§ Order of the Day for the Second Reading read.
THE EARL OF ONSLOWMy Lords, this Bill has been introduced in order to meet the situation created by the passing of the 116 National Health Insurance Act last year, under which sanatorium benefit ceases. It also carries out the assurance given by the late Minister of Health on the Second Reading of this Bill in another place—namely, that there will be no hiatus in the change from one method of the treatment of tuberculosis patients to another. Before dealing with the clauses in the Bill, it would be convenient to explain briefly the general provisions in regard to tuberculosis treatment, and also the financial result which the cessation of sanatorium benefit under the Act of 1920 will produce.
Your Lordships will remember that under the Act of 1911 the benefits obtainable under insurance included medical benefit, maternity benefit, sickness benefit, disablement benefit, and, lastly, sanatorium benefit. In respect of the sanatorium benefit, considerable discussion arose, and after somewhat lengthy negotiations and consideration, which I need not go into, an arrangement was arrived at by which local authorities were to be encouraged to undertake schemes for the institutional treatment of tuberculosis, the treatment to be available-for insured and non-insured persons. This was taken up by local authorities throughout the country with general enthusiasm, and opportunities for treatment were created in most parts of England and Wales.
The insurance committees which were set up under the Act of 1911 worked in co-operation with the local authorities, and insured persons were taken by the local authorities for institutional treatment, payment being made by the insurance committee from the general Insurance Fund. The way in which this scheme was financed can best be explained by a concrete example. Supposing the total amount expended was £10,000 per year, 20 per cent. of that amount would be available for the institutional treatment of insured persons out of insurance funds. Therefore, £2,000 of the £10,000 would be payable to the county council by the insurance committee, and that would leave a sum of £8,000 which would have to be met from other sources. The way in which that £8,000 was dealt with was as follows. Half was paid from the rates and the other half from the Exchequer. The half which came from the Exchequer was known as the Hobhouse Grant, called after Sir Charles Hobhouse, who took a leading part in connection with the first Act. That was 117 the situation until the end of last month, April 30, when, under the Act of 1920, sanatorium benefit ceased.
Before going into the actual details of the Bill I might also explain the way in which that part of the cost which formerly fell on the Insurance Funds will be met in future. It is proposed to make a fixed grant, equivalent to the amount which the insurance committees had available towards meeting the cost of treating insured persons during last year. This fixed sum will amount, roughly speaking—exact calculations have not yet been made—to £300,000 per annum. The rest of the cost of the scheme is estimated to amount to nearly £2,000,000 during the present financial year, and that sum, as I have already explained, will be met, half by rates and half by the Exchequer. Therefore, the whole finance of the scheme will in future be met by a fixed grant of approximately £300,000 from tire Exchequer. and half the rest of the cost by what is known as the Hobhouse Grant, also front the Exchequer, and the other half from the rates.
Now I come to the Bill as it lies upon your Lordships' Table. Let me refer first to Clause 1. As I think I have already said, the great majority of the county councils and the county borough councils have already undertaken schemes for the institutional treatement of tuberculosis. These schemes have been approved either by the late Local Government Board or by its present successor, the Ministry of Health. In fact, I can say that of the 145 county and county borough councils in England and Wales, not fewer than 124 have already undertaken such schemes, and all but two of the remaining 21 are taking steps to carry out approved schemes. With these schemes there will be no interference, except on the initiative of any particular council. The clause provides that an approved scheme can only be modified on the application of the council with the approval of the Ministry of Health. The only change will be that the part of the cost which has hitherto been borne from the funds supplied by the local insurance commit tees will in future be borne from the fixed grant of approximately £300,000 with which I have already dealt.
Under subsection (2), if any council objects to make these necessary arrangements, the Minister has power to take action to recover the cost. That is to say, the institutional treatment of tuberculosis, 118 where in the past. it has been optional upon local authorities, now becomes compulsory. But the obligation which the Bill places on the large majority of councils is limited to carrying out schemes already introduced. The object of this is merely to ensure that the very few remaining councils come into line with the great majority. I must draw special attention to the last paragraph of this subsection. The paragraph was added in the House of Commons in Grand Committee in order to meet the objection that if in the future the Government were to withdraw or diminish the grant from the Exchequer, county councils and county borough councils might, be landed with a statutory obligation under the Bill to continue institutional treatment of tuberculosis at their own expense.
