Lords Sitting of 1 May 1947

Preamble
The House met at four of the clock, The LORD CHANCELLOR on the Woolsack.
Prayers.

  BUSINESS OF THE HOUSE.
  4.5 P.m.
  LORD AMMON: My Lords, the noble and learned Viscount on the Woolsack has kindly informed me that, owing to the heavy demands on the time of the judicial Committee of the Privy Council, after the present week there will be no judicial sittings of your Lordships' House, in the afternoon at any rate, until after the Whitsuntide recess, and that till then, therefore, the Chamber will be available at 2.30 p.m. for the sittings of the House for public business on Mondays and Thursdays, in the same way as it now is on Tuesday and Wednesday. I felt sure that your Lordships would be glad to take this opportunity of earlier sittings on these days, and I am arranging, therefore, with the agreement of the usual channels, that between now and the Whit-sun recess all sittings of your Lordships' House for public business shall begin at 2.30 in the afternoon unless special notice to the contrary is given.
  I should add that we do not propose to sit next Monday, May 5, but that we shall be sitting on the following Monday, May 12, when we shall hope to take the Committee stage of the National Health Service (Scotland) Bill whose Second Reading we are debating to-day. Will noble Lords from Scotland, in particular, please make special note, therefore, that the business that afternoon will begin at 2.30 p.m. and not at the usual Monday hour of 4 o'clock?

  SUNDAY ENTERTAINMENTS ACT, 1932.
  CITY OF BATH ORDER,
  COUNTY BOROUGH OF EASTBOURNE ORDER,
  BOROUGH OF BOSTON ORDER,
  BOROUGH OF RYDE ORDER.
  LORD WALKDEN: My Lords, I beg to move that these Orders be approved.
  Moved, That the Orders made under the Act by the Secretary of State for the Home Department, for extending section one of the Act to the said areas, be approved.—(Lord Walkden.)
  On Question, Motion agreed to.

  NATIONAL HEALTH SERVICE (SCOTLAND) BILL.
  4.7 p.m.
  Order of the Day for the Second Reading read.
  LORD MORRISON: My Lords, last autumn there came before your Lordships the National Health Service Bill to establish a new and comprehensive health service in England and Wales. To-day it falls to me to move the Second Reading of a Bill providing for the establishment of a similar service in Scotland. In that connexion I am happy to see on the front Opposition Bench the noble Earl, Lord Rosebery, former Secretary of State for Scotland, because it gives me an opportunity of congratulating him upon a welcome success near Cambridge University this afternoon.
  In another place one of the right honourable gentlemen from Scotland who spoke for the Opposition said:
  "I think there is general agreement … that the time has come for a great expansion of the health services of Scotland."
  So do I, and most of the discussion on the present Bill therefore revolves around the ways of achieving an objective about which itself there is little or no dispute—a comprehensive health service making every kind of health provision available for every member of the community. In the discussions that took place on the English Bill much light was thrown upon the deficiencies in the existing health services of this country. I do not propose to-day, therefore, to take up your Lordships' time with any extensive review of the existing services. The case for an overhaul of Scotland's health services is very similar to the case in England. Indeed, the inquiries of the Scottish Health Services Committee which reported in 1936 brought out, perhaps more fully and more clearly than any comparable English inquiry, the gaps in the health provision of that time. The existing facilities, indeed, consist of a number of separate services, each developed at different times

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  to meet what appeared to be the pressing need of the moment, without much attention being paid to fitting them into their proper place in a comprehensive system.
  The original formulation of the Government's national health service proposals was undertaken, not in 'relation to England alone or to Scotland alone, but on a United Kingdom basis. The Minister of Health and the Secretary of State for Scotland worked together in this matter and had joint consultations with representatives of the medical profession and of other important interests affected. I say this because I do not wish your Lordships to think that the present Bill originated as a transcript of a bill devised for England and Wales with some minor changes here and there. The position is that the two Bills have a common origin, which accounts for their many similarities, and it is a mere matter of Parliamentary and legislative convenience that the Scottish Bill comes second in point of time.
  The divergences between the two Bills reflect important differences between conditions south of the Border and conditions in Scotland. Scotland has her own legal system, her own traditions and her own machinery of local government; and the geographical distribution of her population is different. It is necessary, therefore, to adjust the application of general principles so as to suit Scotland's particular circumstances and needs. It is to these points in the present Bill that I shall devote most, of my time to-day. The patient in search of advice and care in health matters normally turns first to his own family doctor. Yet at the present time less than half our population can seek the aid of a general practitioner under any organized arrangements without first having to stop and count the cost. For the rest, and this includes the vast majority of wives and children, the family doctor's services are a matter of private arrangement, for which the patient has to pay.
  Under this Bill everyone will be entitled to the services of a; family doctor of his own choosing, without any question of payment by the patient otherwise than through the rates, taxes and insurance contributions he normally pays. That is, of course, the financial basis of the whole of the new service; not merely of the family doctor part. As the family doctor service is to be available for everybody,
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  and in all parts of the country there must be a means for securing that the distribution of doctors is not so uneven that some areas get a much poorer service than is generally provided. The Bill does this by abolishing the system of sale and purchase of medical practices, and setting up instead a mainly medical body—the Scottish Medical Practices Committee—with power to forbid a doctor to enter practice in the public service in an area where there are already sufficient doctors. And the system of remuneration proposed by the Government is to include a basic salary element which can be varied so as to attract doctors to areas where their services are most needed.
  Such an arrangement closely resembles the system that has been in operation in the Highlands and islands of Scotland for the last thirty years, under which grants of varying amounts are paid directly from State funds to general practitioners who would not otherwise be able to obtain a reasonable income owing to the sparsely populated nature of the area and the relative poverty of most of its inhabitants. The Government believe, therefore, that the proposals in this Bill will make it possible to provide the service that is promised—and to do this without conferring any power to direct individual doctors to work in particular localities or particular jobs.
  In the past the family doctor has had to provide out of his own resources the premises and equipment needed for his work. There is general agreement today that, if the family doctor is to do the best work of which he is capable, the conditions under which he works will have to be radically improved. In the last generation or so there has been a trend away from the individual doctor working in isolation towards the partnership system, where two, three or more doctors work in a loosely organized kind of team, helping one another in various ways. It is along these lines that the Government seek to foster the development of general practice. Not only will doctors be encouraged to work in groups, but they will be provided with premises designed for the purpose, with all the equipment and ancillary staff necessary to enable them to carry on their work under the most favourable conditions. These premises are the health centres of the future, to the development of which

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  the Government attach very great importance.
  It is here that we find the first important difference between the Scottish and the English proposals. In England the function of providing health centres is entrusted to the local authorities, working subject to the approval of the Minister of Health. In Scotland the Bill places the responsibility for providing health centres directly upon the Secretary of State. While at the same time it authorizes him to delegate his functions in this respect to local authorities, he has made it clear that he does not intend to do so in the early and experimental years of the new service. In Scotland, where conditions in different local authority areas vary so widely, and the country as a whole is not unmanageable as a single unit of administration, the Secretary of State thinks that the lessons of the early years in the development of health centres can best be learned and generally applied if he retains the task in his own hands, at least for that period. The Scottish local authorities have not intimated any serious objection to this course, and the medical profession in Scotland, I understand, prefer that it should be so.
  Alongside the family doctor service of the future there are arrangements for dental care. In the past the number of dentists available has been pretty well sufficient for the treatment of all who sought dental attention. As was emphasized, however, by the Committee which recently considered the subject, under the chairmanship of the noble Lord, Lord Teviot, it by no means follows that there are enough dentists to give all the dental treatment that people require—if they can be persuaded to seek it! The Government, however, have accepted the course urged upon them by that Committee, to make a free dental service generally available, in the expectation that demand for dental treatment and recruitment to the dental profession will proceed hand-in-hand. At the same time, supplementary measures—to which I shall refer in a moment—are proposed to secure that those sections of the community in special need of dental care do not have to go without it as a result of any shortage of dentists that may arise.
  Responsibility for the local administration of the family doctor service and the general dental service, with the necessary
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  arrangements for providing drugs and medicines, will be entrusted to executive councils, composed as to one half of professional representatives, nominated by the professions in the locality, and, as to the other half, of non-professional members, of whom two-thirds will be nominated by the local authorities in the area and the remaining third appointed directly by the Secretary of State.
  The second main division in which the new service is organized includes the maternity and child welfare clinics, and other local services which can suitably be administered by the major local authorities—the councils of counties and large burghs. In carrying out part of these duties the local authorities will provide dental attention, supplementary to the general dental service, for expectant and nursing mothers. The school health service, run by the local authorities in their capacity as education authorities, will provide dental as well as other forms of health care for the children, including all up to the age of eighteen in attendance at junior colleges under the 1945 Scottish Education Act. Thus we complete our implementation of the Teviot Committee's recommendations on dentistry.
  It is true that the transfer of hospitals from the local authority field will diminish the direct interest of local authorities and their medical officers of health in the treatment of disease. The most important health function of the authorities in future, however, lies in the social and preventive side of health work. Responsible already for watching over the incidence of disease, especially infectious disease, in their areas, the authorities will find that the new powers and duties entrusted to them open up the way for great advances in the expanding field devoted to the prevention of disease and the promotion of health in community life.
  I turn next to the future organization of the hospital and specialist services. Before going any further may I add my tribute to the splendid work which the voluntary hospitals in Scotland, as elsewhere, have done in the past? Voluntary effort in this, as in so many other fields, has blazed the trail and paved the way to progress. But costs in all directions have greatly increased and are still increasing. With any form of national health service the hospitals would have to be paid for their treatment of patients

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  coming within the service. These payments would bulk increasingly large in the revenue of the voluntary hospitals, and the State could not go on handing over such large sums without having a very large measure of control over their spending.
  The Scottish local authorities too, especially some of the larger ones, have an excellent record in the hospital field. Almost all the hospital accommodation for infectious disease is at present administered by these authorities, as also is the bulk of accommodation for tuberculosis and for mental illness. But the time has passed when this division of responsibility for hospital services among a multiplicity of agencies can be contemplated with equanimity. In Scotland to-day there are about 250 hospitals belonging to the fifty-five local authorities; and about another 220 voluntary hospitals, nearly every one of which has a separate governing body. Thus there are more than 250 hospital authorities all with their own interests and ideas, leading to overlapping, unnecessary competition and, worst of all, to gaps in the service provided for the patient.
  For the future, we start with general agreement that the individual hospitals of to-day need to be welded together into a single hospital service, organized on a regional basis. Instead of having several hospitals in the same district attempting to provide the same kinds of specialized treatment, we must arrange that the provision for any particular kind of specialized treatment is concentrated at a relatively small number of units in each region. Only thus can we secure that the best use is made of complicated and expensive equipment and—what is more important—of the limited number of experts fully trained and experienced in each particular field, and that all patients needing a particular kind of specialized treatment get that treatment in the hospital best staffed and equipped to give it.
  It is clear that existing local authorities could not be entrusted with responsibility for running the new hospital service, for their areas are not nearly big enough for this purpose. Joint boards are generally an unsatisfactory device. The provision of a directly elected body, operating over a wider area, is not a step that could be taken without prejudicing any reorganization of local government that may become necessary. The remaining alternative, if
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  the new hospital service is to fit into our democratic scheme of government, is that the duty of providing it should be placed upon a Minister responsible to Parliament. In Scotland the obvious Minister is the Secretary of State, who is already very much concerned with health matters. The Government's proposal, therefore, is that all existing hospitals, both local authority and voluntary, should be transferred to the Secretary of State.
  The administration of the new service is not, however, to be centralized in a Government office in Edinburgh. Instead, administration is to be entrusted to a specially created local and regional organization. Regional Hospital Boards are to be established to act as agents of the Secretary of State, undertaking on his behalf the general administration of the hospital service in their regions. In turn, to act as agents of the Regional Board for the control and management of particular hospitals or groups of hospitals, boards of management are to be set up. It is the Secretary of State's firm intention that these Regional Boards and boards of management, each in their own sphere, should have the maximum possible freedom in the carrying out of their work, consistent with his overall responsibility to Parliament for the service. On these Regional Boards and boards of management members with all appropriate kinds of experience and local knowledge will find a place.
  The Secretary of State contemplates that five Regional Boards will be set up in Scotland. Each Board will be based on one of the five main centres—Edinburgh, Glasgow, Dundee, Aberdeen and Inverness. The precise boundaries of the areas covered by each Board are not determined by the Bill itself but will be settled by subsequent Orders, subject to annulment by either House of Parliament, made after consultation with the local authorities, and other interests concerned in Scotland. Preliminary consultations to this end are already under way. The grouping of hospitals under boards of management will be settled by the Regional Boards themselves, in schemes which they will submit for the approval of the Secretary of State. While it will usually be found an advantage to group two or more existing hospitals under single board of management, this cannot be done at the expense of losing local interest by setting up a board to run a number of hospitals

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  which do not form a geographically convenient unit.
  There are three important points in which the hospital organization proposed for Scotland in the present Bill differs from the form adopted in the English Bill. The first point is that in Scotland the ambulance service—like the hospital service, in association with which it will be run—is made a responsibility of the Secretary of State, and not of the local authorities (as in England and Wales). On the average, local authorities in Scotland have smaller areas than in England and Wales, and a very large number of ambulance journeys would involve crossing local authority boundaries. The next main difference concerns the provision of clinical teaching facilities in hospitals. Your Lordships will recall that in England certain hospitals are to be designated by the Minister of Health as teaching hospitals, and that special boards of governors for these teaching hospitals are to be appointed, responsible directly to the Minister. While these boards of governors will include members nominated by the Regional Board for the area, the teaching hospitals for which they are responsible do not come directly within the hospital service administered by the Regional Board.
  In Scotland, on the other hand, we propose that all the hospitals should come within the field of the Regional Board, but that the special position of hospitals in which clinical teaching is carried on should be recognized by the inclusion on their boards of management of members nominated by the university concerned, and by the teaching staff. The fundamental reason for this difference is that, although the, number of hospital beds in Scotland is only about one-tenth of the total for the United Kingdom, Scotland is training about one-third of the total number of medical students. We are proud in Scotland of our standing in the field of medical education. If our standards are to be maintained, student and teacher must in future have access to an ever-wider range of practical experience and demonstration in the hospitals. This cannot be achieved if the bulk of the clinical teaching facilities are confined to a few hospitals. On the other hand, if even the main teaching hospitals were to be excluded from the scope of the Regional Boards in Scotland, these Boards would
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  be left with quite inadequate provision at their disposal to enable them to organize a regional system. Indeed, the core of the hospital service would have gone.
  The Scottish Bill places a specific duty on the Secretary of State to provide facilities in the hospital service for the teaching of medicine. Responsibility for the conduct of teaching will, of course, continue to rest with the universities, who for this reason are given a very special position in the proposed hospital organization. In settling the grouping of hospitals for the purpose of constituting boards of management, the Regional Board are required to consult the university concerned. As already mentioned, the universities nominate members to the boards of management responsible for running any hospitals in which teaching facilities are provided. In addition, they nominate members to a medical education committee, which is set up in each region for the purpose of advising the Regional Board on the administration of the hospital service so far as relates to the provision of teaching facilities. The Regional Boards themselves are to include members appointed by the Secretary of State after consulting the university concerned. Provision is also to be made, in regulations governing the appointment of members of hospital staffs, for the universities to play an appropriate part in the selection of doctors who are to participate in teaching work.
  These proposals were worked out by the Secretary of State in consultaion with representatives of the Scottish universities, and he thinks the universities are reasonably confident that the provisions of the Bill will enable them to discharge their teaching responsibilities. It is also interesting to observe that while in another place the critics of this Bill objected at first to its proposals for teaching hospitals, after a full discussion on the Committee stage, no Amendments on this issue were put down for consideration on Report, nor was it mentioned in the reasoned Amendment for rejection of the Bill on Third Reading.
  There is one more important difference between the hospital service proposals in Scotland and those in England. I refer to the treatment of voluntary hospital endowments. In both countries the fundamental principle is the same. Endowment assets, subject perhaps to the discharge out of them of certain existing liabi-

