HL Deb 28 July 1942 vol 124 cc15-44

LORD DAVIES rose to draw attention to the failure of the Ministry of Health to deal with the staffing requirements of institutions for the treatment of tuberculosis; and to move for Papers. The noble Lord said: My Lords, I desire to draw the attention of the House to a matter which is, I believe, an important one—namely, the present position in regard to the treatment of persons suffering from tuberculosis. I need not remind your Lordships that in the past this scourge has taken an enormous toll of the youth of this country, especially between the ages of twenty and thirty-five, and some of us entertain certain misgivings that the steps which are being taken to deal with the problem now, in war-time, are inadequate. I would point out that this is really a very urgent matter because it does not mean merely dealing, as in peace-time, with the provision of treatment for persons who have become victims of this disease; it also, in these days, in this time of war, bears upon the conservation of our man-power and woman-power. I am sure we shall all agree that that is a very important matter in the conduct of the war, and that the provision of treatment for persons suffering from tuberculosis is a factor which affects our war effort.

I do not think I need labour that point because it is quite obvious that if there is an increase in the number of persons throughout the country suffering from tuberculosis, there must also be an increase in the sources of infection. It is cumulative, and we all realize, also, that this danger is increased under war conditions, because the powers of resistance possessed by people throughout the country have become lowered. My noble friend the Earl of Cork reminded us the other day of the deterioration which had occurred in the health of some of the personnel of the Mercantile Marine owing to conditions under which our sailors have to serve during the war. I think we shall be agreed that not only is it ameliorative treatment that is needed. The other day the House decided to insert in a Bill an Amendment, which the noble Earl submitted, to provide pensions far sailors discharged from the Mercantile Marine in consequence of their having contracted tuberculosis. I venture to suggest that not only are they entitled to pensions, but they are also entitled to treatment in appropriate institutions in order that they may have the opportunity of recovering their health and strength once more.

It was anticipated that, owing to war conditions, there would be a considerable increase in the number of new cases which would require treatment, and in the number of deaths from tuberculosis. But, fortunately, up to now at any rate, there has not been a tremendous increase in the number of cases. In 1938 there were 26,176 deaths. In 1941 the figure went up to 28,669. That is to say, that in the 3, years there was an increase of 2,493 deaths from this disease. But if we compare these figures with the figures relating to the last 25 years we find that, whereas in 1916 54,000 persons died from tuberculosis, in the year 1941 this figure had been reduced to less than 29,000. That is to say there was a decrease during the 25 years of 26,000, or, roughly, there was a consistent decrease in the number of deaths at an average rate of a thousand a year during those 25 years. Unfortunately, as I have already said, during the last 3 years there has been a setback, and the figures are beginning to rise again. This does not necessarily mean that we should be alarmed, but it does mean, I think, that we should be concerned about the position. That is, apparently, the view of the Ministry of Health, because I understand that the Minister, in co-operation with the Medical Research Council, has arranged for an expert investigation to be made "of the extent and causes of the war-time increase in the incidence of tuberculosis, particularly among young women, and also to advise the Medical Research Council regarding possible preventive measures." It is very satisfactory to know that the Ministry are taking measures in advance to deal with what may become a very serious matter, in view of the war conditions which now prevail.

I venture to think, however, that the real problem is that of how further facilities and accommodation are to be provided for the treatment of these cases. There are, unfortunately, considerable numbers of persons who are now awaiting treatment in our tuberculosis hospitals and institutions. A few days ago I asked a question on this subject, and the Government's reply was to the effect that in England there were 1,507, in Wales 400, and in Scotland 652, or a total of 2,559, civilian persons who were waiting for admission into hospitals and sanitoria. This figure does not, I understand, include ex-Service patients—men who have been discharged from the Services because they were suffering from tuberculosis. In Wales we have 130 ex-Service men waiting for treatment, in addition to 400 civilians.

I hope that your Lordships will forgive me if I make special allusion to the position in Wales, because it is one with which I happen to be more familiar than I am with the position in England and Scotland. In Wales, thirty years ago the local authorities, realizing that this disease paid no attention to county or borough boundaries, decided that the attack upon it should take the form of a national campaign, and therefore the King Edward VII Memorial Association, in memory of King Edward VII, was established, to provide treatment and diagnosis for all the counties and county boroughs in the country. King Edward once said, "If preventable, why not prevented?" Consequently, as I have said, the county councils and borough councils constituted this Memorial Association, the Council of which is a sort of joint authority to deal with this scourge from a national standpoint and attempt to eradicate it. The number of beds which the Association has up to the present is 1,952, and in 1938 the number of people who were waiting to receive treatment, and who in many cases had been waiting for a considerable time, was 360. That figure rose to 530 in 1942, an increase of 170.

I need not emphasize the necessity for early treatment. Obviously a patient has much more chance of making a recovery if he is able to secure early admission into one of these institutions; and there is also the obvious benefit that, when patients go into these institutions, they do not spread infection amongst their families, their friends and their colleagues. Although it is very important, as the Minister of Health pointed out the other day, to have early diagnosis, it is perhaps even more important that the patient should receive early treatment. In the debate on this subject in another place, the Minister said: "We need to give greater practical effect to early diagnosis." I am sure we shall all agree that that is a very important part of the campaign, and recently, as your Lordships are probably aware, great strides have been made in the technique of early diagnosis. Instruments and apparatus have been designed for what is described as "mass radiology." Up to a short time ago, the plant for this purpose was manufactured in the United States of America, which was the only country where it could be obtained. Unfortunately there has been considerable delay in securing some of these plants, but we are told by the Minister that they are now being manufactured in this country, and that steps are being taken to supply local authorities and other bodies concerned with this new apparatus, which will enable mass radiology to be carried out on an extensive scale.

