NATIONAL HEALTH SERVICE.

HL Deb 21 March 1914 vol 131 cc118-66

Debate resumed (according to Order) on the Motion of Lord Woolton (made on Thursday last), to resolve, That this House welcomes the intention of His Majesty's Government, declared in the White Paper presented to Parliament, to establish a comprehensive National Health Service, and on the Amendment moved by Lord Moran to insert at the end of the Motion the words, "but regrets the absence of sufficient detail on many important matters, in particular on the consultant service, to enable the House to give a considered judgment."

LORD HORDER

My Lords, in moving that this House welcomes the intention of His Majesty's Government to establish a comprehensive National Health Service my noble friend Lord Woolton said that the subject of the nation's health was one which for a long time had been very near to his heart. I hope that the noble Lord, on looking back over the last five years, takes comfort from the thought that he has made a very special contribution to the health of this country, and in that way has fulfilled much of the task which he set himself years ago. For surely no greater contribution could be made to preventive medicine than to make good food available to the public at a price which they could afford to pay, and to provide school meals for our growing children. I should be the last to decry the value of good doctoring, but I feel sure that the noble Lord will riot think me impertinent if I express the hope that in his task as Minister of Reconstruction he will not only see that his own contribution to preventive medicine continues after the war, but will stimulate his colleagues to get busy with other large basic factors making for health—homes that encourage family life, security from unemployment, and the servicing of the workers in industry.

It is generally recognized that British health services, looked at singly, are the best in the world; but that they lack co-ordination and availability is equally notorious. Most of them have grown up in typical British fashion, often voluntary efforts, and to-day they badly need integration. We have not in this country suffered bloody revolution, thank God, and so we have had no chance of starting our health services from scratch. On the need for action in regard to availability— and I want to stress this word because I believe it to be the essence of our problem—there can be no difference of opinion. If availability is what the Government really mean by comprehensiveness, then I support the Government's intentions heartily, as I believe all my colleagues do. It is when we come to consider ways and means of achieving this desideratum that the matter becomes difficult and at times contentious. I have heard the White Paper now before us called a "sinister" document. Those who have used this word really mean "specious" or "disingenuous." It has not escaped the notice of the sceptics that both the Minister Without Portfolio and the Minister of Health are eminent lawyers. I must myself believe that the Government's intentions are honourable. My personal relations with both these Ministers and with the Minister of Reconstruction are such as to leave no doubt in my mind on this point. But good intentions are not enough when the question at issue is such an expert one as that of not only maintaining but increasing the national health services. What matters then is not the good faith of those who draft the scheme, but rather the degree of their knowledge and experience of these services as they now stand and the vision which they show in regard to the future.

Careful analysis of the White Paper does not convince me that the knowledge and experience that we actually possess in these matters have been fully utilized in framing the Government's scheme. I therefore share the misgivings already expressed by my noble friend Lord Dawson of Penn and join in several of the criticisms of my noble friend Lord Moran. If the White Paper is only a tentative expression of the Government's ideas as to how a national health service might be run, and if it is open to modification after further discussion with those who actually run these health services to-day, my own fears are to a large extent allayed; but if the White Paper as it stands is to be made the basis of an Act of Parliament, discussion being subsequent and not prior to the drafting, then I believe that certain principles and institutions which I must regard as of paramount importance to the efficiency of our health services are likely to be lost to us. I want to emphasize this because we are told that Parliament is being asked to endorse the principles of the White Paper when it is by no means clear what these principles are. I agree again with my noble friend Lord Dawson of Penn when he said last week that there is a clear divergency between the general statements made in the introductory and in the concluding paragraphs of the White Paper—statements which are quite acceptable—and the paragraphs which carry these general statements into a line of action. We are told in that introduction that methods of organizing the new service must be closely related to history and to past and present experience. This conforms to a principle laid down by the Prime Minister in his recent talk to a group of doctors. "The longer you can look back," said Mr. Churchill, "the further you can look forward."

In these general statements freedom is the dominant note which is struck and it is repeated in the paragraph headed "General principles to be observed." And yet the main trend of the White Paper does seem to me to go off at a tangent from the evolution of our health service in actual practice, and it poses an administrative structure which in my judgment threatens the very existence of two of the institutions in British medicine which both past and present experience show to be vital. These two institutions are the private practitioner and the voluntary hospitals. To quote the Prime Minister again, "Any health service must rest on two arches, the first the general practitioner, the rank and file of the profession; the second the hospital service dependent upon the staffs of the hospitals sustained and guided by the consultants." Now it is true that the White Paper tells us that both of these institutions are to be allowed to remain but their continued recognition is not definitely encouraged. It is permissive and they must fight for their survival. The private practitioner is spoken of in the White Paper as a man carrying on a "separate" practice and the word "separate" is put into inverted commas as though this means that his function will in future be a somewhat unusual one, a deviation from the normal, if not slightly irregular. He is to be penalized by not being allowed to use the equipment of the health centre for his private patients and in this his patient will be penalized also.

On qualification the White Paper says he may not be free to engage in private practice at all for a few years, nor to work where he likes; but he must take direction from the Central Medical Board. It is true that in the course of his speech last Thursday in another place the Minister of Health modified this power of central direction so as to make it refer only to those doctors who undertake to engage only in public practice or in both public and private practice; and in the course of a speech on the day following the Minister's Parliamentary Secretary said "I wish to say, quite categorically, that no doctor is going to be directed." It is clear that this matter needs some clarification. Can Dr. Smith, for example, just qualified, go and help his overworked father in a busy practice if engaged in public work, or if he takes up a certain amount of public practice, as he is invited to do, will this place him under the direction of the central authority? Frankly, I think the attitude of the White Paper towards the man who wants to continue private practice and yet to avail himself also of the manifest advantages to his patient that this new scheme offers, is too colourless, if not actually negative. Almost it reads as though some patients prefer to be doctored privately and so, as this is still a free country, their whim is to be indulged, for a while anyway.

It is very much the same in regard to the voluntary hospitals. It is as though the authors of the White Paper said: "Well, they have certainly made good and here again the public has a fancy for them, so, provided they can find enough benefactors to keep them alive, then they, too, may remain." It is admitted that the co-operation of the voluntary hospitals is a necessity in the building up of this new health service. It is certainly not the wish of the Government, says the White Paper, to destroy or diminish a system which is so well rooted in the good will of its supporters. But this expression of a mere desire for co-operation, this permission to continue to exist, seems to me demonstrate a great lack of appreciation of the intrinsic value for the nation of an institution in which there has resided for hundreds of years, and still resides, the best that British medicine holds both in respect of its science and its art. Shall we not come to earth and be realists in this matter? The voluntary hospital attracts the most gifted and promising men and women who join our profession. It is the voluntary hospital that attracts them. The voluntary hospital gave us Harvey, and Hunter, and Bright, and Paget and Lister. It constitutes the vanguard of medical progress and it is the centre from which radiates both the best trained personnel in medicine and a constant stream of new knowledge and the best methods of applying it. The White Paper dismisses medical research in a few lines. It says that it has been the policy of the Medical Research Council to encourage research work in the hospitals and to assist it financially. I agree that that is a good policy as against the alternative policy of setting up super-State institutions for this purpose, over and above the already established Central Medical Research Council. May we hope that this Medical Research Council will still attract men of the calibre of the present secretary and of his predecessor?

But what are these hospitals by which our medical research in this country is undertaken? In the years 1938 and 1939 out of fifty-eight pieces of research work which were farmed out in this way by the Medical Research Council, fifty-one were distributed amongst workers in the voluntary hospitals. Since its inception in 1923 the British Empire Cancer Campaign, the great clearing house in this country for cancer research, has spent £450,000 in subsidizing research into the problem of cancer. Every penny of this has been spent in grants to voluntary hospitals, either as block grants to the cancer departments of the voluntary hospitals or as individual grants to research workers attached to these hospitals. In view of all this, in view of the full stature to which the voluntary hospitals have arrived, and in view of their maturity, it does seem odd that the Minister of Health should say "We wish to take the voluntary hospitals by the hand." Noble Lords have referred to the popularity of these institutions and to the enthusiasm and affection with which they are universally regarded by the people of this country. These sentiments are not illusory. They are the practical measure of the use which these institutions are to the community.

It is on this account that we ask on their behalf not only for permission to exist but for positive encouragement and a guarantee of financial security. On this point I must confess I share the anxiety of those who, whilst recognizing that the Government scheme does not kill the voluntary hospitals, fear that it may quickly starve them into inanition. They fear, in short, that it will be a case of Thou shalt not kill, but needs't not strive Officiously to keep alive. The Minister of Health says he cannot believe that the anxiety which has been shown is really justified. If so, then may I suggest it is a duty laid upon the Minister to allay this anxiety, because the expression of it has been very real and very general throughout the country. As to what form the financial security should take I cannot offer a suggestion. I am not a financial expert. It should not be beyond the wit of the Minister, however, with his financial experts, in consultation with those equally expert finance members of the great bodies that watch these matters on behalf of the voluntary hospitals—and there are fortunately many such experts—by getting together to devise a scheme which should be satisfactory.

The noble Lord, Lord Nathan, spoke of this proposed scheme as a compromise. He did not say a compromise between what and what, but perhaps the noble Lord's ready acceptance of what he termed "this excellent White Paper" on behalf of his Party in your Lordships' House, makes the position clearer. If it does not, it is certainly made clear by the speech of that eloquent champion of the noble Lord's Party in another place, because Mr. Greenwood, who also used the word "compromise," welcomed the White Paper as a great contribution towards the kind of plan which, in the fullness of time, his Party would like to see established. We know what that plan is, for the Labour Party at least knows what it wants. It wants a full-time salaried medical service for all doctors and State control over all hospitals. I do not think this scheme by the Government need be regarded as a compromise. I think that with certain modifications—granted, important modifications—the scheme may mark a great advance in our National Health Service and will be of permanent value.

