THE NATIONAL HEALTH SERVICE

HL Deb 26 March 1952 vol 175 cc964-1021

2.41 p.m.

VISCOUNT BUCKMASTER rose to call attention to the working of the National Health Service; and to move for Papers. The noble Viscount said: My Lords, in moving this Motion I do so in no Party spirit. I hope that noble Lords opposite, with whom I have enjoyed brisk but happy exchanges in the past, will not interpret this as any lack of zest for battle on my part: it is due merely to the fact that I deplore the Health Service being drawn into the maelstrom of Party politics. I have not, I am sorry to say, any medical qualifications, such as many of your Lordships possess, but I have tried to find out how this great Service operates. I have not spared myself in the task, though to some particular problems I cannot offer a solution. But I hope to promote a discussion, from which constructive suggestions may emerge. If I achieve that, I shall have done what I set out to do. I am, of course, in favour of a comprehensive Health Service, though I am doubtful whether it can best be achieved within the terms of the present Act. It may be helpful if I group my remarks under four heads: first, the cost of the scheme; then the hospitals; then the position of the doctors; and, finally, the position of the patients. One may well overlap the other, but this cannot be avoided.

To take the cost of the Service, I think we are thrown back on the Beveridge Report—I see that the noble Lord, Lord Beveridge, is not here to-day. I do not propose to express any criticism of him, but I should like to say a word about his figures. He estimated, I think, that the cost in 1942 would be £170,000,000, with a further estimate that in 1965 the cost would still be about the same—that the cures would about balance the cost. I think that forecast was as unfortunate as some of the forecasts which may be made by your Lordships at an important event at Liverpool next week. Be that as it may, lot only have we now reached the £400,000,000 mark, but every ceiling which every Chancellor of the Exchequer has imposed is immediately penetrated. There seems no upward limit of what the Service will cost. There operates in these matters a law as exact as any known to science, A law on which, as your Lordships may remember, Mr. Micawber had some pertinent observations to offer: if outgoing, exceed revenue then there can only be one result—bankruptcy and collapse. I am well aware that there is at this moment passing through another place a measure dealing with the imposition of charges. It would be out of order for me to refer to that measure to-day, but at least something may be said in general terms. If we are to count the cost of this scheme, and successive Chancellors have fell that we must do so, then I do urge that we must not count the votes. While we must make such economies as we can, we must on no account whittle away the scheme so that the quality of the service given is diminished.

Everyone who works the Service, or who takes any part in it, must strive in every way he can to economise in time, in material and in money. It should not be too difficult to effect some drastic economies. The house governor of one of our big London hospitals has complained that he is completely submerged by a five-fold increase in officials. I am anxious not to weary your Lordships with too many quotations, but there are some figures which I should like briefly to give. They come from a book called The Cost of Health, published by Dr. Ffrangcon Roberts, and relate to Addenbrooke's Hospital, at Cambridge. His figures show that in 1925 this hospital had 190 beds, and a grand total of staff of 119. It now has a total of 360 beds, and a total staff of 544—that figure refers only to medical staff. If all the staff are included, the total is 680, or one and a half people for each patient. I will not weary your Lordships with the figures of out-patients, or file cost of treating patients but the graph of those rises so sharply upwards, and is so nearly vertical, that I imagine it would excite the envy of any man who was attempting to design a jet aeroplane.

Nor do I think that we can altogether acquit the hospitals of waste. The last figures which I have show that, in theory, every man, woman and child (including babies) in this country had four prescriptions last year. I feel that the hospitals are in some way responsible for this medicinal Niagara which pours down our throats and flushes out our drainage systems. I have had more than one case brought to me of patients being given far larger prescriptions at hospitals than they ever asked for or expected to receive. In one case a patient received three months' supply of pills. He protested that he would rather test the effect than embark upon so long a course. In another case brought to me by a working man, his wife was suffering from eczema. She was given medicine, lint, bandages and ointment. She came back again in better health and asked for some more medicine. She was handed the whole prescription over again. She protested and said that she had had enough of the other supplies. She was told: "No. The prescription says you are to have these things. Here they are. Take them." I feel that, possibly with the exception of the teaching hospitals, it is not altogether right to blame the general practitioner for the urge to consume every known—and to me, hitherto, unknown—forms of drug.

May I turn to the hospitals themselves, in a more narrow sense? The teaching hospitals, as your Lordships know, are run by management committees directly in touch with the Minister. That system appears to work well. Noble Lords distinguished in the exercise of their profession know far more about it than I do. I am not so happy, however, about the position of the other hospitals. These other hospitals, as your Lordships know, are organised in groups under a management committee which deals with a regional board. Perhaps. I may interpolate here that in my remarks, I do not wish to be regarded as critical of those who give loyal and devoted service on regional hoards and hospital management committees. I feel, however, that the intervention of the regional board between the hospital and the Ministry must tend to cause both waste and delay. I think it causes waste by duplication of staff, although I admit not on a very large scale. It also causes delay by attempting to achieve much which the hospital management committees themselves could do.

It may well be that some of these regional boards are too large. The South-West Metropolitan Board, I believe, has a complement of nearly 70,000 beds—five times the size of the East Anglian Board or the Oxford Regional Board. I feel that these regional boards should be either effective executive bodies or purely planning authorities. If they are to be executive bodies, the best method of staffing them would be to have them composed of the chairmen of the hospital management committees of the hospitals under them. Certainly it is hard to feel happy about the method of selection at the moment. In it the Minister clearly plays too large a part—I speak of course with no particular Minister in mind. The Third Schedule of the Act provides that A Regional Hospital Board shall consist of a chairman appointed by the Minister and such other members so appointed as the Minister thinks fit.… That hardly seems to me to be a democratic method of selection and dealing with a democratic service. I feel that we should elect on a democratic basis. I hope the noble Earl who is to reply, even if he has no concrete proposal, may at least be able to give me some assurance that some modification of the Minister's power in this connection is contemplated. If we turn to the hospital management committees, we see that their hands are tightly tied. I should like to see a delegation of the power from the centre to these committees. At the present moment, for example, the salaries of their staff are paid on a basis controlled by Whitley Council decisions. It is impossible for a hospital management committee in any way to reward valuable service. In one case brought to my notice a man working at one task has been described as working at another, which carries a higher rate of pay. That is ingenuity, but not the type of ingenuity which I imagine we are seeking to encourage.

I turn next to the position of doctors under the scheme. It is plain that I must find myself, if not on troubled water at least on water that is not altogether smooth. Like many of your Lordships, I owe a great debt to the medical profession. In particular, I have not forgotten the great act of kindness and the skill shown by a noble Lord present today when one of my sons was ill. I have no wish to repay unworthily the debt which I owe the profession; on the other hand, medical men are human beings, and are not more prone than any other race of human beings to agree among themselves. All I can hope is that what I say will not greatly offend them, and that they will, be able to find themselves at any rate partly in agreement with me. The specialists at our great teaching hospitals were formerly masters of the situation —and rightly so. One cannot cure disease by dictating to the doctor. But now, at any rate some of them feel themselves frustrated by inspection, direction and control. One whose name is well known to your Lordships has written to me, and in his letter he says that he has received what I believe is called a directive, instructing him how Government-supplied wigs should be cleaned. In case he should fail in that important task, a records officer has been supplied with duplicate instructions and has been told to advise him how and when this delicate operation is to be performed. He closes his letter in language which, without disrespect to the Senior Service, I had regarded hitherto as being naval rather than medical.

My Lords, if we turn to the general practitioner we come to what has been described as the anchor and the pivot of the scheme. I see the general practitioner in rather a different light. I do not look upon him as an anchor, but rather as Atlas who, on his head and with his hands, holds up the whole of this mighty structure. May I say at once, that I welcome the decision to increase the payments to general practitioners, but that payment in itself will not guarantee a cure of some of the evils which now exist. Most of the flaws in the scheme derive from the weakness of the position of the general practitioner. To what extent that will be altered now remains to be seen. Certainly, doctors' lists need scrutiny and revision. Some doctors have patients who give no trouble some have patients who give a great deal of trouble, and some have patients who do not exist at all. It may surprise some of your Lordships to know that in Middlesex 106 per cent. of the population appear on the doctors' lists. All I can say is that the Chancellor of the Exchequer would be in a fortunate position if 106 per cent, of the population were in the hands of Somerset House for taxation purposes.

Unfortunately, this percentage does not operate quite as one might suppose. The Minister land none can doubt his wisdom) has said that he will pay out only 98 per cent. where the odds are so much against him. The result of that, of course, is that the doctor in an area of small inflation receives less than the doctor in an area of what official language calls "not inconsiderable inflation"—in other words, some get a little too much and some a little too little. I can only hope that the r hope Earl will give me an assurance that the central index which is being compiled will throw off these non-existent names, and that we shall have a more realistic list as a future basis. But, my Lords, that does not mean that lists will not be too long, and from this position of lists hat are too long very serious evils flow. I have had a letter from another medical man, distinguished in the exercise of his profession, as was his father. He says this: Any full examination by a general practitioner is often impracticable. Many are giving up the treatment of things such ac varicose veins which are well within their competence. He adds, From a hospital point of view this leads to great overcrowding of the out-patients' department with patients who need not really he there at all. An enormous number of unnecessary investigations are carried out. It would certainly seem that the figures support what he says. For the year ending in March, 1950, there were 11,500,000 pathological and nearly 8,000,000 radiological examinations in our hospitals. It is scarcely to be wondered that there is a shortage of X-ray film. Yet the demand continues to increase. In the first six months of 1951 there was an increase of 16 per cent. over 1950 in the amount of film used, which in turn showed an increase of 60 per cent. over 1947. I hope that these increased payments will strengthen and fortify the doctor so that he will resist the demands so often made by patients for aspirin, iodine, liquid paraffin, lint, cotton wool and all the potions and medicaments clear to their hearts, with which they propose to stock up their medicine, chests.

My own strong feeling is that we must do our utmost to strengthen and improve the whole status and standing of the general practitioner. Above all, I think we must try and encourage young men of the best type to enter general practice. As it is, they are faced with obstacles which are formidable indeed. In the first place, few doctors are willing now to take on a partner. They find it unprofitable. Whether after this payment is made the situation will alter, I cannot say. If we take the case of the young man starting against someone else, not only has he to obtain permission but he is also in the unfortunate position in which he nearly always fails to find a house in which to live and a place in which he can practise the profession which he is privileged to follow. Formerly, when the practice was sold the surgery went with it. Now, of course, when a man retires from practice he sells the house; if he dies, his executors do it for him. In either case the incoming doctor has nowhere to go. Apart from that, under this Service there is no reward of any sort or kind for added skill or effort. In fact, the Service punishes the man with highly costly apparatus who tries to give the finest service, because his list of patients is small.

But there is even a graver feature than that, and that is the almost complete exclusion of the doctor from the hospital. One of the chief points stressed in a Ministry of Health Report was this absolute division between the general practitioner and the specialist. The general practitioner now feels riot only that he is excluded from the hospital field, but that the cottage hospital is all too often becoming a specialist unit, and that that door is closing to him also. The health centres which we were promised have proved to be chimeras, Will-o'-the-wisps—they do not exist. I doubt whether, in fact, they ever will. We have to do what we can to make the general practitioner feel confidence in the future of general practice, not purely as a means of earning money but as a field in which he can exercise the art of healing. We have to do that and we have to encourage the young men to enter the profession. If we do not, we shall strike a mortal blow not only at preventive medicine but at the very heart of the Health Service.

