will appreciate, I have not sought to deal with every point raised by the hon. Gentleman. He said that he would leave the subject of charges, which looms so large in the Motion, to his hon. Friends, and I hope that the House will forgive me if I follow the hon. Gentleman and leave that subject to be dealt with by my right hon. Friend.

What I have endeavoured to do is to set out for hon. Members what has been achieved, and what we are planning to do. I do not claim that our arrangements for health are ideal, and that our plans are incapable of improvement. This, above all others, is a field in which we can never be satisfied, and where medical men themselves are certain that the morrow will bring fresh challenge. Many years ago a wise man said: The ideal is never here, it is always over there; it is not an inn at which one can put up but a journey one must undertake. But I do claim that the record is one of solid achievement and real expansion, and that further improvement and expansion is possible precisely because the Government have got their priorities right, and that is why I feel justified in asking the House to accept our Amendment.

5.55 p.m.

Mr. Charles Morris (Manchester, Openshaw)

In the unhappy circumstances in which the vacancy in the Openshaw constituency arose, I wonder whether I might start today by paying a tribute to the late Member for the constituency, Bill Williams, who was respected and beloved on both sides of the House. I think that to him we can truly apply the words spoken by Pericles, 2,000 years ago, in his funeral oration for the Greeks who were killed in the Peloponnesian war. He said: For the whole earth is the sepulchre of famous men; and their story is not graven only of stone above their native earth—but lives on far away, without visible symbol, woven into the stuff of other men's lives. It is fitting, and in keeping with the deep and abiding interest which the late Bill Williams had for those whom he represented, that today, in this my maiden speech, I should seek to direct the attention of the House to at least some of the health problems which affect the lives of the people of Openshaw constituency and the City of Manchester, of which they form such an important part.

I should, perhaps, explain that the Openshaw constituency includes the delightful semi-rural Urban Dirstrict Council of Failsworth and goes on to cover the three wards Newton Heath, Bradford, and Openshaw which together form possibly one of the most heavily industrialised areas of Manchester. I think that one can accept what one distinguished correspondent of The Times said about the people of Openshaw during the recent by-election. He described them as "worthy and level-headed." I do not know whether that was before he knew the result or after, but I would endorse it, in any event. They are a particularly industrious people.

The vogue in recent times has been for hon. Members to seek to determine which section of the community produces the nation's wealth. I would seek to advance the claims of the workers of Openshaw and the north of England. But as residents of a constituency and of a city where industry and atmospheric pollution abound, they seem obliged to suffer some health hazards to which I should like to draw attention.

At this festive season of the year, with the advent of Christmas and its religious and joyous significance, it is, perhaps, appropriate that I should focus attention on infant mortality and address myself to explaining the shocking, indeed squalid, housing conditions in which so many people in my constituency are obliged to live. Of 19,000 houses owned by landlords, the local authority has determined that 7,400 have deteriorated to the state where the only solution is their complete demolition. That is the state of housing conditions in an area where infant mortality is a serious problem.

My hon. Friend the Member for St. Pancras, North (Mr. K. Robinson) referred to the question of infant mortality and the recent perinatal report. The right hon. Gentleman took pleasure in the fact that there had been a reduction in infant mortality in recent years, but I would refer him to an article in the British Medical Journal of Saturday, 7th December, because the pleasure which the right hon. Gentleman expressed—and which to some extent I share—is not entirely reflected in the contribution to this eminent medical journal.

The article is headed "Too Many Infant Deaths". In the context in which the right hon. Gentleman spoke, it appears almost as an addendum. It says: For some years satisfaction at the falling perinatal mortality rate has tended to obscure the fact that in Britain the rate is reported to be higher than in many countries with comparable living standards. In one list of 18 countries only five had worst rates than England and Wales and only Italy, Portugal and Japan showed rates worse than Scotland's. That is a situation which causes anxiety to many of my hon. Friends.

But the situation is slightly more ominous than that, because whereas these comments were written against the background of an infant mortality rate for England and Wales of 20–7 per 1,000 births, the infant mortality rate in Manchester in 1962 was30–43 per 1,000 births. It was 0.59 higher than in 1961. I am mindful of the detailed study and the attention that is being given to this problem by the city's medical officer of health and the medical authorities generally, but I must draw the attention of the House to the seriousness of this problem.

The Chief Medical Officer of Health for Manchester carried out a detailed study from which it has emerged that there seems to be no one single discernible cause for this unfortunate position. My hope is that the right hon. Gentleman will give consideration to the need for improve educational facilities for the expectant mother, because it seems that here is a reluctance among expectant mothers to start prenatal care early enough.

I now turn to the problem of cancer in Manchester. The statistics for 1962 show that 2.42 per 1,000 of the population died of cancer in one form or another, compared with a rate of 1.68 per 1,000 for the whole country. Naturally, as a Mancunian, I therefore ask, "Why?" When we hear of so much public money being spent in many directions we question why the existing situation obtains at the Christie Cancer Hospital in Manchester. Many hon. Members will be aware of the high reputation that that hospital enjoys. It was no less than staggering for me to learn that of the funds available for research into cancer at this hospital, only 10 per cent. came from Government sources. The rest came entirely from private sources.

I want, next, to refer to a health hazard from which I and all other city dwellers suffer. It is a peculiar complaint—almost a city sound. It is discernible when one listens to people talk who are obliged to live in cities. I do not want hon. Members to confuse this city sound with any other sound, such as the "Liverpool sound"—that delightful cacophony of noise made by our current entertainment idols. The sound to which I am referring is easily discernible, in the rather heavy nasal catarrhal intonations of the human voice, which seems to emanate from everybody living in a city.

I hope that this problem of sinus, catarrh and nasal trouble will be tackled. I hope that the right hon. Gentleman will consider whether further research should be carried out into the problem.

I want to quote from a speech made in this House by the late Member for Ebbw Vale, Aneurin Bevan, on 9th February, 1948. "Nye"Beyan—one of the most illustrious Ministers of Health that his country has ever had—in welcoming the coming into force of the National Health Service, referred to it as something which offers comprehensive medical care and treatment and lays for the first time a sound foundation for the health of the people…"—[Official Report, 9th February, 1948; Vol. 447, c. 35.] People viewed the introduction of the National Health Service in different ways. I viewed it as a declaration of war on disease and the conditions which give rise to disease—a war where the only sacrifice asked of us was the acknowledgment that we are our brothers' keepers, and that we should have a willingness to accept the financial obligations involved.

The foundations having been laid in 1948, I ask the right hon. Gentleman to have done with parsimony and financial stringency and the like, so that the great British medical profession to which we all owe so much can establish in these islands a health service which is not only the envy of the world, but which will develop and expand to meet the changing health needs of our people.

6.9 p.m.

Mr. Anthony Kershaw (Stroud)

The hon. Member for Manchester, Openshaw (Mr. C. Morris) has paid a moving tribute to the late "Post Office" Williams, as we used to call him, and I know that that tribute will be accepted by hon. Members on both sides of the House and by everyone in his constituency.

I can assure the hon. Member that even people who do not live in Manchester get very nasty colds. Whatever The Timesmay have said about his constituents being level-headed and worthy, the House will judge from the hon. Member's speech that he is level headed, and I have no doubt that he will also prove himself very worthy of his constituents. I look forward, with pleasure, as I am sure do other hon. Members, to hearing from him again on numerous occasions in the future.

I also wish to raise a matter which concerns my constituency rather more, perhaps, than the general ambit of the Health Service, although I make no excuse for so doing because I believe that this matter also has a bearing on the whole of the Service. This is not the first time that I have raised it. My hon. Friend the Joint Parliamentary Secretary will remember with a certain amount of pain that the last occasion on which we discussed the matter was at five o'clock on the morning of 26th June last. In case my hon. Friend has forgotten, I will remind him that the matter concerns the possible closure of three hospitals in and around my constituency at Tetbury, Berkeley and Stroud, and what will be the position if they are closed.

I am sorry to say that since the debate in June the position has not improved. In fact, it has worsened. Since then we have had news that the casualty department at the Stroud Hospital, with 52 beds, is likely to be closed. I wish to make clear that neither I, nor anybody else, so far as I know, who is concerned in this matter opposes the whole pattern of hospital services set out in the Command Paper published in January, 1962. I agree, as who would not, that a large hospital of 800 beds is able to provide better equipment and in many ways better services than a smaller hospital. But I say that these great hospitals are not an adequate substitute in rural areas in general, and in the Stroud district particularly, for our present medical facilities.

I will summarise my arguments, because I know many hon. Members wish to speak and the time for our debate has been curtailed. I believe that these great hospitals lie too far away from some areas—particularly the Stroud area—to be able adequately to cope with accidents for both medical reasons and industrial reasons, because of the time taken to get to diem. Secondly, large hospitals which are far away make visiting much more difficult and expensive. Thirdly, there is the problem of nursing. The small hospitals may be staffed adequately in almost every case at the present time by part-time nurses. But these ladies will not be available in a bigger hospital because they are not able to travel to the hospital in the time available to them.

Although it is not the case everywhere, there are some very large hospitals where the standard of nursing provided is not the same as that which smaller hospitals provide. That is inevitable. It does not mean to say that nurses are less skilful, but that the organisation is more difficult to run. Recently, a constituent of mine in the Southmead Hospital after a motoring accident was three times threatened with a syringe containing the wrong sort of "wallop" and wielded by a young doctor or nurse. On one occasion, had she not been alert and refused the injection, the consequences might have caused serious trouble. This can happen more easily in a large hospital than a small hospital.

Mr. Braine

It ought not to happen in any hospital.

Mr. Kershaw

Yes, it ought not to happen in any hospital, but it can happen more easily in a large hospital than in a smaller one.

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

Does the hon. Member recognise that in a hospital such as the one he mentioned, which I know extremely well, there is the problem of a lack of staff and the nurses are under extreme pressure all the time? There is, therefore, a great deal of excuse, and until we provide staff in numbers which are more adequate for such a hospital, there will be a liability for mistakes to be made?

Mr. Kershaw

I take the hon. Gentleman's point and I agree with him. I say, without there being any fault on the part of anyone, that the difficulties are greater n a bigger hospital.

Possibly the most important point relates to the general practitioner service at large hospitals. In a town the doctors can and, so far as I know, do attend the big hospitals. But in the country they cannot follow their family patients all the way to a hospital which may be 30 miles away. The doctors have not the time to do this. Their patients are taken away and dealt with without the doctor being au fait with the situation, which depresses their morale and the standard of doctoring. I believe that my hon. Friend would not disagree when I say that one of the main problems facing him today relates to the general practitioners. I believe that the local hospital is one place where the standard of medical knowledge and the enthusiasm of local practitioners may be improved and maintained.

While I accept the pattern of the hospital scheme, I believe that in some areas it has to be modified. Local hospitals in rural areas should be kept open. In turn, I recognise that if I demand they should be kept open I must accept that extra expense will be incurred because large hospitals also must be built.

Turning more particularly to the local problem, we knew in June last year that Stroud Hospital might be closed in due course if something better could be provided to replace it, and one could not complain if something better had been provided. But since that time we have been much disheartened to hear that the regional hospital board proposes to close the casualty department, with all that that means regarding the depression of the standard of the hospital, the danger that accidents may not be dealt with and the annoyance caused by the distance which visitors to the hospital may have to travel.

A local committee has been formed to deal with this problem, headed by the noble Lord, Lord Robertson of Oak-ridge, who lives in that area. They sought and obtained an interview with the regional hospital board at Bristol, and were received most courteously. But I cannot do other than admit that, locally, there is a feeling that the strong enthusiasm for a local hospital is being entirely disregarded by the regional hospital board.

The alternative set before us is that every facility will be available in Gloucester and Bristol. But, there are reasons, which it is perhaps a little invidious to state—though I feel it my duty to mention the fact—why, we are not entirely satisfied that the services available there at present are adequate to meet our needs. This is exactly the problem which faces other rural communities. Last week, a little boy aged 5, was knocked down in the street in Stroud at a quarter-to-four in the afternoon. He was taken to Gloucester and it was not until half-past one the next morning that his broken leg was set. There was no one to do anything for him. He was not given any drugs, although he was in great pain, because adequate medical staff facilities were not available. We cannot blame people if they ask why they should give up a hospital, which they trust and like for another hospital about which they have certain misgivings. It would seem sometimes that the regional hospital board, acting of course, under the guidance of the Government scheme, has a rather empire-building frame of mind.

There is another institution, the physiotherapy centre in Dursley, where, I would have my hon. Friend know, I go for treatment for my lumbago. There facilities are available to industrialists and certain ailments may be treated which would mean many hours off work if the workers had to go elsewhere for treatment. We hear that this is to be closed down unless more help can be given from the regional board. I do not think that that is a reasonable course of conduct. Local people may be wrong, but they have not so much confidence in the way in which the regional board is running things at present.

I plead with the Minister to take a long, hard look at the way things are going and decide whether 50,000 people, who live in the Stroud area—which is so typical of areas with hospitals in many of the rural districts of this country—are right or whether a few members of a regional hospital board, who disagree with them, are right. I know of no one locally who agrees with the hospital board. After all, this is a democratic service in which the voices of those who use the Service should be listened to. I ask my right hon. Friend to look at that matter most closely in future.

6.20 p.m.

Mr. H. Hynd (Accrington)

I promise that I shall not detain the House for more than five minutes. I want to follow a remark made by the hon. Member for Stroud (Mr. Kershaw) about nurses who have to transfer to other hospitals for training, because in my constituency there is a case to which I want to call public attention.

The Minister will be glad to hear that, strangely enough, I am not criticising him. It is a case of a staff nurse at Victoria Hospital, Accrington, who wanted to extend her training in midwifery. For that purpose she terminated her employment at that hospital to go to Preston and gave notice that she would do so. Unfortunately, before she could do so she was taken ill and put off duty by the hospital doctor, as she was suffering from German measles. Because she was a patient in hospital she missed the course at Preston, but arranged with her own hospital to carry on there. When she recovered, after about a month, she carried on with her duties, but, believe it or not, the local hospital committee deducted her salary from the date when her original notice expired to the date when she actually resumed.

The hospital management committee wrote to the Ministry for a ruling and the Minister replied, quite properly, that, technically, she had given notice, but he suggested that the committee ought to make a concession and that he would be glad to give further advice. That was a straight tip to the committee to be reasonable, but the committee turned it down. Incidentally, the regional hospital board made a recommendation to the same effect, but that was turned down. Since then, I understand the Minister has written to the committee suggesting that it should make an ex gratia payment. The committee met yesterday and, by a vote of 6 to 5 turned down the Minister's recommendation. This is absolutely disgraceful.

At a time when we are trying to attract nurses and to get staff to give the best possible service as mentioned by the Motion this is just the sort of case which can have the worst possible effect on the morale of staff. I raise this case deliberately in this public way—and I am sure the Minister will be glad that I do so—to make the local hospital management committee thoroughly ashamed of its decision. I hope that the Minister will find some way of allowing this nurse to get her pay for the short period when she was ill.

As I am well within my five minutes, Mr. Deputy-Speaker, perhaps I may be allowed one minute more in which to emphasise a point I made in an interruption. That is about patients being told that they may have an operation, but that they will have to wait for some months, or that if they attend hospital as a private patient they can have the operation next week. I assure the Minister that this is generally the case. I have had many complaints about it. When I raised this matter before the Minister asked me to bring forward a definite case and said that he would look into it. It is not easy to find a definite case.

I have tried, with the co-operation of a constituent who needs to have an operation, to provide a definite case. This constituent went to his doctor and was told the usual thing. He asked the doctor for a receipt for the money and the doctor asked why he wanted a receipt. He replied that he wanted it for Income Tax purposes, but he did not get a receipt. Doctors are "too fly" for that; they do not give receipts. It is not easy to give details of definite cases, but every hon. Member will support me in saying that many people are told this formula. It is something which must be stopped.

6.25 p.m.

Sit Hugh Linstead (Putney)

I followed with much interest the opening speech by the hon. Member for St. Pancras, North (Mr. K. Robinson). I understood why, for the purpose of this debate and as part of the duty of the Opposition, he found it necessary to underline the defects of the National Health Service, but I feel that from time to time it would not do any harm if this House were to look at the Service from the point of view of what it has accomplished and what it has to offer today, as well as looking at its defects.

I, and I suppose other hon. Members, have had on occasion to speak in North America about the Service. There, I never have any difficulty in defending the National Health Service of this country, particularly in comparison with what is nationally available in Canada and the United States of America. It is probably true that in other countries those who can afford to pay for medical attention get better medical attention. Possibly they get quicker medical attention than is available in this country. But, if we are to make a proper comparison with what the National Health Service here offers we have to look at what it offers to the community as a whole.

If we look over the whole of our Health Service we see that something is offered here which is superior for the whole range of the population to anything which can be offered in any other country. I am sure that when the hon. Member was putting forward his criticisms of the Service he was not seeking in any way to depreciate the great advantages that it has to offer in comparison with conditions which obtained before it existed.

I want to discuss for a moment the proposal in the Motion for the abolition of charges under the National Health Service. As one who was in this House at the time when the Service was first introduced and remembers the Willink White Paper as well as the energy and enthusiasm of Mr. Aneurin Bevan, I was always sympathic to the original conception of a Service without charges.

