§ 2.52 p.m.
§ Debate resumed (according to Order) on the Motion for the Second Reading, moved yesterday by the Lord Chancellor.
§ THE POSTMASTER-GENERAL (THE EARL OF LISTOWEL)
My Lords, I think it will be convenient for the House if I start by replying to some of the points made during the debate yesterday afternoon. My noble and learned friend on the Woolsack will repair any omissions that I may leave and will wind up, in order to reply to the speeches made to-day. I will, then, make a few general observations about the Bill. I should like to start by congratulating the noble Lord, Lord Amulree, on a maiden speech of really peculiar excellence. My only regret is that owing to the late hour at which he spoke so many of your Lordships were unable to hear it. The House particularly appreciates a speaker who addresses it with personal experience of the subject under discussion, and the noble Lord spoke from the fullness of his own medical experience and with the keenness to improve the lot of the chronic sick that betokens the genuine 70 social reformer. I know that I am speaking for the House when I say that I hope we shall hear him often in time to come.
My noble friend opposite, the Earl of Munster, was good enough to give me advance notice of what he intended to say. He delivered what I may not unfairly describe as a lively and challenging Party speech. I am not complaining of the Party note, because Party controversy is the lifeblood of British politics, and it is probably a good thing for us in this House to hear now and again an echo of the controversy that goes on outside. But I could not help wondering, as I listened to my noble friend, whether his own Party might not be a trifle embarrassed by the impetuosity of his attack, and I felt quite uncomfortable when I pictured the state of mind of those of his colleagues on the Front Bench who were in office at the time of the publication of the Coalition White Paper. My noble friend paid tribute to this White Paper and then, I thought, proceeded to demolish it with no less vigour and relish than he did the Bill. My noble friend will remember that the original White Paper proposed the transfer of responsibility for personal health services, such as child welfare and maternity clinics, from the minor to the major local authorities. He will also remember that the White Paper recommended that no doctor in the public service should start a new practice or fill a vacancy in an existing practice without the consent of the Central Medical Board. The name of this body in the present Bill is the Medical Practices Committee, but the function is the same.
The noble Earl, Lord Munster, went on to complain that we are weakening our organs of local government and, consequently, the spirit of local patriotism and the voluntary service it encourages, by the transfer of such an important function as the hospital service from the local authorities to the State. But I cannot agree. I will give my reasons. The public-spirited persons who have served on local authorities will not be in the least deterred by the change, nor will the electorate become apathetic and indifferent to local politics. In the first place, in the past many counties and county boroughs have done little or nothing to develop a hospital service. Their position will, therefore, be virtually unaltered by the present Bill. They will have little or 71 nothing to transfer to the State. Secondly, those large local authorities who do run the general hospitals—which, of course, constitute the vast majority of hospitals in the country—will be no worse off than they were in 1928. It was not until the following year, 1929, that Parliament again gave those authorities power to start such hospitals in their areas.
There is a third reason. The larger local authorities are acquiring a whole range of obligations and permissive powers in health services which they have never hitherto had to discharge. For example, the obligation in Clause 21 to provide health centres for group practice by doctors or dentists is entirely new. So is the obligation in Clause 24 to provide health visitors to advise on health matters in the homes of the people in the district. So also is the duty in Clause 25 to organize home nursing services. Clause 29 allows a, local authority to send in a home help on occasions of sickness or incapacity which necessitates such assistance in the home. Therefore I think it would be agreed that the scope of these medical services is considerably enlarged by the Bill, and many local authorities will be able to do more than they have ever done before.
My noble friend also feared remote control of the hospitals, because he said this would mean the handicap of bureaucratic inefficiency resulting from administration by a distant Government Department. But the Bill does not propose that the Ministry of Health should run the hospitals. That would be a complete misunderstanding of its purpose. If my noble friend will look at Clause 11, he will see that the Minister of Health must—not "may," it should be noted—delegate his powers to Regional Hospital Boards and from there to hospital management committees or, in the case of teaching hospitals, to boards of governors. The Regional Boards will not interfere in the affairs of the management committees and their offshoots in so far as they are conducting the ordinary daily routine business of the hospitals. The business of the higher authorities, of the Regional Boards, is to supervise and plan for the region as a whole. I should like to make it perfectly plain, with regard to another point raised by my noble friend opposite, that there will be no financial leading strings, because each hospital committee 72 will be free to decide how its money should be spent within the limits of an annual budget. It will not have to apply to the Regional Board or to any other authority every time it wants to buy a dustbin or to make any small improvement in its facilities. In fact, the hospital committees and boards of governors will be just as independent in their day-to-day arrangements for running the hospitals as the committees that run them today.
Now I do think that there is a lot of misunderstanding about the proposals in the Bill, and it is extremely important, whether you approve of them or not, that everyone should be absolutely clear about what they mean. My noble friend also said he wanted rationalization and co-ordination of the hospital services without the transfer of ownership and control proposed in the Bill. I am not going into this important issue in any detail, but a unified national service would have been quite impossible if ownership and effective control had been left in the hands of over two thousand separate local or voluntary agencies. There would have been no means of obliging an obstinate hospital committee to carry out the terms of a regional plan, or of distributing our hospital and consultant services more evenly throughout the country.
My noble friend also asks about the size and distribution of the regions to be administered by these Regional Boards. The exact delimitation of the areas into which the country will be divided has not yet been decided, but my noble friend will have noticed in Clause 11 that each region will centre, so far as possible, upon a university school of medicine, and that the Minister is under an obligation to consult the interested parties in the regions before making up his mind. At this stage, that is to say, when all these preliminaries have been fully carried out, the Minister will define the different regions under regulations, and if my noble friend dislikes or disapproves of one or all of these regulations he will be in a position to move their rejection in this House.
My noble friend asked me—and I think this was an important question and a question that very many people have been asking—whether it is the intention of the Government to institute a fulltime salaried medical service. I can assure him quite categorically that it is 73 not, and has never been, the policy of the Government to institute such a service, which, indeed, would wreck the whole health scheme from the outset. What we desire is a system of remuneration based partly upon capitation fees and partly upon a basic salary. At the same time I rather deprecate my noble friend's suggestion that the full-time employment of doctors in public service leads to any inefficiency or neglect of patients. The professional standards of medical officers of health and of many other doctors employed in hospitals run by local authorities are just as high as those of doctors in private practice. This applies with no less force to those doctors who are employed by the armed services of the Crown. Many of your Lordships, including myself, have experience of their qualities during the course of the war. I will gladly deal with any other points later on in the Committee stage.
I will pass on from that to the speech, which I think all your Lordships listened to with peculiar pleasure on account of its measured wit, by the noble Marquess, Lord Reading. I should like first of all to thank him and his Party for the support they have offered to the broad outline of the Bill. The noble Marquess asked me in a very direct question whether the hospital endowments in memory of a specific individual would be appropriated by the Minister of Health. I think he used the picturesque phrase whether they would disappear into the "omnivorous till of the Ministry." I can assure the noble Marquess that this will not happen. The money will still be used for the benefit of the sick and, when an allocation is made from the Hospital Endowments Fund to any particular hospital, the wishes of donors will not be forgotten.
§ THE EARL OF LISTOWEL
I think that is covered by the second part: that when an allocation is made to a particular hospital the wishes of the donors to that hospital will be considered. Now the noble Marquess stressed—
THE EARL OF CORK AND ORRERY
I am sorry to interrupt the noble Earl, but it is impossible to hear him.
§ THE EARL OF LISTOWEL
I am sorry. I will speak up. The noble 74 Marquess stressed, and rightly stressed, the desirability of functional buildings as health centres. Of course we agree with him that a new building, constructed for the use of doctors in group practices, is infinitely preferable to an old building merely adapted for that purpose. But I am sure he will appreciate that we must get on with the job. These health centres will be experimental, and we want to find out how this experiment is going to work. It is impossible to wait, in view of the other demands on the building industry, until every health centre can be newly built.
The most reverend Primate the Arch-bishop of York also gave his blessing, in general terms to the Bill. He was good enough to tell me he would be unable to be present this afternoon, but would like a reply to what he regarded as his most important point. I can give the most reverend Primate the assurance for which he asks about the continuance of the existing facilities for worship and the services of the ministers of religion in hospitals after the hospitals have been transferred to the State. The maintenance of chapels and other expenses connected with the services will, of course, be part of the running cost of a particular hospital, and will be provided for in the annual budget. I should like to say how grateful I am to the most reverend Primate for pointing out, with special reference to tuberculosis, that there is more ill health among poorly-paid wage-earners than there is among those earning a reasonably good salary. That, after all, is the simple justification for a free health service.
The noble Lord, Lord Moran, whose words obviously carry a special weight, was also good enough to support the Bill. I am extremely grateful to him for the terms in which he offered his support. The noble Lord was, I think, afraid of excessive centralization in the administration of the hospital services. He asked specifically whether the Ministry or Regional Board will investigate hospital complaints, and engage or dismiss nursing staff. Both these powers will be delegated to the Regions, and there is no real danger of Whitehall interfering in the domestic affairs of hospitals. I can give him an assurance on that point. The noble Lord also referred to the unfortunate difference of opinion that has arisen between the Ministry and the panel practitioners. My 75 right honourable friend is most anxious to break this deadlock, and a meeting with the representatives of the profession will take place tomorrow. We all desire the co-operation of the medical profession in working out the machinery for the new health service which will, of course, include the terms and conditions of their own participation in its work.
The noble Lord, Lord Teviot, who was good enough to tell me that he was unable to be present this afternoon, raised the question of dentistry in the new service. That is a subject with which he is particularly well qualified to deal in view of his long and indefatigable chairmanship of an Inter-Departmental Committee which produced a most valuable report on dentistry from which the Government have greatly benefited. I think the noble Lord was under a slight misapprehension when he said that the Bill takes away the relationship that now exists between the dentist and his patient, for there will still be complete freedom for any patient to go to any dentist he likes. He will not be limited, as I think the noble Lord thought, to a dentist practising in the neighbourhood in which he lives. This is assured by the right of the dentist to put his name on the list of any executive council in the country.
I will pass on to subsequent speeches. I should like to say that I was particularly glad to receive the support of the noble Lord, Lord Inman, because it was extremely reassuring to hear a former chairman of the Charing Cross Hospital say that the voluntary hospitals would continue to flourish under the new dispensation. I agree with him that the spirit of voluntary service must be retained in the hospitals. It is something exceedingly precious that has rendered great service to the community and it must be preserved. There will be plenty of scope, as he said, for voluntary workers in time to come both in the wards and on the management or house committees which will run the hospitals. I hope some of the ladies who in the past have sold flags or carried collecting boxes will continue their good work by visiting the wards or, if they want to render even greater service, by scrubbing the floors.
The noble Lord, Lord Horder, in a speech to which I am sure we all listened with great respect, in view of his position 76 in the medical profession, said that his ideal of a medical service was a maximum of central direction and a minimum of central control. That is exactly what we are aiming at under the Bill. If we are able to carry out that principle, which is what we are trying to do, then I hope we shall all be equally satisfied. I am sure that his fear that there will be a dead level of mediocrity in the medical profession if the proposals in this Bill are carried out will prove to be groundless. We are not dispensing with the material or the moral incentives to an efficient medical service. There will continue to be a graduated scale of salaries in the hospital service and progressive remunerations for general practitioners. The good man will be able to get on in medicine just as he is able to get on in law or in any of the other liberal professions, and he will have every encouragement and incentive to do so.
I have endeavoured to cover the salient points that were made yesterday afternoon and I shall conclude with a few general observations about the Bill. The scheme in this Bill, in whatever form it finally emerges from Parliament, will be only a paper project, the skeleton of a national health service. The service it prescribes will need the willing co-operation of all who supply or benefit from it, before it becomes a living reality clothed in flesh and blood. To function successfully it will require, in the first place, as many noble Lords have emphasized, the genuine good will and co-operation of those engaged in medicine, and also of the public authorities and voluntary agencies who will take part in the vital business of day-to-day administration. No less essential to its, success, although I do not think this aspect has been mentioned so far in the debate, will be an intelligent and responsible attitude to their own health and a keen desire to take full advantage of their fresh opportunities on the part of the mass of the population for whose benefit these services have been designed. Public bodies, health experts and ordinary people are the three partners in this great enterprise. It will only become a great and lasting achievement in the field of national health on one condition, and that is if each partner accepts and carries out with conscientious determination and to the best of his ability his own share in a joint and concerted effort to build an A1 nation
77 Some of those involved in the administration of this health plan will welcome the new Statute, while others will no doubt say that they would have preferred a different approach. The subject of national health has always aroused fierce controversy, and no one would expect the final decision, whatever Government had been in power at the present time, not to run counter to the sincere convictions of many people well qualified to express them. There has, however, been ample opportunity for consultation and debate and every view of any importance has been given a fair hearing and prolonged and serious consideration. When the time for discussion is succeeded by the time for action, it is greatly to be hoped that past differences will be forgotten and that the ranks of medicine will be closed to implement the plan. Whatever criticism there may be of the machinery and organization of the proposed health services, everyone desires for the country the complete cover they set out to achieve. I do not think it is too much to ask that all concerned in the execution of the scheme that Parliament ultimately approves, including former opponents and honest but unconvinced sceptics, will do their level best to make it work. I would go further and say that such an attitude of mind is a patriotic duty.
If the general public is backward, ill-informed and ignorant about health matters, a common and not wholly unjustifiable complaint, we should not forget that this state of affairs is largely our own fault, for as legislators we have not hitherto given the care of the body its rightful place in school curricula. We have also failed to grasp soon enough the immense addition to personal instruction that modern methods of mass publicity can make. We had to wait for the impulse of war, to measure the impact of health broadcasts, films, posters and exhibitions upon the public mind. We now realize that the increasing emphasis properly laid on physical education and training in the schools must be accompanied by mass publicity campaigns directed at young and old alike. We hope by these means to breed a generation of keen and intelligent individual and family users of the new health service. In this way, by wider education in these matters, the rising generation will grow up better equipped than its predecessors, physically as well as mentally literate, and sufficiently sensible 78 not to regard good health as merely a state of not being ill. The day will surely come when people do not wait for a violent toothache before they go to a dentist, and when a periodic overhaul by a doctor is as normal for healthy adults in civilian occupations as it was in the Services during the war. We shall do everything we can to encourage the young to develop a pride in their own physique and a sense of responsibility for their own fitness in and out of school which they will later hand on to their children.
