§ LORD MERTHYR had given Notice that he would ask His Majesty's Government how many county councils in England and Wales have failed to formulate arrangements for securing that medical officers of health shall not engage in private practice a medical practitioners, in accordance with the provisions of Section 111 of the Local Government Act, 1933; in respect of how many of these counties, if any, the Minister has not exercised his power of requiring the councils to formulate arrangements; in respect of how many counties, if any, has the Minister not himself formulated arrangements after the failure of the councils to do so within six months of being so required; and what steps are proposed to be taken for ensuring the better observance of the law; and move for Papers.
§ The noble Lord said: My Lords, I beg to move the Motion for Papers and to ask the Question which stands in my 498 name. This Question is substantially the same as one which I asked in your Lordships' House about twelve months ago, and the reason why it is being asked for the second time is that the position disclosed by the answer which I then received from the noble Viscount (Viscount Gage) was to my mind of a highly unsatisfactory character. The noble Viscount gave me, I am satisfied, the very best answer which he could give, but he cannot make bricks without straw. The legal position, if I may state it very briefly, is that in the Local Government Act of 1929 there is, in Section 58, a mandate to county councils to formulate schemes under which medical officers of health in county districts shall not be able to engage in private practice, and, also in that Act, power is given to the Minister of Health, in default of the county councils doing this work, to enable him at the expiry of six months' notice to do the work himself. That mandate and those powers were renewed by the Local Government Act of 1933, in Section III.
§ In December, 1936, when I asked this Question before, I was told that out of sixty-one county councils no fewer than twenty-seven had not formulated these arrangements, and that was nearly seven years after the Act came into force compelling them to do so. I think that is unsatisfactory, and I am very anxious to know, now that we have nearly reached eight years since that day, how many more county councils have carried out and observed this mandate. I have paid careful attention to the reasons given me by the noble Viscount in the reply which he was good enough to make last year. Amongst other things he said that the principal cause of delay was the fact that the review of county districts, also under the 1929 Act, had not been completed. Unless I am mistaken, that review has now been completed, with one possible exception, and I do not think even that; and if that was the principal cause of the delay I venture to suggest that now that cause is removed the work ought to proceed apace.
§ The noble Viscount then mentioned the default powers contained in the Act, and stated that those who did not agree with this particular reform resented the imposition of these default powers. No doubt that is correct, but I who am on the other side in this little battle claim, and 499 I hope with some justification, that His Majesty's Government ought to help those who are on the side of the law in this matter and ought to implement the wishes and directions of Parliament expressed in one of the best known Acts which is upon the Statute Book. Then the noble Lord said that the relations between the Ministry and the local authorities have to be maintained with discretion. My observation upon that is that what is called, in Whitehall perhaps, "discretion" is a quality that may bear different names in the country, and I do not think I should be overstating it if I said that in some places that quality is called not "discretion" but "weakness." In 1936, a year ago, there were these twenty-seven councils and the noble Viscount said that the majority of them were taking steps to comply with the Act. If that be so, I confidently expect that he will be able to tell me to-day that that majority have now completed taking those steps and have reached the end of their journey.
§ He also mentioned that three counties only appeared to have failed to take any steps at all to comply with the Act. I desire to know what has been done by the Ministry in connection with those three counties. Has the Minister taken upon himself his powers to give the necessary notice? If so, has that produced any result? And if the notice has expired has the Minister himself formulated the arrangements? The noble Viscount said, quite rightly, that this appointment of full-time medical officers had to be delayed until the existing medical officers retired, which might, in some cases, mean a long period. I agree, but does not that really add an argument to my side? If there is to be this inevitable delay in the appointment, is that not an argument for all the greater haste in the formulation of this scheme? Temporary appointments of medical officers of health on a part-time basis are still being made, to my knowledge. I know of one appointment made since last year in an urban district where the medical officer receives the princely salary of £10. He is not a permanent official and yet presumably he is expected to acquaint himself fully with local government and public health legislation.500
§ I do not think that is a satisfactory state of affairs. Why, if that is so, has the Minister not used these powers? Why are we always being asked to pass fresh public health legislation if the existing legislation is not to be enforced? Why are we so often asked to spend, and why do we spend, so many hundreds of thousands of pounds upon the building of wonderful sanatoria for curing disease if we cannot afford the few thousands which would be necessary for the appointment of full-time medical officers which might prevent the disease? This is not, as I said last year, a good subject for economy. If it is thought to be so then something should be done to indicate quite clearly that this particular piece of legislation is not going to be enforced. I do not want to weary your Lordships, and sometimes I have asked myself whether I am right in persisting in this matter, in renewing the Question which I asked only a year ago. But when I think of some of the conditions in country districts in regard to housing and sanitary arrangements the answer is always that I ought to persist.