We have to face the fact that today the charges bring in something like £64 million a year. The problem a Minister of Health has to face in relation to those charges is whether, if he has that sum of money available to spend on the Service, that is the precise point at which he should expend the £64 million. When one listens, as one is bound to in a debate like this, to weaknesses in the Service being developed, to the need, for example, for more attention to be paid to mothers and children at the time of childbirth, one asks whether, if £64 million is available, the best place to apply that money would be in removing the charges. Personally I doubt it, sympathetic though I would be to that being achieved.

We are bound to be realistic and to say let those who can afford to pay the charges pay them and let those who cannot afford to pay them be relieved of them.

Mr. Denis Howell (Birmingham, Small Heath)

How can one do that?

Sir H. Linstead

I was about to develop that point, because I have a criticism to make of the present method.

We are all aware of the National Assistance Board provisions whereby someone who cannot afford to pay out of his own pocket can obtain the money from the Board. In theory, that is a satisfactory method, but, in practice, it is not. I have no doubt that between the level at which the Assistance Board's help is applied and the level at which someone who is sick can readily afford the charges there exists a band of people in the community who are seriously affected by charges which they cannot afford. I am not saying that this is general. It would be a mistake for people who can afford the charges to be relieved of them, but the present method does not give the relief that should be given.

I meet many pharmacists who tell me of the problems with which they are faced individually when talking to patients who collect their medicines or leave their prescriptions. The patients say, "I cannot get the money from the Assistance Board. I am doubtful whether I can afford, say, 6s. for three items. Will you tell me which one of the three I should take and which two I can afford not to take?" That is an intolerable position in which to place a pharmacist or anyone else.

In chemists' shops, particularly in industrial areas, many stories of people being unable to take every item on prescriptions can be told. My right hon. Friend is fresh to his office and all of us welcome him there. I want him to believe that there is a case for further easing the Assistance Board's rules. We have not yet coped with this question of hardship.

This is an occasion when I could briefly mention one or two features of the pharmaceutical service more closely, for I have been the secretary of the Pharmaceutical Society of Great Britain for many years, and, although I have nothing to do with the administration of the National Health Service or negotiations for remuneration, I am closely in touch with what the pharmaceutical service is doing. The one thing that is noticeable about the manufacturers, the hospital pharmacists and the pharmacists in general practice is that all three are at cross-purposes with the Minister. That is an unhappy state of affairs. Basically, it is a question of finance, but one does not like to see a whole professional group of people at cross-purposes with the one person with whom they should be working in the closest collaboration. I hope that we will not have an indefinite continuation of what is, in effect, a cold war that is doing no one any good, least of all the Service and its patients.

We have had many discussions about the difficulties of the manufacturers with the Minister and I will not develop this facet of the argument. Something should be done to break the cold war in that sector. We have the most clumsy method of discussing the prices which the Minister pays to the manufacturers for the drugs they supply to the Service. The negotiations take place between the Ministry and the manufacturers, while the Treasury remains in the background. The Treasury takes its own part at second-hand in these discussions. The Public Accounts Committee and the Comptroller and Auditor-General also come into the picture, but again at second-hand, and at no point does the Public Accounts Committee, which is the most stalwart of the critics of the manufacturers, ever have the opportunity of meeting the manufacturers face to face and discussing directly with them the problems that worry the Committee.

I would have thought that it should have been possible to devise some method—if necessary, by an alteration of the standing Orders of the House—whereby the Public Accounts Committee could directly call as witnesses the people whose conduct it is criticising so that it did not fall on the accounting officer of the Ministry of Health to defend or, if necessary, attack that group of people criticised by the Public Accounts Committee.

The hospital pharmacists are at present about 25 per cent, below establishment. The answer which my right hon. Friend's predecessor gave was that the establishments represented an artificial figure. If so, it is high time that the establishments were redrawn and made realistic. The hospital service is being kept going only by the loyalty and public spirit of a comparatively small number of senior pharmacists. When they retire there will be a substantial gap in the hospital pharmaceutical service. It is said that recruitment is going well, but if that is so I doubt whether recruitment will be permanent, since a great deal of it is the recruitment of women who are likely to marry and leave the Service, at least for a time.

The present feeling of hospital pharmacists is that they are a neglected section of the hospital service. Anything that my right hon. Friend can do to assure hospital pharmacists are not being left out in the cold, but that their position in the Service is recognised—and that usually means recognised by remuneration at the right level—will be very helpful to the service and him.

Some years ago it was proposed that assistants to pharmacists should be used in the hospital service. The Ministry has issued circulars on this subject, but has never pushed this staffing conception home. A study within the Ministry of the possibility of the pharmacist being aided by skilled technicians might well help towards solving the staffing problem. This matter should not be neglected, for we are now in danger of a breakdown in the pharmaceutical service in some hospitals.

The other day I came across a large teaching hospital which because of a shortage of staff, was buying its sterile injectable solutions. Anything more un-remunerative than carrying around large quantities of sterile water it would be difficult to imagine. The cost of having those sterile solutions made at a distance and sent by a firm to a hospital is so substantial that the cost of paying for a pharmacist scarcely enters into the picture in these circumstances.

The grievances of the pharmacist in general practice probably date back to the time when a swingeing cut in his remuneration was imposed by the Minister and when, at the same time, a claim for increased remuneration was rejected. I will not argue the merits today, but the speed with which that was done and the effect it had on the standard of living of pharmacists was substantial and it is that which has soured the relations of that group of people in the pharmaceutical service.

I suggest that the Minister has some responsibility for the general practice of pharmacy. His Department is inclined to take the chemist's shop as it finds it, but my right hon. Friend's responsibility is deeper and wider than that. He should not be content with using the chemist's shop merely as a convenient way of getting his medicines distributed. Because of historical necessity, the chemist's shop in this country has had to base a great deal of its economy on the sale of things that are not pharmaceutical, and the pharmacists themselves dislike it intensely.

Unfortunately, that helps the Ministry—the Ministry sees its overheads spread over a larger range of things sold—but, basically, I do not believe that it is right that pharmacists should be required to subsidise the National Health Service by sales of completely non-pharmaceutical products, it divides the interests of the proprietor, it divides the interests of the staff, it spoils the atmosphere of the business by turning it into a purely commercial atmosphere, and it encourages the public to regard drugs as ordinary articles of commerce instead of, as we are learning more and more nowadays, as things to be taken with great care and attention. I am sure that the result of my right hon. Friend's just accepting the chemist's shop as he finds it is that he is inhibiting the development of professional pharmacy as we would all like to see it, and as it is, for example, in Scandinavia.

I therefore ask my right hon. Friend to say that he is interested in the future development of pharmaceutical practice in this country. I should like to see him, in any action he takes, particularly in regard to remuneration or the question of contracts with executive councils, encouraging the development of professional pharmacy, and discouraging the reliance the pharmacist now has to place on his other commercial activities. I believe that, somewhere in the Ministry, inquiries are now going on into the possibility of comprehensive legislation on medicine. If, when those inquiries are completed—during the next Parliament, perhaps—a new piece of pharmaceutical legislation is brought forward, I urge that it be not only legislation dealing with poisons, but legislation dealing with medicines, and to help pharmacy develop professionally in pharmacies, just as it has in the hospital and manufacturing branches.

It is a weakness in the National Health Service that the three sections of the pharmaceutical service—the manufacturer, the hospital and the pharmacist in general practice—are all at cross-purposes with my right hon. Friend. I hope that he will consider that position seriously, and will feel that he has some obligation to try to improve his public relations with pharmacy. In that way. he will render a great service to his own National Health Service.

6.43 p.m.

Mr. Laurence Pavitt (Willesden, West)

The hon. Member for Putney (Sir H. Linstead) always interests the House when he talks of the drug industry and its relations with the National Health Service. Although he has made a number of constructive proposals, I submit that—although in the most cour- teous way, as is customary with him—he has supported our Motion in saying that the Minister has failed to adopt policies in connection with the provision of drugs that would benefit the Service. I agree very much with the hon. Gentleman that the National Health Service is second to none, but we on this side do not regard that as a ground for complacency. Although we are proud of what has been done, we believe that Ministerial failure has prevented the greater achievement we think is possible.

The hon. Member referred to the £64 million raised in increased charges. When that charge was made in February, 1961, the whole basis was that it would satisfy the grand new ten-year hospital plan. In 1961–62 we spent £30.8 million, and in 1962–63, £35.5 million, but if my calculations and those of the hon. Gentleman are correct, the Exchequer took in nearly £200 million in the last three years. The main purpose of the prescription charges was to raise £12½ million in a full year towards that £64 million. We think that there has been a great gap between all the promises and professions of this and the previous Minister and what is being done in practice. The Parliamentary Secretary said that the Government were now, at this late stage, very much in favour of the idea that the strong should help the weak, but nowhere is that idea so much stood upon its head as in these prescription charges. The average person sees his general practitioner 5.5 times a year. If the person is over 65 or under 5 years of age, he sees his general practitioner ten or eleven times a year. That means that a person over the age of 65 pays twice as much in prescription charges as the person in middle age, and so does the man with a large family.

The more sick the person, the more he pays. If it is only a matter of a bottle of cough medicine once a year, he pays 2s. 0d., but if the trouble is a colostomy or he is a diabetic the cost is probably 10s. or 12s. each fortnight. The Parliamentary Secretary may talk of the strong helping the weak, but this is not working out in practice, because the weaker the person the more he pays to help the strong.

The extra charge for welfare foods raised only the paltry sum of £1¾ million. After that decision was taken, a number of my hon. friends tried to find out how it worked. In questions about their own constituencies which ranged throughout the country, they found that there was a 60 per cent. drop in the take-up of cod liver oil, Vitamin A and orange juice for babies. There was an immediate drop; but I wanted to know what had happened in the years since then. I found that, in my locality, 10,790 bottles of cod liver oil were being taken up before the charges were imposed, but that the figure had dropped during the following six months to 3,779 bottles. We have risen slightly since then, and in the last half year the figure has risen to 4,582 bottles. That is still less than half the amount taken up before the charges were raised. The same applies to the other items.

This has happened at a time when more babies are being born—the Parliamentary Secretary has referred to this fact which has recently been called a "birth quake". The index has risen from 100 in 1957 to 138 in 1962 in the area covering my constituency. That being so, we cannot see how the Government's policy has succeeded in helping the weak at the expense of the strong, for while more babies are being born, only half the 1961 take up of welfare foods takes place. In industrial areas, areas of difficulty, areas of acute housing shortage, problem families and social difficulties make these welfare foods essential, to ensure some balance of diet.

I want to follow the point made by my hon. Friend the Member for St. Pancras, North (Mr. K. Robinson) on the effect of the 2 per cent, straitjacket put on the hospital service. We have had this large scheme for spending between £700 million and £800 million by 1975, but Ministry circulars have informed the hospitals that their revenue estimates must not exceed 2 per cent. those of the previous year.

In the first circular in 1960 it was made clear that the 2 per cent. applied in real terms to 1961–62 allocations, which included the cost of increments to staff on salary scales, though it is true that since then there has been some let-up in that respect. This was repeated in the second circular and again in the one issued on 14th September, 1962. Although the pay pause seems to have been relaxed for almost everyone, it has not been relaxed for the hospital services, with the result that the approach to hospital management is basically wrong because financial considerations come first and needs are made to fit in with those considerations. Is this done for administrative convenience because it is a handy form of commitment merely to give a figure of 2 per cent. whereas in fact in one area it shot Id be much more whilst in another area, the hospitals might be able to manage with less? Maintenance work has been deferred and deferred again, and there is now an accumulation which must be met if we are to succeed in returning to proper standards.

Two-thirds of most hospital budgets deal with staff pay, which means that when budgets are confined within this rigid 2 per cent. straitjacket there is no room for manoeuvre, except of maintenance which thereby suffers. In spite of easement on pay increases which enables the hospitals to have a little more freedom, the Minister has failed to provide any alleviation in two categories. No addition was made in respect of extra leave given to the nursing staff, with the result that hospital committees have had to cut into their funds to meet this cost. No allowance has been given for extra staff needed as a result of the reduction in hours worked by those already employed by hospitals.

There has been no mention of what is to happen about price increases if the 2 per cent. rate is to continue and we are still to have this Treasury approach to the Service. The Minister should instigate research into the cost index of hospitals and should check prices to find out whether a 2 per cent allowance can be fitted into sound business management. Heavy increases are being made in local authority rates. There are increases in the Metropolitan area water rates and large increases in the cost o: electricity. If these costs rise by more than 2 per cent. a hospital management committee will find itself having to try to cope with an impossible situation with deferred maintenance having to be put off again and again until events ally it is too expensive to be undertaken, or too late.

I presume the £4½ million mentioned by the Parliamentary Secretary will deal with such matters as provision of furniture, fittings, surgical instruments and appliances and current building maintenance, but in terms of backlog and assessed need is this considered adequate, or is it to be said that a sum of £4½ million is available and the hospitals must try to fit their programmes into it? By seeking to put all the emphasis on the capital programme for new hospital building we believe that the Minister is leaving behind a legacy of maintenance work on existing buildings which will have to be cleared up by the next Labour Minister of Health. This is a failure to do what is considered to be normal in any well-managed household or business concern.

I should like to draw the attention of the Minister to some of the problems which his policies have failed to tackle or even touch. The first is that of the 18 people who, during the time covered by this debate, will die from lung cancer. A total of 26,383 died last year, and 72 die every day from this disease. At a time of year when the Minister of Transport cannot get to the television screen too quickly to tell us about the 7,000 killed on the roads, which we all deplore, why cannot the Minister of Health be equally active about the three times bigger problem of the people who are dying of lung cancer? In Willesden 30 people died in 1950, according to the medical officer of health. In 1962 the number was 78. In our local hospital in 1958 there were 141 lung cancer patients. In 1962 the number was 169 and of all the cancers now treated in hospital in my constituency a quarter are lung cancer cases.

The annual report of the medical officer of health for Middlesex shows that cancer and coronary disease were last year again the two largest causes of death in Middlesex, accounting for 40 per cent. of those who died. What steps is the Minister taking to meet this great problem? The right hon. Gentleman cannot even stand up to the Advertising Council which refuses to put up his posters designed to discourage young people from smoking.

I received a letter only this week from a consultant physician of my local hospital in which he asked me if anything can be done to draw the attention of the House and the country to this great problem. He gives the example of Mr. X who died last week and says: He smoked thirty cigarettes a day until shortly before he died. He had started smoking at the age of 14 and it is my belief that cigarette smoking was the cause of his death. He leaves a young wife and six children between the ages of 18 months and 9 years. I do not know how we can get these human facts home. We talk a lot of nonsense about having the strong will to put a cigarette down, or there is the kind of Boy Scout approach that it is manly not to smoke; we take an attitude and then defend it, instead of the Ministry dealing logically, scientifically and effectively with this problem.

The Parliamentary Secretary raised the question of waiting lists at hospitals and the efforts made to deal with them. As he said, emergency cases are admitted quickly, but I should like to know from the Minister how soon he expects to receive the report, which has been mentioned several times in the House, on steps taken to reduce waiting lists and what effect the returns which he expects on 31st December will have on his action.

I should also like to know what policy the Government are pursuing on the question of part-time and full-time consultants, which is fundamental to the problem raised by my hon. Friend the Member for Accrington (Mr. H. Hynd). Is the Minister's policy that there should be whole-time consultants, or are we to continue with the nine-elevenths arrangement? In view of the fact that the right hon. Gentleman is examining the Platt Report, I should like to know what he proposes to do about the bottleneck in the supply of consultants which is the main cause of delay in admission, and the fact that it pays a consultant not to have another in his specialty because he would share fees for the available private patients with him. It is no use giving us phrases about looking after the weak or earnestly considering the problem. The right hon. Gentleman should now be presenting a solid policy to the country.

There are many other subjects which I should have liked to mention had there been time. There is the question of the health authority services and the place of welfare, and there is no time now to go into the Gillie Report. The Minister talks about the general practitioners being the keystone of the Service, but he has left this Service as the last to consider and even this last report is not issued as a Government report. Do the Government intend to consider the implications of a number of the Gillie recommendations, and will the House have an opportunity of debating the whole subject of general practice? In view of the seething unrest in the medical profession, will this matter be one of those things which somehow or other never sees the light of day?

Tributes have been paid, as in the fine maiden speech of my hon. Friend the Member for Manchester, Openshaw (Mr. C. Morris), to the way in which the foundation of the Health Service was laid against a background of terrific opposition, and was laid so soundly that in spite of the attempts to nibble it away, and in spite of the philosophy put forward in a famous pamphlet in 1951 by the right hon. Member for Wolverhampton, South-West (Mr. Powell) and the right hon. Member for Enfield, West (Mr. Iain Macleod), the present editor of the Spectator, we have achieved, as the hon. Member for Putney has said, a marvellous Service. But that foundation should be the starting point which now gives us the opportunity to go further, not only in the three sectors, but to establish an occupational health service and to start a drive with new initiative to cure some of the modern killing diseases. So much could be done, for instance, about bronchitis, which causes 31 million lost working days each year. We are fed up with the promises of the Minister. Instead of promises for the future, let us have some policies today which will lead to positive results.

7.0 p.m.

Mr. Geoffrey Johnson Smith (Holborn and St. Pancras, South)

I hope that the hon. Member for Willesden, West (Mr. Pavitt) will not mind if I do not follow him closely in his discussion of lung cancer and other matters. In the short time which I intend to take, I shall discuss the work of the general practitioner, but what I have in mind arises not so much out of what the hon. Gentleman said but out of what was said by my hon. Friend the Member for Stroud (Mr. Kershaw) in drawing attention to the future of the small hospital within his constituency and the cottage hospital generally.

