THE HOSPITAL SERVICES

HL Deb 02 July 1958 vol 210 cc447-514

2.42 p.m.

LORD NATHAN rose to call attention to the hospital services; and to move for Papers. The noble Lord said: My Lords, it is very appropriate that this discussion should be held this week, because it marks the tenth anniversary of the coming into operation of the National Health Service. It is an appropriate moment at which to review certain aspects of the National Health Service. The coming into force of the National Health Service Act marked a revolution in many ways in the social life and habits of the country. It affected vast numbers of the population; it had a striking influence upon the standing and procedures of the medical and dental professions and upon the nursing profession. It was a central feature in what, from that time onwards, has been known as the "Welfare State"; if not the central feature, it was at all events a central feature.

It would be too wide a range if I were to attempt to-day to cover the whole ground of the National Health Service. I propose, therefore, to limit myself to a field which is well defined and pretty precise; that is, the hospital services. I propose, so far as I am concerned, though other speakers will no doubt touch on other aspects of that subject, to limit myself to the experience which I personally have had of an undergraduate teaching hospital here in London. I have for about a quarter of a century been actively concerned as a governor of such a hospital. After being for a time vice-chairman, I became, ten years ago, as many of your Lordships know, Chairman of Westminster Hospital—Parliament's own hospital. It is from the vantage point of that experience that I venture to address your Lordships to-day.

I have nothing to say that is, at least in a political sense, at all controversial—indeed, I have not a great deal to say that is controversial even in a nonpolitical sense. As we look back over a period of ten years of experience in the hospital world within the National Health Service, I think it can fairly be claimed that the situation has clarified and improved; and that, although there are undoubtedly matters upon which the administration can be criticised and points at which it can be improved, on the whole the Ministry are entitled to have our congratulations on having performed a new and a difficult task—I stress particularly a new task—with general satisfaction. It was difficult for them to come to an entirely new subject matter outside the range of previous ministerial experience, and on the whole I think that they have adapted themselves pretty well. Therefore it is within the general temper of friendly congratulation to the Ministry and to ourselves, the hospitals, that I approach this subject.

I think it will perhaps be interesting to your Lordships that I should say a word about the subject in its quantitative sense, in order to indicate the dimensions of the problem and also the changes that have taken place quantitatively during the last ten years. For instance, so far as the teaching hospitals are concerned, whether within or outside London, both post-graduate and undergraduate hospitals, there has been no increase in the number of hospitals; there has been a slight marginal increase in the number of beds. The number of beds has increased from rather over 26,000 to very nearly 28,000, an increase of 5 per cent. That is over the whole range of teaching hospitals throughout the country. In the non-teaching hospitals, including mental and mental deficiency hospitals, the beddage has increased, very slightly, from 475,000-odd to 481,000-odd, an increase of approximately 1 per cent. That increase has been almost entirely, and rightly, in the mental hospitals. As regards bed-occupancy, after all, what one wants to know is how beds are being used and whether they are being used; and for my part I find it interesting to note that the bed-occupancy in the teaching hospitals, at just over 80 per cent., is almost constant now compared with what it was in 1949; whereas in the other hospitals, the non-teaching hospitals, the bed-occupancy has increased from 79 per cent. to 83 per cent. I think that those of your Lordships who have experience within hospitals will agree that when a hospital has a bed-occupancy of 80 per cent.-plus it can be regarded as being full. Certainly with a bed-occupancy of 85 per cent. a hospital would be full.

The number of the medical and dental staffs has increased, taking the country as a whole, by about 30 per cent. It is also interesting to note that in the teaching hospitals the number of nurses has increased by 20 per cent., and in the non-teaching hospitals by not more than 10 per cent.

It is also interesting to observe that the total number of nurses in the various hospitals now is approximately 155,000, which is not much less than the total number of the newly streamlined Army of which we were speaking in a debate the other day. I doubt whether it is fully realised that the number of nurses in hospitals is about the same as the number of soldiers in the Army. The administrative staffs have gone up by only about 20 per cent., notwithstanding the very wide range of new responsibilities that have been placed upon hospitals, mostly in connection with demands made by the Ministry for this and that in the processes of administration.

I ought to have told your Lordships earlier the interesting figures as regards out-patients. In the teaching hospitals they have gone up since 1949, when they were about 7½ million, to, in 1956—the last figure I have—9½ million. In non-teaching hospitals, where the figures are not strictly comparable, the number of out-patients was about 18½ million in each year. I have given those figures to your Lordships partly because it seemed to me interesting, and perhaps important, to note what changes have taken place and also to know what the quantitative importance of this problem of hospitals is. At least your Lordships will agree with me that it is a matter affecting vast numbers of people and it is of the first importance that the hospital service should be in all its aspects well run and progressive. I feel, from the point from which If have been able to regard hospital service, that too much cannot be said in praise of the assiduity and devotion of the medical staffs and of the nursing staffs; and the administrative staffs of the hospitals have, of course, played their full part.

There is, however, one aspect of service to hospitals about which I have found here and there some misconception and which I for my part regard as important. In a long experience I have realised the enormous value attaching to voluntary service and, speaking from my own experience, I can certainly say—and it is curious, but very satisfactory to be able to say it; I should scarcely have expected it would be so—that the number of volunteers giving voluntary service in the hospital with which I am most familiar is greater than at any previous time in the 250 years' history of the Westminster Hospital. That shows that people will not consent to be deprived, whatever the change in circumstances, of the opportunity for voluntary service; and if they cannot perform it in one direction they will find another in which to do so. I regard that as one of the most satisfactory features of the hospital service as it has emerged under the new Act.

My Lords, you will say in regard to the figures I have given, "What about the total cost of it all?" I am bound to say that throughout the period every one of us responsible for administering hospitals has had to allow "I would" to wait upon "I can", for expenditure, both capital and maintenance, has gradually been becoming more and more restricted, at any rate so far as certain of the hospitals are concerned although there are indications that, taking the expenditure globally, there may be some expansion at all events in capital expenditure in certain directions. As regards capital expenditure, the Guillebaud Committee found that hospital capital expenditure in 1952–53 was only about one-third of what it had been in the pre-war year 1938–39. There has been a great reduction between the immediate pre-war and post-war years. It is true that there has been an increase since the Guillebaud Committee reported, but still only £20 million was allocated for such expenditure, which is a long way from the £30 million recommended by the Guillebaud Committee as a suitable figure.

I want to say to your Lordships that a careful eye must be kept to see that capital expenditure is not unduly restricted. There was undoubtedly a tendency in past years, before the war, when money was scarce and had to be culled from the pockets of individual well-wishers, to build hospitals as small as might be, just sufficiently large for the needs and purposes for which they were required. But experience has shown that although at the moment there has been no appreciable increase in the number of beds, the requirements for space have grown very greatly: new techniques have been developed, more laboratories are required, the coming young men of the medical profession require an opportunity for seeing what fresh disciplines they can create and what fresh methods they can adapt for helping the patient, who, after all, is the first concern of the profession and of all those engaged in the service of the hospital—" How can we best help the patient? "

As things are, the running costs for 1958–59 are estimated at just under £400 million; that is, at about 4 per cent. more than in 1957–58. But when the difference in the value of money is taken into account, £400 million in 1949–50 would now require some £480 million to provide the same service. When we survey the cost of the medical service as it falls upon the Exchequer I think we should, before criticising it and deploring it as so many do, try to form some idea of what in the pre-war years was spent by the nation on similar services; what proportion of the national income is now represented by the National Health Service as compared with that part of the national income expended on the same services before the new medical service came into operation. There are no scientifically accurate figures upon that subject, because this was a matter of private expenditure out of the personal pockets of the patients, but I should be very much surprised to learn that the expenditure falling on the country at this time is appreciably more than it was in the years before the war. At any rate, it is a subject which would, I think, be well worth some inquiry.

I was saying just now that new developments in surgery and treatment generally demand increased space. I have had this problem brought before me with great emphasis. I will give your Lordships a simple example of the sort of thing that arises. For instance, provision has now to be made in the anæthetic room for emergency surgery for heart massage, and also there is a requirement for such modern apparatus as the artificial heart and the artificial kidney. These take up quite a large area and it must necessarily be aseptic. In my own hospital, we have brought to this country the latest installation, called the Theratron, which deals with cancer. That has had to be installed in the hospital without any appreciable increase in the area available. It is a large installation; at is a life saver; it is a principal instrument in the fight against cancer. Without space we cannot have that sort of installation. It was only by a clever adaptation by the architects that we have managed to find space for it, and only then, as some of your Lordships may have seen as you have passed by, by placing one of the departments in an otherwise derelict field. I would press upon the Ministry that in building new hospitals they should have regard to the urgent necessity not for limiting their building to the space actually required at the moment but for exercising a certain imaginativeness, so that they can provide in anticipation for what is likely to be required in the future.

I am worried about whether the Ministry are really justified in pursuing the course which they have been pursuing for some time—that is, coming to hospitals who have their own endowment funds and saying to them: "We recognise that you require additional buildings: we know that Parliament has placed upon the Ministry a duty to provide proper services; but you have these private endowment funds set aside by Parliament for hospital purposes and research and we feel that we, the Ministry—or the Treasury—cannot, or should not, provide money for building unless a contribution is made out of the private endowment funds of the hospital." So far I have resisted that, although some of my colleagues in a similar situation have succumbed, it may be for greater good: but I believe that that is a procedure open to grave criticism and that it should receive reconsideration on the part of the Ministry. It means that private funds are being used to subsidise expenditure the responsibility for which Parliament has placed upon the Ministry. I cannot think that that would be in accord with what was anticipated at the time or with what Parliament would approve now.

Hospitals are a subject upon which one could speak for a great length of time. Before I sit down, I would only say to your Lordships a word upon one other aspect of the subject—that is, the extreme importance of research, and research not merely in laboratories forming an integral part of individual hospitals but also resulting from sending medical men or members of the nursing and administrative staffs to other parts of the world to find out what is happening there. In my own hospital in certain instances, when a new man is appointed as a consultant in a speciality, we have adopted the practice of saying, "First of all, we want you to go away for six months and see what you can learn about the latest methods elsewhere, and then come back and start here with your new appointment.'" I am bound to tell your Lordships that that has paid an admirable dividend. It was a risk, but a risk that has proved to be well worth while.

