HC Deb 31 July 1964 vol 699 cc2012-32

2.46 p.m.

Mr. Llywelyn Williams (Abertillery)

On 11th June, at the end of what I regard as a very brilliant speech, my hon. Friend the Member for St. Pancras, North (Mr. K. Robinson) referred to the welfare of patients in hospitals, and I want to deal with this aspect of our hospital services today. There is no hon. Member who feels a greater sense of gratitude to the hospital services of the country than myself. Metaphorically speaking, I raise my hat every time I pass a hospital. I was brought up next door to a hospital, and I have been associated with hospitals in one way or another as a pastoral visitor, as a hospital chaplain, as an administrator and, last but not least, as a patient on more than one occasion.

I suggest that I am embarking on a far-reaching subject. Every year three million of our fellow citizens in England and Wales leave their homes and their families to enter hospital, and according to the Powell Committee, to which I shall refer again shortly, the average man in the street in Britain is likely to be a hospital patient five or six times in his lifetime. This, therefore, is a problem which comes home to every one of us.

In the speech to which I have referred, my hon. Friend mentioned the greater sense of awareness in the land today of the question of the welfare of patients in hospitals. This awareness has become much more articulate than it was in the past. The old mentality of so many of our people, which could be described as passive and resigned to whatever conditions the hospital régime saw fit to impose upon them in terms of discipline and noncommunication, has largely passed away or is in the process of passing away.

This is mentioned graphically in an excellent: Report of the Ministry entitled "The Pattern of the In-Patient's Day". I quote from paragraph 5: In recent years, however, criticism of hospital life has become less inhibited and we believe that unless changes are made in the arrangement of the patient's day, the volume of criticism will grow. The man in the street can expect to be admitted to hospital five or six times in the course of his life: It is inevitable, therefore, that he will become increasingly familiar with hospital and the hospital way of life and increasingly critical of the ways in which that life departs from the pattern to which he is accustomed outside hospital. As a taxpayer who finances the cost of the hospital service, he will be less inclined to accept the way his stay in hospital is organised. In short, up to the present the hospital service has been living on the capital reserves of good will built up in the days of the voluntary hospital: these reserves are running low and will be exhausted unless the hospital service is prepared to adjust its ideas and modify its attitude to the arrangements it makes for the comfort and welfare of patients. This changed or changing attitude is continually being intensified by the publicising of hospital activities through such media as the television, be it over-romanticised or over-glamourised programmes such "Dr. Casey", "Dr. Kildare" and their like, or the more serious hospital programmes in the "Your Life in Their Hands" series on the B.B.C. There is no doubt that in future we must take cognisance of this changed attitude.

It is reflected also in the increasing number of patient associations being formed. These groups are springing up all over the country. I suppose that the raison d'être of these associations is to ensure a better liaison between hospital staffs and patients. I confess that I personally am a little suspicious of these organisations. I think that the chronic bellyachers may too easily find further complaints in this type of organisation.

In addition, some very thought-provoking books have been published in the last few weeks. I have in mind, first, a book written by a lady called Gerda Cohen in the Penguin series entitled, "What is Wrong with our Hospitals?" She writes with wit, a rather sharp wit, perhaps, but obviously on the basis not only of personal experience but also of wide observation. There is too much truth in some of the rather alarming revelations in her book to allow any of us who are genuinely interested in hospitals to become complacent. A more objective book has recently been published in the Institute of Community Studies by a lady called Dr. Ann Cartwright. This book is based on close analysis and statistical evidence. I found this book very stimulating and challenging. It confirms many of my own personal impressions.

Before these books were published, to the credit of the Ministry of Health it must be said that some absolutely first class pamphlets have been produced by the Central Health Service Council. I have referred to one—" The Pattern of the In-patient's Day ", which was the result of the work of the Powell Committee in 1953. An excellent pamphlet entitled, "The Reception and Welfare of Inpatients in Hospitals" has been published. More recently, a pamphlet entitled, "Communication between Doctors, Nurses and Patients An Aspect of Human Relations in the Hospital Service", was published. This pamphlet is the work of the Cohen Committee, presided over by one of our most distinguished medical men, Lord Cohen of Birkenhead. These pamphlets contain first class practical advice to all those engaged in hospital administration today.