I think the course of this debate so far has shown a firm foundation of agreement about the main principles on which this Bill is based. This would have been less easy to understand if the scheme had sprung fully fledged from the mind of the present Government, after wiping from the slate every mark left by its predecessors. But it is not the product of any single party or any single Government. It is in fact the outcome of a concerted effort, extending over a long period of years and involving doctors, laymen and Governments, to improve the efficiency of our medical services and to make them more easily accessible to the public. I will not drive home this point by a lecture on the past, but certain events do stand out in sharp relief from the multitude of recent happenings that led up to the present scheme. For example, responsible people were advocating a much wider and more comprehensive medical service long before the war. During the war this school of thought became more prominent in the British Medical Association and many doctors began to press for drastic improvements in what they conceived to be the present inadequate system. The imagination of the public, focused on the better days ahead, was gripped irresistibly by the social security proposals in the Beveridge Report, and this gave rise to corresponding pressure for action from outside. It was indeed fortunate for the country that a comprehensive medical service, with family allowances and full employment, figured among the postulates without which all-round security was deemed by the noble Lord opposite to be unobtainable. The All-Party Coalition, soon after accepting this Report as a basis of its plans for post-war reconstruction, announced its intention of establishing the free and all-inclusive medical service envisaged by Assumpton B. Then, after full discussion with the profession and ethers concerned, 79 the Coalition White Paper followed a year later, to test Parliamentary and public opinion before the framing of legislative proposals.
These salient events—and I have only chosen the most outstanding—illustrate the many and varied sources from which the ideas in this Bill have come. They show the scheme as the next step in the long and continuous process by which this country has gradually built up its health services. It is a typically British scheme in its effort to incorporate in the new structure all the serviceable elements of proved usefulness in the old, including, above all, the voluntary spirit and the voluntary effort. If it moves a bit further in the direction of State medicine, it nevertheless combines freedom for doctors and patients alike with over-all planning, private and public practice, and unpaid voluntary service with salaried contractual obligations. It is as far from the all-embracing State system of medicine practised in Russia as it is from the commercial medicine favoured by the United States of America.
Seen in the broader context of social change, it is a sign of the transition from the nineteenth century to the modern State. The functions of Governments in the Victorian era were mainly negative—the preservation of law and order, the defence of the country and the Empire, and the levying of taxation for those limited but essential services. The State was there only to prevent interference with the legitimate activities of business men. It was a gamekeeper whose job was to prevent poachers from encroaching on the preserves of that vigorous and prosperous community. But to-day the main function of Government in normal times is quite different. It has now become the instrument, by means of a planned and expanding economy and a system of education, health, housing and other social services, for ensuring satisfaction for the essential needs of the whole population and, more particularly, of those under-privileged elements who have hitherto gone short. The aggregate of individuals is doing for the financially handicapped what he cannot do for himself. We have long recognized our collective responsibility for supplying these basic wants, and we are already more than half-way from the watch-dog to the social service State. Looked at in this 80 light, a national health service is one aspect of our progressive and practical British spirit, as it transforms the one-sided political democracy it fashioned in the nineteenth century into the fully grown social and economic democracy of the century in which we live.
We also agree—I think this is common to all sides—about the new pattern of excellence in medicine. The standard of achievement towards which our health services will work is pitched as high as we can place it. The sanitary standards from which they began, aiming no higher than the prevention of epidemics spread by the dirt and squalor of living conditions in the nineteenth century, is already a thing of the past. It has been succeeded, since the turn of the present century, by an elaborate but incomplete network—or perhaps I should with more accuracy say patchwork—of personal health services for the prevention of illness and the cure of those already ailing or disabled by sickness. This period made the stride forward from sewage disposal and chlorinated water supplies to human bodies, from the control of environment by public authorities to communal care for the individual man, woman and child.
We are now moving forward to the third and final stage in the evolution of our national health services. At this stage the human and technical resources of medicine will be harnessed to the social ideals of the age in which we live. They will become, in alliance with adequate housing and nutrition, a means of raising the whole population to an optimum standard of physical and mental fitness. It is this new and constructive conception of positive health, which, though it may appear a somewhat remote goal viewed from the present moment, is the object of our endeavour and which will play an active and increasing part in medical education and practice and in the future development of all our public health services.
Everyone in this House and outside wants the common man to reap the full benefit of the recent and spectacular progress of medical science. In the last 150 years medicine has advanced more rapidly than in any corresponding period in the past. Our ancestors in the days of Walpole knew nothing of anæsthetics or antiseptics, of the circulation of the blood, 81 of the minute living organisms that cause and carry disease, or of protection against infection. Our ancestors knew nothing of this great range of recent discoveries in medicine. Our own fathers were no less ignorant of the healing qualities of the sulphanomides and penicillin and of the new insecticides discovered during the war that stop the spread of typhus and kill the malarial mosquito.
But, although there has been steady and general improvement, there has been no equal or corresponding advance during this period in the level of health enjoyed by the whole population. This has been due to the time lag between the discoveries flowing from experiments and research, and their application for the common benefit to individual health needs. There has been not only in this country, but throughout the free enterprise world, a deplorable hiatus between the progress of medicine and its social application. It has taken the intervening years to convince slow moving public opinion that the free play of supply and demand, aided by private charity for the poor and public provision for the destitute, even in conjunction with the environmental health services instituted later by the local authorities, cannot bridge the wide gap that still remains between the health needs of the majority of the population and organized medicine. The public has now learnt from long and bitter experience that it must look to the State to give an equal opportunity of health and happiness to all its citizens, to the children of poor or wealthy parents, to those born in our great and densely populated cities or in tiny hamlets buried in the depths of the countryside.
This measure, by its inclusiveness, by its more even distribution of the nation's medical resources, and most of all by breaking the cash nexus between medicine and the individual, will remove the gravest of the present obstacles to one of the most important forms of equality of opportunity. And surely equality of opportunity is about the best thing that democracy has given to the world. I am proud of this measure, not as a Party man but as a citizen of a country which still cares about social justice and the intangibles that really matter, and I commend it to your Lordships for a Second Reading.
§ LORD BROUGHSHANE
Before the noble Lord sits down, would he be good enough to clarify the assurance he gave to the noble Marquess, Lord Reading, with regard to money subscribed to hospitals as a memorial to an individual? Will that money be kept for the purpose for which it was subscribed or will it go into the general fund?
§ THE EARL OF LISTOWEL
I would gladly deal with that point, but I think it would be convenient for the House if I did so privately or, if the noble Lord wishes it, on the Committee stage.
§ 3.33 p.m.
§ LORD LYLE
My Lords, I would ask for the indulgence which your Lordships always extend to members who address your Lordships' House for the first time. This Bill which comes to us from another place deals with matters which are of vital importance to every man, woman and child in this country. I cannot help feeling that the Bill follows the policy and the programmes of the present Government and that it is just another step on the slippery road leading to nationalization. In passing, one may notice that this Bill is described by some enthusiasts as a free health service. Well, I am politically old enough, I am sorry to say, to remember that a great statesman in the past brought in an Insurance Bill and he was severely criticized for a slight exaggeration. He told the people that he was going to give them ninepence for fourpence, but that surely was a very small exaggeration—what was called a "terminological inexactitude"—compared with the promise of a free health service, which in fact is going to cost approximately £150,000,000 a year. I am not going to criticize this Bill on account of the expense in which it is going to involve the country. In fact, I would support, and gladly support a national health service at great expense, provided that that expense did not mean that the individuality of the people of this country and their general power of doing as they wanted within reasonable limits were affected, and provided also that the scheme was soundly framed.
But in my opinion this Bill, in so far as it deals with the position of the doctors and their patients, and in so far as it deals with the voluntary hospitals, is a thoroughly bad Bill. I have no doubt that the Government have made up their minds 83 and they are going to go on with it and pass it through this House. Although your Lordships may be able to make some alterations and Amendments which may prove of value, I say quite definitely that it is impossible to make what is fundamentally a bad Bill into a good Bill. Apparently His Majesty's Government propose to take over—and I use those words in the full sense of their meaning—the hospitals and the medical practices of this country in toto. Thus this nation, which fought to a successful issue against totalitarianism, proposes to enslave its medical profession and to turn every one of its physicians and surgeons into clock-watching civil servants. Men who formerly devoted their lives wholeheartedly to dealing with the sick and the poor and the relief of pain and suffering, are now going to devote much of their time—of course not the whole of their time but very much of their time—to satisfying the wishes of the bureaucrats and to disentangling themselves from the red tape which bureaucrats always weave.
There is no conflict of opinion amongst the people of this country, or at any rate there is none in this House, as to the desirability of improving, if we can, the health services of this nation. We all admit that there is room for improvement in the present system, but I do not think that any fair-minded man could possibly say that the services which have been given by the medical profession in this country, or the services which have been given by the hospitals of this country, were inadequate and inefficient. I think testimony will abundantly show that that is not so. But if indeed you do find inefficiency and inadequacy I think it is interesting to note that the most obvious examples of inefficiency and inadequacy to-day are to be found in the services now being rendered by the State or municipalities in such things as the T.B. services and the mental hospital services. What I say is that it is absurd that an edifice which has been built up in the light of experience and which has so much to recommend it, should be ruthlessly scrapped because it does not fit in with the political views of our new dictators.
The B.M.A., amongst others, have been criticized in the past because it was said they were reactionary. I think that in passins one ought to say for the B.M.A. 84 that as long as thirty years ago they proposed a comprehensive medical service, and in 1935, I think, published a scheme. This was amplified and republished in 1938. In 1940 a Medical Planning Commission was set up and by patient and careful work a further interim report was published. It was not until then that Parliament sat up and took notice, and the noble Lord, Lord Beveridge, got to work on the basis of that report. One asks oneself why it was that the Government did not carry on from that point and take the B.M.A. with them. I am afraid it is just another example of the mentality of our present rulers, who ignore the experts, take the advice of the planners and, when they get into a mess, call in the experts again to clear it up.
I do not wish to take up the time of your Lordships for too long this evening, for I know there are many who wish to speak on this all-important subject, but I do want to make one or two criticisms of this Bill, particularly from the point of view of its effects upon the medical profession and the voluntary hospitals. With regard to the medical profession, I feel that there is no doubt, however much it may be camouflaged, that it is the intention of the Government to turn that profession ultimately into a full-time State-salaried service. That is my view, and a great many other people hold it also. Under the family doctor service outlined in the Bill, it is proposed that the doctors should be paid in part by salary and in part by capitation fee, with the capitation fee, as other speakers have pointed out, diminishing according to the number of patients who come on the doctor's list. It seems to me a very curious way of recompensing and rewarding merit and ability, but that is the basis upon which it is to be done.
Doctors coming into the service, it is said, are not to be allowed to sell their practices. I noted that the noble and learned Lord, the Lord Chancellor, yesterday said that doctors were to be allowed to sell their practices. Now the noble and learned Lord is very good at putting a case from his own point of view, but in what he said in that connexion I think he must have been referring only to those who do not remain in the scheme. He was arguing in favour of this Bill which seeks to bring everybody into this scheme. In so far as people come into this scheme, then they are not 85 to be allowed to sell their practices. I think that that ought to be made plain. The Minister, and, I think, the noble and learned Lord also, said that there would be no direction of doctors. But there again I think he must have been speaking about doctors who remain out of the scheme. They are going to be allowed to sell their practices—there is going to be no direction—but to whom? Not to the people who come into this scheme but to people who stand out of it. In any case, it is clear that though the Minister says that there may be no direction of doctors, there is a negative direction, inasmuch as the Commission on medical services which is to be set up under the Bill may take the view that a certain area is sufficiently "doctored." It is a horrible expression, but there it is. In that case no more doctors can be set up in that locality. I need hardly say that it does not seem to make any difference to the planners whether the doctors in a district are good or bad doctors; it is enough if the area is sufficiently "doctored."
These features, to my mind, are very unsatisfactory and will clearly lead, as I have said before, to the ultimate setting-up of a salaried service with State control of doctors coming into force. I think it is just as well that the doctors should realize now that that will be the position. I consider that it is vitally important that a doctor should retain the good will of his practice, and should be remunerated in accordance with the work done and the responsibility undertaken. It is only by that system that the public can retain a free choice of doctors, and only in that way will the public have a say in the control of these comprehensive services.
Sir Lionel Whitby, in his inaugural lecture as Regius Professor of Physic at Cambridge University, made the following observations which I should like to quote to your Lordships:One of the attractions of the profession is the personal and individual character of its practice; the latitude with which a qualified doctor may exercise his own judgment, express his own opinions and practice his own art. It is indeed one of the strongest arguments against nationalization and standardization. If the profession of medicine be robbed of its scope for individuality, the soul will go out of it.As the years go by, I think it will become increasingly apparent to everybody in this 86 country that the doctors, the nurses and others who have hitherto helped them in their illness and sickness are no longer concerned primarily with the personal relationship between them and their patients. Their loyalty will be expected to apply to the Ministry of Health. The interests of the patient as an individual will no longer be paramount. We have already seen enough in this country of bureaucracy and State-run enterprises to know that, with the best intentions in the world, they can very seldom—at any rate, for any length of time—function with maximum efficiency. It is only in the unnatural stimulus of war that they are able to "get a move on," and even then it is in an extremely expensive and cumbersome manner.
I find it extraordinary that the present Minister of Health should have such a thirst for dictatorial power. One would have thought that after he had observed our victory over tyrannical dictatorships he would have had a very real desire to see that nothing of the sort should be established in this country. Yet this Bill, from the first page to the last, is utterly undemocratic in conception. It sets up a highly complex plan of Regional Boards, management committees and so forth. But all these new bodies, which, after all, are not in being yet, are merely planning figments, and they will in effect be completely and utterly dependent on the Minister of Health and his Ministry, who will lay down the smallest details of their behaviour and activity. There is no question whatever, to my mind, that under this Bill the Minister of Health and his Ministry will obtain dictatorial powers affecting the intimate life and health of every single man and woman in this country.
I think that the outlook for patients is pretty poor under this Bill—indeed I would say it is gloomy. They will have no satisfactory way of airing their grievances and complaints, if they have any. The doctors, nurses and staffs are no longer to be the servants of the committee of the hospital. They will be the servants of some distant Regional Board, which, in turn, will be the puppets of the Minister. Complaints will be passed from the committee to the Board, from the Board to the Ministry, from the Ministry to the Minister, and then, possibly, they will go back, I suppose, in the same way from 87 the Ministry to the Board and away through all the tortuous channels to which unfortunately we have become so unhappily accustomed in this country, until the unfortunate complainant gives up in despair, realizing that in this brave new world there is no room for complaints. But he will have the abundant consolation of knowing that throughout the whole of his life he will be looked after by a utility doctor provided by a utility State, and in the end, when the fight is too much for him and he gives in, he will have the overwhelming satisfaction of knowing that he will be provided with a utility funeral.
