§ 4.14 p.m.
§ LORD SALTOUN rose to move to resolve, That in the opinion of this House a large proportion of the failures in the Welfare and Health Services are due to imperfect co-ordination between the various authorities concerned, that local resolution of difficulties is essential to an efficient service, and that in many cases greater local discretion, financial and administrative, would result in better service at less cost. The noble Lord said: My Lords, before addressing myself to the Motion that stands in my name this afternoon, I want to say expressly that I am not attacking anybody: I am not attacking the Government, and I am not attacking any individual. So far as I know or can see, everybody connected with the matters to which I am addressing myself is doing his duty with zeal and sympathy. If there are failures—and I think I can show your Lordships that there are many failures—then it is the system that I seek to correct, and not any individual.
§ It is nearly three years since your Lordships debated a Motion of this kind, but, while I do not suppose for a moment that your Lordships have any recollection of what I said on that occasion, I shall not repeat it, although I believe that what I said then is, with one exception, just as true to-day as: it was then. The exception is the list I gave your Lordships of the various departments and authorities who are concerned with the functions of the Welfare State. They have changed a little and I propose to read to your Lordships the present list. To-day the principals are: the Assistance Board, the Ministry of Education, the Ministry of Health, the Ministry of Labour and National Service, the. Ministry of Pensions and National Insurance, the Ministry of Housing, the county councils—the welfare officer, the children's officer, the health services and the mental services (through the duly authorised officer), the borough councils (especially with regard to housing), the citizens' advice bureaux, and a great many other voluntary associations. I do not suppose that even this list is complete. It must be obvious to every one of your Lordships that if all these bodies acted in complete harmony at all times. It would be little short of a miracle. 1086 The point is that the field of exercise of their several functions is the body of one unfortunate man, woman or child; and it is this which suffers when these august parties act in a dilatory way or when there is any disagreement.
§ During the past three years, the trend of the various services has been a little towards crystallisation. For example, bodies have been formed like the institute of Welfare Workers, alongside others which already existed. These bodies all tend to want to institute examinations to ensure the fitness and ability of their members, but this all tends towards the marking out of boundaries between various branches of what should be a common service. If I may offer my own humble opinion on this, which is a minor matter, my view is that no examinations should he officially recognised save those which exact a thorough knowledge of the Acts under which the services are supposed to work; any medical knowledge that may, be needed and also a thorough working knowledge of certain elementary social laws such as the law of divorce. After that, working experience is probably the best thing to demand. I have gone into this detail because it is the essence of the Motion that I am proposing to your Lordships this afternoon that all branches of this army of ours, which is fighting the results of poverty, misfortune, helplessness, sin and disease, are part of one force, and all must come to each other's support. The motto is not "Trespassers will be prosecuted" or "Over to you." We are all part of one army.
§ Now I have to show as shortly as I can that there are failures due to imperfect co-ordination. Three years ago gave examples and statistics which I had extracted from a large number of cases and to which I have since added a large number. A complaint was made in the debate that I had not communicated the examples I wished to choose to the Ministries concerned, although I cannot imagine that they were ignorant of the kind of things that would he produced and I should have thought it almost lèse-majesté, to assume that the noble Lord who had to answer for the Government on any point was ignorant of it. But to-day, I shall adopt a rather different method, even though I know this afternoon that the noble Lord, Lord Mancroft, has practical experience of this matter and will 1087 probably give us a very interesting answer. I will, therefore, ask your Lordships to take it for granted that I can produce a good many cases in support of what I am saying, and leave it at that. The fact that Lord Mancroft is going to reply for Her Majesty's Government is interesting in another way. As your Lordships will see, I have drawn my Motion as widely as possible, to cover the whole of the welfare services, because I wished to put the Government in this quandary: that they must ask themselves who would reply. I wished to emphasise the fact that so many different authorities are concerned in this matter that some sort of co-ordination is rather difficult.
Nearly two years ago, at a health conference at Margate, emphasis was laid on the difficulty of getting hospital beds for those who would benefit from ordinary and nursing care, and one doctor, I remember, complained that
Beds are reserved for those likely to benefit from newer medical and surgical techniques,
the other people being shut out. Another responsible official, in a careful paper, said that the division of responsibility only aggravated the situation. He continued:
With the current shortage of accommodation … committees … have been most concerned to see that their organisation was not overburdened with patients who might conceivably be regarded as the responsibility of … other organisations.
He went on to add:
Each has made great efforts to pass the buck.
This is the complaint running right through the welfare services. I ought to add that I am told that in some areas the county councils have united the responsibility of their health and welfare services, and that seems to me to be a step in the right direction and one that should be encouraged. Last summer I was present in the North at a conference of hospital administrators and welfare workers, and I well remember the discussion one afternoon, when as many as half of those who addressed the conference spoke most eloquently on the need to have someone with the power of commanding an emergency bed in a hospital, of determining on the spot how any particular case should be dealt with, and of discovering urgent cases before it was too
late. About half of the remainder, I noted, said much the same thing in rather different words. I humbly suggest that these voices, coming from persons actively engaged in this work, do merit attention and indicate a primary need. The powers that they were asking for seem to me to be the necessary tools with which the work ought to be done.
Last November two well-informed articles appeared in the Manchester Guardian. They were headed "The Welfare State Fails." They quoted a report of the medical officer of health for Brighton, saying that:
The lot of old people has in some ways worsened, not improved, with the system of divided responsibility; as the individual falls into the gaps between National Assistance, local authority welfare, national hospital and local authority socio-medical services.
Several unpleasant cases are quoted of which I will refer your Lordships to just one, to show the kind of thing that is happening. This is the case of a woman, 78 years old, who was being treated as an out-patient for a broken wrist. She was discovered by the district nurse in her room which was five storeys up, unable to move from her chair: the nearest tap was two storeys down, the nearest lavatory three. I forbear to inflict upon your Lordships the description of her condition. The sanitary inspector, the doctor and the welfare officer had all failed to get her into hospital. The nurse did what she could, but it was nineteen days before she could be got in.
That is only one case out of many, and the writer maintained that the cases quoted are:
the small change of the record and as such a more valid basis for protest than the occasional 'horror' stories; and that none of these cases are likely to appear surprising to anyone who really knows what is happening.
He adds that there are grounds for assuming that the upper strata of administration are less acutely aware of them. My Lords, that is as may be. It is the old cry of those in touch and in immediate contact with acute misery—"The King does not know." It is the same as the Abbé Pierre said to us the other day, when he complained of the "façade of official satisfaction with conditions." I do not put too much emphasis on that, but that is the feeling of the men on the spot. After reading these articles, a group secretary consoled himself that
such things could not occur in his area and then, stung by his own complacence, he made an analysis of the waiting list of his hospitals, and found 50 male and 206 female cases which were in danger of becoming similarly discreditable. Your Lordships will see that I have brought my facts from every corner of England, and I submit that they merit attention.
§ Now let me turn to the welfare side. As your Lordships know, the county council provides homes and hostels for old people. I do not suppose that any home of any kind can be provided at a cost less than £1,000 per bed, nor do I suppose that it can be run at less than £5 a week per bed. My noble friend Lord Amulree has, I believe, calculated that the local authority must spend at least £4 a week to keep people in their own homes. I still feel, quite unrepentantly, that if some local authority had discretion to give relatives of old and sick people three guineas a week, less, of course, any contribution that they might obtain from that person's pension, it would be an economy and would lead to the registration of some old people who would otherwise escape observation. As near as I can calculate (I think my figures overestimate the number) there are only four persons in regular work for every person in this country who is technically old, and unless economies can be effected in respect of this matter the time will come when the four people who are in regular work will begin to rebel, and we shall get into difficulties. Only yesterday morning I received a letter on this subject from a man who said that six years ago his father was looking after his mother who was senile, and his father had a stroke. This man had to abandon his business to help them. He could get no adequate help. He could not get anybody for twenty-four hours a day—not at any price. He lost his insurances, which he could not keep up. Both his parents have just died and he has now got to pull his life together as well as he can. He says that some sort of help of that kind would have been a godsend to him and would have saved the situation.
§ May I turn to another side? With respect to Part III accommodation, one serious difficulty which we have to face is that the local authority is not the hospital authority, and if a patient becomes 1090 difficult—becomes incontinent or something like that—the county council cannot be sure of handing him over to the regional hospital board. I know that in some cases those hostels make it a condition of acceptance that the in mate shall be removed if sickness occurs. I do not think that such a condition is justifiable front a local authority which has a statutory duty, but it is done. Moreover, we hear horrible stories of much worse cases, where the county council, which can certify patients even though it cannot get a bed in a hospital, actually proceeds to certify patients to move them out of the hostel. I have heard of such cases. I do not know whether it is true. I know that it is commonly spoken about. It seems to me that it would be a great improvement if hostels had a sick bay attached. But I leave that to people who know the working of these things better than I do.
§ There is another question of Part III accommodation. Not long ago, I brought to the notice of Her Majesty's Government the case of an old woman who all her life, until she was past work, had worked in London, and who had sought in vain for accommodation in London. Then, in despair, she took shelter for a night or two in or just over the boundary, turning a relative out of his bed in order to get a bed for herself. She was refused Part III accommodation and, according to the answer I got, the refusal was on the ground that she was not ordinarily resident and not in need of care and attention. If such a person does not come within that category, I do not see who can be brought within it. Until I received this answer, I thought it was one of those ordinary cases occurring after five o'clock or at the weekend, when there was no one at hand in the office who could give an effective decision.
§ This led me to put a general Question to Her Majesty's Government. I received a very careful and extremely interesting reply. It was to the effect that the decision lay entirely with the local authority; that there was no reason to suppose that the local authorities were unaware of their duties, and that the Minister would inquire into any case brought to his notice. In plain words, a person might die of exposure on the Embankment, and still the local authority might determine that he or she was not ordinarily resident and not in need of care and attention. In 1091 the "bad old days," it is fair to say, such a case would have been dealt with at local level; and, in the event of failure, the delinquent would have been pilloried in the Press, and probably severely punished. But to-day, for a case like that, we have to carry it to the footsteps of the Throne; and there we have to complain against a party so highly placed that even the Government are reluctant to find fault. I submit that that is a weakness in the system. I do not want to be misunderstood. I do not impute the smallest blame to any individual. I am convinced that everyone is, within reason, conscientious and keen. One cannot expect people to sit in their offices all night on the chance of something happening. But the fact is, as I know very well, that most of the unforeseen evils that afflict humanity occur after five o'clock or at the weekend. And the reason for that is obvious.