I cannot say, and I do not think that any one can say, what may be the ultimate type of hospital service in this country, how controlled, how administered, how financed. But most of us doctors believe it is essential to maintain the voluntary hospitals pending the proposed development in our hospital service, and most of us believe that, whether the view be short or long. Most of us believe that it is not in the best interests of the health of the nation that the medical profession should be a branch of the Civil Service. But what the public believes is more important than what we believe. As to this, I must ask that the Government should take some steps to enlighten the public as to the real implications of the White Paper before an Act of Parliament is framed in relation to it. If this be done I venture to think public opinion will take much the same view as we take on these two points.

Since this debate opened I have read the speech which the Minister of Health made in another place, hoping that my own anxieties would be relieved. They have not been relieved. The Minister stated clearly four principles which he hoped the House would accept. The first referred to the comprehensiveness or availability of the whole range of health care for every person. The second dealt with the freedom of the individual. The Minister said: On the whole professional people know their own professional job best, and should be left as free as possible to practise it in their own way. The third principle dealt with democratic responsibility. The fourth was the principle of professional and vocational Guidance. On that the Minister said: The whole service must benefit throughout from the very best professional and expert advice and guidance. As thus stated I take it that there is none of us who does not accept these principles. The trouble is that these principles, with one exception, do not seem to have influenced the authors of the White Paper in formulating their scheme. The exception is the principle of democratic responsibility. In so far as this is covered by the Minister at the centre and the county and county borough councils locally, this principle does, as the Minister says, run through the whole of the White Paper; but what some of us feel is not that there is too much of the spirit of democracy in the White Paper but not enough democracy in it. The White Paper smells too much of bureaucracy. In regard to the first and second of the Minister's principles, if the positions of the private practitioner and of the voluntary hospitals are jeopardized, well then the comprehensiveness and availability of the whole range of health, care and the freedom of the patient and of the doctor are not achieved.

As for the fourth principle, that of professional and vocational guidance, this appears to be traversed more than any of the others in the suggested administrative machinery. The principle is traversed at the centre, and it is traversed at the periphery. The Central Council is not appointed by the profession nor by professional organizations. It has no executive power, and, presumably, it may not publish its reports. I, like my noble friend Lord Moran, have had great experience of advisory committees, and I share my noble friend's distrust of any real service that can be rendered to the community by an advisory body so "cabined, cribbed, confined" as is the proposed Central Health Services Council. There are only two ways in which an individual, or a group, can accomplish anything in the national interest—through either the possession of executive power or the ability to appeal to the public. The noble Lard, the Minister of Reconstruction, finds himself to-day shorn of executive power, but he retains the right of public appeal, and surely he will be sympathetic in this matter and use his, influence with the Minister of Health to enable the Central Council to publish reports of its work. The Central Medical Board has executive power, but here, again, nomination is by the Minister and not by professional organizations. In the case of hospitals the anomaly calls for special consideration. I am, myself, very doubtful if in this case anything short of an ad hoc Hospitals Board will resolve the conflict that will undoubtedly face the Minister. Such a board should certainly be set up, and an analogous type of administrative structure should be adopted locally.

I have dealt—not, I hope, to the point of wearying your Lordships—with the positions, of the private practitioner and the voluntary hospitals, because it is quite clear that these are the two matters concerning which most doubt exists, so far, in the country, as to the effect of the White Paper scheme upon our health services. If it be advanced that what I have said is not constructive criticism but destructive criticism, I would suggest that it is surely constructive to avoid destruction, by which I mean the destruction of existing health services which have proved useful, and to show how these may be saved. In many other respects than in its attitude to these two health services, the Government's scheme shows courage and foresight, and deserves all the active support that we can give it.

When I spoke in your Lordships' House recently on this subject I advocated three ways in which the machinery of our health services could be improved. These were by the inclusion of the dependants of the workers in the national health insurance scheme, by the regionalization of our hospitals, and by the setting up of health centres. If I had added a fourth it would have been the provision of a full consultative service for all persons. The Government's present scheme takes all four of these into its ambit. In regard to the last-mentioned service, the consultative services, I would not, myself, have considered this fraught with much difficulty, always provided that the hospitals continued to furnish the medium as they do at present, through which a consultative service can be planned and provided. The dependants of the workers are in the scheme, and the outlook for them seems to me to be more rosy than in the present panel system, at whose obsequies I do not imagine there will be many mourners. Let us hope that the days when overworked doctors struggle with long queues of people with cut fingers and other trivial complaints, on a capitation basis, are numbered.

In the matter of regionalizing or rationalizing the hospitals, I agree with my noble friend Lord Dawson of Penn that care should be taken to see that the areas chosen for the hospitals and allied services shall be large enough to embrace all types of hospital and clinic in close liaison, and working always upwards to a key hospital which should be, whenever possible, a teaching hospital of university status. It is in the sanctions for and the encouragement of and support of health centres that the new scheme will probably achieve its greatest success, and even go far to justify the Minister of Health's belief that this scheme, if it comes to fruition, will be long remembered for good in the history of the British people.

Complaints have been made that the White Paper does not specify with sufficient exactness the type and size of health centres proposed. I am glad that it does not. I visualize a number of different types of health centres ranging from the centre that is designed—why not?—primarily to make group practice more efficient, through more ambitious centres where are available for patients and their doctors—whether doing public work or private work—laboratories for clinical pathology, X-ray diagnostic installations, and rooms equipped for consultative purposes, up to the Peckham type of centre, where the family is the unit of investigation and of help and where field work in what in these days is called social medicine can be undertaken. The credit of the Peckham full-scale experiment belongs to my colleagues Dr. Scott Williamson and Dr. Innes Pearce, and as President of the Pioneer Health Centre I take this public opportunity of paying them the tribute they deserve. They have not only mixed social medicine with scientific research, but they have met with enthusiastic support from the people with whom they did this fine piece of work. I would like to express the hope that the Government's scheme envisages both moral and financial support for clinics of this kind.

My noble friend Lord Dawson of Penn referred to health centres with beds for the use of general practitioners. I have always advocated the provision of beds where the general practitioners could keep contact with their patients when these pass from domiciliary to institutional care. But I have seen such a great advance in the facilities afforded to the general practitioner by our splendid cottage hospitals during the past few years that my concern is not so much the provision of beds in health centres as it is once more to maintain and increase the beds for this purpose in cottage hospitals. I must confess to some surprise when I read the Minister of Health's comment on these institutions—namely, that the old conception of the local hospital is outworn. I await with interest the comments of the admirable boards who run these splendid institutions. I am convinced that, given proper vocational representation on the controlling and administrative bodies, both central and local, the development of health centres will, as I infer that the Government themselves think, actually bring about that availability of our health services which I called just now the essence of the problem. In these health centres the Government can nourish that spirit of adventure and enterprise which lies at the heart of British medicine, and which the shadow of some parts of the White Paper threatens to obscure.

I believe that the Ministers and the accredited representatives of medicine, by coming together, can make satisfactory adjustments in this suggested scheme. I wish that medicine could offer the Government what I and some of my friends dream of but have not so far realized—an Academy of Medicine in this country for these deliberations, a body which would be authoritative, representative and judicial. But, failing that, there are bodies with which the Government have already made contact, bodies animated by good will and by a desire to do the best in this matter for the people of this country. If discussions with these bodies fail—which God forbid!—I am reminded finally of a promise made by the Prime Minister last year. "There is no question," said Mr. Churchill, "of far-reaching changes of a controversial character being made by the present Government, unless they are proved indispensable to the war." The Prime Minister continued: "I could not take the responsibility … without a Parliament refreshed by contact with the electorate."

LORD GEDDES

My Lords, I am sure that your Lordships, after the speeches of the great leaders of the medical profession in this House—referring to them in the order in which they spoke, Lord Moran, Lord Dawson of Penn and Lord Horder—must feel that there is a deep questioning in the hearts of the medical profession of this scheme which is now being considered. We have had three most able and most interesting speeches from these great physicians. It is true that I have a medical degree, but I am speaking to you to-day not as one with any association with medicine but as one concerned, and very deeply concerned, for the health of the people of this country.

When I first read this White Paper, I thought that it was the most brilliant White Paper that it had ever been by lot to read. It is brilliant, but what does it mean? It is the merest skeleton so far as anything with regard to health is concerned. It is called "A National Health Service," but what is outlined in it is something of a medical service, which is not quite the same thing. After I had read it once, I read it a second and then a third and a fourth time, and I came to the conclusion that there was some hidden meaning in it. I therefore said to one of those who, according to himself, had been doing a great deal of work in connexion with the formulation of the plan, "What are you getting at in this White Paper?" He replied: "Don't be silly; we have to make Beveridge security safe for the Treasury." Then I began to see something in the Paper which I had missed before.

It is, of course, quite true that social security does make being ill a gainful occupation—that is rather an understatement—and therefore it is probable that a certain number of the baser sort may like to continue in that easy occupation of making an income on the flat of their backs in bed; and therefore there has to be certification by medical people. I had a good look through the White Paper to see exactly where all this came in, and I find that one humble little condition labelled (d) covers the point. It is on page 36 of the White Paper, under the heading "Creation of a Central Medical Board." After saying that it is not for the Paper to suggest the details of the doctor's contract at the present stage, it sets out in (a), (b), (c) and (d) what the provisions should be, and there it is stated that it will be necessary to provide— (d) for the observance of reasonable conditions, centrally determined with the profession, respecting certification and other matters which must arise in any publicly organized service. That is what a great part of this scheme deals with. It provides that there shall be available—the availablity is made clear and distinct here—throughout the country people who can issue certificates. Do not let me misrepresent what these certificates are to be. They are certificates written in connexion with reasonable conditions. That explains, it seems to me, the extraordinary dichotomy that there is in this Paper. There is at the beginning of it a series of the most admirable principles with regard to a national medical service, and then the whole thing peters out to a tail at the end.