I think that the Lord President of the Council, with whom I seldom agree, put the case very well in another place in 1945 when he said that while as a local government man he did not mind what was done with water, electricity and drainage and impersonal services of that kind, when it came to human services he thought one must balance efficiency with humanity, and accordingly it would not be right to take over the hospitals as a national concern. I do not agree with him about efficiency, but at any rate we are agreed that he saw the point about humanity. It is really extraordinary that the Lord President of the Council, whom I have known and appreciated for a good many years and whom I have always regarded as pretty tough, should have been out-argued and out-voted and out-manœuvred in the Cabinet by the decision of a newcomer in the person of the Minister of Health.
In introducing the Bill in another place the Minister of Health said it was repugnant to him that the hospitals of this country should be supported by charitable donations. It is interesting to note that he has altered his view a little in the past few months. He has modified his view, and is now prepared to allow hospital management committees to receive gifts and legacies; he is even appealing to charitable people to continue to make gifts to the hospitals during the period that will occur before his scheme comes into effect. How much better it would have been, my Lords, if the Minister had disposed entirely of his foolish prejudices in this matter before the introduction of the Bill at all. There would have been no loss, nothing but gain, had he allowed the existing endowments to be preserved 88 as far as possible, so that the wishes of the long-departed donors could have been respected. I am told that it has been estimated that these endowments amount to not more than £1,000,000 a year. And that, after all, is a comparatively small sum when measured against the total cost of the Bill of something like £150,000,000. I can only imagine that the Minister's decision is the outcome of living too long with Socialist doctrinaires, to whom it is repugnant to think in terms of charity and humanity, and who are inclined to think only in terms of paper plans in which human beings become mere cyphers. I very much fear that if the Socialist Government are to remain in office much longer, and they adhere to their present policy, then the idea of service to one's fellow men—personal service—will largely disappear.
In conclusion, I should like to make an appeal to the Government to consider where this policy of theirs is leading. Whilst I differ from the Government and their policies, I do know and appreciate that all my noble friends on the other side of this House and so many of my friends in another place, are actuated by the same objects as we are—namely, to benefit our fellow men and women in this country—and that they believe in, and wish to preserve, the greatness of our country which has done so much to preserve the freedom of the world. I appeal to them to give up their mistaken ideas that there is anything derogatory or repugnant in the idea of charity. Charity is one of the most beautiful of the gifts that have been vouchsafed to us. Of course, people cannot live on charity. Nobody for a moment suggests that we should be dependent entirely on charity, but I do think that that idea and that ideal should have been maintained as strongly as possible, instead of being run down and abused as it has been in certain quarters.
It was my privilege to serve Queen Mary's Hospital as Chairman for seventeen years and I served on the King's Fund for six years and on perhaps the most important committee, the Distribution Committee. My father served before me, and my children are serving now. Yet I am only one of hundreds and thousands. I have done very little. Hundreds and thousands have been doing this great and wonderful work, and it is a terrible thing that such work should be allowed to cease. I do not believe that 89 my noble friends opposite mean that to be so, but it is going to be so. The other day when I visited Queen Mary's Hospital I found one of those great meetings going on, the sort of meeting that is held in all our hospitals—a meeting of the Ladies' Linen League. Here were ladies, some from the East End, some from the West End, with all their differences and divergences, putting an end to creed and class and sect to meet together with the one wonderful stimulating ideal of helping each other. I said goodbye to them with a heavy heart, because I know that they will not be required any more.
We have been living in an unhappy world, a torn and tattered world, a world where people have been hating and killing and destroying, when one's faith has been sorely tried, and it was a wonderful thing to be able to turn to this great uplifting ideal and find solace and consolation. The Government, by their suggestions, are going to kill that thing stone dead. That is my opinion. I would beg them to hesitate before they do so. I warn them that we cannot afford to-day to kill such a priceless asset in the nation, and I beg them to hesitate and pause before they go forward on these lines and in other directions. The appeal which I make to the Government on this subject is a genuine appeal, and I make it from my heart. So far as the Bill is concerned, as I said before, I am afraid that the Government have made up their mind and that the damage has been done. Perhaps your Lordships may be able to improve the Bill in various directions, and if we can do so we shall have at any rate accomplished something.
§ 3.59 p.m.
§ LORD BEVERIDGE
My Lords, before I say anything else I am sure that you will wish me to express our appreciation of the excellent maiden speech just delivered by the noble Lord, Lord Lyle, with refreshing vigour of opinion, clarity and force of expression. We hope that he will make many more. I have peculiar pleasure in thanking him and expressing my own appreciation, because while it is very easy to make a good speech for a good cause the noble Lord who has just sat down has made an excellent speech for what seems to me a very bad cause. He has called this Bill a very bad Bill. I want to submit to the Government that it is such a good Bill that it is well worth 90 while making it better by accepting Amendments from your Lordships' House.
Indeed, I think it is so good a Bill that, literally, there is only one point in the admirable—I might say the customarily admirable—speech which the noble and learned Lord, the Lord Chancellor, made yesterday, in introducing the Bill which raised any doubt at all in my mind. That was not with regard to the Bill or the details of the Bill. It was a remark which he made at the very beginning of his speech, when he said that there was no subject to which we could better bend our energies, resources and time than to improve the health of the people of this country. That raises a doubt in my mind, because, after all, health is a domestic problem, and it is clear that there are many international problems to-day which are more important than almost any domestic problem. I do not suppose the Lord Chancellor would really differ from me with regard to that. I want, however, to make that point at the beginning, because I do feel that it is most important for the people of this country to realize that they must look outward and not inward, to be sure that the Government have an organization capable of dealing with international problems, and for Parliament to make these problem, its main concern. If you read The Times report of the proceedings in another place yesterday it would seem that the other place was much more interested in the motor car of the Lord President of the Council than in the control of atomic energy. I think that the control of atomic energy is much more important.
There is no real difference between us with regard to this Bill. For that reason I think it may be possible for me to speak only for a short time. I give my whole-hearted support to the Bill in practically all its main features. Of course the Bill does not do everything that is wanted to promote the health of the people of this country. It is not intended to. Health depends on housing, nutrition, sanitation, and so on. But the Bill does do two quite essential things within its own field. The first is that it removes completely the economic barrier between sick persons and the best possible treatment for them. We all know how much has been done on a voluntary basis, by the spirit of service by our great specialists and others, and by the organization of the hospitals, to give 91 treatment to people although they were poor. But we also know that has not been complete, that the best possible treatment has not been available without any economic barrier at all. This Bill removes that economic barrier.
The second thing that the Bill does is to set up for the first time a true Ministry of Health, a national authority with the duty and with the power of attacking disease as a national enemy. I hope that is going to mean not only that the Ministry of Health does its own job of administering what comes within its sphere, but that it is going to be a continual irritant to authorities which are not getting on sufficiently well with housing, sanitation and nutrition by saying: "This is causing us to do a good deal more than we need." For the first time we are making the Ministry of Health a true Ministry of Health, and that is enormously important. This Bill does mark a revolution in the sense of values in the country. It does so because, among other things, of its connexion—to which the noble Earl, Lord Listowel, referred—with the National Insurance Act. As your Lordships know, the White Paper of 1944 began with the declaration that the Government had announced its intention of introducing a comprehensive health service. The White Paper somewhat oddly did not say when that announcement was made. Actually it was made in the debate on the so-called Beveridge Report. It was made as a means of carrying out Assumption B of that Report. I thank the noble Lord opposite for referring to that fact. May I say that the reason why I introduced those things as assumptions was that I considered possibly they might be thought to be outside the terms of reference of the Committee over which I was presiding? But I thought it important that that should be said, and the device of assumptions was a means of getting them in.
Of course, my Committee did not do any of the hard work of preparing this Health Bill. A great deal had been done before, and a great deal has been done since. But I do think that the connexion with National Insurance is real in this sense, that the publication of that report, for some reason or other, caused considerable democratic interest and an assertion of a democratic demand for the carrying 92 of it out, including the health side. In other words the Bill, which I hope will be passed shortly, gives effect to what I believe is a vital principle, that health, as well as bread, for everybody should come before cake and circuses. That is a revolutionary change in values in this country to which we are giving practical effect. It does involve I suggest, a revolution in the organization of the great healing profession and does involve making that profession not in any sense whatever any longer a business, not very much of a charity, but a service. And I speak of a service without saying "free," without saying "the State," but a service to humanity.
I do not think myself, and I do not believe many people think, that this exception of private practice will really be very important. I cannot really imagine any large part of the people of this country continuing to pay for a service when they can get a service, are entitled to get it and ought to get it, at least equally good, without paying for it at all. I do not believe they will do that in Scotland, anyway, whatever they may do anywhere else. And also it will become a service, I am sure, predominantly—not solely—supported by public funds and probably in the main by national funds. For that new change in the medical profession and the carrying out of that revolution—I think it is a revolution—I suggest that it is better to have a new machine of a new design rather than to keep the old machine and make a lot of minor adaptations of it.
It is because of that that I personally believe that the Bill now introduced is a very considerable improvement on the Coalition White Paper. On the whole, it is well designed. I suggest that the Regional Hospital Boards are an improvement upon the joint authorities, as the Lord Chancellor indeed so cogently pointed out. I do not think there is any doubt about that. If you say that the setting up of these Regional Boards represents an attack upon local government and a change in local government, well, is it not clear that a considerable change in local government is already long overdue in this country? Why should we hold up the best health treatment because we have not yet put our whole local government machine into the best form? It is not in the best form to-day.
93 Coming to the executive councils, there is one point I should like to make about the membership of these councils. These bodies do pretty well represent the local authorities, the practitioners and so on, but I am not sure that they are sufficiently representative of what I may call the consumer—the ordinary citizen. The Minister can only appoint four out of the twenty-five, and the local authority appoints eight. I think it is quite possible that the local authority, while it could appoint people who would represent the consumers, might just appoint representatives of the local authority's interests. That is something quite different. I am not sure it would not be worth considering whether, in making the appointments, either by the local authority or by the Minister, there should not be some consultation with voluntary bodies such as the friendly societies, the trade unions, and women's organizations, which would see that people got on whose main interest was in developing the health of the private citizen. I only throw that out as a suggestion. I believe the executive council is a good and suitable machine.
Then the health centres. My impression is that the health centres were one of the things which were most emphasized in the report of the British Medical Association, which was before me when I was making my report on social insurance, and that the considered opinion of doctors generally at that time was very much in favour of getting these health centres. I hope it still is so, and I hope we shall proceed to get them. One point I should like to suggest for consideration. Suppose the local authority does not set up a health centre. Is there any means of compelling it to do so? I am not sure the Bill would not need looking into from that point of view. I suggest that we should have for this new purpose a new machine, rather than tinker with the old machine, but, of course, the new machine ought to keep the good in the old.
Can a new service relying upon public funds keep the individual relationship of practitioner and patient? Can one keep initiative, and can one keep experiment? Can one keep the spirit of service, rather than get the spirit of bureaucracy? I just want to give my answer to that, based upon my experience of another profession, a profession not nearly as important as the medical profession, but still of a reasonable standard—the profession of a university 94 teacher in which I was, myself, engaged. My experience as a university teacher is that it is possible to get the whole of your income as a salary, and while retaining considerable freedom and initiative, yet retain a sense of being in the service of the people with whom you are dealing. That is the exact position of all university teachers. You can also get a salary if you belong to a body with a large measure of self-government without becoming anything like a civil servant. I do not think civil servants are bad, but I do realize the difference between being a teacher, where the essence of his work is to give individual treatment to his pupils, and a civil servant, who must carry out orders.
Then there is this question of reliance upon public funds. The universities are becoming increasingly reliant upon public funds. In the Public Grants Committee the universities have got a system for getting public funds without getting public control, except in general. I hope that that principle and a system of that sort can be applied to the medical services and, above all, to the teaching hospitals. What is essential is that there should be enough money so that the hospital management committees can make a decision as to how they can spend their money, and can experiment in spending it. Of course there are important differences between the medical profession and the university teaching profession. I think the main difference is that the medical profession has, on the whole, to work a good deal harder, also it has to work at less regular hours, and, on the whole, its job is not so pleasant because there are many patients who are not quite so attractive to deal with as the young men and young women in universities. For that very reason, I personally think you ought to pay the medical profession better than you pay the teachers. It would be quite easy to do that without paying them very much.
I think, also, that it is right to make a greater variety in the income, according to the amount of work done. That is why the plan of a relatively small salary and capitation fees seems to me a good device in relation to the medical service. It would not be at all a good device in respect of teaching; no lecturer would like to be paid according to the number of people who came to listen to him. It 95 would have a most unfortunate result. I think the doctor ought to be able, more or less, to choose to work rather harder to get more income. It is good, too, that, to some extent, there should be reward for special services, although that is not a practice of the university profession. Although this is not an exact example, it is an example of a profession which I know, and it shows that it is possible to have a service which does not destroy initiative and experiment. There are many other things the medical profession can take from the university teaching profession. I hope it will take the practice of refresher courses. That is one of the great things which is going to be possible under the new system, and which was not possible under the old system. A practitioner will be given the chance of getting six months or a year at a time to rub up his subject.
I suggest that it is possible to have a service, and not a business, without making it a Civil Service, and without making it rigid. That depends upon the spirit in which this Bill is administered, and I suggest that the spirit in which this Bill is administered, so long as, at any rate, the present Government are in power, will be judged, to some extent, by the spirit in which they approach Amendments which may be moved in this House. The main lines of the Bill, I believe, are right. I, personally, would not want to alter any of the main lines of the Bill, but the debates in the other place, which I have studied with some care, suggest to me that an occasional rigidity has extended beyond the main lines of the Bill. Quite a small point, one of no importance, which has been brought to my notice and which illustrates what I think is excessive rigidity, is the treatment of the staffs of the contributory associations which work for more than one hospital. Where you have a contributory association which has been getting money for one hospital, that is going to be treated as staff entitled to compensation for a job. Where four or five hospitals, instead of cutting one another's throats by each having its own contributory organization, pool their activities and get a single association, that is going to be treated as not entitled to compensation. I suggest that that kind of distinction is quite indefensible.