I should like to turn for a moment to the patient. In passing, may I say that I am not one myself? Your Lordships may have read a conversation reported in one of the daily papers in which one woman asks another if she is going to the cinema that evening. The second answers that she is not going as the film which is being exhibited is not worth seeing. "Well," asks the first, "where are you going; what are you going to do?", and the other replies: "Oh, I shall go and see the doctor." I do not suggest that there are many patients like that, but there are many who are not easy, to say the least of it. Only recently this example came to my notice— this is something which actually took place at one of the greatest hospitals in this country. A patient went to see a specialist. That patient did not exhibit any symptom of illness nor did he say that he had any disease. There was, in fact, no statement of disease concerning him. He merely said: "I want an electric razor." The specialist, somewhat taken aback, said, "In that case, go to a man who sells them." The patient said: "I have a tender beard." The specialist replied: "In that case go to a man who sells these razors." The patient said: "There is no question of that; I must have it." At that stage, the specialist said: "Thank you, but we are not living in Soviet Russia. If you must have an electric razor, you had better fetch a policeman, and tell him to order me to take steps to give you one." That ended the interview.

I do not say that there are many patients like that, but I do say that there are patients in a minority—I stress in a minority—who need educating. They may be ignorant, but it is necessary to instill into them a sense of restraint and an understanding of the harm they may do to their fellows by excess. Personally, I would shrink from the enforcement of any form of discipline against patients. It may be that a possible solution would be to draw up a form of code, something like the Highway Code, which could be brought to their notice from time to time. Be that as it may, something certainly should be done. So far as the patient himself is concerned, his position is not altogether happy because, owing to the congestion to which I have referred, we have very long waiting lists at our hospitals, and in an out-patients department it may be six weeks or sometimes two months before an interview with a specialist can be obtained. Then, if an X-ray examination is needed, there is still further delay.

So far as in-patients are concerned, there is a waiting list at the present moment—according to the last figures available—of 124,587 people for surgical treatment which involves staying in bed in a hospital. That surgery does not include orthopedic surgery, thoracic surgery, plastic surgery, neurological surgery or a whole list of other forms of surgery which I sincerely trust that none of your Lordships or I will ever be called upon to experience. I say that these figures are appalling—I can use no other word. It means that minor ailments have to be suffered as best they can by those afflicted with them. A solution is not easy to see, nor is it, indeed, for the whole problem of the service. The man who is cured of one illness merely lives to die of another. The cost of medicine has increased. As we roll back the frontiers in our battle against disease, the defence stiffens. Penicillin has destroyed one form of organism only for a penicillin-resistant strain to emerge. The use of streptomycin in treating some forms of tuberculosis has resulted in the proliferation of a strain of tubercle bacillus which is resistant to streptomycin.

My Lords, I have attempted to give only a bare and brief outline of this vast subject. I hope that I have shown that this Act does need re-shaping. It will be no small task, and the Ministry of Health, the practitioner and the patient will all have their parts to play. I beg to move for Papers.

3.7 p.m.

LORD SHEPHERD

My Lords, I think we can all express gratitude to the noble Viscount for giving the House the opportunity of discussing this important subject to-day. I believe, however, that he would have added to the obligation which we feel towards him if, during his speech, he had mentioned some of the achievements of the Health Service. I do not think I am saying anything unfair about the speech to which we have just listened if I say that it was unmitigated criticism from the beginning. I hope that when the noble Viscount rises to reply to the debate he will indicate to us that, in his opinion, despite all the difficulties that he has mentioned, some good things are being done. I want to refer in the first place, very briefly, to what the noble Viscount has said on the subject of cost. Noble Lords will remember that he made reference to the originator of these Health Service schemes, the noble Lord, Lord Beveridge, and indicated that the estimates of costs which he had put forward have borne no relation to the facts. I think the noble Viscount was accurate in also saying that costs will continue to rise until the full needs of the nation have been met.

The figures and facts which he has given about patients are indicative of the point that although we are spending a great deal of money, although we have provided a great number of institutions, and although we have enrolled the medical service in our aid, vast numbers of people are still waiting for treatment, and if we are to overcome these shortages and difficulties, then, undoubtedly, the cost will rise until the Service performs the task we expect of it. I think that although the noble Viscount was critical of Lord Beveridge in regard to his estimates, it would have been well if in addition he had mentioned that the costs of the Service are higher to-day than they were last year, or the year before, or in the year of the inception of the Service, because prices have been advancing against us. We know to-day that the Health Service has to find many more millions of pounds to pay the doctors, part of whose claims rested on the supposition that the value of money was not what it used to be. So I think we need to be fair when we are assessing the cost of a Service of this kind and acknowledge that there have been changes which neither the noble Lord, Lord Beveridge, nor the late Government, nor the present Government, could prevent occurring.

I cannot follow the noble Viscount in many of the points he made during his speech, because I had no idea what he was going to talk about, and at this Box I cannot commence an investigation into their accuracy. Therefore, I am going to devote most of my speech to the broad issues of the Service, mentioning some of the difficulties that I see and pointing to some of the blessings which we have obtained and then I am going to make certain suggestions of my own.

First of all, there, is the organisation of the Service. This is determined largely by the fact that Parliament is responsible for the Service. Parliament is the body which finds all the money for the Service. Parliament is answerable to the taxpayers for the wise spending of their money and must retain control, especially in the realm of expenditure. Parliament discharges its obligations in this matter by placing these responsibilities on the original Minister, and in the application of these responsibilities that Minister was bound to consider alternative methods of meeting them. The original Minister could have said that the most efficient way to make the Service applicable everywhere; would be to work entirely through a professional staff as we deal with the Army, Navy and Air Force. But the Minister and the Government of the time determined other-wise. They were of the opinion that this great service had to deal with the community as a whole, and that the best way of understanding the difficulties of the community and so realising in what direction the community required its assistance would be by the use of the voluntary services of many men and women in the localities. I admit that if the first line had been taken, certain costs; would have been avoided, but others would have been added. And I admit that the professional staff that would have been employed would be more answerable to the will of the Minister than bodies of men and women recruited because they want in their own way to do something for the community. It would have been easier, but I think it has been the desire of Parliament that in the administration of this great citizen scheme every possible effort should be made to secure the support of those prepared to give social service to the community.

The country has been divided into about 400 hospital areas, over which management committees preside. I should like noble Lords to consider the difficulties in matters of administration of a Minister who had to deal with 400 separate authorities spending his money for him. He could have had secured contact directly between himself and the management committees through the employment of a professional staff. Instead, however, the Minister, and the Government, decided that the supervision, the oversight and the co-ordination of this large number of management committees should also be performed by voluntary social workers; and for that purpose the regional boards were established. To-day we have this position, that the whole of Parliament's responsibilities in the administration of the hospital service are in the first place set firmly on the back of the Minister. Secondly, by devolution on the Minister's own part, certain functions are transferred to the regional boards; and thirdly, again by devolution, certain functions of the regional boards are delegated by the boards to the hospital management committees. At present, therefore, we have an organisation based on voluntary service, from the Minister at the top to the management committees at the bottom.

I think it is only right to say that although difficulties have arisen here and there in the management committees and regional boards, although mistakes have occurred and may still occur, on the whole the work accomplished by both kinds of machinery has been beyond praise. The willing and unselfish service of people who give their time to these authorities is worthy of the thanks of Parliament and they are entitled to the appreciation of the people of this country. That is my own view of the matter. I should like to refer to a report that has just been published under the auspices of the National Council of Social Service and King Edward's Hospital Fund for London. It is entitled Voluntary Service and the State: A Study of the Needs of the Hospital Service. The Council and the Fund authorities have certain regrets because of presumed changes in the relationships of the regional boards and the hospital management committees, but beyond that they believe that things have been working very well—I will quote their own words: We feel that the original conception of the boards as planning and co-ordinating bodies, with the duty of overseeing the operation of the Service in their area, should not be abandoned. This is not a plain citizen like myself standing at this Box expressing that view: these are the views of an expert body of men and women appointed to go more closely into the working of the hospital service than is open to most noble Lords in this House. They continue: We would regard it as a misfortune if the mass of administrative detail with which the boards were concerned left no time for planning as 'a fluid and continuously developing process.' At the same time we believe that it will be in the interests of the Service for the regional boards to continue their present administrative functions, at least for a further period, provided that they are given by the Ministry adequate responsibilities and powers of decision. I feel that statement should be set against what the noble Viscount has said about these organisations. Based on what these men and women consider, although they often admit mistakes. I think the report shows that on the whole these bodies have rendered a very good account of themselves.

I now want to speak on another point raised by the noble Viscount in connection with these bodies. In the case of the regional boards the men and women on them were appointed by the Minister, after consultation with bodies likely to be interested in the hospital services. The management committees, in their turn, were appointed by the regional boards themselves. If that kind of organisation is to continue it will be seen at once that it is desirable that the membership of the regional boards, in a large part, should be different from that to be found on the management committees. Merely to turn a regional board into an executive committee by co-option from the management committee will not bring fresh, critical minds to bear upon the work of the committee. The noble Viscount suggested that in place of what has been happening there should be election of some kind. I know something about elections; I have spent my whole life in conducting them. One of the points that arises with bodies that are duly elected is that they demand powers and rights. Under the present set-up the management committees and the regional boards are the agents of Parliament, which finds the money. If these bodies are to be elected, to whom will they owe responsibility? From whom will they take guidance? If there is to be an integrated service, established and paid for by Parliament, then there must be some means by which the will of Parliament can go right the way down.

The report of the National Council of Social Service from which I have made one small quotation, contains another point that is worthy of mention, because it bears on this issue. The report says: In the course of our investigations we have heard much criticism of the 'undemocratic' method of appointment. No reasonable alternative has been suggested. I should like your Lordships to note those words. It goes on: There are few who consider local election practicable. We have heard that one management committee has advertised house committee vacancies in the local Press with a view to giving oganisations and individuals the opportunity of submitting names, thus widening the field for future employment. In our view the present method of appointment of management committees is reasonably satisfactory, provided that the regional boards continue to take all possible care in the making of appointments. Again, I am expressing the view, not of one of your Lordships' colleagues without a great deal of hospital experience but of men and women in the medical world, and in that of social service, who, if not supreme, will at any rate be admitted as being of some standing.

I should like next to come to the question of finance and waste. When charges of waste in the Health Service are made in your Lordships' House, where we like to look at the whole of a subject, and not just A part, some indication ought to be given as to the methods by which the finances of this great Service are managed, and the attempts that are made from time to time to prevent waste. At the present time there are two schools of thought. First, there is the school which believes that the hospital service, like every other Government service, should submit its estimates of expenditure to Parliament, so that Parliament can exercise a view when deciding what taxes it will levy upon the taxpayers. That seems to me all the more important when income tax is 9s. 6d. in the pound. I cannot understand people who suggest, at a time like this, with a tax of that magnitude, that we should give block grants as a practice, and that we should not persist in asking for too many details. I would suggest that, if we have got to pay due regard to economy, it is desirable that we should maintain the Parliamentary system and ask the hospital authorities, who must provide estimates for their own guidance, to give their estimates to the Minister and to Parliament, in order that a proper decision may be reached concerning calls for large expenditure.

But there is another reason. A hospital management committee which is given a block grant in a "take it or leave it" style will probably have to do the best it can on the money that is advanced. That is not my conception of the position in which a management committee should be placed. Not only has the committee the responsibility of organising its institution in accordance with the will of Parliament, but from time to time, in accordance with its own knowledge of local affairs, it should be in a position to ask for more. How could such an authority ask for more without putting in estimates? Merely to ask for an increase in the block grant would be futile. If the request were passed on to the Chancellor of the Exchequer by the Minister of Health, the former would have nothing whatever to do with it. I look upon the submission of estimates by the management committees and by the regional boards as one of their rights, to make the requirements of their own local people clear to the Government. I hope that Her Majesty's Government will not for a moment think of departing from the present Parliamentary practice in order to go over to a scheme like that operated by the University Grants Committee. I can understand the taxpayer being quite willing to make a block grant of £10,000,000 a year to the universities, who find most of their own money themselves. I can understand the people of the country not wanting to know many details about that. But since, as the noble Viscount has indicated, we are spending on the National Health Service over £400,000,000 a year—which is a considerable sum taken out of the taxpayers' pocket—I cannot understand how it can be thought that it the country would agree to block grants in these circumstances.