The noble Lord, Lord Moran, in his Amendment draws attention to one of the important things which is missing in this Paper, and refers to others. There is no elaboration at all of how the consultant service is to be trained and how it is to be developed, and indeed not very much about how it is to be administered; but one thing is clear, and that is that it is to be administered by, and under the control of, the hospitals and the local authorities concerned. This is an extraordinary position. You have the general practitioners under the control of the Central Medical Board, and the Central Medical Board is, as I read it, a mainly bureaucratic body, controlled by the civil servants of the Ministry of Health acting in the name of the Minister. That is what is set out in this Paper, and it is what will happen. It is what the noble Viscount, Lord Dawson of Penn, reminded your Lordships would be likely to happen. And that is a bureaucratic body sitting beside the bureaucrats of the Ministry of Health, who are a very able lot of men. They are to lay down the conditions of certification as to whether those who think themselves sick are to be allowed to continue in the gainful occupation of being sick. And that is the principal part of a great many of the things that are worked out in detail in this White Paper. The general practitioners are under a bureaucratic body. They will have a contract in which are stated the conditions on which they are to certify. That is stated in the White Paper. Until that was pointed out to me it was a point upon which I was being silly, and when it was pointed out to me I ceased being silly, and I saw what would happen.

There must be certification for any Beveridge security plan, and let us make it quite clear to everybody in the country that there has to be a medical inspectorate if there is a Beveridge security plan. It is an essential part of it; and if that does not degenerate before very long into something not very dissimilar from a Medical Gestapo I do not know the way the Civil Service of this country works. What would happen is that you would have this continual supervision of every person who, on medical grounds, is a beneficiary under this plan. I do not think there is any way of escaping that. If you are going to have a security plan, with medical benefit on a great scale, there must be certification. If it is to be safe there must be some way for the wage earners who are caught by the certification to get to independent medical opinion.

And therefore I am profoundly disquieted by the suggestion in this White Paper that everybody is to be insured. The British Medical Association, if I am correctly informed, decided, in its preliminary study of the matter, that it would be possible to work a great insurance scheme if about 90 per cent. of the people were insured, and 10 per cent., in the upper income limit, were not insured. In the sacred name of equality many of the noble Lords who sit on the Opposition Benches apparently think that everybody ought to be insured. I think it is a profound mistake if they are, because for a short time there would then be no doctors who were not under the control of the Central Medical Board, whose future and whose promotion were not determined by it. So in the interests of us all I believe that there should be an uninsured class of people in the country—obviously in the upper income limit—and they would, of course, pay for the real health service, not this health service through taxes and rates. If they were not insured they would be adequate to maintain a strong body of independent leaders of the medical profession, to whom appeal could be made from decisions of the doctors controlled by the Central Medical Board. That there should be such an independent group of doctors is, to me, of the greatest possible importance.

I suggest to the Government, if I may, that they should look at that point again, because, remember, this document is based upon the idea of treatment of ill health. It must necessarily increase the vested interest in ill health, because it is raising the amount of money spent on dealing with ill health. It is increasing the number of people concerned with ill health. Now what we want to get is a tremendous drive for real positive health, about which I have spoken to your Lordships before. We want to see housing right, we want to see recreation facilities right, we want to be certain that water supplies are right, we want to be certain beyond a peradventure that food supplies are right, we want the women of the country taught to cook and to use food properly, and we want to see the houses much cleaner than they are. Those are the things which are going really to make for health, and we are going to take here £150,000,000 a year to deal with ill health. When? Not immediately. All we are going to provide immediately, if we follow out this White Paper, as I understand it, is a real certification service at an early date. We are not going to have for years to come a consultant service adequate to the hopes of the authors of this White Paper, as the noble Lord, Lord Moran, has so clearly pointed out; we are not going to have a general practioner service for years to come adequate to the hopes of the authors of this White Paper.

Turn to page 37 of the White Paper and take that paragraph headed "The need for a new attitude in patient and doctor," and you will see what is the real view of the people who are behind this document, who are really working for improved health services—namely, that there has to be a new view in medical education, that people have to be trained anew. And that is quite true. I do not know whether the noble Lord who brought this matter before your Lordships has been following the question of medical education at all, but if, in advance of the Report of the Goodenough Committee, he wants to see the opinion of the faculty of medicine of the University of Edinburgh, a body entitled to express opinions on this subject of medical education if any such body is, he will find it set out in the University of Edinburgh Journal, autumn number, 1943, and he will see what that faculty regards as the weaknesses inherent in much of the medical education of to-day. It is not their view alone, but it happens to be expressed by them in that Journal in a way that is extremely readable and extremely simple. For anybody not concerned in medical education it is the best short account I know, and that is why I refer to it.

Under this White Paper what is going to happen to medical education? What is going to be the governing principle of the great teaching hospitals? Where are they going to come in? Remember that medicine is a continually growing science and art, changing year by year tinder the influence of the great teaching hospitals. Medicine must grow, must live, must change, and although an enormous quantity of the finest medical research stands to the credit of this country, Canada is treading close on cur heels with a far smaller body of medical expert opinion to draw on, and the United States—just think of the work coming out there, and before the war of the work that was coming out of other countries. We must do our best to keep in the van of medical knowledge, medical research, and medical teaching. That means that the great teaching hospitals which will be, which must be, in any complete scheme of hospital organization the key hospitals of great regions, must be governed by bodies of men who understand fully what medical research, medical science, and medical teaching mean. Let your research stop, let your teaching down, and before you know where you are the whole medical profession will be degraded by the lack of that stimulus of new knowledge which keeps its leaders on their toes, which keeps them steadily adding to human welfare by the work which they do.

I have kept your Lordships rather long, but I do want to urge you to remember this. We cannot trifle with health. We must not make the mistake of allowing our health services to be disorganized in the sacred name of any theory. They are living things that have to evolve. You cannot tear them from their living stems and think they can go on unimpaired. Evolution of these existing provisions is what is required, and through evolution of them we can go forward. But the one thing I would wish to impress on your Lordships to-day is that this is not a health service, it is a medical service, a clinical service if you like, a service for the treatment of disease and injury. That is what this is. The word "health" really belongs to something much greater. It belongs to what the noble Lord himself has been one of the great apostles of in these years of war, and that is the whole position and condition of the people, their education, their training, and everything else. Let us make it plain to the Government that although we are prepared to support them, because we ought to support them in so far as the Motion is concerned, in their desire to establish a health service, we do not accept this as anything more than a small instalment on the side, perhaps on the less important side in the long run.

There is one word more before I sit down. No two medical men really think exactly alike. Sometimes bodies of them think more or less alike, and you get such a great division in the profession as homœopathy and allopathy. I do not know how you are going to maintain freedom, real freedom, without something in the nature of victimization if you are going to have a sort of central administration such as you have here without a section of the population being outside insurance so that they may support what may be called the fancy sides of medicine, or the cranks, or anything else you like; but remember that in medicine the heterodox of to-day is the orthodox of to-morrow only too frequently. So I say to your Lordships that this Paper as it stands shows how the Beveridge security sickness is going to be dealt with by certification, and it holds out a lot of promises with regard to what the Government hopes it will be able to achieve at the cost of £150,000,000 a year in the course of the next ten, fifteen, or even twenty years—because it will be twenty years before students who have not yet started are really fully able to deal with all the problems set out for them in this White Paper. I am sure that all your Lordships wish the Government to go forward with their plans, but I would say to them, "Pay attention to the voices of the great physicians who have spoken in this House."

THE EARL OF HUNTINGDON

My Lords, I wonder if the average man or woman realizes what a dramatic moment this is; that in the middle of this terrible war in which the forces of aggression and tyranny have thrown a shadow over all the world, we are proposing to take a great step forward, one of the most significant steps forward we have ever taken as a nation, along the road of progress, civilization and hope. Because that is what we shall be doing, if we accept the proposals the Government have put forward in the White Paper. These proposals offer to every citizen in this country access to the best skill, equipment, and medical knowledge which we possess. No longer will a man, however poor, not get medical attention because the hospital is full up or too far away or because his practitioner has not the time to deal with him. From now on, if these proposals are accepted, each single man, woman, and child will get, as soon as the plan is brought into being, the full advantage of any medical equipment, technique, or knowledge that we possess. In other words, they will be given a passport to health in so far as medical knowledge and equipment can give it to them. You may think I have been talking on a rather broad basis, but I urge that we should really free our minds from detailed controversy and examine the basic fact behind this White Paper.

The basic fact, as I see it, is this, that the Government have decided that the medical services of this country belong to, and must be used for, the whole community, and not either solely or in part to enhance the prestige of or provide a livelihood for the medical profession. This is a magnificent proposal, and we must allow no vested interest, no selfish reluctance, to stand in the way of this great conception. For this reason, although I agree with my noble friend Lord Nathan that it is a compromise plan, for it is not all that we on these Benches would like to see, yet I do welcome it as a great step towards what one would like to see as a comprehensive national medical service for this country. The backbone of the plan is obviously the division of the country into areas, distributing all our equipment, hospitals, specialists and knowledge into the different parts of the country where they can be best used. Even more important is the scheme for allowing and forming groups of general practitioners to work together in the health centres.

I would suggest that the criterion for success of this plan of the Government will ultimately lie in the speed with which they can establish these health centres. There is no practical difficulty in setting them up. After the war there must be a vast quantity of Forces' medical equipment which can be used; and there must also be many buildings now in use for military or civil defence purposes which could be turned into health centres, until more suitable accommodation can be found. I think the idea that it must be twenty years before any result can be seen is a very pessimistic one. If the will is there I think we can speed on this plan. The only limitation that I can see is the time it takes to train new medical students to take part in the plan. The more speedily you can get them trained the more fully you can work this new scheme.

