§ Order of the Day for the Second Reading read.
§ THE LORD CHANCELLOR (LORD JOWITT)
My Lords, I beg to move that this Bill be now read a second time. I feel quite certain that there is no subject on which it is more worth while to spend our time, our energy, and our resources than on the health of our people. There is no investment we can make which is more likely to repay a thousandfold, and there is no task which will more readily attract men of good will, in whatever quarter of the House they may sit. The idea of a comprehensive health service is not new. It is not a product of mere post-war reconstruction, and it is certainly not the preserve of any one Party. Indeed, I may fairly claim that the principle underlining the Bill, foreshadowed as it was in the 1944 White Paper of the Coalition Government, is non-controversial. So far as method is concerned I do not conceal from your Lordships that the present proposals are, in many respects, radically different from those then put forward, and, therefore, I do not claim that the particular method indicated by this Bill is non-controversial.
2 I should like to start this discussion, in which we are all going to criticize the faults here and there, by paying a tribute. I think we can all of us be immensely proud of the medical service which we have in this country. I think we can be proud, immensely proud, of the services the doctors have rendered to the health of the people. I am sure we should all wish to offer our thanks for the services which the nurses have rendered, and there are countless others in all walks of life, not medically trained, who have rendered voluntary service of the very greatest value. We have not, therefore, to meet the criticism that we are destroying for the mere sake of destruction. I am not an iconoclast. I do not think I look like one. On the other hand, I do not doubt that we shall have to alter, to modify, and to expand our existing institutions to make them fit in with the new ideal of a completely integrated medical service. Destruction for the sake of destruction is, as I hold, always foolish. It must be doubly foolish in a case like this, where you have not got to root out something that is bad, but have to improve something which is good, and improve it without losing or destroying the great merits it has to-day. On the other hand, I must remind your Lordships that this is a Bill to introduce an altered, an extended, and, in some respects, a new service. It is not a Bill to preserve ancient monuments.
This Bill falls into six Parts. The first Part deals with central administration, the next Part with hospitals and specialist services, and the third Part with the local authorities' services. The fourth Part deals with the general medical services, and 3 when I say "medical" I may be understood as including dental, pharmaceutical and ophthalmic services. Part V relates to mental health services. I feel that—I am quite candid—to be rather a blot on the Bill because the rest of the Bill is very well drafted, but this Part of the Bill is obscure. What we have tried to do is to fit into the framework of this Bill the mental services, but I do not conceal from your Lordships that this is a mere temporary job, and it is quite obvious we must undertake, when time permits, a complete review of the legislation dealing with mental health. I do not propose to say anything about this topic to-day. Finally we come to the general provisions.
It is idle to pretend that the main framework of the Bill is not well known to your Lordships; it has been canvassed in another place with very great care. If it would be convenient to your Lordships, I propose to discuss now the general structure of the Bill. My noble friend the Earl of Listowel will open the discussion to-morrow and will deal, so far as he can, with the observations which your Lordships make in the course of to-day's debate. With the permission of the House I will conclude the discussion to-morrow and I too in my turn will try to deal quite briefly with the points which have been made. I would like to start by saying something about the Central Administration, Part I. Clause 1 of the Bill reads as follows:It shall be the duty of the Minister of Health … to promote the establishment in England and Wales of a comprehensive health service designed to secure improvement in the physical and mental health of the people of England and Wales and the prevention, diagnosis and treatment of illness, and for that purpose to provide or secure the effective provision of services in accordance with the following provisions of this Act.The language is simple; it is as curt as the Commandments. This is, however, the greatest task which has ever been placed upon the shoulders of any one man. I ask your Lordships to put to yourselves this fundamental question: Do you agree that those duties should be placed upon the Minister of Health? If you do agree with that, then you cannot deny him the very wide powers for which he is bound to ask in order to put himself in a position to carry out those duties. To help him in his task he has a Central Council which consists of no fewer than forty-one 4 members. You may not be surprised therefore to realize that it has Standing Committees, and it has the right to appoint ad hoc committees which will advise the Minister on matters on which he wants advice. It will also have the right to advise him on matters in regard to which he has not asked for advice, and its Annual Report, which will of course embrace the reports of the committees, will be made available to Parliament, subject to the proviso that there may be circumstances—which I should imagine in this connexion would be very exceptional—where the public interest would otherwise require it.
I concede at once that the Minister of Health under this Bill does have very great powers. He is in the position of a Commander-in-Chief planning a campaign against a very dangerous enemy, the forces of disease and ill health. It is inevitable that he should have to plan, to supervise plans and generally throughout to see that the administration is as he desires it. According to this Bill, he exercises those powers by a regulation-making power. That, I think, is good, because it prevents him from being what I may term a pocket Hitler. Every single one of the regulations which he makes has to come before Parliament and either must receive affirmative approval or can be quashed by a Resolution of either House. I think that is the right course to adopt. I saw in the paper the other day that His Majesty's Ministers were all accused of possessing the vice of "pompous infallibility." It does us good to see ourselves as others see us. I think that "pompous infallibility" is a very unpleasant attribute, but it is good for me to know that I possess it. However, this is an exception to that rule. Quite frankly we realize that we must have regulation-making power, because we shall learn by experience. We shall inevitably make mistakes and we shall, I hope, profit by our mistakes. We do not want to be fitted into the strait waistcoat of a tight legislative scheme which gives us no room for expansion, alteration or experiment. I may say that I am quite satisfied that any Government would have taken the same course, and this was certainly so in the days of the Coalition Government, as is indicated in the White Paper. We contemplate a great central responsibility on the Minister, and we contemplate that he 5 should be controlled and checked by Parliament in all his doings. So much for Part I.
I turn now to Part II which deals with the hospital services. Let me say something about our hospital services by way of criticism. Our hospital services have been developed in a haphazard way. The distribution of these services is quite irrational; they overlap in many respects. Twenty-five years ago the Cave Committee said this:Sometimes two hospitals of similar character are within a stone's throw of each other; sometimes a special hospital exists side by side with a special department of a general hospital doing similar work.I think it is true to say that these hospitals have planned without regard to what their neighbours are doing. They have been isolated; they have been self-contained. Sometimes they have attempted work for which they were neither staffed nor equipped. Our hospital system fails just because it is not a system at all. Many are too small to justify independence. The Minister of Health quoted figures in another place. There are something like 1,000 voluntary hospitals, and of that 1,000 70 per cent. have fewer than 100 beds, and 30 per cent, have fewer than 30 beds. What kind of general hospital service, with the attendance of specialists and the like, can you have in those circumstances? I am told that modern developments in medicine and surgery demand more specialized organizations. It would be desirable to see some hospitals concentrating on this and some hospitals concentrating on that, seeing that in each area there is a complete range of all the necessary hospitals. In short, admission to a hospital is not enough; it must be admission to the right hospital. That has been the report of the Cave Committee, of the Sankey Committee, and of the Hospital Surveyors more recently appointed by the Minister, and of the Nuffield Trust.
With regard to local government hospitals, some of them are merely outworn relics of the Poor Law and others are first-class modern hospitals. What they are depends in large measure on the enterprise and the resources of the particular local authority. There are 150 hospital authorities, or, if you include the minor authorities with their hospitals, 1,500. One often finds that where the need is greatest the resources are least. At any rate, all your Lordships will agree that local gov- 6 ernment boundaries, expand and treat them as you like, are completely irrelevant when you come to consider the provision of a hospital service. So far as voluntary hospitals are concerned, they differ so much; they are very good at the top, not so good in the middle and not good at all at the bottom. A layman like myself is apt to think, when he talks of a voluntary hospital, of some institution like St. Thomas's or St. Bartholomew's, but of course that is to miss the picture altogether. There again you find that the resources differ and vary with the accident of past will and endowments, and that is not a good basis for a general hospital service.
This fact is true and cannot be controverted. In this country at the present time it is not the duty of anyone to see that the range of hospital services is fairly distributed among the people. That being so, no one, I think, doubts the need for rationalizing existing resources, supplementing here, distributing there, and generally overhauling the organization of the basic units of hospitals in each area, either singly or in groups, containing about 1,000 beds and therefore containing specialist services. That is the problem. How can we bring about the integrated service which is necessary? In the first place, I do not believe we can any longer rely on charity to defray the main hospital expenses. Some of us may like it and some of us may not like it, but the days have gone when you could run these services on the principle of "Drop a shilling in my little tambourine." The people who are now going to be compelled to pay something towards this service under the National Insurance Act which your Lordships have passed should not be called upon any longer to provide by charity for the essential expenses.
In the scheme which the Coalition White Paper put forward in 1944 (and for which I take a very small amount of the credit or blame) we said that we were going to have joint boards constituted, consisting of the major local authorities, that is to say, county councils and county borough councils, who would run the local authority hospitals. These joint boards would then enter into contracts with the voluntary hospitals, allocating to the voluntary hospitals in their areas certain duties and responsibilities. In that way, by the combination of a joint board and a contract between the joint 7 board and the voluntary hospitals, it was hoped to build up an integrated, complete and comprehensive service. As a corollary, the voluntary hospitals were, of course, to remain independent and therefore compelled to rely substantially on private contributions. I think it is common knowledge that in the negotiations following upon the White Paper that scheme was rather departed from, but that was the scheme.
Let me say a word about joint boards. I am sure that most of your Lordships in all parts of the House will agree with me that sometimes they work and sometimes they do not. It is necessary to adopt an expedient of that kind sometimes, but it is not a device that I like. I always feel that the constituent members of a joint board are apt to be too conscious of the rock from which they are hewn; they are apt to come to a meeting as mere delegates, and such an organization is very apt to lack the esprit de corps which is so essential to the happy working of any organization. Then I feel that the system of relying on contracts between independent hospitals to provide an integrated service is one which is almost certain sooner or later to break down. There would be many engagements entered into, and there would be many separations on the ground of incompatability of temperament.
I want you to consider it now from a different angle. If I was right in the analogy I used just now when I referred to the Minister of Health as the Commander-in-Chief of our forces, what would you think of a Commander-in-Chief who had to rely on contracts and persuasion in his dealings with the officers serving under him? A Commander-in-Chief must prepare, or at any rate approve, a plan, and if he is a wise man he will only work out his plan after consultation with his Army Commanders. Having got a plan of which he approves, he will, if he is wise, leave a great deal of discretion to his Army Commanders in carrying out that plan, just as the Army Commanders in their turn will leave some discretion to their regimental officers, and their regimental officers to the sergeant-majors. But one cannot imagine a system under which the Commander-in-Chief has not the absolute 8 right to give such instruction as he thinks the situation demands.
That is what we have done here. All hospitals, local authority hospitals and voluntary hospitals, are transferred to the Minister, and the first duty the Minister has is to prepare regions. He does that by order, and that order comes before each House of Parliament. It can be, if the House is so minded, disallowed. He constitutes Regional Boards, and their duty is to plan the hospital facilities within the area. They consist of persons representing the medical profession, representing the local health authorities and representing the voluntary hospitals. The Regional Hospital Boards in turn appoint hospital management committees and the hospital management committees will control either a group of hospitals or a single hospital. Where they are controlling a group of hospitals the regulations will provide that the particular hospital is controlled by a house committee. That scheme involves no bureaucratic management from Whitehall, and this scheme does not involve a single additional civil servant.
I want to see the Regional Boards doing their job, delegating to the hospital management committees their job, just as the owner of a large estate would leave to his agent all sorts of matters. The agent would engage servants, but they would be servants of the owner, and so here the hospital committees act on behalf of the Regional Hospital Board, I hope without undue interference from the Regional Board and, I am quite certain, without undue interference from the Minister. I devoutly hope that we shall be able to secure the services of some of those people who have rendered such splendid service in the past in connexion with our voluntary hospitals.
The necessary expenses of running these hospitals will be provided from public funds, but to supplement that money, to provide those little—dare I call them trimmings? which make so much difference to the comfort and happiness of patients is something which in the future, as in the past, I have no doubt will be done largely by people who are interested locally. At the same time the Regional Board and the hospital management committee must act in accordance with the Minister's instructions, and in that way 9 I claim that you have a completely integrated system and no other system would work as well. May I say a word now about existing endowments? The existing endowments of teaching hospitals will belong to the boards of governors who will be reconstituted as provided by Part III of the Third Schedule. With regard to the non-teaching hospitals, their endowments will be shared amongst the Regional Boards and the management committees as may be provided by the regulations. I would point out to your Lordships that until the appointed day comes the Regional Boards and the hospital management committees will not be in the saddle, and whether they would have any legal existence I rather doubt. When that day comes, then bequests may be made to the hospital management committee or Regional Board, and they will be enabled to devote the money they get either to hospital purposes or research.