I venture to suggest to your Lordships, however, that early diagnosis really does not solve the problem at all. What it means is that the waiting lists of those certified as suffering from the disease, and who are awaiting admission to sanatoria, will be increased, without any practical measures being taken to deal with them. It seems to me, therefore, to resolve itself into a question of treatment, and particularly of an increase in the existing facilities for the treatment of tuberculosis cases in sanatoria and hospitals, enabling the institutions which exist already to keep their beds fully occupied, and preventing the closing down of wards, which, unfortunately, is taking place at the present time. We felt the need for an increase in the number of beds even before the war, and, if the war had not intervened, by this time in Wales we should have opened a new hospital with between 250 and 300 beds. Unfortunately the war put an end to that project. In the meantime, emergency hospitals have been established by the Ministry to deal with casualties and ordinary cases. They were not specially erected for dealing with tuberculosis cases, but we hoped that, until the necessity arose for utilizing them in the manner for which they were intended, they would become available for the treatment of tubercular cases. In one instance in North Wales six pavilions with 200 beds have been built, and unfortunately we have only been able to use about half that accommodation for tubercular patients, the remaining half still remaining empty. In the existing institutions there are at present about 150 beds with no patients, in spite of the fact that we have this long waiting list, and, unfortunately this number tends to increase rather than to diminish.

I understand that the bottle-neck has been caused through a shortage of nurses and of domestic staff. Before the war—I suppose as a reminiscence of the days of Florence Nightingale—the nursing profession was regarded as the noblest profession any woman could enter, but even before the war we experienced difficulties in finding an adequate number of nurses to take charge of the patients in our hospitals and sanatoria. During the war the situation has been aggravated very much owing to the competition of the fighting Services, and especially of munition factories, where the remuneration is so much more attractive. We have been blamed—I think all hospitals have been blamed—for not having improved the conditions of service, and especially the remuneration, of nurses, and I think that criticism is very well founded; but at any rate in the case of the Association during the last three years, 1939, 1940 and 1941, increases of salary have been made, and attempts have been made to improve the conditions under which our nurses work. As your Lordships know, this matter is now being considered by the Rushcliffe Committee. They have been charged with investigating the whole problem. I venture to hope that the report of the Rushcliffe Committee will be expedited, and that they will be able to recommend improvements in the conditions of service for nurses throughout the country, and also the establishment of a uniform standard, so that there may be an end of the competition which has hitherto gone on among various institutions for the services of nurses.

But, when all is said and done, I think we shall all agree that the real responsibility for this state of affairs rests with the Ministry of Health. The Minister rather contradicts himself, because he said in a speech on June 30: Indeed, it is really a difficult problem for propaganda because it is true to say that there is no national shortage of nurses, but that there are particular shortages of nurses in particular places, and especially a particular shortage for particular services. He was asked "Is there, or is there not, a total shortage of nurses?" To which the Minister replied: Over the whole field of the nation I estimate that I could do with another 12,000 nurses. … For tuberculosis we need an immediate enrolment of about 1,200 nurses. That is our national problem. In Wales our normal establishment is down by 15 per cent. and although we have taken all sorts of measures to enlist the number required we have miserably failed, and we attribute that failure—not altogether perhaps, but more or less—to a circular, Circular 2340, issued in April, 1941, by the Ministry of Health.

We have two criticisms to make in regard to that circular. In the first place, it gave all the nurses an option, and there was an undertaking that they would not be directed to go to any particular form of nursing or any particular institution: there was to be complete freedom of choice. Most people in these days are being ordered about, told where to go and in what sphere their services can be most usefully employed. When our men are being sent to fight, I fail to see why, in the case of the womanhood of the country, similar directions should not be given as to where their services can best be utilized. I suggest, therefore, to the Ministry that they should withdraw this undertaking, which was made more than a year ago, and exercise their powers of direction, so that these persons may be employed where their services are most needed. The second objection we have to the circular is that it has done a tremendous amount of harm in influencing nurses to go to hospitals other than tuberculosis institutions. It is suggested in Paragraph (c) (3) that there is far greater risk of infection from this disease in tuberculosis hospitals and sanatoria than there is in general hospitals. Actually young women under the age of twenty-one, even with their parents' consent, are unable to volunteer their services in tuberculosis institutions.

We thought at the time that this was a most extraordinary statement to make, and we are glad now to find that the Minister in his speech the other day said: I want to say advisedly that there is no ground for the belief that nursing in a sanatorium need involve any greater risk of contracting tuberculosis than nursing in other hospitals. I want to underline that. Then there is a very interesting report, in which Dr. Trayer, Medical Superintendent of Baguley Sanatorium, Manchester, recently produced figures showing that whereas 6o probationers out of 1,807 passing through fourteen general hospitals over a period of seven years, developed tuberculosis, only 36 developed the disease out of 1,776 passing through twenty sanatoria over a period of ten years. The comparative risk of infection in general hospitals was thus 3.32 per cent. and in sanatoria only 2.03 per cent. I think that proves—in fact the Minister has admitted it—that the risk of infection in tuberculosis institutions is really less than in other hospitals. One wonders how this statement crept into the circular, and one is inclined to ask whether the Minister is really master in his own house. I sincerely hope the Minister will be willing to circulate widely the statement he made in the House of Commons, and that a direction will be given not only to the Civil Nursing Reserve but to all nurses as to where their services can be most usefully employed.

I come lastly to the question of domestic staff, which is indispensable to the effective functioning of an institution, otherwise it is like a ship without any stokers. This, I understand, is a matter primarily for the Ministry of Labour. Again, I must apologize for referring to the debate in another place, but there the Parliamentary Secretary of the Ministry of Health stated that she would be grateful to any member who urged upon the Ministry of Labour the need to direct women into service in the hospitals. Such work should be regarded as vital war work. The extraordinary thing is that in his speech in the same debate the Minister said that "on the domestic side my right honourable friend the Minister of Labour and National Service is willing to direct women to service of all kinds in hospitals." If that is so, how is it that the Parliamentary Secretary should get up afterwards and express gratitude to anyone who would bring pressure to bear upon the Ministry of Labour to direct women to assist in the running of tuberculosis institutions? In Wales, we have a shortage of 31 per cent. in our domestic staff. That increases the train of work on the other members of the staff who remain loyal to their service, and it also increases the work of the nurses in these institutions, compelling them to undertake all sorts of jobs, like scrubbing floors, when they should be exclusively employed in looking after their patients.