I should now like for a moment to consider the position of the general practitioner. Medicine in our days has become so complicated, so vast, so dependent on elaborate technical apparatus, that the average practitioner has little chance of ever possessing the fell apparatus necessary, or the time required to keep in touch with the latest developments of knowledge, to give all that medicine can give to his patient. Now, as we all know, too well, he is overworked and very often in financial difficulties, short of time, short of money and subject to the temptation to give most of his time to his wealthier paying patients. Furthermore, he is on call at all hours, has few holidays and almost no chance of promoting preventive medicine. Let us consider what is now proposed. The Government suggest that the general practitioners should work together in teams in health centres, and here, I am afraid, I must disagree with the noble Viscount, Lord Dawson, in his conception of what these health centres should be. In saying this, I do not wish in any way to derogate from the very able report made by the committee of which he was Chairman, but surely we do want to get away from the small cottage hospital, which is so often terribly inefficient and uneconomical to work, and to concentrate much more on the large hospitals specializing in certain types of treatment. You might, for instance, have a fracture hospital, or a hospital devoted to brain surgery, and so on. That is much more the idea of the future than distributing little cottage hospitals based on a major hospital.

We see from the Government's proposals that these health centres in good modern buildings should have consulting-rooms, laboratories, waiting rooms, offices for a secretarial staff, and theatres for minor surgery. In other words, they are to relieve the general practitioner of all the overhead and unnecessary worry and expenses which each individual doctor now has to bear. Not only that, but doctors will have the great advantage, in a health centre of that kind, of having far better equipment available than any individual local practitioner could purchase for himself. Again, there would be the added advantage that the doctor would be able to discuss with other practitioners difficult cases, and perhaps have lectures from visiting specialists. Thus he would get a great stimulus to his own ideas from outside contacts. Another point, perhaps one of the chief points, is the fact that the general practitioner could really concentrate on preventive medicine. If now, he were to start a series of lectures I am afraid that he would be accused of advertising and told he must not proceed, whereas a team of doctors in a health centre would be able to plan a campaign for educating their patients and the public—which is very necessary. There, I think, you coin to one of the great and important steps, initiating preventive medicine.

The chief criticism is based mainly on two grounds. One is the objection to a salaried medical service; that the doctors may well object to working for a salary. The doctors who have sunk large sums of money in practices see that this new service may absolutely knock the bottom out of the value of their practices. They would be more than human if they did not resent the prospect of this vast national service taking away the practical value of their practices. But I think this could be completely got over by a generous system of compensation and superannuation, and I hope the Government will not in any way be mean or niggardly in their compensation to doctors who have lost, or may lose, through this new plan. To impute to a doctor that he will not give of his best unless he is scrambling and competing for paying patients is obviously such a libel on the profession that I am sure no one would consider it seriously.

But I would like to emphasize that finance is the key to the success of this scheme and for that reason I must disagree with the noble Lord, Lord Geddes, when he says that only a percentage of the population should insure. I think the basis of the scheme must be that everybody ensures. There is, however, no reason why a percentage of the population—say 10 or 20 per cent.—should not still go to private doctors while at the same time automatically contributing to the nation-wide scheme. If you want to attract the best brains into the service it is desirable that you should give doctors worth-while salaries to work for. In any case, the salaried service should not be an objection because this is entirely optional in the White Paper. The doctor can either practise in the new health centre or he can continue in private practice, or, I understand, he can do partly one and partly the other. There is a danger in that that the public patient may be sacrificed to the private one, but that again I think can be got over if the salaries are on a generous scale; and if the doctor is not threatened by financial disabilities he will, I am convinced, be more interested in promoting the general health than he will be in curing individual private paying patients. In other words he will give his best to both. In any case I think this service of general practitioners in health centres will certainly be welcomed by all the young doctors now in the Forces who have not been able to buy practices. They will be only too glad of this chance of security and to be able to work in this concrete scheme for a national health service.

The second objection—and this I must confess is much more important—is the genuine fear by the medical profession that they will be interfered with by ignorant laymen or will be obstructed by bureaucracy. Their fear should be considered and met. I should imagine it could be largely met in the present structure of the White Paper if more influence and prestige were given to the Central Health Council and the local health councils. Already a great step has been taken to help them, in that they can offer advice on anything they wish, and not only about what they have been asked. I hope that some way may be found of ensuring the prestige of these bodies and of making them a powerful influence, because then I think this fear might be eliminated. It is the duty of all of us in the post-war reconstruction period to fight that very great menace of bureaucracy which it is feared may creep in, although I see no reason why it should creep especially into this particular service. When we hear these pessimistic forecasts I think we should bear in mind the pessimism of the older members of the medical profession when the national health insurance scheme was first introduced. If you turn up the files of the British Medical Journal and the Lancet of that time, you will find the Bill described in doctors' letters as "the death blow to every man in practice." It was to bring "inevitable and absolute ruin to a great number, probably the majority, of general practitioners throughout the country." We read that "if the panel comes into existence no prudent parent will educate his son for the medical profession, and no man of decent breeding will dream of entering it." Yet, as we have seen, the general practitioner has, by now, survived more than thirty years of panel practice; prudent parents continue to educate their sons for the profession, and men of decent breeding in it are not the exception but the general rule.

Certainly no one can deny the urgent need for co-operation between our medical services. We have, at the moment, an infinite variety of services all working independently of each other, some doing very fine work and some doing hardly any work at all. It is for that reason that I earnestly hope that the great voluntary hospitals, which have done such magnificent work in the past, will rally round and support this scheme, and that they will realize the logic and necessity of combining in this National Health Service. They are, one must confess, in a dilemma. If they should be entirely financed by the Government they would obviously have to accept entire Government control; if they should choose to remain outside the scheme they would incur the odium of having sabotaged this great plan for giving medical treatment to the whole of the population; and, as the national hospitals grew and became more effective, they would inevitably lose their private subscriptions and finally have to give up altogether. But in this scheme they can co-operate in building this new service and as long as they can find people who believe in them—and I am sure that will be for a long time—they can continue being autonomous and continue as independent bodies. We could not find a better compromise. We must plan nationally. We must employ all the means we possess in the best possible way if we are to succeed in doing away with the pitifully long waiting lists of patients for whom there is no room in the voluntary hospitals, and if we are to make the service available to all.

I should like to support the emphasis of the noble Lord, Lord Nathan, on the need for recruitment. If we are going to have a comprehensive service we must have a great access of new doctors, new nurses and new personnel. I hope that the ban against women medical students will be completely lifted. I think it is the case that out of twelve big medical schools in London only three receive women students. There is enormous prejudice against them. That is a dreadful anachronism and we must get rid of it. Means must be found also to allow of a greater number of medical students. Recently, for twenty vacancies in a large medical school, there were 400 applicants. We must alter that. I hope also that the Government will consider the question of improving conditions for nurses who have always been looked upon as a kind of devotional order giving hard service for extremely small remuneration. Means must also be found, I suggest, to enable talented children of poor parents to obtain medical education. Although there are scholarships, it is so difficult for a boy or girl without financial backing to get a medical education that we may say it is almost impossible. That means a great waste of talent and brains in the country.

I apologize to your Lordships for having kept you so long, but I should like to make one more point which is perhaps the most important of all. This scheme opens up tremendous possibilities of research. These health centres all over the country will make it possible, for the first time, to collect statistics which we have never been able to collect before. We shall be able to plan, finance and combine medical research on a national scale which will herald the dawn of a new day. I hope that the Government will stand firm and resist any opposition to this scheme, whether it takes the form of whittling down the scheme until it becomes ineffectual, or whether the time-honoured technique is followed, of delay followed by delay. I hope we shall be bold and resolute in supporting the Government scheme and rejecting the Amendment.

LORD TEVIOT

My Lords, I am very grateful to my noble friend Lord Moran for moving his Amendment, because it enables me to bring before your Lordships a subject which has been only lightly touched upon so far and will make my remarks somewhat more relevant than they might have been without his Amend- ment. Coming into a debate at this stage one naturally finds that one or two points have been touched upon which one hoped would not be mentioned until one spoke. The first thing I want to say is that the White Paper says little or nothing about the question of research, which, to my mind, is of the greatest importance. When we are going to embark on a great campaign of securing positive health, and putting aside the continual pressure of finding how to cure disease, I am disturbed to find that research has not been more fully dealt with in the White Paper. The reference to health centres rather leads one to suppose that they will be hospitals or surgeries. What I want to do is to begin before you get the patient. We have adequate, or very nearly adequate, services to deal with patients to-day, but, in regard to dealing with this all-important question of how to maintain health, I wish to see doctors, who to-day are snowed under with patients, brought into a state of affairs in which they will wonder where the next patient is coming from.

Now how is that to be brought about? I remember that when I was in another place a fellow-member said to me: "Never make a speech without making a suggestion; try to be constructive." I am going to be constructive now, and I hope that my noble friend, the Minister, who is to reply will bear this in mind. I would like to see organized immediately a National Joint Research Council, which would embrace the medical faculty, the dental faculty, the veterinary faculty, agriculturists and the Board of Education. That sounds rather a mouthful, but, if we are going to find out how to organize health, and to maintain health, all these people are very heavily implicated, and their status and their work, in my view, are closely allied. Now the terms of reference are perfectly simple—maintenance and inducement of health. Without health, as we are all perfectly aware, there can be no happiness at all. What I would like to see—as General Smuts advocated not very long ago—is priority given to health in all this planning that is going on. Unless we can bring health to the people, we are not going to have them happy no matter what we do.

Your Lordships will not be surprised when I come to the next part of my speech. We must all of us agree, whether we are doctors or laymen, that food is of first importance in this connexion. I quite realize that it is a difficult question, but surely it should be possible for us so to organize things as to bring to the tables of every family in the country a far higher percentage of fresh food than reaches them to-day, food that will give them virility and vigour—vital food. It is easy to give everyone plenty to eat, to arrange that we all get enough to fill ourselves, but we want to get the right foods into the people. That I admit is a difficult thing to do up to the 100 per cent. level, but I believe that we can improve the health of the people to an enormous extent if we organize in such a way that they receive a far greater percentage than at present of fresh, disease-resisting food, food grown with the vital elements that a great deal of the food in this country is not grown with to-day. What is happening? I admit that you cannot get away from the war difficulties, but I am very anxious about the future. We know that certain foods are produced now which are denatured, and what do we do with them? We make up what we have taken out of them in an artificial way. While it may be necessary to do that in war-time, it cannot be necessary in peace-time, and it ought not to happen except on very rare occasions. Look at the parts of the world where they do not eat food that has been tampered with, where such a thing as tampering of this sort is practically unknown, and then proceed to examine the health of the people in those countries.

