§ 4.29 p.m.
§ LORD MORAN rose to call attention to the Government White Paper Cmd. 6761, and to move to resolve, That this House, while regretting any measures which might impair the efficiency of the general practitioner's service, welcomes proposals for the better co-ordination of the hospital services of the country. The noble Lord said: My Lords, it is difficult for a doctor who has been nurtured in the voluntary system to speak of its extinction with detachment. My working years have been spent in a great voluntary hospital every stone and turning of which is associated with some incident in my youth. But a scientific training would be lost on us if, when our feelings are stirred, we allowed mere sentiment to oust that passion for exactitude which is the ultimate reward of the scientific way of life.
§ There are three questions which I think we ought to begin by trying to answer. The first is: Is a drastic reorganization of the hospital system of the country necessary? The answer to that question is to be found in the surveys made for the Ministry of Health during the war by physicians and surgeons. Those surveys are a measured statement of facts, amounting at times to an indictment. I shall not attempt a summary of the surveys. I merely wish to direct your Lordships' attention to them. But I would like to say this. One third of the 93,000 beds in the 1,059 voluntary hospitals in England and Wales are in voluntary hospitals, of which each has fewer than 100 beds. There is no doubt that here and there gifted men overcome difficulties inherent in such a situation, but generally speaking these hospitals; are much too small to fulfil the functions of a first-class hospital. In many of them—too many of them—major surgery is performed by men without surgical training, and the duties of physicians are usurped by those who have not had the training of a 823 physician. This practice of medicine without the aids of modern science results in patients being deprived of the benefits of these aids.
§ Passing to the municipal hospitals, a more disturbing situation is found, because of the 152,000 beds in these municipal hospitals in England and Wales, 78,000 are general beds—not for infectious diseases or things of that kind. Then of this 78,000, 29,000 or more than one-third—three-eighths to be exact—are in public assistance institutions. Noble Lords may have read in The Times a few days ago a shocking account of one particular public assistance institution. That, I am sure, is not typical but these institutions provide little but food and shelter. Many of them might have stepped straight out of a reforming novel of Charles Dickens. That is a state of affairs which is disturbing, and it is reinforced by the financial circumstances in which voluntary hospitals now find themselves. I am sure that, generally speaking, voluntary hospitals will have greater difficulty in balancing their budgets in the future, owing to the greatly increased cost of maintenance. What is more to the point, they cannot begin to meet the capital expenditure which is called for by six or more years in which nothing has been spent in building and equipment, and by the effect of bombing. That means we shall have to call upon the Government or the Treasury for the money—and it is a very considerable sum indeed—for the hospitals. I think if there is to be public expenditure on this scale, your Lordships will admit that it probably means some measure of public control.
§ I think I have said enough to explain, perhaps, why the vast majority of consultants and specialists who work in the hospitals are convinced that a drastic reorganization of the hospital system of the country is overdue. That brings me to my second point. If this large sum is to be given by the Government, and if it does mean public control, who is to exercise that control? Is it to be the local authorities, or is it to be the Minister working through the regions? I do not want to say anything which could possibly be called provocative, but one must recognize that local authorities have behaved with great patriotism in accepting the proposals of the Minister in the White Paper, which must be very unpalatable 824 to them. I think your Lordships ought to know certain facts, however. Every discussion among consultants and specialists who work in these hospitals has been dominated in the last few years by one fact, by one fear, that the hospitals would come under the control of the local authorities. It is because this White Paper appears to lift that menace from the profession that so many consultants and specialists are reconciled to the passing of the voluntary system. It is that dread which on the whole makes them prefer the proposals of the present Minister of Health to those of his predecessor, which handed us over, bound hand and foot, to the local authorities.
§ The Minister of Health has, I think, shown great political courage—courage not always shown in the past—in facing the realities of the situation, and in recognizing that there is this general feeling throughout the profession that it will be impossible and unthinkable to put hospitals under local authorities. I think I might be asked, justifiably, why do doctors dread being put under local authorities? It is a difficult question to answer. I have made man inquiries in the past year of those who practise clinical medicine in these services. You find rather a sense of frustration, due to the fact that the doctor has so little to say in the services, and owing to the greater delays which take place in getting anything done. You are bound to get difficulties of that kind in any large service. Even in the R.A.M.C. during the war, when they had a very able Director-General, and when that service was stimulated by the interest of the people of this country, you found quite often that the rigidity of a great service interfered with research. I will give you only one example. There was a large outbreak of diphtheria at Alexandria. It was necessary to trace the carriers, and for that purpose guinea-pigs were necessary. There was no money to buy them, no Imprest Account, and so they had to be obtained as Red Cross Comforts.
§ It would be quite unfair to isolate a few striking aspects of the service and not give the other side of the picture. It is absolutely true that doctors are working perfectly happily under municipal administrators, under the Middlesex and Surrey County Councils, and I think that proves that there is nothing inherent in the municipal 825 system which would make doctors discontented. But I think we must also accept the position that the present view is such that no statesman would dream of putting doctors and hospitals under local authorities. If hospitals are not to be controlled by local authorities, they must be controlled by the Minister. Up to this point, I think, there is agreement between the great majority of consultants and specialists. But when we proceed to ask the Minister who exercises this control whether it implies the transfer of ownership of hospitals, agreement ceases and there is great difference of opinion in the profession on this particular point.
§ I would make it perfectly clear that I am speaking personally, and not for my colleagues. I would explain to your Lordships the two different views. One is that local interest and local spirit around hospitals are so very, very important, and attachment to these institutions of those who were in them is so great, that it would be a great disaster if that were lost. They would like to see the Minister give a block grant to the region. The block grant could then be used for sanctions, so that any local hospital in that region which remained backward and did not come into line could be made to do so. That, I think, fairly represents what one section of those who work in the hospitals feel should be done. Other sections take the view—and it is one to which I subscribe—that although such a procedure would meet with our wishes a region in these circumstances would not possibly work. You have to picture a region applying these sanctions to a powerful local authority to get something done, and I think the local authority would not tolerate that. It would immediately begin to agitate for an alteration in the composition of the Regional Board, and presently we should end up with a local authority majority on that Regional Board—the very thing the profession wants to avoid.
§ It is very difficult to be certain of, these things, but, generally speaking, I think there was another argument which to my mind was conclusive. Every day I am meeting doctors from provincial towns, who say they will never have a proper hospital service in their town until their municipal hospital and voluntary hospital unite so that there is one first-class hospital instead of two second-rate hospitals. Obviously such a hospital could not be under two ownerships; it 826 must be under one. I do not want to see the region beginning its troubled life with the power of a big local authority on its flank. This question of ownership is after all the question that stirs all the consultants and the specialists. If this change of ownership did not occur the hospital proposals would be much more popular. We: have to ask: Supposing this change of ownership takes place, what do we gain and what do we lose? We gain the co-ordination of hospitals, which has long been overdue. We gain financial peace. We shall not find progress handicapped by poverty at every tarn, as occurred so often in the past. We gain freedom from the menace that the hospitals will be put under the local authorities in their present condition. Further, the Minister of Health has refused to blunt the growing edge of medicine, for the teaching hospitals are left alone. The non-teaching hospitals are put under a region with real power—the very thing we asked in vain from the Minister's predecessor.
§ What do we lose? We lose the voluntary system. Why has the name of the voluntary system gone over the world? It is because the ablest men in our profession, for as long as men can remember, have deliberately chosen when qualified to work within the walls of these institutions, so that almost every addition to knowledge has come from, these institutions. But not every voluntary hospital is a centre of learning. Nearly all these advances in the past have come from the teaching hospitals, and since they are left intact, this, the very essence of the voluntary system, is preserved by the proposals in this White Paper.
§ We may ask just for one moment, why did these men choose to work within these hospitals. The answer is that there they, found intellectual freedom. May I bring those words to life just for a moment? In my early days as dean of a medical school it fell to my lot to take inspectors from the University of London and the University Grants Committee round my hospital and school. The school had a progressive policy. Our grants rose year by year. As we went round words of encouragement and praise were common, until we came to the door of the Pathological Institute. There their faces fell and their interest seemed to have gone. Sir Almroth Wright's provocative personality had temporarily alienated the official 827 world. If he had been in a service I think he would have had a very thin time. Yet it is from that laboratory that penicillin came, the greatest discovery of my working days. Most of the advances in medicine have been met by professional and lay incredulity. We want to give the man of initiative his head, however angular a man he may be.
§ The voluntary hospital has made another gift to the country. Every hospital is a very human affair. It has a personality of its own which stirs up around it a spirit of service, and that spirit of service not only inspires the toil of the working day but it contributes to the efficiency of the hospital. Now if we lost this local interest we should lose something of great value not only to the hospital but to the community. But is it necessary that we should lose it? Letters have recently appeared in The Times from Sir William Goodenough and the Secretaries of the King's Fund which explain in detail how this local interest can be preserved within the fabric of the proposals of this White Paper. Briefly, what is proposed is that all these hospitals should have a larger measure of autonomy and that they should have some control over their finances. I think that everybody will be in sympathy with these aims. I believe the Minister of Health will go very carefully into the detailed suggestions in those letters coming as they do from people with authority to speak on these problems, while not forgetting that the more the local management committee gains in power the less is the influence of the university; and after all it was to get the influence of the university throughout the country that was the whole object, or the chief object, of putting up the regions.