The clause was moved by Sir Herbert Nield and accepted by my right hon. friend. Any demur that the Government might have felt in accepting this clause was due to the possibility that the mention of the withdrawal or diminution of the grant under the Bill might conceivably be held to foreshadow the possibility of an intention on the part of the Government to contemplate such a course in the future. Such an intention was never in their mind. The Government wishes it to be distinctly understood that it is their settled policy and intention to carry out the financial provisions of this as described in the White Paper; that is to say, to make a grant of approximately £300,000 a year to compensate councils for the withdrawal of the insurance committees' contribution, and an equal moiety from the Exchequer of the sums contributed from the rates for the institutional treatment of tuberculosis. Thus, the Hobhouse Grant will be continued.
I can quite appreciate the fact that even if this clause removes from councils the obligations to continue institutional treatment, if the Government were to fail in their obligations they would not be able to close down their activities at once, because it would he impossible for them to abandon immediately, or even to diminish, the schemes they have in hand. What the clause does is to provide that, in the event of the Government failing to carry out their obligation, the whole responsibility would be thrown on the Government for ally diminution of institutional treatment carried out by the councils. The clause relieves councils of any responsibility in this respect.
119 My noble friend opposite has placed a Resolution on the Paper which seeks to make the obligation of the Government a statutory one. I would venture to point out that the present tuberculosis grant has always been non-statutory, and has been voted by Parliament each year since 1913. In this respect this grant is in the same position as the grants from the Exchequer for other public health services, such as the grant-in-aid for the treatment of venereal disease, the grant for maternity and child welfare, and the grant for the welfare of the blind, although in the case of venereal disease and the welfare of the blind the grants are in aid of services which the local authorities are under statutory obligation to provide. I think it will therefore be realised that the proposal to make the tuberculosis grant a statutory one raises far-reaching issues and is an entirely new departure. In view of these considerations, and of the serious Parliamentary difficulties which would obviously be involved in the insertion at this stage of any such clause, I trust that your Lordships will be satisfied with the undertaking set out in the White Paper, and repeated by my right hon. friend in another place, and again repeated by me this afternoon.
I now come to Clause 2. This clause was added in another place to the Bill as originally proposed by the Government. It is a useful clause, giving power to local authorities to afford after-care to tuberculous patients. I should point out, however, that the cost of this after-care does not fall upon the funds provided by the Exchequer or the rates for the institutional treatment of tuberculosis. If the councils avail themselves of this power, they must make provision for the cost themselves. Clause 3 gives power to the Minister to withdraw approval from institutions.
Clause 4 gives the councils power to act through sub-committees. As your Lordships, many of whom are members of county councils, are well aware; these functions are generally exercised by the public health committee of the council, or even by a sub-committee of that committee which deals with tuberculosis alone. This clause simplifies the procedure by enabling the committee or sub-committee to be the responsible authority for the exercise of the powers of the council, except, of course, as to the raising of the rates or borrowing money. The clause also gives power to the council to add to any such committee 120 or sub-committee members up to 33 per cent. of the whole who are not member of the council.
I should like to draw your Lordships' attention to the object of this. It is more especially intended to enable councils to co-opt on to these committees members of insurance committees. As the administration of insurance benefit has been in the hands—and, in the opinion of the Government, the very capable hands—of insurance committees during the last eight or nine years, it is clear that every facility should be given for retaining the valuable services of members of those committees in working the new arrangements. This clause gives the fullest facilities to councils to avail themselves of the services of such persons. In a discussion in another place the suggestion was put forward that the co-option of members of insurance committees should be made obligatory upon councils, but it was felt that to make such a provision would he to interfere with the independent rights of councils, and that the proper course would be to give the councils full power and every encouragement to co-opt such members, but not to make it compulsory. This clause, I think, carries out that intention.