I have before me some particulars of operations now taking place in respect of the management of finance by the various management committees of the country. I hope that noble Lords will bear with me while I place a few of these facts at their disposal. Every month each management committee must send to the Minister, via the regional board, an account of its income and expenditure for the previous month. There are five columns of figures in the return that has to be made. In the first column there is the previous month's expenditure; in the second column, expenditure up to date for the financial year; in the third column, the proportionate part of the approved expenditure, in order that comparisons can be made. In the fourth column there are lists of items on which there has been over-spending and, in the fifth column, a list of items on which there has been under-spending. The charge is made that, because unspent balances had to go back to the Ministry, hospital management committees are tempted to spend their surplus money at the last minute; and there is a suggestion that waste arises in this connection. If your Lordships will look at some of the items I am going to mention in one particular case I think it will be realised how baseless that suggestion can be. I am speaking of a particular management committee, whose name shall not be mentioned, although I shall be happy to give it privately to any noble Lord.

The balance of unspent money on staffs is £6,480 for this particular month —the tenth month in the year, with two months still to go. It is unlikely that that management committee will spend that money in the employment of fresh staffs rather than send it back to the Minister. On clothing, there is an under-expenditure of £1,100; on surgical appliances an under-expenditure of £4,300; on the grounds (and here, perhaps is a case where waste might be supposed to take place) an under-expenditure of £2,900; on replacements an under-expenditure of about £1,000, and on others £869—a total under-expenditure in the tenth month of lust under £17,000. If I mention £17,000 just like that, it seems a very large sum of money. But when I tell your Lordships that the authorised expenditure of this particular management committee is in the region of £1,000,000 a year, you will realise how comparatively small is that under-spending in the tenth month of the year. I suggest to your Lordships that on those figures alone there is very little opportunity for waste, even if the committee were anxious to waste Government money. I deny that these management committees think so little about the interests of their country as to waste public money in that way.

I want to pursue this question of waste in another direction, because in December the present Minister sent a circular to the hospital authorities drawing attention to the need for economy. This particular management committee, which is no exception, got busy immediately in order to meet the requirement of the Minister to practise economy. The regional board invited all the management committees connected with it to give consideration to the matter and to reply to the regional board on all the items where they thought some saving might be made. Let us admit at once that, in a great Service of this kind, now and again redundancies, will arise and waste will take place, because of forgetfulness or idleness or some weakness in the organisation Therefore, by and large it will be necessary, not only for these committees and boards but for the Government themselves, to see that these wastages do not accumulate.

The management committees have replied to the invitation which I mentioned just now, and the regional authority has now sent out to the management committees the suggestions in toto for the attention of the management committees in order that the cost of the services of their areas should be brought down. They cover staffs, drugs, dressings, equipment and stores, laundry, heat and lighting, food and catering, service of meals and general matters. In order to see how detailed the investigation can become—especially as the noble Viscount has talked so largely about prescriptions and the like—let me take what has been said under the heading of drugs, and break it down for your Lordships: (1) "Joint consultation between medical staff committee and pharmacists should be undertaken with a view to the curtailment of excessive prescribing." It should always be remembered that a prescription is not written out by a patient himself. The prescription is always written out by a medical man. It is therefore desirable that there should be a meeting between medical men and pharmacists to reduce the amount of prescribing in connection with the hospitals or with the health services. (2) "There should be a benevolent interest of senior members of the medical staff to secure alternative prescriptions to avoid the use of particularly expensive drugs in favour of cheaper but adequate substitutes." (3) "There should be an avoidance of the use of proprietary medicines where adequate substitutes are available under the standard of the hospital authorities." (4) "Prescribing inadequate but not excessive quantities." (5) "Review of arrangements for requisitions, with a view to checking over-requisitioning." (6) "Reaching comparisons between one hospital and another in order that guidance can be given." If the House will take cognisance of those facts, and if it is prepared to give sup-Port to the Minister of the day in seeing that the services are carried through properly, we shall be making a far better contribution to the improvement of these services than merely by expressing criticisms.

I need make only one further point and it concerns the proposal that there should be some form of "hotel charges." In the interest of economy it has been suggested in a number of quarters that there should be something in the nature of hotel charges paid by patients when going into hospital. May I say for myself that I hope the Government will stand firm against that suggestion, even when it comes from such an important body as the British Medical Association. We have to remember that the people of our country are paying for this Service in one way or another. They will always have to pay for illnesses, whether they get services or not. We do not reduce costs merely by reducing money charges; and if we increase money charges we may increase the cost to the country in the form of bad health. I should like to see this matter fully ventilated in this House, and I hope that the House will go with us in suggesting to the Government that it should not be put into practice.

If I were not a member of your Lordships' House and, therefore, if I had not reached what one might call a respectable status in society, I should be continuing my old job in life of organising the electorate against the Party in power. If I did that once more I could wish for nothing better than that this Government should institute a "hotel charges" scheme in connection with the hospitals. I could wish for no better issue upon which to go to an Election. Although noble Lords may say that it would be sharp practice on the part of anybody who did that, I say that the people of the country, having a right to decide these issues, ought to be made aware of the reasons. How do they themselves want to pay for the services that are given to them? Make no mistake of this, my Lords: whether the, working man or working woman or the middle-class man or middle-class woman pays heavily in income tax or not, it is out of the fruits of their labour that this country stands; it is from the fruits of their labour that these hospital schemes become possible. Therefore I hope that the Government will take note of this and give us an assurance that they are not considering the imposition of "hotel charges"; and that they want to continue, not a free admission to the hospital—because we are all paying—but an entry into the hospital without further charges which could be administered only on a means test basis.

3.41 p.m.

LORD CHARNWOOD

My Lords, I shall detain you for only a few moments. It seems to me that there are two small gaps in this health scheme which have to be filled. The two ills which I am anxious to see remedied are these. It seems to me an extremely unfair thing that if someone chooses to pay his own consultation fee he loses every bit of benefit under the Act. In other words, if he pays for a consultation he loses the medicine, dressings, spectacles and everything else. I know that it can be urged that any other arrangement might lead to a person profiting unfairly, particularly in my own profession of optician. That could easily be prevented by stipulating that benefit could apply only in cases where the prescriber does not dispense. This simple safeguard would render it safe and would eliminate an obvious injustice The other very small technical gap which I want to mention is that size lenses, which are a real help to some spectacle wearers, can, theoretically, be obtained under the hospital scheme, but in practice can be got only through the supplementary scheme at the patient's own expense. I cannot enlarge upon that point here, but I should like to have an assurance that something will be done to stop these gaps.

3.42 p.m.

LORD MORAN

My Lords, it happened some time ago that I was listening to a soldier talking to a politician. They were old friends and soon began delving into the past. The soldier said to the politician, "Do you remember arguing that a corps of professional soldiers was necessary to leaven the raw mass of National Service men?" The words, "raw mass" now sounded to a politician's ears as rather undemocratic; "glorious raw mass," he corrected. The soldier looked at him whimsically. "That is politics," he said. Now, my Lords, when you are told that these charges on prescriptions and for dental treatment have demolished the structure of this Health Service, that is politics. No doctor would believe that criticism. Surely the foundations of this Service are not quite as shaky as that. We have been building for many years scaffolding; presently there will be a building, and if any section of the community has difficulty in gaining admission on account of this charge it should not be beyond our wits to invent a free pass. I am not saying this in any controversial spirit. Those who have struggled for equal opportunities are naturally sensitive about providing free treatment for everybody, but I would earnestly ask every member of your Lordships' House not to allow politics to enter into the question of the health of the people.

What are the criteria that we can apply to the working of this Service? Much as I dislike simplification, we may say that a Service like this can be judged by two tests. First, has it affected adversely the entries into the medical schools in either quantity or quality? We know that the numbers seeking admission to the medical schools are increasing. Three thousand applicants for one thousand vacancies in the twelve London schools is very roughly the position to-day—that is to say, one in three. Incidentally, the woman medical student has no more difficulty in getting into the schools than has the male. This increase is not due to the Act. The system of grants, which makes it possible for any boy, whatever his circumstances, to become a medical student if he has the brains, is responsible. It is, of course, much more difficult to be sure about the quality. If that had been affected it would be noticed first in the public schools. I therefore wrote to the headmasters of fifteen public schools to ask them whether the type of boy had been affected by the Act. They all reassured me about numbers, and on the whole they were all reassuring about the type of boy. But there were three answers that contained a note of caution. They said it remained to be seen in the next four or five years what would happen to the status of the general practitioner; if it continued to fall they did not know whether the type of boy would be affected. We may take it then that the Service at present has not affected either the quality or quantity of the entrants.

Now we have to ask whether, when these boys are qualified as doctors, they will find in the Service terms and conditions of service which will provide an incentive to them to give their best and to put their hearts into their work with their minds at peace. Perhaps it will be convenient in answering if I follow the noble Viscount who opened the debate, and divide my remarks into two categories— general practitioners and specialists. First, with regard to the general practitioner, there is, I think, general agreement that there is a good deal of discontent among the practitioners: that they are not happy about a number of things. Some would claim that this unrest is financial in origin, that the doctors felt they had had a raw deal, and that consequently they were disgruntled. I myself believe that that is not the whole story. If it is, then Mr. Justice Danckwerts' judgment yesterday will perhaps reconcile them to the service.

But I feel sure that there is a more deep-rooted cause of their discontents and I think it is to be found in the insidious decline in the status of the general practitioner over a number of years. This began, I think, when men and women, vaguely conscious of the technical advances in medicine and surgery, decided, when they were seriously ill, that they were safer in hospitals under specialists than in their own homes under their own practitioner. And your Lordships will realise how common the use of hospitals has become when I tell the House that one in fifteen of the population is an in-patient every year, and one in seven attends as an out-patient. The general practitioner could put up no kind of resistance to this tendency because, owing to the scarcity of nurses and domestic staff, it was difficult, or, shall we say, impossible, to treat serious illness in the patient's own home. This must have been mortifying to the general practitioner. He saw a patient whom he had known for years, who apparently trusted hi fn, put himself in the hands of a complete stranger in a medical emergency. When that happened the general practitioner must have felt that his pride of craftsmanship had suffered a blow and that he no longer counted for as much in the scheme of things. There is, indeed, no doubt that some lost heart. This decline in the status of the practitioner was, however, not the result of the Act but of the conditions of his life before tin Act.

But the practitioners received another blow, this time to be ascribed to the Act. The best of them had made modest excursion into the specialist's field. They had done their own surgery or they had become known as, reliable anæsthetists. When the, Act came, all that was taken from them. I am not saying it was wrongly taken from them, because, if a man is going to practise as a consultant or a specialist, he should surely he trained as such. Nevertheless, I am only concerned at the moment to find the factors which have denuded the practitioner's life of much that made it absorbing in the past.

What is the remedy? You will never put the dock back. You will not persuade these patients to be treated at home when they are seriously ill. There is only one remedy, and that has been mentioned by the noble Viscount—namely, to let the practitioner follow his patients into the hospitals, to open the doors of the hospital to him. That is a great issue. It seems to me the most important reform in administration that has occurred in medicine in my lifetime. But it is not going to be easy. It will meet with much opposition. For these hospitals are largely staffed by specialists—there are 500,000 beds in the country and, of those, only 6,449 are in general practitioner hospitals—and naturally these specialists are proud of their institutions and jealous of their good name. The will resist the dilution of labour, as every ether section of the community has done. And I am afraid the general practitioner may be very tepid towards pressing for admission to the hospitals. Why should he be? Because, if he is given diagnostic aids, if he is allowed to have radiological and pathological reports on his patients direct from the hospital, and if, in addition, the small number of general practitioner hospitals is multiplied, he may well be content; particularly when he reflects that if he attends a great hospital for two afternoons a week as a clinical assistant, he may lose financially, unless, of course, he is very well paid.