It may surprise my hon. Friend and other Members from rural constituencies that I, who represent a constituency within which many of the big teaching hospitals are situated, should express concern about the future of the smaller hospital. I do so because I take the view that the small hospital has a future inasmuch as it provides, or could be made to provide through the growing development of our health and welfare programme, a suitable place for the general practitioner to work, and, more than that, it can within the terms of the Hospital Plan and the Health and Welfare Plan for the next 10 or 15 years, have a tremendous part to play if its buildings are used for the provision of special services.

Perhaps my hon. Friend the Member for Stroud and others like him who are worried about the possible closure of smaller hospitals do not fully realise that there may be a valid case for using these hospitals for a different purpose. In Other words, although a small hospital may not be closed, it may quite properly continue to exist though not in its present form. In this connection, I hope that my right hon. Friend will be able to give hon. Members on both sides the sort of assurances which I think we want about the future of this type of hospital.

In paragraph 25 of the Blue Book, A Hospital Plan for England and Wales, after reference to the need for new district hospitals comprising 600 to 800 beds to be provided, it is said: But many small hospitals will still be needed. Some will be retained as maternity units…Others will provide long-stay geriatric units Others again, where a local population is remote or inaccessible, or where isolated towns receive an exceptional seasonal influx of visitors, will continue to admit medical emergencies which do not require specialist facilities. One can see a use for such hospitals in those ways. The paragraph points out, also, that some of the small hospitals will be needed where patients can go as out-patients, the idea being that out-patient services will be provided there.

What is suggested in that paragraph of the Hospital Plan does not indicate to me that the small hospital will necessarily continue in its present form, but it does indicate that, if the plan is to be properly developed as envisaged, those who fear that such hospitals will be closed and left empty or put to another use could have their fears put at rest if the Minister would emphasise the intention as outlined in that paragraph.

I believe that an assurance from my right hon. Friend is necessary. Like other hon. Members, I do not have much time to look at television—

Mr. Denis Howell

Because the hon. Member is on it.

Mr. Johnson Smith

No, not because I am appearing on television, because I have no time for that, either. However, the other evening I did take a little time to look at Panorama. That evening, Panoramashowed one of its special reports—a good sort of newspaper trick—about what is wrong with our hospital service. It took the example of a particular cottage hospital, quoting the views of various people who are very anxious about the possibility of its closure. An eminent member of the medical profession, whose name escapes me for the moment but who represented the views of general practitioners, said that he would be very disappointed if the hospital were closed, that its closure would be a crime for the neighbourhood, and so forth.

Towards the end of the rather frightening story which was unfolded, we began to learn that the possibility of the hospital actually being closed was not likely to be discussed for about 10 years or so, and, moreover, it did appear in due course, though rather fleetingly, that these discussions would be without prejudice, and, in all probability, the hospital might be kept open.

Nevertheless, that television broadcast was not an isolated example of the fears which people have. One has seen similar views expressed in the Press and elsewhere, and I believe that there is here a cause for considerable concern, not only in such places as the constituency of my hon. Friend the Member for Stroud but in many other parts of the country.

I suggest, therefore, that it would be a most timely use of the opportunity of this debate if my right hon. Friend were to reassure people throughout the country that there need be no fear of wholesale closure of small hospitals and that they will continue within the pattern of the Hospital Plan to provide very useful medical services for their neighbourhoods. Not only that, the smaller hospitals can provide for the general practitioner the opportunities which many people feel are all too frequently denied to them.

As I understand it, what is envisaged—here, I think, some people may, perhaps, be disappointed—is that such hospitals will not necessarily close but people may have to become accustomed to the idea that they will change in terms of their actual use. This is why I drew attention to paragraph 25 of the Hospital Plan which envisages that small hospitals could be turned into maternity units, long-stay geriatric units, and so on.

Looking at the possibilities in the light of the welfare plan generally, not just the 10-year Hospital Plan, it seems to me that the function of the small hospital can be of very great importance in the development of the community services which are so vital within the scope of the National Health Service as a whole. Therefore, if it is decided to change the use of a particular small hospital, the decision, instead of being viewed in isolation, could be seen to be a progressive move for the benefit of general community care in the neighbourhood.

That is all I have to say on that wider point. I turn now to two matters which arise more particularly in London. The first concerns the general practitioner. We have had the Gillie Report and other reports, articles have been written in the Press, and much has been said generally about the rôle of the general practitioner not only in relation to the opportunities he has or should have for access to hospital, but also in relation to the better facilities which all hon. Members are convinced that he needs if he is to carry out his duties more effectively and efficiently. One hears a good deal said about better conditions for group practice and better ancillary services.

The sooner some of the ideas mooted in the Gillie Report and elsewhere are implemented, the happier I shall be, but one must admit that it may be some years before they are implemented on as wide a scale as one would wish. A question arises, therefore, with reference to the general practitioner in London. The London general practitioner receives the same emoluments as his colleague anywhere else. Whenever it has been suggested that there ought to be some sort of London weighting allowance to take account of the increased cost of rent and other matters connected with his circumstances in London—one knows how important these things are—the reply has always been, "No, that would not be fair to general practitioners elsewhere. The rural doctor may not have such a large list of patients as the London doctor, and he does not have quite the same opportunities as his big city colleague for taking on other jobs in hospitals, such as consultant posts."

I suggest that this does not really hold good to quite the extent suggested. The complaint now among general practitioners in London is that they have extreme difficulty in getting the same access to hospitals as used to be open to them some years ago. There are not the requisite number of consultancies available and it is not as easy as it was in the past for them to augment their income to take account of the increased cost of practising in London. Therefore, I ask my right hon. Friend to comment on the suggestion that in the interim period, before we are able to implement the suggestions of the Gillie Report and others, further consideration should be given to the possibility of introducing the principle of London weighting for general practitioners in London.

My second more local point, although it may have a wider interest, arises from another report which has not so far been quoted in the debate and which is one of the least known of the various reports concerning the medical services of this country. I refer to the recently published Report of the Committee of Inquiry into the Recruitment, Training and Promotion of Administrative and Clerical Staff in the Hospital Service—or, more succinctly, the Lycett Green Report.

Many of us are concerned with the general overall efficiency of hospital management, and there have been a number of criticisms about its shortcomings. This Report makes a series of suggestions designed to improve the training and general standard of efficiency of the administrative side, the non-medical side, of the Health Service. So far as I know, it is held to be a good Report. I have not seen any criticism of its recommendations.

Hon. Members on both sides of the House will know that one of the factors having a bearing on the standard of recruitment is the remuneration that a person can expect if he wishes to embark on a career of administration in the National Health Service.

The Lycett Green Committee was not allowed to discuss this particular subject, because it was not within its terms of reference. I should, therefore, like to make a point concerning this aspect. Anyone who knows anything about hospital management must be convinced that one of the most onerous and responsible posts is that of group secretary of a hospital management committee. I remind hon. Members of the relevant grade definition in this Report: A Group Secretary: the principal administrative officer, responsible for the administration of the group of hospitals and for the work of the Committee. This officer may be medical or lay, but, if medical, should not be engaged in clinical work. The group secretary's salary ranges from just over £1,000 to a maximum scale of just over £3,000. The minimum scale is £1,125 to £1,382 per annum. How can it be possible to get anyone of sufficient calibre and with sufficient qualifications to undertake a tithe of the responsibilities as set out in the Report if such salaries are to be paid? I again refer to London because it is the area that I know best, and the financial aspects of living in London are well known. It seems to me that, if we are to have this Report implemented and improve the efficiency of the overall administration in the Health Service and of the hospitals particularly, it is essential to increase the salary scale of people who carry out such onerous duties, because only in that way shall we be able to get people of sufficient calibre to come into the Service.

Let me come to another point which affects this particular aspect at the other end of the scale. I come to the question of the remuneration of a secretary who comes within the ordinary clerical grade officers engaged in clerical and related duties which may include the handling of particular matters of minor importance not clearly within the scope of defined instructions, and so on.

Such a person, at the age of 16, if he wishes to come into the service, would enjoy the princely salary of £278 rising to £445 at the age of 21. Many of the post-graduate teaching hospitals are trying to compete in this very important field for people in the clerical grades and I submit that this put an almost impossible burden upon them. It is extremely difficult to get people to engage in this sort of work when the salary cannot increase beyond £445 at 21, although there is a maximum scale which allows such people to enjoy a salary up to £696. I could go through the various grades, but I have chosen one at the top and one at the bottom which cry out for swift re-examination.

I should like to wish my right hon. Friend well in his new post. I think that he has made a good start by his reaction to the pleas of the general practitioner and I feel that he is in a fortunate position because he follows in the footsteps of a man whom the British Medical Journal recognises as being one of the finest Ministers of Health that this country has ever had. I have a great appreciation for the tremendously valuable work carried out by my right hon. Friend the Member for Wolverhampton, South-West (Mr. Powell). After all he is the man who put his hand to this Hospital Plan, and to the Welfare Plan, both of which have his personal imprint. That is why I pay tribute to him.

7.18 p.m.

Mr. Charles Grey (Durham)

I hope that the hon. Member for Holborn and St. Pancras, South (Mr. Johnson Smith) will forgive me if I do not take up his remarks, because, in the interests of brevity, I want to confine myself to one specific issue—the shortage of doctors.

It was put to me some time ago that during the recent Indo-China dispute it was said that if Nehru had called in all his doctors from this country our hospital services would not have been able to carry on. That is the plight that this country is in. The blame for this position entirely rests with the Government. The Willink Report has been mentioned and my criticism of the Government is that while it was fair that they should have the Report they were far too long in discovering that a 10 per cent. cut in the number of medical students was a bad assessment. When we take into account the 10 per cent. cut in the number of medical students recommended by the Willink Committee we have to measure this alongside the fact that today we are so short of doctors that we have to rely upon 3,760 doctors from abroad to fill the vacancies.

In addition to this, we have the Robbins Report, which estimates that by 1981 we shall require a further 3,000 medical students. Further, when the House realises that it takes about six years to train a doctor, it will understand the country's plight. This is a situation which demands immediate remedial action. Even if we start now to train doctors it will be six years before the first one qualifies. My hon. Friend the Member for St. Pancras, North (Mr. K. Robinson) said that it would not be possible to get the first doctor inside 10 years. If we do nothing about this now, we can imagine what this country will be like by 1980.

I have mentioned the Robbins Report and said that by 1981 we shall require an additional 3,000 medical students. It is said that six or seven new medical schools will be required to cater for this number of students. This information comes to me from a reliable source, although several figures have been mentioned. We hear from the Parliamentary Secretary that all that is proposed is one new medical school. It is shocking that we should be recommended to accept this. I am sure that the hon. Member has not read the Robbins Report.

Mr. Braine

I am sure that the hon. Member would not wish to misquote me. I said that the University Grants Committee had been asked to advise my right hon. and learned Friend the Lord President of the Council, as the Minister responsible for university grants, what provision should be made, and it recommended that at least—and I emphasise "at least"—one new medical school should be planned and that, at the same time, the possibility of further expansion of existing medical schools should be examined. My right hon. and learned Friend has accepted that advice.

Mr. Grey

That sounds a bit better, but the point is that we are to get only one new medical school. He could have put it to the University Grants Committee that one was not sufficient. I hope that he will consider this point.

I am sure that the House will forgive me if I put the case for Durham, which I often do when I speak in the House. We must get the position in focus. Regions suffer in differing degrees, and it is because of that that I want to put the case for Durham. Durham University has lost its medical faculty, not because it has lowered its standard, but simply because the universities of Newcastle and Durham have been separated and the faculty has gone to Newcastle. I could stir up many emotions about this, but all I will say is that it is to be regretted that the Durham medical degree, which had become internationally famous, ceased to be awarded after1st August this year. I will cot enlarge on the sentimental side of this argument, because the factual side is even stronger.

Not one, but at least half a dozen medical faculties are wanted. They should be properly spread throughout the country, and for this reason I want to put in a claim for Durham. One of my hon. Friends said that in Birmingham about 60 per cent. of the students are from overseas. The North-East is so badly off that 51 per cent. of the junior hospital staff are doctors from overseas. It is not without significance that the British Medical Association has stated that there are strong tendencies for young doctors to settle in areas near to the medical schools in which they were trained.

No matter how good Newcastle is now—and it is good—or will be in future, it is absolutely impossible for it to produce all the doctors required in the North-East. The B.M.A. has also noted that there is great difficulty in filling positions in the industrial North. It recommended—and I hope that the Parliamentary Secretary will note this—that new medical schools should be silted in the industrial North. That is not a plea from me, but a statement of fact by the B.M.A.

It is estimated that, by 1981, the population in the Northern region will have gone up from 2,875,000 to 3,300,000. I quote this because of a statement which appeared about a month ago in one of the medical publications—I believe it was the Lancet—which estimated that what was needed for setting up anew medical school was an administrative and geographical area of 1½ million people. On this basis, Durham qualifies for a new medical school, and I can find to better argument in favour of this proposition than the fact that there will be that increase in population by 1981. This is further proof of the fact that, with the best will in the world, Newcastle University cannot possibly provide all the doctors which the North-East needs.

This argument for a new medical school for Durham is no emotional spasm, because it goes back as far as 1935, when a Royal Commission considered this future development of Durham University There was a committee in 1952 which considered the matter. The members of that committee included the Earl of Scarbrough and Sir Edward Collingwood. If the people who sat on the Royal Commission in 1935, or who served on the committee in 1952. had been able to look into a crystal ball and see the position as it is today, they could not have been more dogmatic in favour of Durham having a new medical school.

I know that the hospitals come into this matter. We have been promised a 1,000-bed hospital. The sooner we get it the better, because we need it. However, surrounding the university are some hospitals which could work in a kind of network system. These hospitals could be adapted for such a purpose. I would much prefer the Government to announce that they are going ahead with the 1,000-bed hospital. But if we cannot have that, let us at least have the other thing which we need—the medical school; and. as I have said, we could use existing hospitals until the new one is built.

Durham University itself is backing this proposal with the support of Durham County Council, Durham City Council, Durham Rural District Council, the local branch of the B.M.A. and many other organisations of people not only in Durham but throughout the country. Durham is a grand old cathedral city and the university is ideal for undergraduate medical education. It is in a picturesque setting. Behind it lie hundreds of years of fine scholarship. What more could one wish for a medical school? Durham would also be very suitable from the point of view of residence for students, because all the local authorities will back efforts to see that there is sufficient residential accommodation. I hope that the Minister will favourably consider this request, because if he does he will earn our gratitude.

7.32 p.m.

Mr. Daniel Awdry (Chippenham)

I hope that the hon. Member for Durham (Mr. Grey) will forgive me if I do not follow his arguments about Durham. My knowledge of it is limited. I come from the South and that is a nice place, too.

I have been present throughout the debate and am the third hon. Member to say something about cottage hospitals. I do not apologise for referring to them again, for this shows the depth of feeling that exists on this topic. I realise that my hon. Friend the Member for Stroud (Mr. Kershaw) has already made some of the points to which I want to refer, but I am glad to reinforce some of his arguments.

I understand that the main concept of the Hospital Plan is to concentrate all facilities into these large, district general hospitals. This is bound to mean the elimination of a great many smaller hospitals and such a large-scale operation is bound to lead to a certain amount of amalgamation.

But a large proportion of the threatened hospitals are staffed by general practitioners and are an integral part of general practice. They are not out of date or old-fashioned, and I wish to put in as strong a plea as I can for their salvation. I am thinking most particularly of the Bath clinical area, where I live, but the principle applies to many other rural areas as well.

The Bath clinical area is one of the best in the country, because the large number of these hospitals in the area has raised the standard of work done by general practitioners and consultants. To close these excellent hospitals would be a retrograde step. There are four arguments, in my view unanswerable, in support of my case. Some were touched on by my hon. Friend the Member for Stroud.

First, the smaller hospitals were started by public-spirited men and over the years have been sustained and maintained by the generosity of local people. Local feeling runs very strongly about them and if these hospitals are to be closed there will be a storm of protest.

Secondly, my hon. Friend the Parliamentary Secretary said that there was a tendency to increase visiting facilities in hospitals. That is obviously good for patients. But what is the use of such facilities, if a hospital is to be moved 20 or 30 miles away from the place where many patients live? I suppose that it could be argued that relatives and friends could travel to see them, but that would involve expense just at the very time when the family finances are at the lowest ebb. I believe that hardship will be caused if people have to travel these distances.

Thirdly, these hospitals give an excellent opportunity for discussion between general practitioners and consultants. New methods of treatment are discussed, anaesthetics are administered and there is opportunity for the general practitioner to keep up to date with operating theatre techniques. I am sure that all medical authorities will agree that we should encourage greater liaison between general practitioners and specialists. It will be extremely frustrating for the keen family doctor if, in future, all hospital patients are to be taken 20 or 30 miles away, where he will lose touch with them.

Finally, only a very small number of patients are sent on to the general hospitals. The larger proportion merely need good nursing under their own doctor who, of course, knows far more about the background of the patient and his or her family than anyone else. He can thus give a very much better service than the specialist who has no personal knowledge of the family. The Annis Gillie Report says, in paragraph 172: These particular hospitals play a great part in maintaining the high standard of general practice in the rural areas, and even if substitute facilities are provided for the general practitioners in the district hospitals distance may well preclude the rural general practitioner from using them. The Report follows this with the recommendation, on page 48, that Many hospitals in rural areas staffed by general practitioners and visiting consultants should be retained. It would be a very great tragedy if these hospitals were extinguished.