I do not want to exaggerate my case, but I believe that some progress has been made on the lines of the recommendations in these documents, but the progress is far from satisfactory. Much more prompting by the Ministry is needed before we shall achieve the results aimed at in these pamphlets. Naturally, the Ministry is concerned about conditions in hospitals. It has every reason to be concerned. We spend £550 million per year on the maintenance of our hospitals. That makes hospitals in Britain a vast enterprise. We are embarking upon a hospital construction programme which will cost about £750 million in the next ten years. In view of all these considerations, I make no apology for drawing the attention of the House and the country to this aspect.

What concerns me is the question of human relationships. This is the nub of the matter. In the post-war period we have witnessed incredible medical technological advances. Surgical skill seems to go from one new wonderful discovery to greater discovery still. We have discovered drugs which are indeed miracle-working. One would wish that there were a comparable advance in human relationships and that, as medicine has become more specialised and the skill of doctors and nurses more specific, there had been a parallel development in securing that human atmosphere which should prevail in a modern hospital.

One feels that this is not so and that there is a tremendous amount of work still to be done by those engaged on this very important work. I do not think that it is a question of unkindness or callousness. No one who knows anything about a modern hospital would dream of using those words. It is probably more a question of thoughtlessness. It may be merely a question of concentrating on one aspect of hospital work to the detriment of other aspects which, in my opinion, may well be more important. This issue goes wider than mere hospital work. It is a problem in modern industry. We must apply our minds more and more to what can be done.

I want to give some instances—time will not permit me to give many—of what I mean by the deficiencies in the welfare of patients in modern hospitals. I want to take, first, the question of the fantastically absurd early rising of patients. I have tried to approach this problem with all the common sense at my command. I have tried to weigh the justifications which one always hears from hospital staffs about the necessity of waking patients at these unearthly hours. I have not yet been convinced by any of them.

There are a few statistics gleaned from Dr. Cartwright's book. She made a very full analysis of hospitals in different parts of the country. According to her, 62 per cent. of the patients in hospitals are awakened before 6 a.m. Teaching hospitals are slightly better, the percentage there being 50 per cent. That is a poor show, judged on any count. Further, 35 per cent.—more than one-third—are awakened before 5.30 a.m. Of 723 patients investigated by Dr. Cart-wright, only two expressed satisfaction with that state of affairs.

I know the usual excuses. Shortage of staff is a very important excuse, if it can be proved. Then there is the question of the hours of duty. Night nurses must finish their work before the day staff comes on, and that often impels the night staff to wake people up at an unconscionably early hour. We are also told that the wards must be made ready for the entrance of the consultants. One is prompted to ask—I hope that this is not a false antithesis—what are hospitals for? Are they for the convenience of consultants and nurses, or for the welfare of the patients?

The mystique of the hospital, which was for so long fostered by the Establishment, is disappearing, and people just will not accept the old philosophy As it was in the beginning, is now and ever shall be: world without end. Amen. As I see it there is no justification for this absurd early waking hour, and I speak as a patient and as one who has been intimately concerned with hospitals. People desperately need sleep.

What are they awakened for? They are awakened to have their faces washed, and to have their temperatures taken. According to the Powell Report a tremendous amount of temperature taking is completely unnecessary. This preoccupation with peripheral things is one aspect of hospital work which baffles me—this tidying of the beds, this mouth washing and face washing. I cannot see that it serves any useful purpose. I am sure that patients would be the better for a much more reasonable waking hour. Why cannot we have a three-shift system in our hospitals? I know that some hospitals are working such a system, and that it solves the problem immediately. I believe that 10 per cent. of our hospitals are working this system, and I beg the Minister to see whether more and more hospitals cannot be persuaded to adopt it.

I move on now to the question which can best be summed up in the word "communication" because that is the one thing which concerns all those people who are in any way connected with modern hospitals. The Cohen Report emphasises this in a particularly lucid and graphic way. It is the basic question, in as much as a patient is in a world which in many senses is an unknown one. He is naturally perturbed by his environment. He often feels that he is not encouraged to ask questions and to seek information. Sometimes when he does this he is put off with a platitude—and sometimes with something which is worse.

The eminent medical men presided over by Lord Cohen realised that a hospital is never satisfactorily functioning unless communication is a two-way system—not only communication from the doctor to the patient but also from the patient to the doctor. I was particularly fortunate in this matter. The consultants to whom I owe so much—indeed, to whom I owe my life—treated me with remarkable kindness and understanding. They explained things to me, and answered all my questions. Bat a number of my constituents are forever telling me that they feel completely left in the dark during their sojourn in hospital. Who is to tell them? Many of them just pick up scraps of information from other patients or from some junior nurse.