I must impress upon your Lordships the necessity for space as well as for research, because the two things are closely linked together. The fact of the matter is that, as experience shows, or seems likely to show, we cannot retain in our hospitals or in this country the right young men upon whom the future of medicine and surgery, and in fact the future of the ailing population, depends, unless we provide them with adequate remuneration and what to their minds is, and is rightly, even more important—the opportunity of developing their powers and their careers within their profession to the utmost. They feel, as I know too well, that now they are being restricted as regards space and facilities, and the temptations offered to them by higher rewards and more adequate facilities on the other side of the Atlantic are temptations which they may find—and there are indications that they are finding—increasingly difficult to resist. That is a grave matter for the future of the medical profession, for the future of the hospitals and also for those for whose service the hospitals exist.

Within a few minutes almost I have tried to present to your Lordships some of the reflections that have occurred to me as a result of a long experience in a London teaching hospital and of viewing the hospital service from that standpoint. I conclude by saying to your Lordships that I am increasingly impressed by the devotion of those in every range of the service who make it their life's task to do the best for the patient. We all receive many letters of thanks, some from those who are able to express themselves with great eloquence and some from the simple and humble. The reward for all those engaged professionally and administratively is to know that they have—as indeed they have—in the hospitals the good will of the patients for whose service the hospitals exist. My Lords, I beg to move for Papers.

3.8 p.m.

LORD AMULREE

My Lords, I think your Lordships must agree that the noble Lord, Lord Nathan, has put us into great debt by bringing before us this Motion today. I think it is appropriate, when the National Health Service has been working for about ten years, that we should have an opportunity of discussing some of the facets which present themselves. I am extremely pleased to be following the noble Lord because whereas he has been the Chairman of one of the big London teaching hospitals for many years, I am a member of the medical staff of one of the big London teaching hospitals. I am bound to say that there is nothing which the noble Lord has said with which I do not entirely agree. I think he has put forward a good case and I entirely support every word he has said—which will mean that I shall not need to address your Lordships at any great length, as I might have done if I had not been in agreement.

What I would like to do is to go a little farther afield and say a few words about the hospital position in general. I think that all who have visited hospitals around the country must agree that there has been a considerable improvement in the hospital service during the ten years during which the National Health Service has been running. There are a great many hospitals that were rather poor, but which have now become very good. This refers largely to some of the old municipal hospitals which, really by no fault of the municipal authorities, had not been given opportunities to progress as they should have done, because of the depression of 1931 followed by the war in 1939. Nevertheless, a great amount of excellent work has been done in improving these municipal hospitals and also some of the other hospitals that were not so good. Another fact which I feel is interesting is that at the present time there has been no corresponding falling off in the work of the good hospitals. So that I think we can say that the balance is very much in favour of what the National Health Service has done for the hospital service in general.

There is one thing, however, about which I am a little frightened and worried for the future. Supposing that too rigid a ceiling (as it is called) is placed on the amount of money available for the hospital service, then I think that inevitably we are bound in time to get some kind of falling off. It must be realised that medicine is a very expensive work to carry out properly and well. It is something on which one can economise, but one cannot avoid spending money. I am sure that it is most important now that every attempt should be made to run the hospitals as economically as they can possibly be run, so that there will be enough money available for improvements which will inevitably be needed in the future. If such improvements are not adopted or accepted by the hospitals, then it will mean that the service will in a short time become a second-rate one. At the present time one finds many drawbacks in hospitals. One great drawback, it seems to me, is a lack of facilities available for the surgeons who carry out the innumerable operations that are now performed. In the past operations were numerous, but not so numerous as they are now; and, of course, they were far less complicated. I am sure that to-day there are a large number of hospitals in which the surgeons have to do their surgery under conditions—I will not say of great difficulty, but certainly of some discomfort. One would like to see more progress made in that respect, if possible, by sensible economies in the running of other parts of the hospital.

One point that I have never regarded as of great importance is the fact that, as one sees stated in some quarters, the hospitals in this country are not very modern buildings. I have never thought it necessary to have a brand-new building to do first-class work: so long as there are good equipment and good staff, and the building is structurally sound, I am not at all worried by the fact that new hospitals have not been put up in place of some of those which have been there for a number of years but which are working quite well. The branch of the hospital of which I have had experience was built in 1874, I think, as part of an old poor law hospital. We have done a great deal of work internally, changing it round, but the actual structure, which, as I say, was built in 1874, is as strong as ever; and I think it would be a pity to say that, merely because the building is getting on for eighty years old, it is old-fashioned and not very satisfactory.

The same thing applies to the talk about building new hospitals. I am not at all convinced that, except in one or two parts of the country, there is a great demand or need for more beds than exist at present. It is true that in some places the waiting lists are long, but the importance of that fact greatly depends on the amount of time a person has to spend on the waiting list. If there are a great many people on a waiting list, but they can be absorbed or got rid of in from ten to fourteen days, then that does not seem to me so serious as if the same number were on a waiting list which it would take six months to get rid of. The tendency now seems to be that the turnover in any one particular bed where good treatment is given is far more rapid than it was. I do not think one need be so worried about the large waiting lists, except in certain parts of the country, as some people seem to be. Another difficult point about waiting lists is that certain doctors on the staffs of hospitals are more popular than others. People tend to prefer to consult such a doctor and therefore the waiting list for patients who wish to come in under him will probably be longer than the waiting list for a doctor who is not quite so popular.

There is another rather curious facet of the service which I should like to mention, in passing. A large number of the big London hospitals have private patients' blocks and wings where people who are willing and able to pay the full cost of their treatment and service can be accommodated. This, so far as I can see, has become an important venture from an international point of view, because a large number of people are coming from abroad to make use of these private wings—not because they are free: the patients pay the full cost of anything from twenty-five to twenty-six guineas a week—but in order to get the benefits of the work done under the National Health Service. That, as I say, is an important factor from an international point of view.

The next point I want to mention is a subject which I have brought to your Lordships' attention several times before—namely, the shortage of accommodation for elderly persons in the country. Here again, I do not particularly want to put the blame on the National Health Service, because, broadly speaking, I think the number of hospital beds is roughly what we need. There are few people who would not say they could do with a few more, but I do not think there is much ground for saying that more are required. What I think is required is more accommodation under Part III of the National Assistance Act—that is, accommodation provided by the local authority for the infirm and disabled persons who come into hospital, get what treatment is possible and are rehabilitated as well they can be, yet who are not quite well enough to go back to their homes, and, therefore, according to the law, become the responsibility of the local authority. The amount of accommodation for these people is not sufficient. If you go round any hospital ward where the care of the elderly is the prime object you will find a large number of people who should be the responsibility of the local authority but who are occupying beds which could be filled by sick persons.

To come back to my own instance (my wards are part of St. Pancras Hospital), that means that we are keeping perfectly fit people, though disabled, in hospital beds at a cost of twenty-five guineas a week, which one must agree is not a very economic proposition. Therefore I would suggest that local authorities should be encouraged to provide these beds and that there should be no administrative gap over the transfer home and rehabilitation of these elderly persons who are being treated in hospital to-day. One of the few advantages of the old poor law, which none of us wants to see come back, was that both the sick and the able-bodied, as they were called, were with the same authority, so that there was no difficulty in moving people from the hospital to the house when they were well, and vice versa; whereas now, with the best will in the world, there seems great difficulty in that way.

It is possible, I think for the Regional l3oards and local authorities to do a certain amount by making a joint appointment of the doctor to take care of the so-called elderly sick and of the sick or infirm people in the "Part III" accommodation. That idea appears to me to be sound. It was done years ago in one particular ease in one of the Home Counties, and. so far as I know, is working well. An attempt was made to do something similar in another part of London, but the responsible authorities made the mistake of not having their doctor on a consultant basis, giving him no control of patients at all: he was merely a junior who could go round recommending people to do things, but his recommendations had no sanction. One cannot help wondering whether recommendations of that sort are of much value.

One thing that I am sure we need to do at the present time is to ensure that the hospitals are run with as much economy as possible—not with as much saving of money as possible, if your Lordships can see the difference. Attempts have been made to bring in studies of hospital work. Reports on the work of the hospital nurse have been published by the Nuffield Hospitals Provincial Trust, and one or two other bodies have taken up the same line and made detailed inquiries to ascertain whether people were doing the work for which they were paid, and whether that work was being done as economically as it could be done. One of the London hospitals is making an inquiry into the work of its X-ray department to see whether there is any preventable wastage and, if so, to try to put that right when the occasion arises. Provided that the Ministry, who have done such good work, continue to try to find every possible economy in running the hospitals, yet at the same time try not to stint them of the money they need (we are seeing signs of that to-day, although I hope it will not go too far) then I hope that if, in another ten years' time, the noble Lord, Lord Nathan, puts down another Motion, we shall be able to look back on a further ten years of progress.

3.22 p.m.

LORD EVANS

My Lords, this is the first time that I have had the honour of addressing your Lordships. I hope, and, indeed, I feel sure, that I can count upon the indulgence invariably shown to the unfortunate members of my profession who find themselves in the position in which I find myself now. Perhaps I crave your Lordships' indulgence a little more than usual—I hope this is not out of order—because I should like to recall for a moment the recent loss we have all suffered in the death of Lord Webb-Johnson, my very dear friend, counsellor and colleague, who did so much, as your Lordships know, for medicine in general and in particular, of course, for the Middlesex Hospital and the Royal College of Surgeons. He was one of my sponsors on my introduction into this House, which he always regarded as your Lordships' most friendly meeting place. He will be sadly missed by many.