For all those reasons, I do not look upon the general practitioner as a very staunch ally in pressing open the doors of these hospitals. You may well say at this point, "Why embark on this difficult crusade which is going to be opposed with such tenacity?" There are two answers. The first is that the general practitioner hospital, though it brings contentment to the practitioner by providing good nursing and diagnostic aids, is a place where he tends to work by himself, generally on the knowledge acquired perhaps twenty years previously. It is not really comparable with a first-class hospital. To placate the general practitioner, we must not set up two standards of hospital treatment; because that is the very thing that this Act was most anxious to avoid. There is another and even better reason. The specialist in his hospital works under ideal scientific conditions. Every diagnosis he makes is tested by half-a-dozen laboratories—and, in the last resort, by a post-mortem! Moreover, the atmosphere is critical in the extreme. If he makes a mistake, everybody knows about it. When the general practitioner leaves his hospital and goes out into practice it is as an individual. His diagnoses are seldom put to the lest, except by an occasional X-ray or an occasional pathological report. That is scientifically unsound. It is very important that we should bring these men into the proper scientific atmosphere so that they may develop the skill they are capable of. It is surely not right that 5,000 consultants should work under ideal conditions while 20,000 practitioners are working under conditions which are scientifically unsound. Therefore, I hope that the difficulties which are facing us in getting the practitioner into these hospitals will be boldly faced.

I now come to the very difficult subject of the specialist. If I had spoken yesterday afternoon before I heard Mr. Justice Danckwerts' judgment, I should have found not the slightest difficulty in putting my view before your Lordships. But here we have a body of general practitioners who have suddenly been relieved of a great anxiety, and naturally anything said to-day may easily be misunderstood. Moreover, it is of the greatest possible importance that there should be good relations between the general practitioner and the consultant. I think that is most important. I am anxious that nothing I say should in any way give practitioners the impression that there is a single specialist who does not rejoice that they have been treated in the way they have been. This is an occasion when, speaking of specialists, you may as easily say a little too much as a little too little. Nevertheless, your Lordships will feel that it is important that we should preserve the financial balance between the two branches of the profession. For that purpose I should like to bring before the House the training of a specialist.

When a boy enters a medical school, for the next six years he goes in for annual prize examinations, and at the end of six years it is quite apparent whether he has stood out from the herd—he may have won two or three prizes perhaps. Then he goes up for house appointments. And, of course, there are far more applications than there are vacancies. Finally, the meshes of the sieve narrow rapidly and he goes up for registrar appointments. I have not mentioned another test which he must pass. He has to go up for the higher qualifications. In this manner you separate out what we call the man of promise from the others. It is a ladder and people are always falling from that ladder. To put it-differently, six years after leaving school at the age of eighteen, lie will be told, "You have got to take higher degrees and to spend a number of years as registrar"—and all this on an adequate but a small income. Now you are going to tell him, at the end, "You would have been better off financially if you had not done anything of the sort." That is not going to be easy.

I say so much, though we are not yet certain how the Danckwerts award will work out. It is significant, however, that there is already a feeling that it may mean that the average general practitioner will earn more in the year than the average consultant. If that turns out to be the case it will raise a condition of great difficulty for the medical schools. How are they going to persuade the boy of promise to go through these difficult years when he might easily go out into practice and be as well off? This is a matter that I think requires extremely careful thought. Even when we are rejoicing about the success of practitioners in getting this increase, I think we ought to keep it in mind, because we do not wish to repeat the mistake that was made when these negotiations over betterment were allowed to drag out over a number of years. I hope that we shall not make the same mistake over the consultants. The general practitioner has been awarded 100 per cent. betterment, while up to date the consultants have been given 20 per cent. That is manifestly unjust. I believe that the consultants will act with responsibility, and that they will realise the calls upon the national Exchequer at this time: and I think they will not pitch their claims too high. But the position has to be set right. If it is left, there will be great disgruntlement and eventually the consultants will go to arbitration and in view of yesterday's finding I think noble Lords will agree that arbitration is not necessarily economical. Therefore, I hope that there will be a statesmanlike attempt to settle this question. It will be very much easier to settle now than in three years' time.

There is just one last thing that I wish to say about the Danckwerts award, and that is about the distribution of the money. Almost everything depends on how this money is distributed. If it is distributed wisely it may do great good. A doctor may have 4,000 patients, which is a hopeless number to treat properly. If matters are so arranged that he is paid generously for the first thousand and not at all generously for the last thousand, much good may come of it, for that man's list will soon come down to 3,000. Again, looking after old people and children is far more arduous than looking after an adult. Perhaps two aged people might count for three in the list. It is readjustments of this sort in the capitation fees which will make it possible for young men to enter practice and for the older men to have much more time to do their work properly.

At this point, many may ask: "Where are we going in all this expenditure?" Is it £400,000,000, or ought we to say £440,000,000? Where is it going to end? Is there waste? That is what everybody wants to know. Of course you can find obvious waste in very small amounts.

When the patient takes his empty medicine bottle back to the doctor he does not get it sterilised, he gets a new bottle; and with the container that means that £1,000,000 has been wasted in a year. You wilt find a few things like that. But even if you are experienced in hospital affairs, even if you have spent a lifetime in them, you find surprisingly little waste. I know of a hospital with 700 beds. Its expenditure this year is £1,250,000; in 1947 it was £500,000. Sixty-six per cent. went or salaries for staff, nurses, and domestic staff, 10 per cent, on provisions, 6 per cc nt. on drugs, and 4 per cent. on maintenance, and so on. Go through the list in detail and you will find nothing that really can be cut out. A man may tell you that there are twenty almoners where there were once four. That is true, but a different service is provided now. It is no longer "No. 3" in a sick ward, it is "Mrs. Jones." Everything is done for the patient. The service is transformed.

You may say, when economy is so important, that I am not very helpful in suggesting economies. Well, I either entirely from the noble Lord, Lord Shepherd, in regard to "hotel charges." The case for a "hotel charge" is based on this. These wards are now used by every class of the community, and many of the people who use them are well able to pay for their food. This is an issue which was raised in the question of food subsidies. It is the same issue here. If you were to charge three shillings per day, or a pound a week, for food for these patients, making exceptions where necessary, the institution of which I have been speaking would profit by £35,000 and the general Exchequer would, I am assured, benefit to the extent of £10,000,000 per annum. I realise that I am speaking as a mere doctor, and that these "hotel charges" are a political issue, and even to an innocent doctor it is obvious that if you say to the people, Here is a free service, "and then you put a charge here and a charge there, it is apt to be politically inconvenient.

But when I say that it is a political issue, I want very seriously to say this too to your Lordships. It is vital to economise; there is no alternative. Expensive new techniques and drugs will come along—I will not say weekly, but certainly very frequently; and you must incorporate them in the Service, because they are vital to life. If you do this, what is going to happen? If you expand like that, you must, retract somewhere or you will burst. It is an absolutely clear issue, and if you accept what I have said, then what are you to do? Since you must economise somewhere, are you going to lower the standards of the service or, alternatively, are you going to make a charge? I am not a politician, but it seems to me that it would be disastrous to lower the standards of our hospitals, to close beds, to cut schools or to do anything of the kind. Surely, the alternative is to put a charge on something.

Then we come to this question of the £50,000,000 which is spent on drugs. Every doctor knows that some of that, at any rate, is unnecessary. If think the noble Lord on the front Opposition Bench talked about appeals to people not to use drugs, or something of the kind. That kind of appeal has been going on for several centuries. Appeals to wean the doctor and the patient from his pathetic faith in the efficacy of a bottle of medicine are futile. In the eighteenth century William Pitcairn, President of the Royal College of Physicians, launched a crusade against the abuse of drugs. He said: The last thing a physician learns is when to do nothing—when to leave it to Nature. And that is going on at the present time. The most intelligent members of the community, when they are ill, do not really want a doctor's advice; they want him to do something. It is the instinct of all of us. One patient said to me once: "Charles, you are so desperately negative"; and on another occasion he said: "Charles here does not believe in any kind of medicine, but he thinks it is only decent to put a label on before the end." If you make these appeals, and if you trust to them to bring down the drug bill, nothing will happen in the lifetime of any of us here.

What then can be done? You can put this charge of one shilling on prescriptions, though with the disadvantage that it will be met with great hostility by the 4,000 doctors who do their own dispensing. Further, it is a charge upon a sick man. What is the alternative? In Denmark they divide their drugs into three categories. In the first, there are the lifesaving drugs, perhaps twelve in number. They are drugs which are essential, and they are given free to the community. In the next category come what may be called desirable but not essential drugs, and the public is asked to pay 40 per cent, of the cost of those. In the last category are all the placebos, the tonics, for which the public are required to pay 100 per cent. If I had my way, they would be required to pay 150 per cent. This plan has been a success in Denmark, and in Australia it has been in operation for eighteen months. Therefore it is practical politics. But once more you are faced, not with a medical issue, but with a political issue. You will never bring down this drug bill except by some such plan involving a charge for medicines.

No doubt, your Lordships are familiar with the saying of the Greeks that a physician has opportunities of learning about human nature which are not given to anyone else, and, therefore, a philosopher should begin life as a doctor, and a doctor should end his life as a philosopher. I shall not attempt any flight of that kind, but perhaps I may be allowed one final reflection. For many years I have worked with successive Ministers of Health and those who advise them, and I say that at the present time the Minister's advisers, in their alertness, in their grip and hold on the basic principles of this Service, have never been surpassed in my experience. But we do not give them a chance. We make them spend their days in committees—and a committee, as your Lordships know, is a form of mistrust which prevents a competent man getting out of hand. And when they get back at night with their papers they are tired. What is the result? If you are overworked and tired you are slow at making decisions. It is because Ministers' advisers have been in the past slow in making decisions that we are called upon to pay £40,000,000 to-day. The doctors were anxious to settle this matter, and they would have been happy to settle for very much less earlier on. But the matter dragged on and on and on. I sometimes think, since I heard of the award, that Mr. Justice Danckwerts must be a disciple of Adam Smith, who long ago said in the Wealth of Nations: The doctor has great power, and no one can tell if he is abusing that power. We have to trust him. And therefore he must be a man of substance and character, and therefore he must be paid accordingly by the community. That might almost be a text in this morning's papers.

I think that this important debate in your Lordships' House will have done several extremely useful things. In the first place, it has brought things out into the open; in the second place, it has unravelled medical problems from what I call political issues. Finally, and most important, it will, I hope, confront the public with the immediate necessity of coming to a decision—of deciding here and now whether they are going to be content with a free Service which is bound to be increasingly inadequate and inefficient, or whether they are willing, in order to get a really good Service, to make a contribution to it. That is the issue which is before us, and, speaking as a non-politician, I say there is absolutely no escape from it.

4.16 p.m.

LORD WEBB-JOHNSON

My Lords, it is an unfortunate fact that in considering the Health Service the predominant considerations in many minds at this particular moment must be the need for economy and disquiet at the overall cost of the Service. It is all very well for the noble Lord, Lord Shepherd, to say that the needs or the claims are not being fully met. But try to contemplate what will be the cost of the Service when immediate attention is to be forthcoming, on demand, for many minor and many chronic conditions. It is essential, I think, to remember, and not carelessly to deny—as has been done in some quarters—that the cost of the Health Service is linked with the country's financial position, and that the Health Service has a place in the fight for national solvency. I have a great admiration for what the Service has already accomplished, but that does not mean that nothing should be done about it. It does mean that we should not take up this tender root after three years of trial. It may well mean that we should cut back, and do some radical pruning, not only for the benefit of the surrounding things in the garden—where everything is not lovely—but also for the benefit of the plant itself.