So much for Part II. Part III deals with the health services provided by local health authorities, and here we rely upon local government agents and we rely on the larger units of local government. In that we are following the White Paper of the Coalition Government who thought that it was the right thing to do to rely on these larger units. I am quite satisfied that it is right. The local health authorities will establish local health committees and before taking any action they must consider the report of the local health committee. The first duty of the local health authority is to submit proposals, and if those proposals are approved by the Minister then, and not till then, it is their duty to carry out the proposals. They have to provide for health centres, they provide staff for the care of mothers and young children, they become the authority under the Midwives Act responsible for health visiting, home nursing, vaccination, ambulance services and after care and domestic help when necessary. The exact division of functions between the hospital side and the local authority side is obviously a matter which gives room for argument and discussion and difference of opinion. For instance, we have placed the T.B. clinics and the V.D. clinics on the hospital side of the line, though no doubt the hospital boards will make use of the health centres by agreement with the local health authority.
Some differences have been expressed in regard to the ambulance services. On the 10 whole we have thought it better that the provision of ambulances should fall on the local authority side of the line. But may I clear up a misapprehension in regard to one point which I see? It is not necessary for the local authority themselves to provide all these services. Take for instance home nursing or health visiting. The Act expressly provides that the local authority may provide those services by relying on existing voluntary organizations. Such an organization as the District Nursing Association may therefore find itself carrying on in the new set-up, working these services on behalf of the local health authority. They have a right, be it observed, to apply to the Minister to see that their claims are not forgotten in the scheme.
Then I come to the general medical services. This I think is a difficult Part of the Bill and we have had to set up new machinery. We have set up executive councils which will cover the same area as local health authorities, although there is power in the Minister to make an executive council cover the area of two or more local health authorities. They consist of twenty-five members, some appointed by the local health authority, some by the Minister, and some by the local medical or dental people, and we have adopted that device if only for the reason that the doctors, rightly or wrongly, were quite unwilling to be placed under the local authorities. Accordingly, if a doctor enters the scheme he makes his contract, his arrangements, not with the local health authority but with the executive council.
May I say here that it is to be understood that no doctor is to be compelled either by direct or indirect pressure to enter this scheme? He may carry on his private practice exactly where he likes; he may sell his practice as and when he likes and he is in no way to be interfered with, but if he enters into the scheme then there must be two methods of control. In the first place—and this only applies to new entrants and not to persons with established practices—he cannot go to whatever area he likes. In short, he cannot go to an area which is already fully covered and neglect an area which is not covered, if he is going to indulge in public practice. For that purpose we have established a committee which is very largely composed of practicing doctors. Your Lordships will find it 11 set out on page 70 of the Bill. Six out of the eight members constituting the committee are to be doctors, and there is the right of appeal to the Minister if the application of a doctor to practise in a particular area is not granted. Secondly, if he enters into public practice and gets part of his remuneration from public funds we think it would not be right that he should be allowed to sell his practice. For that reason, we are prepared to pay remuneration from public sources as compensation for depriving him of the right to sell, and the sum provided for amounts to no less a figure than £66,000,000.
Finally, on the matter of machinery, we are setting up a tribunal which is to investigate a serious allegation—an allegation, for instance, that the inclusion of a doctor's name on the list is prejudicial to the efficiency of the service. That Tribunal consists of three members. I appoint the legal chairman, one member is appointed by the Minister, as representing the executive councils, and one is appointed as representing the profession. But there is the right of appeal to the Minister. That compares with the present system under which complaints are investigated by the insurance committee with an appeal to the Minister. Removal from the list is a matter for the Minister alone. That scheme has worked so well that I have never heard any single suggestion that it should be amended or altered. This is complicated machinery—the Executive Councils, the Medical Practices Committee and the Tribunal, the last two of which are central bodies, not one for each area. We believe that with that machinery, we can achieve our object. We want to give full freedom and full scope and opportunity for professional skill, we want no unskilled interference with free professional craftsmanship or training. The doctor or dentist or nurse must be completely free from political factors or lay direction. The function of public organizations is to provide the apparatus; it is for the doctors to work it.
How shall we remunerate our doctors? This is a difficult problem. We do not want to rely solely on capitation fees. If you rely solely on capitation fees you put a premium on having a very large panel, and you tend rather, perhaps, to produce undue competition for patients. On the 12 other hand, we do not want to rely entirely on salary, because if we did, it would almost be inevitable that people would lose the right to choose their own doctor. So, while we want some element of salary we do not think that that should be the sole, or indeed, the main element in the remuneration of the doctor. We believe that, under this scheme, the patient, who will have at his back not only the general practitioner but specialist services, will be better off. We must see that the doctor is no worse off. We must take care to lee that we continue in the future, as in the past, to recruit the right type of man who will uphold the traditions of a very great profession. We should be very foolish if we were to try to construct this scheme on the basis of a disgruntled and dissatisfied profession. For that reason, we appointed the Spens Committee, consisting half of doctors and half of others, to deal with the range of remuneration for the general practitioner. We must try to arrange with the members of the profession themselves not only the range but also the method of remuneration.
With regard to specialists, I have discussed this matter with the Minister, and I have to tell your Lordships that he is quite willing to appoint—indeed, he is desirous of so doing—a similar Committee to the Spens Committee to deal with the remuneration of the specialists. That, I am sure, your Lordships will think is the right course for us to take. With regard to dentists, when the people of this country become more educated and realize the immensely important part which dental health plays in the general health of the population, then they will face up to the fact that we have a completely inadequate number of dentists to look after the community. We must, therefore, do the very best we can to attract more people into this great profession. It, of course, requires long training. As matters are to-day, the numbers in it are hopelessly inadequate and all we can do is to see that we give some general priority to those people who particularly should have dental treatment—for instance, children and expectant and nursing mothers.
That is the scheme. I forbear to go into it at greater length, but your Lordships will notice how at every single step all these various organizations are interlocked with one another. The Regional Hospital Boards have representation on the local 13 health authorities and on voluntary associations, and so on, all the way through. We claim that by this scheme we are giving, as indeed is plain, complete opportunity for these various organizations to work together and to get to know each other. But mere opportunities are not enough. The success of this scheme, like the success of every other scheme, will depend on the day-to-day co-operation which all these people show in serving a great ideal. For my part, I do not doubt that after we have threshed out this Bill and come to a satisfactory conclusion—as I am sure we shall—all sections and all classes of the community will sink their differences in trying to press forward a great ideal for the betterment of the health of the people. I beg to move that the Bill be now read a second time.
§ Moved, That the Bill be now read 2a.—(The Lord Chancellor.)
§ 3.18 p.m.
§ THE EARL OF MUNSTER
My Lords, I feel that the whole House must have listened with great interest to the speech which has just been delivered by the noble and learned Lord Chancellor in commending this Bill for a Second Reading. I also think that your Lordships will be prepared to spend a considerable time on a measure which, as the Lord Chancellor rightly says, deals with the health of the British people as a whole. It is true to say that every Party in the State is now committed to a comprehensive health service. We, on these Benches, have fully accepted the principle of such a service. It was outlined in the original White Paper published by the Coalition Government in 1944. The object which we too had in view, not only for the promotion of good health but also for the prevention and treatment of ill health, was to bring every branch of the medical service into full and active operation. The proposals were designed to secure the building of a new health service on the foundation of the existing service, and at the same time to remove any deficiencies which might exist in the current arrangement. In point of fact, the lack of availability of any full medical service was finally to disappear, but in our scheme we never intended to disregard all past history. Our scheme was, therefore, planned to bring about the closer co-operation of every branch of the health and medical profession, and so to build the new setup into a wider and far more embracing 14 service than exists to-day. It will not, I hope, have been forgotten that this full and comprehensive service is to be free for all classes of the community, but only so far as fees and charges are concerned. That, too, was agreed in the old days of the Coalition.
I for one—in common I feel with many noble Lords in this House—had hoped that when the Bill came along to give effect to this scheme—a scheme which, incidentally, formed part of a legacy left by the Coalition Government—we should have been able to proceed to this discussion freed from acute political controversy and in agreement as far as possible with every branch of the medical and health service. Any measure such as that would have caused little or no wrangling if it had been carried into the present Parliament within the limits agreed by all members of the late Government, including some of the principal Ministers in the present Socialist administration. Unfortunately, that was not to be. The agreements which were reached in other days have now been laid aside, and certain provisions which we believe to be wholly detrimental to the future of the service have been inserted in the Bill.
If those of your Lordships who are interested in this question will examine the White Paper of 1944, a Paper which, incidentally, was issued only after very prolonged and careful consultation with all branches of those whom it affected, you will observe the very wide differences and divergencies which exist between that Paper and the proposals contained in this Bill. It was then admitted that both the central and local authority should find a place in the new organization. The central responsibility would naturally lie with the Minister, and local responsibility for local hospitals would naturally lie with the major local authorities. The two authorities, in their respective spheres, would then both become answerable to the people, in the normal democratic manner. But, my Lords, it was never the intention to supersede local government, and at no time, as far as I am aware, was there ever to be remote, as against local, control.
I cannot help feeling that it would not be impertinent for me to ask His Majesty's Government whether it is merely for political and doctrinaire reasons that the whole of the medical profession are to be saddled with a system which they dislike, that 15 institutions which the British people have so generously supported for centuries are to be removed from their control and that fields in which local authorities have made much progress are to be taken over. However desirable it may have been, or was, to amalgamate local authorities and to set up a regional organization to cover medical, surgical and fever hospitals, both local and voluntary, it was never suggested during the old discussions on this measure that all the hospitals throughout the land should be nationalized and transferred to the control of a single Minister and a monster Government Department. The magnitude of this vast changeover can best be shown by the fact that the London County Council are to-day the largest hospital authority in the world.
That brings me to two very important questions, both of which were touched on by the noble and learned Lord, the Lord Chancellor, in the course of his introduction. The first is the effect of the transfer on local government, and the second is the administration of the hospital services after the appointed day. I do feel that the removal of hospital authority from the London County Council and other local authorities, and the encroachment by His Majesty's Government on and into local affairs, must tend to produce further apathy amongst the electorate, who obviously cannot be expected to take much interest in their local government affairs when the councils for whom they cast their votes are denied a great deal of responsibility and power. But however much the scheme may affect political interests within municipal affairs, it will also radically amend the whole system of local government interested in the general problem of health. Health includes not only housing, education and drainage but it also covers nursing the sick and the prevention of disease. None of these services can be isolated from the others, since they are all, as indeed they must be, intimately interconnected. It may well be said that Parliament has always been very free—perhaps too free—in granting additional powers and in imposing further liabilities upon local authorities. For generation, the first attempt of any kind of government in any country has invariably taken the form of decentralized health services, which include the duties I have just mentioned.
16 After the passing of this Bill there will be dual control. The health centres and other duties which are to be the responsibility of a local authority, and which are enumerated in Part III of the Bill—about which I shall say something later—will be managed by the major local authorities. But all their hospitals through the whole country will be monopolized by the Minister of Health in conjunction with the Treasury—or perhaps I should say in subjection to the Treasury—with this promise, that every citizen in the country will receive the same standard of service. In point of fact, my Lords, a levelling process will be undertaken and we know from other experiences that that levelling process must be downwards. I give your Lordships one indication to explain what I mean. Every noble Lord will remember the convoy system in the war, when ships met at one point to proceed overseas. The speed of those ships was the speed of the slowest one amongst them. There was a levelling down. Whilst the Government appear, then, to despair of the capabilities of major local authorities to run their own hospitals, they nevertheless cast upon them the obligation to become the main responsible authority for the provision of health services. Thus you have this very curious anomaly that an out-patient comes within the orbit of local authorities, but an in-patient comes within the autocratic control of the Minister of Health. There can be no satisfaction to any local authority to be represented on the hospital management committees, for that merely gives them power with no responsibility to the electorate, although, at the same time, they remain the principal authority in the district for the maintenance of a good health service.
Let me come to Part III of the Bill which indicates the various services which, in the past, have been administered by the minor local authorities, but which are now to be taken away and run in future by the local health authorities. They embrace the services which the noble and learned Lord, the Lord Chancellor, enumerated, including maternity and child welfare. In the London area those services have always been administered by the Metropolitan borough councils. I am certainly of the opinion that some health services can be better managed by the borough councils and 17 better organized by those minor authorities who, through their system of direction in each of the boroughs, can come nearer, as it were, to the hearts of the people and deal with their requirements far better than a major local authority. I find it difficult to understand the reasons which have prompted the Government to remove borough responsibility in London and elsewhere, unless it be a method of pacifying and satisfying the local authorities who lose their hospital services. The whole of this tendency, which I have only very briefly outlined, is a matter which I think your Lordships should not lightly disregard. I have no doubt that other noble Lords will elaborate the story in the course of our discussion, but I venture to think that such a system will always create bad feeling between all the parties in the new health system.
I now turn to deal with my other principal point—namely, the administration of hospital services after the appointed day. Noble Lords will recall that under the terms of the Bill the country is to be divided into regions, each region being associated with a university medical school and ultimately every Regional Hospital Board will submit a scheme to the Minister, who can approve it or not, with or without modification. Although this is the basis of the whole of the administrative set-up, we have yet to be told the size and the extent of the region. I know that the noble and learned Lord will forgive me if I ask why it was that he, in his very illuminating speech, was unable to indicate that these facts would be published, and a manual clearly defining the areas in question would be in the hands of your Lordships. I hope that we may hear the answer to this question later on in the debate. It is very important for the discussion of some clauses of the Bill that your Lordships should be in a position to know the size of the region. Noble Lords understand far better than I do that the administration of any large organization from a single centre is the most difficult technique known to administrators. There are many instances which immediately come to mind, but I will not to-day single out any one Government Department to whom that could apply.