I must apologize for detaining the House at such length, but may I sum up? First of all, I appeal to the Ministry of Health to take every step they can to increase the facilities for tuberculosis patients, and to lose no opportunity of utilizing the accommodation in the emergency hospitals until these beds are required owing to the war. The beds should not remain idle, but should in the meantime be used for this purpose. Secondly, I appeal to the Ministry to see that the existing institutions maintain their beds and prevent their wards from being closed. Thirdly, the Government should withdraw Circular 2340, to which I have alluded, and should exercise the powers of direction which I assume they can do, in co-operation with the Ministry of Labour, and include nurses and domestic staffs in the categories which are described as doing essential or vital war work. There seems to be some doubt as to whether they are included at the moment in these categories. Fourthly, I suggest the speeding-up of the proceedings of the Rushcliffe Committee, and, lastly, expedition in the manufacture of instruments for mass radiology. Your Lordships will agree that these are not unreasonable requests and appeals to make to the Ministry of Health. They are precautionary and preventive, and surely we ought to take these measures in time and not wait until, perhaps, some terrible epidemic comes along, as the result of conditions which are deteriorating all the time as regards nutrition and the maintenance of powers of resistance on the part of the population. I beg to move for Papers.


My Lords, I should like to say a few words on the Motion introduced by my noble friend Lord Davies. I spent Saturday afternoon at a sanatorium in which I am interested, and talked over with the staff the very points which have been raised to-day. That particular sanatorium is now 50 per cent. short of its nurses, and has hardly any domestic staff at all. It is being debated whether we should not close up a wing of the sanatorium. A similar condition of affairs exists in another sanatorium not twenty miles distant. With regard to the difficulties of getting nurses, I suggest that the Civil Nursing Reserve might very well, for the period of the war, ease up the restriction which prevents girls from volunteering to nurse in a sanatorium until they are twenty-one. That restriction means that, by the time they are twenty-one, they are probably settled in another job, and no longer wish to go into a sanatorium. As a war measure they might be detailed to go to those places where they are short of nurses. If the General Nursing Council would introduce into the training of nurses the necessity of doing three months in a sanatorium, it would not be bad from the educational point of view, and it would also ease the situation.

The whole thing at bedrock is really financial. If the sanatorium cannot afford to give the wages they will not get any of the few nurses who are available. With regard to the domestic staff, if theirs cannot be scheduled as war work which they are not allowed to leave, they cannot he prevented from going. At this particular sanatorium, which is for men patients—seamen and merchant seamen—men orderlies would do very well, but you cannot get them because if you give what you think is a good wage, they will not stay. Only last week a man who was apparently happy and well-paid left, and it was discovered that he had gone to one of Woolworth's branches for £4 10s. or £5 10s. a week as a fire-watcher. Against that sort of thing the hospitals cannot compete. It is part and parcel of the rise in wages all round which the Government apparently are unable to control.


My Lords, although I was very glad to hear Lord Davies introduce his Motion, I cannot entirely agree with the noble Lord when he expresses merely "concern" about the situation and not alarm. To me the situation calls for more than concern, it calls for really deep alarm. We cannot, I think, consider this question of domestic staff and of nurses in tuberculosis sanatoria without linking it to the rise in the death-rate among tuberculous patients. What are the facts? In the last war tuberculosis was killing off people in this country at the rate of 1,000 a week. I should like to mention to your Lordships that not only in this country but even in neutral countries there was a heavy death-rate due to the strain and the shortages of those war years. The death-rate was almost as high as here. Since then, due probably more to the rise in the scale of living than to any advance in medicine, there has been a tremendous improvement, but as the noble Lord who introduced this Motion pointed out to us, since the beginning of this war the situation has deteriorated, and one is really appalled to learn, as was said I think in another place, that in 1941 the number of deaths from tuberculosis had gone up to 28,600. I think I am right in saying that in the current year for six months the figures have already reached 29,000.

If we go on upon this scale the death-rate is going to make a very serious inroad among the workers in munition factories and have a serious affect upon the organism of war-scale production that we so vitally need. The reasons for this increase are fairly obvious. Poverty in peacetime, I suppose I am right in saying, is the greatest single cause of tuberculosis, and conditions of poverty, through war, have spread out into other classes who normally would not feel them. I mean that we are getting the intensive strain of war work in factories, and we are also getting less of protective foods and fats. Then there are the black-out conditions, the exclusion of fresh air, which is so absolutely and vitally necessary to us. There is also a history of weeks and months of nights spent by people in air-raid shelters, where those infected with tuberculosis meet the healthy in almost ideal conditions for spreading the disease.

One other cause to which I should like to call the attention of His Majesty's Government very strongly, is the stripping, if I may so put it, of the civilian population of their doctors. There has been a tremendous depletion of the number of doctors available for civilians. I think I am right in saying that up to January, 1941, 20 per cent. of the country's general practitioners were taken for the Forces, and since then more than 1,400 have been taken. I think this is a very dangerous situation. You have a big and almost immobolized reserve of medical knowledge in the Forces which cannot be used for the benefit of the civilian population. Surely some way could be found by which the War Department could arrange, through the barricade of red tape, for these doctors to go out and take evening surgeries, and so help the immensely overworked general practitioner in the work he now has to do among the civil population. At the moment obviously our war effort depends as much on the morale of the civilian population as it does upon the Armed Forces. I would suggest that among the Armed Forces alarm and concern would be felt if they felt that their wives and sisters and mothers lacked any necessary medical treatment, if such a lack could possibly be avoided.

The last straw to break the back of public health, if one may put it in that way, is the shortage of nurses. We are told that 1,200 nurses are urgently needed for nursing tubercular cases. That means that hundreds of beds are empty. I believe that the figure of 1,200 nurses short means that there are nearly 4,000 beds in the whole country free for cases and not used at a time when the death-rate is going up and, as we learnt from the speeches made earlier to-day, there are large waiting lists of undiagnosed cases. This menace goes on still more threateningly. I think one of the greatest factors augmenting the position is the ignorance of the public. In my experience—and I should imagine that of your Lordships has been similar—the general public is extremely ignorant about this disease, both about its symptoms and its cure, as well as about the possible risks of infection and the precautions to be taken to avoid it. The leading authorities upon tuberculosis have laid it down that this disease can be cured, and that it can be prevented if reasonable precautions are taken. Children, I understand, are immensely liable to get the infection, while grown-ups are very much less so; in fact, the average of infection among the wives of tubercular husbands and the husbands of tubercular wives is not much higher than the general average. In other words, a grown-up is not so liable to catch the disease as a child. When the disease does appear in an adult it is nearly always the revival of an old affection which started in childhood.