Someone must take on this task and there is in paragraph 20 of the Cohen pamphlet—"The Personal Doctor"—the following very constructive suggestion: … at home the patient has a personal doctor, the general practitioner, who can be expected to treat him as an individual and to interpret the arrangements for his care. The need for a similar service in hospital is not less great, for it is often at the time of serious illness that patients and relatives are under greatest stress. We suggest that a serious attempt should be made to introduce the concept of a personal doctor in hospital. There can be little doubt that the best person to undertake this rôle is the consultant who has accepted clinical responsibility for the patient's care. But where circumstances prevent this the responsibility should pass (and should unambiguously be understood to pass) to the deputy who supervises the patient's medical care in the absence of the consultant. Under this arrangement a personal service would be seen not as a separate entity but as an inseparable part of the wider concept of medical care. Unless the responsibility for personal care is clearly designated and accepted, there is a risk that failure of communication will occur. That is a very constructive suggestion, but I wonder whether it could not be expanded?

In view of the vastness of the hospital system and the importance of this problem, can a case not be made for the sitting up in the modern hospital of what it is the fashion to call the "ombudsman"—a person who can act as a liaison, to to speak, between patients and staff. Whether this ombudsman should be a qualified person, as Cohen suggests, a trained nurse, an almoner or a hospital chaplain I would not like to state dogmatically now, but I believe that in a very subtle but important sense there should be such a personage in modern hospitals. I have not followed out the full implications of this, but I sometimes feel that a case could be made out for a new inspectorate. We have inspectors for schools and inspectors for factories; when we are spending £550 million a year on hospital maintenance alone, a case might be made out for some governmental supervision of hospital work.

Other aspects of the problem include visitation, and in this connection these various reports are bearing fruit. I understand that 88 per cent. of hospitals now allow daily visiting—it is not so long ago since visits were limited to two or three a week. This is very welcome progress, but I think that the visiting system could be made still more elastic so that those unable to visit in the evening could have the choice of visiting in the afternoon or the evening.

The supply and service of food in hospitals is good. I had no complaints about the food or the way in which it was served, but there is still that unconscionable gap between a six o'clock last meal and an eight o'clock breakfast. That is a 14-hour fast, and hospital is not the place for fasting. Perhaps something can be done about that.

I do not think that there can be a country in the world with better hospitals than ours, but we have a Welsh proverb which says "Nid da lle gellir gwell"—"It is not good if it can be better". It is because I believe that wonderful though our hospitals are they can be improved still further, particularly on the personal relations side, that I have ventured to address these remarks to the House.

3.10 p.m.

Mr. Dudley Smith (Brentford and Chiswick)

This is positively my last appearance in this place, subject to the cancellation, or, as I hope, the renewal of my contract in the autumn. I should like to support briefly the case which was advanced so humanely by the hon. Member for Abertillery (Mr. LI. Williams). He said that the average person could expect to pay five or six visits to hospital in the course of a lifetime. Perhaps I am unique in that, unfortunately, I have paid three visits to hospital during the time of this Parliament. The first was as a result of a rather serious road accident, the second because of the need for a routine operation, and the third because I happened to catch mumps from my small son.

These visits at least gave me the opportunity of studying the National Health Service from the inside. Twice I went as an amenity bed patient and once as a National Health Service patient. I agree with a great deal of what the hon. Member said about the psychology of the relationship between patients and hospital administrators. We should bear in mind always that people who administer hospitals have a great deal of power over those who come in. It is right that they should have this power, because they are responsible for the curing if at all possible of those who arrive.

The moment one takes away a person's clothes and he is put to bed one has a great psychological power over him. He is put in a position of inferiority. He is probably frightened and anxious about his state, and he is entirely dependent on those who are administering to him. Doctors, nurses and administrators can never be too conscious of this aspect and there is need for a great deal of improvement in the diplomacy of consultation.