From my little experience of Government Departments, I think it is quite wrong to believe that the capacities of a single Department are sufficient to run a 18 highly qualified and very skilled service such as hospitals. I. can only conclude that it must be through a complete lack of knowledge of administration and the manner in which it really works that the Minister of Health has been bold enough to impose these vast responsibilities upon himself.
Some of your Lordships may have read the leading article which appeared in The Times newspaper on 26th September last, in which it stated that a gradual decrease of efficiency in administration was to be expected as a result of the complete overburdening of departments with the weight of the tasks of readjustment, thus causing excessive fatigue of many municipal servants and a diminished resilience in their administrative thinking. Nothing is more certain than that you cannot obtain the maximum degree of efficiency in the administration of primarily local matters if you divorce them from local control. The local representatives of the people in any regional area should be in a far better position to judge the requirements of their locality than a single organizing centre with excessive powers of control and quite out of touch with local opinion, local feeling, and local thought.
The scheme which is designed in this Bill must tend, as the Lord Chancellor explained to your Lordships it was intended to do, to transfer power absolutely to the Minister who—he will forgive my saying so—is naive enough to believe that by regulations and by a multitude of orders he can assume responsibility for the country's health. Local administration may very well require a measure of reform, but to transfer the whole hospital service to a single centre is certainly to ensure, in the words of Milton, that "wisdom at one entrance is quite shut out."
I pass now to deal very briefly with the voluntary hospitals and also to make mention of the matter of confiscation of their endowments. The voluntary hospitals, which are to pass to the rigidity of State control, have for many years stood omnipotent and supreme in the contribution they have made to the health service of this country. Practically all the discoveries in the prevention, the diagnosis and treatment of disease can be traced to them, and, as medicine knows no frontiers, their findings have travelled the world. The management of these institutions is in the hands of committees freely 19 elected by their many supporters, and on their boards can be found men and women in every class and every walk of life. Although these hospitals are a living entity, largely dependent on local initiative, support and pride, and competing freely with one another—which in itself is a desirable constructive element in the progress of medicine—all that is to pass away. There is no voluntary hospital that I know of which is not anxious to assist in the provision of a comprehensive health service, and to that end the formation of the regional hospital system was supported some years ago not only by the British Hospitals Association but also by the King's Fund. They want to see an automatic link-up between all hospitals—medical, surgical and fever—and they believe, as I do, that this rationalization could be better achieved without the revolutionary proposals which are to be found in the Bill before the House.
If the desire to create a new organization such as I have just outlined had been present in the mind of the Government, I have little doubt that a more beneficent service could be built up on the existing set-up without the procedure for the confiscation of endowments. The Regional Boards, which, as I have mentioned, must play the principal part in a new organization, will become the corner-stone of the administration, and the powers which they possess, such as the appointment of the chairmen of the hospital management committees, are quite sufficient to crush and to stifle all local initiative and incentive to help. Let me ask the noble Earl why it is necessary for the Boards to appoint the chairmen of the hospital committees and for the Minister to appoint the chairmen of the boards of governors of teaching hospitals. What really is the reason for this differentiation? Am I correct in assuming that the Minister has made some deal with the local authorities, and that the chairmen of the hospital committees and boards of governors are to be filled by some trusted local colleagues? In Clause 7 of the Bill the endowments of all local hospitals, other than the teaching hospitals, will pass on the appointed day to the Hospital Endowments Fund, and, after various charges have been made, the remainder will be apportioned between the several Regions. In the case of the teaching hospitals, all 20 endowments will rest, free of the trust under which they were given, in the board of governors.
Noble Lords who take an active interest in voluntary hospitals will observe at once that in the case of voluntary hospitals all endowments which have been left for a specific purpose—such as the endowment of a bed or the provision of books or the welfare of the staff—will be confiscated and used for a totally different purpose from that which the donor had originally intended. I feel that the noble and learned Lord will forgive me if I say that for a Lord Chancellor to support such a proposal must be unique in the history of trusteeship. Surely the Government, on accepting the highly valuable asset of voluntary hospitals which are to become the property of the State, could also, at the same time, have accepted the burden of the outstanding liabilities and thus saved the endowments for their respective hospitals. But that is not all. After this really immoral deal has been accomplished, the Government, in Clause 59, ask the charitable public to subscribe to any teaching hospital for any purpose and to any hospital management committee for the hospitals in their particular group. Nothing, I may venture to suggest, could be really more ludicrous, and nothing could give less encouragement to the public to subscribe in future to any charitable enterprise if they have the fear that at any moment these might be passed into one pool and distributed for purposes for which they were never intended.
If the Minister is anxious, as I very sincerely believe he is, to maintain the support of the British people for their hospitals after the appointed day, then we shall move an Amendment on the next stage of the Bill to secure that between the passing of the Act and the appointed day, any endowments which are received by any hospital should remain the property of that hospital to be used for that hospital, and not transferred to the Hospital Endowments Fund. This will serve two very important purposes. Firstly, it will ensure the co-operation of the British people for this unique organization, and, secondly, it will lessen the difficulties between now and the appointed day for the hospitals to maintain themselves as they have done previously. The Lord Chancellor in the course of his speech made reference to the Minister of Health becoming the Commander-in-Chief of an Army. 21 Every man in the Army has a paper which is known as his G1098. On that paper is the day on which he was born and, if that paper is found after his death, that date also is inscribed thereon. Everything that he does, every move that he makes, is on that paper. I cannot help thinking that each hospital before long will receive its G1098 from a not-too-generous Treasury.
I pass now to make a very few brief remarks regarding the medical practitioners. I need hardly add that on this question we differ absolutely and fundamentally from the Government. The whole scheme of a comprehensive health service can be utterly destroyed and wrecked if the medical profession decline to work it. I should most deeply regret any such action on their part. I can imagine nothing that would prejudice the workings of the whole scheme more than imposing upon doctors a plan to which they are practically wholly opposed. It has never yet been made clear whether this scheme which is embodied in the Bill is the thin edge of the wedge of State control, and I have no doubt that, as the members of the profession are unaware of the Government's future proposals, they feel that before long they may find themselves driven into the full-time salaried service of the State.
The policy of the Government was clearly defined in their pamphlet "National Service for Health," in which it was stated that on the Labour Party coming into power a full-time and salaried and pensionable service for doctors should be introduced. Some members of the present Government have gone so far as to regret that the scheme has been dropped, but the Minister himself made it abundantly clear that he did not believe in a full-time salaried service as the medical profession was not yet ripe for it. The Parliamentary Secretary travelled even further on this slippery slope, and made somewhat similar remarks. Might I ask the noble Earl, Lord Listowel, in the course of his reply, to let us know whether the principle of a full-time salaried and pensionable service is still the intention and object of the Government, or has it been superseded by the proposals which are found in this Bill? At the same time, the noble Earl, in concocting his reply, will no doubt recall the statement of the Lord Privy Seal, who said: 22Of course this is a developing policy and we shall march on to greater and greater public service by the medical profession. What was published by my Party in 1943 we, of course, stand by. We have never repealed any of our policies and we shall continue to march in the light of that policy.I feel sure that if the medical profession could know what were the Government's future intentions their feelings towards this Bill might be better than they are at the present time.
What is the position of the doctor who enters the new service, or of a medical student who will shortly be entering into this new service? There are three things. First, except for a few private patients, he is to receive a basic salary and a capitation fee which will diminish in scale as the total number of patients rises. Secondly, he will not be allowed to practice in any other area without the authority of the Medical Practices Committee. Then he will be forbidden to buy or sell a practice; and, finally, he will work at a health centre which is extremely unlikely to be fully equipped and ready for occupation by what the Minister hopes may become the appointed day. That, in itself, interferes with all freedom for the medical profession, and is a bad precedent for the future. I do not believe that His Majesty's Government could have done more to undermine the competence of the medical practitioners, for these proposals offer no freedom of choice, no freedom of movement and very little freedom of judgment; and they point even more directly to the scheme becoming before very long a full-time salaried service. By introducing this salary element the doctor must cease to be the adviser to his patient and he becomes instead the adviser for the patient to somebody else. That alone undermines the close relationship which should exist between the doctor and the patient. The very fact of a lower capitation fee as the number of patients increases penalizes directly the efficient and brilliant young man, for it automatically limits his status and his promotion in the service.
There is one other point which I should like to make before I close on the question of the medical practitioner. There are a very large number of doctors to-day who work in partnership and from time to time, as we all know, a vacancy occurs which has to be filled and which in other days was filled by the remaining partners in an agreement amongst themselves. 23 In a number of cases the doctors in a partnership have earmarked a young doctor who would suit them well for the appointment when the next vacancy occurs. But in the future the partnership may have forced upon it some doctor who in their belief will be totally unfit for the particular area and not the sort of man to do their particular work. I cannot help thinking that it would be possible for the Government, if they saw fit, to agree to the moving of an Amendment to secure that any vacancies for existing partnership should be filled without recourse to the Medical Practices Committee. I make that suggestion to the noble Earl in order that it may be considered between now and later stages of the Bill.
I will not continue to elaborate some of the points I did want to mention, but I would say that by removing ambition, by lessening the attraction of the profession and in damaging its traditions and by causing distrust of the Government's future proposals, I believe you have very gravely affected the future of medicine and you have slowed down the ever-continuous process of attack upon disease and upon all its causes. On the future stages of the Bill we should like to ask many questions. Some of the principal points will be the recruitment and transfer of staffs, the resolution for the setting up of the Regional Boards, and the acquisition by the Minister of the property of any enterprising service, thereby preventing a private venture. There will also be a number of points on Clause 35 of the Bill, relating to the prohibition of sale of medical practices.
I fear I have delayed the House much too long, but let me add this in conclusion. I have endeavoured to give the House some indication of our feelings towards this Bill. I cannot help thinking how much better it would have been if the Minister had not ridden roughshod over all institutions and persons who have got to be brought into active partnership in order to make this scheme flourish and prosper. How much wiser would it have been if he had decided not to relegate local authorities to a position which is intolerable to their status as the main, health authority in the area. How much safer it would have been to leave the voluntary hospitals to continue their work 24 but to bring them into the regional scheme. And, lastly, how much greater could this comprehensive health service have become if all parties had entered into it freely and without the fear of Ministerial dictations, rules and regulations and had worked together in the future as in the past for the good of humanity and for the lessening of disease and ill health.
§ 3.57 p.m.
THE MAROQUESS OF READING
My Lords, if health and the pursuit of happiness be closely associated, as indeed they must be to everybody but the most valetudinarian, then we consider that this Bill moves a very considerable step in the direction of increasing the general happiness of the people of this country. We on these Benches support this Bill in its general terms perhaps on two main grounds. The first one is that of pious recollection, because it is, in a sense, and I think in a very true sense, a great structure raised upon the foundation which was laid by the provisions of the scheme of National Health Insurance introduced by the Asquith Government in the days before the 1914–1918 war. It must be a great satisfaction to those members of that Ministry of All the Intellects who are still happily with us, to look on this present Bill and to see in it the fruition of the then necessarily humbler beginnings which they were privileged to inaugurate. Perhaps to show that we still have something to offer except our honoured name, in spite of what was said by a very eminent personage a few days ago, I would point out that in the year 1942 a Liberal Committee considered this question of a national health service and subsequently produced a pamphlet entitled "Health for the People" which bears at least a colourable resemblance to many of the features of this present Bill. I do not suggest plagiarism; I merely salute coincidence.
I said that we gave our assent to the general terms of this Bill, and I think we must bear in mind that it is really only general terms which are at this moment before us. We have, so to speak, the scenario of the ultimate Bill, which will not have grown into its full splendour of technicolour for exhibition to both adult and other audiences until the year 1948. The gaps which at present exist have to be filled in by a very multitudinous series of regulations, and those regulations will want the closest scrutiny and attention 25 of both Houses of Parliament. I had the diligence, having been provided with an interval of some weeks since, the House last sat, to examine the operative clauses of this Bill which require the making of regulations, and I find that out of seventy-four clauses no fewer than twenty-six prescribe a regulation under that particular clause; and a separate set under each clause will presumably fall to be made. I cannot help thinking that before the year 1948 dawns not only the printing presses of the Stationery Office but the permanent officials of the Ministry of Health will be chronically over-heated. It is upon those regulations that the efficiency and practicability of this scheme will, to a very large extent, ultimately depend. It is upon their good sense, their good foresight and, incidentally, their good English, that much of the relationship, not only between the Ministry of Health and the medical service but also between the medical service and the public, will depend. Therefore I repeat that to exercise careful scrutiny of these regulations will be one of the most important functions of Parliament in the interval.