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  lities, are to be made available for application by the regional and local bodies, at their discretion, for purposes connected with the hospital service. This money will, therefore, represent additional resources over and above the money provided from the Treasury, and its spending will not be subject to ministerial control. The method of allocating existing endowments to the new governing bodies, however, is entirely different in the two countries. In England the endowments of hospitals designated as teaching hospitals pass to the new boards of governors appointed by the Minister. The endowments of all other voluntary hospitals are put into a single. national pool and re-distributed by the Minister, on a, basis to be fixed in later regulations, among the Regional Boards and hospital management committees.
  In Scotland the Secretary of State has preferred to follow the plan adopted not long ago for educational endowments, when the extension of publicly provided services to wider fields made it necessary to review the purposes to which these endowments could be put under their existing trusts—as will be the position exactly, when the new hospital service is in operation, of endowments left in the past for hospital purposes. The Bill proposes a Hospital Endowments Commission, which will be charged with the duty of reviewing all existing endowments and deciding how and by which Regional Boards or boards of management they can most appropriately be applied in future. In carrying out their work the Commission are required by the Bill to have regard first of all to the spirit of the intention of the founder; so that they will have to address themselves to the question of how the founder might have been expected to allocate his benefaction had he foreseen the organization of the hospital service in the future.
  The powers of the Endowments Commission do not extend to two classes of endowments. The first class is endowments given after the appointed day, which Regional Boards and boards of management are authorized by the Bill to accept and hold on trust for purposes connected with their functions. The second is certain endowments of a capital nature given between November 5, 1946 —the date on which the Bill was introduced into Parliament—and the appointed day; these endowments will be transferred under the Bill to the board of
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  management set up for the hospital to which they have been given, and will remain permanently with that Board. All other endowments, I should mention, will be transferred on the appointed day to the new boards of management of the hospitals to which they are at present attached, and will remain with these boards for use subject to the provisions of any existing trusts until such time as the Endowments Commission are able to undertake their review of these particular endowments.
  I cannot conclude without a brief reference to the central administrative machinery proposed. It is to be the duty of the Secretary of State—I quote Clause I of the Bill—
  "to promote the establishment in Scotland of a comprehensive health service designed to secure improvement in the physical and mental health of the people of Scotland and the prevention, diagnosis And treatment of illness, and for that purpose to provide or secure the effective provision of services in accordance with the following provisions of this Act."
  In his discharge of this duty the Secretary of State will be answerable to Parliament in the usual way. The Bill sets up a Scottish Health Services Council, and enables standing advisory committees on particular services also to be constituted. These bodies will include among them persons with all the necessary knowledge and experience to provide the Secretary of State with the expert advice on every aspect of the health services of which he will stand in need, and they will be empowered to proffer that advice on their own initiative as well as at his request.
  My Lords, I hope I have not wearied you in this account of the Bill now before the House. It is, however, a major Bill of great importance to Scotland and her people, and while I have not attempted to cover every aspect of the subject I have tried to touch upon the main points likely to be of interest to your Lordships. I beg to move.
  Moved, that the Bill be now read 2a.—(Lord Morrison.)
  4.35 p.m.
  THE EAEL OF ROSEEERY: My Lords, I should like to thank the noble Lord, Lord Morrison, for the clear way in which he has expounded this Bill. I observed at the start of his speech that he said that it was quite fortuitous that the English Bill came before the Scottish Bill.

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  It may be quite fortuitous, but that has now become almost a habit. I do not think it would be a bad plan if occasionally we had before the House a Scottish Bill before the English Bill, because we would not be told what we are so often told—namely, that we cannot alter a particular clause because it has been agreed in the English Bill. If we could persuade Parliament to alter a clause in a Scottish Bill, possibly, as a result of listening to or reading our debates, English members would accept that Amendment. At any rate, we would have the Amendment considered with an open mind, knowing that the whole thing had not been pre-judged in London before it had ever been thought of in Scotland.
  As I see it, there are at least five principal differences between the Scottish and English Bills. First of all, endowments of voluntary hospitals in Scotland will at first remain with the hospitals and will be reviewed later and, if necessary, re-allocated by the Hospital Endowments Commission. Secondly, teaching hospitals are not to be separated from the rest of the hospital services as they are south of the border. I will, if I may, deal with those two matters later. Thirdly, in Scotland the responsibility for the health centre development is placed directly in the hands of the Secretary of State. He has power to delegate, although we are told it is most improbable that he will. In other words, he will keep that power and make substantial use of it.
  I do not see—and a number of people in Scotland do not see—why the local authorities should have this power taken away from them and put under the authority of the Secretary of State for Scotland. This Government have been far too fond of diverting all power and authority from the local authorities and taking it to St. Andrew's House. Indeed we are lucky if it only stops there, because most of the power is now going from St. Andrew's House to London. I think that under this Bill the Secretary of State for Scotland is taking on himself far more power than is necessary. He is now responsible for the ambulance services. There may be a case argued for that, but the ambulance services have heretofore been conducted quite well by the local authorities. I am not talking of the air ambulance service, responsibility for which I think has always been vested in the Secretary
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  of State and which, of course, is a different scheme from any other.
  There is one difference between Scotland and England about which I am glad —namely, that there will be no ex officio officers of the Scottish Health Services Council. I do not care for ex officio officers on those Councils, and I am glad that the Government have agreed that in Scotland we are not to have them. I should like to call attention to the change that is being made with regard to teaching hospitals. These hospitals are now to be taken under the ægis of the Secretary 'of State. We think that this Bill goes a long way (and out of its way) to destroy not only their independence but also their prestige. In dealing with the English Bill, Mr. Bevan said:
  "The transfer of the hospitals to the Ministry will not make St. Thomas's Hospital any less St. Thomas's; 'Bart's. any less Bart's. or Guy's any less Guy's."
  He allowed each of them to appoint their own doctors, nurses and other staff. That staff belongs to the hospital and is appointed by the hospital, and there is naturally, if I may say so, that esprit de corps which we know so well exists in the various hospitals in London.
  But in Scotland the staffs are to be nominated by the Regional Board. It is the Regional Board who nominate the staff, and the staffs are, as I understand it, responsible to the Regional Board. I think that is, I would almost say, an un-necessary degradation, of the governors of those hospitals. It is, of course, the way they are going to administer the other hospitals, but it seems to me clearly ridiculous that our great teaching hospitals in Scotland should be administered in exactly the same way as a small cottage hospital in the outlying Highlands. In England, as I understand it, the board of governors are in direct contact with the Minister, and directly responsible to him. In Scotland the board of management are to be appointed by the Regional Board, and will be answerable to them. I think I am correct in saying that. In England, as I said before, the teaching hospitals settle the conditions of their servants as well as appointing them; but in Scotland these conditions also will be entirely settled by the Regional Board. I hope the noble Lord will relent in some way, so that the staffs may be directly under the hospital management and not under the Regional Board.

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  Let me now say a few words on the question of endowments, which are dealt with in Clause 8. In England, as your Lordships know, the endowments are left to the control of the teaching hospitals, and grants are given directly by the Minister. In Scotland these endowments may be re-allocated anywhere else. I would ask noble Lords to realize why these endowments are given to particular hospitals. They are given by someone who lives in the particular locality, to ensure that that hospital will be properly maintained for himself, for his relatives and for his friends. There is another reason why endowments are given or left to hospitals —namely, that someone has had a serious illness and has been well nursed in that hospital; or that his dear ones who have been taken ill have been nursed, perhaps to health, or may be until the final end. In gratitude to that hospital, and to the doctors and nurses who have looked after those patients, he has given or bequeathed a certain sum of money.
  If the donors are still alive, what can their feelings be when they realize that the money which they have given to a, hospital in some district, say in the Lothians, is to be taken away at the whim or wish of the Secretary of State for Scotland to support some pet scheme of his in the Highlands or elsewhere? When people have endowed teaching hospitals, the endowments should be allowed to stay with those hospitals. It does seem, on the face of it, that the real reason why the secretary of State has gathered these teaching hospitals into his maw is to' get a grasp on the endowments which go to them so that he can put them elsewhere. If the Government want more money for some of the smaller hospitals they should give a grant out of Government funds, and leave the endowments where they are.
  I would ask your Lordships to turn now to Clause 35, which deals with the distribution of medical practitioners. The noble Lord told us that one of the objects of this Bill is to introduce clauses which will help in regard to legal matters where those matters differ in Scotland as compared with England. In my view, this is a clause which is necessary only in the case of England; it is totally unnecessary in, regard to Scotland and should never be
  in the Scottish Whatever the case may be for direction (or "negative control," as Mr. Bevan termed it) in England
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  and Wales, there is no such case in Scotland. In England and Wales the ratio of doctors to population is I to 971, and in Scotland it is I to 902. In general practitioners only, in England and Wales it is I to 2,296, and in Scotland I to 2,032. I have seen—no doubt the noble Lord has them in his possession—the details for the whole of Scotland and, so far as I can make out, there is only one place in Scotland which might be called a "black spot," and that is Greenock. Surely we do not want a whole clause for Greenock, which has, I believe, a ratio of about to 3,000, or just over.
  In England there are, I know, a number of places where the ratio is very high. It goes up to I in over 4,000 in South Shields. If it is necessary for this clause to be in the English Bill to get the proper distribution, I have nothing to say against that; but I do say it is entirely unnecessary to have it in this Scottish Bill. In actual fact, if you make the service free, it will surely attract doctors to the heavy centres of population, because so long as their remuneration is mainly by way of capitation fee the highest rewards will obviously follow the largest practices. I hope the noble Lord Will listen to me with a sympathetic ear on this clause, because it is not necessary in the case of Scotland, and there is no need to have it.
  I want to mention Clause 36, to which I may say I take great exception. It is a complicated clause, and its aim is to prohibit the sale of goodwill by any medical practitioner whose name is on the list as having entered the public service either on the appointed day or any time thereafter. He is liable to a criminal charge, for which the penalty can be three months' imprisonment, if he does any of the things mentioned in this clause. There are subsections in the clause dealing with the sale of premises, partnership, assistantship transactions, and other matters, under which in certain circumstances a doctor is- deemed to be making a sale of goodwill to another doctor. He may be doing this in quite an innocent manner, but find that he has contravened this clause and become liable to be sentenced to prison. We know very well that there are thousands upon thousands of things nowadays which people can do without knowing that they are doing wrong, because no one in Great Britain has any idea what most of these regulations are—not all of them, at any rate. I see no reason why

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  a clause should be put in to make a further one which is totally unnecessary.
  I would particularly emphasize the outrageousness of the restriction on the sale of his house by a doctor to another doctor. It is impossible for anybody to know if the price is excessive, as it is always a matter of opinion what premises are worth; and it would be quite impossible for a doctor to sell his house in safety by auction, as he would not then be able to go to the Scottish Medical Practices Committee for a certificate, as is required under subsection (9) of this clause. The clause as drafted is practically unintelligible to the ordinary layman, yet it imposes new crimes on doctors who will not have, what I believe is called the mens rea—that is, the guilty mind—which, according to our law, is necessary to convict in nearly every conceivable crime on our Statute Book.
  I will not go any further into this complicated clause, but there are certainly half a dozen ways in which an innocent medical practitioner may find that, in the opinion of the court, he has committed a breach of one of the subsections of this clause. Of course, the clause is intended to prevent evasion, but may catch perfectly innocent people, as' a doctor may be held to be selling goodwill by some more or less unintelligible subsection, and thus, although he may not have dreamt of selling his practice, he may be deemed to have done so. I hope the noble Lord opposite will go once more into this clause and see if he cannot in some way alter it to make it fairer to the medical practitioner.
  Then there is Clause 43, by which an executive council, or any other person, can report to a tribunal that they consider that the name of a doctor, dentist, chemist, ophthalmic surgeon or optician should not be retained on the lists prepared under this Bill. The first stage is the complaint and the decision of the tribunal, and that tribunal is of a quasi-judicial character, the composition of which, on the whole, is satisfactory. If the tribunal has not acquitted the person before then, as the Bill stands at present, he may appeal to the Secretary of State for Scotland. We do not think it fair that the appeal should be to the Secretary of State for Scotland in a matter which intimately concerns his own official responsibility. I would like
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  to see substituted for "The Secretary of State for Scotland" the words "The Court of Session," which would be a much fairer procedure than taking the matter up direct to the Secretary of State.
  I will turn to the general dental services of Clause 45. We very much desire that there should be a possibility of a system of grant-in-aid for better dentistry. As the Bill stands, there is provision for only a uniform standard of dentistry, and dentists feel (to quote one of their own publications) that this will result in "utility" dentistry throughout the scheme. In France, which I think has a Socialist Government strongly in power, they have a scheme of this kind, and I understand that it works very well. The noble Lord shakes his head, but I believe they do.
  LORD MORRISON: I did not want the noble Earl to think that I accepted the belief that they had a strong Socialist Government.
  THE EARL OF ROSEBERY: Perhaps it has not a strong Government at all, but whatever it is I think it is Socialist, although I may be quite wrong. However, if we cannot learn from France we can at least pay attention to what the dentists feel so strongly.
  LORD CALVERLEY: We feel it more than the dentists.
  THE EARL OF ROSEBERY: We think it would be for the benefit of the people, and also of the dentists. If they are to have only the same standard of work the people who would benefit would be the least conscientious type of dentist. There will be nothing to induce the better dentist to provide better accommodation and even more recent copies of Punch, because if he does that sort of thing he will be losing money, since his remuneration will be no more than that of a "utility" dentist who works in shabby surroundings, without any papers for the people who are waiting. This principle of bringing professional men down to a low average standard runs right through the Bill, and is one of the reasons why we think it should be amended so much. It has been said repeatedly elsewhere that there are not enough dentists in this country to work the scheme; but that I do not believe. Estimates have been made of the numbers available who do little more