96 I think I have mentioned the question of the position of the executive council. There are many other Amendments which will be moved. Naturally, I hope particular attention will be given to the Amendment the noble Marquess, Lord Reading, may be moving in regard to endowments. My final word is that no doubt the Bill can be improved, and I hope that the noble and learned Lord, the Lord Chancellor, and the other representatives of the Government in this House, will show that their minds are not rigid in regard to the details of the Bill, and thus suggest that they will not be rigid in the administration of the Bill when it becomes an Act.
§ 4.21 p.m.
THE LORD BISHOP OF SHEFFIELD
My Lords, among people of humane principle there can be little disagreement with the intention of this Bill. A few elect souls win to great achievement through suffering and ill health, but these two things remain great evils, and debility, sickness and disease prevent fullness of life and cause great miseries. Given, then, the desire to provide a full service evenly distributed throughout the country, it seems to me that the general set-up and framework of this Bill is the right one. Those who have lived and worked in working-class dormitories and industrial areas know from personal experience that our health services at the present time vary enormously in their efficiency and in their fullness. That experience, of course, is confirmed and documented by those hospital surveys which have been made under the auspices of the Ministry in co-operation with the Nuffield Provincial Hospital Trust in recent years.
I am not going to weary the House by quotations from some of those surveys at this stage, but they abound in evidence of uneven distribution of ordinary and specialist services, of consultants, of nurses, of ambulances and so forth. There are gaps between statutory authorities, and while there are some excellent voluntary hospitals there are some which are not so excellent, and there is, broad and large, a great lack of co-ordination. I think it is true to say that a poor man's chance of recovery from serious illness depends too much on where he happens to be when he falls ill. Therefore I feel that the case for building up hospital services originally around, university teaching 97 centres and teaching hospitals is irrefutable, if the facts are clearly considered. Possibly if future groupings should prove to be rather unwieldy, it may be necessary to increase the number of teaching centres. I think we also ought to recognize that existing inequalities are very often due to the very excellence of voluntary services in one place as compared with other places. Therefore it is really unreasonable to try and say in one breath: "Let us have a national service and let it be on a voluntary basis."
Basically the services to be comprehensive must be statutory, and in a society where differences of wealth are still fairly pronounced they can only be fairly distributed if those services are free after specific charge of a patient. In the sequel quite obviously the operation of the laissez faire principle, which is not quite the same thing as freedom, and the range of voluntary activity will be greatly restricted in a field where voluntary service has had very great scope in the past. So we are rightly faced with the question: Is this too high a price to pay for greater equality and greater efficiency? Personally I think it is not too high a price to pay, but it would be unrealistic not to recognize that in some respects the price is high. If, therefore, by Amendment here and there, we can reduce the price, that will be a work well done.
May I briefly refer to one case of real sacrifice? On the appointed day most contributory schemes will end. It has been my privilege for the last seven years to be chairman of a committee which manages one of the largest of the contributory schemes in Sheffield and district. Very many people indeed, especially among the manual workers, have in recent years contributed over £300,000 a year to the maintenance of voluntary hospitals in that place. That is an extraordinarily fine democratic effort. Those contributions have drawn with them an immense amount of interest and good will towards those hospitals. We recognize that with compulsory all-in insurance those schemes will come to an end, but everything that can be done should be done to maintain the interest and the good will. Further, if I may make a passing point of some importance, those schemes ought to be kept Lilly going until the appointed day. In order to make that continued interest more certain, and also to acknowledge the extraordinarily fine 98 effort, not only of contributors but also, as the noble Lord, Lord Beveridge, has mentioned, of the professional staffs, I would suggest that those who speak on behalf of the Minister might be just a little more appreciative of that service and of that magnificent contribution so characteristic of our national life.
Then again those of us who have lived and worked in ordinary places cannot but sympathize with some of the older general practitioners who have served their people well and who not unnaturally regard changes with some dismay. I think we can do that without necessarily agreeing with some of the propagandists who exploit their fears. May I, in this connexion, once again ask that the Government should pay very great heed to one thing which the noble Lord, Lord Moran, said yesterday, and that is the essential importance of attracting men of the highest promise into the profession and of safeguarding the whole scheme of national medical service by being most generous in the endowment of research. In spite of what the noble Lord, Lord Lyle, said, I have not quite so much sympathy with people like myself who have sat on boards of management for a good long time and who may possibly, although not certainly, no longer find themselves sitting on those boards when the Bill has become an operative Act. So far as I am able to understand it, the Bill was amended in another place (and I have some hope it may be further amended in this place) in such a way as to allow the local hospital boards sufficient freedom to do good without too much freedom to do nothing, which sometimes of course has been their practice.
Some of those who have criticized this Bill have, I think, in their speeches tended to set the voluntary and statutory services one against the other, but as one who has been deeply involved for many years in voluntary social service, I feel bound to say that the important thing, surely, is that they both should be integrated. Both are needed if the welfare of the State is to function well. In point of fact, during the last twenty-five years have we not seen a growing technique of co-operation and a growing understanding and good will between the voluntary and national services, especially at the national level? It is, at that level at any rate, fairly generally accepted that some things are better done by a competent voluntary 99 organization, possibly grant-aided by the State, than directly by State action.
The noble Lord, Lord Beveridge, has referred to the relationship between the Ministry of Education, the Treasury and the universities. Comparable with that is the relationship between the Home Office and probation work, or the U.A.B. and unemployed welfare work before the war. I think we may hope that the Minister of Health will follow these well-tried and happy precedents. We may also hope that those very large voluntary funds which have been raised from time to time may be preserved to be used along special lines of health service and that they will not just be absorbed into the large kitty-bag.
If I may, without any intended discourtesy, apply a canine metaphor to what the noble Earl, Lord Munster, said yesterday, I felt that at one point in his speech he was barking up the wrong tree. In my experience, it is the local authorities and not the Ministry who are still inclined to regard voluntary organizations as competitors or even as superfluities, and who are inclined to insist that there can be no aid without a good deal of control. As I think the noble Lord, Lord Moran, said yesterday, that is a reason why many of those on the staffs of the voluntary hospitals, especially of the voluntary teaching hospitals, greatly prefer this Bill to the one foreshadowed in the Coalition White Paper, which seemed to hand over the voluntary hospitals, tied and bound, to the local authorities. Nevertheless, I share the anxiety which is felt by many of your Lordships that the Bill should leave so much to be decided by administrative regulation—always jam to the totalitarian. I only hope that Parliament will remain watchful over this and so prevent any danger of the destruction of initiative and flexibility.
In this connexion, may I pass to one not unimportant point from the Churches' point of view, though possibly it is not of major importance in regard to the total service? We should like to feel sure—I am speaking for the Churches now—that the Churches will be allowed to preserve, and indeed to own, hospitals and homes on a religious basis, and to form various communities of nursing sisters. If I may say so, I hope we shall not just be allowed to keep what we have, but that we may even be encouraged from 100 time to time to make new ventures in co-operation with the medical profession. For example, as we all know, a great deal of mental breakdown and nervous disorder is due to disintegrated personalities and purposeless lives. Here, some of us feel, is a department of healing where the inherited wisdom and experience of the Church, in co-operation with medical science in its most modern forms, might enter into a very fruitful partnership and blaze a trail. I, for one, should be sorry if in the administration of this Bill when it becomes an Act that kind of experiment were ruled out. Some of us regard with dismay the prospect that persons of religious convictions who have mental breakdowns should be sent, with the legal authority of possibly not very sympathetic relatives, into mental hospitals where those who practise do so without seeing beyond the purely mechanistic view of life.
Without delaying your Lordships further at this hour of the evening, I would like to come to one final point, which merely takes up something said by the noble Earl, Lord Listowel, earlier this afternoon. Am I right in venturing to say that in this country up to now the medical service has perhaps been too concerned with illness and not sufficiently concerned with health? Deep indeed is our personal debt to the doctors, surgeons and nurses who have rescued us from illness, but as one watches their work one feels that owing to existing limitations, not in themselves but in the whole layout of the service, they have not been able to do enough to keep people in health. It is, more than anything else, because this Bill, if it becomes an Act, is likely in the years to come to focus corporate effort upon good health rather than upon bad health, and so gradually to lift this terrible burden of debility from the minds and spirits of the common people of this land, that I, as a Minister of Christ, welcome it and venture to express the hope that this House, after making judicious Amendments, will send it forward ungrudgingly for the Royal Assent.
§ 4.40 p.m.
§ LORD UVEDALE
My Lords, in rising to address your Lordships for the first time, I crave the indulgence of your Lordships' House. The object of the Bill before your Lordships is to create a comprehensive medical service, and elaborate 101 machinery has been set up to secure the finance, the buildings and the equipment that such a service will require. Your Lordships have heard during this debate that many buildings and much equipment now in use are sadly inadequate, but I wish at this point to remind you that all this new machinery is designed merely to afford a suitable environment for the service. It does not in itself solve the essential problem of how to improve the health of the people. That problem is only in process of solution when patient and doctor meet face to face.
What, therefore, are the essential factors making for an efficient medical service? May I suggest that every patient, on submitting himself to treatment, should be assured of the following points. He should have, as far as possible, freedom from financial anxiety, and one of the laudable features of this Bill is that it attempts to achieve this object. He should have a free choice of hospital and of doctor, the element of compulsion being particularly repugnant to the sick. When admitted to hospital he should find himself in pleasant and sympathetic surroundings and should not be submitted to unnecessary and irksome restrictions. I venture to hope that although the service is to be a State service, any tendency to regimentation will be most strenuously arrested. In sickness every man and every woman is an individualist calling for individual attention.
I now come to the crux of the problem: How are we to secure from the medical profession that concentration of effort, that devotion, that undivided loyalty to its high calling without which all this machinery will be a cumbersome futility? I would say in answer to that question that in the first place the doctor must have his independence in medical treatment; he must have at his disposal drugs, instruments, laboratories, X-ray plant, apparatus for physiotherapy and operating theatres. He must be supported by efficient nurses, radiographers and physiotherapists. The financial provisions must be such as will atract to the profession the ablest men and women from our schools and colleges. There must be opportunities for the gifted to attain all positions of influence and distinction in the national life. The fear of a controlled and a uniform mediocrity must be removed.
Finally, the medical profession must be controlled by the medical profession. The 102 importance of research cannot be over-estimated. I have left on my desk today a small volume on blood diseases. In this volume one hundred separate and distinct conditions are described, each giving a different blood picture under the microscope, and most of these diseases have no known cause and no known cure. The field of medical research is unlimited, and I hope that access to this field will not be made difficult. Any doctor, general practitioner or specialist should be given facilities for research without suffering grievous financial loss. Your Lordships will recall that one of the great discoveries of modern times in medicine, the preparation of insulin, was made by a general practitioner from a small town of Canada.
In conclusion, I should like to say that those of us who have worked under the voluntary system have known how much good will, sacrifice and effort have been enlisted in its service. Particularly would I refer to the large numbers of working men who, from their scanty resources and their limited leisure, have given generously to the maintenance of their centres of healing. The boards of these hospitals have brought into friendly co-operation men of all classes and of varied endowments, and these men have learned mutual tolerance and respect. But the task has outgrown their resources. However, we cannot contemplate their supersession without an element of regret.Men are we, and must grieve when even the shadeOf that which once was great is passed away.
§ 4.49 p.m.
§ LORD LUKE
My Lords, I am very glad indeed that it has fallen to my lot to congratulate the noble Lord, Lord Uvedale, on his maiden speech. I am sure your Lordships will agree with me that it was a speech not only worthy of the occasion and a particularly well-thought-out speech based on experience, but one which will lead us to wish to hear the noble Lord on many subsequent occasions.
This debate on this great subject has been to all of us, I am sure, and to me in particular, of very great interest. I think we may claim that in the speeches which have been delivered a very high level has been maintained. We are dealing with a Bill which has aroused a great deal of controversy in another place and also outside both Houses of Parliament. The controversy, probably, has shifted from the 103 main principles and now in your Lordships' House it centres more on what one might still call great principles, but they are principles more of detail within the framework of the scheme. On the great principle of a comprehensive health service we all agree, but, of course, we are not agreed, and I do not suppose we ever shall be, as to whether a scheme of this comprehensive nature should be carried out by means of a form of nationalization or in accordance with the intentions of the National Government as set out in their White Paper. That is the difference that lies between us. The noble Earl, Lord Listowel, said that it was quite impossible to have a successful comprehensive scheme unless it was carried out in the way that the present Government intend. But I would suggest to him—and I have said this before in your Lordships' House—that we have a precedent for this in the Education Act, 1944, as the result of which the Church Schools were made an offer by the Government, and what you might call a "fifty-fifty" scheme was arranged and is now in operation. The noble Earl is not here at the moment, but I do not think that the answer which he gave was entirely complete and satisfactory.
However, on this matter of principle, whether it is to be nationalization or not, the issue has been fought out; the battle has been won and lost in another place. I do not intend to revive controversy on that question here, though I may think that the greater tidiness that may result under the present scheme will be in the place of greater efficiency and more personal service. The Bill comes to your Lordships' House with quite a number of concessions and I wish to pay my tribute of gratitude to His Majesty's Government for the granting of those concessions. I am thankful for them, but I am afraid my gratitude is tinged with a feeling that they do not go far enough, more especially in respect of the retention of local interest, about which your Lordships have heard a good deal in speeches which have already been made. On the question of whether it is or is not a physical possibility to balance so much control in the hands of the Minister while keeping alive the local enthusiasm that we have known in the past, I cannot help thinking that to endeavour to do so is to try to get the best of both worlds. I know that His Majesty's 104 Government have expressed their approval of the local interest to which I refer.
The Government are creating a Hospital Endowments Fund for receiving all the money that generous donors have given to their individual hospitals in the past. That is a pretty big pill for those concerned to swallow, and they have been trying to swallow it ever since it was introduced. Incidentally, before I pass on, may I say that I am not at all sure that what Lord Listowel said in answer to the noble Marquess, Lord Reading, was in fact a satisfactory reply to the question? I understood him to say that gifts given for a specific purpose would be used for the specific purpose of benefiting those who are sick, but not for the specific purpose which the donors might wish to commemorate. The noble Earl is not here at the moment but it may be that he will be dealing with this later.