Mr. Dempsey

What type of medical cases are treated in these cottage hospitals?

Mr. Awdry

A great variety. As stated in the recommendation, they are staffed for the day-to-day work by general practitioners and visited by consultants. Ordinary medical cases are dealt with by the ordinary family doctor and these include the simple types of operation. Specialist cases, of course, must go further away.

We all tend to pay lip-service to general practice and, as the Gillie Report points out, 90 per cent. of all medical cases are treated by general practitioners. The fact is that the general practitioner deals with what is usual in medicine while the consultant deals with the unusual.

Not long ago a survey was carried out by the College of General Practitioners. A large number of doctors were closely questioned about their attitudes to their profession. They answered a detailed questionnaire and about 80 of the replies were carefully analysed. The doctors questioned were mainly in their mid-30s or early 40s, were nearly all family men with children and all had been in practice for 15 to 20 years.

Just over 25 per cent. were quite happy with their conditions of work. At the other end of the scale, nearly 25 per cent. said that they did not at present enjoy their work. If we look into the matter more closely we find that their dissatisfaction falls under three main headings.

First, I sincerely believe that there is a need for a greater feeling of team spirit throughout the National Health Service. Some of these dispirited G.P.S feel that perhaps they do not matter because so much emphasis is given to consultants. I hope that my right hon. Friend will stress that it is the Government's policy that the family doctor service should be maintained as the back- bone of the whole of the medical health service.

Secondly, I ask my right hon. Friend to see that greater access is granted to ordinary general practitioners to normal X-ray equipment and pathological services in hospitals. This comes out in the Annis Gillie Report, in paragraph 156, and the principle is accepted by the Minister. But it is not implemented in full. Not all general practitioners have access to X-ray departments, and in that way the local doctor loses contact with his patient and a great deal of time is wasted.

Finally, there is the question of remuneration. I do not want to become involved in detail, but if the family doctor is to do his job properly we must remove from him worries about whether his family can enjoy a reasonable standard of life and whether he can have reasonable premises and equipment to carry oat his job.

This was brought very forcibly home to me last week, when I was discussing a case with a local general practitioner. He had been called out in the middle of the night to sew an ear on a man after it had been bitten off by a horse. It was a nasty, difficult job, and it took an hour and a half in the middle of the night, and it had to be done well. He calculated that his remuneration for the operation, after deducting his expenses, was 2s. 10d.

To maintain a competent body of family doctors, we must consider increasing their general level of remuneration, and do it soon.

7.41 p.m.

Mr. Maurice Edelman (Coventry, North)

The hon. Member for Chippenham (Mr. Awdry) began his speech with a plea for more beds, and to that extent I have to support him.

I turn more specifically to the question of the maternity services, in connection with which two extremely valuable reports have recently been published. One is the General Perinatal Survey and the other in the Report of the Maternity Services Emergency Committee of the National Birthday Trust Fund, both of which deal with the appalling fact that today three children are born dead or die every single hour. This should engage the attention of the House very closely.

It has been stated that the perinatal mortality rate in England and Wales is relatively substantially higher than in many other countries in Western Europe and certainly the United States. When the survey was made, the figure was established at 32.9 of every 1,000 live births. I believe that since then the figure has declined. The fact remains that it has to be compared with 26 in Sweden, 27.2 in Switzerland, 23.9 in Norway and 29.6 in the United States. Perhaps I may make reference to my constituency. Coventry is a city with a relatively high standard of living. Nevertheless, the perinatal mortality rate is at the high figure of 32.4.

It is well known to many of us that infants are being born in what can only be described as Dickensian conditions—conditions in which there is no hot water, where asepsis is absent, and where the infant born under domiciliary conditions is born in a manner which makes it inevitable that we have this extremely high rate of mortality around and during the time of birth.

It is true that the mortality of mothers in childbirth has substantially declined. That is due in great measure to the development of antibiotics and other drugs which counter infections and thereby make childbirth easier. Yet the fact remains that because children are being born in circumstances where midwives and doctors do not have access to equipment and other means by which the life of the child can be saved, we have the appalling situation which exists today.

The recommendation of the Emergency Committee should be inscribed as the motto for the Ministry for the next ten years. The Committee's central recommendation was that: sufficient beds should be made available in fully-staffed hospitals or wards to enable every mother whose age or health involves a risk to her child at birth to have delivery in a hospital where specialist care and equipment is available in case of need. That is not a very academic concept. It is a very relevant consideration, a consideration of equipment. The Survey and the Emergency Committee's Report have established that of the children who are born dead or die shortly after birth 30 per cent, die from asphyxia. My medical colleagues will no doubt confirm the statement in the Report that if adequate equipment and experience in the doctors or midwives were available for resuscitation the number of deaths in those circumstances could be substantially reduced.

I asked the Minister a question to which he did not give me a satisfactory answer. He suggested that it was the Ministry's intention within the foreseeable future to provide a hospital bed for every mother who sought one. He stated that as a principle. That seemed to me to run counter to what was said on behalf of the Minister at the Maternal and Child Welfare Conference in 1963, that even the existing hospital building programme undertakes to provide hospital delivery for only 70 per cent. of the mothers of the 900,000 children who will be delivered in 1972. In other words, there will be a substantial shortfall in the availability of hospital accommodation for mothers without even taking into account the exceptional increase in the birth rate. The importance of all this to the mother is that only in a hospital can the specialist care be made available which is necessary in order to reduce the high perinatal mortality rate.

We must all accept that there is a great shortage of obstetric consultants. A point which might have been brought out during the recent Commonwealth immigration debate is that but for the fact that there is a considerable number of Commonwealth consultants engaged in obstetrics today, the lack of consultants would be even greater than it is. But accepting the present situation, since 1955 the number of consultants has risen by only 1.84 per cent. although the number of births has risen by 10.9 per cent. Therefore, there is a very great problem.

As we all know, the problem has been tackled by emergency measures. If my hon. Friends who represent Bradford had been present, I would have congratulated them on the way in which Bradford has tackled the problem by what is known as the Bradford scheme of short-term release from hospitals so that the mother, having had her child delivered in hospital, can return home for the remainder of her confinement. Here is a specific way in which the Ministry can help. There is a £6 confinement grant. If the mother goes into hospital under the short-term emergency scheme, she forfeits the £6. Many mothers who at home may lack domestic help and the attention which they would get in hospital are reluctant to go to hospital to obtain the advantage of specialised attention and equipment because they fear that they will be deprived of the grant. Therefore, I ask the Minister urgently to consider whether if a short-term release scheme is operated it would be possible for the Ministry to give at least a proportion of the grant to the mother so that when she is at home she can engage proper domestic help.

I turn from that to the question of midwives. We are all agreed that the midwifery service is outstandingly good and that the midwife is the queen of the confinement period. Because of the circumstances in this country, it is the midwives who do the greater part of the work. The problem remains, however, that in 1962, of 78,000 midwives who were consulted, only 18,000 said that they intended to practise. This reveals a serious situation.

One of the reasons why the midwives are reluctant to practise is simply because the status of the midwife has not been maintained at a level which is consistent with the important and valuable work which the midwives do. In the past, for example, the midwife had a bicycle. Surely, in the context of contemporary living, the midwife should be provided with a motor car, especially in view of the number of jobs which she has to do. There should be opportunities of promotion and advancement for the midwife. I hope that the Minister will consider the whole question of promotion inside the midwifery service.

There should be a grade of midwife-matron to which the ordinary midwife can aspire, otherwise it seems to the midwife that, unlike the nurse, her prospects of personal advancement are blocked. The status of the midwife should be raised, and so also should her salary. Only in this way will it be possible to get large numbers of women to return to this honourable profession.

The position today is that not enough money is being spent on the maternity services. There have been enormous advances in equipment to obtain the advantages of analgesia, there have been great advances in anaesthesia and modern portable equipment has been developed, yet it is true to say that these resources are not available to the midwife in the course of her domiciliary visits.

The technique of training midwives, although greatly advanced, has been criticised by the Emergency Committee, not in any sense derogatory to the mid wives themselves, but simply because there are modern techniques which could be taught to midwives but which are not being taught. There is the question of episiotomy, something which every midwife is capable of learning, studying and practising. In these specific ways it could, and should, be possible to reduce the perimortality rate of infants.

It has been asked how the money which is necessary for these purposes is to be made available. I am sorry that the hon. Member for Putney (Sir H. Linstead) is not present. I listened to him with great regret when he was defending the making of prescription charges. He said that they were necessary to make money available for other purposes. With his close knowledge of the pharmaceutical industry, the hon. Member might well have applied his attention to reducing the price of drugs. Here, surely, is a direction in which a great deal can be done.

In 1949, when the late Aneurin Bevan introduced this splendid National Health Service, the cost of prescriptions issued under the National Health Service was £30 million. In 1962 it was £83 million, and this despite the imposition of prescription charges. In other words, the Minister who introduced prescription charges, instead of attacking the drug companies and their methods of high pressure sales, chose to attack the patient, the poorest, those who could least afford the burden.

If there are any improvements today in the National Health Service, if there is expenditure which is being attributed to worth-while purposes which, I am sure, the Joint Parliamentary Secretary has in mind, the fact is that the people who pay for it are not the drug companies, who could pay for it, but the poorest patients, who certainly cannot afford it. Here is something which could be tackled. It is true that some Ministers of Health, of whom we have had several, have made various gestures of shaking their fists under the noses of the drug companies, but all that has been disclosed about the proceedings of the drug companies has come from independent sources.

For example, that excellent journal Which?, the journal of the Consumers Association, which recently investigated the price of aspirin tablets, showed that prices of identical forms of aspirin ranged from 4d. to Is. 10£d. for twenty-five. In other words, it is certain that for several years—in fact, ever since the dramatic rise in the cost of drugs—the drug companies have been treating the National Health Service as a cow to be milked and exhausted. They have done so with high profits which in America have been challenged.

It is not without significance that the companies which today dominate the British drug industry are American companies who were tackled by the Kefauver Committee. I wish that the proceedings of that Committee had had wider distribution in this country. The hon. Member for Putney called for a commission of inquiry into various aspects of the Service. I wish he had added that it would be wholesome and advantageous if there were the equivalent of a Kefauver Committee in this country to look specifically into the question of the exaggerated profits of the drug companies.

These are something about which, I know, the new Minister of Health is concerned, but in an extraordinary way the drug companies seem to have preserved a mystique around their operations which not even Ministries have been able to penetrate. Translated into British terms, what is required is a Royal Commission to call evidence and act in the way in which the Kefauver Committee acted, asking the companies to produce their accounts and calling their scientists, researchers and businessmen for questioning to get at the truth.

The companies talk always about how much they spend on research and about how they must make these large profits to be able to engage in the necessary scientific research in the interests of the nation. When, however, we look at that research, we find that it is largely made up of promotional research. We have seen some of the advertisements even in reputable papers, which look like new aspects of "pop" culture. Those advertisements are infinitely more commercial than scientific. They have gone in for the kind of promotional development which in America is called molecular manipulation and sometimes, here, the creation of "me too" drugs. All this is merely to try to create attractive packages with which they can incite the general public, and in many cases the National Health Service, to buy their products.

It has been established that 60 per cent. of National Health prescriptions for branded items are for drugs for which a comparable generic equivalent could be produced at a fraction of the cost. What is the Minister doing about this? I suggest that he should do something about it. I believe that he could cut the cost of the drugs to the National Health Service by 30 per cent. without the nation suffering. If he were to cut the cost of drugs to the National Health Service by this 30 per cent., he could spend the money on improving the maternity services and would earn the gratitude of the nation.

8.0 p.m.

Miss Joan Vickers (Plymouth, Devonport)

I hope that hon. Members will forgive me for not having been here throughout the debate, but I had another important meeting and I did not think that I would be able to catch your eye, Mr. Speaker.

I am glad to have had the opportunity to follow the hon. Member for Coventry, North (Mr. Edelman), who takes a great interest in this subject. I agree with most of what he said. I should like every mother to have her first and fourth child born in hospital, for those are the two critical births.

Perhaps my hon. Friend the Parliamentary Secretary will convey to his right hon. Friend the Minister of Pensions what the hon. Member said about the grant of £6, because I believe that that is a Ministry of Pensions matter, although it is important.

The provision of cars for midwives is a matter for local authorities. Many local authorities do provide cars, but this is a subject on which hon. Members should press their local authorities.

I was interested in what the hon. Member said about prescription charges. The Motion speaks of policies which would improve standards of service to the patient and permit the abolition of health service charges". I gather that these now amount to about £70 million. If we are to improve the standards, costs are bound to go up as salary and building costs increase. I hope that the hon. Lady the Member for Cannock (Miss Lee), whom I am very glad to see on the Front Bench, will be able to tell us how the Opposition propose to improve the Service and at the same time to do away with this sum of £70 million. I am particularly interested in that aspect of the subject, because I did not vote for the raising of the prescription charges. I abstained. Nevertheless, I should like to have it proved to me that the charges can be abolished while the Service is improved. Perhaps this can be done, but I have not yet heard any hon. Member prove how.

The other day, when I was in Brussels on a Parliamentary delegation, I was in the Senate when a debate on health was taking place. Having listened to that debate and having visited and lived in many countries, I am sure that, with some exceptions which hon. Members have pointed out, in this country we have a Health Service of which we can be proud. It is the best all-round service in the world. There are many other services which specialise in one branch or another—New Zealand has always been particularly good about infant mortality and has the lowest rate in the world—but this country has the finest all-round service.

I was a member of the London County Council for nine years and a member of its Hospitals Committee. I was not on the council in 1930, when the hospitals were taken over by the council, but even in 1937 they were in a fairly parlous state. In 1930 some patients in the chronic wards were sleeping on palliasses, and I expect that the hon. Member for St. Pancras, North (Mr. K. Robinson) will have seen that.

Mr. K. Robinson

indicated assent.

Miss Vickers

The terrific change from 1930 to 1963 has been astonishing, especially as it has taken place all over the country.

I have listened with interest to what has been said, especially by my hon. Friend the Member for Chippenham (Mr. Awdry), about general practitioners. I agree that the general practitioner is the backbone of our present Service, but how does the fare in this Service? He is at everybody's beck and call. He does not have limited hours of work and he can never be certain when he will be off duty. We will have to consider the general practitioner service and put it on a rather different basis. I suggest that he is given a salary on the lines of that given in the R.A.M.C. and is no longer paid on the per capita basis which is unfair.

The per capita basis is unfair on the conscientious man and on the doctor in the rural area who cannot get many people on his books. But it has another bad effect. If the doctor wishes to keep up his income, he must accept as patients all those who come to him and it is very difficult for' him to refuse them when they ask for a chit to go into hospital, or a letter for this or that.

I should like doctors to be given a salary which would be reviewed and on which there would be increments for a number of years, and for the doctor to receive special remuneration if he specialises. For instance, if he specialises in gynaecology, or heart diseases, or ear, nose and throat, or eyes, he should receive a special salary. This would build up the faith of the patients in the doctors themselves. I was very interested in what was said about group practice. I believe that the grouping of doctors is essential, and if we could create surgeries of doctors with special qualifications, individual patients might then not think it necessary to go to hospital. This would considerably reduce the hospital waiting lists. One of the present difficulties is that people really in need of hospital treatment are kept waiting by those who could get the same sort of treatment from their general practitioner, but at the moment the general practitioner is liable to fall foul of his patient if he does not give him a note to go to hospital if the patient demands it.

The general practitioner is in a lower grade than the consultant in terms of services provided. Invariably he has to do his own secretarial work because he cannot afford to pay a secretary and he has to take his own telephone messages, and in many cases the wives of general practitioners are unpaid secretaries. I was discussing this with some general practitioners the other day and they told me that their general expectation of life was no more than about 55 years. That is something to be drawn to the attention of my right hon. Friend.

The service of care in the community is building up well. The more we can increase it, the better it will be for relieving the pressure on beds and for the general health of the nation. I was glad to see that the number of home nurses has increased by 20 per cent. since 1951 and that home helps assisted in more than 341,000 cases in 1962. This is a splendid record. The difficulty arises with the mental health services.

The Mental Health Act, 1959, one of the finest Acts to go on the Statute Book for a long time, has meant that far more help is needed in the community. I was rather disturbed to read that more patients than ever before are being admitted into mental health hospitals. In 1962, 12,907 more mental patients were admitted and the average bed-occupancy in my own area has risen from 95 to 96 per cent.

Mr. Braine

My hon. Friend is quite correct in what she says about this trend, but it is offset by shortening the stay in hospital.

Miss Vickers

But bed occupancy is still very high. I am worried about the number of confused old people going into mental hospitals and taking the room of people who are really mentally sick and who, as my hon. Friend has said, go in for a short time.

We have far too many of the elderly confused in these hospitals. Many schemes have been put forward recently for the care of these people. One was that there should be many smaller homes, with about a dozen people in them. I do not think that that would be economically sound, and I do not see how we could staff such homes. I suggest that there should be more special wards in general hospitals to deal with these people, because this would give nurses the opportunity of doing a different type of nursing throughout their careers.

When I was a member of the London County Council, I was told that if one could nurse an old and chronic sick person, one could nurse anybody, because these old people were the most difficult and the most trying to nurse. I hope that my right hon. Friend will consider the proposal which has been put forward instead of letting these old people go to a mental hospital where the nurses and doctors specialise in mental diseases and not in the treatment of the chronic mentally confused.