I believe we can only accomplish all this if a strong body, such as I have suggested, is sitting all the time to carry on research in this matter. When that has been established, the great battle for the maintenance of national health will have begun, and we shall see children coming into the world, and people going about, with tremendous powers of resistance to disease. I was very pleased to read in the Press the other day a statement made by my noble friend the Minister, who is going to reply. The statement which he made—if he was properly reported—was this. He said that if we were to have a healthy nation we must have a healthy agriculture, producing the sorts of food which we must have if we are to maintain a high nutritional level among our people. I go the whole way with him there, and I submit that it is only research that is going to bring this about. The necessary machinery does not exist to-day, and I suggest that the scheme which I put forward is well worthy of careful consideration. It is not necessary to begin at the beginning. My noble friend Lord Horder has referred to the splendid report of the Peckham experiment, of which, I believe, my noble friend is President. From that experiment there has been gathered a mass of information that can, I suggest, be put into the hands of this Research Council. When one reads that report one is made to understand how quickly these people, these families who have been dealt with, respond to the desire on the part of the authorities of this admirable institution to help them.

This is, perhaps, rather a delicate subject to touch on. Many young people do not realize the importance of their own health when they wish to become fathers or mothers, and here is an institution which offers them great help in regard to this very important question. I have often been told by members of the medical profession that the whale basis of an individual's health is built up before birth, and I believe, in view of all the scientific and technical information that I have, that that is true. Another institution to which I would like to refer is the Cheshire Medical Panel, which has gone very extensively into this matter—not lately, but over a period of years. A mass of valuable information is available there. I mention these two institutions as outstanding examples of the sources where the Research Council could find a vast amount of valuable knowledge to work upon and find it quite easily. All the information which is available will, I know, be placed very readily at their disposal.

As I have said, I am doubtful about these health centres. I want a health centre to have nothing to do with curing. I was distressed to see in the White Paper mention of patients at a health centre. Surely a better description would be "members" of a health centre. Immediately a member of a health centre becomes a patient, surely the place for him is the hospital or the clinic or the convalescent home. There are large numbers of sick and semi-sick people in this country, and we can only take real steps to diminish their number by feeding the people better and by giving them the encouragement which they get at a health centre such as that provided by the Peckham experiment. The doctors have done magnificent work in alleviating suffering and providing immunization against certain diseases, and sanitation and hygiene have done a great deal as well, but we have a long way to go before we can improve the health of our people. We have only to consider the amount of rheumatism, arthritis and stomach trouble now prevalent. There is tremendous scope for something to be done there, and I believe that only through a Research Council such as I suggest will it be possible to do something, because it is a question which concerns the growing of food, the effect of the food when grown on animals and on men, and education to take advantage of what is learnt.

As my noble friend Lord Geddes said, we are going to spend £150,000,000 more on attempts to cure, but not a penny, so far as I can see, on the far more important question of research. Do not let us forget the importance of field tests. Do not let us be too much in the laboratory; let us get out amongst the people. Let us have these health centres watching the people and gaining practical experience of them. The test tube in all walks of life has been apt to prove deceptive so far as the results obtained from it are concerned. I should like to see these health centres entirely separate from hospitals and clinics. Your Lordships may ask why I am talking like this. For many years I have been connected with hospitals, and for many years in my travels all over the world I have watched what the results of feeding in the different nations with whom I have come in contact have been. There is an enormous amount of research to be done and a great deal to learn in this connexion. I welcome the Government's intentions, but I am afraid of their methods; I am in entire agreement with what my noble friend Lord Geddes said on that subject. I should like to quote a passage from a speech made by the great Disraeli in 1877: The health of the people is really the foundation upon which all their happiness and all their powers as a State depend. I believe this to be profoundly true. I hope that my noble friend who is to reply will give thought to this matter and will not dismiss the Research Council which I have suggested as being too unwieldy. If we are to conduct research on the right lines, I firmly believe that all the various entities which I have mentioned must be brought into the picture.

THE EARL OF DONOUGHMORE

My Lords, I have listened with great care to every speech which has been made in this debate, and I have enjoyed them all. I particularly value, of course, the opportunity of having heard the speeches made by the noble Lords, Lord Moran, Lord Dawson of Penn, Lord harder and Lord Geddes. They have reminded us of a great many very valuable general principles, and those must be borne in mind whatever happens in the immediate or the more distant future in considering all health questions. I myself, whist accepting the desire of the Government that this White Paper should be the foundation for an Act of Parliament, have tried to tune my mind to the question of whether I can suggest any desirable alterations and, above all, whether I can point out any difficulties which may arise in practice if the Act of Parliament carries out the proposals of the White Paper as it now stands.

Kind tributes have been paid from all quarters of the House to the efficiency of our voluntary hospitals, and I hope that we shall continue to build on their principles. Their main principle is that they embody a very happy alliance between the board which is elected by the supporters of the hospital—a democratic body—and the medical council of the hospital, which represents the doctors, some of whom sit on the board but all of whom have full access to the board and retain their initiative. The Government recognize the value of that principle, and the White Paper says "There is room for special devices to secure that the guidance of the experts is available." I am glad that they accept that principle, but I am disappointed with the way in which they propose to carry it out. I hope I am not a voice crying in the wilderness, but I confess I should have preferred a Hospitals Board on the same lines as the Electricity Commissioners. We now know, however, that we are not going to get that.

LORD HORDER

We might get it.

THE EARL OF DONOUGHMORE

We might. I dislike finding that anybody else is a bigger optimist than myself, but if the noble Lord, Lord Horder, sees any chance of it I will gladly march alongside him. At any rate, at the present moment we have this Central Health Services Council to be appointed by the Minister, which will be consultative and advisory and have no power whatever. It is almost unnecessary for me to say that I am quite certain that the noble Lord, Lord Woolton, and the Minister of Health are perfectly genuine in putting this plan before Parliament, and that they mean to try to make it work. But Ministers come and Ministers go—historians in the future, thinking of these years, will probably say that they go rather often—while bureaucracies go on for ever, and bureaucracies hate advisory councils and advisory boards. The record of the Ministry of Health in this matter is a particularly bad one. Your Lordships will remember that the Ministry of Health was set up in 1919 by a Bill which was piloted through Parliament—with great ability, if I may say so—by the noble Lord, Lord Addison. It contained the following clause—I leave out one or two of the unessential words— It shall be lawful for His Majesty by Order in Council to establish consultative councils. … for giving,. … advice and assistance to the Minister in connexion with such matters. … as may be referred to in such Order. The clause led to considerable discussion in Parliament, and one proposal made by members in another place was that these councils should meet at definite times, but the Government did not see their way to agree to that Amendment.

However, five councils were established under this power in the middle of 1919. The first was to deal with medical and allied services; the others I am not concerned with this afternoon—they dealt with local health administration, national health insurance, approved societies' work, and lastly, general health questions. By September, 1919, most of those councils had got to work and the Consultative Council on Medical and Allied Services, under the chairmanship of my noble friend Lord Dawson of Penn, got busy and produced, in 1920, an interim Report. I ought perhaps to say in passing that the Council on General Health Questions died before it was born. However, three of these councils which were established issued Reports in 1920 and 1921, and, as I have said, the Council on Medical and Allied Services issued their interim Report on the organization of the medical services in local areas. No Final Report was ever published, but it is interesting to note that this interim Report of 1920 contained a recommendation that the home medical service in each area should be based on local health centres and as a link with hospitals and medical schools.

The noble Lord, Lord Woolton, I think said in passing that these local health centres were new and untried. Untried yes, but not quite new. Because here they are most fully worked out by the Ministry of Health in 1920—plans, beautiful pictures, buildings, all sorts of things. But nothing more was ever heard of them. Anyhow, after 1921 none of these new councils published any reports. I do not know whether they were formally dissolved but they were allowed to die, and since then they have been as dead as mutton. May I be allowed to say that I realize, I think, the cause of their death; it was that unfortunately the noble Lord, Lord Addison, ceased to be Minister of Health.

LORD ADDISON

It is very kind of the noble Earl to say that. It would be a correct statement if he had added—"and the economy crusade."

THE EARL OF DONOUGHMORE

Yes, that may be so, but anyhow the circumstances were such that the bureaucracy got its chance and these advisory councils were killed. Therefore I am a little suspicious when I find that this new body is to be purely advisory and entirely appointed by the Minister. I do not want to be unduly obstructive. I am really anxious that this Council should have a long and healthy life, for otherwise your reforms are doomed to be inefficient. Therefore I ask this question: Why should the Minister appoint all the members of this Council? Here I am again a voice crying in the wilderness; I am afraid I shall not get Lord Harder with me this time. I should like to see all bodies of this kind appointed by a Joint Committee of the two Houses of Parliament. But I know that in these days, when the bureaucracy is working day and night to get rid of, or to diminish, Parliamentary control, there is no hope for that. But I really do not see why not. Let the Minister by all means appoint the majority but I do not see why bodies like the Royal College of Surgeons, the Royal College of Physicians, the Royal College of Gynaecologists, the Society of Radiologists, the College of Nursing and the Association of Medical Officers of Health—and those are only examples—should not appoint people to this Central Council. They would certainly appoint most efficient people and, above all, they would be some curb on any attempt to ignore the Council or to kill it, which we might find happening when those who will be responsible for initiating the system have passed away. I hope it is not too late, therefore, for the Government to think over some broadening of the basis from which the Council is selected or appointed.