As I have said, the Government have created a Hospital Endowments Fund and that is a big pill to swallow. They have also made the concession—and, of course, I am very grateful for it—whereby hospital management committees will be allowed to receive and administer money but not until after the date of the operation of the Act. Of course, I understand that the Minister wants to make quite sure of his great equalization trick. He wants to level things out, and when that has been done then by this concession people may give individually to hospitals again. But I would ask what is to happen in the interim period. At the moment people are showing a great deal of hesitancy in the matter of making subscriptions, and that is bound to continue. This state of hesitancy is increased in view of the Minister's assurance that hospitals in financial difficulties may appeal—and not in vain, I understand—to him for assistance. I do not minimize the concession that is being made there. But it is still very difficult to balance this up with the maintenance of an incentive to people to give money to hospitals.
May I put a query as to the interim period? Surely, it may well be longer than two years. How do we know when this measure will come into effective operation? After the interim period, whatever it may be, the Minister wants us to start again subscribing to individual hospitals, when he has got everything 105 tidied up. In this connexion, I would ask another question. Surely if we all start making individual subscriptions to hospitals again, may it not be that we shall make things untidy and unequal, and that it will then be possible there may have to be a further redistribution at a later date? I am just as anxious as the Minister is to see public contributions continue, and I, like him, pay my tribute to the wonderful generosity of people who in great or small amounts have contributed in the past. But I do not think that he is making things very easy by this initial taking away and the breaking of the continuity. I will pass over his unkind remarks about large contributors, merely asking how he expects to get large subscriptions in the future if he continues to insult those from whom he has expectations. Perhaps he does not wish for contributions in proportion to donors' means. I hope that a formula may be evolved for this interim period that will prevent people's generous habits being broken.
I think that the noble and learned Lord, the Lord Chancellor, spoke of voluntary contributions as "trimmings"—that is to say, something rather in the nature of chicken feed, in view of the fact that the Government are paying for these services. That, if I may say so with the greatest respect, thought to be a little unkind, for many millions of pounds have been subscribed in the past, and there is a possibility that there may be millions more subscribed in the future. I do not think the amount of these "trimmings" was quite so small as the Lord Chancellor seemed to suggest.
§ THE LORD CHANCELLOR (LORD JOWITT)
My Lords, will the noble Lord forgive me interrupting him? I feel sure that he has misunderstood me. I did not mean to be in the least unkind. As he has said, necessary expenses of hospitals are going to be met in the future from public funds. When I used the unhappy word "trimmings", I meant all those additional things which mean so much to the comfort of the patient and which will have to come from private funds.
§ LORD LUKE
I thank the noble and learned Lord for his explanation, and I apologize for having misunderstood him. I make an earnest appeal to His Majesty's Government to concede that the gifts in the interim period may be retained by the non-teaching hospitals.
106 I come now to the question of the powers of the non-teaching hospitals, as vested in the new management committees. There is a query that I want to make here: whether it is possible for management committees to manage their hospitals efficiently if in the first place they do not have control of the staff. And that is one of the things which has been vested in the Regional Boards. I think that it is most important that the staffs of hospitals should be responsible to the hospitals themselves, and not to the Regional Boards. Otherwise you are straightaway bringing in remote control and you have in your staff a divided loyalty—loyalty to the Regional Board, to whom they are responsible, and loyalty (of a little doubtful nature) to the management committee. I will not say any more on that aspect, but I very much hope that there may be an Amendment in that sphere.
With regard to the powers of the Regional Boards over the hospital management committees, we have heard from His Majesty's Government to-day of the assurance of the Minister that there will be no interference by the Regional Boards with the management committees. There is still no provision in the Bill to give effect to that assurance, however, and I feel that such a provision should be included. It seems to me that the balance of power between Regional Boards and the hospital management committees has not yet been worked out satisfactorily. Surely, if the initial appointments to these Regional Boards, and indeed, of the management committees, have been approved by the Minister, good people will have been put there, and I should have thought that the people operating this whole scheme on the ground, that is right down the management committees, ought to be trusted to carry out their duties properly, and ought to be given powers to do so.
I do not think that the cost of this new service has been mentioned in this debate. I will deal with it as shortly as possible. I understand that the net annual expenditure of the service will be of the nature of £95,000,000. I would ask whether that sum is for the existing beds and services as they stand, or whether it includes the additional beds necessary to provide adequate accommodation throughout the country. I would also ask whether we 107 may have some figures with regard to the capital cost of the new hospitals and health centres, for repairing the present hospitals and for extensions necessary to provide the additional number of beds required in the country—I understand, about 90,000. It has been estimated that the minimum cost of providing a bed is £1,500, and if 90,000 beds are required the cost would be £135,000,000. If the £95,000,000 which I mentioned at the beginning does not include the additional requirements, then the estimated further maintenance of new beds would cost an additional £25,000,000. I hope that your Lordships will forgive me for bringing in these millions of pounds, but it is just as well to look at the big figures when we are embarking on such a big scheme. The basis for my estimate is 7.6 beds per 1,000 of the population which, on the 1941 census, is equivalent to 315,000 beds. The existing provision is 225,000 beds. And then I ask, when will the extra beds be available? Are we to see them in 1948, 1949, 1950 or hereafter? And how are we to arrange the staffing for the extra accommodation? There is an existing shortage, as is well known to your Lordships. There may be beds aplenty, but will the patients get the attention to go with the beds?
I think that the Minister has had an easy and perhaps pleasant task in taking over the voluntary hospitals and all that goes with them. I believe that his task of operating the new service will not be quite so easy, especially with so much responsibility on his shoulders. The noble and learned Lord on the Woolsack compared the Minister to a Commander-in-Chief and, as Commander-in-Chief, giving the orders. A Commander-in-Chief, however, has a good many conferences and consultations with his staff and I think that he also takes their advice. We heard from the noble Lord, Lord Horder, yesterday that there was not a very great deal of consultation—I forget his exact words—between the Minister and the medical profession before entering upon this scheme. A Commander-in-Chief also relies on vital information from the smallest units in the field, and farms his plan accordingly.
The noble Earl, Lord Listowel, asked that there should be a generous attitude on the part of all of us towards the working of this scheme. I want to assure him 108 that I, shall make every effort to adopt such an attitude. I think that the hospitals themselves will take a pride in handing over a going concern and not—if I may quote the words of the noble and learned Lord on the Woolsack—just an "ancient monument." I think that they will be proud that what they hand over shall be the best example of what the voluntary system has done. That is the hospitals' point of view. I do not speak for all of them, but I believe and hope that that will be their attitude. I hope that the Minister will also take a kindly view, after the taking and the handing over.
The public have been led to expect something very big from the comprehensive service which will come into operation at some future date. They may not expect a miracle, but they have been led to expect something very good, something at any rate far and away better than the present system. I fervently hope that they are going to get it. They will get something some time, but it may take time. (I see that the noble Earl, the Postmaster-General, is back in his place). For my part, in my small capacity, I will do all I can to see that there are co-operation of all the elements and an attempt to forget past differences and, indeed, to improve what is good. May we see voluntary service still flourishing! I do not quite agree with the noble Lord, Lord Lyle, that it is entirely dead. Oh no! Even though we flag sellers may have to scrub floors, I am perfectly prepared; and I am not at all bad at that, anyway. I hope that we shall see this spirit of voluntary service going on, and that the service of the patient will be uppermost in all our minds.
§ 5.10 p.m.
§ LORD CHARNWOOD
My Lords, this is the first time I have addressed your Lordships, and I trust that you will accord me every indulgence. I cannot tell you how nervous I am. I came into your Lordships' House yesterday after lunch, a rather lukewarm supporter of the Bill, not as to its principle, but as to its terms as I read it. I want to thank the noble and learned Lord, the Lord Chancellor, and also the noble Earl, Lord Listowel, for having set my mind at rest on a great many points. They have turned me from a rather lukewarm supporter to a very warm supporter of the Bill. I thank them for what they 109 have given but, like Oliver Twist, I am going to ask for more. There are many things about which I should like to talk, for instance, the aged and chronic sick for whom the noble Lord, Lord Amulree, made so eloquent a plea yesterday, and the deaf whom I do not think anyone has yet mentioned. But I must keep to my own job. I should like to take a few minutes of your Lordships' time to tell you about my own job—I am an optician—and our place in the Bill.
Your Lordships probably mostly belong to the people who go to a medical ophthalmologist when you want spectacles, when as happens to most of us we get to the stage when a man says, "There is nothing wrong with my eyes, but my arm is too short." Most of my friends seem to think that that is the right, the obvious and even the only thing to do, and it comes as a surprise to a lot of them to learn that over 80 per cent. of the spectacle prescribing in this country is done by opticians—not for the fools who go to a chain store and choose their own spectacles, but for the sensible hard working middle-class man whose eyes are his most precious possession, and for which nothing but the best is good enough.
A lot of your Lordships think we are just shopkeepers who make and sell spectacles that another has prescribed. True, we mostly do practise in shops. They are a legacy from the old City guilds, and I do not think they call for any apology. In those shops opticians do sell, but, what is far more important, they fit the spectacles they prescribe. The language is rather obscure. There is only the word "optician" in. English. America has a separate word; optometrist is the American equivalent of the kind of optician I am talking about. The best ophthalmologists are very learned men, but they are woefully few. I should not like to hazard a guess at the number. When you get away from them there is a very big drop in quality. It is due to that that we exist. These few first-rate medical men must be used economically. Not having given any warning of this matter to the noble and learned Lord, the Lord Chancellor, I do not expect him to be able to say anything this evening with regard to it, but I hope that at a later stage he will be able to give us more reassurance on that point.
110 Your Lordships have got to remember what an enormous ground medical education covers, how much a doctor is called upon to know before he starts to specialize. The medical oculist specializes in his particular pathology. On top of this he is asked to be a phycisist as well as an optician, and he has not very much time left for sight testing. Some years ago an attempt was made to produce more oculists, and it failed. The public did not like them. We are still seeing some of their prescriptions in our own hospitals. I should like to tell your Lordships a little more about ourselves. Our training in sight testing—refraction is the technical term—takes three years. We finish at our own hospitals or clinics, and it includes the fullest training in the recognition of pathological cases which need, and are referred by us to, the services of the medical profession, whose members examine us on the subject. In our own hospital, where we are trained, the Government are at the moment paying us the fees for the ninth ex-Servicemen's rehabilitation course since the end of the war. We are already running refresher courses quite apart from our ex-Servicemen's courses. I think I can say that most of the improvements in the art of refraction of recent years have sprung from our hospital, the London Refraction Hospital, near the Elephant & Castle. It has been the mainspring for the introduction into this country of the non-operative treatment of squints. It is also, I think I can say, the last port of call for people whom we call grief cases, people who have nothing pathologically wrong with them but who suffer discomfort and disability from what might be termed mechanical errors of their eyes. I was trained at that hospital, and I now have the privilege of being on their voluntary staff, so that I can speak with some knowledge.
With regard to the Government's plan, the Minister's ideal is to have opticians working under the medical ophthalmologists at the specialist hospital. It is "at the specialist hospital" of which I am frightened. As an interim measure, as I understand it, the intention is that this work shall be done at the health centres, but the Minister has power to say that the health centre shall drop it and that the opticians shall go to the specialist hospitals. I beg the Government to consider very carefully whether the Minister 111 should not refrain from using that power. It is an extraordinary thing that many people with thoroughly poor sight have no idea that their vision is subnormal. Every Thursday I see at least three people who tell me that their distant vision is excellent. If you tell them they have got to go to the neighbouring university town to the specialist service, they will never go. They do not think there is anything wrong with their eyes. Suppose a child is suffering from a squint. If facilities are available for treatment on the doorstep the mother will take advantage of them; but if these facilities are not immediately available dear Auntie says, "The dear little thing, it will grow out of it." One in a thousand may. The other nine hundred and ninety-nine lose the sight of that eye. A squinting eye goes blind as a rule. I think that there is a real risk of the specialist service being too remote for people to take full advantage of it. Handiness is really essential or the scheme will not be used. If the service is remote the door is opened to quacks. Alas! so far we have no public register. We are not controlled, apart from the very considerable measure of control which, in the usual English makeshift way, we have imposed voluntarily on ourselves. Some of your Lordships may have received a circular from a dear old gentleman who has invented for himself and his family an institution where he confers the degree of "Doctor of Optometry" a degree invented by himself. I dare say there are others, but that is perhaps the most conspicuous case.
I hope that before long we shall hear from the Government that they will include in the Bill a definition of what our job is going to be—it is rather vague at present—and who is going to be competent to do it. We have, in the past, worked very happily with the medical profession. Over 70,000 of the employees of the Royal Ordnance factories were handled by our people, and I think I can say that, as a result, we have no warmer friends than the chief medical officers of the Ministry of Supply under whom we worked. Voluntary control is no longer good enough. I do hope we shall be given a definition of our place, and that we shall be promised an early Registration Bill. I also hope that we shall be told we are going to be represented on 112 the executive councils. Needless to say, whether we get this encouragement and assurance or not, we shall do our utmost to make the Bill, when it is an Act, work successfully.
§ 5.22 p.m.
THE EARL OF DONOUGHMORE
My Lords, we have enjoyed several very remarkable maiden speeches this evening, and I associate myself with all that has been said. I would like particularly to congratulate the noble Lord who has just sat down. He is obviously a specialist, and it is one of the great attractions, I always think, of your Lordships' House that we have specialists in so many walks of life. For that reason I have always been a shocking opponent of all friends who want to reform us: I think if we were reformed we should lose all our specialists. That is the polite word; they are generally known as backwoodsmen. Their services to the nation are very real, and they are there whenever they are wanted. I am sure your Lordships will welcome the noble Lord who has just sat down as one of those valuable people.
I support this Bill, and I note with pleasure that there has been no movement for its rejection. I thought, when I went away for the Recess, that that might be the case, but I think the Government are to be conaratulated upon the fact that, although Amendments are envisaged, there is not going to be any voting against the Bill on Second Reading. I support the Bill very warmly because I believe change is essential, and for a reason which I do not think has been mentioned in these debates at any time. We are all taught, when we are young, that fools rush in where angels fear to tread. Perhaps all your Lordships have been angels in this case, and I am unwise in saying what I think. But I do think that change is absolutely essential, because I do not believe the voluntary hospitals can go on paying their way. It is obvious that the medical service is going to be a much more expensive thing than it has been hitherto, and I believe the money to satisfy this service can only come from the State.