§ I ought to say here—it emphasises what I have been saying in this connection—that in the Liverpool region they have accepted a suggestion of the Minister, and the different authorities have agreed that the hospital admitting officer shall determine how each case is to be treated. And they are now said to be free from this trouble. Your Lordships will observe that they have freed themselves by actually implementing the terms of the Motion which I have put before you to-day. What I think we ought to aim at is not dictation by the brain but reflex action by the fingers under correction by the brain. At present, there seems to be no central brain at all in charge of these various activities.
§ I could go on to bring forward examples from other branches, but I think I have said enough to make my point. I know that the Minister is doing everything he can to produce harmony in the services for which he is responsible. I know, too—for I have actually observed this myself—that he is universally trusted throughout these services. But that is his limit. When dealing with other Departments it is "crowned head to crowned head." If the Government do not see fit to accept my Motion I have an alternative to propose. The Service to-day is popular—and rightly so. Everyone is doing his best, and if there are failures they are condoned. But times may change. There may come a moment of economic difficulty, and one or two un- 1092 fortunate occurrences may arouse a storm of criticism. Such a moment is not favourable to judicious reform. It is now, when the winds are light and fair, that action should be taken. I would suggest to Her Majesty's Government the setting up of a small committee—five members would be enough—to examine these services, to find out how better co-ordination can be achieved, and to make a quick report. It need not take long. But if something is not done—I do not say necessarily on the line of my suggestions—and if, in the future, anything should occur to wreck these services, then I do not know that we shall ever be able to afford to re-establish them, and the consequences may, in my opinion, be disastrous to the country. I beg to move.
§ Moved, to resolve, That in the opinion of this House a large proportion of the failures in the Welfare and Health Services are due to imperfect co-ordination between the various authorities concerned, that local resolution of difficulties is essential to an efficient service, and that in many cases greater local discretion, financial and administrative, would result in better service at less cost.—(Lord Saltoun.)
§ 4.36 p.m.
§ LORD MATHERS
My Lords, the noble Lord who has just sat down gave me great relief at the beginning of his speech when he said that he was attacking nobody. I had read his Motion as being rather of a threatening nature, and as it deals with that branch of the welfare services in which I have had some experience, I was setting myself to meet what I thought would he his criticism, if not condemnation. But he has plunged us into a great sea of considerations; and if he has not been attacking anyone he has certainly produced quite a number of very serious problems for the attention of those who are in what he described as the upper strata of those responsible for these welfare services. He says that he deliberately framed his Motion, and decided to make his speech, on the very widest lines, in order that the Government would be placed in a position of difficulty with regard to who would reply to the charges he had to make. I think he has also put noble Lords in a difficulty in deciding what they should say following his speech.
1093 My general answer to any charges of responsibility for unsatisfactory treatment by Departments is that I believe that at the heads of these Departments there are people who are keenly desirous of seeing that every Department should work with the greatest possible efficiency. When the noble Lord was speaking, my mind went hack to a visit that I paid on one occasion, in company with the late Ernest Bevin, to the local employment exchanges in the constituency that I represented for a considerable number of years. I remember the meetings which Mr. Bevin held with those who were serving in the exchanges. He put briefly, and put emphatically, his counsel—nay his command—to those who were working in that great Department, which, at the time of which I am speaking, had a great deal of work to do because of the difficulties of the employment situation. What he said to them may be summed up, I think, in these words: "Remember that you are called upon to deal with these people with the utmost consideration; and keep in mind that, but for the grace of God, you might be the one on the other side of the counter." I am certain that that kind of spirit animates the Ministers and those who are responsible for the Departments of State concerned with the Welfare Services.
I speak more particularly of the Health Service, and I would take your Lordship's back briefly to the origin of that Service. At the end of the war, the Health Service had become almost inevitable, and it was finally established with the approval of all Parties, though only after great opposition from the medical profession, which, perhaps by its very nature, is prone to he individualistic. Many who were opposed at first have been converted by results, but I fear that there is still a diehard minority with reactionary views. I have used the word "inevitable" with regard to the origin of the Health Service. The fact was that the voluntary hospitals were reaching the end of their resources, and they were extremely apprehensive for the future. It became necessary for the State to shoulder the burden, and that was done just in time. Costs have been heavy ever since, because of the need to overtake arrears of maintenance and development, which still require vast sums to complete and bring up to date in the new conditions in which we find ourselves.
1094 Complaint is often made about the large sums involved in running the Service. There is next: to nothing on the credit side in the way of financial return. The gain is not a cash gain. It is to be found in health, in increased capacity for work and earning, and, consequently, increased revenue front income tax and taxes on consumer goods—that is the only place where cash comes in. Another gain is increased longevity, though other problems arise there. We are all aware of the rapid development of problems caused by the increase in the number of elderly people as compared with the working population. The fact is that the Health Service cannot be evaluated on a cash basis, though the cost of providing it can be stated. I assert that the establishment of the National Health Service is one of the greatest things this country has ever done—perhaps the greatest. I know something of the opinion of people in other countries. If there is one thing more than another that has impressed people from other countries, it is the way in which the British people stood up to the impact of the war; and since the war they have had extreme admiration for the way in which we have tackled and dealt with our responsibilities. People from abroad have spoken to me of these things not only with admiration but with envy, because we have in cur National Health Service the greatest organisation of its kind in the world.
Great progress has been made and continues to be made, and while the machinery governing all the wide activities covered by the welfare and health services may be improved here and there, I believe that the greatest factor in making progress is the willing co-operation which I claim exists, and which can be fostered by encouragement and help in carrying out much-needed improvements. That means the provision of more financial resources for developments—in this respect, I am thinking more particularly of the Health Service. As everyone knows, we are hampered in development by the financial restrictions that are laid upon us. The Treasury lay down (one can understand it) that we have not to think about what is desirable but about what is absolutely necessary. I can assure your Lordships that this consideration is recognised and acted upon by the regional hospital boards who have the arranging 1095 of the finance that is placed at the disposal of the hospitals, which amounts to a very large sum.
So far as possible economies are concerned, I am prepared to await the verdict of the influential Guillebaud Committee who are inquiring into the cost of the National Health Service. That Committee are doing their work and I am certain doing it well. Economy is mentioned in the noble Lord's Motion, but I think it would be unwise for me to particularise with regard to individual economies, though one or two might suggest themselves to me. I can see the possibility of closer integration of the specialist and general practitioner services by a closer linking of the functions of the executive councils with the regional hospital boards; but I see no reason why these bodies and the local authority health committees should not co-operate voluntarily, apart altogether from this being laid down as a statutory duty, and should not settle amicably the lines of demarcation between their respective functions. Such co-operation exists to some extent at present, and with good will and official blessing could easily be extended. Any difficulty would doubtless arise over who is to pay, and generally that may cause difficulty; but I am certain that in this regard a great deal can he accomplished by co-operation.
In the actual running of hospitals, I fear that there is still, in some quarters, a yearning for the practice of the former voluntary hospitals, where the senior staff could pick and choose their patients, with the knowledge that there was a parallel line of local authority hospitals with statutory obligations towards patients who were not chosen by the voluntary hospitals. Now we have the position that every patient is entitled to the professional service most appropriate to his or her need, and the younger doctors and surgeons should be clear about that. Their elders who cling to the old ideas do a great disservice to the scheme, established over five years ago, with, I repeat, the general acceptance of all Parties. In making this criticism I hasten to add that I know of the outstanding leaders of the profession, those in the highest rank, who have entered fully into the spirit of the new régime and who are giving a lead and example to their 1096 subordinates which will bear good fruit in the years ahead.
Having no professional qualifications myself, I hesitate to be critical, but I would mention my concern about the way in which many senior members of hospital staffs concentrate their work into the early part of the day. This may even involve duplication of staff to meet peak demands, while, later in the day, operating theatres may be empty and unused. That is a relic of the voluntary system and of part-time hospital work which I consider uneconomic and unsatisfactory. The staffing of hospitals should be on a full-time basis, and the professional service remunerated upon the basis of responsibility laid upon the individual. The paramount consideration must be the welfare of the patients, resident or out-patient, and an appointments system of attendance for the latter is imperative to save long waiting for attention. I think this is a sore point in many places, and I am sure that it is worthy of the utmost attention. I have had reports of more consideration being given to the convenience of doctors than to the urgent needs of patients. That should not be the case. Such a position is quite indefensible.
On the subject of economy there is one possible economy which occurs to me, and that is in respect of proprietary drugs and proprietary medicines and remedies. They make a great appeal to the public, and even to doctors; and the amount of advertising that is done is, to those who do not know of it, almost unthinkable. I question whether it would be possible to check this without actually proscribing the supply of these remedies or asking that they be used in moderation. The former would cause a clamour from patients, and I am sure that we all know that faith has a great deal to do with the efficacy of any remedy that is given.
§ LORD MANCROFT
I want to get the point quite clear. Is the noble Lord complaining of the consumption of proprietary medicines or the advertising of them?
§ LORD MATHERS
I cannot complain about advertising. Most people want to sell their remedies. But doctors should be able to prescribe what are the equivalents of these proprietary remedies; 1097 doctors and others should be able to prescribe equally effective remedies. The difficulty, I know, is to convince the patient that he is getting as good as what is represented and so widely advertised by those who are producing the proprietary remedies, and getting handsome prices for the sale of them. They must be getting a very good profit when the amount of expensive advertising that is done is taken into account.