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  than provide treatment for such priority classes as nursing and expectant mothers, and so on. The idea seems to be that it you make dentistry cheaper you will have more people going to the dentist. Who has ever heard of anybody going to the dentists, even in Scotland, because they found it was cheaper to do so than before? People go to the dentist because they have toothache, and the number of people who are going to have toothache because it is cheaper will not be increased, even north of the border. That is why I believe we have a sufficient number of dentists under this scheme. I am sorry to have detained your Lordships for this length of time but, as the noble Lord has said, this is a most important Bill, and I personally dissent strongly from some of the principal clauses of it.
  4.58 p.m.
  THE EARL OF SELKIRK: My Lords, I should like to thank the noble Lord, Lord Morrison, for his very clear exposition of the Bill and to say how much I enjoyed listening to him. I am speaking to-day in this House not as an expert, on the subject but as one who must necessarily be interested in a Bill which covers so many aspects of every man's life. I was very glad to hear the noble Lord say he is satisfied that this Bill, although it had a common origin somewhere in London, is none the less a Bill to solve Scots' problems and that it is not the application of an English Bill to Scotland. I am glad he agrees with that, because otherwise I should have said that the Scottish Office were becoming Anglicized. It is a great pity that a big, bold, grandiose measure, supported by lavish expenditure such as this, affecting so many people, should not have been welcomed wholeheartedly by those immediately concerned. It has not been welcomed wholeheartedly by the medical profession, and it has not been welcomed by the local authorities or by a great many of the boards of governors of hospitals. I will give you the figures of the voting which took place in Scotland on this subject. Among those who voted—and rather over 8o per cent. voted,—55 per cent. voted against coming into the scheme, and 45 per cent. were in favour of it. I cannot help feeling that in so big and so wide a scheme it should have been possible in the beginning to have en-
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  listed the enthusiastic support of the great body of people who arc immediately concerned with operating the scheme.
  This Bill contains Imo elements Which are fairly common to a great many of the Bills which have come before us. The first is the creation of new crimes, and the second is the centralization of power in one point. About a century ago there were a number of reformers, such as Mackintosh and Romilly, who took great pride in taking crimes off the Statute Book, but to-day our reformers seem more proud of putting them on. In this year of 1947 I wonder how many new crimes have been created which, ten or twenty years ago, we would have thought quite impossible. I will go further, and ask how many of your Lordships could put your hand on your heart and say that in this year you have committed no crime? I think very few of us. The effect of this Bill is to create crimes among the most deserving of people in our community, to whom we all owe a very great deal indeed.
  I will mention one thing about the particular crime which is created here, the crime of selling your practice. It is set up with the intention of making it easy for new men to get going at an early date—a purpose which I am sure will receive great sympathy in all quarters. But are the Government quite sure that that will be the object it achieves? In this respect I will ask one question only and will be glad to have a specific reply. As the Bill is at present drafted is it or is it not legal for the widow of a general practitioner to sell her late husband's house by public roup? The practitioner puts his house up to auction, he sees the price getting higher and higher and recognizes that as the price goes higher so will his fine get larger and larger and his period in prison longer and longer. You can imagine the anxiety that he feels about it. It really is a most unreasonable burden. The second point is the centralization at power. We must, I think, recognize the courage of the Secretary of State in accepting such heavy responsibilities as he does. He has to set up something like fifty boards and committees and appoint a chairman of each and a varying number of its members, amounting in all to at least 300 appointments. Now that, is a formidable task for anyone; but for one whose plate is already overflowing it is an impossible task.

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  I wonder whether it is fully realized that the Secretary of State for Scotland's duties are in fact more difficult, by reason of their variety, than those of the Minister of Health for England. During the Second Reading of the English Bill the noble Marquess, Lord Reading, made a comment on the powers which had to be exercised by the Minister of Health and he doubted whether housing and health could be dealt with by one Minister. He said:
  "Can any one man be expected without imminent danger of collapse or undue procrastination to give vitally necessary decisions on both these great subjects?"
  If I may, I will read a passage from the Report of the Committee on Scottish Administration dated 1937, describing the duties of the Secretary of State. It states:
  "Broadly speaking, he exercises so far as Scotland is concerned, all the functions which in England and Wales are discharged by the Home Secretary, by the Minister of Agriculture and Fisheries and by the Minister of Health, some by the Minister of Labour and the Lord Chancellor."
  to which of course must be added the Minister of Town and Country Planning. And it goes on to say:
  "Even apart from his multifarious duties there is a wide undefined area in which he is expected to be a mouthpiece of Scottish opinion in the Cabinet and elsewhere."
  I could only say that it appears to me that the added duties are such as he cannot personally carry out and that the duty of appointment is not one which can ever be satisfactorily carried out by delegation. That is why I suggest that the system of centralized appointment, of Regional Boards, executive committees and the other multifarious organizations which have to be raised is wrong in principle. I would add that we have recently had many notable examples of the effect which increasing power has on the character and, in that well known phrase, of its corrupting influence. One cannot help wondering how the great genius of the people can find its true expression when almost the only avenue to the responsibility lies in getting known to the Scottish office. Supposing the Secretary of State did not believe in orthodox medicine. Supposing he belonged to that body—for whom I have the greatest personal respect—the Christian Scientists. What then? Are we to have a new form of test to ensure that the Secretary of State is orthodox in his
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  methods, or is he going to be allowed to choose as he pleases?
  I admit there have been weaknesses. There were too few beds, and not enough co-ordination. So far as beds are concerned, I would much rather have seen the £7,500,000 which is to be paid in compensation expended with a view to building new hospitals. So far as co-ordination is concerned, there was never any reluctance on the part of voluntary hospitals who had, in fact, requested it.
  Turning for one moment to local authorities, I may point out that they have had their hospitals for very nearly twenty years. It seems very unsatisfactory that the better they did their job the worse they were paid for it. In other words, if they did a lot they got very little, and if they did very little they got a lot. If a local authority spent its rates on building a hospital it is now being taken over, without compensation, by the central Government. If, on the other hand, the authority did not spend its rates on building a hospital the ratepayers are so much better off. It is clear that the less money they spent, the better they arc treated by the central authority; and the more money they expended on social services, the worse off the ratepayers will be. This necessarily undermines the independence of the local authorities, who are, in fact, pawns in the game.
  This new system is not based on the report of any authoritative Committee; indeed, the reverse is the case, for just ten years ago the Scottish Health Services Report, to which the noble Lord, Lord Morrison, referred, gave as the second of its main conclusions and recommendations the following:
  "It is in the interest of the State to foster the voluntary hospital system, but it would be unwise to endeavour to induce the voluntary hospitals to extend their financial commitments much further than at present."
  In the bare space of ten years the Secretary of State has gone through a complete 180 degrees turn, and he now wants to terminate absolutely the voluntary hospital service. I feel we require some explanation of this complete change of view.
  I should like now to say a word about endowments. Although the system which has been adopted in Scotland is greatly superior to that in England, it is a pity to spoil the ship for what is no more than a penn'orth of tar. The Govern-

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  ment have set up a system which could be excellent, but they have spoilt it by subordinating the whole organization to the alteration and change of the Secretary of State, and in any case anticipate its termination within five years. Thereafter the endowment falls to the sole discretion of the Secretary of State. I found a happy comparison of this arrangement made in another place by a keen supporter of this Bill. It was so good that I would like to repeat it. Dr. Morgan compared it to the despoliation of the monasteries by King Henry VIII— a most admirable comparison. But I suppose there are few historians who do not agree that this was one of the greatest lost opportunities in the history of this country.
  At the same time, the Secretary of State is, I think very ingenuously, asking for further endowments and promising that he will not do this sort of thing again. Unless we can strengthen and safeguard the re-allocation of endowments there is not a hope that any further endowments for health services remotely connected with State service will ever be provided.
  Now I have a further point that I wish to make in support of what the noble Earl has said, and that is with regard to the teaching hospitals. I can only say that in my view the position in this respect is profoundly unsatisfactory. It is generally recognized. I think, that a regional system of hospitalization in Scotland is inevitable, but you could not have a regional scheme, for instance, particularly for the South-East, without including the Royal Infirmary, Edinburgh, the largest voluntary hospital in the British Isles. It is vitally important that the position of the teaching staffs should be safeguarded, and at the present time it is not. To me, it seemed that the noble Lord used very half-hearted phraseology in this respect. He said that the Secretary of State was reasonably confident that the universities were satisfied. I should say that the universities are profoundly anxious about the situation as a whole. They see no chance of ensuring that they will be able to appoint the teaching personnel which are necessary on their staff. They do not even know if they can appoint their own professors of surgery. We have a great tradition in teaching in Scotland and that must be maintained.
  Now I want to turn to the General Board of Control. The noble Lord did not mention them, but as they affect
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  something like 25,000 people who are inmates of these hospitals I think the omission was regrettable. The part of the Bill which deals with this matter is most unnecessarily abbreviated. It cannot by any stretch of imagination be said to disclose a comprehensive service. It tells one practically nothing. I want to know what is going to be the future position of the Board of Control. Are its members to continue to hold Royal Commissions? What is their position going to be in relation to the Department of Health? Are they going to retain independent status and will they retain their powers with respect to the liberty of the subject? Will the reports of the Commissioners be available not only for the General Board but also for the hospital boards and the Regional Boards to see? One further question which I wish to put relates to the boarding out of defectives. According to the terms of the Bill it appears that when a defective is boarded out the charge moves from the Exchequer to the local authority. Does that mean that in deciding whether a defective should be boarded out or not financial considerations will have weight? Will they enter into consideration in this regard? Is the boarding out to be done entirely on medical grounds or will financial reasons influence the decision?
  I would now like briefly to refer to the matter of dentists, particularly with the object of ascertaining what the future of the dental profession in Scotland is to be. I understand that the dentist will have the right to sell his practice, but he gets no compensation. What is his future to be? Is it the intention of His Majesty's Government that dentists should be full-time salaried civil servants, with fixed fees for different tasks and regulated methods of treatment? If that is the case, it is quite useless to expect first-class men to enter the dental profession in the future. In due course, no doubt, the health centres will come into existence and treatment by dentists will, at some time, he included in their scope. But by that time there will not be in the profession the able men who might otherwise have been attracted to it by the prospect of a successful professional career. The best men, under those conditions, will not enter the profession.
  Finally, I would say that this Bill contains in a blue print what can be a

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  magnificent service, but it has a number of weaknesses which cause grave anxiety. The greatest of its weaknesses, to my mind, is that throughout there appears to be an underlying desire to move to-wards standardization. I think that the Under-Secretary of State said in Committee: "We have to accept a standard." Once you have a standard, then you are moving against the principle of evolution which, for its development, depends on infinite variation. This variation will and can only come through the initiative and ideas of individuals acting in a sphere unfettered by any consideration but improvement of scientific method. It is only by infinite variation on this basis that you will get progress and development. The success or otherwise of this system will depend entirely on whoever works it. I should like to feel that the Secretary of State had a little more confidence in those who will run it for him. If he had shown more confidence, I feel that this Bill, embodying as it does projects of such a grandiose nature, would have received a warmer welcome from those best qualified to form a judgment.
  5.16 p.m.
  THE DUKE OF MONTROSE: My Lords, I am very glad to have the opportunity of saying a few words on the occasion of the Second Reading of this Bill in your Lordships' House. I do not propose to travel over the same ground of criticism which has been so ably covered by the noble Earl, Lord Rosebery, and the noble Earl, Lord Selkirk. But I have little doubt that when this Bill goes into the Committee stage, as political lapidaries we shall be able to put a little polish on what is, so to speak, a rough pebble at the moment. There is one thing about the Bill that distresses me. I listened very carefully to the full explanatory statement which was made by the noble Lord, Lord Morrison, in moving the Second Reading of the Bill. I think that, having regard to the speech he made, the Bill was shown to be a first-class example of a comprehensive national effort to produce a measure of this kind.
  I believe that I heard the noble Lord mention in detail the work that was intended to be done for various afflictions. I think I heard him speak of blind people, of dentistry, of pharmaceutical services,
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  and so forth, but I did not-hear one single word about deafness. It is always the same old story, when services to deal with the afflictions of the people are considered —the deaf are by-passed and completely forgotten. The matters which I have just mentioned are referred to in many places in the Bill. If you take the supplementary services dealt with in Clauses 39 to 43, you find that blindness has 55 lines devoted to it, dentistry has 35 lines and pharmaceutical services get 46 lines. But in the whole Bill—not merely in those few clauses—deafness is referred to only once, and that in half a line. Can anybody call that fair? If you can deal with all the eyes which need treatment, the bad teeth, and the bad tummies in the country, you ought to be able to do something for bad ears. You ought to be able to put some service in this connexion fully and definitely into the Bill.
  When the Bill relating to England was before this House my noble friend, Viscount Cecil of Chelwood, who I regret is not in his place to-day, made the very same complaint which I have just made and tried to move some Amendment to meet the lack of reference of deafness. He was moving it in Part IV of the Bill, and the noble Earl, Lord Listowel, who spoke for the Government, expressed great sympathy for the object the noble Viscount had in mind and assured him that the Bill would cover the affliction of deafness. The noble Earl further said, however, that it would have been much better if the Amendment had been moved in Part II of the Bill—that was the proper place for it. As this Bill which we are now considering is based fundamentally on the English Bill, I propose when it goes into Committee to take the noble Earl's advice, and in Part II of the Bill I shall bring up an Amendment very like the one put forward by the noble Viscount, Lord Cecil.
  I know what will happen. I shall be given full sympathy for the deaf, sympathy for which I shall be very grateful, and then I shall be given full assurances that this Bill will cover the deaf, even though they are not mentioned. There is a good old Scottish saying:
  "The best laid schemes of mice and men gang aft agley."
  They do "gang aft agley," and assurances are not always fulfilled. Just before I came into the House, I heard a Minister of the Government make a

