NATIONAL HEALTH SERVICE (SCOTLAND) BILL.

HL Deb 01 May 1947 vol 147 cc300-35

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 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, 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 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 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 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 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 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 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- 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 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 2^a.—(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. 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 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. 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 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 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 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 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- 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. 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 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- 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 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 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, 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 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. 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.

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 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 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 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 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 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. 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 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 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 2^a, and committed to a Committee of the Whole House.