§ If your Lordships will be indulgent, I would like just to quote one illustration of what I mean when I say that housing conditions—and I think they could be improved to some extent, at any rate, by the appointment of full-time medical officers—in this country are very far from being satisfactory. The day before yesterday I visited a house. After walking for a quarter of an hour from the nearest road I reached this building, which contains two rooms, one 12 feet by 11 feet 6 inches and one a little smaller than that. There are apparently no foundations to it. There is no damp-course; there is no back door; there is no food store; there are no rainwater troughs or pipes; there is no ventilation except through the front door when it is open and through a few small holes in the roof which, as a matter of fact, is the best part of the house. There are two small windows, very heavily patched and repaired, neither of which can be opened. All the windows and doors face north. The chimney stacks of the house are loose, and it is clear that if the house did not happen to be in a sheltered hollow at any rate the chimney stacks, and possibly the whole house, would long since have blown down. Water from a mound of earth at the back of the house soaks literally through the wall on to the floor of the kitchen, which is a very bad mortar floor. In that floor is a hole just sufficiently 501 large to take the saucepan which is used for baling out this house. I was told, and I can quite well believe, that in that dwelling sleep does not depend on darkness or light but upon whether it is raining or fine.
§ In this house live seven people. Five of them, of both sexes and of an average age of over eighteen years, sleep in one room. Each of those five persons has 27½ square feet of floor space. Your Lordships will remember that no windows in this house open. Four of the male members of this household work at the local colliery, where there are no pithead baths and where conditions are unusually wet. Your Lordships can well imagine the condition of affairs when they go home, always covered with coal dust: and very often wet to the skin. This house was condemned two-and-a-half years ago. I am informed that the medical officer paid his last visit over a year ago. This is not a picture of life fifty years ago, but of the day before yesterday. I have heard people say—though not referring to that house—that they are satisfied with the present conditions of the appointment of medical officers of health. I am not satisfied, and I have asked myself therefore whether I need apologise to your Lordships for taking up your time this afternoon. So long as these conditions exist, conditions which I have seen for myself, I do not think I need make any apologies. I know that other people are to blame, but am I wrong in starting from the top and in asking that at any rate the Ministry of Health and His Majesty's Government shall do their part in trying to implement this legislation? I should like nothing better than to be told this afternoon that there is no further reason for me to ask this question; and that it will be done, the Act will be carried out and the conditions under which people are compelled to live will thereby be remedied. I beg to move.
§ THE EARL OF LISTOWEL
My Lords, I think the noble Lord opposite deserves the cordial thanks of your Lordships' House for the persistence with which he has raised this Question. He brought it up for the first time just a year ago; he has raised it again to-day, and I only hope that he will continue to raise it until he receives a satisfactory answer from the Government. That hope will, I think, be shared by all members of your Lordships' 502 House who have acquainted themselves with this problem. It is urgent, both in itself and because it raises certain questions of principle. As the noble Lord pointed out, the Local Government Act, 1929, contained a provision whereby local authorities were asked to employ whole-time medical officers of health who were not at the same time carrying on a private practice. That provision has not as yet been fully applied. That in itself is an extremely unsatisfactory situation. An Act has passed through both Houses of Parliament, it has received the Royal Assent, and it has not yet, eight years after its passage, been fully carried out. I am perfectly certain that your Lordships will not wish to encourage people to think that the law of the land can be evaded by quietly ignoring it. I am perfectly certain that your Lordships will wish to uphold the authority of Parliament and to obtain respect for the body of law for which it is responsible. That is the question of principle that is raised by the matter to which the noble Lord opposite has referred.