The last time that I was unlucky enough to be in hospital I shared a small side-ward with a gentleman who had been taken in unexpectedly with what he thought was a stomach haemorrhage. After two or three days he appeared to be fit and well and he was about to be discharged when a 22-year old house surgeon came in breezily and said, "We have found what is wrong with you. You have a quite serious stomach ulcer and you must be given special treatment." This shocked and worried the man. I should have thought that, bearing in mind that this was a London teaching hospital, this sort of thing could be done much more diplomatically and sensibly by a relatively senior member of the medical staff.

A great deal of understanding of psychology is needed in the matter of telling the patient what is wrong with him and taking him into one's confidence, if at all possible, and putting his fears at rest. Only the other week I heard of an hon. Member who was taken to hospital for a routine operation. After the usual X-ray procedure he was visited late at night by a surgeon who said, "We have found a shadow on your lung. I am afraid that it is far more serious than what you came in for and we shall have to operate." The hon. Member was kept for 10 hours in a state of intense anxiety before he was taken in the morning to an X-ray unit for further examination. Fortunately, it was discovered that he did not have a shadow on his lung and that this was an ordinary error. As a result, he went through the routine operation and was perfectly all right and today he is happily back among us in the House.

These kind of things have a bearing on the situation of the individual patient. Those who are responsible for the administration of our hospitals need constantly to bear in mind the psychology of the treatment of the patient and the fears and inhibitions of those who come under their care.

Also—the hon. Gentleman did not mention this point particularly but I am sure that he will subscribe to what I am saying—we cannot emphasise too much the need for respect for the patient. We have come a long way since before the war, when patients were referred to by their surnames and the sister in charge of the ward was rather like a truculent sergeant-major. Today, whoever the person is, he is treated with respect. Even so, sometimes the routine seems to take precedence over the ordinary individual welfare of the patient. I am sure that just as we as hon. Members of this House should never dream of being patronising or rude to any of our constituents, nor should doctors or nurses ever dream of being patronising or rude to any of their patients, however difficult and troublesome they might appear to be.

The hon. Gentleman has done a service in bringing this matter forward. I do not agree with him entirely on the question of early rising. As "lights out" are fairly early in hospitals, it is a good idea that patients should be allowed to be awakened fairly early. The hon. Member had a lot to say about the three-shift system and I hope the Parliamentary Secretary will bear this in mind. I hope that we can do more about it.

I hope my hon. Friend will take note of what has been said and that we may go still further in improving the welfare of patients in the hospital service.

3.17 p.m.

Mr. Kenneth Robinson (St. Pancras, North)

When we discussed health on Monday, the hon. Member for Brentford and Chiswick (Mr. Dudley Smith) followed me and took exception to a certain amount of what I had said. It is not entirely because his contract may not be renewed in October that I will turn the other cheek today and say that I agree with virtually every word that he has uttered this afternoon. In the same way, I agree very much with what my hon. Friend the Member for Abertillery (Mr. L1. Williams) has said. I am sure the House is grateful to him in these dying hours of this Parliament in taking the opportunity to raise this extremely important subject.

I shall not come between the House and the Minister at any length, because this is a matter which I have raised on a number of other occasions from this Box and from the back benches. It is a subject to which we cannot return too often. It is a matter which can be put right, and will only be put right if attention is continually called to it. What is wrong stems from attitudes that go back into history and which cannot be changed overnight. But it is because people recognise what is wrong and call attention to it in speeches and books and, indeed, in White Papers from the Department, that there is a steady improvement the whole time, though I must add that there is room for considerably more improvement in the future.

I wish to make only one point. My hon. Friend the Member for Abertillery paid tribute, and rightly so, to a series of White Papers which have come from the Ministry of Health in recent years on different aspects of this subject which generically I think we can call human relations in hospitals. He mentioned a number of White Papers. Two come to my mind which he did not mention. One was on noise and the other on human relations and obstetrics. I agree that the most important of all of them was the Cohen Committee's Report on "Communications between Doctors, Nurses and Patients". The establishment of proper communications within a hospital between doctors and nurses, nurses and patients and doctors and patients is at the root of this trouble.

These admirable Reports come out. They are circulated in regional hospital boards, boards of governors and hospital management committees. One hopes that they get beyond the doctors to the matrons and, if it is not too much to hope, to the consultants. What I am a little worried about is that nobody seems to follow them up. Where conditions are already tolerably good, these White Papers, I am sure, make them better. I have a shrewd suspicion that where conditions are rather bad and ought to be complained against, not very much notice is taken of these White Papers.