My own interest and occupation is really with bedside medicine rather than with administrative medical affairs, and it may be that this will be reflected in my remarks which will be somewhat different from those made by my noble predecessors. But the one has now become so intimately associated with the other that I am immensely grateful for this opportunity to draw attention to a few aspects of this big and important hospital problem. I speak, of course, especially on behalf of the teaching hospitals. It has been well said, I think, that a very important part of education—academic, technical and professional—is the personal influence of the teacher upon the taught. Be the building, the laboratory, the equipment, and so on, ever so perfect, there yet must be this essential personal contact between teacher and pupil which creates an atmosphere, the atmosphere that develops and makes the teaching hospitals. One can say that this aspect goes very well in medicine in this country to-day. But there is a sad trend for these functional advances to have outgrown the structural. That great doctor and philosopher William Osier said: It is, I think_ safe to say that in a hospital with students in the wards the patients are more carefully looked after their diseases are more carefully studied, and fewer mistakes are made. I am quite certain that this is so, and no one can surely doubt that the quality and standard of medicine in any country must depend upon the quality of its teaching hospitals. If this is ensured first, I think the standards of the non-teaching hospitals will surely follow. But I doubt if the converse is true.

I must remind your Lordships that the teaching hospitals train, not quite all, but certainly most of the teachers, not only in medicine but in all the ancillary services such as nursing, midwifery, physiotherapy and radiography, as well as almoners, dietitians, occupational therapists and domestic science students—all this in addition to undertaking their primary duty in the care of patients, teaching of medical students, and research. Now since the introduction of the National Health Service, almost exactly ten years ago, little has been done for the teaching hospitals except the provision of funds to keep the machinery going. There has been really little structural advance in building except those previously planned, and, indeed, very little of that. We have outmoded, inadequate accommodation for patients, teaching and research, as we have heard; indeed, one has sometimes felt slightly ashamed to show visitors from abroad these features of some of our great teaching hospitals in London. Remember, too, that out of the twelve teaching hospitals in London only two—the Middlesex Hospital and Lord Nathan's hospital, the Westminster Hospital—have been rebuilt. Many of the others, your Lordships will recall, were badly blitzed during the last war. There must surely be some limit to the enjoyment of such austerities.

In the past a great deal of the success of these hospitals was due to the complete freedom of management, lay and medical; and although the teaching hospital still has some freedom it is very curtailed in many ways. Now one hears, for instance, that a lay administrator cannot employ an extra kitchen maid without permission from the Ministry of Health. I agree, of course, that doctors are notoriously bad administrators, and I should consider that good lay administration is absolutely essential to the success of any hospital service. How this can be maintained with the present scale of salaries I just do not know. A catering officer, for example, who may be responsible for spending more than £160,000 in a year, is not paid as much as £1,100 per annum salary. There cannot be more than a handful of senior hospital lay administrators who earn more than £2,000 a year. Surely this seems to be a grave fault in the structure.

The very much higher costs of teaching hospitals have been referred to, and the comparative cost of the care of patients in teaching and non-teaching hospitals has been recently reviewed, as your Lordships will know. This shows, to quote one example, that in a London teaching hospital the in-patient cost per week is now about £27, compared with the in-patient cost per week in a non-teaching hospital of £18. The average cost per patient of a teaching hospital is £67, compared with £41 for a non-teaching hospital. To me the difference in these figures is surprisingly small when one considers all that is entailed, and I personally find it difficult to agree with the Report of the Select Committee on Estimates. Surely it must be absurd for the teaching hospitals virtually to mark time until every other hospital catches up with them. Of course, there must be no hard and fast rules for particular hospitals, teaching or non-teaching; but it is essential, in my view, to maintain the teaching hospital at the highest possible level, whatever the cost, if British medicine is to maintain its high standard.

The immediate past President of the Royal College of Surgeons of England has suggested that for their special requirements in the future the hospitals must not only be set free but must be encouraged to seek additional sources of finance outside the Government budgets of the National Health Service. For the teaching hospitals this, to the minds of many, would be a welcome return to old practices and in keeping with their long heritage. He goes on to say that in appealing to the community, to industry and to philanthropic individuals they would thus behave as do the universities at the present time. Such efforts might even enable us to see in the space of a few years several new teaching hospitals in this country.

My Lords, I believe this is the freedom we need and must: have if we are to maintain leadership in our profession. If we can achieve this and at the same time restore the general practitioner to his rightful place as the family doctor, all will go well with medicine in Britain.

3.34 p.m.

LORD MORAN

My Lords, may I, firstly, associate myself with what the noble Lord who has just spoken said about Lord Webb-Johnson, with whom I worked in close association for very many years. I am sure I am speaking for your Lordships when I say how pleased we are to have the noble Lord, Lord Evans, in this House. The ability of his speech reminds us that he has lived all his life in the critical atmosphere of a teaching hospital and also that his opinion carries great weight in the profession to-day. We are always in need in medicine of sane and able counsellors, and the noble Lord has those qualities to a remarkable degree. I only fear that in his busy life he may find it difficult to take as great a part in our deliberations as we should all wish.

A learned member of your Lordships' House, comparing the professions of medicine and the law, said of the law, "It is not a progressive science; it is much the same as it was fifty years ago". Coming to the revolutionary changes in medicine, he quoted the Dean of Harvard who said, "In ten years' time half of what we know will prove be wrong, and alas! we do not know which half." I am sure your Lordships will realise that if we attempt to measure the progress of a science bounding forward all the time, it is dangerous to use the foot-rule of the administrator. Nevertheless, I think in fairness we ought to congratulate the Ministry of Health on a remarkable administrative achievement. In the first place they have decentralised or redistributed the consultants in this country. Before the National Health Service they were all congregated in great centres of population. It was difficult and sometimes impossible to get a second opinion unless you were in one of those centres. In Barrow-in-Furness, to give a single example, you had to go two or three hours by train to Manchester, or, if you were too ill to do that, to pay a very large fee to a Manchester consultant to come north. This decentralisation has ended that. It was necessary for these men to live in the great centres in the past because in smaller places they could not make a livelihood. By paying men for their hospital work, that was obviated, and now there are available in almost every part of the country first-rate specialists in every branch of medicine.

It is not only that they have been redistributed; they have been greatly increased in number. In the Newcastle region in 1949 there were 164 consultants; there are now 409. Moreover, the patient can not only see a first-rate consultant at any hospital in the country but if he is too ill to go there then, without financial anxieties. he can call him to his house. In the year 1956 there were 265,000 domiciliary consultations. This decentralisation has been made possible without discontent, because wherever the consultant went, whether it was to Truro or Carlisle or some distant peripheral part, he knew he had the same chance of a merit award as if he stayed in London.

This decentralisation has made possible a second great reform, which is the upgrading of hospitals throughout the country. Before the Service there were, of course, first-rate hospitals, some of the best in the world, but there were other institutions which Dickens would have delighted to describe in one of his reforming moods. That has really ended. The difference between the first-rate hospital and the second-rate hospital is the quality of the staff—it is as simple as that; and by redistributing those consultants it has been possible to upgrade hospitals because it has been possible to provide all of them with first-rate staffs. Examples will occur to all your Lordships: St. Anne's, Tottenham; St. Mary's, Colchester; The General Hospital, Barnet—are all examples of first-rate hospitals which had very humble beginnings. If the Service had done nothing else than to decentralise the consultants and upgrade hospitals, that would have fully justified its existence. It has transformed things.

I agree with the noble Lord, Lord Amulree, that buildings are important, to the extent that they make it easier to get staff, and so on; but they are only of relative importance. Much has been said about the rebuilding of the mental hospitals. I would point out that in recent years the conditions in the mental hospitals have been absolutely transformed. Doors have been unlocked. The padded room is virtually a thing of the past. Eighty per cent. of the inmates are voluntary boarders and can walk out when they like, and out-patient departments have been opened. People come from America and the Commonwealth countries, from all over the world, to see how these institutions should be run, and it has been done without rebuilding. What we need more than anything else in the mental health service is not so much new buildings as more men of first-rate ability, who will add to our knowledge of the mind in health and in disease.

The third great reform in the Service is concerned with the remuneration of consultants. Before the Service came in, the consultant, broadly speaking, obtained his remuneration from private practice. Now I think it is true to say that the vast majority get their remuneration for hospital work. This is a very great change. The man about 40 years old will get £3,255 per annum as a maximum basic salary, and he will get no more for the rest of his working life—twenty-five years, perhaps, before he retires—unless he is given a merit award for professional efficiency. That is to say, his material prosperity now depends upon his professional efficiency. It would not be too much to say that before the Service it was dependent to a great extent on his personality—and they are very different things. That is perhaps one of the great changes that have taken place in the consultant service.

I have spoken of merit awards. Merit awards are given to one-third of the 6,902 consultants in England, Wales and Scotland. One-third of that number get awards added to their income ranging from A, B and C in sums of £2,500, £1,500 and £500. That is a substantial contribution. But we must remember that they do not really get these sums unless they do the full number of sessions; otherwise they get only a proportionate figure. Why were these awards introduced? They were introduced because the Spens Committee felt that when the incentive of private practice was removed it would be difficult to keep the consultants on their toes. The merit awards were to provide that incentive. Have they been a success? You will no doubt have seen in the Press many arguments for and against. I would remind your Lordships that when the Treasury, which is not at all in love with the principle behind these awards, gave evidence in the person of Sir Thomas Padmore before the Royal Commission, he said: "This is an odd system; it is a curious system. There is nothing like it in the public service. But it works, and we hope it may go on ". Of all the various bodies that have given evidence before the Royal Commission, with one insignificant exception, every one has spoken in favour.

Why has this system worked? I am revealing no secrets when I say that when it began practically the whole profession thought it could not work. To give one-third of the consultants remuneration denied to the other two-thirds could only, they felt, lead to ill-feeling. It has worked, first of all, because it was thought out. It was seen at once that the selection of the recipients of these awards must be decentralised and that it must be done by the consultants themselves all over the country. Further, instead of explaining this in one White Paper, every year for seven years thirty or forty meetings have taken place all over the country to answer criticisms, to make it clear that the scheme is fairly administered, and I think that the profession are now convinced that, difficult as the system is to administer, a great attempt is made to make it fair and to distribute the awards all over the country.