That wonderful body which I never cease to admire, the Select Committee on Estimates, who seem to undertake a colossal task with very little recognition, came to the conclusion that something more than a slight modification of the system of financing seems necessary. And when we had a debate on the hospital services in your Lordships' House only last year, I think it was pretty generally agreed that there was need for more decentralisation. There was, of course, stalwart opposition by the noble Lord, Lord Shepherd, to any suggestion of carrying over block grants or savings, but one can recall from experience that the university grants system has led to mutual confidence, instead of mutual distrust. I readily admit that the bulk of the income of the universities comes from other sources, but nevertheless I think it should not lightly be thrown aside that the block grant system is unsuitable for the hospital service. All of us have been appalled by the enormous increase in the administrative staff, and in the organisation as a whole, and many of us feel that this increase has led to some extravagances. When we members of the medical profession reflect on these extravagances we know that every pound unnecessarily spent on the administrative side may mean a pound taken away from the patient.

We were warned by the then Minister of Health, when the Bill was going through Parliament, of the danger of a Government service becoming over-centralised. He told us that the wider the decentralisation, the better it would be. I submit to your Lordships that the dangers of remote control have not been avoided. It has been pointed out that some regions are outrageously large and their regional boards must necessarily be remote from the people who are looking for hospital services in certain districts. This, in my view, is one instance of extravagance, because it means a cumbersome staffing organisation. I believe that the regional hospital boards have been burdened with too much concern about details, when they were established definitely for policy, planning and coordination. Therefore, I think if individual hospitals had more discretion they might secure more efficiency and, in the end, some saving.

There is a considerable disquiet throughout the country because the hospital management committees have no direct responsibility to the communities which the hospitals serve; and the feeling of responsibility of and to the people of the district has been undermined. Surely means can be devised to ensure that the hospital management committees are to some extent representative of the people of the district and responsible to them, as well as up the ladder, through the regional hoards, to the Ministry of Health. I feel that if this were so, local interest would he revived, and it is important to revive this local interest because by doing so we shall foster and encourage voluntary workers who are, or who have been, discouraged from playing a part in this humanitarian service. Not only have they a feeling of being discouraged, but in many of their activities they have been told that they should not exercise those activities within the precincts of the hospital. In regard to organisation, the ideal should be a maximum of guidance from the centre and a minimum of control. That has for many years been the policy of the King Edward's Hospital Fund, and it has been extraordinarily successful. Moreover, as the King Edward's Fund committee have pointed out, much can be done with global budgets if there is a uniform standard of costing. Much has been done by way of study by the King Edward's Fund committee and the Nuffield Provincial Hospitals Trust. I hope that this work, which was carried out on the invitation of the Ministry of Health, will bear fruit.

There are other means of meeting the financial strain. One that I should like to mention is an increase of pay-bed accommodation on reasonable terms, because I am sure many people are willing and anxious to pay for the hospital accommodation and treatment they receive. I would join my noble friend and colleague in supporting the idea of a "hotel charge." I am surprised that my noble friend Lord Shepherd should work himself up to such a state, as if he thought he might be approaching a General Election, about this "hotel charge." Is it not already admitted and practised in principle? Ts it not a. fact that, after a patient has been in hospital a certain number of weeks, his sickness benefit is reduced? And is it not a fact that in a maternity case a mother can claim for a greater allowance because she is having her baby delivered at home? Is that not a fact? The noble Lord shakes his head, but has he chapter and verse?

LORD SHEPHERD

My Lords. I did not shake my head for the purpose of denying what the noble Lord was saying. It is a fact that anyone in receipt of money from the State in the way of sickness benefit may be required to contribute part of what he is receiving towards payment for his bed and treatment. That is one thing, but I hope the noble Lord, Lord Webb-Johnson, is not going to suggest that, because an operation of that kind is carried out, the country is to-day pledged to the principle of "hotel charges" for everybody.

THE EARL OF ONSLOW

My Lords, perhaps it would put the noble Lords who have been talking about "hotel charges" out of their agony, if I say that at the moment the Government have no idea of imposing them.

LORD WEBB-JOHNSON

That just shows how easy it is for any one of the noble Lords in this House to work himself up into a state about something which has already been decided.

In regard to increased costs, I should like to support my noble friend and colleague again in pointing out that medical investigation and treatment to-day are enormously more costly than they were not only because of increased costs generally but also because the use of some of the wonderful discoveries that have been made entails repeated, almost daily, pathological investigations; so the cost is driven up enormously. The remedies themselves are extremely costly and often have to be imported, which again shows that the hospital service is linked with the national economy, as has been pithily put by the author of a book recently published, from which quotations have already been made. Dr. Frangcon Roberts has said, "If we want more cortisone, we must sell more coal." That is a fundamental truth. We must remember that while the demands of medicine may be potentially unlimited, there is a limit to what can be provided. I supported in your Lordships' House the charge for appliances and was surprised when it was proposed that patients in hospitals were not to pay for them, because inpatients, on the average, are better able than out-patients to pay for the use of appliances. In regard to prescriptions, again I favour a charge, because unless a charge is made I feel that there is inevitably waste and greed. It is the experience of generations of general practitioners, including my own father, and I had experience of it when I was a boy. It is also the experience of general dispensaries and of hospitals that a small charge cuts down the wasteful use of drugs. As my noble friend Lord Moran has said, it is well that steps should be taken to discourage reliance on the bottle of medicine.

I want to detain your Lordships for a few moments with some reflections on the general practitioner. I would remind your Lordships that when general practitioners were joining this Service, they were promised facilities for diagnosis; they were promised well-equipped health centres. In fact, it was said in the White Paper that the main feature of the personal practice service was to be the development of health centres. They were also told that great importance was attached to the general practitioner hospitals. Yet they see being taken away even that which they had. Is it any wonder that they have a feeling, or did have, of restlessness and frustration? They knew the difficulties of providing these health centres, but they knew, also, how vital they were to the success of the Service. Can you imagine their chagrin when they saw no health centres going up, and no premises being requisitioned for that purpose, yet enormous accommodation being requisitioned and buildings put up for offices? I would conclude by saying that we cannot have a good Health Service unless the general practitioner is given a chance to do his work properly; and it is only the Ministry, backed by Parliament, that can provide him with adequate facilities.

4.32 p.m.

LORD BURDEN

My Lords, I am sure we must all be grateful to the noble Viscount, Lord Buckmaster, for raising this important question. If I do not deploy my arguments over such a wide field as the noble Viscount did, it is because my noble friend Lord Shepherd dealt, if I may say so, very effectively with him. I must, of course, be exceedingly cautious in endeavouring to answer in any way two such highly-placed members of the medical profession as the noble Lords who have preceded me— after all, one never knows when one might be in the hands of the profession. But may I remind the noble Lord, Lord Webb-Johnson—and this is by no means an attempt to reply in detail to his speech—that the memorandum which that great public servant, Sir George Newman, submitted to the Ministry of Health in 1919 (and I would make that memorandum compulsory reading for anyone who presumes to take any part in public life) states that we had a number of hospitals, but no hospital service.

I venture to say that that conclusion of Sir George Newman was amply confirmed by the reports of the various surveys which were undertaken as a result of the generosity of Lord Nuffield in connection with the Ministry of Health, both before the outbreak of war and during the war. If it were necessary, one could give quotation after quotation from those reports indicating the lamentable state of the hospital provision in this country. So that when we criticise, let us remember the standard from which we began. The noble Lord, Lord Webb-Johnson, has shown some knowledge of the Report of the Select Committee on Estimates. I should like to commend to the noble Lord's attention the remarks of Sir Basil Gibson on the condition of hospitals which were taken over in the Sheffield region when the Sheffield Regional Hospital Board was set up.

The National Health Service, as has been pointed out repeatedly this afternoon, is a partnership between the State and a large number of people giving voluntary service. But it is more than a partnership: it is a bold and courageous experiment. This point has been well expressed in that valuable study already referred to by my noble friend Lord Shepherd of Voluntary Service and the State, published recently by the National Council of Social Service. I commend to your Lordships the actual words, which are: The hospital service has been 'nationalised,' but its administration in the field has been entrusted to voluntary committees, each of which is given by the Act statutory responsibilities and corporate status. It is the first example in this country of a public service which is financed almost entirely from public funds being operated by a Government Department and voluntary service in partnership. The 'freehold' is vested in Parliament, and the 'leasehold' is entrusted to voluntary service. Despite what my noble friend Lord Webb-Johnson said, I would suggest that it is quite wrong to submit this great experiment to continual hostile criticism. It is now three years since the National Health Service began to function. On the other hand, everyone who wishes the new Service to succeed—and here I am at one with other noble Lords—must be constantly on the watch. We do not want to create a new set of vested interests, whether doctors or administrators. Nor must this great experiment of voluntary co-operation between voluntary service and the State be hampered and destroyed, as might easily happen if the hospital regional hoards and the hospital management committees were forced into the position of rubber stamp agencies carrying out the instructions of an all-powerful Ministry. The report I have already mentioned puts this point with great clarity. It says: If it is desired to attract men and women of quality and ability to voluntary service of this kind, and to retain their interest, these committees must have reasonable freedom of action and decision, and this is possible only on a basis of trust and delegated responsibility. Busy men and women will be unwilling to give up their time to serve on committees which exist merely to carry out the instructions of a higher authority. I am bound to say that, in my view—and I think it is one of the advantages of this House that one can say precisely what one feels—there is an increasing disposition on the part of the Ministry to extend and tighten the control over the regional hospital boards and hospital management committees. Quite briefly, I should like to submit to your Lordships three examples—and there are others—of what I suggest is a most unfortunate tendency.

The first is in regard to the staffing, the establishment of hospitals. In May, 1950. the Minister announced his intention to send teams to review the establishments of regional boards and management committees. Now I do not for one moment complain of that decision. There have been allegations of over-staffing and extravagance. These allegations have been repeated this afternoon, and it is quite right that allegations of this kind should be investigated. That, however, is not the point I wish to make. In the review of the establishments, the Ministry sought to obtain the co-operation of experienced hospital administrators, but the Ministry obtained this co-operation on a clear and distinct understanding, which I am assured was accepted by the Ministry at the time. This understanding has been publicly described by one of the surveyors in the following terms: … it is most important to note that where the surveyors recommend an establishment smaller than the existing one (or lower grades) this does not mean that any officers are dismissed or down-graded. The establishment, if approved by the Ministry, merely becomes that to which the Committee should conform as vacancies and other opportunities arise, without hardship to individuals. In order that I may not be regarded as provacative, I should like to give your Lordships a quotation in the actual words taken from the official organ of the Institute of Hospital Administrators. These are the words: The surveyors and the Service as a whole cannot but now be seriously perturbed by the terms of the letter which has recently been addressed to various management committees conveying the conclusions reached by the Minister as a result of the review of their establishments. As expected, this letter informs the committees concerned of the numbers and grades of administrative and clerical staff which have been approved as their establishment, and provides—broadly—that no increase in the number of staff in any grade shall be made without the prior approval of the regional hospital board. The letter, however, then goes on to instruct committees that wherever the numbers of staff in any grade at present exceed the approved establishment, immediate action is to be taken—to be completed within two months—to conform to the new establishment. This is to be done, first, by reorganising and re-grading staff where this is possible (it being provided in this connection that individual officers, as opposed to their posts should not be down-graded unless the duties of the post itself are diminished, which, however, would seem likely to be frequent) and, secondly, by discharge of redundant staff, who are to be chosen for dismissal in accordance with the principles of the recent circular on redundancy—the principle of 'Last in, first out.' To this procedure two exceptions are made. First, where an officer to be discharged is 'one who is near pensionable age, say within twelve months' he need not be discharged before that age. Secondly, where the Minister approves an establishment substantially less than the existing one on the basis that a major reorganisation of work should be effected, then the Committee, it is said, 'may need a longer time to effect the reorganisation recommended before discharging redundant staffs.' The basis upon which the Minister has now decided to apply the results of the review is thus a complete breach of the understanding upon which the surveyors have so far undertaken the review, and to all intents and purposes is no less a complete breach of faith with the service as a whole. This is a very serious matter. I know quite well that the Ministry will be able to enforce their policy. After all, might is right until right is ready. But I do plead most earnestly that in this connection the Ministry will give sympathetic consideration to cases of individual hardship arising out of this new order.