Therefore I suggest that the first step His Majesty's Government should take is to inaugurate a big campaign for educating the public. There should be a national campaign. There is no need to alarm people, but we should have a series of talks on the B.B.C. about the symtoms of this disease, about its preventability and about its cure, and urging the public to take what steps they can immediately to eradicate it. The Press has always given magnificent support to any campaign of this sort, and I am sure it would do its utmost to join in spreading knowledge. We ought to abolish the reticence about this disease which makes people think it is a shameful thing, and we ought to stop completely people staying in their homes and spreading the infection among their children month after month.

Ignorance, too, I am convinced, is one of the causes of the shortage of nurses. It has been pointed out, and I should like to support this very much, that the loss of younger girls coming into tuberculosis nursing is due to the impression that it is more dangerous to nurse in a sanatorium. As Lord Davies has pointed out, that is in fact far from being the case. Owing to the slightly lighter work, possibly better food, fresher air, and conditions generally, nursing in sanatoria for tubercular cases is actually much safer than in a general hospital where the tremendous strain and overwork are liable to react on the nurses and cause tuberculosis. In this matter a national campaign of education would help, because the strongest resistance to the idea of their children going to nurse in a sanatorium is probably offered by the mothers of girls of eighteen who are entering the nursing profession. One suggestion that has been made in another place is that the wages of nurses in sanatoria should be increased. I think that would be a great mistake, because it would at once give grounds for the suspicion that this was a very dangerous type of nursing. Instead I would strongly suggest that the Ministry of Health should find means to raise the wages of all nurses, and if possible to better their general living conditions.

Actually the situation in this country is that we look on nurses as being not quite such worthy people in regard to their earnings as the average domestic staff or domestic servant. About two weeks ago I took up The Times and read through the advertisements on the front page. I was surprised to find that a cook is offered as much as a departmental sister, a parlourmaid is offered £35 more a year than a trained nurse, a housemaid was offered £13 more than a staff nurse, and a girl of fourteen, presumably completely inexperienced, was offered as a scullery maid the same pay as a probationer nurse. Can it be matter of wonder that there is this shortage in the nursing profession? The day has gone when we could use the excuse of vocational inspiration for getting sweated labour. An increase in general pay, I submit, would help to eliminate the shortage. There is one point on which I am afraid I must disagree with the noble Lord, Lord Davies. I do not think compulsion is the best way out. It has been suggested that nurses from the Civil Nursing Reserve and other women might be directed into the nursing of tubercular cases. I personally would not care to be nursed by an unwilling conscript, and I think there are other ways than the method of direction of achieving the same object.

One other reason which I think is causing the shortage of nurses is that in many sanatoria—not all—nurses are remote from general amenities and social life, and the old tradition of discipline remains which prevents young nurses or probationers from going out and finding a little more completely necessary recreation. Steps should be taken to try to bring nurses in sanatoria nearer to social amenities—I know it is difficult in wartime—by arranging 'bus services and giving relief so that the life of the nurses could be made more agreeable. What happens to-day is that a nurse prefers to go into a general hospital which is fully staffed and where there are social amenities.

More serious is the fact that a probationer nurse looks upon going into a sanatorium as a completely dead end. She has no way of continuing her medical training. The remedy for this is as simple as the mistake. If all sanatoria would copy the better and more enlightened ones, and employ a sister tutor who could instruct these young girls in hygiene, anatomy, physiology and so forth, so that they could continue their training and prepare perhaps to take the elementary examination, they would not feel that they were wasting their time. Coupled with this there should be the compilation of a tuberculosis register by the General Nursing Council similar to what has been done in fever and mental nursing. That would give tuberculosis nurses the feeling that they were on an equality with other nurses. The Tuberculosis Association has been trying for years to bring this about, but apparently the General Nursing Council is still wedded to the old-fashioned idea that tuberculosis nursing is merely a matter of carrying trays and doing unskilled work. Nothing could be further from the truth. In the last twenty years the treatment of tuberculosis has made enormous strides. I need only remind your Lordships of the modern technique of collapsing the lung either by artificial pneumothorax or by removing portions of the ribs. Tuberculosis nursing is nowadays a highly skilled branch of nursing.

I have dealt at some length with the reasons for the shortage of nurses and some of the methods which in my view can meet the problem, but we have to go deeper than that. There is something radically wrong when this important, insidious and dangerous disease is spreading on all sides and at the same time we are short of nurses, the public are woefully in ignorance and the general tendency on the part of infected persons is to conceal the disease rather than try to get it cured by early treatment. The answer to that is that prevention is the real solution. In this country we are apt to pay attention to cure rather than prevention. In advanced cases the interest of the medical profession and of the Government is aroused, but the real secret of good health is prevention. If more preventive measures could be taken we could go far to eradicate the disease.

I have seen some interesting figures from the Soviet Union which has reduced its tuberculosis figures by 83 per cent. since 1914. That reduction has gone on through the most grim and bitter years and it is entirely due to prevention. In Russia they use mass radiography on an enormous scale. Practically every working man going into a factory is examined and photographed, and anyone who has even a minor operation, such as the extraction of a tooth, is again photographed. The result is that there is continual examination of the population. Immediately anyone is found to be affected he is taken away and treated. Not only is tuberculosis a notifiable disease as it is in this country, but in Russia all contacts with the patients, children, parents and people with whom they have been living or working, are compulsorily examined. I think I am right in saying that in this country there is no such compulsion. Nobody need be examined for tuberculosis. That is a step that should be taken immediately. Mass radiography unfortunately has been terribly neglected here, and it is only now that the Services and certain firms with over ten thousand employees are adopting it with the object of saving them from having to pay pensions to persons who collapse under war strain. I hope the Government will take steps to give priority to any equipment that we can still get from America for this purpose.

In other countries there are preventoria in which children of tubercular parents are given an opportunity to go and live in camps or colonies, where they can lead free and happy lives under observation, to rejoin the family when their parents come out of the sanitoria cured. One thing which I am afraid will prevent any possible reform so long as it is allowed to continue, is the fact that a. worker or a poor tradesman or any man of insufficient means is punished for having this disease. If a man earning say £3 or £4 a week goes to a sanatorium he is looked after and treated, but his wife and family are reduced to living on a sick benefit under the national health insurance scheme of 18s. a week. His wife will have to go to the public assistance committee and be subject to a means test even to get the fare to visit her husband in the sanatorium. The result is that if a man gets the early symptoms of tuberculosis—it may be a slight cough or a little tiredness—he will go on working in the hope that he will get over it, and end up as a dying case and perhaps infect his children. There is one other point which I should like to mention. I do not know if it is fully realized to what extent research has been paralysed by the war. I have heard that in France, before the collapse, efforts were being made to immunize children. It had not been found successful in all cases, I admit, but a distinguished research pathologist had discovered valuable evidence of the possibility of the immunization of children as simple and complete, it is hoped, as that against diphtheria; but during the war this has been curtailed and almost completely stopped. It is important, however desperate we are for resources, that research of this kind should be carried on, and that we should, if possible, discover this immunization which might mean so much to us now.