Leaving the question of merit awards, I should like to say a few words about finance. Perhaps the most anxious matter is what is going to happen to the amount expended on this Service. A short time ago it was £400 million; to-clay it is £661 million per annum. One new antibiotic may add £2 million a year. We know that in a progressive science essential expenditure must always be mounting. How are we going to check it? Certainly we cannot check it by denying the population real advances. Nor can you economise on doctors' salaries. Years ago Adam Smith in The Wealth of Nations said: The doctor has great power. Nobody knows whether he is abusing that power or not. We have got to trust him. Therefore he must be a man of character and substance, and therefore he must be paid accordingly by the community. That was said by Adam Smith. It is still true to-day. These are not the fields, therefore, in which we can economise. On the other hand, I think the time may come when we may have to give a sum of money to the regions and tell them to get on with it, to restore the spirit of economy which was so prevalent in voluntary hospital circles in their clay and which is not quite so evident to-day.

Again, when committees, some of which have been mentioned to-day, begin to investigate and suggest economies, it seems to me that they go the wrong way about it. For example, take the drug bill of £74 million per annum. Recently a committee went into that matter. What did they do? They set out to find whether there was irresponsible prescribing—whether the doctor prescribes drugs in which he has no faith. Most of us know that the average doctor believes in the drugs he is giving. That is not the point. The point is, has he any scientific reason for his belief?

The Regius Professor of Medicine at Oxford, Sir George Pickering, said recently that in his time, as in mine, tons of iron were given to anemic patients without the slightest effect. It was proved experimentally later that we were giving much too small a dose, and that many cases of anæmia do not respond to iron. He said that this is no isolated instance in the Pharmacopoeia. Many of the drugs, he said, with a touch of levity, are given for no better reason than the reasons that govern the changes in ladies' fashions. What is quite certain is that Pickering is right when he said that every drug in the Pharmacopoeia should be experimentally investigated to see when it is necessary, and then, and only then, shall we get an economy in this drug bill, for much money is completely wasted. As we have been told before in this House, drugs in two of the countries of the world are separated into three groups. There is the first group of life savers, about a dozen in number, paid for by the State; and then the second class, where some good is done by them, paid for partly by the State and partly by the patient. Then there is the third class which includes the great number of tonics, for which the patient pays the whole amount. We may come to that here.

The second point in economy which I think is worth touching on is this. I hope that the Ministry will take its courage in both hands and bid in the open market—by which I mean the universities—for the men of promise, to compete with other professions. Has that been done? No. In 1954, £3 million was awarded to the consultants as a partial equivalent to the Danckwerts award given to general practitioners of £40 million. When that £3 million came to be distributed by the Ministry of Health it was given to the junior grades those who had A and B awards, the flower of the consultants, did not get a penny. That, of course, is a prudent political move to avert the wrath of an Opposition which does not believe in giving to him that bath. But if we really wish to compete with the other professions we must take longer views.

It is important not only that we should get the right quality of men into I medicine, but that when the man is in we must give him some reward if he submits to the discipline of years and years of training to become a consultant. To become a consultant he will probably have spent ten, fifteen or more years on a very small salary as a registrar, and if he gets no reward for this, if his family are no better off than if he had become a general practitioner at 26, he will not do it, and recruiting will suffer. Yet when I said this to the Royal Commission, and said in answer to a question that of course the man at the end of all these years was a better man than the man who had not taken this course, I received a spate of abuse in correspondence in the Press which must have discouraged other consultants from giving evidence in that way. It surely is all wrong.

At the risk of boring your Lordships, may I say this further about it? If we do not maintain a proper balance between the pay of the consultant and that of the general practitioner, recruiting to the consultant service will die away and wither. Confusion has arisen because when the 1954 award was given for the consultants they felt it was a very poor substitute for the Danckwerts award to general practitioners, and there was a good deal of discontent. Those then in authority naturally made the best of it and said, "This is the best we could do." Now, to be consistent, one or two felt they must say the same thing, but their position was absolutely riddled by members of the Royal Commission itself. One member of the Royal Commission said: "Do you think it is equitable that consultants should get a 30 per cent. or 40 per cent. increase and the general practitioner 100 per cent.? "He said, further," It is a mystery to me how you can think that the Spens Report in the case of consultants has been implemented." Finally the Chairman of the Commission said: "I think you would like to go away and think this over." Could there be a more definite proof that the present relationship of the remuneration between the general practitioner and the consultant is not yet finally settled?

I have been taking up a great deal of your Lordships' time on the scaffolding" erected in the last ten years. We want to know what is happening to the people who work and live within this scaffolding. Are they productive? Are they adding to knowledge? Is research starved in this service? When I was President of the Royal College of Physicians for some years I was chairman of their Science Committee on which was the President of the Royal Society at the time and the Secretary of the Medical Research Council; and I learned then that there is nearly always the money for research but that the difficulty is to find the man capable of it. I quite agree with what has been said about the danger of the able man going abroad, but that comes under a different heading. If what I have said is true, I believe we might say this about research: we must provide, in the Service, posts which are as attractive financially as any that can be found in other professions outside it. If we do not do so I do not know where we are going. I feel that that is essential.

That brings me to something on which in the last resort the efficiency of the Service really depends—not administration but the quality of the entry and the training of the students in the medical schools. I am not happy about the quality of the entry. I want your Lordships to realise that that is only an impression. It has no roots in statistical facts, but I have that impression. Not very long ago middle-class parents paid for the fees of all medical students. Now exactly two-thirds of the students are maintained by the State and are selected by examination without any test or regard to character. I believe that that is absolutely fallacious and can end only in disaster. There are already signs of the effects. One cannot possibly select people solely on examinations for a profession like medicine which requires the human touch more than almost any other. Money which is spent on bricks and mortar wants watching very carefully. It is, after all, a question of priorities.

I should like to say a word about the discontentment in the profession. That may seem irrelevant when we are speaking of the hospital service, for such discontent as there is is to be found among the general practitioners. I have not the slightest doubt, although we cannot measure it, that there is considerable discontent among general practitioners and I do not believe that that is based upon their remuneration. Although it is, of course, always unsatisfactory for a general practitioner to know that he can increase his income only by taking on a bigger list of patients, whom he feels he cannot adequately look after, the discontent has deeper roots. I believe the cause is to be found in the general decline in the status of the general practitioner, which began when people generally felt when they were seriously ill that they were well advised to go into hospital. That was extremely mortifying to the doctor. He found that the patient, in this particular crisis in his life, preferred to put himself in the hands of a complete stranger. It is hardly surprising that, as a result, the general practitioner was inclined to lose heart.

Moreover, the Service has exacerbated this because, with consultants in every branch of medicine on their very doorstep, the general practitioners are not able any longer to make those modest excursions into the consultant field which previously lent flavour and interest to their life. For these reasons I believe that there is a great deal of unhappiness in the general practioners' camp and if that is true it is most serious. What is the remedy? I have no doubt that what I am saying is highly controversial and probably many consultants will differ completely, but I believe that in time the very pick of the general practitioners must follow their patients into hospital and will become part of the staff of those hospitals. I know it will be said that the standard of those hospitals will go down, but I do not think that that should happen if we see that the general practitioners are properly integrated with the consultants already on the staff of the hospitals. It is the bond between these two which will decide the success of this experiment. I shall not myself live to see it carried out, but I believe that it is the most important administrative move in the next decade. If that is not done, with a discontented profession, efficiency must wither, whatever the remuneration.

I am sure your Lordships will agree with me that our fundamental problems in this Service are not to be settled by any committee or by any multiplication of committees. The great administrator, no matter what are the calls upon his time, will always find the opportunity to think for himself, and he already sees that in medicine, as in every other field of human, endeavour, if we are to compete in world markets we need a more sym- pathetic attitude on the part of high authority towards the gifted minority, who in the past have been responsible for all progress, upon whom we now depend for every advance and to whom we must look for the fulfilment of our hopes in all the time to come.

3.58 p.m.

VISCOUNT ADDISON

My Lords, this is the first time that I have had the privilege of addressing your Lordships and I am conscious of my limitations. I am encouraged, however, in the knowledge of your Lordships' accustomed kindly tolerance towards new speakers. Perhaps I should declare some interest in the matter before your Lordships, though it is not a financial interest. I am a member of the board of governors of one London teaching hospital and chairman of a group of hospitals in the country administered by one of the regional hospital boards. In the circumstances it would be appropriate for me to speak in general terms only, and I do not propose to stress any matter of particular concern to either of the two organisations with which I am associated.

I believe that the rising curve of expenditure over the first ten years' experience of the new service was to be expected. I feel that that is largely the natural result of great uses to meet the needs of people hitherto probably not fully provided for. In the light of advances in medical science the curve of expenditure may not even yet have reached the limit, though I believe that in the course of time the advances and developments which have taken place will themselves bring about economies.

Like the noble Lord, Lord Nathan, I wish to draw your Lordships' attention to the comparatively small amount of expenditure on capital development as compared with the large and increasing bill for maintenance. I feel that perhaps we should aim at a somewhat more unified and streamlined service; and I feel that economies in maintenance may be achieved (I hope that the noble Lord, Lord Amulree, who is not at the moment in his place, will not mind if I disagree with him here) by the scrapping of some unsatisfactory buildings and, in some cases, their replacement by modern units, though I think they will be fewer. I believe that an imaginative and bold programme of capital development is needed and that modernisation, particularly of buildings, must itself result in economy in maintenance.

I think it has become clear that advances in medical science have brought about some changes of emphasis, and I should like to illustrate this by mentioning particularly the great advance in the treatment of tuberculosis, which seems to me to indicate, for instance, that the large number of sanitoria, as a permanent feature of the organisation, may well be somewhat out-dated. The treatment and cure of various infectious diseases by modern methods have also taken some load off the shoulders of the organisation generally, and I hope we may hear that the Government will consider taking steps as a result of these changes in emphasis. Surely there must be, as a result, savings, either now or in the future, in premises, medical staff, services and so on. We may be sure that there will be other advances which will result in like savings. I should like to make the point that I think we should always endeavour to have an adaptable organisation, so that when these changes of emphasis come about they do not upset the balance of our plans.