I am going no further than that in the way of criticism, because I feel that, so far as the service in which I have been engaged is concerned, we must be careful not to cast any slur upon the large number of devoted men and women—I might say dedicated men and women—who carry on the administration of the hospital and other services without any reward except the satisfaction of serving their fellows in a great cause, the alleviation of human suffering and need. They may have a reward in mind. It is the reward that comes to us when we think of our Lord's reference to the Judgment, and they may be looking forward (I am sure many are) to the commendatory:Inasmuch as ye have done it unto one of the least of my brethren, ye have done it unto me.That is the spirit which animates much of the voluntary hospital and other services in this country. I am sure that service should be developed along those lines. Let us not imagine that, because we have these services carried out under the ægis of the State, there is no need for personal and individual voluntary work. Indeed, the State is co-ordinating and applying—and can continue to do so—the individual work of great masses of people for the benefit of the whole community. I believe that that would be the wish of the noble Lord who has moved this Motion and the great wish of all of us who have heard that Motion put before us to-day.
§ 4.57 p.m.
§ LORD BEVERIDGE
My Lords, I do not propose to attempt this afternoon to range over the whole field of welfare like the noble Lord who has just spoken. I shall deal only with the National Health Service, in so far as I can, and only with those defects, if they are defects, or problems in regard to the National Health Service which seem to indicate the need for better and closer co-ordination of the service. With a view to preparing for 1098 this debate I have been re-reading the first discussion in this House of the measure which is now the National Health Service Act. That was in October, 1946, when the noble and learned Earl, Lord Jowitt (as he is now), then the Lord Chancellor, moved the Second Reading of the National Health Service Bill. In a speech which I had the pleasure of describing the next day as "one of his customarily admirable speeches," Lord Jowitt began by saying that there was no subject on which it is more worth while to spend our time, energy and resources than the health of the people. Somewhat oddly, I found myself disagreeing with that remark, in all his speech, because it so happened that the day before I spoke here, by a curious repetition of history, the other place had been engaged in a debate upon atomic energy and had shown hardly any interest in it at all. The Prime Minister of the time had moved the Atomic Energy Bill in a speech of twenty minutes, and nearly all the Members who until then had crowded the House to hear the Lord President of the Council discuss the use of the motorcar in elections, trooped out as soon as atomic energy appeared on the scene. That event suggested to me that there was one thing even more important than the Lord President's motor-cars, or even health. But I think I should agree with the Lord Chancellor of that time that health is the next most important subject of all to that of atomic energy.
I welcome the Motion that has been put down by the noble Lord, Lord Saltoun without accepting all of its words. It seems to me a pity to use the term "failure" anywhere about a great service which represents a most remarkable achievement in converting the financial basis of a great, noble and learned profession, and in convening the financial basis of the control of a mass of splendid institutions. We must all agree that, although there may not be outright failures in this Service, there are things which could be improved, largely by co-ordination. One has to realise that lack of automatic coordination is inherent, in a sense, in the nature of the Act of 1946, because that Act was based on a tripartite division of regional authorities by different functions: the general practitioners, under executive councils hospitals, under regional hospital boards; and prevention and welfare, under local authorities. Your Lordships 1099 may remember that the first White Paper of 1944 did not propose that kind of arrangement at all, but proposed regional authorities for all functions together. I believe that the second plan was better than the first, but it did present the problem of co-ordination of the three kinds of functional authorities, all dealing with the common subject of the human being in need of treatment.
I began by saying that I agree entirely with the underlying idea in the Motion of the noble Lord, Lord Saltoun, that co-ordination should not mean control from Whitehall of bodies on the spot. Most of us who have tried to do anything at a distance from London have had a chastening experience of what that control means. I would suggest that coordination, when concerned with regional bodies, means delegating to them all the powers and all the material resources necessary to enable them to co-operate freely, as I think, in the nature of things, they will do when faced with their single human subject in need of treatment. Although, in a sense, the scheme of the Act of 1946 rather opened the door to disco-ordination, there was one remarkable feature in it which also tried to set out to correct that; that is to say, the institution of health centres, combining in each town, or part of a town, the general practitioners, the local authority clinics, maternity, child welfare and other things, and any outlying hospital services which could conveniently go there.
I want to say a few words about these health centres, because the tragedy is that up to the present the dream of establishing them nearly everywhere has failed. It is interesting to note that the institution of health centres appeared long before 1946, in the Interim Report of the British Medical Association Planning Commission, who devoted seven whole pages of their Report to health centres, among other things, as a means of getting over what they described as the greatest grievance and disadvantage of the general practitioner"—this sense of isolation; and they set out a detailed scheme for health centres. When the Government proceeded to legislate in 1946 they described health centres, in their White Paper of 1946, as one of the main features of their scheme. When the then Minister of Health, Mr. Aneurin Bevan, moved the 1100 Second Reading of that Bill in another place, he said that the Government attached very great importance to health centres; the provision of them was imposed as a duty on the local authorities; their creation was to be encouraged in every way. They were, in the intention of all who framed, introduced and advocated that National Health Service Scheme, an essential measure for coordinating the different regional authorities.
If your Lordships want to compare their dreams with achievement, you can turn to the last published Report of the Ministry of Health—at any rate, the last I have been able to procure—up to the end of 1952. That shows that three health centres have been established, in Stoke Newington, in one part of Bristol and in one part of Nottingham—and I know that one or two others have come along since. We all know that the development of these health centres was stopped in 1948, owing to the necessity for limiting building. To my mind, health, and the proper provision of health, are as important as houses; and I suggest that quite soon it is going to become even more important than houses. I have had the experience, in starting a new town in Durham, of trying to get a health centre there at once. There is already in the new town a population of 5,000 people. All the doctors, all the hospital people, and even the Durham County Council, in principle, agree that there should be a health centre. But after years of trying there still is not one, and the merest hope is that a health centre may be begun next year or the year after. There are already 5,000 people there, as I say, and the necessary local authority services have to be given in a quite inadequate and ridiculous community centre; and all that the hospitals and doctors were willing to do in working together has not happened. I do ask the noble Lord who is going to reply for the Government to use his best efforts to get this dream and main intention of the National Health Service Act, 1946, put into reality; to see that all the obstacles are removed, and to encourage health centres, as the Minister of Health said in 1946, in every possible way.
I pass on to a different topic, which is also concerned with freedom from Whitehall control, in order, by co-operation between regional authorities, to get the 1101 work of the Health Service done more economically. "Economy" means using the simplest, rather than the most elaborate and costly, means to restore the patient to health, or to give him what he needs. We all know that with the growing mass of ageing people there is a great tendency for them to occupy, in many cases, expensive, elaborate hospital beds, although it might be possible by other treatment to get them cared for in part at home, with the help of the local authority's preventive service. There is a means of economy, not depriving any people of anything they need, but as a means of ensuring that the really expensive specialist hospitals are available for the people who must have them. There is a problem of removing from hospitals to homes those older people who are fit for that and will not suffer from it, and who can be cared for in their homes by their families and local authorities. That is a question of co-operation between the local authority and the regional hospital board. I can put this only as a question, but the information I have is that although regional hospital finance has been most blessedly released from certain controls within the last two years and made much freer, that freedom does not extend to enabling them to use part of their money to help the local authority to bear the cost of such a scheme of cooperation. If it does not, I hope that the Government will make it possible for the regional hospital boards to use money allocated to them in whatever way will produce the necessary service to the aged or the sick person at the minimum cost.
Let me come to another point of greater freedom from Whitehall controls. I suggest that the 'Treasury rule of annual budgets is wholly and utterly inappropriate to a National Health Service. I cannot understand how anybody can even for a moment defend it. It means that towards the end of the year a hospital board which has resources unspent may have the choice of trying to spend them hastily or of handing them back. Of course, if it is sure that if it hands them back it may get them next year, it will probably hand them back instead of spending them wastefully. But it cannot be sure of that. It can trust only to the kindness of the people who take the money back. Above all, since hospitals can effect improvements in many eases only by capital expenditure, it becomes 1102 even more absurd to apply this Treasury rule, which is applicable to Civil Service Departments, to people who are carrying on what is really a great national industry using capital equipment on a large scale—the national industry of health.
I come now to a third case in which I would hope we can get more freedom from controls—not only those of the Treasury, but all the controls on materials, building and so on. We need more freedom of capital expenditure for replacing out-of-date buildings and equipment, in order to save annual expenditure and to increase equipment so as to put an end to waiting. That is one of the things most urgently needed in the whole Health Service. I know, of course, of all the other people who are competing for the use of materials and for money, but I would suggest that there is an excellent argument which the Minister of Health could use with that even more important person, the Chancellor of the Exchequer, to get the latter on his side in an effort to enable the regional hospital boards to improve or replace their, in many cases, utterly outdated, inefficient equipment.
We know from the actions of the Chancellor of the Exchequer that he is well aware of the fearful problem of providing pensions for old and aged people which is facing him or any of his successors over the next twenty years. The only chance of saving on pensions for the aged is to lengthen the average working life. Now that depends, among many other things, on health. I will not deal with all the other difficulties, because that is a different subject; but in the field of health it depends, among other things, upon keeping the older people thoroughly healthy, so that they can work with pleasure and want to work, and not be forced to work when they are feeling thoroughly unfit. I suggest that if the Minister of Health could enlist the powerful aid of the Chancellor of the Exchequer in getting freedom from many of the financial and material limitations which are desperately hampering the work of many regional hospital boards to-day, the Chancellor of the Exchequer would in the end find himself saving money on pensions. He will do it only in that way.
We know that there is now sitting a Committee on the Costs of the Health 1103 Service. I hear excellent accounts of the work of that Committee, and I think its appointment was one of the best things done by the Government last year. But I hope that the Government will encourage that Committee to deal with more than finance—to deal with the way of true economy in the Health Service by getting as good or better results by less expenditure. Of course, there are many other problems in co-operation between the different bodies concerned with health, such as the relationship between teaching and other hospitals. There is the problem of how regional hospital boards can survive under the extreme rigidity of the Whitley Council machinery for fixing wages and salaries of all kinds—not fixing minimum wages, but fixing the maximum. I cannot deal with those, and perhaps if I did attempt to deal with them I should be departing from what is the brief to which I have tried to keep on talking about the Health Service and the cooperation between the different functional authorities who undertake it.