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  speech, and he referred to assurances. I will not mention his name because I do not wish to inconvenience all my noble friends opposite, but he is what we call in the Service a "V.I.P." This is what he said:
  "I endorse the view that no one should depend on a Minister's statement when we are dealing with a Bill that will become an Act of Parliament. I have listened to assurances for many years, and I now take no notice of them."
  That was said by a V.I.P. on the Government benches.
  We deaf people do not want to be included in the Bill because of sympathy or because of assurances. We want to be in the Bill by the same legislative right that has been given to blind people, people with bad teeth, and people with bad insides. We want to be in this Bill in black and white; we want to see it printed here. I am speaking not for myself, but for the deaf people who feel they have been very seriously slighted, and we want to get rid of that feeling. We want to have clinics set up in different parts of the country where deaf people can be treated.
  What happens to-day? First of all, I should say that most of the deaf people are working people. A far greater proportion of working people than the rich are deaf. They suffer and then they go to a doctor because the preservation of their hearing enables them to keep their jobs. If they lose their hearing, they may lose their jobs, and their homes, so it is vitally important to them. The doctor looks at the patient and says, "Yes, you want an aural aid; it will save your health and if will save your hearing. It will also prevent you from worrying." The patient then asks the doctor, "What sort of aid, and where can I get one?" The doctor tells him, "I cannot tell you because I am not an expert in aids, but there is a man down the street who will sell you one." So the wretched working man goes down the street to the man who sells the aid. The man puts him up against a wall, fits him with an aid, steps back three or four paces, and says, "One, two, three, four. Do you hear me? "The wretched man says he does, so the deaf aid man goes back another three or four steps and repeats the performance. If the patient says "Yes," the deaf aid man goes still further back, and finally says, "Well, there you are.
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  There is the aid for you. You hear perfectly, and I was speaking with my ordinary voice all the time." But the man was shouting. When the wretched working man patient goes back to his home (after paying twenty-five to thirty guineas for his aid) he finds he cannot hear anything. He cannot take the aid on trial, and he has to pay for it. That is the way these poor deaf people are exploited, and I have received hundreds of letters emphasizing that point.
  There are 400,000 deaf people registered as being deaf, and most of them are anxious to preserve their livings and their homes. I implore the Government to put in a proper clause dealing with the deaf, and I hope the noble Lord, Lord Morrison, will seriously consider it. I do not know why the Secretary of State should be annoyed with me for my persistence in this matter. I am not asking the Government to alter a single principle in the Bill. I am trying to help the Secretary of State to make it a good Bill by bringing in 400,000 people to support it. I ask the noble Lord to consider this matter carefully between now and the Report stage, because if he does, and if these people are included, it will make the Bill much more popular with a very large circle of people.
  5.25 p.m.
  LORD TWEEDSMUIR: My Lords, I am much obliged to the noble Lord, Lord Morrison, for his brief but very clear explanation of this Bill. He quoted some words from Clause 1 of the Bill, that it was
  "designed to secure an improvement in the mental and physical health of the people of Scotland."
  That is an aim with which we can identify ourselves unreservedly, but we on this side wonder whether this measure is the instrument to bring it about. We have doubts, because good intentions and good results are not necessarily co-extensive, and very often a great gulf exists between them. The noble Lord assured us that the Scottish Bill was not merely an amended copy of the English Bill, but rather one that has been built from its foundation to cater for the needs of Scotland. Of course, conditions in England and Scotland are very different on many vital points, but there is a remarkable similarity between the two Bills in almost every important principle.

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  This Bill is, I think, a sincere attempt at the improvement of the medical services of Scotland. It is a ponderous document of eighty clauses, and eleven schedules, involving a large expenditure of public money, and a prodigious expenditure of the time of those concerned. It would have been appropriate had Scotland's medical service been a notable and deplorable failure, but, on the contrary, the medical services of Scotland can stand comparison with the medical services of any country in the world. It is our duty to seek to improve when we can, but, at the same time, it is important to remember that one is liable in one's enthusiasm to lose the substance for the form.
  In the minute or so I have left I will address myself to Clause 35. It is a clause with which the noble Earl, Lord Rosebery, dealt at some length. It deals with the distribution of medical practitioners. The principal argument for the English Bill was that there were too few medical practitioners in ratio to the numbers of the public, and, few as they were, they were unevenly distributed. My noble friend the Earl of Selkirk pointed out that the same problem does not arise in Scotland at all. There are, of course, isolated examples, one of which he quoted —the town of Greenock—but the problems of these few isolated examples could have been solved without invoking the force and ponderous strength of this particular clause. This is using a steam hammer to crack a nut, which is the most expensive, most ponderous and most inept way you can do it. There are eighty clauses in this Bill, and I cannot find a definition of "a proper distribution of doctors" anywhere. The Scottish Medical Practices Committees will have to accept or refuse doctors to practise in a certain area, but the criterion of whether or not adequate numbers already exist there is not included in this clause or, indeed, in this Bill.
  In another place it was argued, rather heatedly, that there were a large number of areas which were over-doctored or under-doctored. That must have had reference to some standard, and I would have thought that the place for a precise definition of the standard was in this clause, where in fact it is wholly omitted. Those same committees will be employment agencies, or Labour Exchanges, with no criterion as to the ratio of labour between supply and demand. While I
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  am quite sure this ponderous document of some eighty clauses represents a most honest attempt on the part of its authors to assist Scotland in the way of medical services, it has all the attendant trappings of centralization and the introduction of even further restrictions, which we on this side of the House deplore. In sitting down I would say that although I am entirely at one with the wording of Clause 1, which talks of an improvement being desired, I cannot applaud the Bill in its present form.
  5.31 p.m.
  LORD MORRISON: My Lords, if, by your Lordships' leave, I may be permitted to speak again, I would say that this has been a very interesting discussion, and the reception given to the Bill of which I moved the Second Reading has been greatly beyond my expectations. There is one remark that I would make with regard to the discussion generally, and that is that with respect to most of the charges of the unfairness of this Bill to doctors, local authorities, dentists, those who left endowments, and so on, we must be careful not to lose sight of the fact that this Bill is not a Bill to improve the position of any of those people or authorities, but primarily to improve the health services of the people of Scotland. That is the main object of the Bill. No one who took part in the discussion emphasized the fact that that is its real purpose, and the success or otherwise of the Bill will stand or fall on whether it results in an improvement in the health of the people of Scotland. The noble Earl, Lord Selkirk, summed up in one sentence what I want to say, when he said that this Bill contained in a blue print what can be a magnificent service. In the light of that statement—which I think is generally endorsed by all the Scottish members of the House—the Government can go forward at least to the next stage of the Bill with some confidence, in the knowledge that the advantages of the Bill considerably outweigh any disadvantages.
  THE EARL OF SELKIRK: I am sure that the noble Lord would agree that a blue print never improved anybody's health.
  LORD MORRISON: I will perhaps come to that presently. The noble Earl, Lord Rosebery, asked why local authorities should have their powers taken from them. Under this Bill no power is being

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  taken away from local authorities. They have never had any duties at all outside the Poor Law arid the field of general practice. With regard to the ambulance services, those services are not at present under the local authorities, as the noble Earl pointed out, except incidentally in connexion with the hospitals. The noble Earl—as I expected he would—and other noble Lords, also, raised the general point that their objection to the Bill is that the Secretary of State under this measure is taking too much power unto himself. I think that sums up the position fairly accurately. That brings me to a problem in respect of which I frankly do not know the answer. If any noble Lord can give me the answer I should be very grateful. In connexion with this subject—as with all manner of subjects—it has been asked over and over again whether it is possible to devise any system under which those who do not pay the piper will still be enabled to call the tune. If somebody would be good enough at some time to answer that problem I should be very grateful. If the Secretary of State (who is to be responsible for this service as representing all the ratepayers in the whole of Scotland) is not to be responsible, are we to give the responsibility to someone who will have no responsibility at all with regard to the finances of the scheme?
  THE EARL OF ROSEBERY: The people who endowed the hospitals are certainly not going to be allowed to call the tune.
  LORD MORRISON: A good many of the people who endowed the hospitals are dead, which raises quite another problem.
  THE EARL OF SELKIRK: I am sure that the noble Lord would agree that the local authorities paid for the municipal hospitals which exist and have nothing whatever to do with Poor Law. For the last twenty years that has been the case.
  LORD MORRISON: I do not want to take advantage of this opportunity of saying the last word in the discussion of the Bill in order to provoke a lengthy argument, because I realize that many of the points that have been raised during today's discussion will come up again at another stage of the Bill, on which occasion they can be discussed in detail, and because my friend, Lord Amulree, is patiently awaiting the discussion of another Motion. I am not proposing—or
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  at least I hope that I am not—to be provocatively argumentative in my remarks, but I merely want to deal with one or two matters by way of short reply —not final reply by any means—to some of the points which have been raised in the discussion. Less than 5 per cent. of the cost of the services to be provided under the Bill will be met from local rates. Nearly 20 per cent. will come from national insurance contributions, and the rest directly from the Exchequer. In a service which is centrally financed to this extent—over 90 per cent. of the total—it is essential that there should not be areas where the standard of the service provided is much below the general level. In that event, the inhabitants of those areas who are paying taxes and insurance contributions on the standard scale would not be getting value for their money.
  With regard to the point which the noble Earl made about teaching hospitals, although I do not claim to have a very close knowledge of them I should not have thought that there was an exact analogy between the teaching hospitals in Scotland and hospitals such as Guy's and other teaching hospitals in London, where there is a concentration of medical students. The only teaching hospital in Scotland of which I have any reasonably close acquaintance is Forrester Hill in Aberdeen. It is not only a teaching hospital but one of the largest—probably the largest—general hospitals in the north of Scotland, covering a very large and wide area. But I do not know of any hospital, analogous to the Forrester Hill Hospital in Aberdeen, which would be classified in Scotland as a teaching hospital, to be compared to hospitals like Guy's or St. Thomas's. The noble Earl said that he was concerned about the staff of the hospitals. I am advised that, while the staff will have their contracts with the Regional Board, all but the senior members of the staff will be appointed by the board of management of the hospital, and the board of management will have a big say in those senior appointments, subject to central negotiation with regard to remuneration, and so on. The board of management will also deal with the conditions of service. The question of the dental services was raised.
  THE EARL OF SELKIRK: I asked specifically: Can the noble Lord state whether the universities will be able to

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  appoint their own professors of surgery and other professors on their teaching staff, or has this to go through the machinery of the Bill?
  LORD MORRISON: So far as my opinion goes, I can scarcely add to what I have said with regard to the general staff—namely, that the board of management will be able to appoint them, with the exception of the senior appointments. I am advised that they will have a big say in the senior appointments. Subject to central negotiations—that is, with the Secretary of State—on the matter of remuneration, the board of management will also deal with the conditions of service. The board of management, as I am advised, will deal with all the staff with the exception of the people at the top.
  THE EARL OF ROSEBERY: They are the most important people, are they not?
  LORD MORRISON: That is why perhaps it is essential that the Secretary of State should deal with them on a national basis rather than on a local basis. The request of the noble Earl, Lord Rosebery, for a grant in aid of dentists would mean that some people would get a better service by paying for it out of their own pockets. I should have thought that other ways could be found of getting better remuneration for the better dentists by giving them hospitals or specialist appointments. However, perhaps this matter can be left to the Committee stage a little later on.
  With regard to hospital endowments, the Commission will be able to put an endowment with the hospital that provides the services, and so fulfil, and not violate, the spirit of the founders. This question of endowments is not by any means an easy problem. People who left endowments many years ago could not possibly conceive the new circumstances that would arise. I can give your Lordships one example, not taken from Scotland in particular, but probably applying to the whole of the United Kingdom. Many years ago it was quite usual for people in a position to leave money on their death to make large bequests to homes for blind children. That seemed to appeal to them. Generally it was circumscribed that the bequest should be for blind children from a certain town or from a certain county. The result is that to-day there are more homes for blind children than there are blind
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  children to occupy them. With the homes endowed and established, what is to be done with them? The trustees of those homes are unable to make any move, in order, for instance, to meet the case put forward so ably by the noble Duke of Montrose in regard to deaf children. They are unable to move. The Endowments Commission to be set up will have to consider all these matters and, so far as possible, carry out the intentions of the donors, qualified by the altered circumstances of the present day.
  THE EARL OF SELKIRK: Would the noble Lord agree that when the purpose of a trust is exhausted there is a perfectly normal action at law which can apply the trust to other purposes, without going to the point of an Act of Parliament and an Endowments Commission?
  LORD MORRISON: I think it would be much more satisfactory to have an Endowments Commission that will be able to look at the picture and, so far as possible, carry out the intentions of the founders, even though it may be somewhat difficult to do so. They can, at any rate, make the effort and start on that basis. I was asked a question as to whether it would be possible for a doctor to have his house sold by auction. The sale by auction of a doctor's house was dealt with in the Report stage in another place, when the Lord Advocate said that a genuine auction sale could not possibly lead to a prosecution. The doctors in the United Kingdom are to have £66,000,000 compensation for the loss of value of their practices. Therefore steps are necessary to make sure that a black market does not arise. The answer to the question is that no auction sale could possibly lead to a prosecution.
  The noble Earl, Lord Selkirk, mentioned Christian Science. This Bill is based on medical practice by practitioners registered under the Medical Acts. The question of including unregistered practitioners would need an amendment to those Acts. But registered practitioners are not restricted in their methods of treatment; for example, homœopathic doctors will be free to practise as such. Private arrangements with unregistered practitioners are, of course, not affected by the Bill. The noble Earl, Lord Selkirk, deplored the fact that I had not made any reference to the question of the Board of Control in relation to mental diseases.