Is there in the Ministry any system whereby when a Report or White Paper of this kind is circulated someone, after a suitable interval, chases somebody and says, "What have you done in the light of this Report? What reforms have you brought about?". This is necessary in order to get improvement where improvement is most needed.

3.20 p.m.

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

At the outset, I can answer the hon. Member for St. Pancras, North (Mr. K. Robinson) by saying that all the Reports which have been mentioned in the debate have already been recommended to regional hospital boards by my right hon. Friend. In some cases, on the in-patient's day and on the visiting of patients, the Minister has called for reports back. The hon. Gentleman can take it, therefore, that these Reports are received, studied, and acted upon.

Sir John Vaughan-Morgan (Reigate)

I had not intended to raise this matter had I been fortunate enough to catch your eye, Mr. Deputy-Speaker, but I endorse what the hon. Gentleman has said. These circulars are sent out to regional hospital boards. In the responsible ones such as those of which the hon. Member for Abertillery (Mr. L1. Williams) and I are members, they are followed up very carefully. But what assurance can my hon. Friend give us that the Ministry sees to it that reports are sent in within a given period?

I know of no means which the Ministry has yet established of saying, not that such-and-such must be done, because one must not ask that, but, "Please let us know, within a given time, what you are doing about it"? This should be a duty imposed on the governors of teaching hospitals, on the members of regional hospital boards and, through the regional hospital boards, on management committees. I know of no means whereby the Ministry insists on a reply or considers whether such replies have been received when appointments are renewed.

Mr. Braine

Perhaps my right hon. Friend knows of no such machinery, because it has been quite unnecessary, in the case of the hospital with which he is connected, but I can assure him that, in cases where boards delay in replying, we press them for the information. In the absence of any specific instance which any hon. Member can produce to me, I am at a loss to understand why this charge should be made. Regional hospital boards and hospital management committees are like other human institutions. They are often working under considerable pressure, and there are occasions, I agree, when information from them does not come forward quite so rapidly as one would desire. But we are all seeking to promote the best possible service, and it falls to my Department to chase those who appear to be a little lax in this matter. I think that, with good will, we get an effective response to the requests which we send to regional hospital boards.

I join the hon. Member for St. Pancras, North in thanking the hon. Member for Abertillery for using this occasion to raise, as clearly and as fairly as he has, an aspect of the care of patients which is of the highest importance. Many factors bear upon the patient's welfare besides the actual quality of his medical treatment—the quality of buildings and of furniture, the quality of, if I may so describe it, the hotel service side of hospital management, not least the catering department, of the administrative arrangements made for admitting and discharging him and of the services for his rehabilitation and after-care when he has left hospital.

To an extent, these are practical, tangible matters. New wards and departments, new kitchens and other facilities, sometimes more or better trained staff can, and eventually will, put right any existing defects. But—and this is what the hon. Member for Abertillery said and what the hon. Member for St. Pancras, North reminded us about—the best equipped hospital in the world would fall far short of the ideal if it were lacking in human sympathy with the patient and good, human management of the resources used for his or her benefit. One thinks not simply of the patient as one individual person, but of his family as well, because they are part of his treatment; they are worried and anxious about him. A far from model hospital—and we still have too many—may yet have that essential "human" atmosphere which can so greatly help the patient's cure.

It is with the intangible rather than the physical that the hon. Member is, I believe, primarily and rightly concerned, and it is on this that I propose to concentrate my remarks. First—and I intend no criticism of the hon. Gentleman—it is necessary to get our perspectives right. Nearly 4½ million—not 3 million people were in-patients on one or more occasions last year. There were 13 million new attenders in the outpatient and accident departments, and 43 million attendances all told. How many of these had just cause for complaint? On the other hand, how many of them had nothing but praise for their care and treatment? Working in our hospitals there are 24,000 doctors of various grades, 228,000 nurses and mid-wives, whole and part-time, the equivalent of about 25,000 other professional and technical staff, to say nothing of the administrative, clerical and thousands of other staff who provide the hospital service. How many—or, rather, how few—of these gave cause for complaint? There is no clear statistical answer to these questions, but I know that hon. Members will share my view of what the answers are likely to be.