Lastly, I would urge that there should be a change of attitude on the part of the Government towards this problem. It is an important one, as I say, and I think that if these steps were taken, if the education of the public and of the nurses were conducted on a wide scale, if economic penalties could be removed, if the status of the tuberculosis nurses could be increased and made reasonably high, and, above all, if research could be re-established, we should eliminate this disease bit by bit, and solve this nursing shortage problem more fundamentally than by just conscribing 1,200 nurses immediately for work in sanatoria, which is a. very shortsighted way of treating this very important problem.


My Lords, I take it that it will be common ground that there cannot be an increase of tuberculosis in any country without that increase raising a certain amount of concern. But, although we are concerned with the increase of tuberculosis in this war, I suggest that it is important for us to keep our sense of proportion. In the ten years preceeding 1938—the last year before the war—there was a steady improvement in regard to tuberculosis in this country, and as measured by mortality rates, there was the difference between 90 per 100,000 ten years before the war and 60 per 100,000 in 1938. That amounts to an improvement of one-third—no mean achievement. When the war came there was an increase of tuberculosis, as there is in the case of almost all germ diseases. It was found that the mortality from this cause went up considerably in the first year and continually in the second year, and the total increase in mortality amounted altogether to 13 per cent. in Great Britain. Now we do not regard that as perhaps the most anxious feature. A more anxious feature is the selective character of the infection amongst different classes. One thing which has been found in this war, as in the last, is a tendency for increase of infection among young women. In this war it is not only young people, adolescents and young adults, but there is this novelty that there has been an extension of the infection amongst young children. In fact, this extension amongst young children is a most notable characteristic of tuberculosis in this war so far. It is particularly noticeable in the increased incidence of tuberculous meningitis, from which there has been increased mortality amounting to 50 per cent.

The cause of tuberculosis in war is, I take it, broadly speaking, a combination of two things—increased opportunities of infection and decreased resistance. These conditions, a little reflection will show, are inseparable from the conditions of totalitarian war. You have big movements of young people all over the country, their aggregation into factories, the overcrowding of their homes, blackout conditions which impair ventilation and also increase the fatigue that is incidental to war-time life—the fatigue, for example, of getting home after a long day's work—and the harassment of women in the management of their homes. There is also increased opportunity for contact in consequence of overcrowding both in factories and in homes. Now, given such conditions, given a tuberculous person in a crowded factory—and that tuberculous person may be quite unaware of having the disease—or a tuberculous person in a crowded home, it is easy to see that there is almost certain to be an increased spread of the disease.

I would like to submit this. On the whole, up to now, I do not share the grave view taken by the noble Earl, Lord Huntingdon. It is true, I think, to say that, on the whole, tuberculosis is under control. Thirteen per cent. is a considerable figure, but there is no sign so far of the disease running away with us. We have to remember that even in the year 1938, when we were at the peak so to speak, even in that good year there were nearly 250,000 people being looked after by the tuberculosis dispensaries of this country. So that we have to realize that tuberculosis is a germ disease that does not come in waves upon us. It is always with us; its root is in almost every country. It is among its curious features that it is at once a curable and at the same time a very destructive disease. While it can destroy life in a few weeks, the majority of cases of tubercle are so mild that their possessors are not even aware that they have ever been attacked by the disease. That is borne out by this interesting fact. If you take the post-mortems done on old people who have died, it may be as the result of old age, it is extraordinary how often you will find in the lungs of these people old, healed, deposits of tubercle, and yet there is nothing in the record of their lives to suggest that they ever knew that they had been affected by it at all. There is no doubt that large numbers of adult people have had tuberculosis so mildly that they have been only vaguely ill, and so mildly that it has been un-diagnosable. They have come through a time of vague ill health, not knowing what has been wrong with them, and have been restored to good health and have lived to a ripe old age. In other words, this is a highly curable disease, and I agree that that is a good reason for dealing with it as early as possible, when there is every hope of restoring a large proportion of its victims to good health.

If we are to grasp the problems of infection, let us consider in what way people contract tubercle. I take it that there are three ways. One is by contact with the expectoration of a case of established disease; another is by the reawakening of the disease in someone who has had tubercle and recovered from it, the disease being reawakened, perhaps, owing to lowered power of resistance due to unfavourable conditions or environment; and the third, which must not be forgotten, is because tubercle is conveyed by drinking the milk of a tuberculous dairy cow. I should like to deal with that last cause first because it has a bearing on the subject of prevention. In a country like this, where a large proportion of the cattle are tuberculous, it surely would be a wise precaution to pasteurize our milk. My profession has been pleading for years with successive Governments, like a voice crying in the wilderness, to take up the question of the pasteurization of milk, organize it and Make it compulsory. Pre-war Governments have in this respect been a stiff-necked people, and we are in this position now, that pasteurization in this Country is patchy. It is extremely good in London, good in some boroughs and bad in others, while in the country districts most of the milk drunk is raw.

In that connexion, there arises this interesting reflexion. Some children are getting a good deal of milk, and there has been a good deal of evacuation of children from town to country. Take the case of London. While the children were in London, they thank pasteurized milk, but since they have been sent into the country and billeted there they have drunk raw milk. Investigation is going on to confirm or otherwise what I am going to say, but it is not unreasonable to suppose that the increase of tuberculosis in children may be accounted for partly by the fact that they have passed from consuming pasteurized milk to drinking raw milk. Under the heading of prevention, I would urge upon His Majesty's Government—I do not think that it really requires urging, because I am sure that the present Minister of Health is quite alive to it—that it is an important matter that the pasteurization of milk should be organized and established throughout this country.