Clause 5 enables joint committees to be formed of various local authorities to deal with tuberculosis in any particular area as a whole. In theory, under this clause the 145 county and county borough councils in England and Wales could combine to form one joint committee and administer the act as one authority, but, of course, in practice it is not suggested that this should be the case. In practice, the clause is intended to facilitate a small number of contiguous authorities to join together. Thus, a county council may have some small county boroughs within the geographical area of the county, and it may be convenient for them to join with the county council and to administer the geographical area of the county as one whole; or, perhaps, two or three counties with the contiguous county boroughs may join together to form a group; but this will be left to the discretion of the local authorities. Subsection (2) of Clause 5 gives the legal powers of a body corporate to such joint committees. Subsection (3) maintains in being any joint committee of this kind formed under any previous Act. Then I turn to Clause 6, which gives power to the Metropolitan Asylums 121 Board to treat with county councils for the reception of persons suffering from tuberculosis in their sanatoria. The clause merely re-enacts one of the sections in the National Insurance Act, 1915, and extends the, powers of the Metropolitan Asylums Board to receive into their sanatoria any person suffering from tuberculosis, whether insured or non-insured.
This is the Bill as it comes up from another place. In accordance with an undertaking given by the Minister of Health in another place I shall, in Committee, have to move an Amendment having the purpose of appointing an Advisory Committee to assist the county and county borough councils in making arrangements for the treatment of seamen and other persons employed in the mercantile marine who are suffering from tuberculosis, but I need not refer to that at any length, as it will be dealt with when my Amendment is laid before your Lordships in Committee.
I do not know whether any of your Lordships question the wisdom of this Bill, or wish to criticise the action of the Government in making the institutional treatment of tuberculosis a public health matter, but? I think that the following figures may be interesting. For the six years, 1915–1920, the following deaths took place from tuberculosis: in 1915, 54,295, or 151.5 per 100,000; 1916, 53,858, or 152.9 per 100,000; 1917, 55,934, or 162.4 per 100,000; 1918, 58,073, or 169.4 per 100,000; 1919—here comes a considerable drop—46,312, or 125.8 per 100,000; 1920, 42,545, or 112.8 per 100,000. The fall in the rate from 169.4 in 1918 to 112.8 in 1920 is 56.6 per 100,000. That is attributable partly to the cessation of the war and the better living conditions consequent thereon, but it is also, no doubt, attributable to the valuable and admirable work carried out by the councils, and is proof positive of the immense gain to the nation obtained by this work.
I may perhaps conclude by mentioning the increase of facilities for institutional treatment of tuberculosis afforded by local authorities since July 15, 1912. On that date there were but 1,500 beds and 80 dispensaries provided by the local authoritise. At the end of December, 1918, there were 6,749 beds and 365 dispensaries; now, there are 9,879 beds and 411 dispensaries. At the same time the beds in voluntary institutions have increased from 122 2,800 in 1912 to 7,568 now. The total increase, therefore, in beds, in the eleven years mentioned, is from 4,300 to 17,447, or a total of 13,147 beds. I beg to move that this Bill be read a second time.
§ Moved, That the Bill be now read 2ª.—(The Earl of Onslow.)
§ LORD STRACHIE had given Notice, on the Motion for the Second Reading, to move to resolve—
§ " That the Bill be approved subject to the Government undertaking to insert in Committee a clause for the purpose of giving statutory effect to the undertaking given by Sir Alfred Mond to pay to county and county borough councils a grant equivalent to the amount received by those authorities from the insurance committees during the past financial year, and also a grant of 50 per cent. of the balance of the total annual expenditure of those authorities in connection with the treatment of persons suffering from tuberculosis."
§ The noble Lord said: My Lords, the Motion that I have on the Paper was put down by me at the request of the County Councils Association, which had had no opportunity- until the end of last month of examining the Bill. The statement which was made in another place by Sir Herbert Nield, that lie was supporting the Bill as it stood on behalf of the Association, was inaccurate, as it had not been considered by the executive of the Association. I should like to say at once, as regards the Bill as a whole, that the County Councils Association are on the whole, very fairly satisfied. They are very much obliged to the Ministry of Health for the way in which they have considered the many objections which the Association took to the Bill as it was originally introduced, and they are, as I have stated, fairly satisfied with it now.