§ Nevertheless I would not like your Lordships to think for a moment that I underrate the immense importance of preserving this local interest. In wartime you got an outpouring of unselfishness both in the front line and at home, and this spirit of altruism, flowering in two wars, has by its fragrance done something to wash out of men's nostrils the stench of war. When peace comes we tend to revert to our own selfish selves. But the work of the voluntary hospitals has been the expression in peace of the altruism of war. But whenever you find a resolution or proposals such 828 as are contained in this White Paper they inevitably end with a qualification. It may approve the principles set out in the White Paper but always at the end there is the proviso: "Provided the composition of the Regional Boards is satisfactory." Why? These regions are going to have great power. Not only will they be able to say whether a hospital expands and adds beds and adds departments, but they will be able to take away departments. They will be able to say: "You can no longer have a thoracic centre or a head centre, or a tuberculosis centre," and send that centre to some other hospital. These powers in the professional world are a matter of life and death. Therefore doctors from the very first were immensely interested in the composition of these Regional Boards. They have asked the Minister repeatedly to reveal the composition, and although he has done so for other committees he has refused up to date to give that information.
§ I would ask the Minister who is going to reply if he would be good enough to give us information on this particular point, that is the composition of the Regional Boards. I do not myself share the suspicions that, having shut out the local authorities from the front door, he is going to let them in by the back door and give them control of these Regional Boards. I believe he has learnt from the experience of the Nuffield Provincial Hospital Trust, who found quite definitely that the only way to make those boards work was to hand-pick those who worked on them, that it was quite hopeless to say: "Here are 5,000 local authority beds, and here are 2,000 voluntary hospital beds, therefore the representation on this board must be five to two." That would lead nowhere. We must hand-pick the men. There is a very great deal of information gathered by the Nuffield Trust as to who has the time and ability for this particular work, and I think he may very well have in his mind determined to put that into effect later. I am no politician but I can imagine at this particular moment it would be perhaps difficult to make any further proposals that are unpalatable to the local authorities.
§ The critic of these proposals concentrates on what is being done with the endowments of hospitals, and I do not 829 think that any of us have been happy about that. But the position at the present time is very different from what it was. The £18,000,000 which belonged to the teaching hospitals are left intact. £32,000,000 that belong to the non-teaching hospitals are to be used, not for one hospital but for more than one. To me that 'implies some departure from the donors' intentions, but I do not think it merits the word "confiscation." After all, is it altogether reasonable that if the Minister takes all the liabilities and the debts of those hospitals—and they are considerable—and makes himself responsible for their maintenance in the future, he should be deprived of their assets? I do not think in the business world that that would apply. Moreover, I think this proposal did not come from the Ministry of Health but from our side of the table.
§ Let me say this. The hospitals are important to the country because they train the doctors of the future; because we look to them for additions to knowledge, and because nowadays they are responsible for the treatment of most forms of acute disease. But the well-being of any profession depends upon the conditions under which the rank and file work and on their contentment. What does, the general practitioner think of the proposals in the White Paper? Now I think it is very difficult to answer that question. There are thousands of practitioners throughout the land who never go near a meeting of any association. They correspond to the silent vote in politics; we really do not know what they think. There were 17,000 doctors in the Armed Forces, most of whom will be presently demobilized or have already been so. They have been living in a whole-time service under conditions different from any we know. Has that experience reconciled them to whole-time service or has it confirmed their doubts? That is the question which it is extremely difficult to answer. Nevertheless, I am satisfied that there is a fairly general disquiet among practitioners about the future. The remarkable thing is that there is one reason, and only one reason, for this disquiet, and that is the dread that these proposals may lead to a whole-time service. Now you will find the general practitioners critical of many things in the White Paper. They will be critical of health centres and of the 830 abolition of the buying and selling of practices; but when you analyse why they are against these things you will find it is only because they regard them as a first step towards a whole-time service. Therefore one has to ask straight away: Is a whole-time service good for the profession and good for the public?
§ I have spent twenty-five years of my life as dean of a medical school, and almost every day I ask myself, under what conditions will these boys work and live when they go out into the world? Even now I am unable to say definitely what will be the effect of a whole-time service on the practice of medicine. I can only envy the Minister in his ready assurance, gained in the few hours he can take off from housing, that by turning a profession upside down he will necessarily provide a better service for the people. One thing is quite clear, and that is that if you have a whole-time medical service without an adequate incentive, you will have a bad service. Now I think the Minister of Health has recognized this very clearly by providing that those who work at the health centres will be paid by a capitation fee. That is to say, their income will be governed, at any rate in part, by what is thought of their skill by those who surround that health centre. That will be something, perhaps, to keep them on their toes. But it is not only financial incentive that matters; it is the conditions under which men work and whether it is interesting or stimulating.
§ We have to realize perfectly clearly that the life of a general practitioner of recent years has lost something of its colour. He has seen the treatment of serious disease pass into hospitals and out of his hands. When a case of pneumonia becomes interesting to him clinically it is taken out of his hands and put under somebody else in a hospital, and presently we are almost certain to see a sharp division between consultants; and general practitioners on the ground that if a man practises a speciality he should be trained for such. But this sharp division is going to take the milder degree of specialization out of the general practitioner's hands, and therefore deprive his life of interest. If you make the general practitioner's life duller and duller, it will inevitably have an effect on the men who enter that profession. Now this can be overcome in many ways 831 but it is very important that it should be recognized, and I am sure noble Lords will not feel that I am dwelling too much on the importance of the incentive. Why? Because, as I hear from people who should know, in almost every craft and calling in this country there is at present some loss of pride of craftmanship which may, in the long run, threaten the recovery of our export trade. Now in medicine if you lose the pride of craftmanship there is nothing left.
§ There is just one thing upon which I would like to digress before I end because I think it is of some importance. It concerns the machinery by which these White Papers are brought up. There are two questions that have dominated every professional negotiation for the last few years: on the part of the hospitals it is the dread of being put under the local authority, and on the part of general practitioners it is the fear of this whole-time service. Yet I have never once, in all these years, heard a really good discussion on these points, but only a perfunctory mention. It is not lack of time for such a discussion, because, as I have said, all these discussions have been going on for years. They have become part of our life. We shall rather miss them. And the cast is always the same: the same general practitioners and the same consultants negotiating with the same civil servants. Only the Minister of Health comes and goes. I have myself assisted at the obsequies of half a dozen of the present Minister's predecessors, and I want very much not to stand once more at the open sepulchre of another Minister's hopes and aspirations.
§ Why is it that these two crucial questions have not been adequately discussed when there has been plenty of time? I think the answer is best given if one looks over forty years of listening to debates and discussions on medical education and medical services. In all that time one document only has survived—the Report of the Royal Commission of 1913 on University Education in London. That has survived. Why? Because it was the product of the hard thought of Morant, Milner and Haldane. They never, for one moment, allowed details to obscure their central purpose, which was to provide an academic career in medicine. If 832 we get into this habit of very large committees meeting the Minister, in hours off from busy lives, we shall miss that hard thought which is absolutely essential if we are going to put up a fabric which will last. I think it may be said that the doctor lives for his work at the present time, and he lives laborious days. Will that be true in ten years' time? Will the conditions set forth in this White Paper attract in the future the same kind of man who in the past has won the regard of the public? I have no answers to these questions, but they will determine whether we are now merely doodling on scraps of paper which will be torn up by those who will come after, or whether we are working wisely for the betterment of the whole profession and for the good of the country. I beg to move the Motion in my name.
§ Moved to resolve, That this House, while regretting any measures which might impair the efficiency of the general practitioner's service, welcomes proposals for the better co-ordination of the hospital services of the country.—(Lord Moran.)
§ 5.0 p.m.
§ LORD INMAN
My Lords, I recall something that I heard M. Maisky say when he was Russian Ambassador. On his desk he had a large card with the words printed on it, "This also will pass." He told me that when faced with any ordeal those words never failed to give him confidence. I confess to a feeling of trepidation in rising to address your Lordships' House for the first time, but I am encouraged by the knowledge that this experience will pass and by the knowledge that your Lordships are traditionally generous to the beginner—ready to overlook his weaknesses and to forgive his shortcomings. I venture to intervene in this debate to-day because I am really batting on my own ground. If I may be allowed to explain, I should like to say that for over thirty years I have been actively engaged in hospital work—for twenty-five of those years at a well-known London hospital and for the last eleven as chairman of its governing body. I think, therefore, I can claim to know something of the work and the difficulties, and of the strength and the weaknesses of our present hospital system.
The White Paper to which the noble Lord has drawn attention summarizes the provisions of the new National Health Service 833 Bill introduced in another place. It is a long and of necessity complicated measure which will, I assume, come before your Lordships' House for examination clause by clause in due course. I do not, therefore, intend to deal in any detail with the proposals; I would rather content myself with saying a few words on general lines, knowing that if the groundwork is fundamentally sound its detailed application can be worked out afterwards, and that, on the other hand, if the groundwork is fundamentally unsound no amount of manipulation later on can possibly justify the changes proposed. Is the groundwork, then, fundamentally sound? I do not propose to cover the ground already covered by the noble Lord, Lord Moran, but to answer that question it is necessary to glance at the past.