I pass now briefly to consider the class of tubercle to which my noble friend Lord Davies mainly applied himself—namely, lung tubercle. Here infection is invariably brought about by contact with the expectoration of an established case; and it is obvious that, under the overcrowded conditions which we have in war-time, with the lack of ventilation and the other difficulties to which I have referred, the opportunities of contracting tubercle must be greater than in the easier conditions of peace. The question is how we are to reduce the trouble to a minimum. The chief difficulty lies in the fact that it is quite common for an infected person in a factory or in a home to have symptoms so vague or so completely absent that it is not realized that he is an infected person. That is a difficulty which none of us can prevent, but we can be aware of it and be watchful about it.

The noble Earl, Lord Huntingdon, touched on a good many technical questions and referred to the help which we are going to get from mass radiography. The means of establishing that mass radiography are making progress. We are not dependent solely on the United States of America; there are machines in this country which have been standardized according to an agreed pattern, and which will be turned out in increasing numbers from now onwards. The machine has this advantage, that in skilled hands—and I would emphasize those words—as many as 3,000 examinations a week are possible, and it is possible to organize the examination of a whole factory in a very short space of time. On the question of compulsion, to which the noble Earl referred, my own view is that we can do far better in this country by persuasion than by compulsion. There are good grounds for supposing that mass radiography, as it is called, will be received with increasing favour as the people concerned understand it. I believe that that will lead to the discovery of early cases, which are difficult of discovery by other means.

We have to be careful not to speak too optimistically, as we are apt to do about new inventions. Mass radiography is going to be a great aid, but it has to grow into our system of medicine discreetly. To dispatch large numbers of machines all over the country without proper teams to work them would make a very bad beginning, and lead to false conclusions. I have reason to think that the Ministry are well aware of this, and that the medical services of the Armed Forces are also aware of it. There is a combined effort at this moment by the medical services of the Army, Navy and Air Force, working in co-operation with the civilian side of medicine under the Ministry of Health. I believe that we shall make a considerable advance in the direction of early diagnosis. It is easy to see that if we could remove one infected person from a part of a factory which may contain a hundred people, or take one infected person away from his home at an early stage, we might do much towards the reduction of the incidence of this disease.

The noble Lord referred to a certain matter of great importance, the depletion of doctors. I need hardly say that that arouses a sympathetic note in my mind, but I am bound to say in passing that there has been no more depletion than is really necessary. The Army does, where it can, give facilities for medical officers in military depots to give a hand, and they do give a hand. But I think we have to realize that the first claims must be the claims of the war, and we have to put up with the depletion of doctors. It is true that we are now getting help from a considerable number of Poles and Czechs, who work very happily with us and serve in many of the emergency service hospitals.

I pass to another point—namely, the education of the public by cinema. I am doubtful of that. A difficulty in all matters concerning health is to give information without producing alarm, and I think one of the things we have to be careful about in mass radiography is not to raise a sense of alarm amongst the workers. The danger is that they will swing from indifference to over-anxiety, and I think I would rather have indifference than over-anxiety in the case of illness. I think mass radiography, as far as we have watched it up to the present, has been well received, and if it is presented to the people as it should be presented, as a means of establishing how well people are, and not how ill they ale, it can be useful. Make it part of a health measure, which is one of the features of the Youth Movement to-day. They take a youth and say, "Look here, you've got to be fit. Let's examine you and measure your chest, and see how you're growing, and see whether you are straight and upright, and have got good muscles," and then incidentally find out how healthy they are. That is the right way to proceed, as contrasted with health propaganda, which makes a self-conscious people.

The noble Earl, Lord Huntingdon, raised a very important matter with regard to the treatment of the tuberculous, and that is the question of rehabilitation, as it is called. In the past we have all been prone to think that when a patient leaves a sanatorium he is ready to go back to work. There has been a jump from sanatorium perhaps right back to employment, the worker being forced to it after having been a long time out of work. He is anxious to get back to his ordinary social state and his ordinary earning power. What we have to realize in tuberculosis is that there must always be a long period between the end of sanatorium treatment and full-time work. I think it will be found that the Ministry of Health are fully alive to this matter, and that they propose to consider seriously the maintenance and subsidizing of tubercular-infected subjects for a period from the time they leave the sanatorium to the time when they get back to work—if they are on a half-time basis, to make up their wages for so many weeks or months.

We have to remember that the care of the tuberculous is, I believe, primarily the duty of the local authority. The difficulty of local authorities is that so many of the people affected are long distances away from their peace-time homes, and there is difficulty sometimes in the local authorities fulfilling their duties. There is a case, I think, for the emergency medical service adding one more to its many duties, which it performs so well, in trying to provide on a larger scale for tuberculous people. As regards nurses, if it were made clear that there is no more risk of a nurse catching tuberculosis in a sanatorium than there is in the ordinary ward of a hospital, in fact rather less if anything, and if in some way the care of the tuberculous patient could be made part of a nurse's duties—she might, for example, be seconded from medical wards and surgical wards to tuberculosis wards—I believe the difficulty could to a large extent be got over. But of one thing I aim sure, that to start any process of compulsion, to make a nurse take up a particular phase of nursing, would end in failure. If an adequate appeal were made, and tuberculosis were made part of the general care of the sick, I cannot but think that the difficulty about nurses would disappear.


My Lords, the noble Lord, Lord Davies, has drawn attention to a subject which for some time has been one of real concern to the Minister of Health, and this debate merits a very careful reply. I am authorized to say that the speeches which have been made, in support of and in criticism of the noble Lord's Motion, will receive the Minister's urgent and close attention. The main complaint made by the noble Lord in the Motion on the Paper is of the failure of the Ministry of Health to deal with the staffing requirements of institutions for the treatment of tuberculosis. The failure to solve a given problem may be due either to the nature of the problem itself or to the way in which it is being approached, and it is quite clearly in the latter sense that the noble Lord has approached this question to-day. He does not think the problem is insoluble, but he does think that in its handling of it the Government have been inefficient and blameworthy. Let us therefore try to get a true measure of the Government's alleged culpability into our minds.