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  Part V of the Bill deals with this subject, as the noble Earl said. Briefly, the general principle is to assimilate the mental health services with the rest of the national health service. The supervisory functions hitherto exercised by the Board in relation to mental hospitals and mental deficiency institutions are extinguished, for the responsibility of providing and running these institutions will in future rest with the Secretary of State. In performing his functions relating to mental illness or mental deficiency the Secretary of State is required to consult the General Board of Control.
  The Board will continue to exercise all its existing functions relating to the liberty of the subject and the interests of the patient as an individual. It will also continue to exercise supervisory functions relating to private mental institutions not taken over into the new hospital service. In practice a system of dual appointments is envisaged whereby the medical commissioners—that is, the medical members of the General Board of Control—and also the medical officers employed by the Board will, at the same time, hold appointments as officers of the Department of Health. This will ensure that both the Board and the Department—that is, the Secretary of State—will discharge their respective functions with full appreciation of the whole position before them; for example, reports by the medical commissioners on their visits to particular institutions will cover the interests both of the Secretary of State and of the Board, and will be made available to both bodies.
  I would like to make a reply to the noble Duke of Montrose who, not for the first time in this House during my short membership, has made a magnificent plea on behalf of a class of very deserving people. I agree with every word the noble Duke said in regard to the exploitation of the deaf. I think one of the scandals in this country has been the way, not only in which "quack" hearing aids have been foisted upon the deaf at extraordinarily high prices, but also the fraud that has taken place in connexion with them. I have myself had evidence only recently of a lady who had sacrificed all the money she could possibly afford only to get a deaf aid that would not work. She took it back to the makers. Never mind how the information came to me, but someone took it into the workshop, where
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  a pin was stuck through the diaphragm; it was then brought back and shown to the lady, who was told that the reason why it would not work was because the diaphragm had been punctured, and it would cost five guineas to put in a new diaphragm. That sort of thing has been going on for a long time. My difficulty is that the noble Duke has issued an ultimatum that he will accept no assurances.
  THE EARL OF ROSEBERY: Can the noble Lord tell us in what way this Bill is designed to prevent people from playing on the unsuspecting deaf? The noble Duke does not want an assurance, but some prevention.
  LORD MORRISON: I was about to say that as the noble Duke had in advance said that he would not accept any assurances, it was unnecessary for me to give them. I would rather leave this matter until the Committee stage, when we must see whether we can explore it further. The way in which it may be met is that under this scheme it will be possible for deaf people not only to be treated for deafness, but to be supplied with hearing aids as a State service, The noble Duke knows perfectly well that the Government have been for some time experimenting with a deaf aid apparatus, which I think he agrees will probably be better than anything on the market when it is ready. It is not yet ready, and I cannot give the noble Duke any information about that.
  THE DUKE OF MONTROSE: I am sorry to interrupt the noble Lord, but it is a fact that there is mention of deaf aids or clinics in the Bill, and that is making all the deaf people very much doubt: the assurances. If the noble Lord could see his way to include a clause about clinics and deaf aid, I am sure it would give great satisfaction.
  LORD MORRISON: I know that that is the attitude the noble Duke takes up, and the answer to that—whether it is satisfactory or not—is of a somewhat technical character, and I was not going to give it. I will say merely in one sentence that I understand the objection to having this matter specifically put into the Bill is the fact that in regard to other services, such as the service of the eyes, there are certain definite medical standards, medical qualifications, for the people who treat the eyes, which do not

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  exist in regard to hearing troubles. That is the technical difficulty. But the noble Duke has, I know, given notice that he will raise this on Committee, and perhaps we may have a further opportunity of dealing with it then. Before I conclude, may I congratulate the noble Duke, as I understand this is his birthday? I hope that the speech he has delivered will be a forerunner to success in the campaign which he has been carrying on for so long and so well.
  The noble Lord, Lord Tweedsmuir, agreed with what I think is the general opinion, that whether this Bill is of Scottish origin, or a copy of an English Bill, or a combination of both, that, so far as it has gone, the Scottish Bill is better than the English Bill. I think that is the generally accepted opinion of Scottish noble Lords. The noble Lord Lord Tweedsmuir, said that medical services in Scotland compare favourably with any part of the world; I agree with him But that is not the complete picture. The health of the people of Scotland does not compare more favourably with people all over the world, and this is an attempt to create a better and more comprehensive medical service in which the outstanding medical attainments of the Scottish doctors —known all over the world, and renowned all over the world—may be applied in an organized way in their own country, in order to produce what we all desire, a better standard of health among the people of Scotland.
  On Question, Bill read 2a, and committed to a Committee of the Whole House.

  FOREIGN MARRIAGE BILL. [H.L.]
  Amendments reported (according to Order).

  LOCAL GOVERNMENT (SCOTLAND) BILL. [H.L.]
  5.53 P.m.
  LORD MORRISON: My Lords, I beg to move the Motion which stands in my name.
  Moved, That a Committee of six Lords be appointed to join with a Committee of the House of Commons to consider the said Bill: That the Lords following be named of the Committee:
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  E. Selkirk,

  L. Saltoun,

  L. Amulree,

  L. Tweedsmuir,

  L. Morrison,

  L. Shepherd.

  That such Committee have power to agree with the Committee of the House of Commons in the appointment of a Chairman.—(Lord Morrison.)
  On Question, Motion agreed to; ordered that a message be sent to the House of Commons to acquaint them therewith, and to request them to appoint six Members of that House to be joined with the said Committee.

  PLIGHT OF OLD PEOPLE.
  5.54 P.m.
  LORD AMULREErose to call attention to the plight of the old people in this country; to inquire whether the Government intend to carry out any of the recommendations of the Nuffield Report; and to move for Papers. The noble Lord said: My Lords, when, in the year 1943, the Nuffield Foundation appointed a Survey Committee, under the Chairmanship of Mr. Seebohm Rowntree, to inquire into the aged, I think it was the first time that any serious attempt had been made to find out whether there were any particular problems which applied to old people in general; and if there were, what were those problems and what could be done to help them? The Committee should be encouraged in their work, because the number of old people has increased enormously in this country during the past forty years. I do not at the present time want to take up a lot of your Lordships' time, but I want to give you one or two figures to make my point clear.
  In the year 1900 there were about 1,000,000 people whom we should call old people; that is, people who have reached pensionable age, 65 for men and 6o for women. By the year 1947, that figure had increased to about 5,000,000 —it may be a little more than 5,000,000 now—and people reckon that if the present trend continues, by about 1980 that figure will be in the neighbourhood of 9,000,000 people. I think that was the point which made the Foundation feel it worth while making this inquiry. The Report was published in January of this

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  year, and it disclosed rather an unfortunate state of affairs. There was one really important point: the Committee discovered that with the various systems of pensions the problem of real poverty was not now a very bad one for old people. They could, if they took advantage of the various pensions, provide themselves with a competence, adequate but austere, and not fear real poverty.
  The real problem which confronts the old people now is something rather more dreadful; it is the general difficulty of living and carrying on their normal way of life. It is the difficulty of shopping, housekeeping, cooking and cleaning, and taking care of themselves. Those are difficulties which are affecting people in all walks of life, the rich and the poor. It is now quite impossible to find nurses to take care of people in their homes, and it is not possible for many people to live with their familes as they did, since the bulk of the younger people have to go out for themselves. and therefore cannot give up a great deal of their time. That was the general view about it.
  The number of people who are getting into the ranks of what one calls the medically destitute—not financially destitute—is increasing, largely because old people cannot take care of themselves and get along by themselves. One of the great difficulties is that a very large number of people are suffering to a greater or lesser degree from under-feeding. I do not think it is that they are not getting enough rations, because I think the rations are as adequate for old people as they are for the middle-aged or young. The old people find it very difficult to shop, because they cannot stand in queues and carry home large bundles. The Nuffield Report, in paragraphs 135 and 136, refers to the fact that when they surveyed a large part of Cambridgeshire they found a great many old people were living on their meat, bread, butter, tea and jam ration, and nothing else. It was not surprising, therefore, that a great deal of ill-health was found. When these people were admitted to a home for old people, and were given a normal adequate diet, their mental and physical health improved enormously.
  That was brought home to me in rather a different way during the winter when I was presiding over a conference, organized by the London Council of Social
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  Service and attended by representatives of hospitals, local authorities, and voluntary bodies, to inquire into diets for old people. They all said that many old people needed to be admitted to hospital because they had not enough food. Once they got into bed and were taken care of, and properly fed on an ordinary diet, they improved quickly and could be sent back to their homes again. It is extremely expensive to maintain a patient in hospital. There are not a great number of nurses and the cost of keeping a patient in hospital is rising rapidly, ranging from four to six guineas a week. There are various means which could be employed to see that they did get a certain amount of extra food—not rationed food but extra food. It should be possible to assist these people by extensions of such schemes as the service run by the Red Cross in many towns, such as the "Meals cm Wheels" service, or the Invalid Kitchens of London. If it were possible for local authorities, under the Civic Restaurants Act, to supply meals from their restaurants to clubs for old people, their value would be increased enormously. I think that would be extremely helpful.
  Another thing which I think could help in certain areas is an extension of the clubs which have been founded already in some districts, where the old people can go for so many hours a day. These clubs were begun from a rather sentimental reason, but that does not matter. It is pleasant for the old people. But if some extension of the Civic Restaurants principle could be applied to clubs for old people, so that they can get more than they do now—at present they cannot get much more than a cup of tea—it would be extremely helpful. It is not a very costly thing. It is not very easy to find accommodation for clubs, but there are all sorts of things to be done, ranging from taking a small house to finding accommodation in some local hall for four or five hours a day—that is all that is really necessary. The provision of more homes for old people is another method which I think is worth encouragement. A certain number have been opened by voluntary bodies and local authorities and have had considerable success, but most of them have very long waiting lists; indeed the demand for admission is such that waiting lists have become meaningless.

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  Most of these places for old people are very well and adequately run, but some of the voluntary homes which are not nursing homes are purely homes for healthy people. The Nuffield Report refers to some, of the more scandalous of these. Quite recently I came across two homes myself, one in London and one in the suburbs, where the people were charged seven guineas a week, and for that they shared a room containing four beds in a private house. My informant went to visit a relative in one of these homes and wanted to talk to her privately, and it was necessary to take her down to his car and sit there; there was otherwise no accommodation at all. That seemed to me not a very satisfactory state of affairs. The Nuffield Report suggests that these places should be open for inspection. That is going to be difficult, because it is not very easy to decide when a home is a home and not a boarding house or hotel; but I do not think the problem is insoluble. It would be better if these homes were brought under some kind of clause for inspection, even though it might mean that a few hotels might be involved. If an old person makes a complaint he is told that there are plenty of people wanting to come in and he can go elsewhere; so these old people keep their mouths closed.
  The only accommodation that most local authorities can offer now to old people is the public assistance institution. According to the Report, only about 5 per cent. of the aged are in these institutions and anyone who has visited these places will understand why; they are large, grim masses of buildings, with ill-decorated wards, and often built about the time of the Poor Law Commission—1834 to 1840. The people are stifled under a mass of regulations and rules. Doors are locked at certain times and visitors are allowed at only infrequent intervals. There is no encouragement for the people to work or to take any active part in things, and they just sit round the walls of the institutions with nothing at all to do. One or two local authorities have been extremely good. I should like to mention two, because I know them. Excellent homes have been opened by the Surrey County Council and by the Glasgow Corporation. These homes are modern and up to date. They have single and double rooms, and the people are treated as if they were normal human beings.
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  The Ministry of Health have just issued a circular, No. 4947, in which attention is drawn to the necessity of providing reasonable homes for old people. They suggest that the ideal would be small homes for thirty to thirty-five persons where they could enjoy complete freedom with frequent visiting hours. They would have some kind of place for locking things up—a locker or just a drawer—and if possible they should be able to bring some of their personal belongings. I think that is an extremely encouraging circular and I hope it will be widely taken up by as many local authorities as possible. It is not a very costly thing; it can be done very largely by acquiring existing premises and would therefore go some way towards helping in a solution of the housing problem. There is great need for housing of this sort for people who can afford to pay something. A series of homes in North London keeps quite solvent by making a charge of two guineas a week. It does not make any profit, and does not want to. So, the expense, I suggest, would not be very great and would indeed be far cheaper than any kind of hospital provision.
  I think local authorities might be encouraged—as indeed I understand in certain instances they have been—to build special accommodation for old people in their new housing estates or blocks of flats. But it is a great mistake to think that old people like to be segregated. They want to have accommodation near shops, churches, cinemas and other places of amusements, and, in a certain sense, they like to be mixed up with their younger contemporaries. And, be it remembered, provided they are not too much mixed up with them, they can contribute a lot to the lives of their younger contemporaries. Old people, for instance, can take care of children while their parents go out. One knows that when the father and the mother go out, children are liable to get into all sorts of trouble if there is no older person to look after them. Therefore some provision of this sort would be a good move from that point of view.
  With regard to the liking old people have for company, I must say that two things struck me forcibly during the war. The Infirmary of the Royal Hospital at Chelsea was evacuated to a large house in Buckinghamshire. Here there was complete peace, beautiful gardens and a large park about two miles from the nearest

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  small town. But the old men were absolutely miserable; they felt lost and cut off from their friends, and it seemed to them that they had already started upon their last road to the tomb. The matron told me that in London the most popular ward in the Infirmary had been one that faced, I think, Royal Hospital Road, and from those windows the tops of buses could just be seen. Even that meant a lot to these old people, and they were just longing to get back from the country to London again.
  I remember, too, being told by a friend of mine who is interested in housing that during the war she visited a housing estate on the outskirts of a Midland town. While waiting for a bus to take her back to the town one day, she got into conversation with an old woman who lived on the estate and asked her how she liked her house. "Oh, it's fine," the old lady replied, "I have never had such a nice house, warm, comfortable and easy to manage." "Good," said my friend, "then I suppose you will be staying here for the rest of your life?" "Oh, no," said the old lady, "as soon as the war is over I'm going right back to the middle of the town. I know the little house I am going to get; it has been condemned, it is true, but I don't suppose they will pull it down in my time. "Now, that is the attitude of a lot of old people. They do not want to be parked out in the country—even though on beautiful estates—and cut off from the town.
  It has been objected that it is not economic to build small houses for old people at the present time, but I have read that in Hornsey a close of thirty-four one-bedroomed houses for old people has recently been built by the borough council at a fairly cheap cost—I think it was £27,000. These houses are let to old people at an economic rent of 12s. 6d. a week, and old people have been pleased to move into them, thereby freeing much larger houses with many more rooms. Many old persons would be delighted to move into smaller houses. Their families have grown up and left them, and often they find the houses in which they are living much too large for their needs. But the new houses must be modern in design, well found and fitted.
  Now a word about almshouses. There are many almshouses in the country, but more than 50 per cent. of them are old
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  fashioned, having been built in the middle of the 19th Century. They are in many cases quite unsuitable for the aged, as they have steep, narrow, dark stairs, outside sanitation and perhaps no running water, and no coal cellars. Now many of the charities which founded these alms-houses provided money to supply a small pension to the occupants, but left no adequate funds for repairs and modernizing. This is a matter perhaps for the Charity Commissioners, but it does seem to me that this would be an appropriate course to follow. With the scheme for national pensions about to take effect, it would be sensible to attempt to divert this money from paving pensions—which will not only not be necessary but, if they exceed 7s. 6d. a week, lead to a corresponding reduction in the national pension—to work on these houses which is very necessary. As I say, this is probably a matter for the Charity Commissioners, but I hope that whoever is responsible will take the view that the desires of the pious founders will be better met in care of the buildings than in subsidizing the State, which was surely not their intention.
  I have one more point. When people grow older, the distinction between health and disease becomes narrow and very difficult to define, and there must be great care taken to ensure that all old people, particularly those who live communally, can receive adequate expert medical attention when they are ill. In the past, there has been a tendency to consider chronic sickness as an almost inseparable feature of old age, and that all that was needed was careful nursing and attention. Any attempt to remedy a chronic condition in an old person was not attempted because it was thought to be impossible. The attitude to which I have just referred has caused a tremendous dislocation of the hospital services. It has led to a great slowing up of the stream of patients through the chronic wards of any hospital and to long waiting lists. Also, as a consequence, great discomfort has been occasioned to many. But there are hopes of a change. During the last few years a certain number of doctors have shown that old persons with their chronic diseases respond well to treatment, and that a large number of them—40 per cent, or more—who are admitted to chronic sick wards can be discharged either to their own homes or to a Home. The knowledge