If I am anxious on this point as regards the central government I am equally so when it comes to local arrangements. Joint authorities are to be created, and the membership is to be solely municipal. I am the last person to say anything ill-mannered, or even critical, of a member of a local authority. Such people do a great deal of very good work with very little thanks for it. At the same time a man who is elected to a local authority does not thereby have conferred on him all knowledge on all subjects that all local authorities have to deal with; on the contrary, most of them are budding politicians, they have the ambition, a perfectly honourable ambition, of turning their little attaché cases into the red boxes of Cabinet Ministers such as the noble Lord, Lord Woolton, now has. But when we come to think of this from a hospital point of view I doubt whether there are half a dozen men in the whole of England who are elected members of local authorities because they have any hospital knowledge or experience. These local health councils are not to contain anybody except those who have been through a local authority election. Again, this is no new suggestion in our health arrangements.

Your Lordships will remember that in the Local Government Act, 1929, Section 13 provided that— The council of every county and county borough shall, when making provision for hospital accommodation, in discharge of the functions transferred to them under this Part of the Act, consult such committee or other body as they consider to represent both the governing bodies and the medical and surgical staffs of the voluntary hospitals providing services in or for the benefit of the county or county borough as to the accommodation to be provided and as to the purposes for which it is to be used. That could not be better. That clause might be put into the White Paper almost in the same words. But it is not worked that way. I have made careful inquiries of those who have experience of this matter, and I have not found any case where there has been a discussion between the representatives of a local authority and the representatives of voluntary hospitals. I am told the way it works is like this. The local authority makes up its mind what it is going to do; the whole thing is worked out by its very able staff of officials; and then a few days, perhaps even a few hours, before the scheme is brought into operation, a copy is sent to some of the local hospitals and they are told, "This is what we are going to do; we would like you to see it in advance." That is not consultation. That is certainly not carrying out the intention of Parliament as laid down by that Act.

I come back to the same point as I made with regard to the Central Government. Why should these new local bodies be purely municipal? Why not associate with them members with special knowledge, and above all medical men? My noble friend Lord Dawson of Penn said last Thursday, "Let them all sit down in the same room and learn to work together." If consultation by correspondence is all that is to take place, the matter will be very unsatisfactory. This is all the more important as I am rather anxious about local areas. I am afraid that the Government have in mind to make them much too small. It is true that on page 15 of the White Paper it says it will be essential to get larger areas than at present. That displays a very wise intention, and it makes it possible that hospital treatment all over the country will be under the influence of a centre of progressive thought—this matter was referred to by Lord Horder earlier to-day—either a teaching hospital or, better still, the medical faculty of a university.

The White Paper then goes on to advocate the setting up of Joint Boards and says, quite wisely, there is not to be a standard-sized area, but that the delineation must be settled by certain conditions which it mentions. It says that local conditions—distribution of population, natural trends to various main centres of treatment (I do not know what that means) geography, transport and accessibility—must determine the size and shape of the optimum area. Your Lordships will notice that the availability of a centre of progressive medical thought is omitted altogether; it is not mentioned. This gives rise at once to two great anxieties. It was mentioned last week in an article in The Times to which reference has already been made that there are to be 40 areas in England. There are not 4o centres of progressive medical thought in England, and if we are going to organize England into as many as 40 areas two-thirds of them will have no way of keeping in touch with things they ought to know.

That leads me to the final point to which I wish to draw attention. What is going to happen in London? On page 16 of the White Paper it is stated: There will be some exceptional cases (the County of London is the most obvious) where no combination is necessary at all; in such cases an existing authority will fulfil both its own functions and those of the new form of authority. If I understand that correctly, it means that the London County Council area is to be the hospital area without any question of anyone else having authority except the London County Council. If that is brought into the scheme it will be a most retrogressive step. At the present moment London is managed as a very large hospital area in a number of common services. It includes the County of London, the City of London, parts of Essex, Hertfordshire, Kent, Surrey, and the whole of Middlesex. If this very definite statement in the White Paper means that the London County Council area with its four million people is to be one of the areas under the Act, then I feel very anxious as to what is being settled. That brings me to ask a pertinent question. As your Lordships are aware, the Government have lately undertaken a hospital survey. It is a survey which, I understand from friends of mine who have been surveyors, has concerned itself with treatment and not finance. There has been a hospital survey for London, and know it is complete because one of the two able men who have been surveyors has been sent abroad on another job. We have been promised over and over again in the course of the discussions we have had in the last year that some day we should see the results of this survey. I ask most definitely, because a great deal hangs on this as people are making their arrangements in advance: Did the hos- pital surveyors recommend that London should be split up? I should not be at all surprised to be told, "Yes, they did." If they did so, I am sure they based their recommendation on hospital needs and not on historical municipal boundaries. If so, did they advise that the L.C.C. area be one and indivisible and divorced from all others?

It is flying in the face of experience hitherto if this matter is settled on these lines. For instance, the Emergency Medical Service has not confined itself to the London County Council area and treated other things outside as separate. It raises also this question. If the London County Council area is to be a hospital area by itself, what is to happen to the hospitals in the City? What is to happen to those in the County of Middlesex and those parts of Surrey, Kent, Essex, and Hertfordshire which are now worked in with the other London hospitals? It almost makes one laugh, but what is to happen to the hospitals in the London area which in future will be in two or three areas? Middlesex Hospital, for example, is in the London County Council area, but it is also in Middlesex and, I think, in Hertfordshire, although I am not quite certain where the boundary comes. The cases are all interchanged, and it obviously will cause terrible trouble if the matter is settled in this way. What is serious is this, that the hospitals of London at this moment require great extension, but the places where the extensions are wanted are not in the centre, and I doubt whether they are in the London County Council area—they are needed in the periphery where there has been such an increase in population. Whatever is done in London, reorganization must be based on hospital needs, not based on the geographical accidents which arose in days gone by through totally, different causes. That is all I desire to say on this occasion. I have, I hope, carefully abstained from repeating anything which has been said before. I wish to thank your Lordships for your patience, and at the same time to add that, although I do not know what my noble friend Lord Moran is going to do, my instinct is to support him in his Amendment.

LORD SOUTHWOOD

My Lords, at this late stage of the debate I do not propose to detain you for more than three or four minutes. I think it has been made abundantly clear, both in this House and in another place, that the voluntary hospitals of this country are all most anxious to support this National Health Service and to give the very best that can be given to the patient. But those who are responsible for the management of voluntary hospitals are a little mystified as to the Government's intentions on the financial side. We all know the system under which voluntary hospitals are carried on. At present they rely on two means of carrying on their hospitals. One is the support they receive from benefactions and legacies from the public, and the other is the payments that are made through almoners and the contributory schemes. The last figures available from these sources show that in the year 1940 the amount received by voluntary hospitals from benefactions and legacies was £6,843,000, while the payments through the almoners for services rendered came to £6,607,000. The amount received from contributory schemes was £3,250,00. Those are the figures for the year 1940 and they bring the total income of the voluntary hospitals of the country up to £16,700,000.

If we look at the White Paper, page 23, there is one paragraph which I should like to read to your Lordships. It is very short and deals with the financial arrangements of the voluntary hospitals. It reads as follows: As already emphasized, it is the aim of the Government to enable the voluntary hospitals to take their important part in the service without loss of identity or autonomy. But it is essential to this conception that the hospitals should still look substantially to their own financial resources, to personal benefactions and the continuing support of those who believe in the voluntary hospital movement. So long, and so long only, can they retain their individuality. If once the situation were to arise in which the whole cost of the voluntary hospitals' part in the public service (a service designed for the whole population) was repaid from public money, or indeed in which it was recognized that public funds were to be used to guarantee those hospitals' financial security, the end of the voluntary movement would be near at hand. The voluntary hospitals are a little mystified on this aspect of the financial side. If all the services are included in the scheme, what inducement is there to the benefactors to continue to subscribe to the hospitals, and on what basis can hospitals make appeals to the public to contribute to their support if all services other than, say, those given in private wards in hospitals—we know that private wards have to be paid for—are all to be given to the public through this insurance and by means of rates and taxes? In such circumstances, what inducement is, there to the public benefactor to continue to subscribe to the hospital?

There is one other point I should like to mention. If the noble Lord who is to reply can give us some information upon it he would ease the minds of those who are responsible for the management of hospitals, and would oil the wheels of the organization and make it so much easier for those who are responsible for its running. In making this point, I must take an estimated figure. The capital value of the hospitals throughout the country is estimated to be something like £250,000,000 to £300,000,000. That amount has been built up over the years from benefactions and legacies and other receipts. These hospitals, especially under this new medical service, will have to extend their services in a way that will meet with public approval and further they will require to make extensions. Now no provision is made in the White Paper for any capital commitments in connexion with the further extension of the hospitals. If the noble Lord could give us some information as to the basis on which the hospitals can appeal to the public to continue making benefactions and what assurances the hospitals can have to meet necessary capital expenditure for the required extensions, I think that would ease the minds of the voluntary hospitals and enable them to fulfil their intense desire—I can speak from personal knowledge of their intense desire—to co-operate in making this scheme a success. Perhaps the noble Lord in his reply can give an answer on those points. If he does so I am sure it will be very helpful to all of us.

LORD BALFOUR OF BURLEIGH

My Lords, I had not intended, in the very few remarks which I propose to address to your Lordships to-night, to refer at all to the subject of medical research, but in view of what fell from my noble friend Lord Teviot, who, I much regret is no longer in his place, I must just say a word upon it. My noble friend proposed the establishment of what he called a strong body to occupy itself, as far as I could understand, with the tremendously wide range of subjects which apparently were to be the business of this particular body. My noble friend seemed to be apprehensive that all the research at present undertaken is in the direction of the prevention of disease. The only thing I wish to say to your Lordships on this is that I think my noble friend Lord Teviot does not perhaps quite realize that the activities of the Medical Research Council, with which I have the honour to be connected, are not at all limited to the prevention of disease. In proof of that I need only mention the researches which have been made into the questions of vitamins, and the tremendous discoveries that have been made in relation to food values and matters of that kind. I think that perhaps my noble friend in making that statement has not gone into the matter quite on the basis of the existing state of affairs. The same, I think, is true of the Agricultural Research Council, of which my noble friend Lord De La Warr, who also, unfortunately, has had to leave the House, is Chairman. I learn from my noble friend that his activities in the Agricultural Research Council are just as much of a positive as of a preventive kind, as are those of the Medical Research Council. Naturally I would like to associate myself with all the demands which have been made for a continuance and intensification of medical research of every sort and kind, but I am far from being convinced that the new body which my noble friend Lord Teviot suggested would really redound to the object he has in view.