Although the problem of the recruitment of nurses may not perhaps affect the teaching hospital groups so greatly, there have been great difficulties in some parts of the country in attracting young women into the profession. There are obvious reasons for that, and the most important is probably financial. But I am not sure that there are not a good many young people who have been frightened off by the ever-increasing academic standards seemingly required and insisted upon by such organisations as the General Nursing Council. I feel that we should aim, in the training of these young women, to get a high standard of nursing and not give the impression that we are out to produce a number of pocket-sized, female professors of medicine. Wards are largely manned by student nurses, and in my view steps should be taken to try to make life a bit easier for them. I wonder whether the Ministry would be willing to discuss the matter with the General Nursing Council and other bodies to see whether something cannot be done to attract the increasing number of women who, I understand, will be available within the next few years.

I think that some of the burden could be removed from our hospitals by increasing facilities for home nursing; and I should like to stress what I believe to be the desirability of encouraging young doctors to enter general practice. I think that more money might well be provided for the development of district nursing. I get the impression, from my own experience, that in some cases general practitioners may be making use of hospitals unnecessarily. One of the reasons for this tendency may be a fear of litigation, which seems to have crept increasingly into the Service recently. General practitioners, it appears to me, are sometimes inclined for their own protection to send patients to hospital for X-ray and similar examinations, which they would not have thought of doing until recent years. I should like to know whether the Minister has any views on this aspect of the problem, though I admit to finding it difficult to suggest a remedy. I believe that people would always prefer to be nursed at home, under their own doctor, rather than enter hospital, and I wonder whether perhaps the Minister would devote some consideration to this point.

Medical research, as the noble Lord, Lord Nathan, has mentioned, is being financed, at any rate so far as teaching hospitals are concerned, largely from their own endowment funds and from somewhat small grants from one source or another. It is often difficult, in view of the continual economy drive on the part of the Exchequer, to hand over to the Exchequer Vote methods produced as a result of research activities, after they have taken their place as a part of normal clinical procedure. As a result of this difficulty, it is possible that a brake may be placed upon research generally within the teaching hospital groups, and I feel the Minister might well consider whether there should not be some more frequent method of assessing the stages to which various researches have developed. There is also a tendency (I think that the noble Lord, Lord Nathan made this point, with which I entirely agree) to utilise endowment and private funds for purposes which are in fact the responsibility of the Exchequer. In my view, this situation, where it exists, can be regarded only as unsatisfactory and undesirable.

I hope that noble Lords will not feel that I have had only points of criticism to offer. I feel that we have a hospital service which is probably the envy of the whole world, and we have reason to be very proud of the first ten years of its growth. Teething troubles have to some extent already been overcome, but I would stress the need for adaptability and for an open-minded approach to future developments. We have, as usual, been pioneers, and it is satisfying to see the interest in the service taken by other countries, which will not be slow, I think, to try to follow our example.

4.8 p.m.

LORD UVEDALE OF NORTH END

My Lords, to-day we have had maiden speeches from the noble Lord, Lord Evans, and the noble Viscount, Lord Addison: their speeches have been very helpful and they have been expressed in the most felicitous language. We are pleased that they have spoken on a subject in which they are greatly interested, and we hope that in this House we shall hear them on frequent occasions in the future. I am very grateful to the noble Lord, Lord Nathan, who introduced this Motion for the tribute that he has paid to doctors and nurses, because he recognises that the success or failure of a hospital depends not so much on the matter of administration as on the quality of the doctors and nurses who are working in that hospital.

The noble Lord, Lord Moran, has spoken very eloquently on certain aspects of the profession, and with your Lordships' permission I will take up the line that his speech has suggested. I will start with the Insurance Act of 1911. This Act was passed against the violent opposition of the profession. This opposition was overborne only by the threat of a full-time salaried medical service. The National Health Service Act of 1946 was not enthusiastically received by the profession, and did not especially commend itself to the profession; but it was accepted by the profession in that all political Parties supported it. We have to remember that both these Acts improved the financial position of the medical profession.

If your Lordships are interested in the financial position of the medical profession before 1911, I would refer you to the September numbers of the British Medical Journal about that time. Year after year, able and ambitious young men were warned not to enter the profession. It was pointed out that the profession at that time was semi-philanthropic; that no doctor could expect adequate remuneration for his services; that the work was exacting and exhausting, and that a doctor's prospects were particularly gloomy, unless he had private means or was backed by personal influence. The average income of general practitioners before 1911 is not known, but it was notorious that many practitioners at that time were in financial difficulties, doing their rounds on foot or on bicycles. By 1931 the average income of the general practitioner had risen to £850 per year; by 1938 to £1,111 a year; by 1948 to £2,055 a year; and by 1950 to £2,220. And by 1957 it stood at the figure of £2,333 a year.

In view of the consistent increase in the income of the general practitioner, it may be asked: what then are the objections of doctors to these Acts of Parliament? In my view they can be summarised as follows. First of all, there is loss of independence. In our legal system it is necessary to defend the patient against the doctor and also to defend the doctor against the patient, but the introduction of a State medical service has meant more supervision, more attention to records, and more reliance on methods of treatment recommended by the Ministry of Health. The general practitioner is afraid of a loss of that personal relationship which used to exist between physician and patient—the "family doctor" idea—when the family doctor was the friend and confidant of the patient. To-day, the family doctor is being replaced by the State practitioner.

Another cause of dissatisfaction among general practitioners, of course, is the overcrowded surgeries that have resulted from the passing of these Acts and also the increase in cases of imaginary illnesses that come to those surgeries. Then under the State system the general practitioner feels that he is in a groove: that X-ray examinations, laboratory methods and physiotherapy are outside his scope, and that he has no opportunity of specialising in any department of medicine.

Whatever be the disadvantages of the new system, however, the medical register shows a great increase in the number of doctors. In the last twenty years the numbers of men on the medical register have risen from 60,000 to 90,000. This increase in England is from 29,000 to 43,000, so that there is now one doctor to each 900 of the population. If, at the present time, there is a desirable post vacant in general practice, there will be anything from 40 to 50 applications from qualified men for that post. I hold it that one of the objects of nationalisation is to see that no man works to the detriment of his health or to the disturbance of his peace of mind, and in this connection your Lordships may note that the mortality figures for doctors have diminished in recent years, so that they are now nearer to the mortality figures for solicitors and clergymen.

Now a few words with regard to the specialists. There has been a great increase in the number of specialists in the last twenty years. In 1938 there were 2,480 Fellows of the Royal College of Surgeons of England; in 1957 the number was 4,370. In 1938 there were 1,690 doctors who were members of the Royal College of Physicians of London. In 1957 there were 3,749. The specialists are happier than the general practitioners under the present system. Basic salaries, as the noble Lord, Lord Moran, has explained to us, are from £2,205 per annum rising to £3,255 per annum. In addition, they receive pay for domiciliary visits up to a limit of 800 guineas a year. Then there are the distinction awards, and these, in my view, should engage the attention of your Lordships.

There are three distinction awards: £500 per annum for 20 per cent. of the specialists; £1,500 per annum for 10 per cent. of the specialists, and £2,500 per annum for 4 per cent. of the specialists. In 1957 2,343 specialists in England and Wales were receiving these awards at a cost of £2 million to the State. It is astonishing to recall that these are secret awards, a principle that is contrary to what has always been the conception of public policy. Doctors receiving these awards are not allowed to mention them even to other members of the same medical staff. No one can find out why certain doctors are favoured and others are not. The system of these awards has been referred to in the medical profession as one of "diabolical secrecy".

A NOBLE LORD

Shame!

LORD UVEDALE OF NORTH END

Your Lordships may feel that where public money is spent the public should know how and why the liability is incurred.

The maximum salary under the Health Service is in the region of £6,000 per annum. General practitioners and specialists have pension rights where the contribution of the State exceeds the contribution of the individual. Before I leave this aspect of the Health Service, I must mention the plight of certain of the senior registrars in the Service. These are men who are qualified to be specialists but who are not appointed as specialists because there are no vacancies. The number of registrars is in excess of the number of vacancies available. These highly qualified men who are denied promotion to specialist rank have difficulty in getting into general practice, and many cases of hardship have occurred.

May I say a word with regard to the nursing staffs in hospitals? It is notorious that it has been difficult to obtain adequate numbers of nurses for many of our hospitals. The position is that before 1939 the salary of a ward sister was about £90 a year. By 1948, this salary had risen to £180 a year, with residential emoluments, income tax being paid on the net salary only. By 1958, salaries for ward sisters were ranged from £514 to £646 per annum. This seems a great rise of salary, but from the total amount 1173 is deducted for residential emoluments, and income tax is paid on the gross figure. The actual rise in salary, therefore, from 1948 to 1958 is about 80 per cent. The only suggestion I can make to increase the supply of nurses would be that nurses should be paid overtime. They are frequently called upon to spend extra hours in the wards, and I understand that for this overtime work there is no remuneration. I would suggest that they should be paid overtime at the rate of five shillings an hour.

Just a word about the costs of the medical services. It was stated recently in another place that hospital costs over the last ten years have risen from £110 million to £320 million per annum. In the same period the total cost of the Health Service has risen from £400 million to about £600 million. The contributions of the insured population have risen, in the case of a man, from 4s. 11d, a week to 9s, 5d, a week. When the contribution of the employer is added, the total is 17s, a week. The benefits obtained by this contribution are not only health benefits, of course, but also injury benefits and national insurance. In dealing with these large sums the constitution of the responsible spending committees is obviously of the greatest importance, yet when we look into this matter we find that democratic control has been abandoned and that committees are selected by nomination.