The noble Viscount, Lord Dawson, has in his most interesting and helpful speech traversed very much of the ground which I should have covered. It is of considerable importance to have his judgment that, serious though the matter is, and universal as is its application, it is nevertheless not incurable, and it is not a matter either for a grave view or for despair in regard to the treatment of it. The difficulty in dealing with this matter is not one of accommodation ultimately, but one of staffing facilities. The lack of an adequate staff in the nursing service is well known and is far from being new. It is not confined to institutions that have to deal with the treatment of tuberculosis. Anxiety concerning the maintenance of an adequate nursing service led to the establishment of the Athlone Committee as long ago as 1937, and some of the recommendations which it made had to be deferred, as much else which the nation wish to undertake had to be deferred, owing to the extreme exigencies of the war. As one result there was a sudden additional burden thrown on the whole nursing service, and the difficulty of securing staff in regard to the treatment of tuberculosis was greatly increased. For example, a certain amount of the accommodation available had to be diverted to other urgent purposes. Present difficulties however, as I have said, are caused not so much by lack of accommodation as by the shortage of nursing and domestic staffs. These interact on each other. If you get an adequate domestic staff, such trained nurses as there are can devote all their time to their special business of nursing and have not to be diverted to domestic duties.

There arise two essential points to consider—first of all, the scale of the problem; and, secondly, what the Government are doing about it. The difficulty in regard to the nursing service is only one phase of the Government's problem in regard to the best use of woman-power in the nation. The question of Wales has been rightly touched on by the noble Lord, Lord Davies. The administrative system for the treatment of tuberculosis is, I should point out, different in England from what it is in Wales. In Wales provision is made for its treatment by the Welsh National Memorial Association, with which the name of Lord Davies and his family is so honourably and helpfully linked. In England it is dealt with by the local authorities—county councils, county borough councils, and so on. Not long ago the Minister of Health received a deputation from the Welsh Parliamentary Party, when all these things were discussed, and it is very much hoped as the result of that deputation that greater voluntary help will be offered by women throughout the country. Let us look for a minute or two at the question of staffing. The Ministry receives a periodical return of the available nursing and domestic staff, and also of the additional number required. It has separate figures for, roughly, one-half of sanatorium beds throughout the country. The total number of domestics employed, male and female, is 2,400, and 460 additional are required. The remaining sanatorium beds are attached to other hospitals, such as emergency hospitals, and for these there are no separate figures available, but inasmuch as the figures I have quoted deal with one-half of the beds, it is reasonable to assume that if that number is doubled you will get a total approximate figure of 4,800 domestics employed and 920 additional needed.

Let us take such comfort as we can as we go along in this matter. The position, unsatisfactory as it is, is not actually worse than it was a year ago, but is even slightly better. In 1941 the deficiency amounted to 17 per cent.; in 1942, so far as we have the figures, it amounts to 16 per cent. That is not a great reduction, but still it does show we are holding our own, as it were, in the matter. The deficiency is one that sanatoria share with other institutions in the country. It is more difficult, for example, to get daily workers than it used to be, and then there is more glamour, as well as more remuneration, attached to other industries and perhaps to other phases of the nursing service. A good many of the sanatoria are in the country, removed from the attractions of town life, and that again makes it more difficult to obtain as many nurses as are desired. The need is recognized by the Government, and women domestics in these institutions are reserved—that is to say, they are not called up nor are they asked to transfer, and other women who are called up may be directed to this service. The Ministry of Labour and National Service has also instructed Regional Controllers to give high preference to these needs. This action has relieved some of the difficulties, and the position on the domestic side has been substantially improved.

If we deal with the question of the nursing staff exclusively the position is admittedly difficult, because the shortage of nursing staff at sanatoria is only one aspect of the general shortage of skilled nurses, and can only be effectively cured by an increase in the total number of nurses. An increase is being secured. There are now over 90,000 nurses—that is trained nurses, student nurses and nursing auxiliaries—working in civilian hospitals, 8,000 more than a year ago. It is estimated that another 12,000 nurses are required. Taking the question of tuberculosis separately,. there are 2,000 employed at sanatoria, and it is estimated that another 600 are required, and another 600 for beds in other hospitals for tuberculosis. Therefore we need an immediate enrolment of about 1,200 nurses. The percentage deficiency in sanatoria is higher than that in general hospitals, and it has been a matter of long-term experience that the nursing of tuberculosis is not so attractive as other services.

So far as the financial conditions of service are concerned, the Minister of Health, as your Lordships are aware, set up a Committee composed of representatives of nurses and their employers under the Chairmanship of Lord Rushcliffe to draw up agreed scales of salaries and emoluments for nurses, and their terms of reference authorized them to make recommendations so far as sanatoria are concerned in respect of State registered nurses, student nurses and nurses possessing or studying for the certificate of the Tuberculosis Association. As to other conditions of service, local authorities have been asked to review their previous provision for the care of nursing staff in sanatoria in the light of a memorandum of the Joint Tuberculosis Council.

The fear of contracting infection is no doubt one factor which has created a prejudice in the minds of girls and even of their parents, but the Minister has made it clear, and it has also been repeatedly stated in your Lordships' House to-day, that nursing in a sanatorium need involve no greater risk of contracting tuberculosis than nursing in other hospitals. Publicity both of the general type and in the nursing papers has been given to the need for nurses in sanatoria and the valuable experience which it provides as to the conditions of service in sanatoria generally. As I have already mentioned, the actual total number of nurses required will allow for some needed expansion in the number of beds, but the problem of filling individual gaps in particular institutions is admittedly difficult, and the Minister has made his own view clear that if the needs of the situation are properly understood he does not think we shall fail to get the response required.

I was gratified to hear the noble Viscount, Lord Dawson, speak against compulsion in this service. It is one of the services which, so long as that can be managed, we should all desire to remain upon a voluntary basis. The position at the moment is that members of the Civil Nursing Reserve over the age of twenty-one are expected to serve in sanatoria if called upon to do so, but in practice, if they are unwilling, and would prefer to resign from the reserve rather than serve in sanatoria, they are not compelled to do so. That is the position. The Department's present view about compelling nurses to serve was indicated by the Minister in the debate on the Estimates of the Ministry of Health on June 30, and in the same debate Miss Horsbrugh, the Under-Secretary, also dealt with the matter. The Minister stated that no one wanted to use compulsion in the case of such staffs, and though in the last resort we might have to consider a wider exercise of our powers of direction than hitherto he did not think that compulsion ought to be necessary.