The voluntary hospitals of this country have had a long and, in many respects, glorious history. They stand witness to the fact that men and women are by nature merciful and will not willingly allow their fellows to be stricken with suffering without collectively making an effort to find a means of helping them. It was on the great Christian principle of bearing one another's burdens that our hospitals were built, and funds provided by generous-hearted people maintained them. For many centuries the voluntary hospitals held the field, but in more recent years the municipal and county authorities have provided hospital accommodation. At one time these places were looked upon, as the noble Lord said, as cold and heartless institutions, tainted with the stigma of the Poor Law. There are still black spots in the country, but in a large number of cases these Poor Law infirmaries have been upgraded and there are cases where they are now acknowledged to be amongst the best hospitals in the country.
But this development in our hospital system has not had the advantages it might have had; there has been a complete lack of co-ordination between the voluntary and the municipal hospitals. In many cases they have been serving the same areas and this has led to overlapping, competition and, I regret to say, rivalry. The noble Lord who has just spoken will agree with me when I say that the anomalies have been most serious. There have been cases where hospitals have had long waiting lists of patients seeking ad- 834 mission, whilst close by there have been hundreds of empty beds. I will not weary your Lordships by going into other weaknesses in our present hospital system to which reference has already been made—the difficulties in the cottage hospitals, the movement of population from the centres to the: edges of our cities and towns, and so on. No one who has studied this question can entertain any reasonable doubt that changes of a radical character must be made, and these changes are introduced in the new measure. I believe its broad purpose to be the establishment of a nation-wide, all embracing service that will bring within the reach of everybody, irrespective of means, the best medical advice and treatment; and because I think that is its broad conception I shall give this measure my support, whilst reserving the right to comment upon some of the proposals.
With your Lordships' permission, I would like to state my views very briefly on one or two of the main issues. I believe that the scheme of co-ordination on a regional basis is sound. I believe that it will remove some of the evils of our present system, that it will eliminate waste, competition and rivalry, and that it will lead to that unified planning which is so much to be desired. But I venture to hope that in the transfer of the local institutions to Regional Boards care will be taken to preserve the local interest, the enthusiasm and the readiness to serve which the local institution has attracted to itself. I feel that in the interests of the patients that personal and human touch must be preserved. I should also like to feel, notwithstanding what the noble Lord has said, that endowments for specific purposes might be retained by the hospitals concerned.
I am a voluntary hospital man; I have gloried in its great traditions and I have already paid tribute to its fine record of service. How, then, will the proposals in this measure affect that service? I would emphasize what the noble Lord said about the voluntary system. It really falls into two parts—voluntary service and voluntary support. So far as lay voluntary support is concerned, I do not see any reason why it should not continue. In fact, this measure makes provision for its continuance. It is to be found in membership of the governing bodies of the teaching hospitals, of the Regional Boards and of the management and house 835 committees. All this work is to be unpaid and it will afford plenty of opportunities for voluntary service.
Now let me say a word on the vexed question of finance. I see around me to-day those who have served the voluntary hospitals for years. They will, I think, support my contention that the voluntary hospital in the past has had to cut its coat according to its cloth; its work has had to be regulated by its income. When that income has declined, retrenchment has had to take place; wards have had to be closed, and waiting lists extended. The late Lord Knutsford once told me, quite seriously, that so short were their funds that at one time they actually contemplated putting a board outside the London Hospital with the words "This building to let." If that is regarded as an extravagance, let me mention that some years ago at our own hospital we had six wards closed, and we had not sufficient money in the bank to pay the wages at the end of the week.
I submit that financial stringency ought to be removed from our voluntary hospitals, that we ought to be relieved of the scraping from hand to mouth. If the life of a loved one is at stake we say "Spare no expense," and yet cost has far too often been the deciding factor in hospital life. I agree with what the noble Lord, Lord Moran, had to say on the voluntary side of the financial aspect of hospital work. On a future occasion—I will not keep your Lordships any further to-day—I would like to deal with some of the other questions involved. It is quite likely that developments may take place as the Bill passes through its various stages to your Lordships' House, and as this is in the nature of a preliminary run for this measure may I be allowed to close on a note which was struck by the noble Lord, Lord Moran?
In thinking of our plans for the future, I am sure we shall not forget the great debt we owe to the past. In contemplating this new National Health Service Bill, it is fitting that we remember with gratitude the pioneers of yesterday, the devoted labours of countless physicians, surgeons, nurses, administrators and the generous-hearted. Their work has been beyond all telling; their benefits to mankind incalculable. Yet, as we all know, the world moves on; nothing ever stands 836 still; human endeavour is for ever reaching forwards; knowledge and experience are always widening; the potentialities of medical science are indeed tremendous and the possibilities of human health and happiness never greater than to-day. If those of old saw visions and lived up to them, we must dream dreams and translate them into deeds. It is in that faith that I look ahead, and I see emerging the health service of to-morrow, comprehensive, co-ordinated, efficient, available for everybody and above all, I hope, human, a health service that will be worthy of our people.
§ 5.15 p.m.
THE EARL OF DONOUGHMORE
My Lords, I would like to congratulate the noble Lord, Lord Inman, on the excellent speech he has made. Those of us who are interested in the hospital world are familiar with many of his speeches but I think we may congratulate ourselves that in future we shall hear his speeches and not have to read reports of them elsewhere. Your Lordships are in one little difficulty to-day, and I should like to pay my tribute to the ability with which two speakers have avoided that difficulty. We are, of course, perfectly in order in referring to the White Paper which is before your Lordships, but we are not in the least in order in referring to a Bill which is before another place. Therefore quite wisely the two noble Lords who have spoken have avoided going into too much detail, and I hope to follow their example in the few remarks I intend to make.
There is one thing in this scheme which appeals to me above all others, and that is that we are going to get rid of the division of our hospitals between two systems, the voluntary system and the municipal system. They are, as the noble Lord, Lord Inman, has just said, sometimes antagonistic, but they are totally different in their organization and I cannot believe therefore that they are both right. In the voluntary system you have government by the board elected by the supporters of the hospital, working in harmony with the medical committee, the committee of course meeting at the hospital. In the municipal system the governing body is the committee of the council which I fancy does not meet at the hospital but at the council hall. It works through the medical officer of health, and it works through a medical superintendent. 837 He may be the best fellow in the world, but I cannot believe a medical superintendent is a wise substitute for a medical committee, that is to say, a committee representing all the medical departments. I was interested to hear the other day that one of our important municipalities in the Midlands has actually abolished the post of medical superintendent and has substituted a medical committee in one of their hospitals. I think that is a very wise step, and I do not think that procedure is widespread enough.
Under this new scheme, as I say, all hospitals will be hospitals—there will be no word before the word "hospital" and a great deal of the success of the scheme will depend I think upon the regional committees. As the noble Lord, Lord Moran, reminded us we do not yet know who are going to serve on those regional committees, but it is tremendously important they should be the right people, people knowing about hospitals and people in touch with the medical profession. I do not think the medical profession would claim that they must run the show. I think they value the lay element with whom they have been partners for so many years past but, of course, the medical profession must be at the right hand of this regional committee and also of the governing bodies.
You must remember—and I want to emphasize what the noble Lord said—the enormous value of the local interest in hospitals. The ordinary man in the street likes to point across the street to a hospital and say: "This is my hospital." That has been an invaluable element in the whole hospital system all over the country, chiefly, I am bound to say, in the voluntary hospitals, but I hope it will extend to the municipal hospitals when they lose the title "municipal." Take an example. One of the great anxieties at this moment in every hospital is to get nurses and to get domestic staff. You have got to recruit them, and the human element comes in at once. I have had a little experience of candidates, and as a rule a girl does not say: "I want to join the nursing service; I want to join the domestic staff of the medical world." She points across the street and says: "I want to join that hospital where my friends are already working." She takes a pride in that hospital for the rest of her life, wherever her training has been. We must 838 not lose that, whatever happens, and we have to trust to the regional bodies to preserve and make easy the continuance; of that attitude of mind in the rank and file of the people.
For that reason I am a little frightened at this moment by something that has occurred within the last few days. An advertisement has appeared—the one copy of it which I possess is from that well-known newspaper The Hospital—in which the Ministry of Health invite applications for posts as what are called "Nursing Officers." Applicants are warned that they may have to live in one of the following places: London, Birmingham, Bristol, Cardiff, Leeds, Liverpool (including Birkenhead) Manchester (including Salford), Newcastle (including Gateshead), or Sheffield What does this mean? These individuals are to be given salaries, and, obviously, they are to be important people. Their duties will include the inspection of nursing and staff establishments in general and especially at hospitals and other places for the training" of nurses. I want to know, at once, whether these people are going to work under the regional bodies or whether they are going to be: representatives of the Ministry of Health working independently of the regional bodies. I think this particular case is of importance. I want to know in what spirit this new system, if it goes through—as I presume it will do—is going to be worked.
Are these new local authorities, the regional authorities, to be allowed to do their work, or are they going to be interfered with from headquarters? If that is going to be the case, your scheme will fail. I certainly hope to see the Minister of Health—for I fully recognize his tremendous keenness and enthusiasm—leading an army to success in the new hospital world, but I am certain that there will be failure unless he is a wise man and leads his army from behind, allowing the people in the localities to deal with all the details of the show. There is a great deal more arising out of the White Paper that I should like to say, but I think it has been agreed that we all want to confine our remarks to the hospital side of the new health scheme to-day. I agree with so much that has been said by both the noble Lords who have previously spoken, that I do not want to repeat anything. I shall look forward to the Bill reaching us and 839 then no doubt, as the noble Lord, Lord Inman, has intimated, we shall have quite a lot to say.