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  that this can be done will bring about an enormous revolution in the treatment of the elderly.
  I should like to see all old persons who need hospital treatment, no matter what their disability, admitted for investigation and diagnosis into an acute general hospital. Her suitable treatment can be planned, and even if this has to be carried out in some separate building, it should be undertaken under the general supervision of the expert staff of the acute hospital. Any home for old people may well need some kind of a small sick bay where the occupants can be put for a day or two with minor ailments, but it is necessary that great care should be taken in this matter, otherwise these places may well develop into a new version of the old poor law infirmary, and you will get long lists of people waiting for beds. These sick wards or bays should be looked after by at least a general practitioner, and there should be a very firm link indeed between them and the local hospital. It is important that there should be no obstacle to patients' prompt admission when necessary, and to their equally prompt discharge when they are ready to go out. It would be necessary to have a certain number of homes available for, those who cannot quite get back to their normal condition, but who are not so bad that they need to be kept in hospital.
  The last point I wish to make is this. We have a population that is rapidly growing older, and it is reckoned that in a comparatively short time—by 1971 I believe—what I may call the middle or productive group of the population will be smaller than the young and old groups together. That will mean that a small group will have to support two large groups. This will remain true of the older group if you continue to enforce a retiring age of sixty-five. But, I submit, it is important that old people, within the limits of my definition, should be encouraged to work for as long as they are capable to contribute to the nation's wealth. Persons should not be compelled to retire when they are still sound and fit for work and desire to continue. The Nuffield surveyors found that many employers said that a large number of their elderly workmen gave satisfactory work when well over the normal age for retirement. This is important. Clearly, every
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  incentive should be given to those who are fit to work, to do so.
  Some financial adjustment must be made. The surveyors recommend that certain financial rewards should be given to those who remain at work after pensionable age. It is, of course, imperative that no one should be compelled to work who wishes to retire, and that no employer should be forced to employ a man who has reached pensionable age, with whose work he is not satisfied. Many an elderly person would respond to an offer to remain at work, with advantage to himself and the country, and I think all reasonable inducement should be offered to him to do so. I submit that the suggestions that I have put forward would, if carried out, contribute to providing a reasonable service for old people. They do not require much labour or material, and they are not costly.
  6.20 p.m.
  THE LORD BISHOP OF TRURO: My Lords, I am glad that my noble friend, Lord Amulree, has brought this subject before your Lordships' House, and he has done so, if I may say so, out of a large store of knowledge, and with great sympathy and understanding. The number of urgent problems before the country at the present time is so great that they are in danger of crowding one another out. The problem of the accommodation and the care of old people, which is growing steadily more urgent, is certainly in danger of being crowded out, or at least of being pushed into the background. At the present time only a small proportion of the local authorities in England and Wales realize the need for small dwellings for old persons. But surely it is obvious that to build small houses for the old will release larger houses for the young, and it should be made compulsory for all local authorities to include a suitable proportion of small-sized dwellings in every scheme. In addition to cottages and bungalows, a few "plus granny" flats should be provided—annexe flats adjoining dwellings for families, so that an elderly relative can lead an independent life as a householder and yet be within reach of help should need arise. It is greatly to be hoped that the Government will bring pressure to bear on local authorities to provide more of these types of accommodation for the elderly.
  Of course, accommodation is not the only problem. If old people are to be

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  able to live in their own homes, various auxiliary services are needed. The Red Cross are now expanding their most valuable work of visiting elderly people in their homes, and they find urgent need of such services as home help can give. Schemes of home help have been organized in some districts, though as yet they are but few. They should be made general throughout the country. Further, a number of elderly people become unfit to live on their own. As a rule they are reluctant to enter an institution; often they choose to remain at home until their condition becomes truly pitiable. For these people homely hostels are the right solution. A beginning at supplying such hostels has been made in a few places, but only a beginning.
  In the county of Cornwall we have two hostels run by the local authority, and one by a voluntary body. Another "eventide home" is being opened at Bude this month by the local Old People's Welfare Committee. The county authority have also acquired another house in Penzance which should accommodate about twenty elderly persons, and that authority has been trying for eighteen months to get permits for making the necessary adaptations to the building. Why is it that permits are so notoriously difficult to obtain? is it always because there is a great shortage of so many materials, or are these most trying delays sometimes due to some inefficiency in administration? The result, at all events, is very unsatisfactory. Cannot the Government do something to expedite the grant of permits in cases of this kind? As will be evident from what I have said, the provision for elderly people in Cornwall is entirely inadequate. And if I am rightly informed, the position in neighbouring counties is hardly better. Could not the Government take the initiative and give some stimulus and practical encouragement? Wise programmes of extension should be drawn up all over the country and they should have their due share of public attention and effort.
  The Report of the Nuffield Survey Committee contains several practical suggestions which might be put into operation without delay. One of them is concerned with almshouses. There are a large number of almshouses in the country which could make a valuable contribution to the housing problem if they were put into better condition. Surely it would
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  often be more economical to give grants to charities for the improvement of their almshouses (as regards water supply and sanitation, for example) than to build entirely new dwellings. Reputable charities in areas where there is an urgent demand for houses might well receive help from the Government. And, as my noble friend has already suggested, in many instances actual grants would not be necessary—simply some power of modifying their trust deeds.
  I should like to underline two other paragraphs in the Nuffield Report. The first, paragraph 269, refers to a class of the community which is scarcely catered for at all—namely, old persons who have some private means and are able to pay somewhat more than the sums usually charged in existing voluntary homes, but less than the fees of a nursing home. Many of these elderly people are amongst the most thrifty and deserving of His Majesty's subjects. It seems to me that the present tendency is to do far too little to encourage thrift and to reward merit. The Council of Social Service for Cornwall have been receiving numerous applications from the old people of the county, and the large majority of these applications are from persons of this kind, with small savings of their own. In some instances, voluntary bodies or private benefactors are giving welcome and valuable help. Mr. C. C. Morley, for example, has recently most generously handed over his house, the ancestral home of the Trelawny family, with a benefaction, to be a hostel for aged retired clergy and their wives. The possibility of a somewhat similar scheme is being explored in connexion with Cotehele House, one of the best preserved of the ancient historic houses of England, through the kindness of the Earl of Mount-Edgecumbe and the National Trust. If I may say so, the clergy are a good example of aged people relinquishing official residences, often with nowhere to go. Any effort on the part of individual benefactors or voluntary bodies to make provision for such homeless elderly persons should receive every possible encouragement.
  The other paragraph of the Nuffield Report to which I should like to call special attention is paragraph 272. This suggests the setting up of an experimental centre for demonstration and training in methods of caring for the infirm and the

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  aged. The establishment of such a centre would kill two birds with one stone. The centre would take charge of a certain number of elderly people, and at the same time would give a much-needed training to persons wishing to specialize in the care of the aged. One of the last recommendations of the Report emphasizes the need for continued and systematic inquiry into all matters affecting the aged. Very good. "Let knowledge grow from more to more." But let there be no waiting for the result of further inquiry before doing something practical. One of the major industries of this nation at the present time seems to be the making of inquiries—inquiries here, there, and everywhere; masses of inquiries, with but meagre results. As to the aged, we have plenty of knowledge to be going on with. And now, as the Nuffield Report itself concludes:
  "Above all there is need for energetic action to secure enough suitable dwellings for the aged, and much more and better communal accommodation for those unable to continue independent lives."
  6.30 p.m.
  LORD HOLDEN: My Lords, I usually trespass on your Lordships' time with a few observations about the very young, sometimes when they are very good and sometimes when they are very bad. I want to make a few observations (I promise your Lordships that they will not be very long) on the Motion moved by the noble Lord opposite, and I want to make them for two reasons. First, I think that the young and the very old have this in common, that they are quite powerless to look after themselves, particularly if they are impoverished and deprived of a home. Secondly—and this is more a personal reason—like many of your Lordships now in the middle years of life I still have a recollection of the frivolities of my youth but I am sufficiently advanced in years to have to face up to the prospect of old age in the not distant future.
  I should like, if I may, to mention three types of institutions, some of which have been mentioned by my noble friend opposite: first, Public Assistance institutions; secondly, homes run by bodies of a religious character; and, thirdly, homes run purely for private profit. Many of your Lordships will know what a Public Assistance institution looks like. From
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  the outside it can look very pleasant. Architecturally it is sometimes attractive. In many cases it was built in the early years of the 19th Century. As you approach the spacious door you might rather envy the lot of those inside but, as was indicated by the noble Lord, Lord Amulree, your feelings are very different when you get inside. You will find a ward, or a series of wards, sometimes with as many as too beds, separated from each other by only two feet. You will also find that the only furniture a resident has is one chair, although I am aware that lockers are now being more freely installed in those institutions. You then pass into the day room, which is equally dreary. There is no carpet covering the floor boards. You will find those—to me —unattractive Windsor chairs all round the walls. Naturally, in such a place, apathy must exist. There is no doubt that the people in those institutions have nothing whatever to do except to wait for the next meal or for bedtime. The Nuffield Report contains a recommendation, which is rather vague—though in the circumstances it could not be more positive—to urge local authorities to try to build homes for thirty or thirty-five people to take the place of these institutions. I think it can be said that it is homes rather than institutions in which we should like our old people to live.
  May I now say something about homes run by religious bodies, or rather bodies of a religious nature? There are about 100 of those homes. (I am talking only of those for poor people.) Eighty per cent. are run by the Little Sisters of the Poor, the Sisters of Nazareth or the Salvation Army. I should like to pay a tribute to all those organizations—certainly to the first two of which, as a Roman Catholic, I have some knowledge—for the devoted service they have given. And indeed that also applies to the Salvation Army. I have, however, two criticisms which I must make, although not of the people who run the homes. It is perhaps the organization that is responsible. All are run by a headquarters organization. In consequence, up to a point their rules are bound to be stereotyped. Too little regard is paid in the individual home for individual tastes and requirements. The second criticism which I wish to make (indeed it is hardly a criticism because I know how difficult the position is) is that they are very understaffed. They have

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  on an average, one member of the staff for ten residents. That is not enough. It is, of course, easy to criticize but it is difficult to get the people. We have to be thankful for the valuable services which the people in those institutions of a religious character give for no payment whatever.
  Before referring to the recommendation made in the Report, I should like to say a few words about homes run purely for private profit, because the recommendation in the Report is the same for both types of home. Here, as regards staff and residents, we have a ratio of roughly one to fifteen. I think that it is obvious, in such circumstances, that poor people are bound to be neglected, particularly when they have no relative or friend to look after them. The noble Lord opposite referred to what the Nuffield Report said, (and, the, examples it gave, of the disgraceful conditions of neglect and exploitation in such homes. As he did not read them out, perhaps your Lordships would allow me to read two short extracts. They are extremely shocking, but I am not suggesting that in every case this applies. These extracts which I am about to give relate to homes run for private profit:
  "Miss X runs a home for thirty old people. … The registration of the home as a nursing home was cancelled some years ago after a patient had been reported to the Medical Officer of Health as verminous and uncared for. Miss X was recently fined for drawing an old age pension after a pensioner's death. … The patients seen by the Committee's investigator were frightened of Miss X and unhappy."
  Here is another short extract:
  "Miss Y ran a small Home for six or eight old women. Miss Y's manner to visitors was always strange, and her reply to an inquiry about residents' health was invariably the formula She is very well; she had a lovely dinner yesterday of duck and green peas.' Residents visited were not infrequently found naked in bed and often crying. Miss Y eventually had a breakdown and was diagnosed as a dipsomaniac."
  To read of those things hurt us deeply. I am sure it is, or should be, a shock to the conscience of anybody who is aware of them.
  In conclusion, I should like to make a reference to the recommendation, to which my noble friend opposite has referred, with regard to the voluntary homes; that they should have periodical statutory inspection. I certainly think that is essential. I know the difficulties. My noble
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  friend opposite referred to them. One obvious instance was the possibility of a home being able to call itself a boarding house, and therefore being able to escape very necessary inspection. I believe that such difficulties can be overcome. I also feel that all good homes, properly run, should welcome inspection, and should not object to it in any way. The second recommendation made in the Nuffield Report—which is a general one (it is only tentative; and I would like to think that one day it might be possible of achievement) was that there should be created a co-ordinating committee charged with looking after the welfare of the aged people of this country, and that it should also attempt to improve and co-ordinate all the different organizations which look after them. That is perhaps a more remote objective, but I feel that inspection of voluntary homes is important; it is urgent and is practicable. If we can do this, I feel sure that the last years of many of our ageing fellow citizens will be spent in conditions of greater happiness and security.
  6.40 p.m.
  LORD BEVERIDGE: My Lords, I am sure that all members of your Lordships' House will feel they owe a debt of gratitude to the Nuffield Foundation for instituting, and to Mr. Rowntree and his colleagues for making, the inquiry which has resulted in the issue of the Report which is the subject of to-day's discussion. I think your Lordships will also feel a debt of gratitude to the noble Lord, Lord Amulree, for bringing this matter before us to-day, because this problem of the old people (and I would take old people as meaning old people of pensionable age, men over sixty-five and women over sixty) is one of the major problems facing all of us. It is major in numbers. We all know that, roughly speaking, one in five or six of the people of the country will be of that age. In the presence of the right reverend Prelate who has just spoken, I hesitate to refer to an inquiry which I made into social insurance a few years ago, but in the course of that inquiry it was vividly brought home to me how enormous was the problem of the old, and how big a difference every shilling that was added to the pension made to them. That particular-difficulty has been overcome, and we have faced the problem of finding adequate