§ I can assure the noble Earl that they approach this Bill in no hostile spirit. But the feeling at the executive meeting of the Association was that the Bill makes sanatorium treatment for the first time compulsory upon county councils, and that in the Bill there is no statutory provision for the payment of county councils. It is very natural, when ratepayers are told they have to carry out something under compulsion and not voluntarily, that they should say, "Why should there not be a compulsory provision in the Bill that the 123 Exchequer Grant should equally be compulsory and not simply depend upon the undertaking of the Minister, for the time being, or upon Parliament being ready to vote the particular sum required?"
§ I understand that in another place a White Paper was circulated with regard to this Bill. I see that your Lordships have not the benefit of it. It has not been circulated to members of this House, and I cannot see that it is on the Table of the House. Therefore, we are under a disability in this matter because we have not the advantage of knowing how the White Paper professes to deal with the situation. I think it would be desirable that in the future, when the House of Commons have an explanatory Paper given to them, we should have an equal advantage and not be kept in the dark in these matters, and have to go to another place for information.
§ As regards this question of the money, I think, as I have said, it is very natural that local ratepayers, represented by the County Councils Association, should think there ought to be statutory provision. I recognise that in the past it has been done by undertaking, but I would like to remind the noble Earl that the county councils are a little shy of assurances. Assurances have been made in the past, and have not been carried out by the Government, because Ministers change and Governments change, and these undertakings are not always adhered to strictly.
§
I would like to mention a case that happened in the collection of local taxation licences by local authorities. It was proposed in the Finance Act, 1908, that county councils should have the duty of collecting all these local taxation licences. It was pointed out that the duty would involve considerable expense, and an undertaking was given that £40,000 a year would be paid to cover that cost of collection. On July 13, 1908, a deputation went to the then Chancellor of the Exchequer, the present Prime Minister, Mr. Lloyd George, from the County Councils Association and the Association of Municipal Corporations. That deputation urged that the amount was not sufficient. Mr. Lloyd George said in reply—
This is an experiment, and, if you find at the end of a year or two that it costs you more than you expected, the Treasury are not shutting the door to the reconsideration at some point. We propose to begin at that figure, and. if you find
124
that it is a much more considerable burden than the sum we have allocated, then you will have a case fur coming to the Treasury and asking for a reconsideration of the amount.
So far, so good. But what happened? As a matter of fact, although there were constant protests with regard to that matter, and there was insufficient in 1911, and again in 1916, no concessions were obtained.
§ It was not until February of this year that the grant was increased to £60,000. Therefore, although the Chancellor of the Exchequer of that day assured the County Councils Association and the Municipal Corporations Association that if the £40,000 were not found sufficient it would be made up (because that is what it practically amounted to), and although deputations went to the Treasury about the matter, it is only in 1921 that that additional amount has actually been made good to county councils. So that from 1908 to 1921 those county councils have had to bear the loss, sometimes a considerable loss, of the cost due to this cause. I think it is only fair, therefore, to say that county councils have reason to feel rather shy of assurances given, and naturally prefer to have a statutory obligation. No doubt the Minister, when he gives the assurance, has every intention of carrying it out, but apparently, when the thing is done, somehow it is not carried out.
§ There is also the point raised by the noble Earl himself, when he said that under Clause 1 county councils will not be obliged to carry out treatment in so far as money from the Exchequer is not forthcoming. That is, no doubt, a very fair and proper provision, but at the same time it is not one for which the County Councils Association have any enthusiasm. The noble Earl himself very frankly admitted that county councils have done a great deal in the past in this matter to relieve the country of the burden of this great scourge, and they are not likely to want to diminish their treatment. In many eases also, as I think the noble Earl has acknowledged, it would be very difficult, even if the Government reduced their grant, for the councils to reduce their treatment to the equivalent amount, having already made all their arrangements. Indeed, I think there would be a great outcry in the country if they did so. Therefore, I do not think that provision in the Bill is one for the acceptance of which in another place 125 we have any particular reason to thank the Government.