Let me end by asking the noble Lord who is to reply to consider three questions immediately, and perhaps one later when he and the Government have the Report of the Gillebaud Committee. The three immediate questions relate first to health centres. Will the Government do something to carry out the main purpose, or one of the main features, of the National Health Service Act by removing the many restrictions that have prevented health centres from coming into being? Secondly, will they give to all the different kinds of regional authorities greater freedom from inappropriate controls such as I have specified? Thirdly, will they give them greater freedom to save running costs by improving their capital equipment? Those are the three immediate questions.
The remaining question is, when they get the Report of the Gillebaud Committee dealing, as I hope it will, with the administration as well as the finance of the National Health Service (I have no reason to think that the Gillebaud Committee will deal with this point and I am not attempting to get them to deal with it), will they sit down and seriously ask themselves whether a Minister with an ordinary central Department of ordinary 1104 civil servants is the right organ for running a great national industry? It is not the kind of organ that we have in other industries like those of transport or coal. Will they consider whether a Minister, with an ordinary, typical Civil Service Department, is the right organ for running this national industry to secure for the people of this country the means to health?
§ 5.21 p.m.
§ THE EARL OF CRANBROOK
My Lords, it is with some diffidence that I intervene in this debate, having neglected for so long my duties to your Lordships' House, but as that neglect has been due largely to a constant preoccupation with the administration of the health services, perhaps your Lordships will bear with me for a moment. I was interested in two at least of the points raised in the interesting speech of the noble Lord, Lord Beveridge. I should like, however, to join issue with him, if I may be so brave, on one point, and that is his suggestion that it would be reasonable to allow the hospital authorities to carry over into a future year unspent balances. I think that that idea is completely fallacious. The greater proportion of their money goes on salaries, wages, food, provisions, drugs, fuel and the like, and if they have any carry over under those headings it is not due to any saving. It is due purely to some fortuitous circumstance—that they could not engage the nurses; that it was a warm instead of a cold winter and did not require so much fuel. That is not saving: it is merely money not spent; and provided, as the noble Lord said, and as indeed does happen, that the Minister or the hospital board concerned agree to make a similar provision in the next year, there is no reason why there should be any carry over of those moneys. So far as capital expenditure and what one might call ordinary maintenance expenditure on buildings and the like are concerned, however, I would go a great deal of the way with the noble Lord. I think that if a building cannot be completed, or a block painted, in one year, because of the weather, you can always do two blocks the next year, if you are allowed to carry-forward, whereas you cannot engage two nurses if you have not been able to engage one the year 1105 before. For that sort of expenditure, should like to see a carry-forward allowed.
The other point which the noble Lord made stressed this extraordinary dichotomy that we have between the services administered by the hospital boards and the services administered by the local authorities. I am inclined to think that it was owing to the turmoil to which the introduction of the National Health Service Act led, which was referred to by the noble Lord, Lord Mathers, that certain "sops" had to be paid to vested interests and we got this dichotomy, whereas otherwise we might have got a clear-cut service administered by one body, and one body alone. We are now faced with an extraordinary position. We have a constant pressure on the Minister and on the boards to build more beds, expensive beds, of every sort. I am not a doctor, but from what I can see the existing number of beds, certainly the acute beds, is sufficient to deal with all the cases of acute illness that we are likely to experience in this country, for a generation at least, if only we can make proper use of them, if only we can get a more rapid turnover of bed use. But that can be done only by a greater provision of home helps and home nurses, which is the responsibility of the local health authority.
Any money that is saved on the hospitals by their giving better service does not help them, and there is no real encouragement, other than altruism, for them to do it. As regards the suggestion made by the noble Lord on my left, that it might be possible to allow old people to go home out of Part II authority care, where it would normally be the responsibility of the local authority, and certainly out of hospitals, again I think that system could be considerably extended if we had more home helps and home nurses. After all, a person, particularly somebody who is chronically sick, can be sick at home or sick in hospital. The vast majority of us would prefer to be sick at home, but in the end the burden on relatives of nursing the sick mother or the sick daughter becomes absolutely intolerable. Parents wish to stay at home; the children wish to keep them there; but it is more than human beings can stand at the end of long years. If we 1106 could have a quicker turnover in our chronic sick hospitals, helped by a greater provision of home helps and home nurses, we could do for the chronic sick the same as is done in many cases, just as tragic, of mental deficiency. Where there is a mental defective ruining a family's home, he can be taken into au institution for a short time, so relieving the family of that great burden, and allowed out after a time, when another mental defective can be taken in.
All this means that there must be constant co-operation or co-ordination—that is the word that is constantly used—between the various authorities responsible for the health services. I have given your Lordships one example of the home helps and home nurses, but we go from one to the other in every service. The tuberculosis after-care, which is the responsibility of the local health authority, has to be dealt with by the consultant appointed by the regional board. The hospital almoner has to do a certain amount of visiting homes—which again is fundamentally the responsibility of the local authority. In fact, it is an extraordinarily untidy machine that has grown up, I think quite fortuitously. I believe that the time has now come to see whether we have the right machine operating to-day.
It can be made to work. If there is co-operation at every level, we can do it. General practitioners are in constant touch with the consultants. The members of various bodies, the local health authorities, the regional hospital boards and the executive councils are all drawn from people with an interest in local administration. Many people sit on two of them, some on three, and they secure a good deal of integration of policy between the three. The officers of the local health authority, the regional hospital boards and the hospitals are in constant touch. The machine can be made to work by constant care and effort, but effort which I am bound to say I think would be far better directed into other channels in actually making one machine work, instead of trying to make three work in together.
I am never quite certain how far one is right in saying that one is apt to pursue administrative tidiness for the sake of tidiness, particularly in a case like this, where we have two obvious alterna- 1107 tive solutions. The first is to hand over the hospitals to the local health authorities—with all due respect to the executive councils, I do not think the integration between them and the other two bodies is of such great importance as between the Part II and Part III authorities—and the second is to hand over the domiciliary work to the hospital authorities. To hand the hospitals over to the local authorities is possible, but could be useful only if the local authorities were to bear part of the cost on the local rates, or whatever in the future will be the means whereby local authorities will draw their money. Their boundaries by no means coincide with reasonable hospital boundaries; their sizes vary enormously, their rateable values vary enormously. We should have tremendous complications in regard to out-county patients—in particular with some of the more obscure specialities, and with such things as mental deficiency and tuberculosis, where the hospitals concerned are not uniformly spread throughout the country. All these problems could be overcome, even without a reform of the functions and areas of local government, but only with great difficulty.
I am bound to say, in passing, how much I regret, when I read each gracious Speech, to find that Her Majesty's present Government are as pusillanimous as their predecessors in dealing with this difficult question of local government reform. How constantly I hope that one day I shall be proud of them, instead of being ashamed of them, as I am each time we have a gracious Speech! I was surprised to see it suggested the other day by a former Minister of Health, that in administering the Health Service the local authorities should be asked to act as agents for the Minister, as are the hospital boards to-day, the Minister continuing to pay the total cost. I have been a member of a hospital board since the beginning—six years now—and I know that it is an exceedingly difficult position in which to find oneself. We were all drawn from the sort of person who had been on a voluntary or local hospital board or committee. We had been used to formulating and putting into operation our own policies, raising money either from some of the local rich people or from the rates, and to speaking our minds, privately and publicly, just as we 1108 liked. We suddenly found ourselves as agents for the Minister, which required quite a different outlook on life.
I am not suggesting that one has got to be a "Yes man," but one has got to have the sort of loyalties and restraint which is typical of the best sort of civil servant. We have differed from Ministers of both Parties—neither of them has ever given us enough money; we have also differed from them on questions of policy. But we have always felt that we could not publicly oppose the Minister whose agent we were. If we felt that the difficulty was not solvable by reasonable means, our only course was to resign and make our row public. So I cannot see that idea working. Local authorities are elected on a Party basis; they are run on Party lines, with Party caucuses. You would inevitably get hospital policy coming into election addresses; people would ask to be elected to oppose the Minister whose agent they were, while all the time he would be paying the money for the service the local authority were administering. I hope that whatever they consider, Her Majesty's Government will not give that proposal more than the most cursory examination and that they will then throw it into the waste paper basket.
For the same reason, I hope that they will not be led astray into going into the suggestion that members of hospital boards, management committees and executive councils should be elected. Exactly the same trouble would arise if this Service continued to be a Government-run function, with monies provided by Parliament and run by a Minister responsible to Parliament. You have got to look back a little in history, and remember that the justices of the peace were originally appointed by the Central Government to carry out Central Government policy. They were not superseded until they started dealing with local policy, paid for by local finance. I think that in building up this Service, the Minister built better than he knew when he went back to that old old principle, and I hope that Her Majesty's Government will stick out if they are asked to make any change.
My Lords, I have dealt largely with the administrative side because I think it is important. Vested interests grow very quickly indeed. I am a little nervous that, after six years, I may not be 1109 speaking to-day with my own vested interests behind me, but I believe that some reform of the administrative machine is necessary. If the noble Lord, Lord Saltoun, had suggested a committee or something of that kind, I should Gave been prepared to support him. I hope that Her Majesty's Government will look into the whole set-up, the whole machinery, to see whether we cannot get away from what I have always looked upon as the last resort of the really incompetent administrator—the coordinating committee
§ 5.37 p.m.
§ LORD AMULREE
My Lords, the noble Lord, Lord Saltoun, who framed this Motion did so in a wide and general manner, which makes it possible for me to bring forward one of the points about which I have spoken to your Lordships many times—namely, the welfare of the elderly people of this country in general, because I think that they are the people who suffer most from the lack of coordination between the two Services about which we are speaking to-day. One can look upon the National Health Service Act and the working of the National Assistance Act as being rather like two parallel lines and, like two parallel lines, they never meet. The people who fall between the lines are those who are not strong enough to stand on either side: they are the frail, the infirm, the sick and elderly people, to whom I shall refer. We have been told—indeed, I confirm the truth of it—that there is much good will in various parts of the country, and that therefore the gap can well be made up. I am extremely lucky in the local authority where I work; we have no trouble whatever. But one comes across cases where there is not such good cooperation and, quite frequently, as I think has been said, the cause of the trouble is finance—which side is going to pay.