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  pensions, or subsistence pensions, for these old people.
  Perhaps on that question I may just refer to one thing which was said by the noble Lord, Lord Amulree, which might have given the idea that there was a possibility that the middle section of the population—those between the age of childhood, under fifteen, and those of pensionable age—might be less than the other two together. I do not think that is a possibility. There are various estimates made by different people, but they all come down to this: that of every 100 people about twenty, twenty or a little under will be children under fifteen; about twenty or a little under will be people over pensionable age; and the other sixty will be people in the middle group. But it must be remembered that half of that sixty will not be engaged as workers; they are the housewives bringing up families. So it is true that a minority will have to do the paid work. Those are, roughly, the figures. The problem of old age is a major problem, not because of its numerical size, but because of its quality. Although we have now in this country provided pensions which are within sight of being adequate for subsistence for everybody, that does not solve the problem of old age, but only raises the question of how we are to deal with the additional human needs which cannot be met merely by guaranteeing a minimum income. That is really the subject of this debate.
  Most of the points have already been dealt with, so I can speak very shortly about them. I want to say only a word or two upon the most important points. There is, of course, the question of housing. I believe that one of the most valuable points made in this Report of the Nuffield Foundation is in paragraph 268, in their condemnation of the accommodation provided in most homes and institutions for the old. I would like to read the following:
  "The visits by members of the Committee to a number of institutions have confirmed the widely held view that, in the majority of them, the structure, equipment and regulations are unsuited to the needs of most old people."
  From that the Committee draw the conclusion—and I do not think it can be escaped—that it is necessary to contemplate building a very large number of additional homes—they put it at some-
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  thing like 1,000—for the old people who cannot live ordinary, completely independent lives in private houses, either alone or with their families. The Committee point out that the great majority of old people will go on living independent lives; that is to say, they will go on living in ordinary houses. Perhaps 95 per cent. of them now do. I think we ought also to realize that probably a certain number of them ought not to, and if there were reasonable homes they would go to those homes. Let us bear in mind the judgment of the Committee on that point.
  The Committee also emphasize that the provision of houses suitable for the old should be regarded as an essential part of our building programme. I hope that what they have said will help to do what they say needs doing, in the way of correcting the widespread view which they found among individuals and local authorities, that in the present acute shortage of houses of all types precedence in the use of labour and building should be given to the family house, and should exclude any provision for the old. I suggest that that is a wrong. and wicked thing to do, and that the judgment of the Committee, that some percentage of all houses should be designed specially for these older people, and as part of the general housing scheme, should be accepted. I need not go over again what has been said by the noble Lord, Lord Amulree, and others, as to not segregating the old. Apart from housing, what the old need, of course, is home help. I think the only point on which I feel some disagreement with the Committee's report is where they rather suggest that the home help for the old is needed only if they are sick, and while they are sick. Actually a number of old people are not sick, but they are unable to do for themselves the ordinary domestic work; they are not able to do for themselves the shopping, as it now has to be conducted, in queues. The provision of younger people who will come in and do these things for the old people, where they have not got families of their own to do them, is an essential that should be provided, not only for the sick but for the old as such. Then, of course, what many old people need is companionship—not to be lonely. That is a question of organizing visits to them, and of organizing recreations and clubs for them.

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  Finally, I am perhaps in an ever better position than the noble Lord who spoke first to say that what is really needed for the old people of pensionable age, like myself, is employment, if they are still able to be employed—but not compulsory employment. I hope the Government will act on the recommendation of the Nuffield Report, and look very carefully into the working of the present provisions, which are designed to encourage the continuance of the older people at work. If the incentives now given are not adequate, those incentives should be increased. Those things—housing, home help, employment and companionship—are additional needs which, from the point of view of the old, are not met by money. The thing one has to consider is: What is the best kind of agency to meet these needs? I hope that in considering agencies the Government will not think at once that I mean a Government Department, or a local authority. After all, this whole Report has come to us from a voluntary agency, an agency not stimulated by any Government Department but by voluntary charity, and undertaken by voluntary people. The question is, what kind of agencies can best meet these various needs?
  I want to refer shortly to one more point, which has already been made, about the existing endowed charities. I hope the Government will adopt the proposal of the Report that there should be an inquiry. I hope the right reverend Prelate will not object to an inquiry into the existing endowed charities. I do not suggest that with a view to recasting, but to see how they can be made more useful in the quite changed circumstances. I believe there is something like £5,000,000 a year in endowed charities that are now available for the old. That does not go very far in pensions, but it might go an enormous distance in recreation clubs, specialized buildings, and things of that sort. Then there is another type of agency which I hope the Government will not forget in this matter, and that is what I may call the mutual aid agency—the agency represented by the friendly society, or the trade unions on their friendly side —by which, in the past, before the State came into this, people attempted to provide for old people.
  I do not believe the day of that has passed. First of all, a great many people will feel that they desire more money than
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  they are getting from the compulsory State pensions, and I hope the societies will continue to insure them, and that it will be easy for them to do so. But I am not sure that some of these agencies might not consider whether they could not organize themselves to provide, in return for contributions, a guarantee of home help in old age, or even suitable houses. I admit that it might be rather difficult to calculate the right premium for this insurance, but I am sure we should be very much happier—at least I should—if we felt that when we got to be old, instead of being only of a pensionable age, we could be sure of home help coming into our houses. At the moment we are not at all sure. I hope these voluntary agencies will examine carefully what they can do to meet the needs which still remain, and that they will be helped by the Government to do so.
  Then, of course, there are many voluntary organizations, not actuated by any idea of pecuniary gain, which give scope to the social conscience motive—people who desire to devote their leisure time to helping the lives of their fellows. In that way, I believe, you really have great scope for providing for the unsatisfied needs of the old people.
  I want to refer to one last point, and that is paragraph 279 of the Nuffield Report, where the Committee discuss whether there should be any single central agency for examining this matter. The Committee (it says) examined
  "very seriously the desirability of recommending that a new and central body be set up, to study the changing conditions and needs of the aged; to undertake or stimulate research … "
  I am sure we do not need a new Government Department for this purpose. I am not one of those who think there ought never to be new Government Departments, but I do not think we need one for this purpose. I believe there is perhaps need for something which would make itself the adviser of the Government on what could be clone in this major problem of the old. Possibly some kind of advisory council could be, set up, attached to the National Insurance Ministry, which would, I think, be the right agency for that. That advisory council could help the Government to see that all the additional needs which are not met out of the pensions of the old are met. And in a way they are more important for human happiness than

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  a mere provision of a guaranteed minimum income.
  6.54 p.m.
  LORD ADDINGTON: My Lords, I am sure we are all extremely grateful to the noble Lord, Lord Amulree, for having introduced this Motion, and I propose at this hour to touch, as briefly as I can on only two or three aspects of it. I believe that a Christian national life, such as is our aim at the present time, is best founded on happy homes and providing a separate dwelling house for each family as a unit. That is a most necessary step in that direction. The provision of a small house or flat, with modern, convenient fittings, and of a size and at a rental that the aged can quite conveniently manage, would enable them to continue for longer, if not for the whole of their lives, as independent members of the community, instead of adding to the number of inmates of institutions which are already overcrowded and which are certainly terribly understaffed, or of adding to the waiting list of those hospitals to which allusion has already been made. I think, also, that this would help greatly in the housing and happiness of others.
  During the war, many cases occurred when at least three generations were sharing one home, especially when the young folk married during the war and the husband was serving. As has already been realized this creates many domestic problems. Every woman wants a home to manage by herself and to do her own housekeeping. The mother and the grandmother are so apt to have very widely divergent views upon the bringing up of the children, while the old may find that the natural noisiness of the children in the house is extremely trying and very irritating to them. It is therefore most necessary that these young couples, now re-united, should be able to start and create a family and bring it up in a home and family life of their own. This is done most easily by the older generation moving into small houses, which it has been found they are usually ready to do.
  The noble Lord, Lord Amulree, has already quoted the example of the Hornsey Borough Council. In the Nuffield Report at the end of paragraph 94 the Committee say:
  " Where this willingness to move exists, the building of small houses for old people becomes
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  a cheap, speedy and effective contribution to the whole problem of rehousing the population by releasing houses for larger families."
  It would seem to me that by the expenditure of about two-thirds of the amount of labour and material required for a three-bedroomed house, and about two-thirds of the site, we could provide two convenient and happy homes, instead of overcrowding three generations into one inadequate house with all the consequent inconvenience and friction.
  May I say a word about the proportion of houses for the aged? The Nuffield Report says, in paragraph 102:
  "We are inclined to suggest, with great reserve, that on the average 5 per cent. of the houses in any community should be such as are suited to the needs of old people."
  They add that this is a national estimate, and that precise housing needs must vary according to many local factors, The Amersham Rural District Council in my own county of Buckinghamshire, who have been building houses for old people on their housing estates for over fifteen years, are now having 15 per cent, of the total of those houses suited to the aged people, and they have found that in a rural area that is the correct proportion. Of the four great London trusts, the Peabody Trust has no less than 51 per cent. of its buildings of small size. The Guinness Trust has 60 per cent., the Sutton Trust about 48 per cent., and the Lewis Trust about 33 per cent., so that when you get to cities it seems that they should build up to 30 per cent. of small-sized dwellings.
  With regard to the size, taking Amersham again, they have built some under the 1924 Act with one bedroom, one living room, a kitchen and a bathroom, at a standard rent of about 2S., with rates at Is. 2d. Under the 1936 and 1938 Acts they have built them with two bedrooms, a living room, a kitchen, bathroom and hot water, at a rental of 5s. 8d. plus rates. They are now planning to build flats on two floors, which seems to be a very convenient way of providing for these old people houses with two bedrooms, a sitting room, a large kitchen and bathroom and hot water, and they plan to be able to let them at 9s. 6d. plus rates. Some of these houses might be convenient for homes for newly married couples, for small families or for families with children of one sex only. It is entirely optional at present whether local authorities include

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  any proportion at all of houses for their old people in their schemes. It has been shown that the very large majority are building three-bedroomed houses only. I therefore support the plea made by the noble Lord, Lord Amulree, and the noble Lord, Lord Beveridge, that all local authorities should build an adequate number of small houses for these aged people, scattered over their various housing estates.
  As to the question of siting, they should be scattered, and conveniently situated near the houses of other people and of their relatives, and not too far from the main road, so that the occupants can see the tops of the buses and so that they can get easily to the shops and other places. I would ask the, noble Lord who is to reply whether he can see that the Ministry procure this, either by persuasion, by regulation, or even, if necessary, by a short Bill. All the housing plans of local authorities are submitted to the Ministry, and I should have thought it would have been quite practicable for the Ministry to acquire a proportion of these small dwellings in substitution for some of those that they may have acquired—sometimes by drastic alterations to the housing schemes put up to them. The noble Lord, Lord Amulree, referred to circular No. 4947, and I would like to congratulate the Ministry on its reception. It outlines what your Lordships have heard as to the aged in public institutions. We were quite ready to accept suggestions as to modifications of the rules regarding visits, going out, times of closing, and so on, and I do not think they will provide any great difficulty; but I would like to ask whether the Ministry would readily issue the permits for lockers—such lockers as are either of well-seasoned wood or mild steel. I am advised that some of these three-ply lockers buckle up in the dry atmosphere which prevails in these places.
  These needs of the aged do provide, as the noble Lord, Lord Beveridge, has pointed out, scope and opportunity for those social services which were so splendidly run throughout the country through a variety of bodies during the war. This again has already been very well started in some cases. Buckinghamshire has a very efficient Old Folks Welfare Committee. They have already started at least two very satisfactory hostels for old people, and the Public Assistance Com-
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  mittee are just now acquiring one. The small town near which I live has an old folks club. So, generally, welfare for the aged will depend very largely on the way in which all these rules are administered, and on the spirit with which those who look after them carry out their duties. I believe that spirit must depend on our Christian faith and on our love of our fellow men which, in its turn, depends upon our belief in the Fatherhood of God.
  LORD SALTOUN: My Lords, there has been a very pleasant unanimity among noble Lords who have spoken, and I am well pleased, because almost everybody I meet who is really interested in the care. of the aged has a different solution. I believe there is one African tribe which solves the problem of the aged by keeping a convenient pool in a nearby river, with sacred crocodiles. I have met some intellectual supporters of noble Lords opposite who hold very much the same views, but I do not believe they hold those views themselves save possibly only in the case of company directors. But other views are held: some people prefer institutional treatment, some prefer homes for the old; and there are other ideas. There are problems in this connexion; one knows of the senile and impotent hate that sometimes arises when eighty-three and seven weeks takes a chair which eighty-three and eight weeks thinks properly belongs to him. They are not always as happy as one thinks. Then there is the almshouse system, which I think is very good, with one exception—namely, that it keeps the old people together. We must not run away with the idea that all almshouses are bad; some of them are very good indeed.
  Then there are special houses or flats for the old; and finally there are those who maintain the old in their own homes. It is with this type of old person that my own experience has chiefly lain. In some cases it would be cruelty to take them from their own houses. But where so many earnest people have different views, it is likely, I think, that they are all right and that each system has a place in the care of the old.
  I am quite satisfied, from reports that I get from all over the country, from the general population and from doctors, that old people in this country are not being properly looked after. That is a very

