§ Order of the Day for the Second Reading read.
§ LORD STANMORE
My Lords, the principal object of this Bill is to set up a central Department to deal with matters concerning public health in Scotland. If your Lordships will refer to Clause 4, you will see how many different authorities are now dealing with the question of public health in that country. The Local Government Board for Scotland, the Scottish Insurance Commissioners, the Privy Council, the Scottish Education Department, the Highlands and Islands Board, and the Secretary for Scotland are all concerned in one form or another with this same question. Last week my noble friend Lord Sandhurst, in moving the Second Reading of the Ministry of Health Bill, pointed out very clearly and convincingly the considerations which render it desirable that all authorities concerned with public health should be administered by one central Department. About this there was, I think, no difference of opinion among your Lordships; in fact, I do not suppose that circumstances admit of any. I will therefore not enlarge on this matter, but attempt briefly to explain the principal clauses of this Bill.
Clauses 1 and 2 provide for the appointment of a Board, and indicate its powers and duties in relation to health; and also provide for the collection, preparation, and publication of information and statistics, and the training of persons for health services. Clause 3 deals with the composition of the Board. The first subsection sanctions the appointment of a Parliamentary Under-Secretary for Health, who is to be responsible under the Secretary for Scotland for the administration of the new Board. The Secretary for Scotland will be President of the Board, and the new Under-Secretary will be Vice-President. 466 The number of members will not exceed six (in addition to these two ex-officio members), and these six shall at all times include two registered medical practitioners, one or more women, and a member of the Faculty of Advocates or law agent of not less than ten years' standing. The Secretary for Scotland will designate the member who is to be chairman of the Board in the absence of the President and the Vice-President. The Local Government Board for Scotland, at present the main authority for health, to-day consists of three appointed members, of whom one must be a medical man and another an advocate, and also three ex-officio members—the Secretary for Scotland, the Solicitor-General for Scotland, and the Permanent Under-Secretary; and the proposal is that, as at first constituted, time new Board shall include the three appointed members of the Local Government Board and also two out of the four insurance Commissioners, these two to be nominated by the Secretary for Scotland, and the sixth member will probably be a woman. Noble Lords will have noticed that in future the legal member may be chosen from either branch of the legal profession.
Clause 4 is another important clause, and deals with the powers of the new Board. It is proposed to transfer to this Board forthwith all the powers and duties of the Local Government Board for Scotland, of the Scottish Insurance Commissioners, of the Privy Council under the Midwives (Scotland) Act., of the Scottish Board of Education with respect to the medical inspection and treatment of children awl young persons, of the Highlands and Islands (Medical Service) Board, and also certain powers and duties of the Secretary for Scotland under the Alkali Act, the Burial Grounds Act, the Rivers Pollution Prevention Act, the Births, Deaths, and Marriages Acts, and the Vaccination Acts. I have just mentioned the Highlands and Islands Board; and as it is one of those bodies whose powers and duties, in pursuance of the policy of unification, are to be transferred to the Board of Health, I should like to take this opportunity of expressing on behalf of the Government their appreciation of the important services which have been rendered by the Board since its constitution in 1913. In spite of the fact that its activities have been seriously hampered by war conditions, especially in the matter of adequate medical and nursing services, 467 the Board, under the chairmanship of my noble friend Lord Forteviot, has done very valuable work, and various schemes which my noble friend and his colleagues have worked out will prove to be of lasting value towards the solution of the problem of alleviating and preventing sickness and suffering in these districts.
In subsection (2) of Clause 4 provision is also made for transfer to the Board from time to time, by Order in Council, of the powers and duties of the Secretary for Scotland under the Lunacy and Mental Deficiency Act, and the powers and duties of the Minister of Pensions with respect to the health of disabled officers and men after they have left the Service. These transfers will no doubt be made later but cannot conveniently be made at the present moment. Subsection (3), which is similar to a provision in the English Act, is inserted in anticipation of a revision of the Poor Law. The subsection makes it possible to transfer to other Government Departments such of the powers and duties of the Board as relate to the relief of the poor and not to the health of the people, and which would be more conveniently exercised by such other Departments.