Speaking in this particular matter purely for myself, I cannot believe, however dynamic and superhuman a person may occupy the office of Minister of Health, that it is within the power of any one individual at this particular period of time properly to discharge the functions which fall to his lot on housing and health, as it will be under this new scheme, at the same time. That seems to me to be a task beyond any one Minister. After all, what are the prime duties of a Minister? They are to initiate policy and to give decisions on matters of policy. Can any one man be expected, without imminent danger of collapse or undue procrastination, to give decisions which are vitally necessary upon both these great subjects? The Party which now constitutes the Government set up in the past, if my recollection be right, some agitation for the formation of a separate Ministry of Housing. This may be the obverse of the medal, and the time may come when they find themselves faced with an agitation for a separate Ministry of Health to do the work which the name of that Ministry really implies, and having within its competence the health, and only the health, services of the country, divorcing itself of those functions which properly 26 come under housing I appreciate how close is the connexion between good health and good housing, but, at the same time, it should be possible for separate Ministers to keep so closely in touch that the policy of two Ministries on these matters can walk hand in hand, rather than that one individual should be over-burdened to the detriment of both sections of his department. I very much hope that the Government will give some consideration to alleviating the insupportable burden which will fall on anybody who is afflicted by being Minister of Health while these two problems are of such vital and imminent importance as they are, and as they are likely to be for some years to come.
Perhaps I may now pass to the Bill itself, though in no great detail. The Lord Chancellor has spoken of the voluntary hospitals and their position at the present time. I cannot but agree that the fact that so essential a service—essential not only to the daily life but to the future betterment of this country—as looking after the health of the people should be left in the hands of voluntary organizations dependent upon charity is, at this stage of evolution, both an anachronism and an anomaly. After all, many of the hospitals owe their foundation to chance and their continuation to charity. That type of indiscriminate arrangement, infinitely valuable as it has been and vast as are the services which the hospitals have rendered in the past, is now out of date and out of time and tune with the modern progress of events. But I confess that I find this somewhat rapacious engulfing of all the funds of the voluntary hospitals a considerable mouthful to swallow, and more especially that part of the not very attractive morsel which deals with those funds which are the subject of trusts—trusts created by benevolent people, either during their life-times or by their wills.
Only recently there came to my notice the existence in one particular district of a memorial to a young airman of this last war, whose name, during his inevitably short career as one of the leading pilots of this country, was greatly honoured by those amongst whom he had lived. When he died, as die he was sure to do in the work he was doing, the inhabitants of that particular district raised, by voluntary public subscription, a memorial to his memory, and that memorial took the form of a beneficence to the hospital in the locality in 27 which he had lived. The local hospital was endowed by the local inhabitants with a memorial to the memory of a local hero. I would like the noble Earl who is to reply for the Government to tell me whether it is the intention that the money subscribed in memory of that young airman by those who knew him and amongst whom he lived, is going to remain for the purpose for which it was contributed, or whether it is going to be swept into the omnivorous till of the Ministry of Health.
I will pass now, if I may, to the question of the services which are to be provided by local authorities. I should perhaps normally have hesitated to speak on this particular matter because there happens still to be in existence a body colloquially known as the Reading Committee, which was charged with the duty of inquiring into local government in the county of London. I might have thought myself, by my chairmanship of that Committee, prohibited from speaking on that point; but in the Committee stage of this Bill in another place, the Minister of Health was so emphatic—and nobody is a more masterly exponent of emphasis—that this particular question had nothing in the world to do with the Reading Committee that I feel myself free to speak on the subject, since he is not in a position to complain and I doubt whether anybody else would desire to do so.
I want to say this in support of what the noble Earl, Lord Munster, has just said. It seems to me to be a matter of infinite regret that the infant welfare service in London should be removed from the hands of the metropolitan boroughs and concentrated in the already sufficiently grasping hands of the London County Council. The County of London, after all, has a population of over four millions. Those of us who count ourselves as democrats have always been brought up in the belief that one of the foundations of democracy, and one of the surest methods of preserving a democratic way of life, is to interest persons in local government in the areas in which they live. Is this the way to stimulate and to preserve that interest? After all, those people who were interested in infant welfare—and there were many of them—brought a special knowledge, and perhaps particular qualities, into the field of local government, and that knowledge 28 and those qualities were of value not only within the narrow sphere of child welfare but in their approach to all the many problems of local government work. It seems highly regrettable that this opportunity should be taken in this Bill to sweep away from the control of the local bodies those functions which brought into local government so useful a body of people and to take away from people already serving in local government what has in many cases been the great stimulus and attraction of their work. Moreover, there are many cases in which local government authorities have built, and built with enormous pride, enormous love and great sacrifice, buildings which were worthy of the work which was to be done within them. They are immensely proud of the infant welfare institutions which have been set up in their boroughs, and there is a very healthy competition between the various boroughs. All that should not be scrapped and handed over to the L.C.C, telling them to go on with the work with their remote control and eliminate all the functions which made so great and valuable a contribution to the living force of local government work in London. I very much hope that there is still time for the Government to cons consider that decision before the Bill passes into law, because we cannot regard the present position as in any way the last word.
I want to say one word on the subject of health centres. I think it is right to say that the Minister himself recognizes that health centres are an experiment and during the early stages should be regarded as such. I hope that that attitude will be persisted in, because I think it is doubtful whether, from the psychological point of view, this system is going to appeal to the public of the country, whether they are going to like to have to go to these centres, and whether it is gong to be a worth-while proposition in rural districts to have to go to health centres at all. There is another reason for our hope that in these early stages this aspect of the matter will be proceeded with slowly and with deliberation, and that is that here again, as in the infant welfare services—as anyone who has visited numbers of institutions in his time will, I think, agree—there is the overwhelming advantage of having a building which is functional in character, built for its purpose and equipped for its purpose, as against 29 taking over some old building and merely adapting it with such opportunities as it offers. Therefore I hope that until this system has been tried in a few properly constructed functional centres, it will not be made of general application throughout the country. It may be said that a beginning can be made in a few adapted houses, and that the time for functional building must come later, bat by that time you will have set the minds of the people of the country against the use of the health centres because you have invited them to come to buildings which are not properly equipped for their reception and treatment. Therefore I hope that the Government will consider advancing very slowly with the establishment of health centres, and only build a few until they are proved to be a success, and not, as I say, use any but buildings which are constructed for that specific purpose.
I come now to that part of the Bill which deals with, the medical profession. As a member of one professional trade union, I naturally have no little sympathy with the sufferings, real or imagined, of any other professional trade union, but I cannot believe that the noble Earl, Lord Munster, was right in his very sweeping statement that almost the whole of the medical profession was opposed to the principle of that part of this scheme. There will undoubtedly be some who will be opposed. Professional men are on the whole of a conservative trend of mind—I do not mean by that politically Conservative; in fact, from reading the papers recently I rather doubt whether anybody is politically Conservative any more. But at least they are conservative in habit and outlook in the widest sense, and a change of any kind, certainly a very radical change, will be viewed at first with reluctance and with suspicion. I hope, however, that discussions between the Minister and the medical profession will improve matters and that by the time this Bill becomes law there will have been reached an agreement between them which at least will go far towards allaying the not very unjustifiable fears, largely raised by the slightly incautious utterances of some members of the Socialist Party in the not very remote past, as to the extent and character of the Government's intentions.
The medical profession has shown itself at all times, and perhaps especially in times of war, to be so public-spirited and 30 self-sacrificing a body that I feel sure that once its natural fears are allayed it will lend itself, with a good grace, in the very difficult circumstances at the outset, to working a scheme, if satisfied that the general scheme is in the interests of the nation as a whole. I have a feeling that in the end it will be found greatly to the credit of that very splendid profession, that those who come to the final conclusion that it is better to reign in hell than serve with Bevan will be few in number, secure in practice and advanced in years.
So much in general terms for the Bill. It is, I think, a great conception, but at the same time it will require a number of Amendments—not wrecking Amendments, but assisting Amendments in the Committee stage, and I hope the Government will be accommodating in its consideration of those Amendments. So far as we on this side of the House are concerned, we desire only to make it a better Bill and one more properly adapted to perform its functions of supplying a real health service to the people of the country. Many years ago Izaak Walton, an author who will be familiar to many of your Lordships, wrote these words:Look to your health; and if you have it, praise God and value it next to a good conscience; for health is the second blessing that we mortals are capable of, a blessing that money cannot buy.I think that the Government are entitled to claim for themselves in this matter the first blessing laid down by the author of a good conscience, and I believe that by this Bill they will go at least a considerable way towards conferring on the people of the country the second blessing of good health.
§ 4.20 p.m.
THE LORD ARCHIBISHOP OF YORK
My Lords, I rise to support the Bill with greater warrant than the noble Marquess who has just spoken, but with reservations which may detract somewhat from the value of my support. I support the Bill because I am profoundly impressed with the necessity for a national health service to cope with the very large amount of preventable ill health which still exists. I am not sure if it is always realized how extensive is this ill health. It has been stated authoritatively that, in a year, something like 100,000 people die prematurely from disease which is preventable. It has also been stated, again by a reliable authority, that thirty per cent. of the 31 population, between the ages of sixteen and sixty-five, suffer from some ailment or minor illness once a month. And the statistics of panel patients show that an insured person, on an average, visits a doctor five times per annum. I do not place very much reliance on that last figure, because some people take a special delight in discussing themselves with their doctor when their physical condition hardly justifies the waste of his time.
It is also significant that the largest amount of ill health is found among the poorest members of the community. The numbers relating to ill health in this connexion are indeed very remarkable. While sixty-two out of 1,000 people die from consumption among those who have comfortable stipends, the figure is 126 per 1,000 among those belonging to the poorer classes of the community. There is one other figure with which I would trouble your Lordships. It relates to measles, a complaint which affects both rich and poor impartially. The rate of mortality from measles is seven times greater among the poorer members of the community than it is among those who are in a different position. These figures show that there is need for a health campaign on a very large scale. It is true that a considerable amount of this suffering is due to the environment in which people live. Bad housing and poverty are substantial contributing factors, and when these problems are being attacked an attack is also being made on ill health.
Undoubtedly if our health services were more comprehensive and were within the reach of every member of the community, there would be a considerable improvement in the health statistics. The health services, at present, suffer from four defects. First, there is not a sufficient number of doctors, and they are not always where they are most required. Next, there is not a sufficient number of hospitals. Some areas have very few hospitals. Many of the hospitals are very poor, and some of them are very small. The result is that there are long waiting lists in connexion with most of the hospitals for those desiring admission to them. Then, as the Lord Chancellor has pointed out, there is a lack of co-ordination between the various health services. In addition, a large number of people who ought to go to a doctor much earlier than they do are deterred through 32 the fear that they may be unable to meet the cost of a long illness. These are, I think, admitted defects in the present health services, and I welcome this Bill because it is a comprehensive attempt to bring the very best medical and surgical help within the reach of every member of the community, however poor he may be and wherever he may live.
But I go on now to speak of causes of anxiety which I feel about this Bill, causes of anxiety which I share with those who have already spoken. I am afraid that the Bill, as it now stands, may, to some extent, undermine the independence of the medical profession. I recognize that, in these days, the powers of the State must be very widely extended. We are living in the days of totalitarianism, and the State must own, possess, control, and plan where once it acted only in a negative capacity. The individual has no chance of preserving his freedom against the ever-increasing encroachments of the State unless, within the community, there are a number of unions and associations which help him in his stand against the State. The individual has no more power, by himself, against the State than a working man had power against his employer in the days before trade unions came into effective operation. I, therefore, attach the greatest possible importance to preserving in the nation, a number of associations, societies, churches, universities, trade unions, friendly societies, cultural societies and so on, which have independence or partial independence of their own.
I feel that this Bill may, to some extent, undermine the independence of the great medical profession. As has already been pointed out, their admission to the service or their expulsion from the service is not decided upon by their own profession but by outside bodies. It is true that on those bodies there will be representatives of the medical profession, but, so far as I can see, in every case the final authority will always be the Minister. It will be the Minister who, in the last resort, will decide the point. It is true that between him and the individual there will be his advisers. He will be a Commanderin-Chief—but a Commander-in-Chief with a staff. But the staff will consist largely of those who live and work in Whitehall, and probably the majority of them will be people who have never practised within 33 this profession and fail to understand its spirit. I quite understand the fear and anxiety felt by a large number of members of the medical profession about the position in which they may be if this Bill is carried through without further amendment.
I have no doubt that the scheme suggested makes for efficiency, but sometimes efficiency can be bought at far too great a price, and it is too great a price when it means the loss of freedom. I, myself, think that there would be greater efficiency in the Church of England if the Bishops, and, of course, the Archbishops, had much more power in the matter of moving their clergy wherever they wished. But it would be disastrous, for it would mean, if we did have these powers, that the clergy would lose very largely their initiative and their independence. Undoubtedly, there would be very considerable resistance, and very vigorous resistance, if any attempt were made to put the clergy further under the power of the Archbishops and the Bishops in this way. But that resistance would be nothing compared to the outcry which would arise if there were to be set up a Ministry of Religion at Whitehall, with either Mr. Aneurin Bevan or the Lord Chancellor himself as Minister of Religion, for we should feel that an outside body was interfering in and controlling our own affairs. That, I think, is a fundamental objection which is felt by the medical profession to some of the proposals made in this Bill. I hope that various Amendments will be made which will meet and overcome their difficulties.