§ 5.23 p.m.
§ LORD GEDDES
My Lords, your Lordships, I am sure, will all agree that we have listened to three very remarkable speeches. They were extraordinarily interesting, extraordinarily clear, and very much to the point. I started the study of this White Paper just as I studied the earlier pronouncements on the subject, from the point of view that we are going to have a health service. Why do not our successive Ministers of Health declare it to be a means of promoting health? This is a medical service that is proposed, and it is designed to deal with those who have lost health. Primarily, of course, the research work that goes on in the voluntary hospitals—the teaching hospitals as they are to be called in the future, and indeed as some of them are called now—is work aimed towards health. But this service that is proposed in this White Paper is entirely concerned with dealing with those who have lost health.
There have been two great examples of big operations to secure health. The first one was the great operation conducted by General Gorgas to secure sufficiently healthy conditions to allow the Panama Canal to be built. The other great operation—which was modelled on Gorgas's work—was designed to secure sufficient conditions of health in Northern Rhodesia to allow the copper belt development to proceed for the safety and welfare of this country. We have got in this country not a tropical jungle but a jungle of conditions all of which are working against health. It is quite true that we have got housing going forward as well as it may be in these difficult days, and we have got the question of food being looked after as well as it may be in this very difficult period. But here we are dealing with what I wish profoundly had been called a "National Medical Service Bill", for words are important and it may well be that if people think that this is the way to health we shall get the real health services of the country distorted.
That is by the way. It is an objection to the title which has been adopted, and I do not suppose that my objecting to it will have any effect on anybody. But it 840 is really a matter of importance to make these medical services not only real services but a complete health service. In those medical services there are two great parts — the hospital service and the general practitioner service. Your Lordships have heard three speeches dealing primarily with the hospital service. On that I can only add my plea to those that have already been made that, before things have gone too far, the whole country should know what is to be the composition of the Regional Hospital Boards (I think that is the correct title) for on that composition, I am absolutely certain, the well-being of the general treatment hospital service will turn. If those boards are wisely chosen this thing will go. If they do not inspire confidence in the minds of the men and of the profession that have to do the work the hospitals will not work well or properly or for the benefit of the sick. That, I think, is the most important thing on the hospital side. Given proper Regional Hospital Boards and adequate finance, it is fairly certain that the hospitals will be got on to a proper basis and that that co-ordination will be obtained which all of us, for a generation, have known to be necessary, to bring the hospital service up to a proper standard. It has I been a piecemeal thing, built up higgledy-piggledy—some hospitals extraordinarily good, some of them not so good, and every here and there a really bad one.
Then we have the other side, the practitioner service. I have spoken to your Lordships on this subject before, and it is one on which I personally feel very strongly. The general practitioner, with his knowledge of the families who build up his area of practice, is a friend. He is able, if he is a really good practitioner, to deal with the extraordinarily complex background of disease, and of disorder and disease that is constituted by family relations, harmonious or inharmonious, and by conditions in the locality. I am well aware that many general practitioners fall far short of the ideal. They are overworked, and in the last few years especially cruelly overworked. They have not the time or the opportunity to stop and think. But it has seemed to me that it is in connexion with the practitioner service that these proposals are most likely to break down.
I do not think that these polyclinics which are to be established, which in the 841 Paper are called health centres, are going to make for confidence between the patient and the doctor. In the first place there will be a secretarial service provided at these centres. It will be provided, as I understand the proposals, by the authority responsible for the centre. If the people who attend at that centre are to be looked after pioperiy throughout the years there must be records of the various diseases and disorders from which they suffer. Such records of course we all know exist today in every private general practitioner's or consultant's library of case records. But picture the difference when you have these records available at centres controlled and run by local authorities—because that is what is to happen—with the servants of the local authorities keeping the records. I can we'll imagine a man or woman being very unwilling to go to such a centre, merely because there was a greater chance—under present circumstances there is almost no chance at all—of some malady from which he had suffered being recorded on some bit of paper which would pass through the hands of some not-very-resporsible clerk, possibly a girl, possibly a man.
It is not easy to get people to go to see those best qualified to treat them. In connexion with health, I suppose there are nearly as many whimsies as there are in connexion with any other aspect of human life. People seem to have a special desire to respond to diagnosis by advertisement, and to receive the advice of the local dispensing chemist; or they like to go to some quack or to adopt some other form—perhaps some mystic form—of treatment. If you have at the centre where these men and women are to be treated something in the organization which makes them feel it is not quite safe to go, I think you are going to do harm to the general practitioner service. You will do harm also to the health of the country. There is a great deal in the health of nearly everyone of us that we should not like to have broadcast or known to certain people. That fear, to my certain knowledge, has often kept men and women away from the actual place where they should have gone to be treated.
Therefore it seems to me that from the point of view of the patient the idea of bringing the practitioners halfway into the medical service—because that is what this proposal means if it means anything 842 —is going to work against the efficiency of the medical services. And it would work even more against it if they went brought the whole way. It is not possible torn a mass of individual doctors to provide all the equipment that is necessary to-day for diagnosis. Is it not possible to provide instead of these places called health centres, diagnostic centres, where there will be experts to do X-ray work, what is called side-room work, laboratory investigation, and so on, for the general practitioners? Such centres would keep that essential personal bond which exists in the best type of general practice between the patient and the: doctor, without the interloping of anybody who is not immediately concerned with the patient and the doctor as to the nature, course and treatment of the disease.
That is where I think these proposals on the practitioner sick are weak, from the point of view of the patient. I think they are also weak from the point of view of the doctors—for this reason. You are going 10 have patients running after the very best men, and some of the men in the districts are very popular. They will have largo numbers of people on their lists and they will receive less and less remuneration per patient for every patient over a certain number. At a certain point the remuneration comes to a dead stop. What will be the effect of 'that on the mind of the; person who wishes to be treated by that doctor? Will he return to the doctor from whom he has tried to get away, and trust him? Will the doctor from whom he has fried to get away welcome him and treat him as a willing patient? It is in that most intimate relationship between; practitioner and patient that very often the whole problem of health recovery turns. And that is where I am convinced there is a profound weakness in he practitioner's side of the proposals which are sketched in the White Paper under discussion to-day.
What is the remedy? It is not easy to answer. It is very difficult to bring the whole of the general practitioner work of the country up to the best levels. The Minister is undertaking to spend a great deal of money, which in turn means human energy, because it is all to be used to a higher service. I believe it would be still possible to improve the Minister's proposals which, frankly, I think 843 in many parts contain an extraordinary number of good points. The one point I am laying emphasis upon—as I think a weak point—is that they will not make for the relations that should exist between patient and practitioner, and which do exist to-day in the best type of private practice. Throughout a very wide field of private practice you will find that best type, although I agree in connexion with some of the panel patients it does not exist very obviously—at any rate to one like myself who is an outside observer. That, it seems to me, is what we should aim at. I fear that where you are going to have centralized clerical records you will have a counter-force working against the general principle of the Bill. I end on the note on which I began. I do hope that, before this series of proposals, sketched as they are in the White Paper, pass through the necessary stages which would enable them to become the law of the land, it will be found we are dealing with a medical service in this case and not with a thing miscalled a health service
§ 5.41 p.m.
§ LORD PIERCY
My Lords, I should like to pay my tribute to the lucidity and sympathy with which the mover of this Motion set forth his case; one might almost say the great charm with which he set forth his case. I want to say a few words on the second part of it, that dealing with the general practitioner service. I need not say I am highly tempted to follow the last speaker who raised so many issues familiar to us on the general controversy on this subject, but to-day I think it is more proper to devote the little time I propose to take to the arguments that were put forward by the mover of the Motion. I think we are all grateful to him that he did with great candour admit that the mind of the doctor, the doctor in this country and the doctor who will shortly be demobilized from the Forces, is to a large extent unknown territory. I think we are indebted to Lord Moran for candidly admitting that. We are equally grateful to him, I fancy, for having left on one side so many of the slogans with which this discussion is bedevilled.
So I will address myself, if I may, to the arguments which he actually put forward. He stated that, in his opinion, the whole of the difficulty which the general 844 practitioner feels with regard to these proposals, so far as his mind is known, centres upon this idea of a whole-time service, and that the other questions that have been raised are merely secondary or subsidiary to that. I think that wants looking at rather carefully. I feel there is a danger there possibly of another slogan. A doctor, I imagine, whether he is dealing with public patients or private patients, expects to do a full day's work. There is no question of that. His service will be full time service in that sense. I suppose if you analyse it, it really comes down to this, a fear that, if his remuneration comes from public sources, there may be something in the conditions of service which will make the life irksome to him as compared with the more individual life of being a free lance in the field of providing medical services. And indeed Lord Moran's two subsidiary points rather bore that out.