Then there is the question of the nursing auxiliaries under the age of twenty-one. When in April, 1941, the scope of the Civil Nursing Reserve was extended to such institutions as sanatoria, it was laid down that nursing auxiliary members of the reserve under the age of twenty-one should not be allocated to sanatoria even if they volunteered. This decision was taken by the Minister on medical advice; therefore that should be remembered in considering this matter of compulsion. The Minister was advised that women under the age of twenty-one might be particularly liable to infection from tubercle, and in the circumstances the Ministry did not feel it right to call upon them to serve in sanatoria. This point was considered by the Standing Advisory Committee on Tuberculosis which contains representatives of the National Association for the Prevention of Tuberculosis, the Joint Tuberculosis Council, the Tuberculosis Association, the Society of Medical Officers of Health, and the London County Council. A proposal was put before this Committee by one of its members that the Ministry should be asked to withdraw this embargo. The Committee felt unable to ask the Minister to withdraw the embargo, but they did ask that it should be modified so that these young members could serve in institutions dealing with non-pulmonary tuberculosis. This recommendation of the Standing Advisory Committee was given effect to in Circular 2,526. The fact that so authoritative a body accepted the Ministry's view with the minor modification which has since been given effect to, surely indicates that the Ministry's general action was justified.


I submit that it stultifies it.


We have recently been giving the matter further thought, and we feel that perhaps in present circumstances it may be going too far to refuse to allow nursing auxiliaries under twenty-one to serve in sanatoria even if they volunteer. After all, a substantial number of student nurses under twenty-one are employed on the permanent staffs of sanatoria, and of course every care is taken to prevent them from becoming infected. The Ministry are now proposing to modify the embargo further by allowing nursing auxiliaries under twenty-one to serve in sanatoria if they volunteer, provided also, of course, that the fullest precautions are observed in looking after their health.

That, my Lords, is the position of the Ministry at the present time, and perhaps we might get such comfort as we can from an examination of the figures of fatal cases of tuberculosis in recent years. In 1916 the number of deaths from tuberculosis was 53,858. In 1938 the number had been reduced to 26,176. By 1940, however, the number had risen to 28,144 and in 1941 to 28,669. Therefore ground was lost between 1938 and 1941 to the extent of 2,493 cases. How that has been brought about your Lordships can imagine. The noble Viscount, Lord Dawson, has given an illustration of the possible effect of taking children away from urban districts, from the London area, say, where at school they would have the oversight of school doctors and clinical help if necessary and receive milk of a high grade, probably pasteurized, and sending them into the country where they drink raw milk and are without close medical attention. That would account possibly for some of the increase; but we have to remember also that the general health of the community has improved, and we should remember that particularly when we are asked to censure the Government. The fall in the number of deaths in this matter between 1916 and 1938 was due to the action of the Ministry of Health, to local authorities and to voluntary bodies, especially such as the Welsh National Memorial Association.

Complaints have been made by my noble friend the Earl of Huntingdon to-day that the population had been stripped of their ordinary doctors. That may or may not account for some of the increase, but in another place quite recently the impish suggestion was made that the general improvement in health was due to the fact that 10,000 doctors had been withdrawn from the population to the greater affliction of the Armed Forces of the Crown. I personally have never felt able to join in gibes at the medical profession. I have felt it right to defer criticism of their work until they have been provided with social conditions such as are required to make that work effective. Allow me to adapt some words of Kipling to this matter: It's doctor this and doctor that and abuse the brute, But it's fetch the doctor quickly when the pains begin to shoot. We can all criticize the doctors when we are well and they are none the worse for the criticism, but let us remember that they have to work under conditions that are unsuitable for their work; and we ought to remember also that if the national health has improved, as we are thankful to say it has improved, it is probably because we are all of us compelled to do now what the doctors always told us we ought to do.

I think the ground lost has been due to war conditions, which the Ministry of Health could not control and which doctors could not control. It is one of the afflictions of the experience through which we are going, due to overcrowding, to the cessation of the building of new housing accommodation, to congestion in air-raid shelters and to bad air which results partly from the black-out—especially the black-out, because, to use words from the Book of Common Prayer, this is a "pestilence that walketh in darkness" and the "sickness that destroyeth in the noon-day." The ways of recovery are known and they will be open to us to adopt as soon as the war ends. There will be the possibility of earlier diagnosis. We have perhaps concentrated in the past too much upon the treatment rather than upon the early diagnosis of the disease. It has been difficult to obtain the necessary equipment of late, but British-made instruments are becoming available and teams of trained workers are being developed ready to undertake this work by the end of the present year. The Minister shares in the anxiety which is felt concerning the renewed encroachment of this destructive disease, and he will continue every means open to him to get staff deficiencies remedied and the needs of an essential service fully met. The views expressed in this debate will, I repeat, be brought to the Minister's notice and I promise that they will receive his very careful attention.


My Lords, I feel very greatly indebted to my noble friend for his reply, but I must confess that I am disappointed that he was not able to inform us of the measures which we hope may be taken to deal with this problem. It is one of the disadvantages of your Lordships' House that in many instances there is no one who is responsible for the matter which is under debate to speak on behalf of the Department here, and my noble friend has had to make the best of a rather weak case. I do not propose to take up your Lordships' time in going through all the arguments over again, but I would ask my noble friend whether it is really intended to repudiate the circular which has been discussed in the debate. How can it be said that all the learned and administrative bodies about which he told us had agreed to this differentiation between tuberculosis institutions and other hospitals as regards the risk of infection, when the Minister said in another place a few weeks ago that he is in entire disagreement with the views expressed in that circular? I am sure there are numbers of young women who, having heard of this circular, must have come to the decision that they would not voluntarily enter tuberculosis institutions for fear of the risk of infection. Why has the bias been definitely put against the nursing profession in the tuberculosis hospitals and sanatoria? I should be greatly indebted to my noble friend if he could give us an assurance on that point.

With regard to the other matter, the question of giving directions, my noble friend Lord Huntingdon said that he would prefer not to be nursed by someone who had gone to an institution compulsorily. No one of course wants compulsion, but I would point out that it is better to have some treatment rather than to have none at all, and I am sure my noble friend will agree. Voluntary appeals have been made already. I listened to one which was made two years ago by the then Minister of Health. He appealed to the women of the country to come forward and staff these institutions. Unfortunately, these appeals have fallen upon deaf ears, and one cannot help feeling that it is the duty of the Departments responsible for the health of the country to give directions which they think will help to meet a very critical situation. I felt that I should like to divide the House with respect to this important question, but having regard to the promise of my noble friend that he will report all these matters to the Department, we will hope that something will result from it, and I now beg leave to withdraw my Motion.

Motion for Papers, by leave, withdrawn.