§ I have been asked by the London County Council to raise another question, which was dealt with by the noble Earl. It refers to after-treatment under Clause 2 of the Bill. The London County Council were unaware what the provision would be, because it was not made clear, as it has been made clear by the noble Earl to-day, that the Government had no intention of making any contribution towards the expenses of a county council for after-care of tuberculous patients, cured or partially cured. I understand the feeling of the London County Council is that there ought to have' been sonic undertaking given, and some provision made, by which county councils who undertook this after-care under Clause 2 should be reimbursed half the cost, as is the case under Clause 1. I think there is a good deal to be said for the argument of the London County Council, though I am not by any means one who wants to see expenditure increased, either wider local rates or under the Exchequer. But there is this to be said for the point of view of the London County Council—that very often it might be true economy in the end if, under Clause 2, they took steps to treat these people who were thought to be cured and thus to prevent a relapse which would cause them to be put again into sanatoria for further treatment. Perhaps the noble Earl will consider that question at some future time, if it is impossible to do so at the present moment. I desire to move the Motion standing in my name.
§ THE LORD CHANCELLOR (LORD BIRKENHEAD)This is a Motion which I feel, on grounds of order, the greatest difficulty in putting. The Motion of the noble Earl is for the Second Reading of the Bill. It is quite unfamiliar in my Parliamentary experience that on a Motion for a Second Reading there should be a kind of conditional sanction given to it, on which the House is to pronounce before it has pronounced on the Second Reading. I do not know whether the noble Lord has considered the alternative course, that unless he obtains an assurance from the Government that would satisfy him he should vote against the Second Reading. That is the course invariably adopted in the House of Commons, and I think in your Lordships' House, and I have never known a course adopted such as the one suggested, which I think would be a very unwise proceeding.
§ LORD STRACHIEI am entirely in the hands of the House, but I thought there had been Motions framed in this way. May I say, however, that I would move it only in order to get sonic reply? I have no intention of pressing it.
LORD HARRISCan the noble Earl now, or will he at some future time, give the House any idea of what will be the percentage proportion of cost contemplated under the Bill thrown upon the rates, and what will be the percentage, thrown upon taxation?
THE EARL OF ONSLOWThe noble Lord opposite referred, in the first remark he made, to the fact that the White Paper was not on the Table of the House, and he asked that in future when White Papers were issued by the House of Commons they might be available to your Lordships. I am sorry that this White Paper has not been available to your Lordships, but in future I will endeavour to take such steps as will meet the noble Lord's wishes.
With reference to the ease which the noble Lord mentioned, which was brought by the County Councils Association before the Treasury, I think he said that a promise was given to make good certain costs if the councils found that they were greater than they had expected, and that this promise was not fulfilled until this year. I would point out, with great respect, that this is rather a different case. I do not really know the facts of what took place then, but this is a definite promise on the part of the Government to find a sum of £300,000, roughly speaking, per annum, to reimburse the councils for the sum that they have previously received from the insurance committees, plus a further grant this year of £1,000,000—that is, the Hobhouse Grant, the; equivalent of the £1,000,000 which falls on the rates. That is a definite promise which has been given. I have tried to convey it as explicitly as I could. The promise has been given most explicitly by my right hon. friend, and it is also stated in print in the White Paper.
I can assure the noble Lord that it is the fixed and firm policy of the Government to continue this institutional treatment of tuberculosis. If the Government were to fail in its obligations, as the noble Lord contemplated, the result would be that no responsibility would be thrown on the county councils for the continuance of this institutional treatment. It is per- 127 fectly true, and the noble Lord agrees with me, that county councils would not, or could not, immediately abandon their institutional treatment if this almost impossible case were to arise, but the whole responsibility for any failure to carry out the obligations to tuberculous persons would be entirely on the Government, and not on the county councils. Naturally the councils would not be in receipt of so much money. They would be entirely dependent upon the rates and gradually the facilities for treatment would diminish, perhaps to nothing at all. Therefore, I venture to think it would be really impossible for any Government to go back upon this assurance. I hope that the noble Lord and those whom he represents will accept this explicit assurance which we have given him.