There is first of all the question of pay. Well, it is quite clear, of course, that in any publicly-provided service the pay must be confined within narrower parallels than the existing remuneration of the medical profession as disclosed, for example, by Income Tax returns. It is a perfectly valid point, although Lord Moran did not make too much of it, that there should be in the provisions some reasonable measure of economic incentive as well as other incentives. But, as he pointed out, there is an attempt to provide that, within reasonable limits, in the proposals, under which the pay will be partly a fixed payment, which can be varied according to local or individual circumstances, and partly related to the number of patients dealt with. And again, there is the possibility that in a given health centre there could be some pooling, so that still greater differentiation could be made according to experience or knowledge. It may be that that would fully meet that point. I think one must put this on the other side of it, that although security and incentive are not the same things, still in a negative kind of way security can be a form of incentive. By that I mean that no doctor is going to do his best work if he has anxiety about his own health or his own future, and very, very many members of the medical profession, as I have known in the past, are beset by such anxiety. There is the advantage from a publicly provided service that there will be security for the 845 future, and the kind of security of tenure that will safely carry the medical man over periods of ill-health or misfortune.
Then the conditions must be interesting and stimulating. With regard to that, one might justly make two points. There is no suggestion, I think, that in the new service a doctor will be ruled by detailed regulations laid down toy a local authority or any other obnoxious authority as to the conduct of his professional work. It is true he will make a contract of service with the local executive committee, but bear in mind that 50 per cent, of that executive committee will consist of professional members with a chairman appointed by the Minister of Health. Bear in mind, too, that these professional members will be selected by the doctor's own local representative committees. Then again in certain matters, such as the distribution of doctors locally, any attempt to modify that so as to produce a more even spread is protected by the fact that it will be done by a Medical Practices Committee, and finally the Minister is to be guided by a Central Health Services Council which has the duty and the right of advising him, and whose annual report, normally speaking, will be published. So it seems to me that, so far as conditions of service in that respect are concerned, under this scheme—of course one mast see how they work out—a doctor is adequately protected from being caught in an administrative machine which will unduly limit him in the exercise of his professional functions and in his relations with the patients.
Look at the other side of it. I know the medical profession holds out many glittering prizes. It contains many highly distinguished men. But the majority of the members of the medical profession are just like ourselves; they are just ordinary men. At the far end of the scale there are no doubt a number of men who are not fully up to the average of the profession. In existing circumstances a large part of the profession lead a rather lonely and isolated life in their profession, and it is in that state that the anxieties to which I have alluded can come upon them. Suppose there are health centres, either of the pattern sketched in the White Paper or one of the many other patterns which have been suggested—and so far as I know there is no reason why a health centre should be on one single pattern. In a health centre the general practitioner 846 first of all is relieved of a good deal of drudgery; he has a secretary, a nurse and probably a dispenser. Secondly, he has aids to diagnosis, and I really believe, and have seen in many cases, that the doctor who has his profession at heart would very often like the assistance of aids to diagnosis which ordinarily he cannot afford. I feel he would rather be able to use them under his own control at a health centre than go to a kind of diagnostic centre such as was suggested by the noble Lord, Lord Geddes.
Moreover, in such a centre he has the the society of other men. That again is stimulating professionally. The experience of medical partnerships at work in this country, and still more in America, leads the to think that a partnership of medical men can be a stimulating professional thing. Again, remember that in this kind of setting the doctor who has proper rest pauses, holidays and a reasonable working day, is a better doctor than many of those in the lower half of the general practitioner's profession as it now exists. I therefore suggest that it is at least possible—and this can best be judged by professional people—that under the new conditions, should they materialize, the life of the ordinary doctor will be more interesting and stimulating than it commonly is now.
At the present time, if you take the mass of the population—not the 10 or 15 per cent, who enjoy all the benefits and privileges of the doctor-patient relationship so eloquently expounded to us—the people have to choose between very inferior doctoring and the out-patient departments of hospitals. The doctoring is inferior and perfunctory because it is under the panel system. I am not making a general indictment of the panel system, but I am only saying that very often it is unsatisfactory and perfunctory, and the people have to choose beween that and the out-patients department. Is it not possible that the process of the hospital and the specialist taking away the most interesting work from the general practitioner may, at least in part, be reversed, if the doctor has the proper means of diagnosis available to his hands, and is able to consult with partners on the subject and to offer these facilities? Will he not, at one and the same time, get a little back from the experts and a good deal back from the out-patients' department of the hospital?
847 I do not wish to dwell too long on that, but to summarize it by saying that I think the medical practitioner should be led by his advisers to look the proposed terms in the eye. It would be worth while putting some really fundamental thought into the question of whether or not, on the whole, his life will not be more stimulating, longer, and more useful under these new conditions than it could be under the condition of private entrepreneurship where, if he is an able and fortunate man, he is able to rise to a considerable level of remuneration, or if he is a commercially minded man he builds up a practice which is too large and uses assistants whose professional qualifications are less good, or where his future becomes clouded by a certain amount of anxiety.
The background of this whole question is a very large matter of public policy. I believe it must be conceded by everybody that the population as a whole is under-doctored, both in quantity and in quality. I think there are many economic reasons, which, mark you, are the counterpart of this system of private entrepreneurship, which prevent the poor and ignorant person from getting proper medical attention and which at the same time concentrate our rather scarce means of giving proper medical attention upon a limited section of the public. It is highly essential that we should provide the best doctoring that is within our capacity for the whole of the population, and I think myself there is no other way than by making the whole thing a public service, with the cost seated upon society as a whole. If we do that, it is inevitable that changes must take place in the present structure of the medical profession. It is quite likely that those necessary changes will involve some disturbance of conventional habits and modes of thought on the part of the profession.
I yield to nobody in my respect for the medical profession, but, after all, medicine is like religion; the layman is so deeply concerned in it that he cannot, with equanimity, leave it entirely to the profession; he must have a say in it. On one side of the profession the doctor is bound to become, if I may use the expression, socialized. We have had two attempts to bring about something like a measure of general medical provision for the public as a whole. One of them 848 was the great experiment under the National Health Act some thirty odd years ago, which resulted in the panel system. I do not believe there is any layman in this House who knows the facts at first hand, or any professional member of this House, who would say that the panel system was a good or desirable social institution. It must go. That phase has ended. We now have the chance once more to introduce a general system of medical attention in which there shall be one single standard of attention and doctoring, the same for everybody. At present it is like Bismarck's celebrated case of three men trying to cover themselves with a blanket big enough for two. Mathematically it is not as bad as that—perhaps we have 90 per cent, or 85 per cent, of the blanket, but still it is not 100 percent, and in the attempt to make it stretch over the whole of society, that class which had expensive doctoring in the past may not get quite so much of it. On the whole, however, that will be a social benefit.
I suggest that it is very much to the common interest of all of us in this House and of people generally that we should try to make this experiment succeed and really, to borrow a thought from the noble Lord who opened this debate, that we should try to look through the superficial elements of this discussion, do a little fundamental thinking and see where the interest of the community really lies.
§ 6.0 p.m.
§ LORD LUKE
My Lords, at this late hour I will try to be as brief as possible. To start with I should like to pay tribute in particular to my noble friend Lord Moran as well as to Lord Inman, who made such an excellent maiden speech. I think it can be said that the level of this debate has been extraordinarily high and may have helped to blow away some of the great clouds of controversy that have been rather cancelling each other out during the last few weeks since the Bill and the White Paper were issued. I do not know what the attitude of His Majesty's Government may be to what may come out of this debate, but I hope that what has been said will not be taken just as pleading from some vague vested interests but as pleading from those who have knowledge and experience of these matters, and who have the care of patients very much at heart.
849 I realize that there is very strong Government criticism of the present voluntary hospitals system, or, shall I say, of the lack of system. I think this comprehensive scheme is possibly the answer. While there are many of us who feel that it is altogether too big and that it is going to develop into too much of a machine, we are, at and rate, all agreed that there must be some co-ordination of tine health services. I hope every effort in the way of co-operation and partnership will be made to help those who have got to work something which is, after all, a great endeavour in the art of healing. What we want to see is the treatment of illness regarded as a personal and a human thing, because illness itself is a personal and a human thing. Doctors and nurses in hospitals of all types will try to contribute to that end, but they have different ways of doing it. Here I would query whether it is wise completely to standardize when at the present moment we have variety I query very much the unqualified success of public hospitals, and I think my noble friend the Earl of Donoughmore queried that himself. If there is standardization and the removal of all variety I think it will be to the detriment of the scheme as a whole.
Not very long ago we had a great Education Act and we heard a good deal then about standardization and variety. I would remind your Lordships that in that Act the matter of the voluntary schools was dealt with in a very happy way; the churches paid a half and the local education authorities paid the other half. I am wondering why the voluntary hospitals cannot be dealt with rather on the same lines. I throw that out as a suggestion that might possibly find favour with His Majesty's Government. Then again we had very recently in this House the Police Bill, with its voluntary amalgamations, and there we had suggestions as to how the scheme could be worked by co-operation from the bottom rather than by having something else pushed down from the top. I am perfectly well aware of the imperfections and shortcomings of the voluntary hospitals, but there is in them a wealth of experience and of good will and readiness to make an effort. The people in them have that precious thing—the voluntary spirit. That is present in our national character regardless of our station in life; it is the prerogative of none. I think 850 The Times correspondence to which reference has been made was very valuable in that it brought to light the spirit which prevails in this country. We do need to preserve the energy that is derived from people who, of their own free will, put work into a thing, and I believe that voluntary work is of greater value than that which is forced from above. That is particularly true of our national interpretation of practical Christianity—generosity in service and in giving money for good causes.