Times have changed. I have been connected with voluntary hospitals for over thirty years and it has not always been easy to collect money, but it was much easier thirty years ago than it is now. I am thinking now of one particular after- 113 noon. The hospital with which I was connected wanted a rather large sum of money. It was nothing compared to the thousands we had to deal with, but a particular sum was required to buy a new apparatus. I came down to your Lordships. We met in the good old days at 4.30 in the afternoon, and there was always a very pleasant quarter of an hour before we met. We generally adjourned at a quarter to five. I gave £5 myself and when I left your Lordships' House to go home I had got the sum of money that I wanted and the hospital benefited to that extent. I remember that at the particular time we were all in a bad temper because Income Tax had gone up from elevenpence to one shilling. Those days have gone, not only with regard to Income Tax but everything else. It is quite obvious that voluntary contributors cannot face the enormous increase that will be necessary in financing the hospitals of the country.
I am glad that stress has been laid on the fact that the voluntary hospital has not been called a voluntary hospital solely because it was supported by voluntary contributions. You went to a hospital board and you found there medical men, bankers, business men, lawyers, and all the professions represented; all giving their services to the sick for nothing. That has been a most valuable thing all through the community. I was glad that the noble Earl, Lord Listowel, referred to this and I hope that that will continue, but it is up to the Government of course, to encourage the people to co-operate with them in the good old way.
We are this evening considering a new constitution. It is a very far-reaching constitution, and many of your Lordships have dabbled in making new constitutions in the course of your political careers. There is nothing so fascinating, but I think there is one lesson one learns, and it is this—that a good constitution will not work if there is not good will behind it. A bad constitution will often work if there is good will behind it. Now, has this constitution enough good will behind it to carry it to a successful issue? I am thinking particularly of the good will of the medical profession. My noble friend Lord Munster does not think that that good will is overwhelming. The noble Marquess, Lord Reading, was more optimistic, but I do not know whether any of us know how many doctors are going to be behind 114 this thing. I feel very strongly, and it is one of my great anxieties, that unless the medical profession find it possible to support this Bill heart and soul it is bound to fail.
One other danger that I foresee—it has been referred to off and on in the course of this debate—is the danger of over-centralization. The noble Marquess, Lord Reading, stated that he had counted the clauses giving power to make regulations. I did not count them, but I got the impression that there is a tremendous number of clauses which give directive power to the Minister. I think his wants clarifying a little. I am for centralization every time when it comes to giving information, but I am against centralization every time when it comes to interference with the details of administration. The medical profession is one that is altering every day. New discoveries are made, and a central organization is in a position to broadcast the news of these discoveries. Doctors never keep secret about new discoveries; they are much too keen to make them available. In that the Ministry of Health has a great work before it, I believe, in letting everybody know what is going on. But I do hope there will not be too much direction in detailed matters of administration.
That is why I thank my noble friend Lord Moran for referring to a question I asked last April when the Ministry of Health advertised for some nursing inspectors. What are nursing inspectors wanted for by the Ministry of Health? Perhaps it is my fault and not the fault of the Ministry of Health that I do not know the answer to my question, because the Ministry of Health, unlike some other Departments, does not as a rule take six months to answer a letter. Possibly the matter has been explained, but I am a little nervous about it. I do not know if these ladies have been appointed. I heard with great pleasure the noble Earl, Lord Listowel, when he said that obviously he wants to see local administration not interfered with from the centre. It would ease my anxiety if I knew whether these ladies had been appointed and what they are going to do, because if inspectors are going down to individual hospitals over the head of the regional bodies, and they start tackling matrons as to the carrying out of their work, they will get a very lively reception.
115 I have been fortunate in my life in having to 'do with half a dozen matrons who are magnificent women, but the general belief, rightly or wrongly, is that matrons as a body are of a somewhat bellicose nature. If these ladies go down from the Ministry of Health and get into trouble with the matrons, they will get a very lively reception and will come home, if I may use a well-known phrase, with their tails between their legs. The fact that this public advertisement appeared did make us wonder what the Ministry of Health contemplated in this matter. If there are to be nursing inspectors, is that going to be carried further? Is there to be a great crowd of inspectors all located in Whitehall sent down on detailed matters to all parts of the Kingdom? If that is so, it can only undermine the authority of the regions and I am certain that will be detrimental to the treatment of the sick and the success of the scheme.
I noticed that the noble Earl, Lord Listowel, told us that the question has been asked: Can you tell us something about these regions? I take it that the map of England divided into regions is not yet ready, but I hope it soon will be and, above all, if we cannot be shown the map, cannot we be told a little about these regions, how many there are going to be and what their functions are to be? We might even be told where their headquarters are to be. We quite appreciate that they will be associated with a university. It is particularly unfortunate that we do not know more about this from the point of view of London. I have been concerned in some negotiations during this summer between four large hospitals, and we are discussing, without coming to any agreement (we are not authorized to do so) as to whether we can co-operate in certain ways—I will put it that way—and the answer has always been that we should like to. We have reached a lot of agreement where we think our staffs could help each other. We are, however, up against the problem at once as to what region we are going to be in. We have reason to believe that there are to be half a dozen regions in London and the country around, which I for one feel would be a sensible arrangement. But again, without binding the Government to boundaries, it would be a great help, it would help their scheme and help us in pre- 116 paring to work their scheme, if we knew a little more about what is proposed in this regional arrangement.
That is really all I desire to say, except for two very small points which I can mention in a few sentences. One is the finance of the region. In the finance of the region we understand there is to be a pool. I cannot help thinking that a regional financial pool is rather too big, and I suggest to noble Lords (but I do not ask them to give any pledge now) that it might be worth thinking out as to whether there might not be smaller pools—sub-regional pools. I believe they would work better. My last remark is in regard to memorials. It is not only the money of the memorials but it is the memorials themselves. Will they be kept? You can go into a number of hospital wards in which you see on the wall: "This bed was dedicated in memory of" so-and-so, or in memory of something. I quite see that a lot of the individuality of the hospitals will disappear, but I hope those memorials will be left where they were originally put.
§ THE EARL OF LISTOWEL
My Lords, I wonder if with the permission of the House I might reply to the question which the noble Earl has put. The answer is quite simple and it is in the affirmative.
THE EARL OF DONOUGHMORE
I am grateful to the noble Earl. That is all I have to say. I am looking forward to the Committee stage and I look forward to supporting any Amendment that I think will improve the scheme. I will vote for the Government and against any Amendment that I think is of a wrecking nature, and I hope that we shall have none of them when we tackle this matter next week.
§ 5.37 p.m.
§ LORD ADDINGTON
My Lords, I propose to speak in the interests of those whom this Bill is framed to benefit, for I am firmly convinced that people must come before plans and before administrative machinery. We have to regard those people as persons, and to take into account the whole of their circumstances, and not as cases with symptoms to be removed by medical or surgical treatment. It seems to me that the nation's health depends on three vital factors. There is the plan of the Government, there is the advice and 117 services of the medical profession and there is the way in which people live. They can be compared to three legs of a stool. The love, care and consideration which are so essential to healing cannot be exercised if there is friction between the doctors and the Government or between the doctors and the patients, and then the aims of the Government in this Bill will not be fulfilled; nor will they be fulfilled if the doctor is not free to follow his own conscience.
I, too, am one of those who are grateful that this great scheme has been introduced. Yet, as has been said, I also feel that in many ways it is far from perfect, and I hope that before the Bill leaves this House we will be able to make considerable improvements in it. Some of these are desired by the borough councils of England, for whom I speak, being a Vice-President of the Association of Municipal Corporations. The non-county boroughs view with distress and dismay the loss of their maternity, child welfare and other health services, and the county councils—of one of which I am also a member—the transfer of their hospitals to the Minister. One of the most striking and encouraging features of the war years was the way in which borough councils and other local authorities conceived and carried through the many extra services which the war necessitated—evacuation, billeting, A.R.P., food and fuel control and a great many other similar services. After an air raid or a similar disaster it was to the town hall or municipal offices that those who suffered came very willingly and very eagerly, and they there found a full, sympathetic and most efficient treatment. It is, therefore, to the local authorities that the people have come to look for their needs, and I think also for their needs in the sphere of public health.
We should like provision made to enable a county council to delegate some or all of its public health functions to the non-county boroughs in its areas which have performed this service very well and with great efficiency for a large number of years. We feel that the local health authorities should be able to nominate their own representatives upon the Regional Hospital Boards, hospital management committees and the boards of governors of the teaching hospitals. We also feel that we might have some representation upon the Central Council. 118 We feel, too, that in order that there may be some co-operation and co-ordination between the various branches of the health service, the Regional Hospital Boards and the executive councils should be under an obligation to draw up and submit to the Minister a scheme showing the methods by which they propose to carry out their functions. We also desire to see the hospitals continuing to pay local rates.
There are certain other technical points with which I need not trouble your Lordships at this stage or at this hour. They are points on which I think Amendments will be moved at a later stage and I trust the noble Lord in charge will meet us sympathetically upon them. They are all intended to ensure that those who conduct these health services on the spot should include representatives of the localities concerned and have real scope, real interest and real authority. They would then be able better to draw in the devoted voluntary service which has been of such real value in the past, not only to the patients in the hospitals and the clinics concerned but also, I believe, to the spirit of the community as a whole. Those are points to which the noble Lord, Lord Inman, referred yesterday and upon which the noble Earl, Lord Donough-more, touched this afternoon.
Now with regard to the voluntary hospitals. I live in a very rural area and I believe that those who live in such areas would really find it detrimental and bad always to be transported, say, 30 or 50 miles to get the most expert treatment. There are a great many fairly normal cases. We get maternity cases constantly coming up, as well as the ailments of children such as tonsils and adenoids. They would much prefer to be treated in the small hospitals in their own towns and by their own doctors, who have, very likely, known the families for a generation or two. They also want to be visited by their families and by their friends, and I believe that this visiting by friends and families plays quite an important part in the recovery of patients. The home atmosphere and the spirit of caring are, themselves as important as scientific efficiency. Interest and care are what people mainly want, and these are difficult to ensure if patients are removed from the areas in which they live and away from their own doctors.
119 I think this is particularly the case with the chronic invalids, who are usually old and their illnesses of long duration. The noble Lord, Lord Amulree, referred to them in a very eloquent speech to which I am sure your Lordships listened with very great interest. I think that some of these chronic cases might very well be given a few of the beds in these small hospitals in their own towns and that some of those hospitals might also be combined with the local health centres which the local authorities are going to set up. I would ask that these small hospitals should be continued and that there should be a house committee for each of them. I think we have had some assurance given with regard to that to-day. Many of them are 10 or 20 miles away from the next nearest hospital, and in these circumstances a committee for more than one hospital would certainly find it very difficult to work. Then we want those house committees to have real authority to decide those matters which come up from day to day. The matron should have real control over and personal interest in her staff, as the noble Lord, Lord Luke, has suggested. I trust that suitable financial arrangements will be made to enable these voluntary hospitals to carry on during the interim period with the support of their friends.
I believe that what is more important than this matter of machinery is the spirit in which this great plan is to be carried out, and that is a point which was touched upon by the noble Lord, Lord Beveridge. I believe that spirit can be drawn in part from the great traditions of the voluntary service of the past and in part from the spirit in which the war was fought and won—a spirit which, I am afraid, is dying down and which needs to be rekindled. I feel also that in these days of reconstruction we want something rather new, something far greater and deeper—the spirit of sacrifice, love and service to our suffering neighbours, which is the gift of God, which can only come from Him and which must work through a multitude of men and women who are determined to do what is right. I have seen that there is a growing body of such men and women of all types and in all places, including the medical and nursing professions, who are vitally concerned with the administration of this Bill.
120 Only in the last week of September the British Medical Association called together representatives of 31 different nations of the world and inaugurated a World Medical Association, the aim of which is to assist all the peoples of the world to a higher level of health. This was welcomed by the Minister of Health, who pointed out that there was in medicine a catholic interest in and dedication to the welfare of mankind—a concern for the individual, quite independently of his social creed or inheritance, his destination or his origin. The Minister also emphasized that the primary concern of doctors was not who was going to do a certain thing, but that the thing necessary should be done. That gives me very real encouragement, and that encouragement has been increased by some of the words which fell from the lips of the noble Earl, Lord Listowel, this afternoon. There is, however, a great deal to be done. I think the Government have still to win the confidence both of the public and of the medical profession and to show appreciation of that great profession and its services in the past. That again was touched on by the noble Earl, Lord Donoughmore, a few moments ago.
There are, even after the passing of this Bill, a great many important matters on which there have still to be discussions and points to be settled. I hope that if in them the Government show a greater care for the health of our people than for any political advantage or perhaps preconceived plans, the doctors in their turn will show that they care much more for the health of the people—the ordinary common folk of the land—than for financial advantage and some of their professional traditions. They can both combine and co-operate and usher in together a new era of hope and healing for the most suffering sections of the community, and also draw out from our people that spirit of love and service which will carry us triumphantly through these years of reconstruction.
§ 5.48 p.m.
§ LORD BALFOUR OF BURLEIGH
My Lords, my noble friend Lord Addington, in the early part of his speech, directed your Lordships' attention to the unfortunate results in the matter of local government which would follow from the provisions of this Bill with regard to the transfer of certain public health functions 121 from what are described as the minor local authorities to the major local authorities. That was a point which was touched upon by my noble friend Lord Munster, and also by the noble Marquess, Lord Reading. My noble friend Lord Listowel gave us the sketch of an answer. I may not have got it quite right, but I understood him to ask us to draw comfort from the fact that, while what we said was true, the major local authorities themselves would have greater powers. I am not quite sure that I am accurately representing his defence, but if that is what he said, it does not really afford me much comfort.
The real point to which I want to direct your Lordships' attention is the effect of this Bill in London, where the maternity and child welfare services are to be transferred from the Metropolitan boroughs to the L.C.C. This, some of you may say, is a Committee point, and it will be dealt with on the Committee stage, but I wish to let the Government know that I intend to put down an Amendment on the subject. I shall therefore not develop the argument now, but only say to your Lordships that I think we shall all be agreed that the one test by which such an Amendment must be judged is this: What will be the effect upon the quality of the services and upon the lives of the people who are concerned? That is the only test. That is the test which I shall ask you to bring to my Amendment. In the circumstances of the late hour and the long debate I do not propose to develop the argument now, but I will certainly put the Amendment down when we come to the Committee stage.
§ 5.52 p.m.