Turning next to care in the community and the idea of more people living out, what is happening about the training of social workers? Unfortunately we never had a discussion on the Young-husband Report, but in that Report it was pointed out that many of our people were aged, and that we were extremely short of the type of worker needed for care in the community. I understand that two-year full-time courses are now being run in Bristol, Coventry, Leeds and Manchester, and that in Birmingham, Liverpool and London similar courses are being started. The National Institute of Social Work Training runs a one-year course, and I had the pleasure of going there and seeing it in action.

The results of these courses will be of great benefit, but I hope that my right hon. Friend will carry out a survey to discover the number of social workers that we shall need to implement care in the community. At the moment we have no idea of the number required, and I think that far too few areas are thinking about training these people. I have recently taken this matter up with the local authority in Plymouth. The authority is not yet able to implement the scheme, but it hopes to do so in the spring. How many local authorities are thinking about training social workers who are so urgently needed for this work?

I have spoken about the old, and I now propose to deal with the other extreme, nursery nurses and children. What worries me is that in certain areas children, when they first go to primary schools, are hardly able to talk, and are not always house trained. They have a difficult time starting in school. I was glad to see that the number of nursery nurses is increasing, but I think that it is necessary to have even more nursery schools for these children, particularly the mentally and physically handicapped.

Far too many parents have the greatest difficulty in dealing with handicapped children. What can a mother do with a five-year old handicapped child, especially if he is autistic? There is often nowhere that she can send him. I know that the provision of more nursery schools will prove expensive, but I think that the results will be worth while in the end, because we now know that many of these mentally handicapped children can be helped to get on in life.

I am glad to know that my right hon. Friend is to have an annual meeting of the voluntary organisations, including, of course, the Red Cross, and the League of Hospital Friends, to whom we all owe a tremendous debt of gratitude. When we started the hospitals under the State scheme, many of these voluntary organisations had house committees which worked in the hospitals, but I do not think that anybody visualised the tremendous voluntary spirit in this country which created these innumerable voluntary organisations which are doing so much good by helping hospital staff, not only by doing the actual nursing, but by providing entertainment for the staff.

We also owe a debt of gratitude to the National Old People's Welfare and the Women's Voluntary Service. I hope that my right hon. Friend will encourage all the voluntary organisations to continue with their pioneering work, because they can do one thing which a Government Department finds it difficult to do. They can put into practice some ideas which may be beneficial later on.

Most of the child welfare clinics were started by voluntary organisations. They were partly taken over by local authorities, but they kept their voluntary status if they contributed one-eighth of the cost before being taken over in the State scheme. I think that voluntary organisations can still be encouraged to play their part in pioneer work which can be extremely beneficial for the future.

I congratulate my right hon. Friend, and wish him luck in his new job. He had a sympathetic outlook when dealing with Income Tax cases. He gave me very favourable answers when I raised cases with him, and anyone who can do that when dealing with Income Tax must have a very agile mind indeed. I hope, therefore, that the Service will benefit as a result of my right hon. Friend's appointment.

Mr. Barber

If, next year, my hon. Friend would like me to help her once again to fill in her Income Tax return, I shall do so willingly.

Miss Vickers

It was not my Income Tax return; it was my constituents' returns.

8.17 p.m.

Mrs. Judith Hart (Lanark)

My hon. Friend the Member for Coventry, North (Mr. Edelman) raised a point on the perinatal survey on which I want to concentrate my remarks. As the hon. Member for Plymouth, Devonport (Miss Vickers) can probably imagine, I should like to take the time to follow her on what she said about social workers—because she knows that I share her interest in that question—and the possibility of salaried service for general practitioners. I believe that in the Health Service we are bound to move towards a salaried service. Many advantages will accrue from it. Much of what the hon. Lady said has my support, so the Minister can regard it as having been said by me, as it were, in shorthand.

I turn now to the perinatal survey, because there are one or two points which have not been mentioned. The question to which I direct my attention is the simple one—which babies are dying? Many of my hon. Friends will remember the remarkable work of Professor Titmus and his book, Birth, Poverty, and Wealth, which he published before the war. In that book he showed that the chances of staying alive, the chances of being alive at birth, and the chances of being healthy, varied between one social class and another, and between one income group and another.

At the end of the war, particularly when the Health Service was introduced, we thought that that book was a thing of the past. We thought that it was something we could leave behind us because the nation would go forward to good health, and to equal chances of survival. But what do we find in this survey? I do not propose to quote the figures, because they have been quoted often enough. If we consider the figures for 1911, 1921, 1931, 1950. and the figures of our own time, what do we find?

I quote one remark from the survey. Talking of the relationship between one social class and another in our community, it says: The results of this Survey suggest…that the gap may be increasing rather than narrowing between social classes. It seems to me that of all the indictments by which one can judge the Government during the last 12 years this is perhaps the most devastating. At the end of this period of 11 or 12 years we can say that the chances of babies surviving are differentiated more by the factor of social class than was the case when they came into power.

That is a political point, and it is one which my hon. Friends must hold on to and not let go of, because it is the kind of thing that matters when one judges what kind of society we are living in. I cannot think that a good society would permit the number of babies that this society has done to die at, or shortly after, birth.

Let us look at the way in which this survey establishes the simple fact that the gap is widening instead of narrowing. There is no doubt about the adequacy of the survey, or about the depth with which the statistics were analysed. What was done was to take all the factors which are likely to cause perinatal mortality. There is the factor of whether the mother is having her first, second, third, fourth, or subsequent baby; the factor of her home circumstances; the factor of her previous medical history, and the factor, among many others, of social class—whether she happens to be the wife of an accountant or lawyer, or the wife of a builder's labourer or docker, or farm worker This is the kind of difference that is taken into account.

Excluding all the other factors—whether it is the first or fourth baby, and the rest—if we take the single factor of social class the survey shows that there is four times as much danger to the baby born in the lowest income groups in our society than in the highest. That is the scale of difference. What emerges from the analysis is the question of what we ought to be doing to decrease rather than widen the gap. What needs to be done in our maternity services so that the child of a farm worker or a builder's labourer has as good a chance of survival as the child of a lawyer or of the doctor himself?

The two problems that come up are, first, the inadequacy of the number of beds, and, secondly, which people ought to have the use of the available beds? There are tremendous regional variations in this respect. It has already been mentioned that Scotland has a much higher rate of perinatal mortality than does England and Wales. It may be that Scotland has more people who earn less than is the case in England and Wales. Scotland certainly has more people living in bad housing conditions, and therefore a less fair proportion of the number of maternity beds, taking into account the fact that it has to provide beds on a scale suitable for the larger number of mothers who desperately need them.

But it is not just a question of more beds, and how to select the people who are to have the beds. I wish that my hon. Friend the Member for Coventry, North was still here, because he concentrated on the single factor of home circumstances. The survey shows that to limit perinatal deaths it is necessary to concentrate much more on the single factor of social class and the income group of the mother than upon the home circumstances. In other words, a mother's chances of having her baby stay alive in its first weeks after birth are likely to be affected more by her own background—the question of who her father was, how she was brought up, and at what kind of income level she has lived during her life—than by her home circumstances.

The high-risk people ought to be considered much more on a social class basis. This means that a whole new way of thinking must be done in our maternity hospitals about the basis upon which cases are selected when there is a shortage of beds. We find that with the high-risk mothers who are having, for example, their fifth or later baby—this is the group which has a very high perinatal mortality rate—only 29 per cent. are booked for hospital delivery. The same thing happens in the case of people known to have a high degree of risk involved in having a baby, and who are not the people who tend to ask to go to hospital, although some may have to be brought in as maternity cases during the course of confinement. We find that 60 per cent. of those having their fifth or later babies were delivered at home.

One question which will prove to be an issue between my hon. Friends—although perhaps I should speak here only for myself—and the Minister came when the Parliamentary Secretary answered a point made this afternoon about the extent to which the Government need to provide more maternity beds, and the extent to which they are already provided. Here, what again comes out very clearly from the perinatal survey is that if we are concerned to reduce to the lowest possible number the perinatal deaths we must take account, in providing hospital beds, of those hospitals which have consultant hospital services available to them, and not merely general practitioner unit beds.

This is where the difference will come. I quoted a figure this afternoon, and I have the survey with me, so that I can clarify the point which is at issue between us. The survey says, of the population study, of women having babies, that hospital births were 49.1 per cent., homebirths were 36.1 per cent.; those born in a general practitioner unit were 12.4 per cent., and the rest—born in private nursing homes, or born on the way to hospital, and so on—were 2.4 per cent. The fact that barely half the mothers were confined in hospital is of great importance. The general impression was that the figure was 65 to 70 per cent. We remember the Cranbrook and Montgomery recommendations in relation to Scotland. This false impression of security arises from the reports of the Ministry of Health, which have always included general practitioner beds in the hospital category.

The perinatal survey says that this is not good enough. It says that consultant hospital facilities are necessary for pre natal care and for delivery, and in most cases continuing supervision is necessary in order to reduce the number of perinatal deaths to the extent to which it is believed they could be reduced, with adequate hospital care.

This is why there is such an element of condemnation in what I am saying. In this case things can be done and they are not being done. Beds could be provided which have not been provided, and which clearly will not yet be provided, so that avoidable perinatal deaths and deaths of young babies will continue. The Government are not doing the right things to prevent them. It is as clear as that. The conclusion of the survey is that consultant hospital facilities should be available for at least 70 to 80 per cent. of mothers. Perhaps I might illustrate by reference to what could be done. My hon. Friend the Member for Kilmarnock (Mr. Ross) knows of the wonderful record of Aberdeen, where Professor Bury has established that over 90 per cent. of births take place in hospitals where there is a consultant service available and all the excellence of the ante-natal care which is provided in a city where this matter has been taken seriously and where, for many years, the professor has been pushing for the money to do what he thought was necessary.

On the difference between consultant hospital beds and general practitioner beds let me again quote from the Report: …p;such units"— that is, this general practitioner units— must be regarded as having collective domiciliary facilities with improved nursing and domestic services rather than as obstetric hospitals. If I may make a constituency point, I have been told that, after a great deal of pressure, a hospital which serves the new town of East Kilbride in my constituency is to have a new general practitioner maternity unit and not the kind of unit with consultant medical services which is what is needed in a new town where large families are being born; where the parents have a background of Glasgow poverty and where there will be a high proportion of mothers in the highest risk groups when having their fourth or subsequent child. I should like a consultant medical hospital unit rather than a general practitioner unit and I hope that the Under-Secretary of State for Scotland will consider the whole of the maternity programme for Scotland, bearing in mind the points which emerge from this survey.

There is a further point relating to the question of antenatal care. A surprising number of mothers did not avail themselves of the existing antenatal facilities; or rather, some of them did, but some of them, reading between the lines, seemed to have suffered from the fact that the antenatal care which they received was administered by the midwife and the general practitioner, so that the mothers did not get the proper tests—the haemoglobin and Rhesus factor and blood pressure tests which they should have received—at the proper time. Apparently where it was a case of a combination of general practitioner and midwife only 12 per cent. to13 per cent. of the mothers had the Rhesus factor test, which had a profound implication on the chances of the survival of the baby.

Here, we must think of the need to integrate antenatal care much more, and make sure that the mother is attended by one person or receives the treatment at one place, and that it is not divided between the hospital, the general practitioner and the midwife. Emphasis should be placed on the need to educate mothers to use the existing antenatal facilities adequately. We have tended to assume that mothers have learned about these things. But it is necessary to go back and concentrate on that matter again.

Linked with all this is the question of how to start the kind of service which is essential. My hon. Friend the Member for Coventry, North referred to midwives and home helps. Some years ago one of the first posts in sociology which I held involved working for two-and-a-half years for the Ministry of Health, doing social research for a working party looking into the recruitment and training of midwives. I remember the number of investigations which we made. One investigation, I think that it was the first of its kind—it was a very small investigation—established that the chances of examination success, or success in their career for middle-aged women who returned to nursing or midwifery after having their own families was as great, or greater, than among younger women.

We paved the way to encouraging these people to take up their careers again after refresher or training courses. We shall not solve the problem caused by the shortage of midwives unless we bring back into the service those who are registered but are not practising continually. They may be ready to return to practice if encouraged by the provision of refresher courses and training facilities and adequate salaries. We can solve none of those problems unless we pay reasonable and adequate salaries.

I emphasise a point which was made by my hon. Friend the Member for St. Pancras, North. When a student nurse has taken her nursing qualification and wants to go on to become a qualified midwife, she has to go back to student pay. This is ridiculous. Here is a simple decision which the Minister could make and announce to us tonight, which would encourage more people to be trained as midwives. The Minister should look carefully at this. It is tough on hospital midwives to have difficult jobs of actual deliveres and so on in hospital without, as it were, any of the rewards of following up a case and maintaining contact with the mothers when they go out of hospital, particularly when they leave after such a short stay in hospital. Are we sure that it is right to maintain this sharp separation? Would it not be better from the point of view of recruiting more midwives and making the work more satisfactory if we integrated these services.

If we turn mothers out of hospital after 48 hours because of the shortage of hospital beds and make it necessary for many mothers to have their babies at home when they ought to have them in hospital, we must solve the home help problem. The hon. Lady the Member for Devonport gave the total number of cases in which home helps had been working during the year, but as against every case in which a home help was called in there were a dozen cases where a home help could not be obtained. That was partly because there were not enough women prepared to work the hours required in this service, or at the salary which is offered.

The National Birthday Trust, in its report, suggest that maternity aids could enlarge the service and help in recruitment to it. Maternity aids could act as a group to supplement the work of midwives to help the mother when she goes home with her baby and perhaps already has three or four children in the family at home.

Mr. Lubbock

Would the hon. Lady agree that so long as the present set-up lasts there is no incentive for a local authority to do this, because if a mother goes into hospital to have her baby she is outside the local authority's provision of home helps?

Mrs. Hart

A burden is placed on the local authority to solve the problems which the Government are not prepared to meet.

As other hon. Members wish to speak in the debate, I have made by points as briefly as possible. It is a condemnation of the Government when things can be said which are obliquely said in this perinatal survey. I hope that the nation will realise that if it wants the National Health Service to be a reality and to bring health within the reach of all people, whatever their background, we have to leave behind many of the memories of the last 12 years and start a new era.

8.38 p.m.

Mr. Jasper More (Ludlow)

The hon. Lady for Lanark (Mrs. Hart) has spoken very eloquently and has covered a large number of facets of the National Health Service. She touched on two matters which are of particular interest to me, the part which local authorities are to play in the National Health Service in the years to come and the disparities between the regions which administer our hospitals.

I should like to deal with those two topics after I have dealt with what I am afraid the House has heard much about in this debate, the cottage hospitals. I also represent a widespread constituency. All the arguments advanced by my hon. Friend the Member for Stroud (Mr. Kershaw) and my hon. Friend the Member for Chippenham (Mr. Awdry) are realities in a widespread constituency such as Ludlow. Involved in this problem is the question of visiting, the question of local generosity, as many of these hospitals were started by charitable private individuals, the focus they provide for discussions between general practitioners and specialists and the facilities they provide for local patients who need only good nursing under the supervision of doctors who know them. These cottage hospitals serve a need for patients which cannot be replaced by a large district hospital 20or 30 miles away. More important is the effect that the abolition of these small hospitals is bound to have on G.P.S, many of whom in my constituency have spoken to me about the concern they feel at the prospect of these hospitals being closed. I am sure that that concern is only too well founded.

The magnitude of the problem in my constituency can be realised when I say that of our nine cottage hospitals, five will go and one of the remaining four is to be replaced. What has impressed me in the discussions is that this situation causes one to wonder whether the organisation of our hospital service is sound. Is it not time to take a look at the whole organisation of hospital management as we have known it in this country over the years? Hon. Members who have followed recent developments must realise the fundamental improvements there will be in the years to come. These improvements will, naturally, be much greater than those we have seen in years gone by, and if they are to be used to the full there must be effective co-operation between hospital managements and local authorities.

I serve on a local authority and have served on hospital management committees, so I can claim to have seen the problem from both sides. We cannot always be proud of the things that have happened in the past when considering the co-operation that exists between the two sides. Two examples have come to my knowledge in the last six years. The first is the difficulty of getting building done where it is a combined hospital effort, as must happen in country districts, between hospital management committees and local authorities. I know of a case where construction had to be deferred for two years because the two authorities could not agree.

The second, and even more important point, is the question of representation on local management committees. In my constituency one of the members of our local management committee was the chairman of the public health committee of the county council. Suddenly, for no reason, he was dismissed from the hospital management committee. That was not a courteous thing on the part of the hospital authorities vis-à-vis. the county council, and it is unfortunate that such things can and do happen.

I am not a critic of hospital management committees in general, but we are all conscious of the things we see and hear—the long waiting lists, inadequacies of the organisation, unnecessary difficulties and journeys which patients and visitors must endure, and so on. Has the time not come to take a look at the whole question of management committees and regional hospital boards to decide whether improvements need making?

There is a great contrast between the ways in which these boards and committees are constituted and the ways in which, for example, our local authorities are constituted. The most obvious point to appreciate is that we have no area representatives on the hospital committees and boards. That can be of great importance, as in the present case when the question of whether or not a hospital should be closed arises. Who is to speak? There is no one whose job it is to say, "I represent the district in which this hospital is."

What happens in my area is that representatives of the regional board make a point of meeting, rather at random, representatives of local authorities if they wish to make a row, or with representatives of the local doctors or local medical committees if they make a row. This discussion takes place, perhaps, once a week with one and perhaps a month later with someone else. I cannot see any co-ordination here. It suddenly occurs to someone to write to the Member of Parliament, who then comes in as well, but the whole thing is haphazard and derives from the fact that there is no specific area representation on hospital regional boards and management committees.