I have no compunction about again raising this point. I first raised it when I had the honour to address your Lordships first in 1946, on the Second Reading of the National Health Service Bill. I was then assured that things were going to be all right and that I should not worry. I raised it again on the Second Reading and Committee stage of the National Assistance Bill in 1948, two years later. I was told, "Do not worry; 1110 that is going to be all right." I admit that only five years have passed, and I do not blame anybody for this. There has been some progress, but it has been painfully slow, and one still sees the same kind of trouble occurring year after year. One picks up one's paper and sees accounts of people dying because they could not be admitted to hospital. I have received a certain number of letters myself. At this late hour I do not want to tell more stories than have been already told, but one finds accounts of people in welfare institutions, welfare homes and voluntary homes of all sorts, who have become sick, and cannot really be catered for there. It is very difficult to get such people transferred to hospitals where they can get the care they need.
At the same time, an going round some of these so-called chronic-sick hospitals, One finds a large number of people who are perfectly fit and who should be transferred to the welfare homes, or the voluntary homes—call them what you will. Therefore, one gets a demand for more beds. I do not think that more beds are necessary. I agree with the noble Earl, Lord Cranbrook, that there are enough beds for the sick in the country generally. I believe that there are probably enough beds to go round. There may be a few places where there is a local shortage but, generally speaking, we should not need a great many more beds if those which we have were properly used. In, I think, 1947, or 1948, a very good report was issued by a committee called together by the British Medical Association—a committee of which I was a member. It was an excellent report, but, like so many good things, it fell completely flat, and since that time. I do not think it has ever been heard of again. But it propounded practical and economical means of dealing with this problem.
Then there, is a demand from certain quarters that someone should have the power compulsorily to admit people to hospital. I think there may be a good deal to be said for that, but there is also a certain amount to he said against it. As things are now you might well get numbers of people greater than the hospitals could take, and overcrowded wards lead to overworked stalls, which means 'lack of proper treatment and nursing. You might well get into a position where 1111 you found wards as full as those in the old public assistance infirmaries of the past, and we do not want to revert to that state of things again. I think that if the elderly people are treated properly and, after having proper treatment in hospitals, are then discharged, beds would be available for all and emergencies would arise on only comparatively rare occasions, so that there would be little call for the use of emergency powers. I do not want to see compulsory powers conferred in the present situation.
What we do need particularly is free exchange between welfare institutions, especially the Part III type, and the hospitals. This exchange is so often stopped by something or other—just what I have never been able to find out. In the past, I have been told by the authorities of an institution: "We have 200 people that we should like you to have." I would reply: "Very well, I have 200 that I should like you to take." But we never got to the point of the full transfer taking place. Where the business goes wrong I do not know. We may have exchanged one or two people, but the total numbers were never transferred. Local authorities should provide more Part III accommodation than they do now. That may sound inconsistent with what I have just said. But we do want more beds of the Part III type to take care of the infirm and the frail. I consider that what the noble Earl, Lord Cranbrook, has said about the encouragement of domiciliary services is very important. I am afraid I must have misled the noble Lord, Lord Saltoun, in regard to the figure he mentioned of £4. That includes pension with a certain amount of National Assistance relief also. It was not the cost to the local authority. The cost to the local authority I think is about £2: it is certainly not £4.
There is a suggestion I would make following upon what the noble Earl, Lord Cranbrook, said. Would it not be possible for regional hospital boards to assume some of the financial responsibility for people in some of the accommodation under Part III? Supposing that were too difficult front a financial point of view, would it be possible to encourage a joint appointment by the regional hospital board and the local authority so that the same person in 1112 charge of the sick would be in charge of the infirm and could facilitate transfers? That idea I believe has been adopted by one local authority, but it has not been tried out elsewhere to any great extent. I believe it would be well worth trying. With regard to what Lord Beveridge said about the starting of the Health Service I should like to correct him on one matter. A Health Service was started by one of my relations in a small town in Scotland in, I think, 1919 or 1920. It was not called a Health Service but it was one. But because my uncle died shortly afterwards and local interest in it faded away, the project died.
There is one other reason why I should like to press for co-operation between the two sides, and that relates to the question of personnel and economic considerations. It is, I think, rather worrying when we reflect that in 1901 the population of people under ten years of age was 22 per cent. of the whole, and that in 1951 it was only 16 per cent., whilst at the same time the proportion of the population over 65 had risen from 4.6 per cent. to 11 per cent. Thus the pool of young people to draw upon to take care of these innumerable services is steadily diminishing. The number of girls under eighteen years of age was, I think, about 400,000 in 1938. It was down to 297,000 in 1948, a reduction of 25 per cent. These are figures given by the Ministry of Labour. Again, according to figures from the same source the number of women between the ages of 15 and 40 fell by 374,000 between 1946 and 1951.
If we take the figures from the census, we find that in 1901 the total number of people in the medical and auxiliary services generally was about 3,000 per million of the population. In 1951 it had gone up to nearly 10,000 per million of the population—an increase of several hundred per cent. I think that is rather alarming, because it shows that the supply is going to dry up. But you cannot expect every young woman of intelligence to go into one of the welfare services. The same applies to many of the voluntary bodies. Because of the difficulties in which they find themselves, they are having to employ more whole-time staff than formerly and to draw from this general pool. I would made it clear that I have no wish whatever to cut down 1113 the amount of work done; I am, on the contrary, very much in favour of expanding it. But I should like to see whether something could not be done in the way of co-ordination to see that overlapping of work in any way is avoided. A report from one of the Midland towns dealt with a group of seventeen so-called "problem families." These seventeen families were investigated, and it was found that two of them were known to at least seven welfare agencies, three to six, seven to five, and five to four. An investigation was also made on Merseyside, and it was found that of fifty problem families, two were assisted by five public bodies, eleven voluntary organisations, and one private person. There may be good reason for this; but it makes one think.
§ 5.48 p.m.
§ LORD CALVERLEY
My Lords. I have one special interest in this matter, inasmuch as I was for some years President of the Institution of Hospital Engineers of the United Kingdom. That, with one or two other reasons, is why I intervene in this debate. I was interested in the line taken by the mover of the Motion, who read out that list of people, but presented us with no solution of the problem of who can co-ordinate the coordinators. Lord Beveridge, of course, said that on no account should we change our gaolers and become the prisoners of Whitehall. Then, when he had admitted the comparative failure so far in providing these health centres, he said, in effect, "Go back to the gaoler in Whitehall and make a friend of him, so that he can go to the other gaoler at the Treasury and get some money."
I listened with interest to the speech of my noble friend Lord Cranbrook—he is a very new friend, as a matter fact, but we have old associations, because he is the Chairman of the Suffolk Regional Hospital Board and Chairman of Suffolk County Council. I listened to him with interest when he said that he wood not decry the progress which had been made under two excellent Ministers of Health. One was the instigator of the scheme, a man with drive, Mr. Bevan, and the other is the Minister who is in charge to-day, a splendid Minister; Mr. lain Macleod—and I may add, also, his Parliamentary Secretary, Miss Hornsby-Smith. The noble Earl said that we must not be too complacent. I certainly do not share 1114 altogether the enthusiasm and complacency of my young friend, Lord Mathers. If we make an inquest into the position so far as we have gone, we realise that we still have a long way to go.
§ LORD MATHERS
My Lords, I should not like my noble friend to misrepresent me. I hope that I did not appear complacent. I want to see progress being made, just as much as everyone else in the House. I am not satisfied, and I am certainly not complacent.
§ LORD CALVERLEY
May I put it that I thought my noble friend was full of enthusiasm? With regard to the engineers and other "back-room boys." I have found that they are saving the country thousands of pounds. I have gone into their workshops and found them "making do" with, and mending, valuable medical instruments which in the old clays were thrown on the scrap-heap. In the last analysis, the kingpin of the health Service is the general practitioner. Sometimes I think, because we hear only of the general practitioner when he has made a mistake, he has not been treated with the generosity to which he is entitled. The fact that my noble friend Lord Beveridge said he can count the number of health centres on one hand shows that many of these general practitioners are working under great difficulties.
The noble Lords, Lord Amulree and Lord Cranbrook, have mentioned home helps and the care of the aged. Near where I live there is a hospital which has been transformed into a splendid hostel for the aged, whore they are given all kinds of useful employment which they can do under supervision, with some help from the physiotherapists. That is one of the outgrowths of the Health Service for which I am grateful. But when it comes to home helps, if one speaks to the medical officer of health of a large city one discovers that he is generally suffering from a sense of frustration. Although he has an enthusiastic chairman of his social welfare committee, who wants to have a voluntary committee in every ward and wants to develop this service, yet when he goes to the local Chancellor of the Exchequer, from whom he has to draw the money to pay for the home helps, he finds the latter somewhat reluctant to help him.
I hope that the noble Lord, Lord Mancroft, who is the Minister's admirable 1115 understudy—I hope the noble Lord will not mind my calling him that, because he is more than an understudy in anything he undertakes—will convey to the Minister that there is a sense of frustration among local authorities. I have been connected for many years—nearly all my active life—with a local authority who were pioneers in certain municipal work, in the care of children and in child feeding, and we had the first municipal hospital in this country. Now the medical officer of health finds that he is being by-passed by the remote control of the regional authority, of all people. Suffolk is to be complimented, but it has a small population compared with a county like Yorkshire, where there are between 3 million and 4 million people. We find—and I speak here for local hospitals in the county—that there is remote control. I would rather go to Whitehall and see the Minister than go to the remote control of the citadel at Harrogate. Some local hospital committees are finding the same difficulty, because the general practitioner is hardly represented on the regional authority—at any rate, not in my county. When we put forward a really urgent case, we find that there is too much "stone-walling."