There is also the practical problem of how to enforce the existing by-laws and the body of law which have to be applied by local authorities in their areas if our standards of public health are to be maintained. As these provisions can only be applied by a person who can give his whole time to the job and who has enough opportunity to be able to study the matter with which he has to deal for the local authorities, it is clearly harmful that a medical officer of health should have to divide his time between his own private practice and his duties towards the local authority who employs him. It is quite evident that these minimum provisions of public health cannot be properly maintained unless the conditions laid down in the Local Government Act, 1929, are fulfilled.
I think that the claim that can properly be made to the Government is that either we should receive an assurance that this Act, which has by now received the full consideration of the local authorities and about which they have surely had time to make proper arrangements, will be carried out in the spirit and in the letter of the law, either by the local authorities or by the Ministry of Health in virtue of its power to take over this function if it is not discharged by the local authorities; or we should be told by the Government 503 that they are willing to amend the Local Government Act or the Public Health Act, as the case may be, by deleting the provision that has not at present been properly operated. Those seem to me to be the alternatives which can very fairly be asked of the Government. For my part, I share the noble Lord's hope that the Government, in spite of the really unjustifiable delay which has taken place, are in a position to tell us that almost all the county councils have been able to employ a whole-time medical officer of health, and that those who are not in such a position will be relieved of their duty by the Ministry of Health.
My Lords, my noble friend Lord Merthyr presented his case again with great clarity, particularly when he referred to my previous reply as highly unsatisfactory! Again, however, I think he has been inclined to present the issue as a simpler one than it really is. He certainly suggested that if the local authority did not prepare a scheme itself, the Minister of Health had the duty of imposing one on it. Of course that is not actually the position. The Minister has no power to compel the local authority to adopt a scheme that he makes. It is true that he can make a scheme, but if the local authority do not like it, all the Minister can do under the Act is to insist that they shall not engage any more part-time medical officers. It was realised, of course, when this Act was passed that there might be difficult and obstructive authorities who were really intent on frustrating the objects of Parliament, and therefore these default powers had to be given. At the same time, I think that most of us would agree that, when dealing with this rather delicate and important question of public health, it is better if possible to arrange things so that the Ministry, the local authority and the doctors all work harmoniously together as a team. The noble Lord talked about bad housing. I entirely agree with him. I must confess that I did not quite follow his argument, but it seemed to be that the extent of bad housing depended largely on the presence or absence of a whole-time medical officer of health. Yet I think your Lordships will remember that he said that the house about which he was talking had been condemned two years ago. If that is so, it 504 seems to me that the part-time medical officer did his duty, as I suppose it was condemned on his recommendation, and it was the authority which seems to have been at fault in not carrying out that recommendation.
I would just like to put one or two arguments, as a matter of principle, on the other side. Your Lordships may have read recently in the Press a letter emphasising the extreme importance of keeping collaboration between the public medical officers and the local practitioners. Supposing the Minister were to use this power a great deal more freely that he has, and supposing some mishap took place in the locality, might it not be said that the Minister had contributed to lack of collaboration by interfering prematurely and without local knowledge? Then we must also realise the practical limitations of the procedure which the Act lays down. Lord Merthyr did touch upon them, but I do not think he gave quite enough weight to them. As he said, in some places the part-time medical officers have not yet completed the period for which they were engaged to serve under contract. I do not myself see very much point in preparing a scheme a long time before these contracts have ended, because in that case it might be sometime out of date before these contracts did fall in.