In the second place, I must say that I am anxious about the position of the voluntary hospitals. I have had a great deal to do in different ways, in the past, with voluntary hospitals, and I am not sure that the debates in another place showed full appreciation of all that the voluntary hospitals have done both for the health of the people and also for medical research. There has been a great deal of local enthusiasm over these hospitals. It has been said in another place that the money given to these hospitals was given to the patients and not to the buildings, and that therefore the money followed the patients wheresoever they went. That seems one of those abstract arguments, the kind of statement that is sometimes made when it is said that it is much more important for a man to be 34 a citizen of the world than to be a patriotic citizen of his own nation. Human nature does not work in that kind of way. Up in the north there is a large amount of civic pride and local patriotism. I may say that it is far greater in the northern cities than it is in the south. People have built their hospitals, given to their hospitals and worked for their hospitals because they feel that they are their hospitals. I am very anxious that an assurance shall be given that the local committees which have devoted so much time to these hospitals, and have done so much for their wellbeing in the past, shall not become mere vague shadows but shall have real practical powers. I agree with what the noble Earl, Lord Munster, said. I wish we were told more about the new regions. These regions may be so large that the local committee will lose all its powers under their shadow. I am certain that it is a mistake to do anything to undermine or to take away from local enthusiasm and local interest in the voluntary hospitals.
There is one other observation that I want to make, and it is entirely uncontroversial. I hope that in the course of the debate some assurance will be given by the Government that the spiritual and religious provisions which have been made in the past in the great majority of our hospitals will continue under the new arrangements In our larger hospital there are chapels—in some cases very beautiful chapels—and there are chaplains. Sometimes the chaplain is fulltime; sometimes only part-time. The patients and the staff, I believe, welcome the regular visits of those who act as chaplains. I am not speaking now only of the Church of England. What I say applies equally to any other Church. We believe that ministers of religion—and I think most doctors will agree with us—can by their spiritual ministrations very often do something to help the bodily and mental health of the patient. I am not thinking only of the patient, however. These large staffs very often include nurses and others from the country who have been accustomed to church-going but who, owing to the demands of their work on Sundays, have very little opportunity of churchgoing at the ordinary times. It is important that there should be a chaplain to help them. I feel with great confidence that the Government will be able to give us these three assurances, and that the 35 Minister will make regulations which will deal satisfactorily with the problem in the future to ensure that those who work and live in the hospitals have spiritual ministrations.
I noticed in a speech which we have all read that the first plank of the Conservative programme is to be the defence of the Christian religion. I hope that the day will never come when one Party has to defend the Christian religion against another. I should feel it a disaster to religion and a real danger to the nation if Christians had to look upon one Party as their allies and the other as their foes. It is because I am sure that that is not the case, and that there is no possibility of that being the case, that I ask with the greatest confidence about the continuation of spiritual and religious ministration in the hospitals and for extended opportunities for it as new buildings go up.
I support this Bill. I know that it will not work satisfactorily at first, unless there is agreement with the medical profession. I hope that Amendments may be accepted which will enable the medical profession to co-operate happily in the working of this Bill. I have always been deeply concerned about social reform and I am quite convinced that the National Insurance Act, Which we have already passed, and this Bill, if it is passed, will prove by far the greatest social reforms which have ever been passed by Parliament and that they will bring a health and happiness and security to millions in a way which no previous Acts of Parliament ever have done.
§ 4.36 p.m.
§ LORD MORAN
My Lords, when I heard the noble and learned Lord on the Woolsack chastening, reforming and reconditioning a sister profession, I tried to imagine the positions reversed. I saw myself submitting to your Lordships' House, with the support of the Government of the day, a Bill for the reformation of the legal profession. The political Parties have had their say, the Law has spoken, the Church has bestowed its blessing; why at this late hour should I, a mere physician, a mere doctor, try to add anything? I will not weary your Lordships by repeating in any detail the arguments which I submitted to the House in April. The first thing that would be helpful is to consider how far the hospital provisions in the Bill have been sympathetically received by the vast majority of those who 36 work in the hospitals and how far they have been the subject of acute controversy. We have all been convinced by the surveys of the hospital service carried out during the war that a drastic reorganization of the hospital service is necessary. How could we disagree, when a third of the 93,000 beds in the 1,059 voluntary hospitals in England and Wales are in restitutions which have fewer than 100 beds—institutions that are hopelessly handicapped by their size when they attempt to act as general hospitals—when, too, more than a third of the 78,000 general beds municipal hospitals are in Public Assistance institutions, many of which might have come straight out of a reforming novel of Charles Dickens?
We are agreed that this reorganization of the hospital service means a very considerable expenditure of money, which can only come from public funds, and that such an expenditure of public money must entail some measure of public control. We are agreed, too, that that control could only be exercised by the Minister or by the local authorities, and faced by a choice between these alternatives the profession is in no doubt that it prefers the control of the Minister. Perhaps I ought to say something in support of that statement. For a whole decade every professional discussion of the hospital service has been dominated by the dread that the hospitals will come under the control of the local authorities. It is the removal of that menace from the profession which has reconciled so many to the passing of the voluntary system and it is the removal of that fear which has done more than anything else to make so many prefer the hospital provisions of the present Minister of Health to those of his predecessor.
And there agreement in the profession ends. Many of my colleagues for whose judgment and integrity of mind I have a high regard cannot bring themselves to agree to the transfer of ownership of hospitals. They argue that the Minister ought to give the Regional Boards a block grant, which the Board would distribute to the hospitals in the Region, withholding the grant from any hospital which did not put its house in order. This arrangement is attractive to them, as it is to me, because it involves no change in ownership of the hospitals. Others do not believe, and I do not believe, that any 37 Regional Board, particularly one recently created, could apply sanctions in this fasmon to a powerful local authority. We believe that sanctions would not be enough to bring about the drastic re-organization which is so essential. It we feel that these hospital provisions are inevitable, it does not mean at all that we are agreed that the particular provisions in this Bill will necessarily work. A good deal has been said about the great importance of making the local management committees attractive enough to secure able men willing to serve on them, and with every word of that I am in profound agreement. But we have heard far too little of the importance of this hospital service being a university service. When I speak of a university service, I mean that that was the original conception underlying the establishment of the regions. The regions were originally suggested to bring in the universities.
What do I mean by a university service? May I take an example from pathology? If a pathologist goes to work in a hospital in a town some considerable distance from the university centre, he may find himself isolated. There is probably no other pathologist working in the town, no one with whom he can discuss his difficulties. After a number of years he may lose heart and interest in his work. But if he is a member of the university service, then once a week he will go up to the central university laboratory, where he will see what is being done and will learn the research that is being conducted. He will discuss his difficulties with the head of the laboratory, and perhaps the head of the laboratory will pay him a return visit, and will go into his difficulties on the spot. In that way the pathologist will not feel isolated and marooned. He will feel that he is a member of a great service and is only seconded for the moment to a hospital on the outskirts.
This is not mere theory. During the war not only pathologists but physicians, surgeons and every kind of specialist, were sent by the teaching hospitals into the great important hospitals in the region. They attended these hospitals regularly, and they raised their standard almost to university standard. When they were called back at the end of the war, I think doctors will agree that there was a sharp fall in the efficiency of hospitals 38 at the periphery. The university service can do something else for us, and it is a very important thing. In the past specialists have tended to congregate in the great centres. There has been a dearth of them elsewhere. By a university service we can bring about a redistribution of these specialists without duress, because men will willingly be seconded, feeling that they are part of one great service.
Now if there is going to be this measure—as I think an essential measure—of centralization in a scientific service, it is perhaps a paradox that there must also be a degree of decentralization. The powers of the Regional Boards are so vaguely defined in the Bill, that we really do not know what they are. For example, suppose there is a complaint about dieting or nursing in a hospital in the region. Will the Ministry send its inspectors to investigate that complaint independent of the Regional Board, or will it ask the Regional Board to investigate it? If the inspectors do it independently of the Regional Board, the Regional Board will lose authority. The Ministry must trust its Regional Boards, or they will not work. This decentralization may have to go even further. The noble Earl, Lord Donoughmore, who, as the House knows, is deeply versed in these matters and whose good judgment is held in high regard in my profession, said last April that in the regions nursing officers had been appointed who were to be the nursing authority in those regions. They would have power of appointing and dismissing nurses. Are they—we pertinently ask—going to exercise those powers through the Regional Boards or independently of them? There is no guarantee that the Ministry of Health will not interfere in clinical matters. That is not a fictitious, vague phantasy. It actually happened under the emergency medical service during the war. You must trust your hospitals; you must trust your regions; you must trust your doctors to get on with their job.
I agree with what has been said about the great fear that the doctors have that they will lose their independence. If that happens, the profession will indeed have received a very mortal blow. Whatever happens to the health services, however effective the reformation of it, it will avail us nothing if the general conditions under which doctors work do not 39 bring contentment and happiness to them. What we have got to ask, looking at this Bill, is: Are these conditions such that the good type of man, who has come into medicine in the past, will continue to come into it in the future? I think it is singular, in the innumerable discussions which this Bill has provoked, that the effect of the Bill on entry into the profession has been hardly mentioned at all. I say it is singular because the well-being of our profession depends upon its power to attract a good type of man and, in particular, on its power to attract the exceptional man. It is because the Minister treated the teaching hospitals so sympathetically, because he refused to blunt the growing edge of medicine, that, in the first instance, many doctors examined the provisions of this Bill with sympathy. Before I pass on, I would like to say that those who work in the academic world in medicine are greatly perturbed at the present time about the powers and corn-position of the boards that will govern the teaching hospitals. These men are actuated solely and simply by a desire to advance medical knowledge, and I am sure that the Minister will go into their troubles and allay their fears as far as he can.
I have said that the well-being of our profession depends upon attracting the exceptional man. May I enlarge on that just for one moment? It is absolutely vital. The fame of the voluntary hospitals has gone all over the world for one reason and for one reason only—namely, that the great advances of knowledge, which have been of incalculable benefit to the whole world have come from workers within their walls. I am speaking of quite recent history. I am not talking of a long time ago. When I was a student the surgical ward was a cheerful place full of happy patients looking forward to convalescence, but when one passed from the surgical ward into a medical ward it was exactly like walking out of sunshine into a dark, cold and gloomy building where the patients were suffering from incurable diseases for which they had discovered we could do nothing. All that has completely changed. The physician at last has been armed, and, in consequence, there is an almost embarrassing rush on the part of the man of promise in our profession to become a physician. At the present time the men 40 of promise are entering for the examination for admission to the Royal College of Physicians at the rate of 1,400 candidates a year.
Let me say this. I do not know whether I shall be held to exaggerate if I say that this astonishing victory by a few men over disease will be remembered centuries hence, when the martial victories of this war are completely forgotten. I have quite respectable authority for making such a statement. At the height of the war, in Cairo before the battle of El Alamein, General Smuts said to me, "Men of action live on the surface of things. They do not create." Now we owe this victory to a few men. Medicine in the past has been able to attract these gifted few. The real problem is will it be able to continue to attract them in the future? The answer to the question, if I knew it, would determine whether this Bill is really to the benefit of this country or not. How are we going to protect these gifted few? What do they want? In the first place we must scan the Bill very carefully to see there is nothing in it which encroaches upon the leisure which the man has given in the past to research. Leisure has largely gone out of the learned professions, to their very great detriment. Nowadays the spare time of a specialist is taken up by attendance on committees which are the drowsy syrup of the democratic State. When recently a Professor of Medicine retired from a London school he was found to be on thirty-two committees. But leisure is not enough. What else does the specialist want? It is perfectly true that many men with the greatest minds are indifferent to material rewards, but it would be folly to handicap medicine in its competition with other professions by a false parsimony. I gave notice to the noble Lord who introduced this debate that I should ask the Government to appoint a Committee on the lines of the Spens Committee, with laymen on that Committee, to go into the remuneration of consultants. I am glad to hear the Government find such a proposal worth considering and that they will do it.
Your Lordships may feel I am wandering very far from the clauses of this Bill, but I assure you that any time you may give to the consideration of the effect of this Bill upon the entry will be richly rewarded. Only once in my working life 41 have I seen a determined and deliberate attempt to influence the quality of the entry into medicine. It was in 1913 when a Royal Commission on University Education in London, found that the specialists in this country were so pre-occupied by private practice that they were not making those additions to knowledge which we might reasonably expect from them. They found, too, that the men with first-class wits at the university, who did not wish to practice but wished to devote their lives to research, were not going into medicine. The Commission planned deliberately that there should be an academic career in medicine, and when their suggestions and recommendations were carried into law they fertilized medicine.
