NATIONAL INSURANCE (HOME CONFINEMENT GRANT) (Hansard, 30 April 1964)

§ Mrs. Barbara Castle (Blackburn)

I wish to raise the subject of the operation of the home confinement grant. I began to feel that the accouchement or delivery of this speech would never take place. However, even though it is very late, it is worth while for the House to spend a little time on this matter because, as the Joint Parliamentary Secretary knows as well as I do, the present operation of the grant provisions is far from satisfactory. The grant is one of the means that we employ for bringing financial help to women towards the cost of maternity.

All mothers get the maternity grant of £16, regardless whether they have their babies in hospital or at home, but those mothers who have their babies at home are entitled, in addition, to draw the home confinement grant of £6 towards the extra expense in which they are involved. The problem which we are debating tonight arises chiefly from the shortage of accommodation in maternity hospitals. Many women who would prefer to have their babies in hospital are compelled to have them at home, because the beds are just not available, except in certain specified cases, such as first babies, or where there is a medical recommendation that 768 subsequent children should be delivered in hospital.

As a sweetener, to reconcile women to the fact that many who would rather be in hospital have to have their children at home, the Government introduced this grant in 1953. After it had been introduced it was found that there were many cases where complications in the birth arose at the last moment and an emergency booking in hospital had to be made, even though it had been originally expected that the mother would be having her confinement at home. Therefore, the draft regulations were modified to introduce a certain amount of flexibility.

Regulations were made to make the home confinement grant payable in those cases where the mothers had always wanted to have their babies at home but where arrangements for admission to hospital were made not more than two days before the mother went into hospital and, in addition, where the mother was discharged not later than the third day after confinement. That is how the regulations stand at present.

I realise that the National Insurance Advisory Committee has endorsed the present provisions, and has opposed any further relaxation in the arrangement, on the ground that the criterion for the payment of the grant should be the original intention to have the baby at home and not the fact that the mother's stay in hospital was a short one. But I suggest to the Joint Parliamentary Secretary that even though her Advisory Committee may have used this argument, I cannot see that it is a valid one. If the purpose of paying a home confinement grant is to meet the additional expenses incurred by having a baby at home, then the relevant factor is not the date at which it was decided that the mother should go into hospital, but how long she stays there. When she is in hospital she is saving money, and therefore the amount that the confinement costs her is directly related to the amount of time she spends in the hospital.

This was shown very clearly by the case of Mrs. Fenney, of Blackburn, details of which I have sent to the hon. Lady and which I have raised in the House. Here was a case of a young mother who was due to have her second 769 baby. Therefore, in the normal way she would have had that baby at home. But because she lost her first baby with heart trouble at an early age, her doctor advised that she should go into the hospital merely for the delivery of her second child. In the event, Mrs. Fenney went into hospital on 23rd December and was discharged on 24th December. She was in hospital for less than 24 hours but because her doctor had made this decision six months before the date of the birth and therefore this was not an emergency last-minute admission but a prior booking, under the present regulations Mrs. Fenney is not entitled to a pennyworth of grant although the actual expenses of her confinement have not been reduced at all.

In fact, instead of having a normal stay in hospital of about 10 days, she stayed for less than 24 hours. Then she went back home and had to make exactly the same arrangements to be looked after as she would have done if she had had the actual delivery in her own bed. These arrangements involved asking a friend to come in to look after her, because naturally 24 hours after the birth of her baby she was not able to look after herself. The friend, in order to be available, had to pay a minder to look after her own children, end payment still had to be made for the equivalent of the nine days difference between the time she was in hospital and the time she would normally have been in hospital for the birth of the child.

Moreover, at the end of 24 hours it was still necessary for the mother to incur certain additional expenses that are associated with a confinement, such as medical requirements, cotton wool and all the rest; I need not go into details. Those provisions had still to be made for the rest of the confinement. But Mrs. Fenney was not entitled to any financial help towards the cost. She told me when she came to see me that the £6 would have made a very great difference to her as an ordinary working woman, in meeting these additional costs.

I know that the Joint Parliamentary Secretary will say that the maternity grant of £16 payable to all mothers is intended to meet some of these expenses for help in the home because it incor- 770 porates the former attendance allowance. But this grant is payable to women who are in hospital for 10 days. What I am pleading for is some financial help for the mother who, instead of having 10 days in hospital where she is looked after with every attention and comfort, has to return home at the end of 24 hours, or perhaps 48 hours, and has to pay for domestic help for the eight days she spends at home which she would otherwise lave spent in hospital.