I am interested in another hospital, of which unfortunately I was an inmate for some weeks last year, and of which the Minister of Health was also a patient, because he is a Craven man. It is a hospital for eyes, ears and throat, which is ninety-seven years' old. Three weeks ago I put down a Question about this hospital, and the noble Viscount, Lord Woolton, told the House that there were no fewer than 34,000 out-patients in one year. Yet the accommodation for outpatients is 12 yards by 9 yards. Every week, two or three hundred people come in; and if they are children, of course, they are generally accompanied by their parents. We cannot do anything about it, but the matter is most urgent. I know that this is special pleading, but I can make out a splendid case why the Minister should do a little bit of prodding of the Harrogate regional authority, whose attitude seems to be like that of Russian diplomacy when we ask them for anything: they say, "No, no, no." I want to put that point to the Minister. I suggest that he can act as arbitrator.
1116 I do not mind what sort of gaoler I have if he looks after me well, feeds me, and if I can sleep well. I am grateful to the noble Lord, Lord Saltoun, for bringing up this question this afternoon, because it has enabled me to use the Floor of this House to do a little special pleading, which I am sure will reach the ear of the Minister.
§ 6.1 p.m.
§ LORD GREENHILL
I ought first to apologise to the noble Lord, Lord Man-croft, for not having given him notice of my intention to speak, and the reason is that I did not make up my own mind to do so until a very short time ago. I want to raise two points, one as a member of a local authority, and therefore interested in the matter from the angle of a local authority, and the other as a member of the general public who is concerned about one important aspect of the National Health Service which may be part and parcel of the general view which the noble Lord, Lord Saltoun, raised in his Motion. I have a feeling that we are all agreed, no matter what our political views may be, that the National Health Service has performed a vital task for the benefit of the community at large. I have the feeling also that there is a widespread idea that there is too much machinery about it, and as the noble Earl, Lord Cranbrook, very properly said, too great an anxiety to have a tidy machine to deal with a vast and complex problem.
The authority, of which I am still a member, had, before the take-over, nineteen hospitals. All of those have been taken into the National Health Scheme. One effect of the take-over was the reorganisation of certain departments within our local authority, because at the same time, as noble Lords are aware, not only was the whole structure of our local health department affected, but also the welfare committee. In trying to reorganise the machine to cope with the new situation, what we found was that health and welfare seem to go better together; and we therefore merged the two. We set up, as by law we were compelled to do, a children's committee and appointed a children's officer, although that work had been very well carried out formerly by the welfare committee.
1117 On the other hand, two criticisms that can be voiced as the result of the merging of health and welfare are these. First of all, in a desire to keep up the status they enjoyed before the take-over, this large committee have tried to undertake tasks perhaps too great and too many, in order to justify their existence. In that way, the work has perhaps not been carried out as economically as possible. Secondly, I think that from the standpoint of performing adequately the work of this large authority, it would have been better, both administratively and from the point of view of treatment, if the infectious disease hospitals had been retained by the local authority. It seems to me that the transfer of the infectious disease hospitals to the regional hospital board has not been of advantage either to the patient or to the smooth working of the whole administrative set-up.
Within the last week or two there has been published the Report of the Department of Health for Scotland. While I appreciate that the vast number of problems which concern all those who are interested in the Health Service are receiving careful consideration by those responsible, I think we are entitled to ask ourselves whether there is not too much machinery doing it, and for this reason. There is a Scottish Health Service Council, which, I understand, has a number of standing advisory committees. Here are the names of these committees listed in the Report: the Standing Medical Advisory Committee; the Standing Dental Advisory Committee; the Standing Nursing and Midwifery Advisory Committee; the Stan ding Pharmaceutical Advisory Committee; the Standing Hospital Specialist Services Advisory Committee; the Standing Local Authority Services Advisory Committee; the Standing General Practitioners' Services Advisory Committee; the Standing Committee on Health Centres; and the Standing Committee on Health Services in the Highlands and Islands. All these may be very necessary; all these may be doing excellent work; but one does ask oneself whether there is not far too much machinery carrying out the admittedly wide and complicated functions of the Health Service. I wonder, therefore, whether the Government would consider the pos- 1118 sibility of transferring to the local authority the infectious disease hospitals in order that they may be run more effectively, and if not more effectively then more economically, than at present.
Another point I should like to raise is this. Mental health services form a very large part of the general Health Service with which we are concerned. Looking at the Appendix to this Report, I find that out of the approved complement of hospital beds—64,945–21,972 are allocated to mental and psycho-neurotic disorders. The number of occupied beds totals 52,056, of which 20,822 are occupied by mental and psycho-neurotic disorders. I am wondering why it is that in view of the very important aspect that psycho-neurotic conditions occupy in the general Health Service, it has not been possible to include psycho-analysts among the practitioners dealing with this matter. There is an increasing recognition of the value of psychiatrists, but for some reason, which I do not well understand, there appears to be no provision, or very little, for psycho-analysts. Why is that? One reason why I ask is this. Those patients who are being treated by psycho-analysts find that either they or their people are put to enormous expense in order to pay for the treatment. It seems to me that if the National Health Service is to cover all the conditions of human illnesses, then psycho-analysts should be included. Not having given notice to the noble Lord, I do not expect him to reply immediately to these questions, but I should be obliged if he would bring these representations to the Department and see whether some satisfactory answer can be obtained.
§ 6.10 p.m.
§ LORD BURDEN
My Lords, I had not intended to intervene in this debate. I apologise to the noble Lord, Lord Saltoun, for not having had the advantage of hearing his speech, but I have been engaged in other activities. The speeches which I have heard have shown a great interest in this problem. I was glad to hear the speeches of the noble Lord, Lord Beveridge, and of the noble Earl, Lord Cranbrook—Lord Beveridge speaking from the wealth of his knowledge of the Health Service, and Lord Cranbrook from his wide knowledge of hospital and local authority administration. I suggest that we might be able to examine this problem 1119 a little further at a later date. I sometimes wonder whether we have given due attention to the admirable series of Reports which have been submitted to the Minister year by year, by the Central Health Services Council, showing the work of eminent men and women in relation to this problem. There was a Report dealing with the gaps in the Health Service; and I believe that a report on hospital administration is now due—I understand it was in the hands of the Minister to be printed by March 31, but I have not yet been able to procure a copy of it.
This Motion refers to gaps in the social services. Whatever I say, or whatever any other noble Lord has said, in no way reflects on the tremendous advance that has been made in social services, to which all political Parties have contributed. I think it would be doing our people an injustice if in this matter we endeavoured to score Party political points. In this great experiment of the health services, and welding together a number of them, gaps were bound to appear. In calling attention to these gaps, I must not be taken as in any way criticising the conception of our social services—I do not like the term "Welfare State"—but only as endeavouring to sec how far we can consolidate the advance and go some further step forward.
The first gap, I suggest, arises from the fact that, other than the London County Council, our county councils are not housing authorities—I am speaking of England and Wales. Quite frequently families are evicted—either anti-social families, or families where the landlord, for one reason or another, obtains possession of a house. Someone goes to the county council—other than the London County Council, as I have said—and the children's officer says, "We are not responsible. Go to the housing department." The housing department then say, "We cannot do anything for you. We have not got a house available. You must go to the children's officer who will look after your needs." If there were an inquiry at police stations throughout the country one could get evidence of many children and families "sleeping rough," because there was no accommodation for them. The late chairman of the bench at West Ham Magistrates' 1120 Court, Stratford, has time after time called the attention of the authorities to this question, and I know that the police are at their wits' end in regard to it. There is that gap, and somehow or other it has got to be bridged.
The second gap is one that has already been referred to by the noble Earl, Lord Cranbrook; that is to say, the question of the Part III authorities in relation to the hospital management committees or the regional hospital boards. I venture to suggest that if there were proper coordination, a proper working arrangement and proper financial adjustment between the regional hospital boards and local authorities, some of our difficulties in regard to places in hospitals, and particularly in regard to the chronics, would be solved. The hospital management committees, particularly those which have chronic hospitals under their control, know that there are scores of patients in those hospitals who ought not to be there. But if they are turned out, where are they to go? For obvious reasons, their families are unable, or unwilling, to find accommodation for them. There should be a greater development of hostels for older people under the local authorities. But that, of course, is a cost to the local authorities. There ought to be, as it were, a two-way traffic between the hospital management committees and the local authorities, so that there could be an interchange of old people—of those who are able for the time being to look after themselves, and those who are sick and need hospital treatment. For the aged person may be all right one day, and the next day require medical care and attention. There is that gap between the two authorities. I believe that that problem was considered by one of the advisory committees, and reported on to the Minister two or three years ago but, to the best of my knowledge, no action has been taken on that report, except that some local authorities are trying to build hostels. The hospitals are costly to build, and costly to run, and obviously local authorities are reluctant to add to their ever-increasing rates.
The third point I would raise again arises on the financial problems as between the Minister, with his agents, the regional hospital boards and the hospital management committees, and the local authorities. It concerns mental hospitals. 1121 I am fairly certain that an inquiry M regard to the people in mental hospitals would show that there is a large number of persons in mental hospitals who ought not to be in there at all. But if they are sent out, where are they to go? There ought to be, if I may so describe it, a sort of halfway house—I do not know any other term—to which these old people could be sent, where there would be a nurse or medical care and attention for them. The local authorities are naturally reluctant to do that. I am told that, legally, the regional hospital boards cannot do the job—they have no power to do it; that it would be ultra vires if they attempted to provide anything of that kind.
The other point—and again I hope the noble Lord, Lord Mancroft, will not take the opportunity of scoring a Party political point on this—is this terrible problem of the casual, which is not receiving the attention it should. Because we nave taken the term "casual" out of our vocabulary in the Health Service, do not think that the problem has gone, because it has not. There is divided authority in this matter, because the National Assistance Board also come in. I believe that the National Assistance Board have a nice hostel for Polish people, but the casuals are not being cared for in the way which was envisaged. I repeat, because we have taken the word out of our vocabulary, do not think for one moment that the problem has disappeared. Your Lordships will forgive me, but I have not had an opportunity of coming to the House this afternoon with anything in the nature of a prepared speech. I have made these few points because I believe that the problem raised by the noble Lord, Lord Saltoun, is a real one. I hope that this afternoon's debate will be regarded as a preliminary, because at another date, after hearing what the Minister has to say on behalf of the Department—and I am not criticising the Department in any way, because these difficulties have arisen and developed out of the administrative and legislative structure—we might have another look at the problems in the light of the recommen3ation of these advisory committees. Then I believe that the men and women of good will, to whatever political Party they may belong, will bend their energies to finding a solution of these great problems.