It would not be right if I said nothing of how this Bill affects not the very few who have creative minds, but the average man. There are disturbing features at the present time and of late years there has been a great tendency on the part of people who are gravely ill to seek institutional treatment. The general practitioner sees a case whisked out of his hands and transferred to hospital just when his illness becomes professionally interesting. Moreover, when this Bill is put into action there will have to be a consultant service and that will accentuate the difference which exists between the general practioner and the consultant. When I became ill in New York during the war I found by my bedside in the Presbyterian Hospital a book about the size of Who's Who. In that book there was the name of every specialist in the United States. The public had been educated to believe that if a man's name was not in the book he was not a specialist. At the present time anybody can specialize in England without training, without special qualifications, without anything but assurance. The time is coming when we shall have a list of consultants as in America—I hope it will not come yet. When that comes the general practitioner's name will not be in that book, and he will be cut off from the mild amount of specialization he at present undertakes. This is inevitable, for a man who practises as a specialist should be trained as such, but all our plans will come to nothing if the life and opportunities of the general practitioner no longer attract the best type of man.
There is only one remedy. We have to make up our minds to bring the general 42 practitioner into the work of the hospitals. It is full of difficulties, but it must be done. It is not right that the great majority of practitioners should never enter a hospital for work from the time they leave shortly after qualification to the day when they retire. If this is all true, we have to consider whether there are any offsetting tendencies. At the present time the number of people seeking to enter medicine has leapt up. Extraordinary numbers are applying to our schools for admission. This is partly the effect of demobilization but it will continue because in the past those who have entered have come from a narrow section of the community. Many people were unable to afford the cost of putting a man into medicine. All that is going to be altered and you are going to have an immense number of the people waiting to enter the profession or, at any rate, very many more than in the past. You will have to get new machinery such as you have already got in selecting people for the Civil Service because if these men are to be subsidized by the State there must be some machinery to deal with them.
I am less happy about the general practitioner service planned in this Bill than I am about the hospital service. I am myself gravely disturbed by the general fears expressed by practitioners as to the future. They say they are against this abolition of the selling and buying of practices. They are against what they call a measure of direction, and they are against the basic salary, but these "againsts" all come down to one fear—the fear that there will be a whole-time medical service which will interfere with their liberty. Will this whole-time service necessarily be good for the profession or the public? I do not think anyone knows the precise answer, but one thing I am certain of, unless there is an adequate incentive or incentives to keep men on their toes and to keep them keen throughout their working days, then a whole-time service would be an incalculable disaster. The Minister could not spend too much time on this question of incentives. At the present time I am quite certain that the average doctor lives for his work. What we have got to ask is, will it be true in ten years' time? If I knew the answer to that question, I should be able to tell you if the misgivings of the general practitioners are or are not true.
43 There is just one other thing before I leave general practice. That is the unfortunate dispute at the eleventh hour that has arisen between the Ministry of Health and the panel practitioners. I am convinced in my own mind that the claims of the panel practitioners are fair and just, but the dispute is not about terms but about the procedure. The Minister wished to go into the remuneration of panel practitioners at the same time as the remuneration of men in this future service. The panel practitioners felt they had not a mandate for this discussion. I am perfectly certain the Minister will meet their claims. It would be an absolute disaster if we began this service with a considerable section of practitioners disgruntled, men who felt that they had had a raw deal. I hope the Minister will go very sympathetically into this particular claim.
Now let me end as I began by wondering whether this Bill will work. In medicine we always make a prognosis in a case feeling that we may be wrong. When I ask whether the Bill will work I am not sure whether my views are right or wrong, but there are many complaints that the Minister has taken into his own hands very large powers—when I say "into his own hands" I mean into the hands of those who work under him—and that this taking of powers into his own hands will prove a very great strain on the Ministry of Health, and those who are best informed are most alarmed. Men who know the facts tell me that if this service breaks down it will break down because there are not the administrators to run it. The Minister has shown considerable courage in doing what he believes to be right, and I hope that at this late hour he will not shrink from whatever measures are necessary to strengthen his service so that it can meet the duties and responsibilities which are thrown upon it. When the coal industry was taken over they put two of the most capable men on the Coal Board as managing directors, and the area machinery was strengthened in the same way. If this Bill is going to work we have got to do something unusual. It is no good telling me that various senior officers of the R.A.M.C. have been taken into the service. That is not enough. I hope the Minister will put into this service a small number of very experienced men who are the leaders of 44 the profession, who are trusted by the profession and who have been familiar with hospital work all their days. I hope he will persuade these men to give all their time for five years, or some period of that kind, to try to make the regions work. Only in that way, as I see it, can this Bill be really made to work.
It may be said that the Central Health Service Council will supply what I am asking for. Will it? Can it with forty-one members? When it was born a sigh went up from the profession. Why was that? It was because Government Departments in the past have so often tried to shelve responsibility by appointing advisory committees. These committees were born generally in another place they met once or twice a year at most; they were given a carefully prepared menu to keep them out of mischief; and then they were conveniently forgotten. The negotiating committee, fearful of this fate overtaking this new Council, went into this matter very carefully, and they were assured that they could have their own chairman and they would be able to publish an annual report. Your Lordships will know, however, that we can never make any Ministry use an advisory committee unless it really wants to. Why is the Ministry so reluctant to use the best brains from the profession? It follows inevitably, as one noble Lord has already said, that many of those who work under the Ministry have not practised their profession actively for twenty years or more. We want men who are actively engaged in the profession to come into this service and to give us the information which they alone possess. It is only in that way that you can lift the curtain which in recent years has fallen between the Ministry and the profession, leaving so much want of sympathy and understanding.
Much of the criticism which this Bill has provoked has seemed to me to be tethered to the earth; it has never become airborne, and it has been totally lacking in idealism. The politicians have made their debating points, and too many of the doctors have merely expressed their fears and prejudices. It has been left to the Minister to generate the momentum that overcomes obstacles and to enlist the strenuous support of ardent min-is. This is a measure designed for the betterment of the people in health and in happiness. It is not the product of one party but of 45 parties over a number of years, and I believe that when it becomes law, in spite of all the differences there have been, the whole medical profession will unite to try and make it work.
§ 5.5 p.m.
§ LORD TEVIOT
My Lords, my excuse for addressing you is that for two and a half years I was the Chairman of an Inter-Departmental Committee on the subject of the condition of the teeth of the people or the country and the profession of dentistry. Naturally, after a long period of studying this question with many witnesses of all classes in the profession of dentistry and medicine, one picked up a good deal of knowledge There are certain questions which I wish to put before your Lordships, and particularly before the Minister who is going to reply, which seem to me to be suitable for a Second Reading speech. The one anxiety left upon my mind is this. It would be a disaster if this scheme failed. If the scheme is a success then we are faced with this very vital question: How are we going to carry out the scheme? I will show your Lordships in a few moments why I am doubtful about this, and why there is great anxiety in my mind on this subject.
We know—and indeed the Minister only a few days ago made a speech in which he confirmed it—that the state of the teeth of the people of the country is deplorable. Your Lordships will see that the needs of the public for dental improvement are gigantic, and the means available at the present time are adequate to deal with only a very small percentage of what is wrong. Let us study the present position for a moment. There is not adequate service and inspection in the schools, and there is a mass of dental ill health throughout every class in the country. Consequently there is a lack of treatment for expectant and nursing mothers and young children; and, of course, the condition of teeth is so dependent on the state of the mothers and the young children being properly treated and cared for. At the present moment it is estimated that there are about 15,000 dentists, but of that 15,000 quite a number are due to retire. One must not forget that the life of the dentist is a very strenuous one. His position is almost that of the athlete ready to spring off at the starting point. That means that he has got to be very fit physically, and a man advancing in years finds the work 46 a great strain. Consequently the wastage amongst dentists is quite considerable. Thus we have this problematical 15,000, and it is said that in order to maintain that number up to 1970 we shall have to increase the intake into the profession from what it is at the moment, about 300 per annum, to 900.
My noble friend Lord Moran has touched on one or two points which apply just as much to the dentist as to the doctor. We must somehow or other encourage more to go into the dental profession. We must some how or other make the profession more attractive. We must somehow or other raise the prestige and the status of the dentist. In listening to the evidence over those two and a half years I found there was a mass of information about that question. The dental profession is not popular; it is very rare for the son of a dentist to enter his father's profession. Somehow or other, we have got to do something about that. I do not know really how to tackle it, except by suggesting that at the universities and at the schools the status of the students of dentistry should be raised to that of the doctors, but I see nothing, I am afraid, in the Bill as it is now to lead me to suppose that anything is going to be done to help in that direction.
It seems to me that in the Bill there is one very important omission. It takes away, or may take away, the relationship which now exists between the dentist and his patient. How often have your Lordships heard somebody say "You ought to go to my dentist; he does not hurt." I must say that that was the reason why I went originally to the dentist I have now had for some years; I find that he hurts a little less than some of them. It is important that the patient should have confidence in the dentist and I feel that is something which we should try to encourage. The family doctor is probably a doctor who lives in that area, but that is not always the case with the dentist. Some of us travel many miles to see our dentist. I myself, for instance, spend a good deal of my life travelling, and I have a dental adviser in London, in Newbury, and in Edinburgh.
I am now coming to this question of the area. As I understand it, if the Bill is passed in its present state, I can only go to the dentist in the area in which I am living. Would it not be better—and I put this to the Government—to permit 47 any patient to go to any dentist anywhere provided that dentist is under contract to a local executive council? There are many people who do not live in the same place all the year round. There are many who have a job in London for a while, and who then get another in Edinburgh or in another big centre. It will mean much complication if, when they want to have dental treatment, they have got to go back to the areas in which they are registered and in which they originally came on to the panel, if that is the right word to use. I think this elasticity of treatment is advisable and very necessary.
Now I come to another point which is, I think, worthy of consideration. At the moment, only 7 per cent. of those entitled to dental treatment take it. If this scheme is to be the success which we all hope it will be, it is to be hoped that that 7 per cent. will increase very rapidly. It will be deplorable if it does not. Let us say that 10 per cent. take advantage of their right under the Bill to obtain dental treatment. As the Bill at present stands, before a dentist can give treatment he has to prepare a statement of what he is going to do, an estimate of its cost, and get it passed. It is anticipated that there will be some 80,000 of these estimates every week. Who is going to deal with them? Are they going to be dealt with by clerks who really know nothing about dental treatment at all? You cannot possibly afford to take dentists to go into these estimates; the dentists are needed for professional work all the time.
Next I turn to the point made very strongly by the noble Lord, Lord Moran—namely, that these professional men must be trusted. The noble Lord, Lord Moran, has made a plea for trusting the doctor. I make the same plea for trusting the dentist and for assuming that he will not abuse the position in which he is going to be placed, that the estimates he puts forward will be for work which is necessary and that the charges which he suggests will be correct. One can easily see that if that is not done, the sending off of these estimates to be passed will mean delay and the interposition of another opinion, which means that the patient will be unable to deal entirely with the dentist of his choice. Let us take the hypothetical case of a village school 48 master living in a remote village in Scotland and having to travel perhaps thirty miles to Perth if he wants to see his dentist. The dentist examines the schoolmaster and finds that he wants one filling done, but he dare not do it until he has had his estimate passed. It may be that it will be necessary to send to Dundee, Edinburgh or Aberdeen to get a rubber stamp put on the estimate before he can carry out the work. That means that the village schoolmaster has to go back to his village and come to Perth again, perhaps some weeks later, when he is notified that permission has been given to carry out the work necessary.
Now I come to the question of the Central Advisory Council. There are forty-one members of that Council, twenty-one of whom are medical members, I feel very strongly that we must try to enhance the prestige and raise the status of the dentist's profession and to that end I suggest that the President of the Dental Board should, ex officio, be on that Council. That is not so at the moment. I believe the answer given in another place was that, if that were done, many other people would require to be on it, but surely that is not so. You cannot compare the operational side of the medical profession and the dental profession with professions such as pharmacy and others which will be represented on the Central Advisory Council. That was one of the recommendations that we made very strongly in the report of the Inter-Departmental Committee.
I have come nearly to the end of what I have to say. There is this very important question. Supposing there is a complaint about a dentist and it comes before the Tribunal—well, there is no question of any complaint there by the dental profession. Now the Tribunal pass a sentence and the dentist's only appeal as set out in the Bill, as far as I read it, is to the Minister. I hope that this matter will be dealt with in your Lordships' House. In another place this question was raised and there was a very exhaustive debate upon it. There was a Division and the Government were defeated. "The Minister" was taken out and "the High Court" put in instead, but subsequently, on the Report stage, the Minister proposed an Amendment by which he was substituted for the High Court. Surely, it must be advisable to have the High Court. After all, the individual 49 cannot do anything with regard to attacking the Crown and surely he should have the right, if he is not satisfied with the Tribunal's decision, to appeal to the High Court. I hope that the Minister, in view of the strong feeling on this subject in another place, will take this matter into consideration again.