There is only one other clause calling for special notice, and that is Clause 5, which establishes Consultative Councils for advising and assisting the Board. These Councils, which will be on the same lines as the Consultative Councils in the English Bill, will include both men and women and will consist of persons having practical experience in matters relating to health. In constituting the Councils due regard is to be had to any special interests which may be involved, such as those of local authorities and of labour. The reforms inaugurated by this Bill are both important and urgent, and I hope that your Lordships will consent to give the Bill a second reading.
§ Moved, That the Bill be now read 2a.—(Lord Stanmore.)
THE MARQUESS OF ABERDEEN AND TEMAIR
My Lords, I followed very closely and very easily the clear statement of the noble Lord with regard to the duties of the new Board under this Bill, but there was one item of which I did not quite catch the significance. In explaining Clause 3 the noble Lord mentioned that one of the six members alluded to, other than the ex-officio members, would probably be a 468 woman. Well, that is a hopeful utterance. But perhaps by the Committee stage we shall have something more definite as to whether it is an enacting element or merely a possibility.
LORD BALFOUR OF BURLEIGH
My Lords, I am not going to say very much, because I cordially concur, for what my opinion is worth, in the general policy outlined in the Bill. There are, however, one or two things in it which I do not understand. I think that the idea of having a Central Board primarily concerned with all things relating to the health of the people has been generally well received in Scotland, and the noble Lord in charge of the Bill has explained its purport and object; and taken in connection with the English Bill which was read a second time last week, I do not know that there is any real field for discussion on principles.
But, my Lords, there is one most extraordinary provision which was incidentally referred to by the noble Lord at the end of his speech, and I do not understand what to make of it. It is part of subsection (3) of Clause 4, and if your Lordships have not read it I think it would be interesting to study its wording. The second paragraph of the subsection runs—And it is hereby declared that it is the intention of this Act that, in the event of provision being made by Act of Parliament passed in the present or in any future Session for the revision of the law relating to the relief of the poor in Scotland and the distribution amongst other authorities of any powers exerciseable by parish councils, there shall be transferred from the Board to other Government departments such of the powers and duties under tie enactments relating to the relief of the poor then vested in the Board (not being powers or duties relating or incidental to the health of the people) as appear to His Majesty to be such as would be more conveniently exercised and performed by such other departments.What is the object of this provision? Is it a pious opinion or is it a preamble inserted in the middle of the Bill? What object is there in giving the force of an Act of Parliament to what is said to be "the 469 intention" of the Government? Even as it stands, to what does it commit us? Does it commit us to all the intentions of the Government? Shall we be held to be committed to them by having passed this clause in anticipation? Why are all these powers and duties relating to the health of the people specially exempted front transference, when this Bill is really for the health of the people and nothing else? I am bound to say that a more confused clause and one inert, difficult to understand I have never seen in any Act of Parliament, and I hope that in the Committee stage we shall have some explanation of it.
There is only one other matter to which I want to refer, and that is, I frankly admit, purely a Committee point. This Bill is avowedly connected with the health of the people, and if your Lordships will refer to Clause 5, subsection (1), you will see that "such matters affecting or incidental to the health of the people in Scotland" may be transferred. I venture to suggest that it would be an improvement if such things as housing and sanitation were specially mentioned. I know that this has caused a certain amount of heart-searching in Scotland. I have had a number of letters from those interested in repairing and plumbing trades asking why sanitation has, apparently, been overlooked, and a copy has been sent me of the letter forwarded to the Secretary for Scotland, which will, no doubt, be in the possession of the noble Lord in charge of the Bill, and will serve to indicate the points that may be raised when we come to the Committee stage.
§ VISCOUNT HALDANE
My Lords, this Bill follows the principle which has been adopted for the purpose of the English Bill, and that follows the principle of the Committee which was presided over by a distinguished Scottish Member, Sir Donald Maclean, and I think it answers some of the criticisms made by the noble Lord who has just sat down. The principle of the Bill is to define a single service and to transfer to those who are executing it all the powers that are appropriate to that service. That is a very simple principle.