It has been stressed that we should preserve local interest and pride, but I feel that the proposals in the White Paper are aiming to legislate that great thing out of our country. The White Paper itself is rather at pains to deny it, but I think the effect is to squeeze it out. And for what? For the sake of tidiness in a great scheme and for the sake of very remote control. This may sound to your Lordships sentimental rubbish, but I maintain that in this question of disease and its treatment there is something ethical; it is very intangible and something that cannot very easily be put in black and white or put into a law. We have heard to-day of lack of co-operation between public and voluntary hospitals. In that connexion I should like to instance my own county where there is very good and friendly co-operation between the two types of hospitals. I see no reason why, with good will on both sides, that sort of co-operation should not grow and develop under the Regional Boards.
The state of the voluntary hospitals and their buildings is not good in a great number of cases. There are of course new buildings, and very fine ones; but there are old ones and ones that have suffered a great deal from the war. The point I want to make is that we have heard a lot about the endowments that are going to be taken over from the hospitals—I think the figure mentioned is £32,000,000—but we have not heard so much about the buildings, the equipment and the land which are also being taken over. I would like your Lordships to remember that the total value of what is being taken over from the voluntary hospitals is more in the nature of £250,000,000 than £32,000,000.
There is a controversy about appeals to, and the method of approaching, the public. I do not propose to go very far into that; I only propose to say that the test of whether people wish to contribute 851 in a voluntary manner is their willingness to give. I would like to tell your Lordships that in the last year voluntary gifts to hospitals totalled £7,575,000, excluding what was paid by patients and what was received in the way of public money. I wish to interject here something which will, I hope, receive support from all quarters of the House. The voluntary hospitals have got to exist for another two years as they are; the legislation will not come into effect until 1948. I hope that as much publicity as possible will be given to that fact throughout the country because people are beginning now to think "That is all right; that is all over; we need not give to the hospitals any more." That is not fair because the hospitals have got to exist; their work has to go on. I make that appeal to your Lordships; we have got this interim period during which the hospitals have got to live.
There is a principle, and a right one, that where public money is used to assist in the running of any organization public representation must follow. Of course, that is so now. When the hospitals are taken over and run by public money, representation must go to the proper channels. But I would recall the figure I have just given to your Lordships and I would ask: Does not that representation work the other way? If the voluntary hospitals are giving to the Government £250,000,000 or £300,000,000, should there not be adequate representation the other way? I hope I have made that point, and that I may have some answer to that from the Government side. I should be very chary of saying anything about confiscation of funds. I have been warned on many occasions not to do so, but of course it does smack of taking the funds away, and I would query here whether it is not possible to leave funds to the hospitals themselves and use the great amount of Government money for pooling and for distribution where it is necessary.
Before I finish speaking I wish to make an appeal to the Minister that he will trust the hospitals to play the game. The scheme is going to be quite unworkable without them, and they are going to do their best, but I do ask him to give them a fair chance and not to take advantage of the position. I feel that a Government Bill should be framed to encourage all 852 that is best in the existing structure, and not to destroy everything and start from scratch with a lot of disgruntled people. I notice that this Motion before us welcomes proposals. I notice that it does not necessarily welcome these proposals. I do not know whether that is grammatical or not, but while I would welcome proposals I do not necessarily welcome these particular proposals, so I hope the House will not accept with full approval this Motion which is before us to-day.
§ 6.13 p.m.
§ LORD HORDER
My Lords, not only because of the lateness of the hour, but for the reason that I think that this Motion is somewhat premature in your Lordships' House, I am not going to take up very much of your Lordships' time. First of all may I refer to the noble Lord, Lord Luke's reference to the wording of the Motion. With the wording of the Motion as it stands I take it the whole of my profession would associate itself, and I think that everyone who has the interests of the medical services at heart would do the same. But the noble Lord who moved this Motion expanded somewhat the wording of it and welcomed certain proposals which are not stated in the Motion. I hope it is clear that if this Motion is accepted it is accepted exactly as it stands, namely, "That this House welcomes proposals," the nature of which are unspecified.
In one particular direction the mover of the Motion did expand these proposals, and that was in the direction of the transfer of ownership of the hospitals to the Minister. I am very glad that my noble friend made it quite clear that he was speaking for himself and not for the medical profession. The noble Lord's advocacy would have been weakened no doubt if he had informed your Lordships that during last week the Royal College of Surgeons and the Royal College of Obstetricians dissociated themselves very definitely from any approval of the transfer of ownership of the voluntary hospitals. Yesterday this matter came under discussion in the College of Physicians, but we have a by-law which secures secreta collegii, and I may not therefore reveal the result of the voting, but it may not be without significance that the mover of the Motion made no reference to the 853 opinions of the College over which he so honourably presides. Had the question been central direction of 'general policy, I have no doubt that there would have been as great approval of that principle as there was dissent from the principle of transfer of ownership.
Now I should be less than helpful if I did not tell your Lordships, as against that negative view of the Royal Colleges, what is the positive view at this present moment of three bodies which claim surely to have even more concern in the question of ownership of hospitals than we doctors have. We doctors are very interested in the ownership of hospitals, and particularly in the control and administration of hospitals. King Edward's Hospital Fund, in which my noble friend the Earl of Donoughmore played such an active part as chairman of the management committee, has, of course, great prestige. It is a very trusted medium of public funds, which it disburses with great care under the guidance of very experienced men, and it has also made a great contribution in maintaining the standard of the hospitals of this country. From its latest pronouncement, which was only a few days ago, I want to select a very short extract to quote:We are in full agreement with the broad conception of the development of hospital services on a regional basis. Great stress, indeed, has been laid upon this need by the Fund and by other bodies associated with the voluntary hospitals… The regional conception was, however, adumbrated and developed against a background of independence in the individual hospitals, and the retention of local initiative. We believe that, so far as the hospital services are concerned, the success of the Bill will largely depend on retaining local interest and spreading this interest over all the units composing the new service … in the view of the Fund, amendments are essential to provide for a real measure of independence for the Hospital Management Committees.Then the British Hospitals Association last week stated its position quite clearly:The voluntary hospitals support the objective of the Bill in providing a national comprehensive health and hospital service free of charge…. The provisions of the Bill relating to hospital service are not in the best interests of the patient and the community because they eliminate all local interest in hospitals and local autonomy in their management, and extinguish the voluntary hospitals. The proposed transfer of ownership of all hospitals to the Minister, the confiscation of their property and the establishment of a complex scheme of administration, substitutes remote control and impersonalization for direct management and personal interest.854 Then in the current issue of the British Medical Journal I quote from a leader entitled "The Hospitals":With the introduction of a comprehensive National Health Service, it is clear that all hospitals will have to obtain the bulk of their money from central funds. It is clear, too, that both voluntary and municipal hospitals will have to sacrifice some of their local sovereignty to fit in with the over-all hospital strategic plan. But for this to happen is it necessary for them all to pass into the ownership of one man—the Minister of Health, whose power ' to make regulations shall, it the Treasury so direct, not be exercizable except in conjunction with the Treasury'? The nationalization of the hospitals would cut short at one blow one of the most stimulating forces in English life—the blending of voluntary and official effort in promoting the public welfare ….Reforms are needed in both voluntary and council hospitals. But to effect these, there is no need to turn them into State institutions and so perpetuate on a bigger and permanent scale the evils of officialdom that the great majority of medical men see and fear in the hospital controlled by the local authority.I quote these opinions from these three representative groups because they are positive statements of the position of those groups—namely, the King's Fund, the British Hospitals Association and the British Medical Association. I have already told your Lordships of the view of the Royal Colleges as to the transfer of the ownership of hospitals not being in the national—that is to say the patient's—interest. That is all I propose to say at this time, but, such is the importance of the proposals sketched by the White Paper that I take it for granted that there will be opportunity for getting the best possible Bill—if I may use that word—before legislation is actually enacted.
§ 6.23 p.m.
My Lords, I rise to speak in this debate for a very brief time. I do so because I want to bring out one point that none of your Lordships who have spoken before me has touched upon—that is, the question of the ambulance service. I find in this White Paper that it is only when you get to page 16, paragraph 87, that you find any mention of the ambulance service. Now you may have a most wonderful hospital, but unless you can get the patient to the hospital you do not achieve anything. It seems to me that this is a very important consideration, and yet only five and a quarter lines are given 855 to it in the White Paper. In the first place, I would like to bring to the notice of your Lordships that, to the best of my knowledge, 93 per cent. of all ambulance cases are carried by the St. John Ambulance Brigade, a voluntary organization. I would like to ask the noble Earl who is going to reply for the Government whether the Ministry of Health will expect the greater part of the voluntary ambulance service still to serve the hospitals under the terms of the White Paper, or whether they expect the St. John Ambulance Brigade to maintain its ambulances from voluntary contributions.
I know of one case where a county organization has already written to the authorities of the St. John Ambulance Brigade asking what it should do as it feels that donors to its fund are falling away because they do not know where they are and what to expect. We all know how grateful everybody is to the St. John Ambulance Brigade for its voluntary work. We often see members of it at football matches. I do not think many people realize that the St. John Ambulance men do not get paid for the time that they put in. I know that they may get a front seat at a football match now and then, but they give up a lot of time to their training. Besides the ambulance service, there is the service known as the Hospital Car Service, which was brought into being at the request of the Ministry of Health and the Hospital Almoners Society in August, 1945, to replace the voluntary car pool. The Hospital Car Service, as I am sure your Lordships know, is organized by the St. John Ambulance Brigade, the British Red Cross Society and the Women's Voluntary Services. It is rather astonishing to realize that between 18,000 and 20,000 cases a month are carried by this service. These cases, of course, are patients who are not sick enough to go by ambulance, who yet, owing to their debility, have to have transport, and who, owing to their lack of means, cannot engage a taxicab or a hire car.