Mrs. Fenney's case, as the hon. Lady knows only too well, is not an isolated one. I have a number more which have been brought to my attention, some of which I have passed on to the Ministry. The situation has changed because the National Insurance Advisory Council last considered this matter in 1955 and draft regulations were then drawn up, and the situation has changed also because of the increased shortage of maternity beds which, in its turn, has led to the practice of hospitals sending mothers home two or three days after a birth in order that the beds may be made available for other cases.

It is this tendency which has caused the Royal College of Nursing to take up the case of mothers in the situation which I have described. The Blackburn branch of the Royal College of Nursing wrote to me only a month or two ago asking me to take up this matter, and they should know what is the true position. They are the people providing the nursing for these mothers. They asked me to support the demand for the additional home confinement grant to mothers discharged from hospital two or three days after confinement. In some cases, it is an emergency booking for delivery only, but in other cases, the difficulty is shortage of beds.

The honorary secretary of the Blackburn branch tells me that it is felt that there are additional expenses when a mother is discharged early from hospital, and that there is need for a modified grant. The mother needs domestic help and I would suggest to the hon. Lady that the time has come to review the present regulations.

There are two alternatives open to us. First, to pay the full home confinement grant in all cases where a mother is discharged three days after the birth—as in the case of emergency admissions—and that would mean that we 771 would pay as at present, except that we should drop the provision that the admission must have been an emergency one. Secondly, we could decide to pay a modified grant to every case of short stay in hospital, varying with the length of stay. There might be a little saving on food, but the mothers of whom I am speaking still have more expenses than the normal cases where there is a 10 days' stay in hospital. That is a simple arithmetical fact. Those mothers have saved money compared with those who have only two or three days in hospital.

I know that the hon. Lady and her right hon. Friend the Minister appreciate the fact that it is very difficult today, with the cost of living rising all the time, for mothers of young children to meet the costs of domestic life. This £6 makes a lot of difference to them. I know that the hon. Lady's heart is with me, and I can only express the hope that she will carry her Minister with me as well.

§ The Joint Parliamentary Secretary to the Ministry of Pensions and National Insurance (Mrs. Margaret Thatcher)

I am glad that the hon. Lady has raised this matter tonight because it gives an opportunity of discussing some of the more contentious aspects. First, I will go through the relevant points as rapidly as possible. Home confinement grant is one of three maternity payments payable under that scheme, and it is a single payment of £6.

The other two benefits are, first, the maternity benefit of £16 for each baby born at a confinement. This includes the former attendance allowance of £4 to help with the extra expenses required domestically. Until 1953 this attendance allowance was paid separately

The second benefit is for the working mother on her own insurance, a weekly allowance of £3 7s. 6d. payable for 18 weeks. Thus a mother may be entitled to some £82 from the Fund in respect of the birth of her child. The cost of these three benefits is at present about £28 million a year. In the year ended March, 1963, the Home Confinement grant was paid to 334,000 mothers; 918,000 maternity grants were paid to 909,000 mothers and the weekly maternity allowance to 216,000 mothers.

772 As the hon. Lady said, the home confinement grant was introduced for the first time in 1953, on the recommendation of the National Insurance Advisory Committee, which made a thorough examination of the maternity benefits then available. It is important to recall the grounds upon which it advised the introduction of the grant. These are contained in paragraphs 22 to 25 of Cmd. 8446, published in January, 1952. I will quote part of paragraph 25: We are therefore agreed that, in order to make an adjustment to counterbalance the financial inducement to seek a hospital confinement, a larger maternity benefit should be payable to the woman confined at home than to the woman confined in hospital. This was a clear-cut policy decision founded on very definite views which had been put to the Committee in writing and orally. On the face of it, the principle that women who had their babies at home should receive more than those who had their babies in National Health Service accommodation seemed a simple one. However, as the hon. Lady pointed out, variation in the conditions attaching to the grant were soon required because of the number of cases in which a woman who had made all the arrangements for a home confinement had to be admitted to hospital at the last moment as an emergency case.

The regulations to deal with emergency cases became operative in 1955, after a further reference to the National Insurance Advisory Committee. The hon. Lady has already cited the conditions. It was estimated that in 1962 some 20,000 of those who received the grants were emergency cases, within the present regulations. The Committee specifically considered whether to extend the grant to all short-stay cases, and said: We are clear, however, that the condition cannot be relaxed so far as to permit mothers who have all along intended to have their confinement in a hospital, and have booked a bed in hospital in the normal way—and who have thus made no arrangements for, and incurred no preliminary expense in connection with, a home confinement—to receive the home confinement grant merely because they have stayed in hospital for an unusually short period. The provisions under which this grant is payable have not been changed since 1955. Undoubtedly, however, for a number of expectant mothers the facilities available through the maternity services 773 generally have changed. When the grant was introduced there was a wide distinction between a home confinement, on the one hand, and the customary hospital confinement which normally involved a 10-day lying-in period on the other. Today that distinction has been narrowed, for there are a number of schemes in which the mother is admitted to hospital for delivery only, or for a short stay of perhaps one or two days; she spends the rest of the lying-in period at home.