Let me take an illustration from what was said by Lord Balfour of Burleigh. It is quite true that there is in the Bill a provision which says that if it; turns out that the functions of the Departments whose activities are transferred to the 470 new Board in Scotland do not relate to health they may be allocated to other Departments to be dealt with appropriately. That is not only proper but necessary. Take the case of the Poor Law. There is a large part of the Poor Law concerned with health, and there is also a part of it which is concerned with tramps and vagrants and the administration of justice. As I read the clause—which is analogous to the clause in the English Bill—that is meant by the subsection to which the noble Lord referred is that when the powers of the Local Government Board are transferred en bloc to the body which is to take its place, it should be possible to re-transfer to whatever Departments deal with them those things that have nothing to do with health at all and could not be usefully dealt with by a Health Ministry. Conversely, in the case of sanitation, as I read the Bill, all the powers of the Local Government Board are transferred, with exceptions with which I need not deal. I presume that covers sanitation, but I do not know. If so, these things are properly transferred. Doubtless the noble Lord who moved the Second Reading of the Bill will resolve any doubts that may be raised about these things in Committee.
There are other parts which I think deserve attention for a moment. The Bill differs altogether from the English Bill in this respect. The English Bill sets up a Ministry of Health; this Bill does not. This Bill leaves it to the Secretary for Scotland to net through a Board of which he is to be President. That is right enough, for a good reason. Parliamentary Ministers cannot be always in Scotland. They must be here; therefore, the scheme of Scottish government is that many functions of the Secretary for Scotland are performed by Boards over which he presides bat the members of which are in Edinburgh.
Now I come to what is, I think, a rather doubtful provision in the Bill. This Board is to be presided over by a new Parliamentary Under-Secretary. I have great misgivings about the constitution of new Parliamentary Ministers. Still, if yon can had an ideal man who can remain in Scotland, it might be a good provision. But consider what is to happen? Somebody who can stay in the House of Commons, a Scottish Member whose duties take him to Westminster, will be the Vice-President who will preside over this 471 Board. Well, he will not have time or opportunity to attend to the details of the business, and it is to the details that you have to look for efficient administration in a case like this. Consequently, I doubt very much whether the Bill will be the better for the presence of that Under-Secretary. If there is an ideal man in view of the Government among the Scottish Members, who is patriotic enough to prefer the health of his countrymen beyond the Tweed to the glories of Westminster, you will do very well; but whether there is such a man, my past experience of the way in which selections for appointments are made leads me to doubt; and I am not at all sure whether it is a good provision to make a new Minister for Scotland—an Under-Secretary who is to preside over this Board.
Another point was raised by Lord Aberdeen. Women are to sit on the Board. That is quite right. But I observe no clause which says that, in making appointments to the staff of the new Ministry, there is to be an absence of discrimination on the ground of sex. We bad the question before the House the other day on the English Bill. In the English Bill such a clause was inserted in the other House, in Grand Committee, but it was promptly struck out, not by the Ministry of Health, not by Dr. Addison, but on the Motion of the Secretary to the Treasury. I took exception to that, and I have put down an Amendment—I think that Lord Selborne has put down another—endeavouring to restore the principle which the Bill had, not that women are necessarily to be appointed or that people are to be appointed because they are women, but that people are not to be refused appointment because they are women. I should like to see a similar clause here. The noble Lord will doubtless ascertain from the Lord Chamberlain, who sits next him and who is in charge of the English Bill, whether the Government are going to meet us, when that Bill conies up in Committee on Thursday, upon a matter about which we feel strongly. If so, I assume that the decision in the English case will govern the introduction of that clause into this Bill.
Subject to these things, I think this is a very good Bill which follows out a principle and has the great merit that it takes the work of the Maclean Committee and resolves the Poor Law into its constituent elements. Tramps and vagrants 472 will be dealt with by those people who I should deal with them. I am sure that Lord Balfour does not wish them transferred to the Ministry of Health. On the other hand, it brings all the scattered elements of the Poor Law relating to health into the single service which the Bill establishes, and in that way carries out the principle which was produced by the Government on the recommendation of Sir Donald Maclean's Committee. On the other points I have made the observations which occur to me, and we shall, if the Committee stage be not too soon, hear of points of detail on which further questions will have to be raised.
My Lords, the noble Lord who introduced the Bill made a kind and generous reference to the Board over which I had the honour to preside, and while I take the opportunity of thanking him on behalf of that Board for what he said, there are one or two things in connection with its work that are germane to this Bill to which I should like to draw attention. I want to extend a very hearty welcome to the Bill, not so much on account of the Bill itself as that it opens the way for a more vigorous and more scientific treatment of public health in Scotland. The Bill does not do much more than co-ordinate the present services; but if it, does that, it does something which is very necessary and very much needed.