We in the Ministry hear of many complaints. We receive quite a number of adverse comments during the year. I receive them as Parliamentary Secretary through the medium of correspondence from hon. Members. Hospital authorities get a great many more. Hon. Members remind us by letter and by Parliamentary Question that all is not perfect. But who hears about the great volume of letters of praise that also pours in? Every hospital, doctor, nurse, midwife and almoner has a score who praise for everyone who blames.

The pity is that this is not said often enough, here or elsewhere, and perhaps it is in part because the hospitals and their staff are too modest to say anything about it or consider they have a more important job to do. Good news rarely hits the headlines. It often gets no mention. Such is the perverse nature of human beings that they seem less interested in the normal and the continuing, the constructive and the important than in the abnormal and the unusual, the sensational and the morbid, the trivial and the transient.

I should like to use this occasion as much as an opportunity for expressing thanks for the devoted service which is given as for a rare chance to discuss an important aspect of that service. Bluntly, let us not always seem to "knock" the hospital service—I do not suggest for a moment that anybody has done that today, but it is done—and the professional and other staffs who work in it. If we do—and sometimes we must—let us try not to do so in a way which provokes resentment, especially by appearing to generalise from the particular. As Dr. Cartwright says, in "Human Relations and Hospital Care": The majority of patients were satisfied with the medical treatment they received in hospital and had nothing but praise for the nurses and the way they looked after them. Where particular emphasis is put on the shortcomings of the service, this is in the hope that more can be learnt from the occasional criticism than from the general chorus of praise. The speeches made this afternoon were entirely in that spirit.

The Reports to which reference has been made have a theme—a surprisingly consistent one—which I can summarise as follows. Hospitals are old in form. Professional education is established in patterns of teaching and practice set many years ago. There is a long tradition establishing a particular status for the hospitals and their staffs in the world of health and society at large, easily understood but still largely accepted both by them and by patients. But this world is changing. It is changing in ways which very few individuals are in a position to comprehend fully. Astonishing advances have been made in medicine that are changing the whole pattern of medical care. We should not overlook in this connection the very important part that British doctors are playing.

The rôle of the service is changing. Its activities are quickening with the result that contacts with patients are shorter and the work becomes more specialised and technical. Society itself is changing. Education is more widespread and deeper. Sources of knowledge about health matters multiply and are more easily available. Standards are more frequently challenged and criticised. All of us secretly find that change is exciting and stimulating and necessary—for others. We are much less ready to accept and welcome change that affects ourselves. Doctors and nurses are not translated to angelic status merely because they acquire high, professional qualifications, and people do not necessarily become angels when they fall sick and become hospital patients.

What these Reports seem to say in common is that there is a risk that any institution of a specialised kind may suffer from introversion and be led, perhaps unconsciously, to the view that what is best for the institution is best for its clients. The Reports differ, of course, in kind. The Report on the "Pattern of the In-Patient's Day" is a highly competent review of the effect that changes in a hospital's programme of work can have on the patient and the nurses' work.

It has critical things to say about the continuance of practices that seem to have traditional rather than practical significance and which add to the work around the patient and disturb him. Its main contention is that the patient's active day is too long—this is a point that the hon. Gentleman made—and too strenuous for his good, and that a different timing of the programme of work is practicable, with a period of rest and relaxed arrangements for visiting, producing a pattern more akin to his ordinary domestic expectations.

This is something that hospital managements can, if they will, get their teeth into. The other Reports, while paying full attention to the improvement and better use of resources in a general way, deal essentially with attitudes and communications. Miss Gerda Cohen's book is an account of one person's experience and inquiries. It is pointedly critical and sharply worded, and I have no doubt that it will be widely read.

The official publication "Communication between Doctors, Nurses and Patients" is a distillation of the experience of a number of senior doctors and nurses, an intuitive first account of the problems facing all three, with suggestions of principle rather than practice for a review of attitudes.

Dr. Cartwright's "Human Relations and Hospital Care" goes wider and deeper, but, in essence, its summaries and conclusions derive from facts and figures much the same lessons as are dealt with in the official publication on communications to which I have referred. Much of both Reports deals with the needs of patients for information and the need of the hospitals to decide, with others, how it should be given and by whom, and for developing their own techniques for seeing that the right facts are consistently given. In short, the points made by the hon. Gentleman on this question have been discussed in these Reports. They assert that communication is an essential complement of clinical care and a responsibility primarily of doctors, with the help of nurses and others.