The Regional Hospital Boards are appointed by the Ministry from the universities, the medical profession, local health authorities and other organisations. The management committees are appointed by the Regional Boards from local health authorities, any executive council, hospitals and other authorities. The hoards of management of teaching hospitals are appointed by the Minister from the universities, the Regional Boards, hospital staffs (up to 20 per cent. of the committee of management), former members of the governing body and other suitable persons. The field of choice is a very wide one, and many applicants for positions on these boards are totally unsuitable. For example, I heard of one gentleman who applied for a position on the managing board of a hospital on the ground that he wished to avoid washing up at home. A lady who made a similar application said that she wished to serve on the board because she liked to visit the sick on visiting days. The composition of these boards is of the greatest importance.

The general conclusion from these facts and figures is that, by comparison with other professions, the medical and nursing professions have had generous treatment from the State. But in dealing with these figures we must remember that the man who had £700 a year in 1938 now requires £2,500 a year to maintain the same standard of life; and a man who in 1938 had 1,200 a year now requires £5,200 a year to maintain his standard. We may also note that medical salaries have not kept pace with rising costs, so that members of the medical and nursing professions are sharing in the hardships of our times, though, I venture to say, not to the same extent as other members of the community. Any further improvement in standards for doctors or nurses is bound up with the problems of inflation and high taxation.

I should say, as a final word, my Lords, that the conditions of the Service at the present time are such as to attract men of the right type into the professions. I should say that if it is a matter of research and discovery, there is no connection between remuneration and the results of research. The advances come in most unexpected ways. I am all in favour, however, of facilities being provided for research, and of a man being encouraged to take up research, even though there are many lines of research that in the end prove to be unfruitful. I can only say that the conditions of the Service at the present time are good; there seem to be plenty of able and energetic people entering the Service, and the outlook for the future should be excellent.

4.32 p.m.

THE EARL OF LUCAN

My Lords, I should explain that my noble friend Lord Crook, who had intended to speak now in the debate, has been unable to get back to London in time; but he hopes to come in before the end of the debate and I have taken his place. This debate has attracted the usual galaxy of experience and talent. In particular, we are glad that the noble Lord, Lord Evans, was able to make his maiden speech on this occasion. If he at times verged rather near the controversial (I am sorry he is not now in his place) he did not actually overstep the boundary. My noble friend Lord Addison, whom we have at last persuaded to make a contribution in this house has come here with great experience of the hospital world. We have heard a most thoughtful speech from him, and we hope that we shall often hear him again. And although it was not a maiden speech, I think I should mention my noble friend Lord Uvedale of North End, who all too rarely comes to give us the benefit of his experience. I could have wished that while he was speaking the noble Lord, Lord Moran, had still been in the Chamber, because it seemed to me that there was some conflict between the evidence given by those two noble Lords, both speaking from such long experience in the profession.

I speak as a comparatively new recruit to the hospital world, in that I have been connected with a board of governors since the appointed day and on a hospital management committee in more recent years. My noble friend Lord Nathan and the majority of noble Lords who have spoken up to now have dealt mainly with the problem of the teaching hospitals. I should like to say a few words dealing mainly with the non-teaching hospitals, those under the regional boards. The first thing I would say is that one of the criticisms made of the whole Service is that between the teaching and the non-teaching hospitals there is a great gulf fixed; indeed, more than that: there is competition and rivalry and, some say, even jealousy.

In my short experience I have seen the working of a system on a small scale which, to my mind, ought to be greatly extended; that is, the use of non-teaching hospitals as well as the teaching hospitals for clinical teaching of students. Certain teaching hospitals have for some years been working on these lines and have established excellent relations with non-teaching hospitals. The way the system works is that those members of the consultant staffs who are employed both by the teaching hospital and the non-teaching hospital take their students for teaching in the wards of the non-teaching hospital; other teaching is done by the consultant staff of the non-teaching hospital. So you get a merging of the teaching in the two spheres, a softening of the boundaries that have too often become hard and fast, and an improvement in relations. It is, I believe, to the benefit of the students that they should see the work in a general hospital, and it is of advantage to the general hospital to have this link. Naturally such teaching is merely complementary to that which is carried on in the teaching hospital.

In what has been said and written about the Health Service, particularly in recent days owing to the anniversary, some attention has been attracted to another gulf—namely, that between the hospitals and the general practitioners. This was referred to by the noble Lord, Lord Moran, and other noble Lords, and undoubtedly there is a good deal of truth in what has been said about the lower status (in his own eyes or in the eyes of the profession) of the general practitioner as compared with the practitioner in the hospital and specialist services. There again, I have seen the beginnings of a breaking down of this gulf and a bringing in of the general practitioner into the hospital service and its work. In a big London general hospital that I know there are monthly meetings of general practitioners living in the neighbourhood. The occasion is not quite clinical teaching, but a kind of clinical seminar or discussion day. The doctors come in and see the patients in the wards, and discuss the cases, many of which they have themselves sent in to the hospital, with the consultant staff in the hospital. There you get complete cooperation and the beginnings of complete confidence between those in the hospital and those outside.

It seems to me that an extension of a system such as that would go a long way to remove many of the disadvantages from which we hear the general practitioners are suffering. Moreover, in this same hospital the local general practitioners can get the full facilities of the ancillary services of the hospital; they can, as a right, call on all the diagnostic facilities. This local arrangement in West London seems to me to be the key to the mitigation of the disadvantages from which we hear the Service is suffering.

There are only two other small matters that I should like to mention, because to deal comprehensively with the hospital services would need far more time and far more ability than I have. I think that a few points are worth mentioning, and I have already dealt with two. The question of administrative staff has not been touched upon much so far. We have heard about the medical staffing of the service, and on that subject I certainly should not attempt to dogmatise. So far as the administrative service is concerned we have just had the valuable report of Sir Noel Hall on the grading and structure of the service. We hope that that report will produce a satisfactory reorganisation of the service.

The point that Sir Noel Hall's investigation brought out was that the service is not offering a sufficiently attractive career to get the best type of administrator. When we are talking in terms of several hundred million pounds of public money, those who have responsibility for it must be of the highest quality obtainable. We take enormous trouble to select the best people for the other branches of the public service, but so far, I am told, there is no sign of the hospital service becoming popular as a career among young people just leaving school. That matter seems to me to need urgent attention. We have to offer conditions sufficiently good to attract them from the more glittering paths of private industry, and there must be proper prospects of promotion and training. After all, the public service competes against industry only by the conditions of promotion that it offers. It cannot compete in terms of cash—none of the public services ever has done—but by offering a career that anybody might be proud to take up, that of administering the Health Service, and reasonable prospects of promotion (which in itself is a big subject) the Service should, to my mind, be able to attract a number of the best type of young men.

On the training side, there seems to be a serious gap. There is a national scheme for training which started a year or two ago, but on a ridiculously small scale. I believe that the number of students is something like twenty-four, and that the course is of three years duration. If it is to staff a Service with over 400 boards of governors, hospital management committees, and Regional Boards, that scheme represents an infinitesimal contribution to the training problem. The result is that all the training these young men receive is by being attached for periods to different departments in their hospital, or other hospitals, and by learning as they go. It seems to me that something much more systematic and positive is needed on the training side.

Finally, there is the question of economies. We are agreed that the Health Service must not be allowed to deteriorate. We know that costs everywhere are rising. Economies, therefore, can be found only by a greater efficiency both of methods and of buildings. I notice from the report of the Ministry of Health for 1956 that quite a promising beginning has been made with the use of work study. The "O. and M." Service—the Hospital Organisation and Methods Service—has been brought in in a number of cases. I think that they had eighty cases under investigation during the year 1956, and it seems to me there must be a great deal of scope for investigation, because traditional methods die hard, and it needs a scientific investigation to point out where effort is wasted, where staff and labour can be saved, and how hospitals can be made more efficient. I hope that the Minister may put in a word about the prospects of that—as to whether that tendency is developing, as I think it should. There is another direction in which economies can be looked for, and that is by replacing out-of-date buildings and equipment by modern ones. There is no end to the field in which a moderate capital expenditure could produce really important economies.

So we come back to the old question of capital investment. My noble friend Lord Nathan spoke about that, as have other noble Lords, but the deplorably low level of investment in our hospitals is something which I am surprised Her Majesty's Government can tolerate. I believe that not a single new hospital has been built since the war. The number of beds has hardly increased and century-old buildings are almost, I should say, in the majority, causing great inefficiency. The Chancellor of the Exchequer tells us, of course, that there is no money for hospital building. But when we walk round the West End of London or the City, and see the millions of pounds that are being spent on office buildings, put up, so far as I can see, mainly for prestige purposes or to produce profits, I feel that we have much to be ashamed of. I think that historians in 100 years time will look back, unable to believe that we could get our priorities so wrong.

4.50 p.m.

LORD DOUGLAS OF BARLOCH

My Lords, I certainly would not disagree with my noble friend, Lord Lucan, that there is a field for investigation with regard to administration in the hospitals. I am told that a great many wasteful and bureaucratic methods have crept into some of them. For example, when a doctor has a cup of tea in a hospital, apparently it is impossible for him to pay cash for it upon the spot; he is sent an invoice at the end of the month for a few pence, or somebody waylays him upon the stairs and collects it. If the cost of that procedure were analysed, it would be found to be a great deal more than the amount of the debt which is collected. That is one small illustration of the necessity for hospital administration to be examined in a businesslike and scientific manner.

However, I do not wish to pursue that side of the discussion. We have had a debate which has ranged over a very wide field, as it inevitably must do, because the hospital service is only a part of the National Health Service and is, of necessity, very closely linked with the rest of it, or perhaps should be very closely linked with the rest of it. Unfortunately, the aim and purpose of the National Health Service has from the beginning been in the direction simply of treating disease, with little or no attempt towards preventing it. I made that criticism some twelve years or more ago in another place and I think it is still justified to-day. The lessons which were learned by the Peckham Health Centre, for example, have not been put into practice, with the result that instead of preventing disease or detecting it at its earliest onset the Service waits until the symptoms become obvious or acute, with the result that the expense of the Health Service, both on the general practitioners' side and on the hospital side, is increased beyond what it need be. If there is going to be a search for justified economies in the National Hearth Service, I think it ought to go in that direction of trying to establish a genuine preventive service which will prevent people from getting into those bad habits and conditions which result either in acute or, in many cases, in chronic diseases which become quite incapable of cure and can be the subject only of mitigation.