I know that in January last there was a meeting at the Ministry of Health under the chairmanship of Sir Arthur Rucker, and representatives of the organizations which I have mentioned discussed the future of the car service. I have been informed that Sir Arthur Rucker at that time could not give an 856 answer to the question whether the new scheme would supply a block grant for the continuation of this car service. I also know that the St. John organization and the Red Cross and the W.V.S. feel that by October they will have run out of funds for the maintenance of this very valuable service. They do not know yet what is going to happen. I suggest that we should pay a good deal of attention to this matter. As I have said, you can have the best hospital in the world but unless you can get the patient there you are not able to do very much. I would be very glad of any information which the noble Earl can give me upon this subject.
§ 6.28 p.m.
§ LORD CHERWELL
My Lords, I feel that I am in very much the same position as the noble Lord, Lord Horder, who spoke a few minutes ago. The form of this Resolution is such that it could be interpreted in perfectly general terms—almost as general as saying that we all of us want an improvement in the health services. But it is linked, at the same time, with a reference to the Government White Paper, so if it were agreed in this form, it would be said, so far as I can understand, that one part of the White Paper was approved and the other part was disapproved. That seems to me what I believe logicians call "the fallacy of the double question." If the noble Lord who moved the Motion had put it down in the form of a Motion for Papers we could have debated this without any further commitment. But if we are to proceed by way of Resolution, then my friends on these Benches propose to take no part at all. The Bill, I understand, will one of these days appear in this House. It may be altered from its present form, or it may not. But there will be ample opportunity then for it to be debated clause by clause and those parts of which the House, or various members of the House, may disapprove, can be discussed one by one.
It does seem unprofitable, to say the least, at this stage, to try to settle the thing out of hand and to pass a Resolution which is not approved, so far as I can make out, by any of the Royal Colleges or the British Medical Council or, at any rate, is not approved by many of the great medical associations. I know that when doctors disagree something 857 happens—I am not quite sure what—but I do not think that it means we ought to pass a Resolution in favour of the motion of the doctors. Therefore I hope that this Resolution as it stands will not be passed, but that on a future occasion when the Bill comes before the House we shall be able to discuss the various aspects of it.
§ 6.31 p.m.
§ THE POSTMASTER-GENERAL (THE EARL OF LISTOWEL)
My Lords, I think you will agree that we have had an interesting and thoughtful debate, during which many experts on public health have contributed their judgment to the common pool without any gladiatorial displays between opposing political Parties. For that very reason I think this debate will have been especially profitable to the Government. I should like first of all to deal with the point that was just made by the noble Lord, Lord Waleran. I think I can satisfy him, at any rate to the extent of giving him quite a lot of information. The duty to provide an ambulance service under the White Paper is laid upon the local health authority, but of course the local health authority can carry out their duties either themselves or by making arrangements with voluntary organizations such as the St. John Ambulance Brigade. These arrangements may either be without any financial transaction between the two, or they may be paid for. But, as the noble Lord will see, provision is made for the St. John Ambulance Brigade to play its proper part in the new hospital service.
I am sure that all noble Lords who heard the speech of the noble Lord, Lord Inman, will wish me to express our very warm congratulations on his first effort in this House. He spoke to us as a leading authority on hospital services, to which he has devoted so many years of his working life. And this, combined with a modest and becoming brevity, is always the best way of breaking the ice in your Lordships House. I hope—and I am sure I am speaking for other noble Lords when I say this—that we shall hear him again on many future occasions when we are discussing issues of public health.
I believe your Lordships will agree that this is not the right moment for a full statement of the Government case on a national health service. The White 858 Paper Cmd. NO. 6761 to which the noble Lord, Lord Moran, has directed our attention in his Resolution, is not, like many White Papers which your Lordships have debated in recent months, a declaration of policy accompanied by the usual powerful battery of reasons and arguments to support it. This White Paper is a much less pretentious affair. It describes itself modestly and straightforwardly as "a factual summary, omitting comment or argument," of the National Health Service Bill which is now before Parliament. It is related far more closely to the explanatory memorandum which often appears on the outside of Bills than to those more frequent publications of the Stationery Office, clothed in the appropriate garb of innocence, in which the Government set out to give a full explanation of some important decision of policy.
The case for a comprehensive health service, as set out in the National Health Service Bill, is no doubt present in the minds of Ministers, but it has not yet been published or disclosed to Parliament. I feel sure that the proper occasion for the Government to submit their case, and to defend it in face of their critics, is during the Second Reading debate on this Bill in another place, and subsequently when that stage is reached in your Lordships' House. I believe that Lord Moran accepts that view, and I take it that the view is shared by both the principal Opposition Parties, as neither has put up an official spokesman in this debate. I think it will also be of advantage to your Lordships to discuss this subject again later in the Session, because by then the facts will be more fully available and criticism will be more easily directed at the centre of the right target. A curtain-raising debate, if I may so describe it, of the kind we have had this afternoon, may be of real value to the Government as an expression of informed opinion. I can assure the House it has been of real value to the Government, and I will do my best as a textual commentator to make it of some small use to your Lordships.
There are in this House many noble Lords whose views on the subject of public health will always be heard with peculiar interest because of their special experience from a long connexion with many different fields of public health. The former Ministers of Health in this House are, fortunately, divided equally 859 between the Government and the Opposition. If they cancel one another out there will be all the more scope for those noble Lords who at one time or another have represented the Ministry of Health in this House, and acted as its spokesmen in debate. Then we have also noble Lords of great eminence in the medical profession, and other noble Lords who speak with outstanding authority from long personal experience of the administration of voluntary hospitals. The Government welcome the opportunity, whether it comes now or later, of "picking" so large a number of expert brains. Our only source of regret is that the late Viscount Dawson of Penn and the late Lord Moynihan, two noble Lords whom the House will always remember for their keen sense of the social responsibilities of the medical profession, were not spared to offer us their advice at this turning point in the history of British medicine.
For my own part, speaking within the limitations imposed by the circumstances of the debate this afternoon, I shall confine my remarks to an explanation and clarification of certain of the Government's intentions, as described in the White Paper and embodied in the Bill. Such explanations as I shall try to give will be based on what I hope may have been an intelligent anticipation of some at least of the points which noble Lords have already raised in debate. First of all, I should like to explain the exact position of the Regional Hospital Boards, to which several allusions have been made by different speakers this afternoon. These boards are to administer all the hospitals, voluntary and public alike, with the exception of the teaching hospitals, in the separate regions into which the country will be divided. It would be a serious mistake for the Government to lay down in advance the exact constitution for these boards. Their size and composition must obviously vary according to the needs of the area in which they will function and according to the services which they will be expected to provide. But the principle according to which the Minister will choose the members of these boards, and the procedure governing their appointment, are made unmistakeably clear in the White Paper and the Bill.
The Regional Boards will consist of people chosen for their individual suita- 860 bility —those are the governing words—as experts with intimate knowledge and experience of hospitals, and not as delegates or even representatives of different and possibly conflicting interests in the area. Before making his choice the Minister must consult the people concerned. That is an obligation. They will include any university with a medical school in the region, the representatives of the medical profession and the local health authorities, and in setting up the original boards those connected with the voluntary hospitals as well. The only rigid element in the composition of the new boards will be the inclusion on each board of at least two experts on mental health; otherwise the composition of these boards must be left flexible. The principle of individual suitability for each appointment, combined with the consultative machinery for making this principle effective in practice, show clearly that the Government's intentions are to set up boards whose decisions will be shaped by a balanced and informed committee judgment based upon the particular experience and varied points of view of their individual members.
It is extremely unlikely that on any board constituted in this way any one element or interest, whether the local authority members or any other distinctive group, would obtain a clear majority by outnumbering all the others. This assurance I can safely and certainly give to the noble Lord, Lord Moran, and to the other noble Lords who have expressed doubts on this point in the course of the debate.
The second proposal I should like to deal with relates to the degree of independence of the management committees that will run the hospitals under the new health scheme. Some letters have recently appeared in The Times suggesting a larger measure of independence for these committees in their relations with the Regional Boards, and the names of the signatories of these letters, all of them distinguished authorities on the voluntary hospitals, are bound to command respect and careful consideration for their views. The first object of the Government's proposals for the future administration of the hospitals is the maximum amount of devolution and local independence obtainable within the regional framework. Decentralization is itself the goal, and no more central control is wanted than an efficient and co-ordinated service necessitates.
861 There will be, for example, a wide field of financial autonomy. Both the Regional Boards and the management committees will have unfettered financial freedom within the limits of their annual budget. There will be no question of Treasury interference in the detailed allocation they make of this, their main source of revenue. The Regional Boards will also have moneys available from the Hospitals Endowment Fund, and any gifts received from future donors, to spend in the same way at their own discretion. Again—and this is another example of decentralization—it Is provided in the Bill that all hospital staff will be employed by the Regional Boards and not by the Minister. It is intended that the management committees will carry out the day-to-day running of the hospitals, a function that will neither be hampered in any degree by the regional authorities nor at any point cut across the planning, co-ordination and general supervision properly exercised by the Regional Boards.