For most of my working life I was employed in the railway service. Commissions, as they were called, were not unknown in the railway service, but never in the course of my career have I heard of a salaried officer having been discharged from the service as a result of a report of a commission. Normal staff wastage by retirement, the transference of staff and the slowing up of recruitment have always been quite sufficient to rectify the position. I submit to your Lordships that it would be a cruel thing for a man, say, fifty years of age, with a specialised knowledge acquired after thirty years of loyal service, to be thrown on the scrap heap, discharged as redundant when, in the nature of things, the appointment has always been regarded as a permanency. That is not the way to ensure a loyal, devoted and enthusiastic staff, and I would ask the Minister to give some assurance that no injustice of this kind will arise.

I have said nothing as to whether or not a fleeting visit of two men, however expert they may be, can possibly decide what is the appropriate staffing for a hospital, in view of the many and varying circumstances. But there is a further point, and it is this. As I understand the position in Section 14 (1) of the National Health Service Act, the regional hospital boards are defined as the sole employers of the staff other than the staff in the teaching hospitals. Let us assume that, as a result of shortage of staff enforced on a hospital by the Ministry, a patient considers that he or she has not received adequate or proper attention and brings an action for damages. As I understand the position, legal action in these circumstances would not be against the Minister but against the regional hospital board. It would be no defence for the regional hospital board to say that the staff had been cut down on the instructions of the Minister. I am not a lawyer and I cannot presume to be certain, but it occurs to me that perhaps the Minister is going somewhat beyond his legal powers in compelling a hospital management committee to reduce its: staff to an establishment which he prescribes.

The second point which I would make is in relation to the recent instruction by the Ministry to regional hospital boards and management committees, which reads as follows: It has been decided"— observe, my Lords, the word" decided"— that for liaison purposes arrangements should be made for the principal officers of the Ministry, or their deputies, to be kept informed of proceedings of Boards and Committees by receiving regularly copies of the agenda, pipers and minutes of all meetings of regional boards, boards of governors, and hospital management committees (but not of committees sub-committees unless they ask for these) and by attending such meetings as appears to them desirable. Accordingly, boards and committees are asked to arrange for the above documents for all their meetings held after the date of this memorandum to be sent to the officers indicated in the Appendix. I would not for a moment imply that the regional officers of the Ministry of Health are not excellent people. For many years I happened to be chairman of a public assistance committee which administered the poor law. The general inspectors of the Ministry had the right to attend the meetings of the public assistance committee. I am proud to say that some of these inspectors became very close personal friends of mine. But I can assure your Lordships that, notwithstanding this, members of all Parties deeply resented the presence of the inspectors at committee meetings. I do not for a moment suggest that these regional officers will act as spies or snoopers; but one cannot forget that their responsibility is not to the committee but to the Ministry, and that anything said or done in the committee may be taken down (I believe this is the technical phraseology) and used in evidence against the committee.

THE EARL OF ONSLOW

I am sorry to interrupt the noble Lord, but I think it is most improper to suggest that these very respectable officers are acting as a species of Gestapo agents. I would remind the noble Lord that in the case of other bodies, such as local agricultural executive committees, regional officers go down to the meetings and are a great help. The committees are very happy to have them with them. The noble Lord is trying to make some cheap political point on the matter.

LORD BURDEN

[opened this portion of my remarks by saying that I did not for a moment suggest that these people came as spies or snoopers.

THE EARL OF ONSLOW

The noble Lord said that at first, and afterwards suggested that they were, in fact, spies.

LORD BURDEN

If the noble Earl will keep his temper we may get on.

THE EARL OF ONSLOW

My temper is my own, and I keep it.

LORD BURDEN

I suggested only that the persons who attend these committees are responsible to the Ministry and not to the committee they may well report what was said at the committee.

THE EARL OF ONSLOW

They go there as a liaison between the Ministry concerned and the committee and, as I have said, any sensible committee would be only too delighted to have them present.

LORD BURDEN

I am speaking out of a far greater experience than the noble Earl, and I can assure him that the presence of these inspectors from Ministries has always been resented by men and women of all political parties. I can assure him that that is the case, and we will leave it at that. I am sure that that is not the right way to get the best out of members of a committee who are giving voluntary service.

My final point is with regard to the declared intention of the Ministry to develop central purchasing. In order that there may be no doubt about this, may I give your Lordships, from the Minutes of Evidence before the Select Committee on Estimates, the actual words used by a representative of the Ministry? I am sure no exception can be taken to that. These words appear on page 284: There is a general policy in this sense, that the Ministry have said they intend to develop central purchasing of common user goods, that is, the placing of contracts, centrally negotiated, on which hospital management committees and boards can order. They intend to develop that, step by step, on it being shown with each individual case that this is a group of articles or equipment where central contracting is going to result in genuine economy. I quite agree that there is a field for central purchasing where the production of the commodity is a monopoly in the hands of one or two firms. But that is something entirely different from compelling all hospitals to purchase their supplies of a commodity from one firm where there is no such monopoly of production. Is it the policy of the Ministry to put out of business firms who have devoted themselves over a number of years to coping with the specialised requirements of hospitals, for the benefit of one or two firms who will then ultimately enjoy a complete monopoly?

A study of the Minutes of Evidence before the Select Committee on Estimates will show that an able and experienced administrator like Sir Basil Gibson, onetime Town Clerk of the City of Sheffield and one of the most distinguished men in the North, is most strongly opposed to the present policy of the Ministry. I happen to know that there are other chairmen who take the same view. For my part, I want to see this great experiment of co-operation between the State and voluntary service justify the faith that democratic methods in this country are flexible and capable of meeting the ever-changing circumstances of the twentieth century. But if this tendency towards an increasing central domination and control of which I have given instances is allowed to continue and to expand, then it is my respectful submission that this great experiment will end in failure and disaster.

4.58 p.m.

VISCOUNT WAVERLEY

My Lords, I rise with some trepidation, particularly after the speeches of noble Lords who are themselves eminent practitioners, to offer a layman's opinion on some aspects of the matter which has been under discussion this afternoon. I am very conscious that in what I am about to say I may seem to be making some reflection upon a most admirable body of men. Nothing could be further from my intention, but experience of the 1911 scheme, the first National Health Scheme—and I saw it at very close quarters from the beginning of 1912 until the end of 1916—convinced me that the relationship between the practitioner and his patient is such that, if effective safeguards are not available in a national scheme, abuses will inevitably creep in. What nearly wrecked Lloyd George's Health Scheme under the Act of 1911 (I am not using language of exaggeration) was, in the first place, lax certification and, in the second place, extravagant prescribing. The remedies that were adopted, and had to be adopted, then were, first, the institution of an effective system of medical referees which dealt with the matter of certification, and hen a number of devices by which it was hope to cure, at any rate in some measure, the evil of extravagant prescribing.

There was the publication, under authority, of an approved list of therapeutic equivalents. There was resort to stock mixtures, and I well remember the hubbub that the adoption of that device aroused. There was great criticism from people who apparently failed to realise that many of the most elegant and most popular proprietary preparations are, in fact, nothing more than stock mixtures. I have no wish to dogmatise as to what might be the appropriate remedy in present circumstances for any abuse in the matter of extravagant prescribing. I should have said a moment ago that, apart from the devices to which I referred, there was introduced a system of surcharges on the practitioner who was found to have been prescribing extravagantly—not at all an attractive instrument. But I do think that it is necessary that consideration should be given to the devising of effective means of dealing with extravagant prescribing. The noble Lord, Lord Moran, referred to an interesting development in Denmark. He told your Lordships that something similar had been in operation in Australia for a period, I think, of eighteen months—a system under which medicaments are classified and dealt with differently, according to their place in a classification which is related medically to the requirements of adequate treatment.

Apart altogether from the economies that may result from the elimination of abuses—and I hope, as I have said, that careful attention will be paid to the abuse of extravagant prescribing—there is a question of economy which has nothing whatever to do with abuse. The noble Lord, Lord Moran, dealt with the question of imposing a "hotel charge." If I may say so, I thought he made out a very convincing case. He pointed out that the latest advances in medical science to be applied effectively involve heavy expense. I had some personal experience in that matter, because a short time ago I had occasion to obtain a small supply of one of these modern anti-biotics. It was only sufficient for a short course of treatment. It cost me, however, £25. I at once raised the question whether such a supply would be available under the National Health Service, and I was told that undoubtedly it would be.

It seems to me that if, for example aureomycin is the best-known remedy, or perhaps the only effective remedy, for certain firms of virus pneumonia, patients under the national scheme, if the Service is to be worthy of the name, ought to be able to obtain it. The noble Lord, Lord Webb-Johnson, referred to cortisone but surely, if these very costly remedies are to be made available in adequate quantity for the general community under the Health Service, that fact points inevitably to the necessity of making all reasonable economies in other directions. Otherwise, as has been pointed out by noble Lords, this scheme will inevitably deteriorate—if, indeed, it does not break down. I know perfectly well that to talk in this way is to provoke the comment that economies of this kind will be effected at the expense of the sick and suffering. But is it not a perfectly fair rejoinder that these are the very people to whom an adequate, comprehensive Health Service is a priceless boon?

I should like to say only one further word on quite a different topic—the recent addition, under the Danckwerts award, to the remuneration of general practitioners. The noble Lord, Lord Moran, has suggested that that addition may set up a lack of balance between the general practitioner and the specialist in their respective places in the comprehensive Health Service. I do not know, and I do not suppose anyone has had an opportunity of studying the details sufficiently to judge, whether that would he the result. I would only say that if that were the result it would surely be most unfortunate. In any service, in any organisation comprising large numbers of individuals, there must be differentiation. There must be adequate opportunities and adequate inducements for the best qualified and the most experienced to rise to the top. That seems to me to be a matter calling for continuous attention on the part of Her Majesty's Government as the new arrangements come into operation.

I would only add that I believe it to be the case—and I speak from experience as Chairman of the Post-Graduate Medical Federation of London—that there are at the present time a substantial number of highly qualified medical practioners who have gone through the courses of advanced study to which the noble Lord, Lord Moran, referred, who have not found it possible to obtain positions as consultant s under the medical service and who yet find it extremely difficult to establish themselves in the general practitioner service, which I am assured they would be perfectly ready to do, despite their superior qualifications, if the facilities were available. I would venture to express the hope that the recent award may have the effect of enabling a high proportion of these highly qualified practitioner, who, as I say, have not been able to establish themselves in practice, to find a footing among the general practitioners under the Health Service.

5.10 p.m.

LORD KERSHAW

My Lords, I regard it as a very fortunate coincidence that I am permitted to follow the noble Viscount who has just spoken. As he spoke, my mind went back some forty years, when I think he was one of the brilliant group of boys known as Sir Robert Morant's boys, every one of whom has made a mark for himself in the activities of either the Government or the country as a whole. I do not propose to deal at any length with the whole subject—indeed I could not—but there are one or two features of it that have not already been dealt with and f feel that it would be quite a wise thing to consider them. In the first place, I approach the matter with the idea that none of us on either side of the House is concerned to make Party capital out of it. Indeed, if we on this side of the House were disposed to, it would be easy for the noble Earl who is to reply to point to the fact that most of the things that are being done at the moment were started at a time when we had control of them. Therefore, merely as a precautionary measure, I should prefer to be non-controversial at this time. Perhaps I ought to say, first, that I think it would be helpful to the House if noble Lords who put a Motion on the Order Paper were to indicate a little more clearly than has the noble Viscount the line that they are likely to take on a subject of this kind.

VISCOUNT BUCKMASTER

May I apologise to the noble Lord for that omission? In twenty years I have never hitherto failed to indicate what line I was going to take, and I much regret that on this occasion I did not give the noble Lord opposite an opportunity of knowing what I was going to say.