These circumstances have given rise to some pressure for change. There have been two main suggestions, and they have been repeated by the hon. Lady tonight. First, that the regulations should be widened to include all "short stay" cases. The term "short stay" is often not defined by those who advocate this course, but the hon. Lady was brave enough to suggest three days. Secondly, that mothers who stay in hospital for less than the normal lying-in period should receive part of the grant. This would involve legislation.

I will deal, first, with the proposal to include short-stay cases in the emergency regulations. To extend the regulations to cover all short-stay cases not exceeding so many hours or days would involve adding further time limits to those we already have for the emergency cases. The Department has already had a good deal of experience of administering conditions involving strict limits, and this has made us wary of introducing more.

In the past a number of women have narrowly missed qualifying for the grant for one reason or another—for example, because there was no ambulance available to take them home in time, perhaps because all of them had suddenly been called out. Alternatively, possibly the doctor who was required to give a valid discharge to the mother to get her out in time was not available, perhaps because he was already operating or was absent with the flying squad dealing with an emergency which had arisen in a home confinement case. Yet another reason may have been that the mother was advised to stay in another day in order that her baby might see the paediatrician. In the result the mother may stay another few extra hours or an 774 extra day and be prevented from qualifying for the grant.

Whatever the period, the same problems will arise. The hon. Lady may be interested in the figures for the number of day, stay after delivery. In 1961 of 534,445 hospital confinements, 4,257 patients were discharged on the day of delivery, 15,000 on the first day after delivery, 20,034 on the second day, 15,475 on the third day and 11,758 on the fourth day and 13,141 on the fifth day. Thus, wherever the line for short-stay cases is drawn there would be a large number of mothers who would just fail to qualify and we should have more discontent than we have under the present emergency regulations. A few extra hours in hospital would mean the loss of the £6 grant. Moreover, the longer the period which is covered by the term "short stay" the less can we maintain the distinction between home and hospital confinements; indeed, we should diminish considerably the justification for a separate grant at all.

The other alternative is that of paying part of the grant in short-stay cases. Proportionate grants would require amendment of the Act as there is no power to pay less than the full grant. It would avoid the sharp "all or nothing" dividing line of the other alternative, but it would not be easy to find a satisfactory formula for the proportionate payments. One might reduce the grant by a tenth for every day spent in hospital after confinement, extinguishing it after a stay of 10 days, but this would mean disregarding days spent in hospital before the birth. These are taken into account under the existing emergency regulations.

A simpler formula might be to reduce the amount of the grant by, say, £1 for each day spent in hospital. Six days in hospital would then extinguish the present £6 grant, but there is no medical significance about six days as there is about 10 days, which is the period recommended by the Cranbrook Committee and the £1 reduction could not be justified as corresponding to any particular saving of expense. Moreover, the daily reduction would have to be reviewed whenever the amount of the grant was changed. Such a reduction would be purely arbitrary. Even if a satisfactory formula could be devised, there would 775 still be dissatisfaction and frustration. The amount at stake for an extra day in hospital would be much smaller but for some people it would still be significant in itself. Others to whom the amount involved might not be important might argue on the principle, especially if they lost money because they were kept longer in hospital against their wishes.

The problems now emerging are most carefully under consideration in the light of all the factors, not least the health and welfare services for which my right hon. Friends are responsible. As the hon. Lady knows—I hope I have made this clear to her in letters—and as hon. Members on both sides of the House who have written to me also know, this examination is well under way. There would be the possibility of referring the matter back to the National Insurance Advisory Committee again. If we were to reverse the policy we would need to investigate, together with the Minister of Health, the effects which such a change might have on the health services before deciding whether to refer the matter back 776 to the National Insurance Advisory Committee.

We must bear in mind that well over 300,000 mothers receive the present home confinement grant and are satisfied with it. If they were to have babies in future they would expect to receive similar preference over mothers who elected to be confined in hospital. The tendency of critics of the present arrangements is to cite a particular case or cases and to say that the home confinement grant conditions should be amended so as to cover such cases without realising or even considering the full implication of consequences of such a course. We will consider and evaluate the different points raised by the hon. Lady and also the representations, some of which she mentioned, which we have received from many quarters before we reach a decision about what changes, if any, are advisable. I emphasise that we are looking into the conditions of this grant and the premises on which the original grant was made.