Those are not the only Reports and not the only lines of action. I will remind the House of some others. Almost the basis of all of them was a Report from the Central Health Services Council on the reception and welfare of in-patients in hospital, published as long ago as 1953, based on an earlier Scottish Report dealing with a wide range of topics, including those which we are now discussing. The process continued with another Central Health Services Council Report in 1959 on the welfare of children in hospital.

In 1961, besides the Report of the Standing Nursing Advisory Committee on the "Pattern of the In-Patient's Day", there was a smaller Report on the problem of noise in hospitals and a further Report from the Standing Maternity and Midwifery Advisory Committee on "Human Relations in Obstetrics", based largely on evidence collected by the Cranbrook Committee in 1959. My point is that there has been no sudden realisation of a new problem, but a continual and growing process of attention to the human side of hospital life.

What then are we doing about all this? The word "implementation" is a false friend in this context. It is the policy of my right hon. Friend to expand the hospital building programme, and this is something which he can implement. While, however, it can also be the Minister's policy that all men should wish to be good, implementation here is for all men and not for him. While there are practical administrative aspects to many of the matters with which the reports deal, there are also many aspects in which individual opinion counts for most. For some of them, a clinical opinion may be dominant and, clearly, no Minister would wish to controvert the individual professional view. For others, the mechanical difficulties of an apparently simple operation may be immense.

Others, alas, the patients may not want. Some hospitals, for instance, have found that delaying the morning call was quite unacceptable to their patients. Even if a postponement is accepted, it may require difficult planning. Putting back the alarm clock will, for instance, put back pre-medication and pre-operative procedures. If the theatre is not to work into the night, operating may be curtailed. Putting back doctors' rounds or delaying X-ray or collection of pathology specimens may react on the out-patient programme later in the day. Alteration of meal times means fitting in with all the other work and rationing the catering operations. Local transport times may not fit when dealing with buses or ambulances. Indeed, hospitals have had a very hard time trying to implement revised daily programmes. But I have no doubt—and I am sure that the hon. Member, who knows a great deal about hospitals, will agree with me—of their will to try.

A conference organised by the Royal College of Nursing in 1962 on this topic and addressed by my right hon. Friend the Member for Wolverhampton, Southwest (Mr. Powell) was very well attended, and reports from my Department's officers show that the Report on the In-Patient's Day has had a widespread influence on thinking. Besides official issues, over 23,000 copies have been sold and for the most part they are circulating in hospitals.

We shall go on keeping in touch with developments and stimulating further thoughts about this. But there cannot be any question of measuring results statistically and, as the Report itself recognised, we should not look for precision and uniformity. What we look for is the will to change, the readiness to think about these things and to try to do something about them.

Noise, to which the hon. Member has referred, in an affront to the patient. A good deal can be done, incidentally, by patients as well as by staff to prevent it. As Dr. Cartwright's book points out, a lot of noise emanates from patients themselves. In part, the avoidance of noise lies in the will and in widely differing individual tolerances and tastes. In part, also, it is a matter of re-equipment as resources can be spared. A great deal has been done in individual hospital surveys to cope with their own problems, notably the radio nuisance, which we have all at some time or other encountered, or about which we have had complaints from constituents.

Noise consciousness has been stimulated by the admirable Fougasse cartoons commissioned by the King Edward Hospital Fund. In large part, the problem is one of design—internal finishing and protection from external noise. Our first thoughs about this have recently been sent to hospital boards, covering internal, external and equipment aspects.

I turn now to the question of visiting arrangements. Liberalisation—an odd word, but I think that it explains what we mean—of visiting arrangements has been a feature of almost all reports. Here again, as I think the hon. Gentleman recognised, there have been very considerable strides despite the practical difficulties of many hospitals and the conscientiously held views of some professional people that too great a change was asked for. In 1962, a hospital memorandum based on these Reports said very clearly: Visting should be regarded as an important contribution to the patient's recovery and never as a concession or as an unwelcome interference with hospital routine. It accepted that restrictions might be necessary in individual cases, to exclude visitors to colds, for instance, or to enable treatment or essential procedures to be carried out.

Since then hospitals and their staffs have done a great deal. In 1961, about 200 acute hospitals did not allow daily visiting. All but a handful of those have now introduced it, and we are still continuing to discuss with a number that have not, but in those cases there are special local reasons.