The present condition of the medical service of Scotland is absolutely chaotic. It is best illustrated by the well-known case of the Scottish family. The husband and father was an insured person and his medical necessities were attended to by the Insurance Commissioners. The wife was an ordinary patient of the medical man. The children were inspected and attended to by the medical officer under the control of the Education Department. The grandfather and grandmother also lived in the house. One of them was an old-age pensioner, whose medical man was the parish officer under the control of the parish council; the other was a pauper lunatic who was under the control of the. Board of Control; and last of all, one of the children was suffering from a notifiable disease, and his medical man was the medical officer of health for the district. Any system which permits a condition of affairs of that kind is indeed in need of reform.
473 I want especially to draw attention to an aspect of public health in Scotland which does not obtain in any other part of the United Kingdom. A similar condition of affairs did perhaps exist in some parts of Ireland, but up to the year 1912 at least the Government had done far more for Ireland than for Scotland to help to put it right. I refer to the public health conditions of the Highlands and Islands, and I desire an assurance from the Government that the pressing necessities of their case will not be lost sight of or overshadowed by the larger national question. Lord Balfour of Burleigh mentioned that perhaps one of the most pressing matters connected with public health is that of the holies of the people, and I should like to show how little has been done in this Bill, or in any other Bill, to meet the housing conditions in the Islands of Scotland, or by the Bill discussed yesterday in another place, which can have no effect in the Island of Lewis. In a large area, in the Western Hebrides, housing is of the most deplorable description. The houses are of the most primitive kind, and. very little better than the cave dwellings of primitive man. How can these conditions be dealt with under this Bill or under the Bill which was introduced yesterday in another place? They cannot; for this reason. The householders in the Hebrides hold their houses and land under quite a different tenure, and the local authority there cannot be called upon (as they can be in other parts of Scotland) to act, because their resources are exhausted. The public health rate has long been exhausted in the Island of Lewis, and in the other parishes the rates are 14s., 15s., and in one case 19s. in the £. It is a very pressing question, and ought to be taken up and settled without any unnecessary delay.
I want also to refer to the medical and nursing services in the Highlands and Islands, which came under the control of the Board to which the noble Lord referred. Attention was drawn to the condition of these services by the Insurance Act of 1911, and in.1912 a Committee was appointed to consider how far the medical and nursing services were inadequate. This Committee reported that the services were quite inadequate, and the evidence published was of the most startling kind. It was found, for instance, that in large areas a doctor was never present at a birth, and that a supply of maternity nurses did not exist. In one parish of 4,000 inhabitants there 474 was one old woman, nearly eighty years of age, who attended for payment, and she had never been properly trained. The only assistance was got from neighbouring wives. One doctor described this as a great social danger. In many isolated cases the only help that was given was rendered by the husband, and it is not surprising that in many cases whore there was any complication neither the mother nor the child had a chance. Nor is it surprising that puerperal fever and other similar diseases were common, and that there was a great deal of suffering and illness which alight have been prevented.
Thee medical and nursing attendance in ordinary cases was no better. A considerable proportion of the population live from twenty to twenty-five miles from the nearest doctor's house. The country is rugged, sometimes almost roadless, and the weather conditions often make travel very difficult. Besides this, the income of the doctor was so small and so precarious that he very often was not able to provide the best means of transit. Under these conditions the cost of medical aid must obviously be high, and, however reasonable, must in the majority of cases be prohibitive. It is very instructive to note that while the average of uncertified deaths all over Scotland is 2 per cent., or rather under that figure, in the Highland parishes it ranges from 17 per cent. to 80 per cent., and one case was produced of a parish where there were nine deaths one year, and twelve deaths another year, and not, one was seen by a doctor. That was the condition of affairs when the Board to which reference has been made was appointed, and £33,000 a year was granted to help to put things right, with £10,000 additional for insured persons.