§ 6.23 p.m.
§ LORD MANCROFT
My Lords, it seems hardly five years ago that we were all in the midst of the heat and battle of political wrangles over the introduction of the Health Service. If any stranger to our debates were to read to-day's "debates" in Hansard, I believe he would have difficulty in discovering to which political Party any noble Lord who has spoken in this debate belongs. I hope I shall manage to preserve my political anonymity as far as Party politics are concerned in the course of what will be. I am afraid, some rather disjointed remarks in attempting to wind up this debate. I feel that we owe a debt of gratitude to the noble Lord, Lord Saltoun, whose moderate and constructive speech set the tone for this interesting debate. I will tell the noble Lord straight away that l cannot recommend the House to accept his Motion exactly as it is worded, although I am prepared to accept it in spirit rather than in the letter. In the wording of his Motion he goes a little further than he did in his speech. But let me repeat that with the spirit of his Motion Her Majesty's Government heartily concur.
There is no complacency whatever concerning the Health and Welfare Services in the minds of those Ministers who are "charged" with administering them. I do not suppose there ever will or could be a perfect scheme; I do not suppose there could ever be an organisation so perfectly co-ordinated that no holes could be picked in it. Our aim, therefore, is always to be improving, to find where mistakes have been made, and it is upon helpful and constructive suggestions like those that have been made this afternoon that my right honourable friend will naturally rely in trying to bring about still further improvements. Therefore, I assure the noble Lord, Lord Saltoun, that there is no official facade of satisfaction (that, I think, was the expression he used) any more than there is serious dissatisfaction. There is a constant: desire on the part of Her Majesty's Government for improvement.
I myself am in a difficulty this afternoon in answering this debate, for two reasons. First, many of the most important points dial have been made are on subjects which, must be within the terms of reference of the two Committees, 1123 the Guillebaud Committee and the Phillips Committee, which are presently investigating the Health Service, and I should hardly be helping them if I were to offer any half-way conjectures or answers at this moment about matters which are under their consideration. I can, of course, promise that I will make certain that these two Committees see these suggestions, which they will no doubt bear carefully in mind. My other disadvantage is a personal one. I speak as an amateur surrounded by a field of professionals. One of them, my noble friend Lord Cranbrook, speaks with peat authority as the Chairman of the East Anglian Board. He made an excellent speech, with most of which I cordially agree. My personal experience is based solely on four or five years as chairman of a public health committee, which admittedly was spread over the period before and after the Health Act, and I am afraid that my knowledge in this matter is a little rusty.
May I come now to the point which has entered into almost every speech made this afternoon, and which I think is the essence of the noble Lord's complaint? That is the question of the coordination of the different parts of the Health and Welfare Services. It is, I suppose, one of the greatest single problems of the National Health Service, but it is only emphasised and not created by the Service itself. To a greater or lesser extent it has always been there. Just for a moment, may we consider the complexity of the problem and the different parts of the Service administered by independent statutory bodies? There are the regional hospital boards and hospital management committees for non-teaching hospitals, and the boards of governors of teaching hospitals. There are executive councils for general practitioner and allied services, and there are local authorities, acting through their health committees and their welfare committees. There are also subsidiary committees and sub-committees of many of these. There are, I believe, something like 10,000 people engaged in this type of voluntary work connected with the Health and Welfare Services. In addition there is a multiplicity of voluntary organisations which, of course, have extremely important parts to play. To that team 1124 has to be added the team which the noble Lord, Lord Greenhill, produced for our edification, so it is not an easy collection of authorities to co-ordinate. Consider the size of the problem for a moment. There are over 500,000 people engaged in the National Health Service. It is the third biggest concern in the country. The Transport Commission come first with 900,000, the National Coal Board second with 800,000, the National Health Service next and then the General Post Office hot on their heels.
May I offer a word on the methods so far adopted to secure co-ordination? First, there is the interlocking membership of the statutory bodies provided for in the Act; then there is the exhortation and encouragement and the constant watchfulness of my right honourable friend the Minister, who looks at each case where there is need of greater coordination on its merits, and attempts to guide it into more co-ordinated ways. Then there are the standing joint committees of the various authorities. They are working well in some areas but in many places it has been felt that they would be an unnecessary complication of the administrative machinery. Last, and most important, there is the personal co-operation between individual officers of the different statutory and voluntary bodies, and in the last resort I should have thought this must be the most effective, perhaps the only really effective, way of getting the good co-operation which I readily agree we must have. In other words, this, like so many other problems, resolves itself finally into one of human relationships.
I remember a borough council with which I had some professional dealings where the town clerk and the borough surveyor had not spoken to each other in private for seventeen years. They corresponded by bits of paper written in the third person. On the face of it, that was one of the most efficiently run local authorities I ever came across; but how can you say that co-operation was good merely because on paper it looked tidy and good when you had that ridiculous human anomaly under the surface? I mention that only to show your Lordships how much I think it eventually rests upon personalities to secure this co-operation rather than upon tidying up the existing arrangements or upon unnecessarily drastic reorganisations.
1125 I have heard it suggested that it would be advisable to have all-purpose authorities. That means an all-purpose local authority responsible for all parts of the Health and Welfare Services. That suggestion, however, presents serious difficulties. The present structure of local government means that few, if any, of the local authorities have areas large enough for the planning and perhaps operation of a really comprehensive hospital service. Nor am I convinced that the creation of all-purpose health authorities would go the whole way towards resolving the problem of co-operation, since, with an authority of that size, co-ordination between its different departments would not, in practice, be a great deal easier than the co-ordination of different authorities. Anybody who has had to deal with a big county council would, I think, bear me out on that point. But that suggestion and kindred ones for the improvement of co-ordination that have been put forward this afternoon is in the forefront of the terms of reference of Mr. Guillebaud's Committee, and I know that he is directing his mind towards that particular point.
I can weary your Lordships with examples of good co-operation, and equally I can take examples of bad cooperation, but I think, on the whole, the situation is improving and the lessons of the last five years are being learnt. But I admit straightaway that there is still room for a good deal of improvement. The noble Lord, Lord Saltoun, in the course of his remarks, and many other speakers have talked about the need for greater local autonomy. That is something for which we all cry aloud, particularly if we belong to a small local authority ourselves. But in a large service such as this there are some matters over which the Minister must exercise some central control: major questions of policy, extensive building operations and remuneration in the hospital service itself. But, apart from that, my right honourable friend the Minister is most anxious that the whole spirit of the National Health Service Act should be generously interpreted and that local bodies with local initiative and responsibility should run the service in the way which suits the needs of their locality best. There can be no hard and fast rule. I am certain 1126 that if the Act is interpreted in the way in which my right honourable friend wants it, the results will be, as has been indicated to-day, most desirable.
I turn now to another subject which many noble Lords have mentioned in the course of their speeches, and that is the question of services for the aged. The noble Lord, Lord Amulree, touched upon this, and, to me, it is particularly interesting to hear him do so, because he and I served for two or three year's together on the National Council of Almshouses. The greater part of the social services for the aged are not, of course, provided for them alone but are services available to the community as a whole, in which old folk have their share. Let me remind your Lordships of the three principal services of a health and welfare character which apply to old people. First, there is the hospital service itself for those who are in need of medical and nursing care and attention. Secondly, there is the residential homes service for those who, whether on account of old age or for any other reason, are unable to look after themselves and whose relations or friends are unable to provide the necessary care and attention for them. The noble Lord, Lord Burden, I believe, mentioned the question of half-way houses. We have those. There are quite a lot of half-way houses and we hope to have more. They are fulfilling the very purpose, particularly in the case of mental patients. Talking of mental patients, I may have misheard one noble Lord, but I thought he was rather suggesting that it was not a very difficult thing as a certain stage to get people certified.
§ LORD BURDEN: No.
§ LORD MANCROFT
Let us be quite clear that it is very difficult to get people certified, and so it should be. A very detailed procedure has to be gone through. What we are worrying about more than people who are certified is people who are getting a little senile. That is what the noble Lord was worrying about, I think.
§ LORD MANCROFT
Then there is the third service, which is service provided in the home. This includes the ordinary general practitioner service, the health 1127 visiting service, the home nursing service, the domestic health service and the services provided by voluntary effort—the Red Cross, the W.V.S. and so on. What we must do is to make certain that old people are not demanding of the State higher services than their needs really require and are not filling beds which others more urgently need. That is the aim, as far as I can see it. The development of these services is dependent upon the materials and manpower available, as so much else is, and it is the aim of my right honourable friend the Minister to make the best possible provision for the aged and infirm within the general framework of the services I have just mentioned, making certain that we are not wasting any of our facilities.
I must, I am afraid, burden your Lordships now with a few statistics, and for this reason. I can answer questions as to what progress we are making only by showing from the figures the change in the position in the last two or three years. This, I think, will answer one or two questions which the noble Lord, Lord Mathers, raised in his interesting speech. In 1911, there were 2¾million people over pensionable age; in 1947, when the Act came in, that figure had risen to 6½ million, a very sharp rise. In 1977, it is estimated that that figure of pensionable people will have reached 9½ million. That is going to be a really serious social problem. We may as well start facing it now.
§ LORD MANCROFT
United Kingdom figures, yes. The second figure which I think is interesting is this. The expectation of life for a man of 65 is now 12¾ years, and for a woman of 60 it is 18¾ years. Now let us consider what progress we have made. In England and Wales, there are 54,000 staffed beds for the chronic sick, and I am sorry to say that 3,600 of those still he empty for lack of nursing staff—it is mostly nursing staff in mental hospitals and institutions such as that. That figure has been steadily reduced each year from its peak, which was 4,700 in 1949. The staffed beds have increased in the same period from the figure of 50,000 to the figure I have just 1128 given, 54,000. That is progress in which we can take some quiet satisfaction. But it is the turnover of beds that really matters. The expression "turnover" of beds sounds a little odd but at least it is better than "through-put of patients." In 1951, the number of beds increased by 3.3 per cent. while the number of patients treated increased by 10.1 per cent. In 1952 the comparable figures are 1 per cent. and 9 per cent. So your Lordships can see that we are getting a faster turnover in beds. We are, in other words, making more use of the beds available.