I entirely agree with those who have said that splendid work is being done in the hospitals under the National Health Service, and it is being done, in certain cases at any rate, under conditions which seem to me to be unfair to the medical practitioners who are concerned in providing that service. The noble Lord, Lord Moran, said that general medical practitioners were dissatisfied, but the hospital staffs are also, in many cases, extremely dissatisfied. When the National Health Service was established they were promised by the Government that the conditions of employment would be based upon the Report of the Spans Committee, but in fact the salaries which are being paid to medical staffs in hospitals are far below that level. There are the junior registrars, the senior registrars, the junior hospital medical officers and the senior hospital medical officers. There is not a single one of those whose salary in any way compares with that which was proposed by the Spens Committee, and in many cases the salaries are such as the Spans Committee considered to be appropriate to the conditions as they existed before the war, without taking any account of the lower purchasing power of money, or paying very little attention to it.

It can be said, I suppose, in the case of the junior registrars and the junior hospital medical officers, that they have some hope of being promoted into the senior grades, and that may be some consolation for the salaries which they are paid and some encouragement to them to continue. But when it comes to the senior registrars, and still more to the senior hospital medical officers, the position is very different. It has been said to-day that there are not sufficient consultant posts available to provide openings for the senior registrars, and emphasis has been laid upon that fact here and elsewhere but still more is that the case with regard to the senior hospital medical officers, who in fact are doing specialists' work and have specialists' qualifications equal to those held by specialists or by senior hospital registrars, and their grade has virtually become impassable, so that they do not get any promotion at all.

It was in fact intended originally, when it was created, to serve a totally different purpose: to be the means of absorbing a number of general practitioners who, had been doing a limited amount of consultant work, and therefore was a grade which was intended to die out. Instead, it has become a grade of recruitment, and it has become a blind alley because the prospect of promotion from it to be consultant has become increasingly remote—that, apart from the fact that the salary does not conform to that of consultant, as it ought to conform to what is now approved for a consultant, let alone conform to the principles of the Spens Report which were accepted by the Government. That is extremely unfair, and the position has become doubly unfair because the appointment of consultants in practice is made by committees upon which the teaching hospitals are strongly represented. I impute no unfair motives, but it is quite a natural result. The result is that the appointments of consultants are given to senior registrars who come to the teaching hospitals, instead of being distributed among the senior hospital medical officers who have equal qualifications and a great deal more experience in the work which requires to be done. That, I think, is something which ought to be remedied.

I dare say that the noble Lord who is going to reply on behalf of the Gov-eminent will say that this is one of the matters which is before the Royal Corn-mission. If the Royal Commission is fully seized of it and is empowered to deal with it in all its aspects, I shall certainly be delighted; but I am not quite certain that that is so, either from the terms of reference or from the kind of evidence which has been given. I think that a great injustice has been created here, and a breach of faith which the Government ought to remedy.

5.2 p.m.

LORD CLITHEROE

My Lords, I am sure that the House is very grateful to the noble Lord, Lord Nathan, for giving us the opportunity of this discussion to-day. I was glad that he postponed the debate on the previous occasion when it was set clown, because it would certainly have been most unsatisfactory to start so late in the day. We all know how devoted the noble Lord is to the service of the hospitals, and I propose to take the opportunity of reverting to the topic which he raised in the speech with which he opened this debate to-day. I have only one theme, and I shall not be too long about it—that is, to emphasise that it is not possible to overestimate the importance of the teaching hospitals and the need to make sure that they are properly equipped for their work and always in the forefront.

These teaching hospitals are responsible for the training of the doctors who will work in the National Health Service. The standard of British medicine and, if I may say so, the efficiency of the Service depend largely upon what these students learn there and upon the influences under which they come when they are in the teaching hospitals, and the atmosphere they absorb there. To a large extent, this also applies to the nurses; because, although we know that nurses are trained in hospitals which are not associated with medical schools, it is often rather difficult to got recruits for those hospitals, whereas there is no lack of applicants for nursing in teaching hospitals. So it is vital to maintain, and to improve, the standards and facilities of the teaching hospitals. They should be improved in line with the great advances which are, and have been, taking place during the last ten years. There are many new techniques of investigation and treatment Which have been evolved in recent years and which add to the accuracy of diagnosis and provide treatment for diseases that have hitherto proved incurable. One could give many examples of these specialist activities. Let us take, for example, the artificial kidney. All these specialist activities, which save young lives, need for their application, I am told, an experienced and skilled team of medical workers. So, for reasons both of economy and of medical skill, these facilities should be available in special centres such as the teaching hospitals.

I do not for one moment deny that the standards in non-teaching hospitals must be raised, but medical standards and treatment throughout the country will inevitably deteriorate unless the standards in teaching hospitals are allowed to rise too. As the noble Lord, Lord Evans, whom we were so delighted to hear make his maiden speech to-day, said, it is absurd for teaching hospitals to mark time whilst others are brought up. I entirely agree with that. Not only must the staffing at a teaching hospital be on a generous scale, but there is need for the housing of special apparatus; and this requires space so that it can be kept in readiness for immediate use. I have been told that lack of space often hampers scientific development just as much as lack of money, if not more so. Many advances which would benefit the whole community, and not merely the patients of the teaching hospital, are being made too slowly through lack of facilities for them.

At the present moment our doctors are equal to any in the world; and that applies equally to our nurses. But, unless we are to lose this great heritage, we must maintain and improve the standards in our teaching hospitals. It seems to me that it is so important that, the standards in those centres should be something above the average; that they should have also something above the average in quality to offer. A wide area from which to draw case material is a very important asset, and patients will not be sent by their local practitioners, nor will they themselves want to go a long way from home, unless this is so. I think that similar arguments could easily be made to apply to the care of the more difficult and rare cases.

Then again, in order to attract the best minds to compete for the posts there must be above-average doctors and above-average equipment for research. I am sure that research is inseparable from first-class treatment, and all of us who are in business know that unless money is continually and constantly spent in research, you are not going to get ahead. So may I conclude by saying that the teaching hospitals do not seek preferential treatment because they consider themselves superior to the excellent hospitals that exist in the periphery; they seek it because their responsibilities are so much greater, and because we want to continue to lead the world in reputation, in service and, above all, in quality.

5.9 p.m.

LORD HADEN-GUEST

My Lords, we are debating to-day an important Motion on the subject of hospital organisation and nursing. I think it is necessary that we should get our heads clear on the subject. I doubt very much whether everyone who is in this audience really has his head quite clear on what the subject is. The real point is: are we able to get the right kind of nurses to do the work in our hospitals, and are we pursuing the right course with regard to their training and the programme of work which is laid before them? It is absolutely essential to have well-trained nurses, not only in time of war and in time of political disturbance, but for the everyday work of the community as it stands now. I say this because I have had a great deal of experience myself, both abroad, in a world war—a most extensive experience indeed—and afterwards at home in time of peace. I have had experience on the Continent of Europe also in time of peace, and have investigated and written upon the subject of what kind of organisation we require—to an extent which, I am afraid has bored some of those to whom my words were addressed.

The plain fact is that, beginning at an early date in the First World War and going on to the Second World War, we have gone on without making any fundamental organisation and without using the powers of organisation which we have, and with which I have to a large extent been concerned in organising medical services. I am thinking espe- cially of the nursing service, for unless we have more nurses in our hospitals, civil and military, we shall not get a good nursing service. I hope that the noble Lord who is to reply to this debate will be able to give us a clear explanation of what is to be the future of the medical service.

I should like to know particularly what is to be the future of the nursing services, as well as the purely medical services. I have seen failure come on the battlefield as well as in civilian life, and I believe that unless we have a clear-cut statement on what is to be the function of the medical services, in war and in peace, we are going to fail when a big strain comes. Everybody who studies politics at the present time and takes an interest in public affairs knows that the world at present is not a safe one. It is far from being a safe world and it seems very unfortunate that we have no clear-cut ideas on the future of the nursing service and other medical services. I very much hope that the noble Lord who is to reply will let us know how far we are able to proceed in making a really adequate medical service sufficiently well organised, sufficiently strong and well-staffed and with sufficient well-trained people, in the circumstances as we now know them.

5.13 p.m.

VISCOUNT ASTOR

My Lords, I wish to say only a few words as a humble member of a hospital committee for the last ten years and to plead that the time has come for another inquiry into the administrative systems of our hospitals. an inquiry more searching, deeper and going down more to the grass roots than that of the Guillebaud Committee which, I felt at the time, was rather a defensive Committee which had the feeling that they had to protect the hospital service against the potential "Geddes Axe" of a wicked Conservative Government. That Committee never really got down to the fundamentals of administration.

First, I feel that most hospital committees are far too big and that the work could be done by half the number of people in half the time. We go into far too great detail on many minor matters which in ordinary administration should be done by a staff; and at the same time the ordinary house committee has practically no responsibility for the hospital which it is supposed to know intimately. Then we move up to the hospital management committee, and again there is the trouble of excessive size and a proliferation of sub-committees to such an extent that it is extraordinarily difficult for any busy man engaged on active administration to be a conscientious member of a hospital management committee; yet those are the kind of people whom we most want. I believe we need small committees, meeting perhaps half as often, with chairmen and officials having (greater responsibility for many minor decisions. We should try to recruit our hospital officials from a rather wider circle and be prepared to bring in some of those of great administrative ability who are being "axed" from the Services but yet have leadership and knowledge of organisation of people.

Another point is that we get almost complete separation of the medical and the lay side. We have some doctors on the management committee but no layman knows anything of what goes on at the doctors' committees. So we have these two parallel chains of committee both looking after the same hospital; but if one suggests that even the chairman of the hospital committee should go to the doctors' committee—well, my word! I was invited once but I was shown out very quickly as soon as a particular item on the agenda was finished. I believe we should have far greater confidence and mutual knowledge than exists at present in what each side is trying to do.