What I am most anxious to get is an assurance from the Government that the work which this Board began—it was meant to be a temporary Board and has now been abolished—will not be interrupted, and that the schemes which it had prepared will be carried out. Noble Lords will be interested to know that it has been able to enter into agreements with almost all the doctors in the Highlands whereby a patient, wherever he is, no matter whether he is twenty miles from the doctor, will receive medical attendance at a fee not exceeding 5s. for the first visit, and 2s. 6d. for subsequent visits. That arrangement has been largely taken advantage of. The 475 Board on their part undertake that the doctor shall not suffer, and that he shall be properly remunerated. The scheme is working well, and is undoubtedly fulfilling the purpose for which it was designed. I hope that it will not be interrupted, and that it will continue under the new Board of Health.
I am also specially anxious that the schemes which were designed by this Board and have not yet been put into effect owing to the war and other causes shall be proceeded with. One scheme in particular is, I think, necessary. I have referred to the housing difficulty. However unsatisfactory the houses may be for healthy people to occupy, they are quite impossible in the case of illness, and particularly for cases of a surgical kind. There is very little chance that a surgical case will have a rapid recovery when it is carried on under such septic conditions as exist in a "black house." One doctor described to the Committee how he had to conduct an operation which was absolutely necessary, and had to be done in a hurry. He used the table of the house as his operating table; he got the schoolmaster to administer chloroform, and an old crofter to hold the candle to give him light. During the operation the crofter fainted and put out the light, with the most disastrous results. To meet cases of this kind, which occur fairly frequently, and also to meet cases where a patient perhaps needs more attention from a doctor than can be given if he lives at a distance, and also to provide for maternity cases—I think the maternity cases conducted in some of these houses is an outrage to decency—the Board have designed a plan whereby in every centre where there is a nurse accommodation should be provided in the nurse's house for an additional one or two beds for patients of that kind. This scheme will be more important than almost anything else, I think, in improving the public health of the Highlands of Scotland.
There is only one other point that I wish to mention. I heard the noble Viscount, Lord Haldane, say in reference to the English Bill that the training of doctors was not a question for the Ministry of Health but should be dealt with by the Universities and the great hospitals. This is, of course, quite true. But speaking from the point of view of the Highlands, I hope that the new Board of Health in Scotland may be able to do a little more. The supply of doctors, not only during the 476 pressure of the war but under ordinary circumstances, is notoriously deficient for these Highland districts. Noble Lords may be surprised to hear that under contracts with the Highlands and Islands Medical Board there are at least two Hindu doctors practising and one native of the West Indies, and that at least one Chinaman applied, but I think his appointment was not made. However competent those doctors may be—and they are all thoroughly competent men—I do not think that it can be a satisfactory arrangement either for the doctor or for the patient. Perhaps it is more unsatisfactory for the doctor than for the patient that these I gentlemen should be practising in the latitude of the Scottish Islands. One native of India has charge of the medical arrangements of one of the most northerly of the Shetland group.
In regard to nurses the case is almost more pressing. There are two classes of nurses in the Highlands, one class having from six to twelve months' training in one or other of the homes and institutions provided for them in Glasgow and elsewhere. This is a very popular nurse, as a rule. They speak the language and assist in the housework, cook the dinner, look after the children, or even milk the cow, but they have not anything like adequate training to make them efficient, especially in a district where the visit of the doctor is bound to be very infrequent. On the other hand there are the highly-trained Jubilee nurses, and it is the intention of the Highland Medical Board that all the nurses supported by them should have this qualification. After a very careful survey it was decided that it was absolutely necessary to appoint an additional 110 nurses to the area under the control of the Board, but so far only thirty-eight have been appointed, and fifteen of them are of the partially trained variety that I have described. I think everybody who knows the district will agree that it is very important that Gaelic-speaking young women should be induced to take the course which will make them fully-trained nurses. I sincerely hope that help in this matter will not be beyond the province of the Ministry of Health; indeed, I think it does come within its province, because at the end of Clause 2 of Part 3 the duties of the new Board are stated to be to assist in the training of persons for health service. I have tried to show some of the difficulties of dealing 477 with public health in the Highlands, and I hope that the Government may be able to give an assurance that the necessary steps will be taken to overcome those difficulties either by the appointment of a special Department or otherwise, so that in a matter so vital to them the people in the Highlands may be put upon something like terms of equality with the population in the other part of the country.
§ On Question, Bill read 2a, and committed to a Committee of the Whole House.