§ LORD LLEWELLIN
My Lords, many of your Lordships may think, after the large number of speeches we have had—and if I may be allowed to say so, having listened, to most of those speeches, it has been a very interesting and well-informed debate—that all that can be said on this subject has probably been said. Yet, listening as I did, I found that in quite a number of cases the noble Lord who was speaking approached this matter from the point of view of the doctor, or the local authority, whether large or small, or the voluntary hospital. In the few words I shall say I want to approach this from the point of view, and solely from the point of view, of the patient, because, after all, this is the real test: How will this measure affect the patient in his or 122 her home, in the new health clinics, in the out-patients' department or in the hospitals?
There are many doctors and the vast majority of them deserve very well of their country. Many people have done very good work on the boards and in other ways in connexion either with voluntary hospitals or those under local government. However, every person in this country will almost certainly have to call in a doctor one day if he does not do so now, and few will escape a period in hospital or nursing home, or whatever it may be. I speak therefore as a possible or perhaps a probable patient, and I may be addressing some who are patients at this moment. I would say in passing that at one period of my life there was just the slight chance that I might become a doctor. It was an extremely hot summer in 1912 and the smell of the dogfish whose nerve system I was trying to trace, and still more the smell of the hedgehog, the working of whose stomach I was trying to discover, made me, I regret to say, abandon that great profession for another walk of life. So it is as a patient only, or a possible patient, that I address your Lordships this evening.
Looking at the matter from the patient's point of view, it is common ground I think between all of us, that the time has come for a better, fuller and more closely integrated health service than we have had in the past. Had the Coalition Government continued, that would have been its policy. Had the Conservative Party been returned to power after the last Election that would undoubtedly have been its policy as well. We all shared to a certain extent in some of the preliminary investigations and inquiries that have gone on and helped to form the basis of this Bill. I must say that I did not quite follow the whole of the noble Earl, Lord Listowel's reference to the speech of my noble friend Lord Munster, because he said he wondered how those who were sitting on these Benches, having been a party to the 1944 White Paper, could have listened quietly to some of the things he said. I am paraphrasing the noble Earl. I think we can put that another way, too. I rather wonder how some of those who were, equally with our elves, committed to the 1944 White Paper are now those we see sponsoring the Bill before us. The noble and learned Lord, the Lord Chancellor, 123 is one who was more directly concerned with it than either I or the noble Earl, who were members of that Government.
At any rate, it is quite clear that all who were likely to be in the position of forming a Government after the Election were determined and pledged to take steps to improve our hospital services and our health services generally. The only question is therefore: Does this Bill lay the foundations for that task in the right and in the best possible way? In my view in some respects it does not. I will take first its probable effect on the medical profession. I take that first because the patient comes first to the doctor in the order of things before coming to the hospital. Now there is not the slightest doubt that the majority of doctors dislike being controlled—we all do. After all, we were born English or we were born Scots or we were born Welsh—
§ LORD LLEWELLIN
Or Irish—the last race in the world which likes control. At any rate, none of us were born Germans and they are the only people I know of who really seem to like being controlled. If that be so, if none of us like control, why should the doctors? Now I quite honestly feel that there was no need whatever to buy the doctors out of their practices. There was no need to spend £66,000,000 in doing so when, heaven knows, we are already pretty well saddled with a burden of debt on which we have to pay interest. We still want to go on with the great services we provide, and we could have well saved that £66,000,000 with, I believe, just as good a result. It is quite true that there were some parts of the country which were under-doctored, and it is quite true that something needed to be done to attract doctors to those parts. But that was a comparatively small problem, and why the Government did not try to deal with it on lines already very well known in this country, I really do not know. There is a scheme for the Highlands and Islands of Scotland which, by special inducement, gets doctors to serve in those parts where the patients are widely scattered and where the actual travelling takes a very large part of the doctor's time and energy. That provision which has been administered now for a number of years 124 has given special inducements to those doctors, and I believe something on those lines could have been done for these other areas where there has been difficulty in getting an adequate number of doctors.
That could have been worked at far less cost and without upsetting the medical profession in the way that it undoubtedly has by taking over the practices and paying for them as is being done. As it is, another method has been adopted and the doctors who enter this scheme are to be pretty completely controlled. They are to be told where they can work and where they cannot work. So far as I understand it, as the Bill is at present drawn, they are to be told whom they are to take into partnership with them. I think that that is one of the matters which we should try to amend. I think that there ought to be some sort of consultation before one has to take a person into partnership. I wonder what the noble and learned Lord, the Lord Chancellor, would have thought if some outside body had told him, when he was practising at the Bar, exactly where he could take a case and where he could not, and had also told him, when there was a vacancy in his Chambers, whom he had to take into his Chambers with him. That is the kind of thing which is going to be done in regard to doctors if this Bill goes through as it now stands.
What then is going to be the effect on the best men in the profession? What type of new entrant are we going to get in the future? These cases are rare, I know, but I have lately heard of three men in the medical profession, men who are destined to rise to considerable heights in that profession, who have decided that they will have more scope and freedom if they leave this country. Consequently, two of them are going to South Africa and one is going to the United States. They are doing that because they do not like this measure of control. It is true that they will be welcomed in those countries to which they are going. They will have more freedom and more scope. Medical science in the world will not be worse off. But surely, seeing that we are so short of doctors already, our first care should be to see that we do not do anything to drive people such as these away from this country.
I really believe, although some noble Lords opposite may think that I am over 125 stating my case, that there are a lot of people in this country who do not like these general new tendencies for the control of everything. If we go on in this kind of way this is what I am convinced will happen. One of our biggest exports from this country will consist of numbers of our best men. That is a thing which we can ill afford to see happening in view of the big losses in man-power which we have suffered in the recent war and in the one before it. What about the new entrants? I, for one, have little use for the man who, at the outset of his adult life, looks round for a safe job with a regular salary and who thinks to himself—to use the Army phrase—"If I keep my copy-book clean I shall have a pension at the end." These men are not the pioneers; they are not the men with active, striving minds, and they are not the men who rise to the top of their professions. I do not know but I rather fancy that, in the main, the new men who will come into this State medical service (which will, perhaps, rest to a considerable extent on a salary basis) will be men who are looking for safe jobs, and not the active progressive men whom we want to see engaged in a great science such as medicine. Coming back to where I started, as a patient I say: For goodness sake, when we are short of doctors already, do not let us do anything to drive some of them away; let us do everything to get the best possible recruits into the medical profession.
I have dealt with the case of the doctors, and I come now to the case of the hospitals. The noble Lord, Lord Inman, with whose good work in connexion with Charing Cross Hospital we are all acquainted, said yesterday that the voluntary hospitals were voluntary in two senses, and he was quite right. As he said, they were voluntary in the sense that they depended on voluntary contributions and voluntary because they depended upon voluntary services. There was a great deal too, if he will allow me to say so, in what my noble friend the Earl of Donoughmore said about voluntary hospitals. I am very glad to serve upon the board of one of them, with him as my chairman. In future, a very large part of the funds—if we are going to get this good medical service—will have to be provided by the State. But I believe that the hospitals could have been dealt with in a different way. I believe that, 126 as another noble Lord has said, what is to be done, in connexion with the general scheme, to equalize the voluntary hospital endowments is not worth while, in view of the difficulties which will be created. There is the difficulty, for instance, which may arise as the result of the breaking of a trust.
I believe that you would get considerable contributions still from some people if you kept the voluntary hospitals and let the State make up the grants. It could be done. The noble Lord, Lord Beveridge, has indicated a way. It could have been done by letting these institutions keep their entity, and by giving grants out of the Exchequer as you give them to the universities. When you give these universities grants you do not take away their ancient endowments; you do not alter their governing bodies. What you do is to say that a Ministry of Education inspector shall go round, and if the university is providing the kind of services that the Ministry of Education wishes it to provide, then it will get its grant. If it is not providing those services then it will not get its grant. Why not have dealt in that way with the voluntary hospitals? You would have your Regional Board who would get out a scheme in consultation with the voluntary hospitals, and say to one: "This is your part," and to another "That is your part." Having done that, you would say, "Now if you do this work you will get your grant so long as you continue to do it well." In that way you could have gone, on preserving all that was best in the voluntary hospital system, co-ordinating these institutions with the new schemes of the Regional Board, and, at the same time, seeing that they played the game—not that very many of them have failed to play the game; indeed, speaking generally they have always played the game very well. They could be depended upon to come into the scheme, to take their proper part and carry on their services well. That is the way in which I should have hoped these institutions would be dealt with.
The efforts which people have made to-subscribe to their voluntary hospitals have been a great feature of our national life. I am not referring now to the rich people only. I have a letter here, which I received this morning from somebody unknown. It has a very genuine ring. The 127 writer said that he has given £20,000 to a hospital in memory of his wife and on his death he intended to give the residue of his fortune. He say that he has now taken counsel's opinion, and finds that he cannot get back the £20,000. He is quite determined that the hospital shall not have the remainder, because he does not like paying money in aid of the Chancellor of the Exchequer who already gets quite a considerable sum from him by compulsory methods. I am talking mainly, however, about the ordinary small subscribers. Was it not St. Paul who said: "God loveth a cheerful giver." In the past, people have given cheerfully to their local hospital. I have never yet met the employer who looks very cheerful when he sticks a stamp on an insurance card, nor an employee who looks very cheerful when a share of his wages is deducted to help pay for that stamp.
These voluntary contributions, however small, give a man or woman a real interest in the local hospital. It is like the attraction, for me at any rate, in attending a horse race. I do not often go, but from time to time, when I do visit the racecourse, if I put a little money on a horse I do it because that horse, in my mind, definitely belongs to me. It is my horse for that race, and I get it extremely cheaply! In the same way, by giving this contribution to the local hospital, people feel that it is their hospital. That is a great thing. Hundreds of people have given their sixpences, and other quite small sums, and all of them feel a real interest in their hospital. It is sad to see all that going, and I think that we may have to see most of it go on the financial side. But, as has already been indicated, we shall put down some Amendments, to see that people may continue giving to a particular hospital, not merely after the appointed day but before it.
I now come to my second point, the question of voluntary service, on the other side of the twofold picture which the noble Lord, Lord Inman, gave us. It has been said by the noble Earl, Lord Listowel, and it was said by the noble Lord, Lord Inman, quoting the Minister of Health, that there would be an enlarged field for voluntary service in the voluntary hospitals—I have not the exact words. It does not seem so, from the way that this Bill is drafted. The 128 Bill vests everything in the Minister, who delegates a certain amount (as the noble Lord said that he must) to the Regional Boards. When you suggest that this voluntary service has its great field on the local management committees, for the life of me I fail to discover it. The committees cannot sue or be sued. None of their officers is their own. They are all officers of the Regional Board. What does not being able to sue, or be sued, mean? It means that you can order milk for the hospital from the milkman; you can order a tile to be put on the roof; but if you do not pay your bill the milkman cannot sue you, nor can the man who puts the tile on the hospital roof. As a result, the management committees will not really be managers of the hospitals.
During the Committee stage we shall attempt to see that these committees are put in the position in which they ought to be put—the position of being able to employ the general staff of the hospital. I am not saying that they should employ the specialist consultant staff, because these are better employed by the Regional Board; but I do think that the main general staff in the hospital ought to be in the employ of the hospital management committee if that committee (in the words of the noble Lord, Lord Moran) is to attract the right kind of people. I think that we ought to try to do that, so that in these localities people may still know that there is a real job to do, and not merely a kind of camouflage job without any real power behind it. That is one matter which I feel should claim your Lordships' attention, because as a patient I would like to see local men, and local women, whom I knew effectively engaged in the management of my local hospital.
Even if we give them more power it seems to me that one vital thing remains if we deal with the matter in the way proposed. It is this. So far as I can see from the lay-out of this scheme under the Bill, the Minister may be questioned, in either House of Parliament, on anything which happens in any hospital. That is a most frightfully hampering thing. A mistake is made, for example, in one hospital, and the officials of the Ministry—they have done it with us all—loyally try to keep the Minister out of difficult explanations to Parliament. But assume that a mistake is made; the 129 Minister has to get up in the House of Commons, and get out of it as best he can. Perhaps noble Lords will allow me to say how I once answered a question. I got out of it quite all right, although I do not think that my Department liked it very much. I told the right honourable gentleman who asked the question: "A mistake has been made, and is being rectified." The House of Commons absolutely gasped. It had not often happened before.
But if mistakes are made in a hospital an instruction will go out that nobody is to do things in this way or that in the future. The instruction will go to all Regional Boards and hospitals and I have a kind of feeling that unless we are very careful all the people there will be tied up by quantities of forms to fill in, quantities of instructions to read—and that is fatal—unless in some way we can manage this with a decentralized system which leaves effective decisions to the men on the spot. If the Minister eventually decides that one servant is not much good, give him power to sack that servant in the end. I hope, however, that we shall be able to avoid this complete hampering which works down from the top. If there is a mistake the Minister has to answer for it, so for heaven's sake do not do anything rash. Perhaps I should say that if you do not do anything rash in your life you will probably never do anything in life at all. I think if we had dealt with this in the other way we mentioned we should not have had the difficulty which I foresee.
I do not wish to detain your Lordships very long, but I should like to reinforce what the noble Lord, Lord Addington, said about hospitals particularly in the country localities. I hope that there will not be too rigid rules for those places. I quite agree that it is necessary to have a group of hospitals, and you cannot put the best appliances in every one of them. You do not want to. But there is the occasional case. Do not let us too lightly entirely close down the little country town hospital, into which a person goes perhaps for a minor operation. The patient can go into such a hospital and have the advantage of visits from his or her own doctor, as well as from relatives and friends, after their work, which they cannot possibly pay if the patient is taken to a town some distance from home. For the big and major operations and cases 130 requiring special treatment, by all means have the big town hospitals. That is to the advantage of the patient. But it is also to the advantage of the patient to be dealt with as quickly as possible, provided that he can get proper treatment at these small hospitals. So I hope that we shall not too quickly get rid of the small hospitals.
The right reverend Prelate who addressed us referred to what was going to happen to the Church hospitals and homes. I know that the Minister has power to except from this scheme certain hospitals which are not necessary to it. But I very much hope that some hospitals which have been built up by particular organizations for their members will be kept for those purposes. There is the Friends' Hospital which largely treats members of the Society of Friends. There is the one with which I am more concerned—namely, the Freemasons' Hospital, which I hope will be allowed to continue as a kind of nursing home for Freemasons and their dependants. That hospital does not lack for money. It could go on as a home and it would be a great pity if that were taken away from the Freemasons. I do not know whether the noble Lord, Lord Uvedale, whose maiden speech we were all delighted to hear, could say whether the Manor House Hospital should fall into the same category, or whether the hospital authorities are so much in love with this Bill which they are largely sponsoring, that they are ready for it to go into the scheme.