The other matter to which I wish to refer in a very few moments is a different one altogether and has a bearing on the White Paper. I want to call the attention of my noble friend who is to reply to the position of that large body of people in this country who do depend on homœopathic treatment for their medical service. Homœopathy is, I believe, a growing branch of medicine. I do not think it is so firmly established in this country as it is in the United States of America. I am told there are no fewer than 200 hospitals in the United States, and some of them State hospitals, which work on the homœopathic basis and that there are thousands of homœopathic doctors in America. In this country I am assured that there are more than a million people drawn from all classes of society who do rely upon homœopathic treatment. My own experience with members of my own family has been a great success in that way, and I dare say others of your Lordships have had the same experience.

I do not want in any way to strike a discordant note. I think the position of those who are concerned with homœopathy is one of keen interest in this scheme, but also one of a keen desire to know how they are going to be fitted in. There is mention in the White Paper of the division of the country into areas. It is a common thing for a homœopathic doctor to work over a radius of twenty miles. I do not fully grasp how, if the very laudable object of the White Paper, freedom of choice, is to be fulfilled, the homœopaths are satisfactorily to be fitted into this scheme. I would remind your Lordships that homœopaths are fully qualified medical men and women, but homœopathy is a subject of post-graduate study and it may well be that the Government will find it necessary to do something to stimulate an increase in the number of men and women practising on homœopathic lines. I wanted to say that, because I do not think it has been already mentioned in the debate, and I am very anxious that the noble Lord should be aware that there is a feeling of very great anxiety on the part of a very large section of the community on that subject.

LORD GLENTANAR

My Lords, I do not wish to detain you for more than two minutes, but I should like to support what my noble friend has just said because there is a fear that if the medical profession comes under State control, to the extent which many of us see in the White Paper, those sections of the medical profession who follow a particular line such as homœopathy, will find it increasingly difficult to follow their particular form of training and of treatment. It would be a sad day if the possibilities of working along different lines were to be curtailed by any standardization which might result from directly State controlled medical services. We know very well that bureaucracies—the word has been used many times in this debate—do not encourage anything except standardization. If the medical profession—as a layman I can perhaps speak more freely—were to come under any rigorous standardized control in its training and practice, a control outwith itself, I fear we should have a very poor outlook for the development of British medicine. I have no particular brief for homœopathy, but I think that a motto which was adopted by the British Journal of Homœopathy one hundred years ago might be very suitable for the Government to bear in mind when framing this measure. That motto is: In certis unitas, in dubiis libertas, in omnibus caritas.

"THE MINISTER OF RECONSTRUCTION (LORD WOOLTON)

My Lords, I do not wish to detain your Lordships unduly but if I were to repay the courtesy you have shown in this debate by answering all the questions that have been raised, I am afraid we should be here until very late. I hope none of your Lordships will think because I do not answer you in detail that I have ignored the observations that you have made. The truth is, as I stated in submitting this Motion to your Lordships' House, the purpose was not that there might be Ministerial speeches defining policy, but that His Majesty's Government might have the benefit of the views of Parliament on the proposals they have made. My right honourable friend the Minister has already had the benefit of two days' debate in another place, and I am sure he will be even more fortified by the debate that has taken place in your Lordships' House. If I may say so without impertinence, it surely has been a debate of extraordinarily high standard.

I hope the noble Viscount, Lord Dawson of Penn, will not think me unduly familiar if I say to him that during the period which I have been a Minister he has rendered very many services to the Ministries with which I have been connected, but never I think has he placed me more in his debt than he did when he made that statesmanlike speech covering the whole range of this subject on the last occasion on which we met. I can say that in spite of the fact that he frequently damned us with faint praise. The object of this debate was to give His Majesty's Government and those who work under them, the opportunity of getting the benefit of the views of Parliament, of seeing where perhaps dangers lay that they had not anticipated, and I am very grateful to your Lordships for the speeches you have made. The noble Lord, Lord Nathan, assured me of support from his side of the House in the event of our going to a Division on the Amendment which the noble Lord, Lord Moran, has moved. I am bound to say, looking at the House, that I wish that support looked a little more substantial or, alternatively, that the noble Lord will not, in the long run, challenge me to a Division.

Let me very briefly look through some of the notes I have made as the debate has gone on. I was glad that the noble Lord, Lord Balfour of Burleigh, to whom the country is much indebted for his work in connexion with medical research, told us about it. At the end of this war, in which we have been so obviously benefiting by scientific research, how could His Majesty's Government have any doubts on this issue? I can tell your Lordships there is no doubt in any of our minds as to the value of scientific research in general and medical research in particular. It is in very safe keeping under his Lordship's Chairmanship. The noble Lord asked what is going to happen to the homœopaths. I am grateful to him for having raised the question, and I wish I could answer it, but I will have a conversation with the responsible Minister and I will warn him of the noble Lord's remarks on the danger of standardization. The noble Lord, Lord Teviot, did not have the advantage of hearing the speech which Lord Balfour of Burleigh has just made on the subject of research. I can at any rate assure him that research will go on, although in this particular White Paper we were not immediately concerned with it. The noble Lord need have no fear that we shall neglect it.

Now I come to the speech of the noble Earl, Lord Huntingdon. I was glad he reminded your Lordships of those dismal Jeremiahs of the past who told us that the medical profession was going to come to an end, that it was going to lose its moral fibre and all its other qualities, whereas the truth is, of course, that the Liberal Government of that date made doctors more secure in their profession than ever before, and the noble Lord, Lord Addison, must get some consolation from this fact for the part that he took in that movement. I do not see any reason to suppose that, because we are now embarking on another and wider national health scheme, we are in any danger of causing the medical profession to go to pieces this time.

To my noble friend Lord Geddes I would say: "Sometimes first thoughts are right, and when you saw in that White Paper an outline of bold idealism and determination for positive health you were right. That was what we intended. But when that unhappy cynic whom you met told you that this was really an opportunity for making social security for the Treasury, and that that was what we had in mind, you were misled. That never occurred to us." As I say he misled the noble Lord. We have indeed been influenced by the speeches that the noble Lord has made in this House. I refer particularly to those speeches in which he has urged us to take a conception of positive health, and I ventured in my opening remarks to borrow phraseology from him. I did not quite follow him in all that he said to-day as to why he objected to certification, but I will read the report of his speech very carefully. I think he admits that there must be certification. If people are going to be ill we cannot just take their say-so for it. We must have some competent authority telling us, perhaps telling them, whether they are ill or not. It is an inevitable part of any big social insurance scheme.

I wondered why the noble Lord, whose speech I followed with meticulous care, was so depressing about the future. Of course this scheme will take a long time. But it is the proper thing for a Government to take a long view, and to put out plans for a long time ahead. It is right that we should say: "These are the things we are aiming at." In order to achieve those aims we shall want medical staff, people will have to be trained. You have got to tell people a long time ahead that there are going to be opportunities for their labour. I am not dismayed by the fact that before we can get all the consultants we want and all the doctors we want, five, ten, and, I think the noble Lord said, even twenty years might pass. At any rate let us boldly begin now. We have got to begin some time, and unless we make a beginning we shall not make any progress by standing on the brink and wondering what we are going to do. The noble Lord said that this was an evolutionary process. Of course it is. One of your Lordships, I forget which, spoke of destroying. We have tried, in the development of this scheme, not to destroy but to build up from what we have, to build a new system that will grow out of the old. And let me say this. There are people who have made considerable sacrifices of old political principles in order to accommodate themselves to that view, and I believe that the Paper is all the stronger for the compromise. The noble Earl, Lord Donoughmore, said that Ministers come and Ministers go and that they go rather more quickly these days. I thought he said it with regret. It would be comforting to those of us who remain in His Majesty's Government to think that there was an element of regret in his Lordship's voice about that. I will observe and commend to my right honourable friend what he said on the subject of advisory boards of hospitals.

Now as to the size of the area. That is a matter on which we must get agreement and must get some workable scheme. Throughout this Paper we have not put forward a cut-and-dried statement saying "These are the things we are going to do, and if you do not agree with them—well, then the Division Lobby lies there." I am afraid I do not know whether it is on the right or on the left, I have never been into it, but it lies wherever it does lie. We have come here and said: "Will you consider these things? Here are our general aims." And you have been good enough to give us the benefit of your advice. I will inform my right honourable friend as to your doubts about bureaucracy. I, myself, have no doubts on this subject of bureaucracy. You get bureaucracy if you get weak Ministers. If you get strong Ministers, then you get in His Majesty's Civil Service a most faithful body of people only too willing to take directions from their Ministers. I must, and I do, say, out of my experience in this matter, that I have, as a Minister, been extremely well-served by His Majesty's Civil Service, and I have never found any hesitation on the part of that Service in taking such instructions as I felt it my duty from time to time to give. What the Service does not like is a Minister who cannot make up his mind, and who waits to see which way the political cat is jumping.

Now I come to the Amendment that the noble Lord, Lord Moran, has moved. I am, of course, under a great temptation, because I do not want this Amendment to go forward. I am under temptation to deal with it in detail. The noble Lord was concerned, as was also my noble friend Lord Horder, about the Government's relation to this Central Council. All these noble and medically learned Lords were gravely concerned about what the Government were going to do with the profession. My Lords, their concern is unnecessary. The Government—and I know that I can speak for my right honourable friends the Minister of Health and the Secretary of State for Scotland—are most anxious to co-operate in every sort of way with the medical profession, to consult them and to do everything with them—except one thing. The Ministers are determined that they will take the responsibility for their actions, and they are not going to put that responsibility on to a Medical Board. Surely they are right in taking that view; they are responsible to Parliament for what they do. We have all sat on Government Committees in our time, and been rather flattered in our earlier days at being invited to such eminence, but, as time has gone on, have wondered why we spent so much time there.