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  serious statement to make, but I make it conscientiously and soberly, and I want to say, quite definitely, that I do not attribute any blame in the matter to the Assistance Board. As your Lordships know, there has been a very great extension of the duties of the Assistance Boards and they are extremely understaffed. They have had to reduce their staffs and it is difficult to get over the ground. This is an important matter because, with the old, visiting—frequent visiting—is absolutely essential. The Assistance Board is frequently five miles and sometimes forty miles from places where they have to undertake the care of old people.
  One of the most moving passages in this Report is, I think, contained in pages 52 and 53. The passage speaks of the loneliness of old people and of the extreme value, which they put on visits that are paid to them. The need is for people who will make periodic visits to the aged perhaps once a week, at least once a fortnight. A person who performs that sort of service hears about their family affairs, and gets to know the people intimately. He notes indications of failing health—and changes of health occur very suddenly in old people, quite apart from any question of incidental disease—he knows their family circumstances and he understands exactly how best they can be helped. In fact, one of the very few points in this Report that I would criticize—and perhaps my criticism is unfair—is the matter which is dealt with, I think, on page 171 —the questionnaire. While the questionnaire contains almost all the questions one would wish to have answered, it does omit one extremely important question. That question I suggest is: "What family have you living away from home, and where are they? "That is a most necessary question, because the information which it is designed to elicit is of such importance. Not only is it the fact that members of the family are probably the best advisers, but, very often, in the case of those who can manage to do something for their aged relatives there is a duty upon them.
  His Majesty's Government recently, in matters of education, have, I think, been stressing what I have always felt to be one of the most important matters in connexion with education— that is, the influence of the home. If the influence of the home is called into play to assist in the educa-
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  tion of the young, it imposes on the young a special duty towards the persons who have made the home; and whatever theory of social life an individual may hold, I maintain that that duty must always exist. The duty lies on children to look after their elders, or at any rate to assist in their care. The information to which I have just referred ought to be known to the person whose task it is to visit the old people.
  I have one other point. You cannot possibly know who is in need unless you have local people steadily paying visits. This question of visiting has remained uppermost in my mind since reading the Report, and I emphasize it because hitherto in this debate only one noble Lord, Lord Beveridge, has stressed it. And in this connexion I make a practical suggestion, and it is one which does not call for any inquiry or even for a Bill. It is that the staff of the Assistance Board should be so far extended and increased as to permit of an experienced man being appointed in every parish—or, if not in the parish in every case, at any rate, in such areas as may be deemed reasonable to cover—whose duty it will be to visit the old people regularly, and look after them. That, to my mind, is one of the most essential needs in respect of the care of the old. Many people who are interested in this matter differ in the various schemes which they would like to see applied—I believe I am right in thinking that there is merit in all of them—and it is only people who know the conditions under which the old people are living, their family circumstances and all about them generally, who can really say whether they are best left in their own dwellings, or established in a home or institution, or fitted into some other scheme of life which may be most suitable for them. Having expressed my view in those few words, I should like to pay a tribute to the noble Lord, Lord Amulree, for the extremely able and interesting way in which he opened this debate, and to express the hope that what he said has won favour with the noble Lord opposite, and that we shall have a happy reply on behalf of the Government.
  7.15 P.M.
  LORD HENDERSON: My Lords, we all welcome this Motion as drawing attention to an aspect of social service which is of the greatest importance, and I wish

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  to join in the expression of gratitude to the noble Lord, Lord Amulree, for the sympathetic and very clear way in which he has discussed the problem. The importance of the subject will have been realized from the figures which both the noble Lord, Lord Amulree, and the noble Lord, Lord Beveridge, quoted to illustrate the general population trend. The inference is startling. The figures show that the numbers of persons of pensionable age have doubled since the beginning of this century, and in another twenty-five years they will represent approximately one in five of the population. Clearly, the needs of so large a section of the community must be kept in the forefront in the moulding of our social attitudes and the development of our plans of social security and welfare.
  Much is already being done in this direction. As your Lordships are aware, the financial needs of the aged have been dealt with by the National Insurance Act, and noble Lords have rightly drawn attention to the conclusion of the Nuffield Report that real poverty need no longer be one of the fears of old age. This is an important social change of which we can justly be proud. The increased old age pensions which are now being paid have at last brought real security to the great majority of our old people. Whilst on the question of money, I would add that the Government have made people of pensionable age the first to be given facilities for cashing their post-war credits. The health needs of old people will be met by arrangements under the National Health Service Act. We agree, as has been urged, that the present provisions for the chronic or, rather, long-term sick are inadequate—indeed, it is not unfair to say that in some cases they are lamentable, both in quantity and quality. As has also been said, there is much that can be done by way of treatment to restore at least an appreciable proportion of these patients to better health, to prevent their becoming bedridden, and to enable them to be discharged from hospital to live in their own homes or in an old people's home or hostel.
  We welcome, therefore, the noble Lord's suggestion that more treatment should be afforded to the aged long-term sick, and I am, glad to be able to say that, only a week or two ago, the Chief Medical Officer of the Ministry of Health
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  wrote to this effect to the medical officers of health of counties and county boroughs. More particularly we welcome the suggestion that hospitals for the long term sick should be much more closely linked up than they are at present with acute general hospitals. Such a link will undoubtedly make easier and more fruitful the continuous treatment from which many of them could benefit. We may well come in time to an arrangement by which many of the chronic sick hospitals cease to exist as such, and long-term patients are admitted to special wards of general hospitals. All this will become a possibility when the new national health service comes into being. As your Lordships know, the Regional Hospitals Boards, which are very shortly now to be appointed, will have among their early duties the re-planning of the hospital services; and the problem of the long-term sick, so many of whom are old people, will be among those to which my right honourable friend, the Minister of Health, will be asking them to direct their attention.
  Apart from the hospital and specialist services, the national health service will, we hope, bring many advantages to old people. Such things as spectacles, artificial teeth and hearing aids, which many old people are now without because they cannot afford them, will be available to them without charge. And the general practitioner family doctor services will be available to the old as to everybody else—specially important, perhaps, to old people, because of the economic factor. Again, there will be services provided by the local health authorities — domestic or home help when the labour position becomes easier, and a service of care and after care, which will be of special value to old people. Preparations are going ahead, and all these parts of the new service will, we hope, be available to a greater or lesser extent from the outset. The question raised by the right reverend Prelate of providing more adequate nursing service will certainly fall to be dealt with as part of the new health service. I can assure the right reverend Prelate that the recommendation of the Nuffield Report regarding the experimental centre for the training of nurses will be borne carefully in mind.
  Noble Lords have rightly given prominence to the provision of special housing accommodation for the aged. This

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  service must have a high place in our housing programme. Too many old people are living in accommodation which is unsuitable for them. Theirs is a very special housing need which requires a sympathetic and understanding approach. There is, I think, general agreement about the principle on which these dwellings should be planned and sited. The most important of them is this—that the old people should be enabled to lead normal lives in normal surroundings. They want to remain in contact with their friends and with the life of the community. Their dwellings should be close to churches and shops and centres of entertainments and community life, and should be sited amongst the homes in which younger generations are living and growing up. The exact type of accommodation required must, of course, vary according to the age and the vigour of the old people for whom it is intended. But whatever the type, it should have three qualities before all others: it should be small, warm, and convenient. The able-bodied aged are well suited in one or two storey cottages or cottage flats or on the lower floors of blocks of flats. For those who are not wholly able to look after themselves, accommodation can be provided in self-contained dwellings with certain communal quarters, and quarters for a nurse or warden. There is clearly scope for much variation in schemes of the latter kind—that is, in the combination of communal and private living—and scope, too, for experiment of considerable social interest and value.
  I am glad to be able to assure your Lordships that housing authorities are very much alive to the importance of this work and are giving much careful thought to the planning of the right sort of accommodation. More than 10,000 one-bedroom dwellings, a large proportion of which are designed for old people, are now in tenders approved by the Minister of Health. That represents about 4 per cent. of the total houses which local authorities now have in contract. We would not claim that this number was adequate to meet the need. The task must be viewed in relation to the general housing programme on which we are now engaged. But we can claim to have made a beginning. It must not be forgotten that over 90,000 two-bedroom temporary houses have been erected, apart from the one-bedroom permanent dwell-
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  ings to which I have referred. Although I have no figures, I am quite sure that a proportion of that total has gone to the aged people about whom we are speaking.
  There remains the problem of the care of those old persons who are not ill or infirm in the sense that they need treatment in hospital, but who, nevertheless, require accommodation of a special kind. It is clear from the Nuffield Survey that probably more than 95 per cent. of old people live more or less normal lives in private dwellings, some in homes of their own, some with relatives or friends. Many, however, for one reason or another, are really unfit to live in this way. They need accommodation in homes and hostels that are small enough to avoid the atmosphere of an institution, and equipped and staffed to provide the care and attention which the infirmity of old age requires. This is a need which is fully appreciated by the Minister of Health, and he has advised local authorities to use their Poor Law powers, whenever possible, to acquire and adapt premises which would be suitable for the purpose. A number of authorities have in fact already done so. The right reverend Prelate raised a particular case where he said there had been a difficulty about the licence. I have not the details of the case, and, naturally, am not able to deal with it. But now it has been raised by the right reverend Prelate it will be on the records of the House and I will see that it is brought to the attention of the proper authorities.
  It is the Government's intention to introduce legislation in due course to break up the Poor Law and to institute a comprehensive system of national assistance in its place. Under this plan, the responsibility for providing residential care for those of the old who are unable fully to look after themselves is likely to continue to rest with the larger local authorities, the county and county borough councils; but while new legislation is being prepared we are not neglecting possibilities of improving the local authorities' existing services for old people. Much can be done also to brighten conditions in the institutions in which, unsuitable though many of these buildings are for the purpose, many old people still have to be cared for. The noble Lord, Lord Amulree, and the noble Lord, Lord Addington, referred to the recent circular of the Minister of Health which offers many practical suggestions to local

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  authorities for improving the accommodation and atmosphere of their homes and institutions.
  It is, as has been said, most unfortunate that many of the old workhouse buildings have still to be used for the old people, and it is not surprising that the Nuffield surveyors, in suggesting plans for the future, have declared that most of these old buildings are probably unsuitable, even for the classified institutions which the surveyors recommend for specially difficult classes. But I do not need to remind your Lordships that there is a great shortage of accommodation of all kinds and a great shortage also of the labour and materials to build more. We have no alternative but to make the best use we can of such accommodation as we have until new and more suitable accommodation can be provided.
  The noble Lord, Lord Addington, rightly stressed the need in these institutes for furniture such as well constructed seat lockers. I am glad to tell him that the Minister regards the provision of lockers as the least that can be made. In the recent circular to which I have referred, the need for comfortable chairs of a type suitable for old people is pointed out. It is also recommended that each resident should have a wardrobe, chest of drawers, or at least a locker with keys where personal clothes and private possessions may be kept in safety. The circular went on to state that in providing improved accommodation, where the local authorities can supply or find the necessary labour to carry out this kind of work, a scheme should be submitted to the Minister who will give it sympathetic consideration even though priorities may be involved.
  The Minister of Health's recent circular also encourages local authorities to support the development of old folks' clubs to which the noble Lord referred. He rightly emphasized the importance of clubs as a means of alleviating the loneliness of old age. He stressed the value of having facilities for serving meals in the clubs, and I understand that an old age pensioners' club may be licensed for catering purposes if it is sponsored by the local authority or by a pensioners' committee working through a local authority. The noble Lord was a little doubtful about the facilities provided by Civic Restaurants being available, or advantage being taken of them, and he suggested that perhaps many
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  local authorities were not aware of the fact that through these Civic Restaurants there was power to provide meals "off the premises," to use a well-understood phrase. I will have that point looked into at the Ministry of Health, and if it is necessary I am sure that the Minister will not hesitate to bring this matter to the attention of the local authorities.
  The noble Lord, Lord Addington, asked about the payment of subscriptions to these clubs. I understand that the organizations running such clubs may apply to the county or county borough council who, if they wish to make a subscription, will apply to the Minister of Health for his consent under Section 67 Of the Poor Law Act. I am quite sure that the Minister will give favourable consideration to any such applications. Reference was also made by noble Lords to the almshouses and pension schemes which were founded by the ancient charities, and to the desirability of revising the terms of the trusts. This issue was raised recently in another place, and the Minister of Health stated in reply that the matter was under discussion with the Charity Commissioners. The problem is extremely complex, and bristles with legal difficulties which will require close examination. That examination is in progress. and I do not think I can add anything more at this moment.
  As regards the question of continued employment—which was raised by the noble Lord, Lord. Amulree, and other noble Lords—the case has been stated for the continued employment of the aged worker after he has reached a pensionable age. With our population trend, and particularly in these days of labour shortages and production needs, we are all bound to agree with the general principle that all who can— and who wish to— should be allowed to carry on with their work. This would be both in the national interest and in the interest of the able-bodied elderly persons themselves—as has been suggested. But I should like to add one comment. One man may find the continuation of his lifetime's employment as the most effective means of maintaining his interest and challenging advancing years. Another will be eager to make a change, or will feel in need of at least a temporary rest. Retirement may, in fact, be desirable rather as a change of occupation than as the end of

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  working life. Many, I feel sure, could take a new lease of life by making a change and following some interest which they have longed to take up during their lifetime and have never had the time or opportunity to pursue. The important thing, I suggest, is for the pensioner to find an occupation within his capacity. I think I have now covered practically every point that has been raised.
  LORD SALTOUN: Before the noble Lord sits down, while I do not press him for a reply, I would ask him if, with regard to the question of some means of procuring constant visiting, that matter will have attention?
  LORD HENDERSON: It will certainly be brought to the attention of the proper quarter. I hope that I have been able to satisfy your Lordships that the Government are not only keenly aware of, but also deeply interested in, the needs of old people and that, in the face of shortages of every kind, we are doing what we can to meet those needs. Information is being gathered together; experiments are being made by local authorities and voluntary organizations in all parts of the country. An increasing amount of interest is being taken in the valuable work of the old people's welfare committees of the National Council of Social Service; and, in short, the ground is being well prepared for the day when—building, labour and staffing difficulties having been overcome —we may go ahead confidently with the plans which have been outlined to-day.
  In this preparatory stage, the Nuffield Survey will serve a great purpose. It combines a sober survey of existing facts with comprehensive recommendations for a long-term programme, and both will be of considerable service. We are grateful, as I have said, to the noble Lord who moved this Motion and to other noble Lords who have taken part in the debate, for their sympathetic comments and the several helpful suggestions which have been made and which I shall bring to the personal attention of my right honourable friend the Minister of Health.
  LORD AMULREE: My Lords, I should like to thank the noble Lord who replied for the Government for his very encouraging and helpful observations. He has gone a very long way to meet most of the points which I raised and most of the
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  points which were raised by other noble Lords. In those circumstances, I would ask leave to withdraw my Motion.
  Motion for Papers, by leave, withdrawn.

  CITY OF LONDON (TITHES) BILL. [H.L.]
  Report from the Select Committee, That the Committee adjourned this day and pray leave to stand adjourned sine die for the convenience of parties: Read, and leave given accordingly.
  LONDON MIDLAND AND SCOTTISH RAILWAY BILL [PETITION FOR ADDITIONAL PROVISION].
  Examiner's Certificate of non-compliance with the Standing Orders: Referred to the Standing Orders Committee on Thursday next.

  SUNDAY ENTERTAINMENTS ACT, 1932.
  Orders made by the Secretary of State for the Home Department extending Section I of the Act to the

  City of Exeter;

  Borough of Longborough;

  Urban District of Urmston;

  Rural District of Faringdon:

  Laid before the House (pursuant to Act) for affirmative Resolution, and ordered to lie on the Table.