The noble Earl, Lord Donoughmore, coming back from Ireland, seemed to be rather surprised to find we were not going to divide, or that he had heard no indication that we were going to divide, on this Bill. For those for whom I am privileged to speak I can say that we are certainly not going to divide against the Second Reading of this Bill. When the Bill gets its Second Reading, however, we might suggest certain alterations in the Bill which might cause some controversy. Our aim will not be to put down wrecking Amendments, and I hope the Minister will not consider any of our Amendments to be of that character. They will not be intended that way. They will be intended to improve this measure to see that it works better from the point of view of the people who become ill, the people who are patients in the home, in the out-departments or in the great hospitals of this country.
§ 6.25 p.m.
§ THE LORD CHANCELLOR
My Lords, I think I can speak again only with the leave of the House, but I am sure your Lordships will give me that leave so long as I promise at this late hour not to occupy your attention for an undue period of time. I think this House has been at its very best in the last two days, and that is indeed high praise. In particular to-day, we have had a series of speeches to which it has been a real delight to listen. We have heard three of the best maiden speeches which it has been my lot to hear for many a long day. We have had the forthright views of the noble Lord, Lord Lyle, which I thoroughly enjoyed because I profoundly differ on almost every single thing he said. I am glad that he realizes now that it is not that my Party is fundamentally bad. It is really that they are slightly mad. Perhaps what is nowadays called moral insanity.
I do not want, if your Lordships will forgive me, to go through all the detailed points. Many of them are Committee points, but I will make these general observations. I know your Lordships well enough to be aware of the fact that when you say you are not going to move wrecking Amendments but are going to move Amendments to help this Bill, that that is so. I can only on my part promise you that the various Amendments which you move will receive careful consideration, but I am bound to say that very great care has already been taken in preparing this Bill. The Minister, as has been frankly recognized, has made very considerable concessions in another place, and although I say we will consider most carefully every Amendment put on the Paper, I do not want to lead your Lordships to suppose that we are in any way assenting to any particular Amendment.
Having said that, there are a few particular questions which I think I may discuss for a few moments. The noble Lord, Lord Lyle, referred to charity and seemed to think we had some ideological doctrine against charity. Although my Party do not claim to be the defenders of the Christian religion, we certainly do not want to re-write the Sermon on the Mount. I certainly hope that charity will always find its place in this country amongst all classes. Might I explain to the noble Lord that our objection is that services of 132 essential importance to the people of this country should, instead of being provided out of public funds, be left to the mercy of charity.
I may give an illustration of what I mean. Years ago I listened to a broadcast—"The Week's Good Cause"—by a noble Lord, a member of this House, who was speaking about a hospital in Belfast. He is a noble Lord who is always eloquent and he always very carefully verifies his facts. It must have been nearly ten years ago. I remember listening to that broadcast and I remember hearing from him that there were people in that city whose condition required their immediate admittance to a hospital—every day they were out of the hospital made the surgeon's task more and more difficult—who in many cases had been waiting for over a year. When I heard that quite frankly I buttoned up my pockets and thought to myself, "If that is so, it is a scandal, and it is no longer a matter for private charity at all, the State ought to step in and provide the requisite facilities."
Although I, like the noble Lord, Lord Uvedale, who made such a charming maiden speech, frankly look with sorrow at the passing of the voluntary system which has rendered such splendid service and has enlisted the support of many of your Lordships who have spoken to-day, I feel that the task which confronts us to-day is far too big to be dealt with on those lines. I feel it is a complete and absolute anachronism to contemplate that the vast job before us can be dealt with by means of charity and charitable contributions. I most profoundly hope that the voluntary services which have been rendered to a great cause in the past will go on. If they do not go on, if people are not sufficiently generous and do not want that outlet for emotion, everybody ought to feel then it would indeed be ill for our hospitals and an ill day for the character of our people. But the provision of the essential services of today are very different from the simple appliances of 30 or 40 years ago and so much more costly that I feel the State has got to come in and the great bulk of the money required for hospitals which we term voluntary hospitals must, in the future, come from public sources.
I turn next to the freedom for the doctor. Of course the success of this scheme 133 depends upon whether the doctors are willing to come in and give us of their best. I am sorry that some statement has been made which might lead doctors who do not follow these things very carefully to suppose that we are going to nationalize medicine, or that they are going to be enslaved. If it be a fact, as I believe it to be a fact, that doctors would very much dislike to become salaried civil servants, then it follows that if we were to propose any such scheme they would not come in. Therefore it is unlikely we shall propose any such thing. I announced in the plainest terms I could yesterday that we had no such intention. The Minister, whom I think you will agree does not lack courage, said in the roundest of terms, against some feeling in his own Party, that he was going to do no such thing. After all, if we were going to do any such thing, it would have to be done by means of regulation, and if a regulation did come before this House nationalizing medicine I presume your Lordship would have something to say about it. I really think that the fear we are going to have widespread interference with the freedom of the doctor or that the doctor is going to be enslaved, or anything of that sort, is a foolish thing which should certainly not be encouraged by responsible members of your Lordships' House.
There are three respects, and only three, in regard to which it is said we are enslaving the doctor. In the first place, the Minister has announced that he wants to have a power to pay a part, and I think he said a minor part, of his remuneration in the form of salary. Now does that bring about enslavement? Even supposing you were to pay the whole remuneration by way of salary, would that involve enslavement? The noble Lord, Lord Beveridge, pointed out the case of university professors. Are they enslaved? In my own case I deal with Judges. I take the very greatest of pains about the appointment of Judges. They are paid entirely by salary. Are they enslaved? Are they under the thumb of the State? On the contrary, I wish to goodness I could find time to bring in the Bill dealing with civil proceedings against the Crown so that I could put all the activities of the State under the Judges. So far as the County Court Judges are concerned, I certainly appoint them to a particular region—you could not go and set up as a Judge wherever you liked—and if I want 134 to I can remove them. But does anyone seriously suggest that the freedom of County Court Judges is interfered with? Salary, even if it is entirely salary, does not involve that you are a mere wretched—it seems to be the popular idea—civil servant. For my own part, I have the most profound regard for the men in the Civil Service.
Now the next point is this. We say that the new entrant entering the service after the appointed day cannot go and take up public practice—it only applies to public practice—wherever he likes. We say that in this case he must get the consent of the Medical Practitioners Committee. Is this enslaving doctors? If this Government are enslaving doctors by this, so were the Coalition Government, because this is precisely the proposal they made. The noble Lord, Lord Llewellin, says if you want to choose a partner you are going to have a partner put upon you. With the very greatest of respect to him, he has got much too accurate a mind to make a statement of that kind. All that happens is that if there is a partnership of three doctors, and one of them dies and the others want to get a new man, then it is quite true that the new man would have to get the consent of a panel of which six out of eight members are doctors. Do you not suppose that the most relevant fact that would be considered would be "Here is the man the other two want." It is surely foolish to disregard the fact that a partnership only works if the three partners are tolerably happy together. I can conceive that in 99 cases out of 100, unless there were exceptional circumstances, in a case of that sort the man who was wanted would get his way.
The third ground for his story of enslavement is that we prevent the selling of public practices, and provide £66,000,000. On that, I confess, I have not a very great knowledge, but what occurs to me is this. If you are dealing with a country practice, then patients in that area have really no choice of doctors. If a man, indulging in public practice, sells his practice, he is virtually selling his patients, and what he must consider in making up his mind whether to sell or not is not, primarily, how much money he gets out of it. But if he gets two men coming after his practice, one whom he thinks very, very suitable, but who can only pay him a very inadequate sum, 135 and one, perhaps rather less suitable, who is prepared to pay a larger sum, what is his reaction? For this reason we think that the selling of a practice by a man who is getting his remuneration, in part at any rate, from public funds, is no longer right.
Then an observation or two about decentralization. I do profoundly underline everything that has been said about the necessity for decentralization. Here you have got a chain, the Minister at the top, the Regional Board, the hospital management committee, and the house committee, and if before the hospital committee or the house committee can buy a pane of glass they have got to go all the way up the string, then the thing is absolutely impossible. Therefore, and the Minister has said this in the roundest and plainest of terms, this scheme will fail unless the Minister decentralizes on the largest possible scale. The noble Earl, Lord Donoughmore, gave us an illustration of an advertisement put out by the Ministry for nursing inspectors. I have not had the time to make complete inquiries about this matter, but I should like to answer him because he said he would not go away happy if he were not reassured on this point. So far as I have been able to ascertain, I believe these inspectors are not inspectors in the ordinary sense at all. They are not persons who go snooping about to see if there is something wrong. They go round to the matrons of various hospitals to try and help them in order to get staff. As your Lordships know, the difficulty with regard to staff is perfectly awful to-day, and anything we can do to relieve matrons of hospitals of the burden that they have in this respect, I am quite sure, would be most readily welcomed by your Lordships. So much for decentralization.
Now with regard to major and minor authorities. I am not going to say very much about this because the noble Lord, Lord Balfour of Burleigh, was good enough merely to indicate that he would discuss such a point, and the noble Lord, Lord Addington, did mention it. Both in this Government and in the last Government we gave very careful attention to this matter, and both Governments came to the same conclusion. We believe that the transfer of functions from the minor to the major local authorities is 136 essential, because in that way and in that way alone can you remove the overlapping and confusion caused by the present division of function between county and district councils in county areas. Secondly, now that we are starting to impose on the local authorities new services, set out in Part III, it is very desirable that we should impose those new services upon the shoulders of those authorities who are, generally speaking, more able to carry the burden. In a nutshell, that is the reason why we came to this conclusion about the transfer of functions, and although I shall listen most carefully to any argument on the point, it would not be fair to say that we have not already given a great deal of time and attention to this matter.
May I conclude with a few words about endowments? The noble Earl, Lord Munster, referred to this in rather severe terms. He seemed to think that I was the first Lord Chancellor who had offended in this way. Indeed, he said it was an immoral transaction and wondered whether any previous occupant of this great office had ever so blotted his copybook. I am afraid I have not had very much time to make investigations, but I do remember in the last Government an Act entitled "An Act to make provision for promoting economy and efficiency in the carrying-on of the work of public schools and certain other schools." By that Act, in view of the fact that schools were in difficulty, we allowed an Order in Council to be made in which we might take away the endowments given for a particular purpose and, without the consent of the trustees, use it for another and different purpose. Money given for scholarships could be taken away and used for building a new chapel, if you like; and not only the income but the capital. My noble predecessor introduced that Bill, and the only opposition came from the noble Lord, Lord Quickswood, who said that it was robbing the safe. But the noble Earl, Lord Munster, made no protest. Amongst others who spoke in favour of the noble and learned Lord Chancellor of that day was the noble Viscount, Lord Maugham, so that he at least is also an accessory before the fact, and I like to think that if I stand in the dock for my misdeeds over this thing the dock must be large enough to embrace both the noble Viscount, Lord Simon, and the noble Viscount, Lord Maugham.
137 Of course I agree that it is only in the most exceptional circumstances that one should divert or interfere with either the income or the corpus of money impressed with a trust. But if you are considering the enormity of my offence, please consider this. If I am accused of taking sixpence out of the till, remember that when I do that I am putting a shilling on the counter, because I am giving from public funds far more than I am taking. There is not one single hospital in this country to-day that can carry out its full activities merely by reliance on the interest it gets from its investments. If it could not get current subscriptions or could not charge its patients in the hospital for what was done for them it could not possibly carry on. What is the real point here? Every single one of these hospitals will be paid sums in excess of those which are being taken away. It is quite true, as the noble Lord, Lord Llewellin, said, that this could have been done very easily in a way which would have prevented anybody from saying that the Government was guilty of any breach of trust.
Just consider an actual case which I had to consider not long ago, relating to the scholarship fund for a university. There were five boys who were going to a university for four years. The minimum expense at which it could be done was £200. One of those boys whose parents had died had got one of those educational endowments and for four years he was entitled to receive £100. The other four had nothing. What could we have done? We could very easily have said (perhaps we ought to have said) that the boy who had got £100 should only receive £100 whilst the others should receive the full £200. We could have done that quite easily. If we had applied that principle in this Bill we should have taken account of the income of the hospital by diminishing proportionately the amount of the public grant. No one could have then said that we were guilty of any sort of breach of trust.
To go back to my boys, you could have given that boy only £100 and the other four this minimum of £200, or you could have done this: you could have given all five of them £200 and taken away the £100 and distributed it amongst the lot of them, giving them £20 each, and each of the boys would have £220. There is no breach 138 of trust there. So with the hospitals I think there should be an equalization, but I think it is very important that the hospitals should have some money over and above that which they get out of public funds, some pocket money which they could turn to in an emergency if they had some little expense coming along which they wanted to deal with at once. That is why I ask your Lordships to say that our scheme is the right one. Do not regard these various endowments as limiting the amount of public money that you give. Do not, that is to say, give less to a rich hospital than you do to a poor one. Deal with the thing the other way: take away the various endowments and distribute them by regulation amongst the Regional Board or the hospitals management committee.
May I clear up one misapprehension as to the Bill as it stands at the present time? Endowments, whether they are endowments for a particular purpose or just generally for the purpose of the hospital, all pass under the provisions of Clause 7 (9) to the Minister, but, having passed notionally, there comes the question of re-allocation, and that has to be done by regulation. I apprehend that one of the factors which the Minister would plainly consider in re-allocating the funds is whether a particular request was obviously for some local purpose or something of that sort. Obviously that might be treated on quite a different basis to the request which was quite general. Therefore the machinery of the Bill involves in the first instance a transfer of all these things, but in deciding as to which goes back to who, whether the whole thing is spread over the whole range of hospitals is a matter which is dealt with by regulation, and in making those regulations the Minister must obviously consider those facts. That is the position.
I am sorry that I have been so long. I have tried to deal with some of the more salient features. I am grateful for the help and assistance which your Lordships have given, and I can promise you that we shall look most carefully and closely at all the Amendments to see whether we can accept any of them as improving our view of what the Bill should be.
§ On Question, Bill read 2a, and committed to a Committee of the Whole House.