There briefly is the situation in regard to dentistry. I hope some of the Amendments which I am putting down on some of the subjects will be accepted. The dental profession wish to make this scheme a success and will do everything they can to do so, but after studying the whole of the dental profession for some lone time I feel that owing to the peculiar position of dentistry unless some of the objections are removed there will be a further decrease in recruitment. That will be detrimental to the public and it will also mean that the dentists will carry on outside the scheme. Therefore I hope that the Government will do everything they can to make the conditions of service under this Bill as attractive as possible, because really the position of dentists is far worse than that of the doctors. As the noble Lord, Lord Moran, told us just now, the recruitment for doctors is going up by leaps and bounds, but that is not the case in dentistry. I have no doubt that if some of the young men who are going into medicine thought the position was as favourable towards them in dentistry, they would go into the dental profession. From the evidence I have had I know how tremendously important to the health of the people is this question of the condition of the teeth of the people. We must have more dentists. We must not only make the dental profession more popular, but we must make the service of the dentist more popular for the people to go to. We must brighten up the places to which they must go to receive their treatment, and everything must be done to remove that natural nervousness which everybody has on entering a dentist's room.
That is the picture. If we make this scheme a success, and should the demand rate increase, we shall not be able to carry out the comprehensive service set out in the Bill. I have repeated myself no doubt on several occasions on this very important question, which is: How on earth are we going to make or encourage more young men to go into the dental service?
§ 5.25 p.m.
§ LORD INMAN
My Lords, this day has a special and rather a personal interest for me, and I am sure your Lordships will not mind my mentioning it. It was on October 8, 1921, just twenty-five years ago to-day, that I began my association with a well known London teaching hospital. Previous to that for some years I was connected with one of our great central funds, and so for approaching thirty years I have devoted a good deal of my time to hospital work, I should like to feel that my knowledge, gained from actual experience, may be of some value in considering the provisions of this important measure. I should have liked to-night to deal with some of the points such as the health centres, the Regional Boards, and the special relationship for teaching hospitals, but there are other speakers after me and the time is passing. I propose, therefore, to defer consideration of these matters until a later stage of the Bill.
I should like just for a few minutes to confine myself to one of the main criticisms of the measure. "Leave the voluntary hospitals to continue their work," said the noble Earl, Lord Munster, earlier to-day. It has been said repeatedly in another place, in certain organs of the Press and in the very many letters which have reached me, that this Bill will kill the voluntary hospitals. I would like to look at this threatened death sentence and examine its implications. It may be pertinent to inquire: What makes a voluntary hospital? There are two answers to that question, but I suggest that the great majority of people would answer that it is the gifts voluntarily given to maintain the work of our voluntary institutions. Now it was perfectly true to say that years ago our hospitals were maintained entirely from voluntary sources. May I quote from the balance sheet of my own hospital, which I am sure is typical of other institutions? In 1905, forty years ago, our income was made up entirely of voluntary gifts, that is, subscriptions, donations and legacies, but last year 45 per cent. of our income came from public authorities, from payments by patients and from central funds for services rendered. The point I want to make, therefore, is that to-day our voluntary hospitals are only partially voluntary.
51 Now let me say, straight away, that all through the years large sums have been given by disinterested people for the sole purpose of helping to maintain the hospitals, and every credit and great praise must be given to them for their great endeavour. But I would like to draw your Lordships' attention to the increasing number of methods employed to raise funds for our institutions. Some of your Lordships may have seen, just before the war, a large hoarding outside one of our best known hospitals on which it was stated: "We require 10,000 people to sell soap for us." That institution was so desperately hard up that the committee had purchased a quantity of soap to sell again at a profit. Another well-known hospital engaged a staff of 200 canvassers to go from door to door selling stationery. All sorts of weird appeals were organized to intrigue the public into giving. There were banquets of humour, midnight matinées, flag days, and Bridge tournaments. Indeed, the hospital administrator, like the Athenian of old, spent his time in doing little else but seeking to hear of some new thing.
I, myself, some fifteen years ago, went to America to beg funds. On the first Sunday morning that I was over there I attended a service at the well-known Fifth Avenue Presbyterian Church, but when the first hymn was announced, remembering the object of my mission, my heart sank. It was:Guide me, oh thou great Jehovah, Pilgrim through this barren land.It did not prove to be a barren land; but was it right that I should go over to the United States to beg for money to maintain the patients in our own hospitals? I say that it is quite wrong to depend upon stunt appeals to maintain our work. I submit that the care of our sick and suffering is a sacred national duty.
But there is an even more serious aspect of this dependence upon spasmodic and ephemeral charity. A new medical discovery is reported which may have the effect of relieving pain and even saving life. Take radium for example. Radium, as we know, is a costly element, and yet if a hospital wants radium and has not the money in the bank to pay for it, then it is denied to that institution. It is surely not in the national interest that any hospital should be deprived, by reason of lack of funds, of equipment that is essential 52 to enable it to do its work. Only last week, I was talking to a young doctor, the son of a member of your Lordships' House, who has just returned after six years in the Services. He has gone back to his voluntary hospital in the provinces, and he told me that he was appalled when he thought of the condition of the equipment in the Army and compared it with the condition of the equipment in that voluntary hospital.
But if the financial position of our hospitals was so serious in the years before the war, I am convinced that unless something is done it will become impossible in the years that are ahead. Let me give an illustration to show what I mean. The experiences of the past decade have revolutionized our ideas regarding hospital planning. It is now considered that the ideal unit is an institution containing from 800 to 1,200 beds. I may say that we, ourselves, have plans in hand for building a new hospital at Harrow with accommodation of Imo beds. I think it is ideal from every point of view. It is going to be in the open country away from the noise and hubbub of modern traffic. We shall retain in London a mere casualty clearing centre. But this new hospital is going to cost £2,000,000, and I submit that such a cost is entirely outside the scope of voluntary effort. What is true in our case is true in the cases of many other hospitals as well.
If the needs of the public are to be safeguarded, the provisions of this Bill on reorganization and re-grouping must be carried out. This will involve heavy capital expenditure. There are twelve large teaching hospitals within a radius of five miles of Charing Cross. With one exception—King's College—all of them have remained on or near their original foundations, and some of them are working under extreme difficulties. Whilst these hospitals have remained stationary, our population has been moving constantly outwards. In the seven years from 1931 to 1938, the population in the centre fell by no less than 12½ per cent., and yet very little provision was made for those who had removed their homes elsewhere. Now what is true of London applies with equal force to other parts of the country. There are many districts, particularly in the rural areas, where hospital accommodation, as many of us know, is sadly deficient. Problems of the kind which I have mentioned, in my judgment, can 53 only be solved by a co-ordinated national scheme, a scheme that will bring within the reach of everybody, irrespective, of means, the best surgical and medical skill procurable, a scheme that will condemn obsolete and redundant hospitals and erect new temples of health that will fulfil all modern requirements.
Now your Lordships would expect me, after twenty-five years at a voluntary hospital, to pay tribute to the work of such institutions. I yield to nobody in my great admiration of their fine and conspicuous services. They filled the breach with great credit and distinction for many centuries, and now we are told they are to be killed. But are they? I said a moment ago that there are two answers to the question: What constitutes a voluntary hospital? The first is: "The gifts that maintain it." The second is "The voluntary service that mans it." Under this measure the voluntary hospitals are to be relieved of all financial obligations, but I hope and believe that the spirit of self-sacrificing service which has characterized their work will be allowed to continue. I say that it would be a tragedy if the fine voluntary work on the part of so many were to be lost. I submit that voluntary service, under this Bill, does not end. On the contrary, the Minister in another place gave this definite assurance "All the rest of the voluntary attributes of the existing services are preserved and enlarged. There will be more room for voluntary service in the new scheme than exists at the present time." The simple truth is that the times in which we are living, the needs of a modern community, the heavy cost of curative and preventive treatment, the building and equipment of new hospitals make financial demands—quite legitimate demands—which it is not within the power of voluntary effort to satisfy. I believe that this new Bill will continue and expand the work of our existing hospitals, building on their traditions and experiences a firm and worthy edifice of which in the years to come this country will be proud.
§ 5.41 p.m.
§ LORD HORDER
My Lords, in moving the Second Reading of this Bill my noble and learned friend on the Woolsack spoke of the universal desire on the part of laymen, doctors and politicians to do something, at long last, to integrate the medical services of this country, and I 54 do not propose to waste your Lordships' time in saying more about our own attitude—speaking for my profession—in that respect, than to emphasize the point that we doctors are not obstructionists in this matter. I would also add that for the last twenty years we have done our utmost to persuade the powers-that-be to get a move on in this matter, if I may use the vernacular. I mention this only because during the last few months it has been reiterated so often in another place, particularly by the Minister of Health, that (to plagiarise the words of Sir Alan Herbert's song):I want to see the people happy,I want to make the people well.So do we. But we doctors had hoped that it would be through the more natural process of evolution, rather than through the present method of revolution, that the Government would help us to attain our object.
We think that we could have attained it with more certain benefits and with less risk. We believe that we could have rationalized the hospitals without transferring their ownership to the State. We think that we could have covered the health of the dependants of the workers. We could have set up health centres without sacrificing the doctors' liberty. And we could have brought together in a comprehensive whole the industrial medical service and the medical services of the various Government Departments. Of course, we realize that this less dramatic method of advance is not adapted to the present Government's temperament, but we do know from experience that such an advance is eminently suited to the progress of medicine and to its application in terms of the citizen's health and happiness.
More than once I have allowed that this Bill enhances one very desirable thing: that is, the availability of medicine to the citizen. But, as has been said by one of the speakers here this afternoon, we may pay too much for that advantage if it is gained in a way which does not take into account the possible sacrifices that are entailed. And you cannot stereotype medicine without a great deal of sacrifice. We believe that this Bill does risk stereotyping medicine, and whether we look at medicine from the point of view of the hospital services or from the point of view of the work of the individual doctor it 55 must be a great loss to society if by the operation of this Bill medicine is stereotyped.
Mention has been made of the ease with which the doctor's capacity and the hospital's capacity can be levelled down. As we all know it is very easy to level down: it is very difficult to level up. If I were asked to state in brief terms what is the nature of the anxiety facing my profession today I would say—and I am only repeating what has been said by speakers who have preceded me—that it lies in a realization of the tremendous centralization of power which in its present form the Bill invests in the Government. My noble and learned friend was himself impressed with this, and commented on it; but he did not, as I do, think it a danger. It was in your Lordships' House many years ago that the elder Pitt said:Unlimited power is apt to corrupt the minds of those who possess it.A more familiar quotation is that of Lord Acton who said that:Absolute power corrupts absolutely.I feel that the ideal to be aimed at in framing a medical service policy for the nation is not this terrific centralization of power in one man—because it is in one man—but a maximum of central direction and a minimum of central control. I note that in one of his latest public utterances Mr. Bevan referred to this danger of too much central control. He said:I am deeply conscious of the fact that one of the great dangers of the Government service is over-centralization, and the wider decentralization we can bring about, the better for everybody.I cannot help thinking that closer contact with the medical profession during the framing of the Bill would have safeguarded the Minister and his successors under the Bill from this particular danger. When the Minister was criticized in another place for not discussing his proposals with organizations and bodies representing those who will be responsible for carrying them curt he denied the imputation and spoke of "consultations"—that was his word—which were very wide.
But the Minister uses the word "consultation" in a very different sense from the one which we usually attach to that word. I was myself present at two of these so-called consultations. The form they took was as follows: The Minister 56 told us what he proposed to do; he answered a few of our questions, and the conference concluded with his telling as that what he had said was to be kept secret. To this unilateral pledge all of us loyally adhered, to find ourselves quite soon tactically handicapped. We were hamstrung. The word "consultation" was a euphemism for the most blatant form of ipse dixit-ism. It seemed to me at the time—and it still seems to me—a very unfortunate and a very unhelpful handling of this vital situation. It was as though the designer of an aero plane proceeded to the point of manufacture and then—and only then—asked the pilot if he thought he could take the machine into the air. The Minister has advanced that in place of consultation with recognized groups in the profession, he availed himself of private talks with knowledgeable friends. I am sure that those talks must have been of great help. The Minister is a good mixer. But I can only say that, in the public interest, it is unfortunate that I was not chosen to be favoured with one of those private conversations.
I understand that, as soon as your Lordships have dealt with the Bill, the pilots—that is, the doctors of this country—will be asked if they will try out the machine. In other words, perhaps it is within your Lordships' knowledge that the doctors will be asked by a plebiscite issued by the British Medical Association if they will work this Bill. The noble Marquess, Lord Reading, challenged my friend the noble Earl, Lord Munster, when he said that he understood that the majority of the this Bill as it at present stands. The plebiscite will tell us what is their view when the Bill is finally passed. I should like to say that, in my belief, the answer to the plebiscite may even at this late hour be influenced not inconsiderably by what may happen in your Lordships' House during the Committee stage of this Bill, because I hope that the Government will sympathetically consider certain Amendments—and give proper time for their discussion—the purport of which, in the main, might be to preserve the autonomy of the voluntary hospital, might be to safeguard the freedom of the doctors, and thus defer, as many of us hope, indefinitely, the nationalization of medicine. Because the present Bill does go far towards nationalizing medicine. That it gives the Minister the power ulti- 57 mately to nationalize it entirely can surely not be in dispute. The noble Earl has quoted the well-known policy of the Government on this matter as stated by the Lord Privy Seal, and the little more that lies between the Bill and complete nationalization can at any time be achieved through those many regulations with which the Bill abounds and which have never been drafted.