LORD KERSHAW

Knowing the noble Viscount and his kindly and generous nature, I was quite sure that he would be generous in all his remarks in connection with the National Health Service, and that if he had any criticism to make it would be with the one idea of improving the Service.

So many people seem to regard this great National Health Service as something that came about just accidentally in the mind of a certain gentleman in another place in 1948. It was my good fortune for many years to be a member of the Public Health Advisory Committee of the Labour Party, which made a complete survey of the whole of the health services of this country. We went into a great deal of detail in devising some scheme that would place at the disposal of every sick person all that medical science and skill could give. Probably the main part of our scheme of those days, which has not yet fructified and which the noble Viscount referred to, dealt with the lack of health centres. We attached a great deal of importance to the establishment of health centres, which not only would enable the general practitioner to have an easier time than he has had, acting entirely on his own, but would make it possible for general practitioners as a little group to specialise, each one of them, in some particular subject, and all illnesses of that kind would be referred to the person concerned. To-day it is felt in a good many quarters that probably one of the best forms of economy that could be practised would be to establish the clinics to which I have just referred. It is felt that to cause everyone to go to a hospital for proper diagnosis and examination is much more costly than would be the case if there were local centres to which patients could go. That is quite apart, of course, from the value that these centres would be, not only to the doctors themselves but to the people who reside in the areas.

We have heard several views as to the attitude of doctors and consultants to the National Health Service. Perhaps I ought to have said so before, but I happen to be a member of the board of governors of one of our great teaching hospitals, and, for what it is worth, my own experience is that everyone concerned in the administration of the Health Service, from the consultant downwards, or upwards (whichever way you like to put it), is most enthusiastic about it and is satisfied that only by some such machinery will the people of this country get a real medical service. Of course, that is not to say that improvements cannot be devised and economies effected; but, speaking by and large, many doctors for the first time feel that it is now within their capacity to give the skill and service of which they are capable. I should not exclude from my gratitude the nurses, for whom I have the greatest respect. I happen also to be chairman of another hospital, at which the nurses as well as the doctors are most enthusiastic in giving of their best. Only yesterday I was at the hospital, and although I have had shown to me many letters from patients, one that was shown to me yesterday moved me deeply. There is no question but that the service given in the hospitals now is as good as ever it was in their history. I urge those who feel any doubt about that to take the opportunity of visiting a hospital and listening to the people who happen to be patients there. I assure your Lordships that nothing is more moving than the gratitude of people for what is being done for them by the doctors, the nurses and the whole of the staff of the hospitals.

Nor would I leave out of my gratitude the officials of the Ministry of Health, who are doing wonderful work. While my noble friend who spoke a moment ago seemed to resent what he called "the inspectors" coming round, in the hospital that I have the pleasure to serve as a governor we welcome such investigation. As chairman of my hospital, I was asked, as were others, to see what economy could be effected in our administration. I did what I could.

I spoke to my officials, and, at the end of it all, I reported to the central department that I had no yardstick by which I could judge whether or not my hospital was efficiently and economically run. As a result of representations of that kind (I hope I am not telling tales out of school) we have invited the Ministry of Health into our great hospital, to examine things and to tell us whether economies could be effected here and there. But whatever may be done in the way of trying to effect economies, there are a few outstanding factors which cannot be dealt with by any method that may be devised for examining hospital administration. I was shown, yesterday, a list of, I suppose, fifty articles of food which are used in the establishments of one of the largest restaurant businesses in the country. These are articles of food that are sold in all parts of these Islands, and the cost of them now is 37½ per cent. more than it was in 1948. In my own hospital, in 1948, the weekly cost of food for patients was 23s. per head. In 1952 it is 29s., an increase of 28 per cent. The same thing applies with regard to nurses. In 1948, the weekly cost for food for each nurse was 14s.; in 1952 it is 19s. 6d., an increase of 40 per cent.

During this debate, I have had to leave the Chamber to attend to other business, so I have not been able to listen to all that has been said, but I have no doubt that one or another of your Lordships will have referred to the enormous increases in the price of drugs. I have already told your Lordships that we welcome any assistance which the Treasury or the Ministry can give us in effecting real economy in the administration of our hospital. But I think we ought to remember that many of the people who are on the boards of governors or management committees of these hospitals are business people, just as keen on effecting economy and producing efficiency at the hospitals as they would be in their own businesses. I may tell your Lordships, in this connection, that at the hospital to which I have referred we have—I was going to say that great financial genius, but perhaps that is an extravagance—that great man, Sir Frederick Bovenschen, who was for many years head of the Financial Department of the War Office. I myself have been in public life nearly fifty years, and I do not remember sitting under arty finance chairman so efficient and so keen as Sir Frederick Bovenschen. In his hands are the accounts of the hospital I have mentioned. I assure your Lordships that, while we welcome any assistance that can in given to us, we are constantly on the alert to produce greater economy and higher efficiency.

I realise that this has been a long debate and I feel constrained to cut out some of the things which I wish to say. But I do urge the noble Earl—I know that attention is being given to these matters—to see that consideration continues to be given to the question of providing some sort of accommodation other than hospital accommodation for old and chronically sick patients. In my hospital last month, 10 per cent. of all the beds were occupied by people who had been there two months or more; and many had been there for six months. We have a report on each of these cases, meeting by meeting, to make sure that everything is as it should be, and that nothing more can be done. It would be a great help if, as soon as is practicable from the financial point of view, some other treatment than hospital treatment could be made available to the old and chronically sick people. I was told only the other day by a man who is probably one of the most knowledgeable men in this particular business, that, to quote his words: We have substantial evidence that the position of the elderly and the chronically sick for whom beds are not available is pitiable in the extreme. I think we all know how true that is and there is no need to stress it.

Now, I wish to call the attention of the House to two matters which I think are worthy of consideration. I happen to be president of the Marie Curie Memorial, and during the last year we have conducted an inquiry into the social conditions of people who suffer from cancer. We have not attempted anything in the way of medical research; we have simply carried out social rest arch, and the survey has covered the whole of the Kingdom. In England, forty-sic out of forty-nine counties, and seventy, three out of seventy-nine county boroughs, have co-operated through their medical officers of health. In Wales, the whole of the counties and county boroughs co-operated in this survey. In Scotland, twenty-seven out of thirty counties co-operated. The survey was conducted jointly by ourselves and the Queen's Institute of District Nursing, together with the medical officers of health, and some 7,050 cases were examined. I have here a proof of the Report which will probably be published within the next two or three weeks, and I commend it to your Lordships. The main point that emerges from this survey is the wretched conditions in which so many of these people are living. Of these 7,050 cases, 70 per cent. were sixty years of age or over, 24 per cent. were seventy-five years of age or over. While, again, I do not want to weary your Lordships. I feel that I ought to call your attention to one passage in the Report, which, as I have said, has been compiled by a joint and very important body. This is the passage: It was among the elderly that some of the gravest social problems were found. Some patients depended on an equally aged wife or husband, others had outlived all their friends and relatives, and suffered acutely from neglect and loneliness. In some instances their suffering was aggravated by squalid surroundings, which they were unable to improve by reason of infirmity, and they were often reluctant to leave. A few strongly resented the attention of the nurse. A noticeable number were blind, either as a result of cancer or from other causes. Perhaps I may quote three short cases, which I think are typical as showing the conditions under which so many of these tragic sufferers are living at this time. Case 179/58: totally blind and entirely dependent on kind neighbours, whose doctor was unable to secure a hospital bed, although she was critically ill; Case 27/125: whose illness was very far advanced when friends called a doctor, and who lived in extreme squalor, resisting any attempt to wash or care for her; Case 25/16: who had no one to look after her except a sister aged 88. There are two others I should like to quote. The first is: 53/174: alone in a bed-sitting-room, seldom visited by her married children, relying on the goodness of neighbours, and, in the nurse's opinion, receiving very little nourishment; And the last one is: 40/13: living in a large house, which was extremely dirty, as she was almost blind and refused help although she had the means to pay for it. So there is here a hidden sore in the body politic to which I am hoping the survey which has been undertaken, the Report of which will be published shortly, will Call attention. Perhaps the Minister of Health will be disposed to take notice of it. We have started dealing with this question ourselves, and only last week The Earl of Wemyss opened the Hill of Tarvit, a house in Fifeshire, which is intended to accommodate a number of these ill and suffering people. Another place is shortly to be opened in the West Country, and we are exploring the possibility of opening one in the metropolis. I am inclined to think that it will require the efforts of voluntary organisations, such as the one I have mentioned, to bring home to the nation the need for national effort to deal with this particular problem, which is a sad part of our social life.

Let me turn to what I think is a much more hopeful and gratifying feature of our health service. Some twenty-five years ago attention was drawn to the number of deaths of mothers in childbirth. At that time, the death rate was something like four or five per thousand. Sir George Newman, who was First Medical Officer of the Ministry of Health, followed later by Sir Arthur Newsholme. repeatedly called attention to this problem in their annual reports. Government after Government took little or no notice of these reports. The Chief Medical Officer was able to say that if the services which were available in certain parts of the country were made available to the whole country, thousands of women would be saved every year. Although the infant mortality rate had gone down from 150 to 70 in the period I am thinking of, the maternity mortality rate was stationary. Notwithstanding the developments in public health, medical science and everything else, that problem defied solution. As these eminent men have pointed out, it was clear that if we had done what it was possible for us to do, we could have saved lives. Of course, this has nothing to do directly with the existing Health Service we are considering, but it has everything to do with the outstanding fact that medical science is now at the disposal of everybody in the country, and the improvement in diagnosis and the discovery of sulphonamides and antibiotics, useful, valuable and effective as they have been in reducing the death rate, would have been of little avail if they could not have been used on all the people who required their use. We find that from 1935 there began a steady decline in the maternity mortality rate until it is now one per thousand, the lowest in our history. Simultaneously, the infant mortality rate has gone down to the lowest in history.

I do not think it possible to put a financial figure on the value to the community of the saving of these thousands of women, but I would say, with emphasis, that too many people make the mistake of regarding all that is spent on health services as a dead loss. I wonder what value in productive capacity results from the better and prompter way of dealing with minor injuries which is operated to-day through the Health Service. I wonder who would say what could be written on the credit side of any balance sheet we tried to draw up for the better health of our children, which must ultimately recoup the money spent through their better productive capacity when they reach working age. I wonder who would dare to estimate the value in pounds, shillings and pence of the women who have been saved. But there is more than that. Sir George Newman used to say that for every woman who died in childbirth, there were scores more or less permanently injured. Only on Monday I was speaking to one of the most eminent men on this subject, who also said that a great many women were permanently injured by reason of lack of proper service at childbirth. I will not weary your Lordships in recounting some of the indirect effects which Sir George Newman used to ascribe to that cause, but the social effect of the invalidity of women because of lack of proper attention at childbirth must be tremendously costly. I urge whoever may be considering this subject not to regard the £400,000,000 as money thrown down the sink. It has a return, and must have a return, as a capital investment for the future, in the better health of our children, in the better productive capacity of our people and the reduction of the invalidity, particularly of the temporary invalidity, of our working population.

In conclusion, I would say that there was one phrase in the noble Viscount's speech that left me puzzled, and I hope that Lord Buck master will put my mind at rest when he comes to reply. Would he tell me exactly what he meant when he said, "The man who is cured of one disease, merely lives to die of another."?

5.38 p.m.

THE EARL OF ONSLOW

My Lords, we are all grateful to the noble Viscount, Lord Buckmaster, for raising this subject to-day. He, and the noble Lords who have spoken, have contributed a great deal to this important question. I think that everyone who considers this matter seriously agrees that we must have a National Health Service, although it may well need modifying from time to time, at longer or at shorter intervals. We must also realise that the lynchpin of any service is what is known as the "G.P." I think that is the gravamen of the speeches of the noble Viscount and of other noble Lords.