As to the visiting of children, the Platt Report on Welfare of Children in Hospital said: Unrestricted visiting, as we understand it, means that parents are allowed into the ward at any reasonable hour during the day. … The precise times at which visiting hours may begin and end must vary with local conditions. Unrestricted visiting does not mean that parents are in the ward all the time. It does mean that they can arrange their visits to fit in with other family commitments. Here again, great progress has been made. There cannot, of course, be rigid rules. There must certainly remain a discretion both for the consultant and the ward sister to restrict visiting to particular occasions, or in special cases. We have only recently written to hospitals asking them to abandon any remaining fixed hours of visiting, and to adopt and make clear their view that parents are welcome to visit their children at any time, subject to consultation with the doctor and ward sister in order to avoid particular occasions when it would be preferable not to visit.

The parallel recommendation that mothers should be allowed to come in with very young children is very much in the minds of those concerned with the management of hospitals, but it must await the opportunity of redevelopment of hospital premises.

The problem of "communications" remains. To the Minister the essential task—indeed, the only practicable course—is to see that the best advice is available to those who actually do the job and to encourage continual consideration of it and to stimulate further inquiry and research as opportunity occurs. I have no doubt that Dr. Cartwright's book will get the readership and close attention that it deserves up and down the country. The official publication on communications has already reached a wide audience. Apart from the large initial circulation to hospitals, over 30,000 copies have been sold by Her Majesty's Stationery Office. Certainly, most of those have gone to hospital staffs.

The nub of the matter is that clinical responsibility includes the problem of communication and that steps appropriate to the hospital should be adopted to straighten out lines of responsibility so that this is recognised—and not only in the teaching hospitals, as some seem to think, but in all hospitals. What precise arrangements are made is less important than the will to make them. The senior and more experienced people in hospitals know this. For them it is a question of considering whether the means which have already brought success are still right and will go on serving their turn. Perhaps, on reflection, they will not. The results will be of more value, perhaps, to the younger and to the less experienced on whom new responsibilities continually press and who must often see as their objective the immediate task of care and cure. Some say that all must depend on education, and it is true that formative influences and examples may have crucial effects. This is, however, too easy an answer. The problems confront us now, and they cannot be left to the next generation.

Dr. Cartwright's book deliberately restricted itself to the activities of doctors and nurses in the main, and it is of major interest to them. It has its point for other groups and it stresses the power of management to influence the atmosphere in which the professions work. I have no doubt that the general point is not lost in hospital circles. There will be many ways in which administrators can help materially and morally to make responsibilities clear and help the communicating process in treatment.

Mr. Marcus Lipton (Brixton)

At this point, will the hon. Gentleman accept a suggestion that all these brilliant publications to which he has referred have, in fact, reached only a limited section of the population and that we have to get at the patient and to get the patient to fit into the atmosphere which we wish to create? Why cannot we have in every ward of every hospital a hand book for patients setting out the distilled wisdom and recommendations of the Ministry of Health?

Mr. Braine

I should have thought that we should put first things first and that the whole burden of the argument of the hon. Gentleman the Member for Abertillery has been that those who run hospitals and serve in them, and are responsible for the care and treatment of patients, should first understand the importance of communications. I agree entirely about that.

I have, not unnaturally, been talking about the healing professions. They are responsible, however, for only half of the process. The patient is a necessary complement, I agree. He is endowed not only with rights, but with obligations. If he does not know or does not understand, he can ask and perhaps there is merit in what the hon. Gentleman is suggesting. Often the patient does not ask.

Mr. Lipton

That is the point.

Mr. Braine

Every hospital has some arrangement to hear any complaints which the patient wishes to make. But these arrangements are useless if the complaints are made after the event, after the patient has left hospital. Every patient must realise that this is part of the educating process but that insistent or excessive demands merely add to the difficulties which already may be very great. Then again the wider opportunities given for visiting throw new responsibilities on the visitor. Visitors should come prepared to make a worthwhile contribution to the patient's morale. Particularly, they should be considerate in not making unreasonable demands to visit and in not staying for excessively long spells which may tax a patient or hinder nursing care.

The hon. Gentleman has raised a most important topic and the House will be grateful to him. I am particularly grateful for the way in which he raised it. Undoubtedly, there is much to be done for the welfare of the patient. There is also a great deal to be thought about and, if I may say so, a great deal for which to be grateful. Let us add to our exhortations, therefore, our gratitude to all who serve in the hospitals.