The out-patients attendances have risen from 7,000 in 1950 to 14,000 in 1952. The number of in-patients treated through the National Health Service rose from nearly 85,000 in 1950 to 103,000 in 1952, and the waiting list, which is, I suppose, the saddest and most tragic of these figures—I give it with reserve—has been kept fairly steady at about 9,700. In residential accommodation provided by local authorities, there are now some 66,000 places in England and Wales, and since the end of the war about 600 homes, with accommodation for about 18,000 persons, has been provided. I apologise for giving these figures, because they are difficult to understand when they are read out quickly, but it is the only way in which I can answer the questions put to me about what progress we have made towards meeting this problem of accommodating the old people and caring for their needs.
§ EARL JOWITT
May I ask what is meant by a "waiting list"? Is that term used without any regard to the length of time for which a person waits? If one person has waited one day and another one month would they both be included in that figure?
§ LORD MANCROFT
One day would not, I think, count. We come back once again, then, to the human problem. Quite apart from the facilities and the figures I have talked about, a great deal of progress is being made in the ordinary social service, the neighbourly service to old people; and it is that, more than anything, that we have to encourage—to let people think that it is still their duty to act the Good Samaritan to their neighbour, particularly if that neighbour is getting old or infirm.
1129 I now turn to one or two of the other questions that have been put to me. The administration of the National Health Service on the higher level was put to me by the noble Lord, Lord Beveridge. The really important suggestion he made —namely, that we should introduce an entirely new organisation between the Ministry of Health and the lower strata of the health organisation—would cost a tremendous amount, and would need an enormous number of bodies to start it. I have often thought that most of the noble Lord's plans over the years gone by, commendable though they have always been, have never been very sparing of money.
§ LORD BEVERIDGE
I do not know whether the noble Lord is referring to the Health Service, but I have no responsibility either for the original estimates for the Health Service, or for the present expenditure—none whatsoever.
§ LORD MANCROFT
I beg the noble Lord's pardon. I had been persuaded that almost any benefit we enjoy was invented by the noble Lord, and I thus accidentally ascribed that Service to him. However, his new proposal is undoubtedly a matter for the Guillebaud Committee to discuss, and I will not express any opinion upon it, except to say that it is a major and revolutionary change which would require Parliamentary action. The noble Lord discussed health centres. He is quite right in saying that those have not been the outstanding success that had been expected. He mentioned three, but I believe that there are now four—in London, Bristol, Nottingham and Faringdon. Up to a point, they must still be regarded as experimental. They are expensive to build and they have not teen as popular, either with patients or with doctors, as had been expected. An alternative presents itself—namely, the establishment by doctors themselves of group practices where several doctors work together at their own premises. This development is supported by my right honourable friend and is being encouraged by the offer of interest-free loans by executive councils to groups of doctors to acquire or convert buildings to establish a group practice. The noble Lord is quite right when he says that a bigger field for this experiment opens itself up in the new housing estates and in the new 1130 towns. We are going ahead there, and I hope that these schemes will prove more successful than they have done elsewhere.
The noble Lord also discussed hospital finance, and he criticised the handing back of money at the, end of the year. That, of course, is a highly controversial matter. I think the noble Earl, Lord Cranbrook, pointed out, that there is much to be said on both sides, and I am afraid that I must again take refuge in the Guillebaud Committee, because that is one of the points which I am certain that they will he discussing. But I must say this about the matter. It is nothing like so simple as the noble Lord, Lord Beveridge, suggests. There is a great deal to be said on either side about it, and we should be here all night if we were to discuss it. There are £300 million of the taxpayers' money involved, and I think that the Minister responsible to Parliament far that sum is justified in saying that he ought to keep a fairly tight control over it.
The noble Lord, Lord Mathers, mentioned the question of patent medicines. He asked why the prescribing of proprietary medicines of the more expensive kind should not be discouraged. My Lords, that is done. Doctors are frequently encouraged not to prescribe such medicines, and have, in fact, been so urged by the Minister's Chief Medical Officer. Sometimes hospital pharmacists are authorised by their medical staff to dispense nor-proprietary equivalents, where proprietary drags are prohibited, without any reference hack to the physician. I think that may answer the noble Lord's question.
§ LORD MATHERS
The point I wanted to make is that it seems to me that nothing short of proscription, rather than prescription, will cure some people of the idea that only by a proprietary medicine or remedy can they obtain the remedy which they feel they need.
§ LORD MANCROFT
Well, my Lords, Her Majesty's Government will try anything but I am afraid, we cannot legislate for human fatuity of that degree. The noble Lord, Lord Calverley, raised a point about a Yorkshire hospital. Am I right in thinking that it was the Bradford Eye and Ear Hospital that he had in mind?
§ LORD MANCROFT
I am sorry, but I am going to disappoint the noble Lord. He referred to a proposal on foot locally to launch a public appeal for funds for new building. My noble friend Lord Woolton referred to this hospital in answer to a Parliamentary Question the other day. My right honourable friend the Minister tells me that he has been asked to support this appeal, but he feels that he must take the line that, being responsible to Parliament for providing the Service with money provided by Parliament for the purpose, it would not be appropriate for him to associate himself with an appeal for voluntary funds, however much sympathy he may feel with those who wish to make it. Nor is the initial capital cost the only factor in a scheme of this kind. The Minister can give no guarantee—indeed, he cannot encourage the idea—that he could maintain the new hospital from Exchequer funds, even if it were built without calling on the Exchequer. Existing conditions at this hospital are certainly not ideal—that was readily admitted by my noble friend; but as Lord Calverley knows only too well, the Exchequer resources are limited and the needs of the Hospital Service are many. Further improvements have, therefore, to be put in an order of priority, which it is the regional hospital board's function to determine. I am afraid that that will not please the noble Lord, Lord Calverley, but I do not think it will surprise him a great deal.
§ LORD CALVERLEY
Will the noble Lord forgive me? What was the last sentence about the regional board?
§ LORD MANCROFT
My Lords, a large number of other questions have been asked, with which I am afraid I have not the time to deal. I will, of course, make it my business to see that the many interesting suggestions that have been made concerning the wider proposals for reorganisation are brought 1132 to the notice of my right honourable friend and the two Committees behind whom I am afraid I have more than once had to take refuge—not out of cowardice, but out of respect for their terms of reference. May I conclude by once again reiterating the Government's refusal to be in any way complacent about the working of this great scheme. In the end, it comes down to this. I have always felt that the trouble with the Welfare State is that too many people worry about what they can get out of it and never bother to think about what they can put into it. If the traveller on the road between Jerusalem and Jericho, the Good Samaritan, had stopped to look at the battered body of the way-farer he would (if he had thought the way some people do now) have thought to himself, "Now I wonder whether it is the Medical Officer of Health for Jericho whose job it is to look after that chap, or that of the Jerusalem City Council," and he would have gone on his way—
§ LORD BURDEN
My Lords, it was the high and mighty that passed the way-farer by, not the Good Samaritan.
§ LORD MANCROFT
I said that if the Good Samaritan had felt as some people do to-day, he would have put that question. He did not; he did something about it himself.
None of these schemes, none of these improvements, will be of the slightest use, and no investigations will solve these problems, unless ordinary people realise that they have towards the old and the sick just as much personal responsibility as the authorities have. Far too many people say: "Why do they not do something about it; why does the town clerk not get moving?" What they ought to say is: "Why have I myself not a greater sense of public conscience?" One method of helping the aged, which I think I might mention, since it touches on this question of the public conscience, is a method which has been adopted in my borough and in certain other boroughs. A scheme has been devised of issuing to old people who live by themselves—sometimes at the top of flights of stairs—little cards bearing the letters "S.O.S." If need arises they can put these cards in the windows of their homes, and they can be assured of immediate help in their trouble from 1133 neighbours. This scheme has proved of great value. The people I am sorriest for are old people living alone, who often are too proud to say that they are in trouble or to make it known that they may want help. All too frequently their plight is not noticed until someone observes that there are far too many milk bottles at the foot of the stairs. Then investigations are carried out, and, in too many cases, a tragedy is discovered. I would stress that no improvement in services, no new formula, no new rules will help in the solution of that sort of problem, which is still too common to-day. So I only hope that this debate, amongst its other good effects, will have that of drawing the attention of the man in the street to the part which it is his duty to play in making this great scheme work. I am certain that we are all, in every pert of the House, grateful to the noble Lord, Lord Saltoun, and to those who have supported him, for their helpful contributions to our debate on this important subject.
§ 6.52 p.m.
My Lords, before withdrawing this Motion, I should like, in the first place, to thank noble Lords opposite for the extremely sympathetic way in which they have received and supported it. Their attitude has been most helpful to me, and has made me feel that this subject is entirely outside Party politics. I should like to mention one point raised by Lord Burden. He seemed to want to remove housing from the borough to the county. I am in the opposite camp. I want to remove the running of welfare services, so far as possible, to the borough, because that is nearer to the people. To Lord Mathers I should like to say that I think the reactionary things he was attributing to me were really quotations which I was making. My speech was made up almost entirely of quotations, like those works of the late Latin poets which were composed entirely of snippets from Virgil. I am very grateful to the noble Lord. Lord Amulree. I put down this Motion rather in the hope of getting something out of him on this subject. I am glad that he did not disappoint me. I tender my thanks, also, to Lord Beveridge, and to the noble Earl, Lord Cranbrook. The latter, I think, made a great contribution 1134 to the debate. I was extremely pleased with one or two of the things which he said. They were things which—though he said them very much better—I myself said three years ago. I would only acid that I am extremely grateful to Lord Mancroft for the very encouraging answer which he has given to us. I am much more consoled with that answer than I have been with any answer I have had from any Government for a very long time. With those few remarks I beg leave to withdraw my Motion.
§ Motion, by leave, withdrawn.