The noble Lord also referred to the long period which has elapsed since the passing of the Act, and he referred to the explanation of that which I gave on the last occasion, which was that the county review under the Act of 1929 had taken much longer than was anticipated, and that one authority had not yet completed its county review. I do not think it is necessary for me to go into the reasons for the delay in the completion of that county review, but it does furnish some explanation of the delay which has occurred, because it is impossible to formulate a scheme before you know the extent of the area which you have to cover. I am not arguing for a moment that the Minister ought not, in any circumstances, to do anything. On the contrary, I quite agree that these whole-time medical officers should be the rule, and on the whole I rather welcome this debate as showing that Parliament does take an interest in the matter, and would be prepared to support the Minister in any action which he might take. But I 505 do want to suggest that these default powers ought to be used with certain judgment—I will not use the word "discretion" if the noble Lord thinks that means "weakness." I think they ought to be used with discretion, and when you have different values in different parts of the country, it is rather difficult to lay down any hard and fast rule as to what the Minister ought, or ought not, to do.
Parliament gave the Minister a discretion in this matter, and he has, rightly or wrongly, used that discretion to encourage the authorities where he thought that there was a real case of obstruction or a real breakdown in the Act, and he has not used it where he felt that there was a genuine but slow effort being made to formulate these schemes. I think it is necessary to repeat this point, because I quite admit that if you do not take them into account the noble Lord has prima facie a good cause for complaint. I am perfectly prepared to lay any Papers that he may require, and to give him any information which he may require; but I would ask the House to judge these statistics in the light of the difficulties which the Minister himself has got to face, and which I have endeavoured to put forward, and not to dispose of the matter in quite such summary fashion as the noble Lord would have us do.
There are sixty-one counties which, under the Act, have to formulate these arrangements. Thirty-nine have already done so. One is on the point of sealing arrangements which have already been made, and in another case the Minister has used his powers and formulated a scheme himself. That leaves us with twenty outstanding cases as against twenty-seven last year. In one case the county review under the Act of 1929 is not yet completed. In two cases arrangements have only just been completed. In two more cases the populations of the counties concerned are so small that arrangements have in fact to be made with neighbouring counties, and these, in turn, have been held up for some of the other reasons indicated. In all the remaining cases except four, the Minister is satisfied that a scheme in some degree or other of completion is under consideration. I can give the noble Lord full particulars of these cases if it is necessary, but he will see that there are two more 506 cases where the Minister now feels that the arrangements which he thought were going to be ready last year require further consideration, and in two of them he has already started default procedure. In the county in which I think the noble Lord is particularly interested, default procedure was started but was suspended temporarily because it was understood that the county was putting the matter in hand and was likely to produce a scheme of its own.
I would perhaps draw your Lordships' attention to what I said last year in my concluding sentences. I said:I hope I have satisfied the noble Lord that, though progress may be rather slow, it is going steadily on. It never was contemplated that this reform should be carried out in a short time; but, provided the progress is steady, we feel that the purpose of the Act is served.I do not know whether, having now heard what I have said, my noble friend still thinks the Minister has not made sufficient use of the "big stick." I would suggest that there is the other side of the question, because although I am entirely in agreement that the law ought to be observed, and there are great advantages to be derived from having whole-time officers, the really important thing is that their employment should take place under conditions where the best advantages can be obtained. Although wilful defiance of the law ought to be resisted, if you are going to achieve durable success, as we hope we are, you ought to start your scheme in a good atmosphere and not one of suspicion and non-co-operation. After all, we are a democratic country, and although I hear noble Lords opposite reiterating that, I do not always feel that in practice some of their speeches seem to bear that out. We are trying, as I have said, to preserve co-operation, because we feel that it will be the most efficient course in the long run.
My Lords, much as I should like to, I do not intend to enter into any argument upon the points raised by the noble Viscount. I may possibly reserve that for a future occasion, though I hope that that will not be necessary. But may I just say that I do very much envy the facility with which the noble Viscount can present to your Lordships' House in such an admirable way what I really must describe as a very unsatis- 507 factory case. I am very grateful to him personally for taking so much trouble this afternoon, and I beg leave to withdraw my Motion.
§ Motion for Papers, by leave, withdrawn.