The hon. Lady the Member for Lanark has referred to disparity between the regions, and I should like my right hon. Friend to consider the elementary question of size. Is there or is there not an optimum size for a hospital regional board? This is very noticeable in my own case. I live within the area of the Birmingham Regional Board, but our population is more than twice as large as that of the Oxford Hospital Regional Board next door. Should we not consider whether there is a right and a wrong size?

Then there is the important matter of delegation of functions. In very large administrations, such as the hospitals have, a matter of importance must be at what level, and by whom, decisions are to be taken, and at what level there is to be financial authority. We have the situation now that for individual hospitals the decisions are taken, and the financial authority rests, at regional level. Does not my right hon. Friend think that the time has come for more delegation of function, at any rate of hospital management committees, and some delegation of financial authority?

I subscribe wholeheartedly to what has been said of the wonderful voluntary help the hospitals have, in particular the help they get from those who form themselves into voluntary committees, but I should like my right hon. Friend to take this further, and consider whether there should not be, compulsorily in every hospital a house committee which is, at any rate in part, representative of the local management committee; and whether that house committee should not have some degree of responsibility and financial control.

A really important question for the future is: ought we not to look at boundaries? If local authorities are to play this important part, as they must, is there not a case for saying that boundaries should be so readjusted that, as far as possible, the local authority area corresponds with the area of the hospital with which it has to work? It may be an extreme case, but in my constituency, although we are within the Birmingham regional area, we are divided between no fewer than three hospital management committees—although we are all in the same county. I think that serious consideration should be given to whether local authority boundaries should not, to some extent, be taken as a model for hospital boundaries.

As other hon. Members have done, I congratulate my right hon. Friend on his appointment. All of us—certainly, on this side—had the very highest respect for his predecessor. I wish my right hon. Friend well while he occupies this important office, and I am sure that he will find no lack of problems to occupy his attention.

8.50 p.m.

Mr. E. L. Mallalieu (Brigg)

This has been a most interesting debate, particularly for me because of the degree to which it has shown that hon. Members on both sides of the House recognise that the National Health Service, whatever particular criticisms we may have of it, is one of the finest things that have been introduced into the country for many years. However good the institution, there are bound to be faults in it; there are bound to be human failures.

I am grateful to the hon. Member for Ludlow (Mr. More) for having again stressed the absurdity of closing down small hospitals at this time. Surely the case now is for improving them rather than shutting them down. There might be admirable financial reasons for shutting them down, but where, by their services, they have earned the respect of the neighbourhood in which they are situated, these hospitals should not be closed down wantonly merely on financial grounds.

During the few minutes at my disposal I want to refer to a matter which has been touched upon by every hon. Member, and that is the position of the general practitioner in this Service and his status relative to that of the consultant. At present, many people say that the general practitioner is the linchpin of the Service, but is that the regard in which he is held by those who are now responsible for the Service? I am not at all sure that it is.

I believe that the way in which the specialist has been upgraded compared with the general practitioner is the reason for one of the greatest malaises in the Service. There have, of course, been tremendous changes in the character of the specialist, and I do not want it to be thought for a moment that in the criticism I have of certain specialists, though, thank goodness a small minority, I am condemning all specialists. I am not doing anything of the sort. But there have been rather too many instances of consultants under the Health Service treating their patients as soulless clots who are incapable of understanding what the specialist might tell them, if he were so minded to tell them anything at all.

There has been this tendency to regard them as clots and not to explain their condition and the treatment necessary. In some instances which I could mention there have even been cases of no reports being made to the general practitioner about the condition of the patient. This is an utterly outrageous state of affairs. I will not even say from what part of the country it comes, but I know of one case where the general practitioner was afraid to complain when he had not received a report about his patient from the consultant, because, as he said, "I might need this man's services for my family some time." What a lamentable state of affairs that shows. It is merely because some of these consultants have been so up-graded compared with the general practitioner that they have just not been able to carry their corn.

Is there any logical reason why a consultant should be paid more than a general practitioner? I do not think that he is a cleverer man. He is a man who has more knowledge of a particular subject and not, in general, more knowledge than the general practitioner. His knowledge is more channelled, and that is all there is to it.

Mr. More

Is there not something to be said in doctoring for "knowing your patient"?

Mr. Mallalieu

It is very important to "know your patient", and that is where the general practitioner comes in.

At the moment, I am pointing out that it is, so far as one can see, accepted almost universally that for some reason or other the consultant, the specialist—call him what one likes—is a man of greater capacity "upstairs" than the general practitioner. This is not necessarily so at all, although the difference in remuneration is colossal.

Of course, the general practitioner is the kingpin of the Service. It is he who, as the hon. Gentleman says, knows, or should know, the patient, his family background and all the things which concern him and which are of such vital interest to the medical man who is trying to decide what treatment to prescribe. It is the general practitioner who has to fit the report of the consultant into the general picture. There may be several consultants involved and the general practitioner has to fit all their reports into the general picture. In fact, the general practitioner is the commander-in-chief in the operation of making the patient well. It is quite wrong, in these circumstances, that the general practitioner should be regarded, to judge by his earnings compared with those of the consultant, as the scum of the service.

If he has a full list, the general practitioner may have a gross income of about £2,750, but out of that he has to pay for his professional consulting rooms, for his secretary, for his car, and for his locum when he takes a holiday, if he can afford one. The net result is that his earnings are by no means princely. The specialist, on the other hand—I do not say that he is not worth it—earns far more.

The point I urge upon the Minister is that there should be a reappraisal of the general practitioner's part in the Service. Is not the general practitioner worth more at present than he is given? Is the Minister satisfied with the intake of general practitioners into the Service? Has not recruitment something to do with the level of remuneration? If the Minister would consider these things, he could do immense good for the future of the Service.

Whatever the institution, of course, there will inevitably be human failures in it. There were human failures in the Garden of Eden, according to one view of what happened there—although, on another view, perhaps, it was rather a good thing. In the National Health Service in the future, no doubt, there will be human failures as there are now. Nevertheless, it seems to me that one way in which the Minister could make his mark upon the Service and give it a more fruitful future would be to reappraise the position in it of the general practitioner. In my submission, the time has now come to upgrade the general practitioner.

8.58 p.m.

Miss Jennie Lee (Cannock)

During the course of this wide-ranging debate, more than enough has been said to justify the Motion of censure which we have put down.

Straightaway, I pay my compliment to the hon. Member for Manchester, Openshaw (Mr. C. Morris) who, in a most sensitive and distinguished maiden speech, emphasised a point which, I believe, all of us on this side of the House would regard as one of the central themes to which attention should be called. He told us, for instance, that, although the average infant mortality rate is two per 100 for the country as a whole, in Openshaw it is three per 100.

Later in the debate, my hon. Friend the Member for Lanark (Mrs. Hart) returned to the same point, the essence of it being that, after twelve years of Conservative Government, a Government who have had full powers and full opportunity, the maldistribution of wealth in this country is in some respect worse than it was before, and this maldistribution is reflected in the health of the people and their relative chances of health or even of survival in infancy. There have been moments when hon. Members opposite have been speaking that have led me to ask myself who has been governing this country in the last 12 years. I hope that when the Minister replies he will address himself to the record of his party in those 12 years—not tell us about the future, because he will not be there in the future.

I should like to compliment him personally, but I would be more inclined, at the moment, to sympathise with him, because I think that the Sunday Times, which is not one of our Socialist journals, was quite right when it headlined the fact that he had inherited an awful mess from his predecessor. He has inherited a crisis in a great number of different fields. As I say, I am inclined to ask who has been governing this country.

Hon. Members opposite have been talking about the plight of the family doctor, the bad food in hospitals, shortcomings of many kinds. Before we go on to deal with specific sins, either of omission or commission, it is well for us to understand, and for the people of this country to understand, how it comes about that hon. Members opposite can stand for such a mass of contradictory evidence and contradictory apologies.

My hon. Friend the Member for St. Pancras, North (Mr. K. Robinson), in opening the debate from this side of the House quoted from One Nation, produced in 1950, and I think that most of us know it almost by heart. We have also had quotations from the Social Services: Needs and Means, 1952, with which two right hon. Members opposite have been closely associated. It may be said that there has been a change of heart, that the Conservatives are now "with it" and that they have come up to date. In fact, the most recent writings of young Conservatives express the same basic attitude towards social questions in general and the Health Service in particular as was expressed 10, 11 or 12 years ago.

What is the essence of the Conservative position? The right hon. Member for Wolverhampton, South-West (Mr. Powell) in his book twelve years ago stated quite boldly that redistribution of income in this country had already gone too far; that the gap between rich and poor had been narrowed too much. Again and again we have heard the plea in those earlier books that a means test should be applied, that no one should receive any benefit from the Health Service unless he was not able from private resources to look after himself. I do not think that hon. Members opposite would contradict that this was the philosophy put forward. What have the young Conservatives got to say?

A fascinating book was published in 1961 called Principles in Practice, produced by the Conservative Bow Group. Mr. Geoffrey Howe was particularly responsible for it. They certainly have had time to put their principles in practice. Part of the advice given in this book is that the public should insure in private companies and opt out of the Health Service. In order to encourage them to do so, it is proposed in this book that those who opt out of the Health Service should have their tax liability reduced by an amount equivalent to the average cost per head of the service.

I am not saying that the Minister has reached that point yet and I should be delighted if he would repudiate both the theory and practice of his pre- decessors. We have had about as many different Ministers of Health as Ministers of Defence, but every Minister of Health, however good his personal intentions may have been to begin with, has had to carry out Conservative policy. It is clear, both from theory and practice, that hon. Members opposite do not understand the meaning of a comprehensive Health Service.

The Government have even failed to give us even an adequate medical service. There is a difference between the two concepts, that is a comprehensive health service and a mere medical service. We are, after twelve years of Conservative rule, asking hon. Members opposite whether they think that they have brought this country to that level of economic well being when we can exempt at least the sick from financial worries when they are sick. We shall have the answer when hon. Members opposite go into the Lobby tonight.

What is the verdict of those on the benches opposite on Tory rule? Will they say to us that this country had such faith in its people and such vision two or three years after the most destructive war in history that it could say that from our combined resources the strong would look after the weak and that, whatever we had to go without, we would try to provide complete medical care for everyone, beginning with the mother before her child was born? What have hon. Members opposite done to this proud record? They should be providing not just a medical service but health service. Today, we should have been discussing preventive medicine. We should have been discussing health, not disease.

Even the party opposite should know that some of the main causes of illness today are tension, strain, nervous exhaustion and worry. Can any of us think of anything more liable to maximise strain and nervous exhaustion than for a family, at the very moment that it has to cope with sickness and needs additional income in the home, to be told by the great Conservative Party, "We have had our ups and downs in the last ten or eleven years". It has been rather like the case of the Grand Old Duke of York: we have gone up and then come down again. There have been times when we have been able to come to the rescue of Surtax payers."

Every time that there has been an economic crisis, it has been seized upon by the Government as an opportunity to put taxes on the sick and to transfer the burden, so far as it lay in their power, from the Chancellor of the Exchequer to the employer and the employee. This is Conservative philosophy.

Hon. Members opposite are not fit to be in charge of this Service. They do not understand it. If, once again, they were entrusted with power, they would be no better in the future than they have been in the past. They would simply try to take one step further towards their ugly, vulgar philosophy of asking the rich to look after themselves and leaving the insured worker, whether industrial or professional, to pay for his services as much as possible from his insurance and his taxation. For those not rich enough to sign a cheque for their child's schooling, for illnesses or for hospital services, if they were not covered by insurance, back they would go to the spirit of the old poor law and then to National Assistance, with a rigid means test making them feel that it is a crime to be poor.

I could spend the limited time at my disposal in taking each of the health charges one by one—spectacles, teeth prescriptions and the rest—but I consider it more important that we should be completely clear about why hon. Members opposite behave as they do. They belong to what I can only describe as a social handicapped group. Therefore, they must not expect me to be indignant with them or shocked by them. I would rather try to understand them.

Our medical services are not quite adequate to deal with the physically handicapped and with the mentally handicapped, but I hope that one day we will be able to deal even with the socially handicapped. By "socially handicapped" I mean having many of our Conservative leaders conditioned by birth to segregation. It was not for them in their school years to make friends with the little lad who did not have the right kind of accent. They had to be careful about all their social contacts. I do not blame them. Hon. Members opposite belong to a socially handi- capped class who, from their earliest days, have been conditioned to think in terms of the masses and the classes, in terms of "them" and "us", because I do not for one moment believe that they would ever allow their own children or their parents, or anyone who was close to them or one of them, to be treated in the way in which they expose hundreds of thousands of other children and parents to be treated.

There is something extremely brash and vulgar about the philosophy of "I'm all right, Jack", but there is something utterly contemptible in the philosophy, "My child's all right, Jack". For the love of one child should come the love of all children. Therefore, I am serious in speaking about enabling hon. Members opposite to understand themselves better. I am talking in all seriousness when I say that there are ranges of knowledge and experience which they simply do not share.

Hon. Members opposite want the type of society in which the rich look after themselves. They have increased the insured workers poll tax. They have increased the tax on the insured worker three or four times since they came to office, so that the maximum amount should be added to the burden of the employer and the employee, which, incidentally, is a burden upon industry and upon the products that we sell. Thus we have the three categories. The rich look after themselves. The insured worker, industrial or professional, pays through insurance. The third category goes for National Assistance, and National Assistance is made as rigid as possible.

Do not hon. Members opposite realise what a close link there is between welfare and industrial production? Let them imagine a typical working-class family with the man working overtime so that he has a little extra to spend in addition to rent and food and can go out and be a man among men, standing treat to himself and his friend. Visiting his mother and father, he would enjoy saying to the old man, "Here is 10s. Go out and enjoy yourself". But if he finds when he stands treat to his parents that his father has to use the 10s. to pay for a prescription for cough mixture or his mother has to use it to buy tablets for her rheumatic pains. what do hon. Members opposite think the typical industrial worker feels?

In other words, it is very important to realise that our social services are part of the standard of living of the country. When one transfers charges to the industrial worker through his insurance payments and when his parents have to use their savings to pay for prescriptions, one is depressing his standard of life. If hon. Members opposite want that, the young man's reply will be, "Right. If I am not going to have my standard of life sustained by civilised social services, then I want more money." Hon. Members opposite have not the slightest chance of carrying forward the country's economy on a buoyant basis with peaceful co-operation in industry.

Among the many letters sent to me is one from a retired couple. The writer says: I have money invested in Defence Bonds and local government stock that give me an income of £52 10s. a year. Because of this I am barred from assistance and have to pay for four different medicines, milk and a diet out of a health benefit of £5 9s. for myself and wife. Perhaps I should not have said 'a diet', because if you subtract £2 6s. 96. rent you can see my situation. Because of his life's savings, this retired worker is placed just a little above the bare retirement pension.

What hon. Members are saying is "Let us all end up on National Aissistance". Why should anyone trouble to set aside Is., £1, or £100? It seems a lot of money to poor folk. It may be that a worker may save between £1,000 and £2,000, but the investment income from it may be such that he will find that he has to pay for the prescriptions which he gets from the doctor.

The Conservative Party was the party which was supposed to believe in saying, dignity and independence. But this is why I call hon. Members opposite a socially handicapped class. They think it is quite all right for poor people to come appealing for National Assistance. Consequently, whether we are dealing with the general situation of our hospitals or these disgraceful charges for prescriptions and services, hon. Members opposite are not fit to administer the scheme.

I go further and say that when the right hon. Gentleman's predecessors had to deal with sick people, old people and crippled people they were very brave indeed. They got their own way. But when they were dealing with some of the highway robbers exacting quite indefensible profits in the drug industry they were beaten They met more than their match.

No Conservative Minister will really deal with the profiteering at the expense of the sick and the National Health Service and the community because it is alien to his philosophy to do so. There is no point in attacking the pharmaceutical industry for these vast profits and still leaving it to do the research. Many of these firms are sulking. They say, "If you are going to encourage the family doctor not to use our products, we shall not do your research for you." Right hon. and hon. Members opposite cannot do it both ways. There is no answer to the problem unless we are prepared to have competitive public ownership in the drug industry.

The Government must do proper costing and their own research to know what is happening. The other day I looked again at the Cohen Report of 1951. It set out clearly what had already been begun by the Labour Government and what could have been done by the Conservatives. I remember the joy it gave to many of us on this side of the House when we started investigating the profiteering that was going on, not just in medicine but in all kinds of equipment needed for patients and hospitals. I recall the case of the hearing aids brought down in price to one-tenth of what they had cost before.

It is nonsense to expect right hon. and hon. Members opposite to do anything about profiteering in any sector of the National Health Service, but I can promise them that in the near future, when what have now become the caretaker Government have got the verdict of the country, we shall be concerned not only to spend money on the National Health Service but also to save money in it. The pharmaceutical industry cannot be tackled, its high profits cannot be tackled, unless we are willing to go into this ourselves, change the costs and do a great deal more of our own research than the Government are doing at present.

I come now to an aspect that right hon. and hon. Members opposite have not touched—preventive medicine. The other day I was talking to the distinguished head of a dental institute. He was listing the diseases that are the result of dental neglect. The Government have managed in twelve years to begin and complete four hospitals. They have managed to begin and complete one dental institute. I hope that the right hon. Gentleman will contradict me at once if I should be misleading the House in any way in saying that.