Let me take, as an example, a matter which has been touched upon several times to-day. That is the remuneration of doctors. We are told that the remuneration of doctors will in part he by basic salary and in part by capitation fees, and we are told that the capitation fees will scale down as the number of the doctor's patients under the national service increases. Now, by regulation, the percentage of remuneration by capitation fees may be reduced; it may ultimately disappear, at which point the doctor becomes a whole-time salaried civil servant. Has it been realized that for the first time in the history of our so-called democratic country, I suppose, a ceiling is being fixed, whether for an industry or a profession—in this case a profession, and a profession concerning which bouquets have been handed out quite liberally this afternoon—and above this ceiling the individual may not rise by the work of his mind or his hands? Whatever natural talent he has, whatever energy he may possess, however ambitious he may be, he is condemned to a dead level of—shall I not say mediocrity? Not only has his economic position, but his professional status and prestige have been given a ceiling. Unlike his fellow civil servants of the future, there is no chance of promotion.
There is, as I say, a dead level as the final goal. Is this good for medicine? Is this good for the community? I see no escape from this unthinkable state of affairs except through the medium of a black market in doctoring, and my mind boggles at the thought of its probable immensity. And yet could we be other than sympathetic if we believe that it is the only salvation for the patient? The Minister tells us it is not possible to insert the terms of remuneration in the Bill. But it should be possible so to amend an existing clause that the method of payment is stated and this method should be the capitation method unless in the opinion of the executive council 58 in whose area the services are rendered, a different basis is considered necessary.
The prohibition placed upon the buying and selling of a doctor's good will in his practice, the power of negative direction of doctors and the refusal to allow a doctor, charged with some offence under the Bill the right of appeal to the High Court, are surely matters that require amendment. They seem to me, a layman in a sister profession, to be gross infringements of personal liberty. I think they are pathetic verifications of the warning given by Herbert Spencer to his American hosts fifty years ago when he said:As one of your early statesmen said, 'The price of liberty is eternal vigilance.' But it is far less against foreign aggressions upon national liberty that this vigilance is required, than against the insidious growth of domestic interferences with liberty.Now it cannot be charged against me that I make long speeches in your Lordships' House, but I hope you will bear with me for a few minutes. I have already expressed the hope the Government may still improve this measure that is now before us for Second Reading. In the matter of both central and local administration there are improvements in the Bill which we should welcome. We doctors think that the Standing Advisory Committee of the Central Health Services Council should be appointed by, and take their references from, the Council, and that they should report through the Council to the Minister. We also consider that the constitution of the local executive council should be safeguarded in respect of its medical, dental, and pharmaceutical representation. At present the Minister has power to vary the proportion of medical and lay representation. We think that this is a power which he might be willing to sacrifice.
Then in order to ensure more autonomy for hospital and, therefore, in order to retain local interest in them, hospital management committees acting for a group of hospitals should appoint a house committee in each hospital of the group subject to the hospital management committee and the Regional Board. Another point: it should be one of the functions of the hospital management committee or of the house committee to set up a medical staff committee, and such committee should have the right to nominate a reasonable number of its members to be members of the hospital 59 management committee or house committee. Lastly, on the side of medical education, the Bill needs amending for at present it makes no provision for the laying upon the boards of governors of teaching hospitals any duties in respect of furthering medical education and research.
Finally I want to go into this glaring anomaly, to which the noble Earl refers, by which any gifts and legacies received by the non-teaching hospitals between the passing of the Bill and the appointed day will go direct to the Hospital Endowments Fund: whereas any gifts and legacies received after the appointed day will, according to the amendment of Clause 59 in another place, be retained by the management committee. That, I think, is an obvious anomaly which can be corrected by a simple Amendment. We have to bear in mind that it is a very vital period from the passing of this Bill and April 1, 1948, and if all gifts and legacies during that period are collected by the Central Fund it will be an extremely serious position for these voluntary hospitals which, up to the passing of this measure, have been paying them into their own banking accounts.
There have been moments of impatience in which the Minister has forgotten that if he does not take the doctors, the hospital administrators, the dentists, the nurses, and the health workers, with him, this Bill cannot succeed in its great purpose. Sometimes he remembers this, as he did in one of his latest utterances only a few days ago in which he said "Now what we hope is to get the co-operation of the great medical profession and of all health workers in the country; because without that co-operation this scheme is bound to fail. The House of Commons only passes Bills; it is the men and women outside who can make them living realities." Not because of the implied compliment, but because these words are true, do I say that there is surely here the beginning of wisdom. The Minister has courage, enthusiasm, a nimble mind and, I believe, a conscientious belief that these proposals are in the best interests of the community. I think that the Minister will go far, but in what direction I am not able to say. I find the prognosis in that respect extremely difficult.
Finally, and seriously, it is quite obvious that we are about to embark 60 upon a great experiment in the nation's medical services, an experiment in which the State takes a much greater part than it has ever done. I have said that I conceive it to be the doctor's duty to do his utmost to make the experiment succeed. It will fall to him in the main to use this instrument in the best interests of the public, but there is, for the doctor, an over-ruling duty—his duty to his patients. If he can fulfil this paramount duty through these means, he will, but if he cannot it will be for the patient to decide how long the sacrifice of efficiency shall continue.
§ 6.8 p.m.
§ LORD AMULREE
My Lords, this is the first time I have had the pleasure of addressing your Lordships and I hope I may claim that indulgence which is always afforded to speakers in that position. The first thing I am very pleased to see in this Bill, and I think it will be a great improvement in the service, is the clause dealing with the provision of regional hospital services. In regard to the treatment of cancer, that was one of the matters in which I have been particularly interested. We have been trying to get that going for a very long time. The Cancer Act of 1939 tried to do the same thing. Where members of the medical profession have succeeded in running these centres, great advantage has been derived by the patients as the result of the treatment. I do not think that people should be forced to travel many miles. There are a great many of what we might call simple maladies that can be treated in small hospitals, but for certain diseases a high degree of skill is required. It is an enormous advantage if the patient's journey can be made easy to a centre where there will be trained and experienced persons. For that it will be necessary to have increased services. I think it may also be necessary to arrange for visits by relatives to the patients at the centres. Patients do not like going away to places where they cannot be visited by their friends, and I think from that point of view a very great advantage will have accrued.
The second point I want to make is in regard to the large body of the sick who I think will benefit enormously from the transfer of the municipal hospitals to the central authority. I am now referring to that sad and melancholy collection of patients who are usually classed together 61 under the general term "chronic sick." It is very hard to say what the number of those patients will be, but, so far as I can make out, in 1944 there were about 60,000 for the whole country, of which about 6,000 were in London. I do not think there was anywhere near enough treatment for them, because one has frequently heard tragic tales of people suffering from one of the chronic incurable diseases who could not get treatment at any hospital at all. There has been a tendency to say that these people are old and not much can be done for them before they die. That again is not at all true, because if you take the total figures of the chronic sick you will find that at least 30 per cent. are under 65 and ten per cent. are under 45. So you have a very mixed lot who are at present treated in some of the smaller institutions in conditions which are really deplorable and almost Dickensian. No attempt has been made to classify them. You get young people in the same wards as mental defectives and people suffering from senile dementia, and all kinds of people are jumbled together with no attempt to treat them and they have no examination before they go in.
There is generally one doctor on the staff who comes in occasionally, but the patients are never given the benefit of an examination by anybody of consultant or specialist standing and therefore no attempt can be made to treat them or to remedy their condition properly. It was thought that their condition might improve when the Local Government Act of 1929 was passed, under which it was possible to transfer the Poor Law infirmaries, where the bulk of these people are housed, from the Public Assistance Committee to a committee of the local authorities. But that did not quite work out as expected, because once that transfer took place, as it did in a good number of towns with progressive authorities, the medical attendants who were appointed to the staff of the new hospital tried to turn the place into a general hospital, with the result that the conditions of the chronic invalids was not made very much more comfortable. That is quite understandable, because other cases are much more interesting and one feels that one is doing much more good if one is treating a number of patients for a very short-term disease.
62 The real trouble about these people is that once they went in there they were admitted for life and there was very little or no chance at all of their ever seeing the world again. There is one particular tale that I was told by a friend of mine who was a doctor. About fifteen years ago he went into practice in the country, and one of the places where he visited was the local Poor Law infirmary. He was there for about a year and then moved to somewhere else. About fifteen years passed and he went back to the same part of the country on some other work. He called at the infirmary, where he was pleased to find that the same master and the same matron were there as well as several of the nurses. What really horrified him, however, was to find that a large number of the same patients who had been there when he had seen them fifteen years before were still in the infirmary. They had never left the building. There is another story which I was told. It did not happen to me personally. A new doctor was appointed to one of them Public Assistance infirmaries. He went there and was inquiring what was wrong with the various patients when he came to one woman who looked youngish and seemed quite well. He said: "Why is that person in bed?" and the nurse replied: "I do not really know. I have been here five years and she has been in bed all the time." Those two stories are typical of the general attitude of a large number of people in this country.
For a very long time nobody thought there was very much you could do about it; there was a kind of defeatist attitude that there they were and there they lay. However, fairly recently one or two doctors have been put in charge of the chronic sick wards at these institutions, and because they were interested in seeing what they could do for the people there it has been found that a remarkable change can take place if a proper approach is made. There is one big institution which I know not far from London where they have got an extremely good medical officer in charge of the chronic sick wards. She has been there now for about fifteen years. When I went down to see her the other day she told me that about 60 per cent. of the patients who came into the chronic sick ward were discharged and went into their own homes, 63 or if they could not go to their own homes they went to various hostels for old people, or somewhere like that. I asked her "Can that be done by anybody or is there something special or expensive about it?" She said "No; you have merely got to realize that these patients are sick, and that it you have got a person who is sick the first thing you have to do is to make him better and get him up out of bed and walking about."
I do hope when we get this Bill passed and the hospitals are taken over, that the chronic sick wards will become part of the big acute sick wards. I do not think it will be possible to do it physically, because they are generally separated and in different parts of the town, but that does not seem to me to be of any great importance. It should be possible for the chronic sick to get the same medical attention from the same staff which the acute sick get who go to the voluntary hospitals. I think that no persons should be admitted to a chronic sick ward without first passing through an acute sick ward of a general hospital where they can be seen by a consultant and specialist, a line of treatment can be worked out for them, and they can continue to be seen by these doctors during the rest of their stay. It will probably be the case, then they have been seen, that they will have to be put into two categories, because I think there will be those who can be cured as well as those who are going to be chronic invalids and will probably stay in bed for the rest of their lives.
It is very important that accommodation should be prepared for them where they can stay for six Months, nine months or whatever it is. If you have these rather unattractive old buildings, something can be done to make them more cheerful and more comfortable for the people who have to spend the rest of their days or long periods in them. A tremendous amount can be done with colourful curtains, flowers and counterpanes. If you go into the normal Public Assistance infirmary you will find it is a most depressing place. The walls are usually painted brown and the lights are wrong; as you lay in bed you have lights shining in your eyes all the time. Simple things like those I have suggested will make a tremendous difference to those places, and also to the nurses and the patients. I hope that will be one of the directions in 64 which progress will be made when this Bill comes in.
Arising out of that, there is another thing on which I should like to touch briefly. Although I have said a certain number of these chronically sick people are comparatively young, the bulk of them, naturally, are elderly. You will get into a very difficult position if you try to separate your elderly people into those who are healthy and those who are sick, having the sick under one authority and the healthy under another. Both, I think, should come under the medical authorities. When people grow old, there is a very narrow borderline between sickness and health, and there has got to be a simple, easy flow to and from the hospital, if they want to go in for a few days and come back again to their homes. That is a thing which can be done very simply and easily. It has been done. I have just paid a visit to some of the Public Assistance buildings in France, and there the central authority takes charge of all people who want any kind of institutional treatment, whether they are sick or healthy. A certain number of voluntary bodies in this country founded homes for old people, and they all began with the idea that they were not going to have any sick people in them; they were going to be purely for healthy old people. In two of them which I came across quite recently that just did not work, and I think they have realized that if you are going to have a collection of old people living Together you must have some kind of sick ward. If you try to organize any kind of institution for old people and there is a sick ward there, you are going to get a recurrence of the old Poor Law infirmary, which is a thing we have been trying to get rid of for a long time.
§ THE POSTMASTER-GENERAL (THE EARL OF LISTOWEL)
My Lords, I beg to move that the debate be now adjourned.
§ Moved, That the debate be now adjourned.—(The Earl of Listowel.)
§ On Question, Motion agreed to and debate adjourned accordingly.