I claim the right, on my own behalf and on behalf of my right honourable friends, to say this. We have been responsible for putting this White Paper before you. We have done so with great deliberation, having spent very many weeks in producing it. There is no insincerity in it; if there were, neither my right honourable friends nor I would have been parties to it. When we say, therefore, that we are going to have a Medical Council, it is not something which is merely put up as a screen; it is a deliberate effort to get the best of medical opinion to advise His Majesty's Ministers. I think that I am at liberty to say that we discussed for some time whether that Council should report direct to Parliament, and the only reason for deciding against it was that a constitutional issue was raised, as to whether such a body of people should report direct to Parliament and therefore, possibly, against the Minister's decision. I can assure you, however, that the attitude of mind of the Government on this matter is an open one, and on this as on other matters they are prepared for the fullest possible consultation before legislation is brought in. The question has been asked whether the Government will say, following the White Paper and this debate, "Here is the legislation; you can take it or leave it." The answer is in the negative. The profession will be consulted throughout before legislation is brought in.

I am conscious of the fact that I am detaining your Lordships unduly and am not doing justice to the questions which the noble Lord, Lord Moran, raised in his speech, but there is one question on which I must spend a little time, and it is that of the powers of direction which the noble Lord, Lord Moran, attributed to the Central Medical Board. I think that the noble Viscount, Lord Dawson of Penn, also mentioned this point. There were two powers which he said would be possessed; the first is to direct existing doctors where they should work, by what he called a negative pressure process, and the second to direct every single entrant to the profession to work full time in the public service. As the noble Lord was speaking, I failed to recollect anything in the White Paper or in the very long discussions which we had on this issue which would justify that view. I do not think that your Lordships will find in the White Paper any proposal which can be fairly described in these terms, or which is in any way analogous to the power of direction at present exercised by His Majesty's Government under the National Service Acts.

Let me state the true position. There is an assumption by the community as a whole of the responsibility for guaranteeing to every member of it the services of a family doctor. That is what we are guaranteeing, and that involves new duties with regard to the distribution of medical practice. The Government must do what they can, without regimentation of the profession, to see that every area has enough doctors to meet the needs of the patients, which is not always the present position. Two proposals are therefore made in the White Paper for methods to be used by the Central Medical Board for this purpose. The first is that the Board shall be able to say that a particular area already has enough doctors to carry on the public service, and that no newcomers into the public service shall be allowed in that area.

How restricted this power is, and how little it resembles direction, even of a negative kind, is clear from the fact that it does not apply to private practice. Any doctor will be at liberty to practise privately wherever he likes and at any time he likes. Moreover, it applies only to newcomers to an area, and does not in any way disturb or affect the doctors already practising there, and it does not involve directing any doctor to go anywhere. It merely restricts the range of his choice of the area in which he will take up practice in the public service. I submit to your Lordships that when a young man wishes to enter a public service where he will be paid out of public funds, it is not a very hard condition that he should be told where there is a vacancy and where the State is prepared to pay him to do his work. I do not want to spend more time on that, because my right honourable friend the Minister of Health has dealt with it very fully. I think that there has been a misunderstanding. If there can be a misunderstanding, that must be the responsibility of those of us who drafted the White Paper, because on this issue there ought to be no possibility of misunderstanding. I hope that the speeches which have been made in another place have removed the possibility of that misunderstanding continuing.

I now come to a subject which has obviously been of the greatest possible interest to your Lordships, the subject of the voluntary hospitals. The noble Lord, Lord Moran, said that this was an obituary notice, and that we were speaking kindly of what is about to pass. We do not want them to pass. I measured my language very carefully in what I said in my opening speech, because I thought that it might be of some help to the voluntary hospitals, I find it very difficult to answer the question which has been addressed to me by the noble Lord, Lord Southwood, when he said, "What are you going to do for the voluntary hospitals?" Voluntary hospitals are voluntary hospitals, but they come and ask the Government what they are going to do. I am not trying to avoid responsibility in this matter. We have very deliberately stated that the sum total of the cost of this National Health Service will not be met by rates and taxes or by contributions under the insurance scheme—that all those put together will not be enough to maintain all the hospital services and all the other services that will be required. Therefore, it will be necessary for the voluntary hospitals to continue. I did not understand Lord Horder—if he will forgive me for the sake of personal friendship for picking him up rather—when he indicated that the offer of a partnership to the hospitals did not mean much. I felt he was in some doubt as to how much we cared for the voluntary hospitals.

LORD HORDER

I did not use the word "partnership."

LORD WOOLTON

I beg your pardon; it was another speaker. Let me be clear on this. We cannot do without the voluntary hospitals in the conduct of this scheme. It does not seem to me that we should serve any good purpose for the voluntary hospitals if we were to say—and I have no authority to say that—"Whatever your deficits are we will meet them"; because it would not be long before the voluntary hospitals would go out of existence if that were so. But what we have said to them, and said to them after close consultation, is this: "We want you to remain in existence, we regard you as the greatest possible benefit to the community. We recognize the great service that you will render in the future". And I am more interested in the service they are going to render in the future than I am in the service that they rendered in the past. A great deal of the research was done by the voluntary hospitals in the past. There was not anyone else to do it, and of course it was done in voluntary hospitals. And we know they are going to do it in the future. Therefore we say to them: "We will pay you for services that you render to us, and we will leave you with your complete autonomy."

I do not know why noble Lords who have been interested in hospitals have been so fearful on this issue. I do not think they have reason to be fearful, but at any rate I can assure them that both by word and by deed His Majesty's Government will do whatever they can in order to maintain the existence of the hospitals and to maintain their existence in full vigour—for we do not want hospitals that are slowly going away from efficiency because they have not got the money to remain efficient—and that has been with many of them a condition that was precedent to the introduction of this Report.

Perhaps what my noble friend Lord Moran will think the most important part of his speech I have not dealt with, that is the question of consultants. I should have thought that the whole basis of this Paper was that we were anxious to develop a consultative service for the whole community. The noble Lord thinks we have not consulted the consultants enough. I am sure that has not been the intention of my right honourable friends, but this I can say, that before we go to legislation—if you like, before either good or harm is done in this matter—my noble friend can rely upon it that we will enter into the fullest discussion with reference to the position of consultants and as to the training of consultants. Much of this debate has gone, and inevitably has gone, along the lines of discussing whether we are going to damage the things that now exist. I think it is reasonable that it should have done so, because we have in this country a great medical service to which all of us in health, but particularly in sickness, are profoundly indebted, and are conscious of that debt. We have a great hospital service as well as a great medical service. And we have mainly discussed in the course of this debate the position of doctors and the position of hospitals.

But there is something else that is above all these things. If my noble friend Lord Geddes will look at page 10 of this Report he will see that there we expressly state that the thing that we have in mind is a programme of positive health for the people of this country. All the things that he said will find support in this Report. It is for that that we are out. I believe that we are going, through this legislation, to bring great benefit to future generations in this country. We have forgotten perhaps during our discussions the importance of the ordinary people because we have been considering more the technical details of the problem. But the people of this country will benefit immeasurably by the recommendations that His Majesty's Government have so carefully worked out and have put before you. And I appeal to the noble Lord, Lord Moran, with his great prestige in the office that he holds, to come over and help us, to say that he is on our side in this matter. I hope that he will not divide the House, because I should not like to think that there was any possibility of your Lordships' House being divided on this issue.

LORD MORAN

My Lords, the noble Lord has asked me to withdraw the Motion, which I shall of course be very glad to do. There are several points on which he will perhaps allow me to comment. We have had such experience of his giving rather less perhaps than we had hoped for, that I did not expect him to answer my questions. The first point was about the Central Health Services Council. I am not perfectly clear what the responsibility of the Minister to the Cabinet has to do with the suggestion that the Central Health Services Council should make its own Report so that the profession might follow it. The second point that he touched upon was the Central Medical Board. I may have been very stupid, but when I was very perturbed by reading in the White Paper about this board I asked a lawyer friend of mine, one of the most eminent in the profession, if he would tell me whether this did mean in fact the perpetuation in peace of civilian direction in war. His reply was, "There is no doubt about it," so I may at least be said to have erred in good company. With regard to the consultant service, the noble Lord said that that is the whole basis of this Paper. But the Minister in another place said that there was little in this White Paper about the consultant service and there has been little discussion with representatives of the consultants and specialists. There seems to be rather a division of opinion on that point.

Then there is the question of the voluntary hospitals. I want to put in one sentence what is our real fear about the survival of these hospitals. It is this. We believe that hospital building in the future will be largely municipal building because it will be directed by the municipal authorities. If that is going to be so, we fear that in ten years' time the municipal authorities—or shall we say the Joint Board?—will come to a voluntary hospital and say, "We are very sorry, but we cannot have our patients treated in out-of-date buildings with out-of-date equipment. If you will rebuild, well and good, but if that is not possible it is just too bad. We shall have to see that our patients are treated in our own hospitals." That situation is perhaps not entirely fanciful, and if it arises the voluntary hospitals will find themselves in an impossible position. In Leads yesterday I was talking to the very able Superintendent of the Leeds Infirmary, and he suggested a way out of the impasse. He suggested that if there were a sinking fund spread over forty years, at 2½per cent. on the capital of the buildings and everything else concerned, then that sinking fund could be reserved strictly for rebuilding purposes. He calculated that it would mean an addition of £30 to the £100 per bed of which the White Paper speaks. If some such plan were adopted, at the end of ten years—for the danger to the voluntary hospitals is not immediate but in, say, ten years' time—the voluntary hospitals would be in an immensely stronger position than they would otherwise be. I ask leave to withdraw my Amendment.

Amendment, by leave, withdrawn.

On Question, Motion agreed to.