When the right hon. Gentleman comes to reply, I would like him to tell us what he has done about preventive medicine. But I can tell him now. He has made it more difficult for children to get their orange juice and cod liver oil. He has made it more difficult for expectant mothers to get their vitamin pills. By the charges on prescriptions he has added money worries to the anxieties of every home where there is sickness.

I can think of nothing that has been done by the Government that can be genuinely called preventive care. I listened carefully when the phrase was used by the Joint Parliamentary Secretary, but he had nothing to say. He talked about the importance of the local authorities and, of course, the Government have managed to transfer from hospital care to the local authority care many of the mentally sick. They have managed in that way to make a bad hospital situation seem a little better than would otherwise have been the case.

But I wish that the Minister would tell me what he thinks he is doing for preventive medicine when he has these charges on the most vital disease-resisting foods and when he takes them from mothers and children, the most vulnerable in the community, and when he is harassing the health as well as the physique of many old people who are just above the National Assistance level. Far from being preventive medicine, this is exactly the opposite, but I do not see any hope of hon. Members opposite doing anything else.

A short time ago, I asked a child what a gentleman was. He was a very young boy, but, quick as a flash, he said, "Gentle and a man". He did not say someone who was very rich; he did not say someone who had 1,000 acres or 100,000 acres; he did not say someone who talked with a special quaint accent; none of those categories; he said, "Gentle and a man".

It is only someone who is both gentle and strong who is fit to be Minister of Health in this country. Gentleness alone is not enough, not when dealing with some of the tougher hon. Members opposite; gentleness is not enough when dealing with some of the great vested interests outside the House. It will take someone who is really tough and who really believes in what he is doing.

But, at the same time, it needs someone who is prepared to regard all the people of this country as his friends, all the children, all the old and all the young. This National Health Service was hard won. We fought hard to have it. Hon. Members opposite fought hard to prevent us from having it. All that has happened in these succeeding twelve years has proved that it cannot be left to their narrow, unloving, insensitive prejudices.

9.28 p.m.

The Minister of Health (Mr. Anthony Barber)

I hope that the hon. Lady the Member for Cannock (Miss Lee) will not think me offensive when I start by saying that, whatever views hon. Members may have about the policy underlying her speech, the whole House will recognise the honour being done to her by inviting her to wind up the debate for the Opposition. It is with complete sincerity that I say that it is all the more fitting because of the great contribution to the National Health Service which was made by Aneurin Bevan. I shall have something to say about her remarks in a few moments.

However, first, I should like to refer to the speech of the hon. Member for Manchester, Openshaw (Mr. C. Morris). His speech could truly be said to have been all a maiden speech should be. He spoke modestly and wittily and he was more or less uncontroversial, although I must say that he seemed to get away with one or two rather telling points. He was particularly concerned about infant mortality, to which I shall refer later, saying now only that he was quite right to stress the importance of effective education of expectant mothers. I join in the congratulations given to the hon. Member by the hon. Member for Cannock, and would say that those of us who were fortunate enough to hear the hon. Member look forward to doing so again.

It is less than two months since the Prime Minister invited me to become Minister of Health, and I hope, therefore, that the House will allow me one or two words by way of introduction, and a reference to two people in particular. In all I am doing, and in all that I seek to do, I am conscious that I have the advantage of being able to build on the sure foundations which were laid by my predecessor the right hon. Member for Wolverhampton, South-West (Mr. Powell). Whatever right hon. and hon. Gentlemen opposite may think, those who work in the Health Service, and those who benefit from it, have cause to be grateful to my right hon. Friend.

Then there is the hon. Member for St. Pancras, North (Mr. K. Robinson). I think that it would be ungenerous of me not to admit in public what I have said in private, that I am delighted that it is the hon. Gentleman with whom I have to deal. Although he may from time to time make the mistake of equating good medicine with bad Socialism, he has an intimate first-hand knowledge of the Health Service, and I know that he wishes only to improve it.

Total expenditure on the health and welfare services this year will amount to more than £1,000 million. Part of the service is administered centrally, and part locally, but one thing that is clear is that if the great range of services is to be used to the best advantage those services must be considered as a whole, in fact, as one integrated service, the overriding purpose of which is to make the most effective provision for those in need. Looked at in that sense, there is no other undertaking in the country which is at once so large and so complex, and that was certainly evident from the remarks of my hon. Friend the Member for Ludlow (Mr. More).

The difficulties with which any Minister of Health is faced are not simply difficulties of magnitude. There is the added complication that medical science is advancing at a pace which makes it impossible to lay down rigid criteria for the years ahead. It is not simply a question of finance. What was appropriate 10 years ago, or even one year ago, may well be out of date today.

I mention by way of example only two changes. In 1949, there were 20,000 deaths from tuberculosis, and the 32,000 beds allocated for its treatment were so inadequate that even in those days arrangements had to be made for patients to be treated in Switzerland. By 1962, the number of deaths had dropped to 3,000, and only two-thirds of the 18,000 beds available were filled. In 1950, if capital had been available—and I think that the hon. Lady will agree with this—we might well have embarked on a major programme of building T.B. hospitals, which, 10 years later, would, have turned out to be white elephants. The decline in infectious diseases has had a similar effect. The 20,500 beds allocated in 1950 had fallen to 6,600 in 1962, and only half of those were filled. Unfortunately, the hospitals for Doth T.B. and infectious diseases were specially constructed and so located as to be of limited use elsewhere.

I mention those examples to show how difficult it is to plan for any number of years ahead, and I think the lesson is that hospital accommodation has to be so designed that it can be modified quickly and cheaply, and that room must be left for expansion of those departments where the change is most likely.

No arm of the National Health Service can be said to be pre-eminent but before I came to the Ministry of Health I had always taken the view that the Health Service revolved round the general practitioner, the family doctor. What I have seen during the past few weeks has served only to confirm that view.

Several hon. Members have referred to the position of the family doctors—the hon. Member for St. Pancras, North and my hon. Friend the Member for Plymouth, Devonport (Miss Vickers), the hon. Member for Stroud (Mr. Kershaw), and the hon. Member for Holborn and St. Pancras, South(Mr. G. Johnson Smith) among them. It is true to say that the supreme duty of the National Health Service is to serve the patient and the individual family. But if the public is to be well served it seems to me that it is essential that the profession should be in good heart.

Hon. Members will have read the Gillie Report. I agree with the hon. Member for St. Pancras, North that it it a remarkable document. I have rarely considered a report which is at once so concise and so very readable. The Report draws an inspiring picture of what general practice can become, and it is based on what the best doctors are doing today. I can see no reason why this picture should not become the reality throughout general practice, provided that the profession and the Government work in partnership. There are some things which only the Government can do; there are others which only the profession can do. But each can help the other.

Hon. Members know that the pay system of general practitioners is a fairly complex one, and I shall not go into any detail about it this evening. The purpose of the pool system is to provide doctors with a sum of money out of which they can meet their practice expenses and be left with a fair level of net pay. It is sometimes forgotten that the Government pay into the pool every penny of practice expenses which doctors incur and which is accepted in their Income Tax returns. This is not always understood, but it is the case. For 1961–62, the sum came to about £31½ million.

The other element in the pool, amounting to about £53¾ million in 1961–62, represents the net pay which the Review Body says that the average doctor should receive for his public work. This is the element which was increased by 14 percent. last April. All this money—the practice expenses and the net pay—is distributed to general practitioners, mainly in the form of capitation fees.

This distribution system is not dictated by the Government; it is agreed with the profession. As hon. Members will have read in the Press, the profession is soon to present a case for increased net pay. The profession is not ready to send it to me, and when it does, I shall doubtless seek the advice of the Review Body, so I will say no more about it now. But on the distribution of practice expenses, to which the hon. Member for St. Pancras, North again referred today, I believe that we can make some progress. I certainly hope so.

The present system has some very odd results. Again, I shall not go into detail, but the fact is that two doctors with widely differing expenses may be reimbursed to precisely the same extent. One gets more than his actual expenses, and the other less. If a doctor increases his practice expenses, the Government find the extra money, but it does not go to that doctor; it is distributed over the whole profession. In a sense, one can say that this is a useful deterrent against individual extravagance. Unfortunately, it also provides a disincentive to the doctor who wants to increase his expenses in order to improve his standards.

We have, therefore, asked the profession to consider ways of channelling the money more equitably, and I hope that it will agree. We shall also be discussing the question of capital expenditure. But we do the profession an injustice if we think of it as concerned merely with its own status and pay. Some doctors may sometimes give that impression, but, generally speaking, it is unfair. Doctors want to practise good medicine, and my task is to help them to do just that.

I have no power—I do not want any power—to compel doctors to adopt an appointments system or to make more use of health visitors and to do all the other things that are recommended in the Gillie Report. That is not for me. Doctors value their individual freedom to run their practices as they wish. But although further progress is, to a considerable extent, in the hands of the doctors themselves, I want, on this the first occasion when I have the opportunity of speaking to the House on health matters, to make my attitude clear. It is to do everything that I reasonably can to help, because after all the overriding objective of us all is to secure the highest standard of medical care which general practice can give.

Dr. J. Dickson Mabon (Greenock)

Would the right hon. Gentleman be kind enough to consider the question of deductions from the central pool, which is a great irritant? The harder that doctors work in relation to matters outside general practice the less there is from the general pool. The 14 per cent. award has become a 6 per cent. rise to general practitioners.

Mr. Barber

If the hon. Gentleman will look at the Official Report of what I have said about the 14 per cent. I think that he will agree that I have stated it correctly. The other point had not escaped me.

A good deal has been said in the debate, by the hon. Member for Durham (Mr. Grey) and other hon. Members, about the shortage of doctors. I agree with the hon. Member for St. Pancras, North that there is a shortage. But to listen to hon. Gentlemen opposite, one would think that nothing was being done about it. Certainly, hon. Members who have referred today to the shortage of doctors seem to have taken no account whatever of the figures given by my hon. Friend the Parliamentary Secretary, when he opened the debate.

The fact is that despite the advice in the Willink Report that the annual intake in British medical schools from 1961 onwards should be reduced to about 1,760, in fact, in 1961–62 it was increased to 1,896. The next year it was increased again to 2,047. The October entry this year rose still further to 2,153. The number of family doctors in practice has increased by 3,500 during the past 12 years. Then there was the announcement made by my hon. Friend this afternoon concerning at least one new medical school.

Mr. K. Robinson

Is the right hon. Gentleman aware that he has made history, that he is in fact the first Conservative Minister of Health to admit that there is a shortage of doctors?

Mr. Barber

The hon. Gentleman has already referred to the fact that I have admitted this in an interview which I gave only the other week. It seems to me obvious, in present circumstances, that there is this shortage. If there had not been a shortage of doctors in the past, my predecessors would not have arranged for the intake of medical schools to go up at the rate that it has gone up. I certainly should not seek to minimise the shortage of doctors. But it would be a travesty of the facts to pretend that the Government have not made good progress over these years. The real trouble with hon. Gentlemen opposite is that they proceed from fabricated facts to foregone conclusions. Fortunately, the British public is more intelligent than some hon. Members opposite seem to realise.

A good deal has been said about nurses, and the first point which the House should be in no doubt is that there is no shortage of recruits. I ask hon. Members to remember that the pay of nursing staffs was increased by 7½per cent. last year and again by an average of 6½ per cent. this year, and within the last fortnight it has been agreed that over a period there will be a reduction in hours.

One fact which has struck me as somewhat strange is that there is no general yardstick for measuring staffing needs. The needs are determined locally and in different ways. What we must do, and, indeed, are doing, is to try to find a better method of assessing individual hospitals nurse staffing needs. I have already said that there is no general shortage of recruits. The truth is that, for one reason or another—the most obvious being marriage—a good many women leave the profession, although we should not forget that the number of qualified nurses still practising today is an all-time record. That certainly does not bear out the assertion of the hon. Member for St. Pancras, North that they are disheartened.

My hon Friend the Member for Stroud, who referred to part-time nurses, may like to know one striking fact. During the past 12 years the number of part-time qualified nurses in the hospital service has almost doubled. I am quite sire from all I have seen so far that much more can be done in some hospitals to make the best use of nursing staff and to relieve them of non-nursing duties.

I have been getting round the hospitals during the past few weeks and I mention a few possibilities: the rearrangement of duty rosters to enable more part-time staff to be used, the introduction sometimes of five-day wards to enable waiting lists for minor operations to be dealt with more quickly—these can be staffed largely by part-time staff—the greater use of nursing auxiliaries and ward orderlies and the grouping together of patients according to nursing needs. My right hon. Friend's Hospital Plan will help by providing more facilities in out-patients' departments so that patients can undergo investigations and treatment there rather than being admitted to the wards.

I turn, in the limited time available, to maternity services, to which so many hon. Members have referred, particularly my hon. Friend the Member for Plymouth, Devonport (Miss Vickers) and the hon. Member for Lanark (Mrs. Hart). The first thing I want to do is to express my gratitude to the National Birthday Trust Fund for having set up a body of such distinguished practitioners to consider the problem of the maternity services. There are two important points about the report on perinatal mortality which should be recognised, although they do not diminish at all either my concern about the shortage of beds and the shortage of midwives, or my recognition of the great importance of the Report.

The hon. Member for St. Pancras, North said that according to the survey perhaps 100 deaths a week or more could be prevented. The Report itself fairly points out that it is impossible to assess what proportion of deaths recorded could have been prevented. The second point is that all the data in the Report on perinatal mortality relates to a period more than five years ago, early in 1958. This is important because since then a considerable amount of work has been done. I have the figures for perinatal mortality, both for stillbirths and live births, but I shall not weary the House with them because I have a great deal more to say.

Mrs. Hart

rose—

Mr. Barber

I have not very much time and if the hon. Lady will allow me to continue I shall not give way.

The House will agree that great credit is due to the devoted men and women in the maternity service who have been responsible for the improvement since 1958.

Mrs. Hart

May I ask one brief question? Would the right hon. Gentleman agree that it is a reasonable assumption that the perinatal rate achieved in the highest social class could have been achieved in the lower classes if proper maternity provision were made?

Mr. Barber

I hope that we shall increase the average rate across the whole country. I was about to say that it is obvious that we must try to do much better. To anyone like myself, with two healthy children, even one solitary family tragedy, especially when one has seen it close at hand, is a distressing reminder of the extreme urgency of this problem.

One of the principal reasons for the present difficulty is that the birthrate has risen more steeply than any of the experts could have foreseen. The remarks of the hon. Member for St. Pancras, North were, to say the least, a little ungenerous to my right hon. Friend the Member for Wolverhampton, South-West. The action required is twofold, more midwives and more maternity beds. In the need for more midwives we start from the position that in the hospital service the number of full-time midwives has gone up by 19 per cent. since 1958 when the report was made and in the same period the number of part-time mid wives has gone up by 51 per cent. The number of pupil midwives has also increased. But this is still not enough. The answer lies largely in improving the working conditions of midwives and, in some cases, in delegating work to other staff and, in other cases, in the better organisation of midwifery departments. I heard the other day, for example, of one hospital which is encouraging the return of part-time staff by providing a nursery for children of the staff.

Then there is the domiciliary service. The numbers here have been increasing, but some areas still need more. There is no shortage of qualified midwives. The task is to persuade them to return to practice and many local authorities provide houses and cars. The hon. Member for Coventry, North (Mr. Edelman) mentioned that many midwives were still riding bicycles. My own wife thinks that every midwife should be given an E-type Jaguar. Many local authorities have introduced rot as for night duty and many are employing more part-time staff for post-natal care.

This is the right sort of approach, but the other need to enable us to cope with the unforeseen rise in the birthrate is more maternity beds. I accept without qualification the opening words in the summary of recommendations of the Committee's Report, which are to the effect that the Committee considered that sufficient maternity beds should be available in fully staffed maternity hospitals or wards to enable every mother whose age or health involves a risk to her child to have her baby delivered in hospital.

The original Hospital Plan, introduced by my right hon. Friend, provided for a net addition over the next 12 years of 6,500 new maternity beds. Since then it has been revised, and, as hon. Members know, provision has been made for a further increase. I am asking regional hospital boards to bring forward as far as possible the starting dates for the construction of new maternity units or extensions to existing units. In those areas where the need is most pressing I want them also to consider bringing to maternity use every bit of other ward accommodation. And the closing of some maternity units due for eventual replacement can be deferred.

My Chief Medical Officer is arranging to hold a conference of representatives of all the main professional bodies concerned with maternity services. The Chief Nursing Officer is also arranging a meeting of maternity matrons and superintendents of maternity units. The hon. Member for St. Pancras, North said he thought that a State-registered nurse, when taking a midwifery course, reverted to the pay of a student nurse. A State-registered nurse who takes a midwifery course, which lasts for about 12 months, gets the rate of pay of a pupil midwife, that is true, but the hon. Member will be pleased to know that three weeks ago arrangements were made which will enable a hospital which has a nurse who is willing to train and subsequently to return to practise as a midwife to make up to her the difference between her pay as a pupil midwife and her pay in her previous nursing post.

There was much more I wanted to say about all we are doing in industrial building and in other respects. I had also hoped that I would have had time to say something about the points raised by my hon. Friend the Member for Putney (Sir H. Linstead) concerning the pharmaceutical service. I listened not only with interest, but with some concern, to what my hon. Friend had to tell me. I can assure him that I am well aware of the essential part played by the service. My hon. Friend asked about new legislation. The intention certainly is that it should deal with medicines and not just with poisons.