As your Lordships well know, until yesterday there were three bodies looking into this matter, two of which are still sitting. The findings of Mr. Justice Danckwerts in his award were announced in another place last night by the Minister; and several noble Lords have touched upon the matter to-day. In the short time at my disposal since seeing those findings I have made what study I could of them, but the matter is obviously very complicated, and I feel that it would not he wise to discuss it in detail until we have had an opportunity to consider it and give considered views upon it Perhaps your Lordships would like me to refresh your memories by reading the exact statement made by the Minister in another place last night, so that we may be clear just what it was. The Minister said (OFFICIAL. REPORT, Commons; Vol. 498, Col. 209): I think the House should be informed at once of the result of the claim by general medical practitioners for increased remuneration in the National Health Service. As the House is aware, the late Government agreed to refer the doctors' claim to an adjudicator on the understanding that his award would he binding on both parties, subject to agreement being reached on an improved method of distributing doctors' incomes. The present Government continued these arrangements and Mr. Justice Danckwerts was appointed to act as adjudicator. The Secretary of State for Scotland and I have now received the adjudicator's award. Its precise effect can be determined only after more detailed study, but, broadly, it amounts to the award of an additional £9,750,000 remuneration for the year 1950–51 (the tear on which the award is based) with corresponding increases for previous and subsequent years. While, as I say, the full calculations have yet to be made, I feel I should inform the House that—in very approximate terms—this may involve an additional charge on the Exchequer of as much as £40,000,000 in the coming financial year to cover the period back to 5th July, 1948. This means that in spite of the serious measures of economy which have already been proposed to restrain Health Service expenditure within a ceiling of £400,000,000, it will be necessary to seek a Supplementary Vote for this additional amount. I think the House will agree that so far as we can go at the moment that is a full and frank statement of the situation after the award was given.

The concerns of the other bodies are still sub judice, but perhaps your Lordships would like me to give the details and the terms of reference. There is a Working Party, consisting of representatives of the medical profession and of the Health Departments, which has the following terms of reference: To secure an equitable distribution of the Central Pool based upon the recommendations of the Spens Committee, the object being to enable the best possible medical service to be available to the public, and to safeguard the standard of medical service by discouraging unduly large lists;"— that was one of the points raised by the noble Viscount, Lord Buckmaster— at the same time, to bring about a relative improvement in the position of those practitioners least favourably placed under the present plan of distribution, to make it easier for new doctors to enter practice, and to stimulate group practice. Those terms of reference, I feel, cover a large number of the points raised by the noble Viscount and other noble Lords this afternoon. It shows, in a nutshell, that those points are being taken up actively and will be dealt with. In effect, what it means is that the Working Party, now that Mr. Justice Danckwerts has determined what I might call the total size of the cake, must discover how best it should be distributed.

The other body that I mentioned earlier, which is also at the moment sitting on this subject, is a special Committee of the Central Health Services' Council, under the Chairmanship of Sir Henry Cohen. This Committee has the following terms of reference: To secure and make a report on whether the existing arrangements for engaging in general practice under the National Health Service are such as to enable general medical practitioners to provide the best possible standard of service and, in particular, to advise upon—

1. (i)The range of work and standards of practice which should be expected from the 1016 general practitioner by the public and medical profession.
2. (ii) Types of general practice.
3. (iii) Mode of entry into general practice.
4. (iv) Non-medical help.
5. (v) Equipment and environment.
6. (vi) Method of remuneration.
7. (vii) Liaison with hospital and specialist services.
8. (viii) Liaison with local authority services."

This Committee is, of course, looking at the broader aspects of the organisation of general practice. It began its labours in February, 1951, and is still taking evidence. I feel that the investigations I have described should go a long way to satisfying the noble Viscount, Lord Buck master, and other noble Lords who spoke on these points, that something very active is being done though, like all such investigations, they will take time and are not yet completed.

The considerations mentioned by the noble Viscount, Lord Buckmaster, regarding remuneration and the size of doctors' lists are, as your Lordships will appreciate from the terms of reference that I have just read, very much in the Minister's mind. And, quite obviously, while these two bodies are still sitting it would be improper and unhelpful to discuss the matter in too great detail. It is agreed by all that the doctors' lists of patients are at present considerably inflated. A great deal of this is due to the fact that it is difficult to keep registers up to date; and with common names like Smith, Jones and Robinson it is difficult for those who are keeping the register to make certain that they still have the right and not the wrong ones on their register. I feel that that is very much borne out by the fact that there are thirty-six pages of Smiths in the London Telephone Directory. I hope that on that particular point I have covered what the noble Viscount sought to find out.

The noble Viscount, Lord Buckmaster, and other noble Lords, raised the question of charges. Here I am speaking for myself, because I feel that on these matters one is entitled to say what is one's view, wherever one may be, provided, of course, that one makes it quite clear that it is one's own view. I consider that any matter such as this affects the whole nation so much that it should be well above Party politics—though there is no doubt that an element of Party politics must come into it, because it is a question of method, of the best way of applying the Service. That is where we argue. When I say this, I mean that the method we devise (and obviously this involves how the money is spent to achieve the service) must be the one that will provide for the community the best Service that will fit in with our national economy. I would emphasise that it should not, by taking too large a share, prevent us from running other essential services as efficiently as they should be run. On a particular point which I mentioned earlier, when the noble Lord, Lord Shepherd, and others were discussing it, I repeat that the question of a "hotel charge" is not in the mind of Her Majesty's Government at the moment.

The House will remember that when the 1946 Act was introduced it was debated in the greatest detail, and I think all sides of the House can take credit for the final measure. It was fully discussed in your Lordships' House and was amended considerably. I think it left here with members on both sides of the House rather (if I may use a colloquialism) "backscratching" on the Third Reading. But I do not think that either the authors or those who took part in assisting to amend it regarded the Act as a perfect answer. A huge plan and an enormous experiment like this cannot possibly be perfect, and I think it is perfectly fait to say that neither this Government nor the noble Lord's Party opposite, if they were still in office, could honestly say that they were still satisfied with the working of the Act. They would, I think, agree, that it must be amended from time to time. I suggest that the more we can keep this subject away from Party politics the better will be the results of the Act for the nation as a whole.

Noble Lords have raised the question of over-prescribing. That problem is very much in the Minister's mind, and I think we all agree in whatever part of the House we sit that we do not wish to see the Service abused. We hear stories—the noble Viscount and others have told us anecdotes—of people who try to get more than their fair share of what they consider a free Service. Of course it is not a free Service; in fact, as we have already heard, it will cost £40,000,000 more than it does now. Hewever, as I have said, this question is very much in the Minister's mind, and there are bodies looking into it and discussing it. Among other things, there is this little booklet which is being sent round to doctors, in cooperation with the Ministry and the British Medical Association, advising them on the question of prescriptions. One particular thing it does, for instance, is to suggest the use of certain drugs which do the job and which happen to be cheaper than the o le the doctor might first, shall I say, put his hand on in his dispensary cupboard, The noble Lord, Lord Haden-Guest, is not here this evening, but I am sure he will not mind my saying that he told me about a certain prescription which can be made up and which has exactly he same effect as, although it is a great deal better than, a certain patent medicine often used by doctors to-day for the take of convenience. That is the sort of thing which is being looked into, and I am given to understand that this little booklet should have a useful effect. I think that what I have said also takes in part of the remarks made by the noble Viscount, Lord Waverley.

The noble Lord, Lord Kershaw, in what I thought was a most interesting and instructive speech, mentioned the question of the old people. I would say straight away, and with all frankness, that we are all interested in this matter and will certainly pursue every possible avenue to alleviate this very distressing situation. I do not think any of us who goes about the countryside, or takes an intelligent interest in what is going on, can fail to realise that there is this tremendous sore in our social life which must be dealt with as soon as possible. The noble Viscount, Lord Buckmaster, mentioned the question of health centres. The Minister is most anxious that this idea should be developed, but, of course, there is no doubt that its progress has slowed down. Indeed, this was bound to happen, because of the shortage of building materials and the building of houses. In my opinion, in the long run it is probably more important to ensure that the number of houses built is at least sufficient to ease the housing situation.

My Lords, I think I have covered nearly all the questions which have been raised. The noble Viscount, Lord Buck-master, mentioned a code for patients. I understand that there is one on the hack of the health card, although I am bound to say that I have not read mine. Once again I should like to thank the noble Viscount for raising this subject. I think and hope that I have covered all the points raised by your Lordships, and I hone that I have satisfied the House.

5.57 p.m.

VISCOUNT BUCKMASTER

My Lords, I am indeed grateful to those noble Lords who have taken part in this debate, and in particular to the noble Earl for his reply. May I be allowed a very few moments to say something about some points which have been made? The noble Lord, Lord Shepherd, is not here, and I can only say that I thought it a little unfortunate that he should express regret that he had been unable to check the accuracy of my figures. I can assure him that such an operation is not necessary. If he studies my remarks to-morrow he will see that in my references to extravagance I was prompted solely by the desire that the quality of the Service should not be diminished. That is the basis of my reason for supporting a charge. The noble Lord, Lord Shepherd, is right in saying that the public decides how they are to pay for it; but if the public are not going to economise there will be no Service worth having for which to pay. It will be such a second-rate thing that it will be of no value for anyone.

The noble Lord, Lord Kershaw, in what, if he would allow me to say so if he were here, was a very thoughtful speech, asked me what I meant by saying that a man cured of one disease to-day lives merely to die of another disease to-morrow. Unfortunately the noble Lord has gone. If I have left obscurity in the minds of other noble Lords who sit with him, I hope they will interrupt me. What I meant was this. The cost of medicine is ever increasing. The battle is never finished. Death is the sole conqueror. When, at costly expense, you cure a man of one disease, it is a great achievement; you prolong his life. He lives on; but he dies in the end, as we all must. In the end his disease may be more costly and more difficult to cure and very protracted. I am not meaning that in any sense of criticism of the service. If I was criticising anybody, body, it would he criticism of the plan of creation. That is an inescapable fact.

EARL JOWITT

Would the noble Viscount say what lesson he wants us to draw from that? Does he mean that we should not trouble to cure the man of the first disease, because ultimately some other disease is bound to get him?

VISCOUNT BUCKMASTER

I am grateful to the noble and learned Earl. I am sorry that I have not made myself plain, and I hope he will interrupt again if I do not do so. My point is that I rejoice in the fact that we cure people, but I am anxious that we should understand what the cost of curing people is. I am anxious that we should understand that that cost is ever soaring, and that as we prolong life into old age so we probably increase the cost of curing diseases which are more complex and which the patient is less able to resist. In other words, the battle as I see it, if the noble Earl will permit me to put it in this way, is eternal—it is never won. I hope that if the noble and learned Earl does not agree with me, he nevertheless sees what I am trying to say.

EARL JOWITT

I understand what the noble Viscount is saying, but I am at a loss to find out what lesson he wants us to draw from his remarks.

VISCOUNT BUCKMASTER

I am grateful to the noble and learned Earl. One does not often have a verbal exchange with him without being worsted, but on this occasion I feel I am right. I am merely saying that the scheme is costly; that you cannot limit the cost; that it will go on increasing; and that the cure of people, noble and splendid though it is, and to be encouraged in every way, will not limit the cost of the scheme, and that we must be prepared to have rising expenditure.

With regard to health centres, about which both the noble and learned Earl and the noble Lord, Lord Kershaw, spoke, I would point out that these centres were estimated in 1948 to cost £374,000,000. I do not quite see how we are going to carry out such a task now. I have rather in mind, not so much the creation of health centres as securing that cottage hospitals, in which the general practitioner now has an opportunity of exercising his skill, should not he turned into specialised units. That seems to me the alternative way of dealing with the most vital aspect of this whole subject which noble Lords skilled in the profession have stressed—this cleavage between the general practitioner and the specialist. I think that that concludes the brief remarks which I wanted to make. I should like once again to offer my thanks to the noble Earl for his full reply and the assurances he has been able to give. I beg leave to withdraw my Motion.

Motion for Papers, by leave withdrawn.