The last point mentioned by the noble Lord dealt with after-care, which is provided for in Clause 2. This was not put in the original Government Bill; it was added in the House of Commons somewhat in the light of an afterthought. If provision were made for this after-care treatment in the same way as for the institutional treatment it would be a matter for discussion when the further measure is brought before Parliament. I do not think it could be introduced at the present moment, but I can promise the noble Lord that the question he has raised will be borne in mind by the Ministry and considered when there is a further opportunity.
I am not quite certain that I followed the point raised by the noble Lord, Lord Harris, and if my reply does not satisfy him perhaps he will give me another opportunity. In the next financial year it is thought that the total cost will be £2,300,000. Sums of £300,000 and £1,000,000 will he found by the Exchequer —that is, £1,300,000 by the Exchequer—and £1,000,000 by the rates. I do not know whether that answers the noble Lord's question.
§ LORD SYDENHAMCan the noble Earl say whether the figures he has given represent the maximum annual expenditure which would fall under this Bill?; because, in dealing with these Bills in this way one is always afraid lest they open the door to steadily progressive expenditure. The 128 Ministry of Health now expends £24,250,000 a year, which is rather more than the whole cost of the Army not many years ago. I should be glad to know whether the figures given by the noble Earl may be regarded as final.
THE EARL OF ONSLOWI do not think I can say that they may he regarded as final. The block grant of £300,000 may be regarded as final I think, but the sum of £2,000,000 depends upon the amount which the councils spend under the approved scheme each year, which may be more or less. I think that is the answer to the noble Lord.
VISCOUNT GALWAYI should like to ask the noble Earl over what period the expenditure of the £3,000,000 is supposed to be spread. Is it all going to be spent in one year, or in two years? It seems to me an enormous sum to ask the ratepayers to spend at the present time, when the limit of their capacity has already been reached. I do not think they should be asked to embark upon an extravagant scheme of this character, which seems to be a legacy from the late administration of the Ministry of Health. After what happened in this House last session one hoped that there was going to be an improvement. Will the noble Earl kindly tell the House over what period the spending of the £3,000,000 will be extended, and whether it is to be capital expenditure or not?
VISCOUNT GALWAYI understood the noble Earl to say that a sum of £3,000,000 would be expended from the rates.
VISCOUNT GALWAYThen I was mistaken, but I trust that no additional expenditure will be placed on the ratepayers, considering how heavily burdened they are already.
THE EARL OF ONSLOWI think the noble Viscount is under a misapprehension. It is not additional expenditure. He knows much better than I do that this institutional treatment has been going on for some time, and that half of the cost has been found by the rates and half out of 129 the Insurance Grant. This is merely prolonging that. The£300,000 will now be found as a block grant from the Exchequer to compensate councils for what they will no longer receive from the Insurance Commission.
LORD HARRISMy Lords, if I have not exhausted my right to speak on this matter, I should like to take this opportunity of entering a protest against the enormous charge which is being thrown upon the rates for this purpose. In concluding his speech just now the noble Earl referred to this as a national object. He said that a reduction of something like 20 per cent, in the number of tuberculosis cases was a great national advantage. It is a very great advantage, but it is a national advantage as the noble Earl said; so why should so large a proportion of the cost be thrown upon the rates? This is merely a continuation of what has already been done. It means that the House of Commons has agreed to it in past years and allowed this extra charge to be thrown on the rates. It is growing every year, and the ratepayers are getting very indignant that these charges should be laid on them almost carelessly by Parliament. Therefore, we are entitled, I think, when we have an opportunity, to enter our protest against it. I do not know how the suggested proportion was arrived at. Why should it not be 25 per cent. on the rates and 75 per cent. on taxation, which seems to me to be a very much fairer proportion?
The fact of the matter is that Government officials, who are paid, are very glad of the opportunity of inducing Parliament to throw upon county councils, who are not paid, a lot of the work they ought themselves to do. Of course, they will go on throwing all the burdens they can upon county councils and local authorities, regardless of the cost to the rates, until a very firm protest is made by those who represent the local authorities and the ratepayers. I should deem myself neglectful of my duty if, upon every occasion that I find in Bills brought into this House a proposal to increase the gross charges, or rather the gross amount that is going to be spent out of rates upon some national project, I did not enter my solemn protest.
§ On question, Bill read 2ª, and committed to a Committee of the Whole House.