As to the closing of small hospitals—and this subject has been referred to by many hon. Members—I know that some people are still concerned about this matter and I would, therefore, like to give four assurances. First, the Hospital Plan does not represent final decisions on the future of the individual hospitals named in it. Secondly, no hospital will be closed unless and until there is alternative provision for the services which are needed. Thirdly, as long as I am Minister of Health no hospital will be closed without my personal consideration and approval. Fourthly, even where a small hospital is no longer required for its present use we shall consider the possibility of using it for some different function.

The Opposition Motion says that the Government are not securing "improved standards of service", and the hon. Lady the Member for Cannock—and, indeed, the hon. Member for St. Pancras, North—referred to the record of Conservative Government; for the last 12 years. The hon. Lady asked me to deal with that record, but perhaps I might put a few questions. Is it not an improvement that during the past 12 years there has been an increase of 34 per cent. in the number of in-patient courses of treatment in our hospitals? Is it not an improvement that some 400 new operating theatres have been provided since 1948—most of them since 1951—and that 157 more are now under construction?

Is it not an improvement to spend £52 million on hospital building, as we are doing this year, rather than £11 million in 1951—the year in which the Labour Government unnecessarily cut the social services? I am quoting from the present Leader of the Opposition, who said that an "integral part" of the Budget proposals of his right hon. Friend the Socialist Chancellor …involves the first cutting-in to our social services…I cannot believe it to be necessary."—[Official Report, 24th April, 1951; Vol. 487, c. 229.] Yet the Opposition have the nerve to table a Motion regretting this Government's failure to secure improved standards.

Of course, there remains an immense amount to do in practically every field, but the terms of the Opposition Motion bear no resemblance to the truth. Is it not an improvement that since we came into office, while the total population has increased by less than 7 per cent. the number of nursing and midwifery staff in the hospital service has increased by 30 per cent., and the number of family doctors by 18 per cent.?

The very last Budget of the Labour Government provided for what the Socialist Chancellor was pleased to call "A slight increase in expenditure on health." That was a mere £7 million above the previous year. Since the present Government has been in office, the current annual expenditure on health and welfare has increased by more than £500 million.

What is the only positive proposal in the Opposition Motion? It is to abolish the health charges. One would think that the idea of such charges had nothing to do with the Labour Party. Nobody would believe that it was a Labour Government which first imposed charges for false teeth and spectacles. Nobody would believe that, together with some 250 other hon. Members, there went tripping into the Lobby in support of those charges, not only the hon. Member for St. Pancras, North, but the

right hon. Gentleman the Leader of the Opposition.

The idea now is to abolish the charges at a cost of £50 million. Let the House realise what that would mean. It would mean that expenditure on the Health Service would have to be cut by that amount, or that there would be the same amount less for some other public service which no member of the Opposition has been frank enough to specify, or that taxation would be increased to the same amount. The reason we are not told which choice a Socialist Government would make is that it would tarnish one of the Labour Party's brightest electoral gimmicks, but I have absolutely no doubt that the people of Britain would infinitely prefer to keep these Health Service charges rather than to slow down the development of the Service, which was admitted by the last Labour Minister of Health.

We on these benches have good reason to be proud of what has been achieved, and we do not mean to be diverted from our task of further expanding and improving the Health Service either by the magnitude of the plans which my predecessors have set in train or by the nebulous promises of the party opposite which, on past performance, it has no hope of fulfilling.

Question put. That the words proposed to be left out stand part of the Question: —

The House divided: Ayes 170, Noes 249.

Division No. 7.]	AYES	[10.0 p.m.
Albu, Austen	Darling, George	Grimond, Rt. Hon. J.
Allaun, Frank (Salford, E.)	Davies, G. Elfed (Rhondda, E.)	Gunter, Ray
Allen, Scholefield (Crewe)	Davies, Harold (Leek)	Hamilton, William (West Fife)
Bacon, Miss Alice	Delargy, Hugh	Hannan, William
Barnett, Guy	Dempsey, James	Harper, Joseph
Beaney, Alan	Dodds, Norman	Hart, Mrs. Judith
Bellenger, Rt. Hon. F.J.	Doig, Peter	Hayman, F. H.
Bence, Cyril	Donnelly, Desmond	Henderson, Rt. Hn. Arthur(Rwly Regis)
Benn, Anthony Wedgwood	Driberg, Tom	Herbison, Miss Margaret
Bennett, J. (Glasgow, Bridgeton)	Duffy, A. E. P. (Colne Valley)	Hewitson, Capt. M.
Benson, Sir George	Ede, Rt. Hon. C.	Hllton, A. V.
Blackburn, F.	Edelman, Maurice	Holman, Percy
Bottomley, Rt. Hon. A. G.	Edwards, Robert (Bilston)	Holt, Arthur
Bowden, Rt. Hn. H.W. (Leics, S.W.)	Edwards, Walter (Stepney)	Hooson, H. E.
Boyden, James	Evans, Albert	Houghton, Douglas
Bray, Dr. Jeremy	Fernyhough, E.	Howell, Denis (Small Heath)
Brockway, A. Fenner	Fitch, Alan	Howie, W. (Luton)
Butler, Herbert (Hackney, C.)	Fletcher, Eric	Hughes, Emrys (S. Ayrshire)
Carmichael, Neil	Forman, J. C.	Hughes, Hector (Aberdeen, N.)
Chapman, Donald	Fraser, Thomas (Hamilton)	Hunter, A. E.
Cliffe, Michael	George, Lady MeganLloyd(Crmrthn)	Hynd, H. (Accrington)
Collick, Percy	Ginsburg, David	Hynd, John (Attercliffe)
Corbet, Mrs. Freda	Gooch, E. G.	Irvine, A. J. (Edge Hill)
Cronin, John	Gordon Walker, Rt. Hon. P. C.	Irving, Sydney (Dartford)
Crosland, Anthony	Grey, Charles	Jay, Rt. Hon. Douglas
Dalyell, Tam	Griffiths, Rt. Hon, James (Llanelly)	Jenkins, Roy (Stechford)
Johnson, Carol (Lewisham, S.)	O'Malley, B. K.	Skeffington, Arthur
Jones, Dan (Burnley)	Oram, A. E.	Small, William
Kelley, Richard	Owen, Will	Smith, Ellis (Stoke, S.)
King, Dr. Horace	Padley, W. E.	Snow, Julian
Lawson, George	Paget, B. T.	Sorensen, R. W.
Ledger, Ron	Pannell, Charles (Leeds, W.)	Steele, Thomas
Lee, Frederick (Newton)	Pargiter, G. A.	Stewart, Michael (Fulham)
Lee, Miss Jennie (Cannock)	Parkin, B. T.	Stonehouse, John
Lever, L. M. (Ardwick)	Pavitt, Laurence	Stross, Dr. Barnett(Stoke-on-Trent,C.)
Lewis, Arthur (West Ham, N.)	Peart, Frederick	Swingler, Stephen
Lipton, Marcus	Prentice, R. E.	Taverne, D.
Loughlin, Charles	Price, J. T. (Westhoughton)	Thomas, Iorwerth (Rhondda, W.)
Lubbock, Eric	Probert, Arthur	Thorpe, Jeremy
Mabon, Dr. J. Dickson	Pursey, Cmdr. Harry	Tomney, Frank
McBride, N.	Randall, Harry	Wainwright, Edwin
MacColl, James	Rankin, John	Warbey, William
Mackie, John (Enfield, East)	Rees, Merlyn (Leeds, S.)	Weitzman, David
MacPherson, Malcolm (Stirling)	Reid, William	Wells, William (Walsall, N.)
Mallalieu, E. L. (Brigg)	Reynolds, G. W.	Whitlock, William
Mallalieu, J. P. W.(Huddersfield, E.)	Rhodes, H.	Wigg, George
Manuel, Archie	Robertson, John (Paisley)	Wilkins, W. A.
Marsh, Richard	Robinson, Kenneth (St. Pancras, N.)	Willey, Frederick
Mendelson, J. J.	Rodgers, W. T. (Stockton)	Williams, D. J. (Neath)
Millan, Bruce	Rogers, G. H. R. (Kensington, N.)	Williams, W. T. (Warrington)
Mitchison, G. R.	Ross, William	Willis, E. G. (Edinburgh, E.)
Monslow, Walter	Royle, Charles (Salford, West)	Wilson, Rt. Hon. Harold (Huyton)
Moody, A. S.	Shinwell, Rt. Hon. E.	Wyatt, Woodrow
Morris, Charles (Openshaw)	Short, Edward	Yates, Victor (Ladywood)
Morris, John	Silkin, John	Zilliacus, K.
Moyle, Arthur	Silverman, Julius (Aston)
Mulley, Frederick	Silverman, Sydney (Nelson)	TELLERS FOR THE AYES:
		Mr. Redhead and Mr. McCann.
NOES
Agnew, Sir Peter	Critchley, Julian	Hollingworth, John
Aitken, Sir William	Crowder, F. P.	Hope, Rt. Hon. Lord John
Allan, Robert (Paddington, S.)	Cunningham, Sir Knox	Hopkins, Alan
Allason, James	Curran, Charles	Hornby, R. P.
Amery, Rt. Hon. Julian	d'Avigdor-Goldsmid, Sir Henry	Hornsby-Smith, Rt. Hon. Dame P.
Anderson, D. C.	Deedes, Rt. Hon. W. F.	Howard, Hon. G. R. (St. Ives)
Atkins, Humphrey	Doughty, Charles	Howard, John (Southampton, Test)
Awdry, Daniel (Chippenham)	Drayson, G. B.	Hughes Hallett, Vice-Admiral John
Barber, Rt. Hon. Anthony	du Cann, Edward	Hughes-Young, Michael
Barter, John	Duncan, Sir James	Hulbert, Sir Norman
Batsford, Brian	Elliot, Capt. Walter (Carshalton)	Hurd, Sir Anthony
Beamish, Col. Sir Tufton	Elliott, R.W.(Newc'tle-upon-Tyne,N.)	Hutchison, Michael Clark
Bell, Ronald	Emmet, Hon. Mrs. Evelyn	Iremonger, T. L.
Bennett, Dr. Reginald (Gos & Fhm)	Errington, Sir Eric	Jackson, John
Berkeley, Humphry	Erroll, Rt. Hon. F. J.	James, David
Bidgood, John C.	Farey-Jones, F. W.	Johnson, Dr. Donald (Carlisle)
Biffen, John	Fell, Anthony	Johnson, Eric (Blackley)
Biggs-Davison, John	Foster, John	Johnson Smith, Geoffrey
Bingham, R. M.	Fraser,Rt.Hn Hugh(Stafford&Stone)	Jones, Arthur (Northants, S.)
Bishop, F. P.	Fraser, Ian (Plymouth, Sutton)	Jones, Rt. Hn. Aubrey (Hall Green)
Black, Sir Cyril	Galbraith, Hon. T. G. D.	Kaberry, Sir Donald
Bossom, Hon. Clive	Gammans, Lady	Kerans, Cdr. J. S.
Bourne-Arton, A.	Gardner, Edward	Kerr, Sir Hamilton
Box, Donald	Gibson-Watt, David	Kershaw, Anthony
Boyd-Carpenter, Rt. Hon. John	Gilmour, Ian (Norfolk, Central)	Kimball, Marcus
Boyle, Rt. Hon. Sir Edward	Glyn, Sir Richard (Dorset, N.)	Kirk, Peter
Brains, Bernard	Goodhew, Victor	Lagden, Godfrey
Brewis, John	Gough, Frederick	Langford-Holt, Sir John
Brooke, Rt. Hon. Henry	Green, Alan	Leather, Sir Edwin
Brown, Alan (Tottenham)	Gresham Cooke, R.	Leavey, J. A.
Browne, Percy (Torrington)	Grosvenor, Lord Robert	Legge-Bourke, Sir Harry
Bryan, Paul	Gurden, Harold	Linstead, Sir Hugh
Buck, Antony	Hall, John (Wycombe)	Litchfield, Capt. John
Bullard, Denys	Hamilton, Michael (Wellingborough)	Lloyd,Rt. Hn. Geoffrey (Sut'nC'dfield)
Bullus, Wing Commander Eric	Harris, Frederic (Croydon, N.W.)	Lloyd, Rt. Hon. Selwyn (Wirral)
Carr, Compton (Barons Court)	Harris, Reader (Heston)	Longden Gilbert
Carr, Rt. Hon. Robert	Harrison, Brian (Maldon)	Loveys, Walter H.
Channon, H. P. G.	Harvey, Sir Arthur vere(Macclesf'd)	Lucas, Sir Jocelyn
Chataway, Christopher	Harvey, John (Walthamstow, E.)	Lucas-Tooth, Sir Hugh
Clark, Henry (Antrim, N.)	Harvie Anderson, Miss	McAdden, Sir Stephen
Clark, William (Nottingham, S.)	Hastings, Stephen	MacArthur, Ian
Cleaver, Leonard	Hay, John	McLaren, Martin
Cole, Norman	Heald, Rt. Hon. Sir Lionel	Maclean, Sir Fitzroy (Bute & N. Ayrs)
Cooke, Robert	Henderson, John (Cathcart)	Macleod, Rt. Hn. Iain (Enfield, W.)
Cooper, A. E.	Hill, J. E. B. (S. Norfolk)	McMaster, Stanley R.
Cordeaux, Lt.-Col. J. K.	Hirst, Geoffrey	Macmillan, Maurice (Halifax)
Corfield, F. V.	Hobson, Rt. Hon. Sir John	Maddan, Martin
Contain, A. P.	Hogg, Rt. Hon. Quintin	Maitland, Sir John
Craddock, Sir Beresford (Spelthorne)	Holland, Philip	Markham, Major Sir Frank

Martowe, Anthony	Redmayne, Rt. Hon. Martin	Temple, John M.
Marten, Neil	Rees, Hugh (Swansea, W.)	Thatcher, Mrs. Margaret
Matthews, Gordon (Meriden)	Rees-Davies, W. R. (Isle of Thanet)	Thomas, Peter (Conway)
Mawby, Ray	Renton, Rt. Hon. David	Thompson, Sir Richard (Croydon, S.)
Maxwell-Hyslop, R. J.	Ridley, Hon. Nicholas	Thornycroft, Rt. Hon. Peter
Maydon, Lt.-Cmdr. S. L. C.	Ridsdale, Julian	Thornton-Kemsley, Sir Colin
Miscampbell, Norman	Rippon, Rt. Hon. Geoffrey	Touche, Rt. Hon. Sir Gordon
Montgomery, Fergus	Roberts, Sir Peter (Heeley)	Turner, Colin
Neave, Airey	Robson Brown, Sir William	Turton, Rt. Hon. R. H.
Nicholson, Sir Godfrey	Rodgers, John (Sevenoaks)	Tweedsmuir, Lady
Noble, Rt. Hon. Michael	Roots, William	van Straubenzee W. R.
Nugent, Rt. Hon. Sir Richard	Ropner, Col. Sir Leonard	Vane, W. M. F.
Orr, Capt. L. P. S.	Royle, Anthony (Richmond, Surrey)	Vaughan-Morgan, Rt. Hon. Sir John
Orr-Ewing, Sir Charles	Russell, Ronald	Vickers, Miss Joan
Osborne, Sir Cyril (Louth)	Scott-Hopkins, James	Vosper, Rt. Hon. Dennis
Page, Graham (Crosby)	Sharples, Richard	Walder, David
Page, John (Harrow, West)	Shaw, M.	Walker-Smith, Rt. Hon. Sir Derek
Pannell, Norman (Kirkdale)	Shepherd, William	Wall, Patrick
Partridge, E.	Skeet, T. H. H.	Ward, Dame Irene
Pearson, Frank (Clitheroe)	Smith, Dudley (Br'ntf'd & Chiswick)	Watkinson, Rt. Hon. Harold
Peel, John	Smyth, Rt. Hon. Brig. Sir John	Wells, John (Maidstone)
Percival, Ian	Speir, Rupert	Whitelaw, William
Peyton, John	Stainton, Keith	Williams, Dudley (Exeter)
Pickthorn, Sir Kenneth	Stanley, Hon. Richard	Williams, Paul (Sunderland, S.)
Pike, Miss Mervyn	Stevens, Geoffrey	Wilson, Geoffrey (Truro)
Pitman, Sir James	Steward, Harold (Stockport, S.)	Wise, A. R.
Pitt, Dame Edith	Stodart, J. A.	Wolrige-Gordon, Patrick
Pott, Percivall	Studholme, Sir Henry	Wood, Rt. Hon. Richard
Pounder, Rafton	Summers, Sir Spencer	Woodhouse, C. M.
Powell, Rt. Hon. J. Enoch	Talbot, John E.	Woodnutt, Mark
Price, David (Eastleigh)	Tapsell, Peter	Woollam, John
Prior, J. M. L.	Taylor, Sir Charles (Eastbourne)	Worsley, Marcus
Prior-Palmer, Brig. Sir Otho	Taylor, Frank (M'ch'st'r, Moss Side)
Pym, Francis	Taylor, Sir William (Bradford, N.)	TELLERS FOR THE NOES:
Quennell, Miss J. M.	Teeling, Sir William	Mr.Chichester-Clark and Mr. Finlay.

Proposed words there added.

Main Question, as amended, put and agreed to.

Resolved, That this House welcomes both the considerable expansion of the National Health Service which has taken place in recent years and the further improvements which will be brought about by the policies of Her Majesty's Government.