§ VISCOUNT SAMUEL
May I ask the noble Earl, for the sake of elucidation and to prevent possible misunderstanding, when he said these local committees would have full control over their finances within the link of their annual budget; did he mean the total of the budgets, or the budget as divided into a number of specific heads?
§ THE EARL OF LISTOWEL
I can answer the noble Viscount immediately on that point. I was referring to the total budget and not to any particular allocation made within the whole budget. In the view of the Government these proposals strike a fair balance (and that is what we all want) between central and local responsibilities in the future administration of the hospitals. But it should be remembered that one of the main objects of the new Bill is to provide a carefully planned and well co-ordinated hospital and specialist service, and that this object would be entirely defeated if the new services were broken up into isolated and disconnected units, which would merely reproduce some of the most serious defects in the present system, defects which are admitted, on all hands, to be regrettable.
It has sometimes been suggested that the proposed health service will deprive the medical profession of much of its independence, by turning its members into employees of local authorities. This sug- 862 gestion arises from a complete misunderstanding of the Government's intentions. The specialist and consultant will be employed by the Regional Board, or in the case of a teaching hospital, by the Board of Governors. The general practitioner will be in contract with one or more Executive Councils, new bodies composed half of professional men, such as doctors, dentists and chemists, chosen by their own representative bodies, and half of lay member, acting in the capacity of representatives of the patient. One-third of these lay members will be chosen by the Minister, and the remaining two-thirds by the appropriate local health authority. Even in health centres general practitioners and dentists carrying on their practice in groups from the centres will, not be employed by the local health authorities, but will be in contract with the Executive Councils exactly on the same footing as other practitioners working independently from their own consulting rooms.
Another common misunderstanding relates to the powers of the proposed Medical Practices Committee, which has sometimes been regarded as a coercive body for "directing" the general practitioner into a particular practice. This committee will have no such powers, and doctors need have no fear that they will its subject to the sort of direction for which the Ministry of Labour was made responsible during the war. But the need for a body of some sort to control the distribution of doctors, so as to spread: them evenly throughout the country, is essential to any health service that sets out to cover the needs of the whole population. This was recognized as long ago as the beginning of 1944, in the White Paper published at that time by the Coalition Government. For so long as the distribution of doctors is mainly governed by financial considerations, there will be too many practising in wealthy areas and too few in the poorer parts of the country.
The guarantee of payment for every patient, which is incorporated in the Bill, and the variation in the scale of salaries so as to bring doctors into poor districts, will do something to direct the flow of medical skill to the real needs of ordinary people. But these inducements will not suffice in themselves to attract doctors to the places where they are needed most 863 urgently. Hence the Government's proposal to set up a Medical Practices Committee whose consent will be necessary, once the service has begun, to the filling of vacant practices and for the starting of new practices within the service. It is interesting to note that this function was precisely the function assigned to the Central Medical Board, as it was then called, by the Coalition White Paper, so that the necessity of a body of this kind with these powers has already been accepted by all political parties.
What will actually happen is that the doctor wishing to start up a practice for the first time, or to move away from his existing practice to a different area, will have to seek the committee's consent. The consent of the committee to this application will only be refused if they consider that the area to which the doctor wants to go has already enough doctors, compared with other areas, or of course if the number of applicants exceeds the number of vacancies. But under no circumstances will the committee be able to tell an applicant that he must go to a particular area. The function discharged by these committees is essentially negative rather than positive. It is a power to refuse a doctor admittance as a practitioner to certain parts of the country, but not a power to assert positively that a doctor must go anywhere in particular.
This procedure can surely no more be described as "direction" than when a specialist goes to one hospital, because there is a vacancy on the staff of that hospital, but not of another hospital at which, possibly for reasons of proximity to his home, he might have preferred to work. The Medical Practices Committee will in fact be performing the functions of an appointments board or employment agency, keeping a record of vacancies and helping applicants to find suitable openings in the service. A further safeguard to the doctor whose application is refused is the right of appeal to the Minister. So much on a number of detailed points. Whatever differences there may be about the machinery of the proposed national health service, I believe that the principles on which it stands do appeal to the great majority of our fellow countrymen. Most people accept the view that health should now become, like education or defence, a collective responsibility of the 864 entire community, and furthermore that this responsibility should be extended to cover the whole population, so that every citizen, regardless of his means, will receive the best medical treatment the country can afford to provide.
The noble Lord, Lord Moran, initiated this extremely valuable and instructive debate, and I hope that, considering the excellent service he has rendered, he will be willing to withdraw his Resolution. On the matter of procedure, I agree entirely with what has been said by the noble Lord, Lord Cherwell. For the House to vote on the Resolution now would be to anticipate the decision that the House will be called upon to take when the National Health Service Bill is considered. The noble Lord, Lord Moran, considers, on one interpretation of his Motion, that our proposals are good in part. There may be other noble Lords who maintain that they are wholly bad. We shall hope to show that they are, in the main, satisfactory. We have not had an opportunity of presenting our case, the other political parties have not presented their case, and I hope very much that, in view of the danger of precipitating a premature decision, the noble Lord will be willing to withdraw his Resolution.
§ 6.54 p.m.
§ LORD MORAN
My Lords, I will not detain your Lordships at this late hour for more than a moment. I should like to begin by associating myself with all that has been said about the noble Lord, Lord Inman's maiden speech. His great experience lends weight to everything he says and he will be very valuable to this House. In my profession we look upon the Earl of Donoughmore as really one of ourselves; he has such a tremendously intimate knowledge of everything that concerns hospitals that whenever he talks one recognizes his right. He said a thing this afternoon which we really ought to underline because it is so important. He said that you must trust the Regional Board and not interfere. That is the whole crux of the matter: if the Regional Board is trusted and is a really good board, the whole thing will work. If, on the other hand, there is interference, it will not work at all. He also mentioned medical committees. Every hospital should have a medical committee, so that whoever manages the hospital should be advised at first hand technically, by the 865 medical people there. That is the essential difference between the voluntary hospital and the municipal hospital where one medical superintendent is supposed to have in his head the knowledge that covers 700 patients.
I am an unrepentant advocate of health centres. To send a man out from the discipline of a teaching school, to practice for twenty or thirty years by himself, is one of the things I most regretted when dealing with medical schools. There are certain dangers, such as that you lose personal touch with patients, but surely that depends on two things: on the doctor himself, which is a matter that cannot be explained, and upon the time he can give to his patients. There are two things to be done in examining a patient: one is to find out what is wrong, and the second is to put his mind at peace and to explain to him what it all means. That is a thing that takes a great deal of time, and it is one of the great regrets of those who work in hospitals that there is not more time to give to that matter. The only remedy is the provision of more doctors.
The noble Lord, Lord Horder, has referred to this Motion as premature. The reason it was brought forward is simply this. Meetings are being held all over the country, and they are having put before them not the considered views of people who have been following this think on negotiating committees, but in many cases just slogans, and great harm is being done. It was imperative that at an early date somebody should try and rescue this question from slogans and bring it on to a level of fact and of the policy of the profession.
The noble Lord made some remarks about myself and the Royal College of Physicians. I shall not make any reference to those remarks. He did make one statement, however, which I must answer at once, when he spoke of mentioning secreta collegii, and then he proceeded to tell us what happened at the meeting. Therefore I have not the slightest hesitation in reading the actual resolution which was passed, as sent up by the proposer of the Motion. You will see that the words he used and my Resolution are exactly applicable and the whole profession could easily subscribe to it. The resolution is: 866That the College approves the central direction and co-ordination of the general policy of hospitals provided the composition of Regional Boards is satisfactory.I do not think that in not revealing that before I was really hiding any important secrets. That is an innocuous motion. I think it would be perfectly frank to say to this House, however, that there is a great difference of opinion on this subject, and I thought I made it clear that I was speaking as an individual.
In regard to the other point, that opinion is divided, I think the noble Lord tried to make out that opinion is unanimous. He quoted quite rightly a resolution that had been passed, but he did not quote resolutions worded the other way. The most representative body is the Consultant Service Committee. It has ninety-four members, thirteen from the Royal Colleges, twenty-two from the eleven universities in England and Northern Wales, twenty-five from non-teaching hospitals, twenty from the British Medical Association, and three from the Association of Municipal Specialists. Therefore the universities and non-teaching hospitals are all represented. With four dissentients, they passed a motion of which the noble Lord did not approve. Representatives of the staffs of the non-teaching hospitals of England met the same morning and unanimously passed this resolution which approved co-ordination, very much as in my Motion. It was entirely concerned with hospitals. We could go on quoting against each other bodies which have done this or that. Is it not fair to say that opinion is much divided? I think it is inevitable, and I do not believe we could get far by quoting people who have passed this or passed that.
I am much obliged to the noble Earl for his reply which, though it does not altogether satisfy me or my Motion, has given the House a very large amount of information, particularly on the composition of the Regional Boards, which is causing us grave anxiety. I am sure it will be very useful and we appreciate it. I do not propose to put your Lordships to the trouble of a Division on this matter. I think the debate has served a very useful purpose, and I ask leave to withdraw my Motion.
§ Motion, by leave, withdrawn.