I believe that Parkinson's Law is in full operation regarding secretarial staff as compared with pre-war numbers, and yet there is less liaison between general practitioners and the hospital. Often when a discharged patient goes back to the general practitioner the general practitioner has literally to wait for weeks before he can learn what the hospital has found out, because of the clog of sheer paper work in administration. I feel that the Organisation and Methods Branch is a promising development, but far too small; and at the moment when they arrive they are resented as if it were the appearance of the Spanish Inquisition, If we are to have the disadvantages of nationalisation, let us have the advantages, too, and proper administration and inspectorate going down.

We all want to help at local level and to get the advantages of other people's improvements and administrative methods; and we want a more responsible feeling about finance. Once at a committee the chairman said, "Ladies and gentlemen I have desperate bad news to tell you." We all blanched, and he added." I have underspent by £16,000." That is the spirit in which finance is sometimes tackled. We also want a careful and searching appraisal as to how much money is being spent in patching up old hospitals as opposed to making a clean break and starting on a new one. The noble Earl, Lord Lucan, made a very good point. Those of us on committees of old hospitals have a desperate time, and it would be much better if we had a programme for the future building of modern hospitals of most simple construction.

Those are some of the minor points I would make. I hope that I shall not be considered as criticising my colleagues or anybody else, for everybody tries to do his best; but I believe the time has come for a practical, down-to-earth inquiry again into our hospital system.

5.19 p.m.

THE EARL OF CRANBROOK

My Lords, all of us who have spoken or are to speak this afternoon speak with experience of the hospital services—as indeed I do, having been chairman of a hospital board since the appointed day. The majority of the previous speakers have said (and I would agree) that during that ten years we have vastly improved the hospital service. I think most of us would be ashamed to come here to-day and speak at all if we had spent ten fruitless years and could not say that. I do not think it is really to be wondered at, for we had a good administrative machine, although I agree with the noble Viscount, Lord Astor, that we want to have another look at it. During that ten years we have also seen the most remarkable advances in the art and science of medicine; so it is small wonder that we have an improved service.

On the other hand, I do not think that we should be complacent. Several noble Lords have drawn attention to the fact that some of our hospital buildings have been starved of capital development—and I suppose that I know as much about that aspect as anybody, having as hospitals in my own region a quite considerable number of Gilbert Act workhouses adapted as hospitals, one of which will celebrate its bicentenary in a couple of years' time. The noble Lord, Lord Nathan, drew attention to the fact that to-day we are getting about one-third of the capital spent that was spent before the war. It is a ridiculous position that the State cannot provide to-day even an equal amount to that provided by private individuals before the war for a voluntary service.

One of the results of that starvation—which I look upon as the most disastrous; it is one of the respects in which I think the hospital services fail—is to be seen on some sides of the mental health service. We still have up and down the country to-day low-grade, mentally-defective children ruining the lives of the rest of the children in their family, and ruining their parents' lives, merely because we have not accommodation in which to put them, entirely due to the fact that we have been starved of capital in the past ten years. In passing, I may say that one of the nicest things of the hospital service has been that it has always been run on entirely non-political lines: we have always, within my recollection, all been at one in being absolutely certain that the Government of the day were not providing nearly enough money for the service for which we thought they were responsible.

There has been a great advance in the treatment of mental disease. More people have been coming into hospital and going out sooner. The increase in out-patient clinics has done a great deal, and we are finding more and more that we are able to treat mental patients at home without their ever coming into hospital at all. I speak with some diffidence in front of the noble Lords here who are doctors and surgeons, but with that sort of idea in my mind I would venture to look, not back at the past ten years, which are dead and gone, but on to the years that are ahead. I am inclined to think that in the future, with the improvements in housing and living conditions which are taking place, affecting both mental and physical health, actual residence in hospital may become an increasingly smaller part of the treatment. After all, to-day 90 per cent. of patients are, I suppose, treated by a general practitioner, with the assistance of the home nurse, the home help, the psychiatric social worker, and the other help which he can get.

The noble Lord, Lord Moran, referred to the general practitioner coming into the hospital. That is a thing we are all trying to arrange, whether by clinical assistantships or otherwise, and one hopes that in the future the general practitioner will be brought more and more into the hospital. But my own feeling is that the hospital needs to be brought more and more outside itself and into contact with the general practitioner and those who are serving the public in the homes. I have referred to how this is happening in the sphere of mental health; it is happening also in every other branch of medicine. I remember how, when I was a young man, the old arthritic patient was put to bed in a hospital, nursed with care and with kindness, and how he rapidly stiffened up and stayed there for the rest of his natural life. To-day, with the new services that we are being enabled to provide, such patients are going into hospital for a short time and then going out again under the care of their general practitioner, the home nurse, the home help and the like. Of course, they may be returned to hospital again, but we are, so far as we can, bringing the home and the hospital together, and people go from one to the other with much greater facility than they did in the past.

The noble Viscount, Lord Astor, referred to the Guillebaud Report, and in particular to the fact that he felt there should be another investigation into the administrative side of the hospital services. I should like to see another investigation into the whole of the administrative side of the National Health Service Act. The Guillebaud Committee were appointed, if I recollect aright, entirely to investigate the cost of the National Health Service; that was the yardstick by which they had to measure the work. They were concerned not with whether the administrative side was good or bad, but only with whether they thought any alterations would lead to a saving in cost. At the moment, whether we are in hospital or out of hospital, we are still patients of a doctor, whether he happens to be the consultant under whom we are in hospital or our general practitioner at home. But for administrative reasons, we pass from the hospital service to the local authority service, or we pass to the service administered by the executive councils; and I do not think there is One of us concerned with the administration of any one side of the National Health Service who would say that there are not patients, and I think many patients, who fall between two of the three stools which are meant to support it.

The noble Lord, Lord Amulree, suggested as a solution to this problem joint appointments. The usual solution offered is that last resort of the incompetent administrator, the joint advisory committee. I, my Lords, do not believe that that is the answer. Successive Governments have always avoided this prickly problem. I am fairly certain that the noble Lord who is to reply to this debate for the Government will tell me that the National Health Service is only ten years old and that it is much too soon to look at it again. But in ten years a vast amount of vested interests can be built up, and it is the vested interests concerned which perpetuate incompetent administration. After all, medical work, if the noble Lords who are doctors and surgeons will forgive my saying so, is teamwork. It is the consultants, general practitioners, nurses, home-helps, psychiatric social workers, the local authorities which provide the homes for old people and the hospital service which provides the hospitals, and so on, who should all be working, together as a team to cure us when we are ill—and, indeed, as the noble Lord, Lord Douglas of Barloch, said, to try to arrange that incipient illness is found out before we are ill.

I think that the present administrative set-up makes that more difficult, and I would most urgently ask Her Majesty's Government, and most strongly support the noble Viscount, Lord Astor, in his suggestion, that another committee (much though I dislike committees being set up) should be set up to investigate not only the hospital service but the whole of the National Health Service, to find out whether the good service which we now have can, be made better, as I myself believe it could be if the administrative machine were tidied up.

5.30 p.m.

LORD PAKENHAM

My Lords, I know that everything that falls from the noble Lord who spoke last on this subject will be studied fully, and I hope and believe particular attention will be given to what he said about mental health, a subject rather neglected throughout the rest of the debate and to which I will return in a moment or two. Before coming to that, however, may I say what a privilege it is to speak last for this side in a debate where so many notable pundits have made their contribution. The noble Lord, Lord Nathan, made, I think we all agree, a most impressive, balanced survey, and, as we expected, the noble Lord, Lord Evans, excited our interest so greatly that we all felt sorry when he sat down after what seemed to be only a few moments. I hope and believe he will speak twice as long on subsequent occasions. It would have given pleasure to our dear chief and late revered Leader of the House, Viscount Addison, to hear the maiden speech of his son and to hear him speaking so well—and speaking so well on a medical subject. We hope to hear him often again.

I am glad that the noble Lord, Lord Clitheroe, paid tribute to the services rendered, not only to-day but on many other occasions, by the noble Lord, Lord Nathan, to hospitals and to health in general. I echo those tributes. I recall an occasion when I went to visit the noble Lord, Lord Nathan, then a patient in his own Westminster Hospital. I was trying to find my way to the noble Lord, when I was stopped by a charming young doctor, who asked me a question in these terms: "Which side are you on?" Not quite picking up the local jargon I replied, "I am on the Labour side." He replied in his turn, "Good show, I'm gynæ ', too!"

I hope, as a mere layman, I shall be allowed to speak from a patient's point of view, but if I concentrate on mental health I do not want the House to think I am necessarily speaking from the point of view of a mental patient. That has not been my experience of hospitals. Indeed, looking around your Lordships I should think the prognosis for most of us was fairly good. We are too old to he diagnosed as mentally deficient—I have no doubt that the doctors will tell me if I am wrong—and as regards mental sickness I feel the atmosphere of the House is so charming and tranquillising that we have no need of drugs and hospitals.

I echo what has been said about the great glory of our Health Service, and our hospital service is a very large part of it. I was inclined, however, to feel at certain moments in the debate, and at one moment, with great deference, when the noble Lord, Lord Moran, was speaking, that we were in danger perhaps of being almost complacent about the state of our buildings, and particularly the buildings for mental health. There I feel that if the noble Earl, Lord Cranbrook, had pursued the topic longer, it might have acted as a corrective to the noble Lord, Lord Moran. I have heard references this afternoon to the Hospital Year Book and I was trying to equip myself by studying the editorial in the current edition. The editorial in this annual survey is far more troubled about the provision which is being made for hospitals than were some of the speakers this afternoon.

I will not weary the House with many quotations but I found this sentence: Although especially acute in the mental health field, the need for increased capital expenditure is general to the hospital service. The noble Lord, Lord Nathan, reminded us that the Guillebaud Committee's recommendation was for £30 million a year and that we are now spending no more than £20 million. Although the Hospital Year Book quotes this amount, the £20 million, as "some advance on past years", it says it remains totally inadequate for the proper maintenance of capital assets, and would be so even if there were no enormous legacy of arrears to make good. I am still quoting the Hospital Year Book: In the absence of a substantial increase of capital expenditure the position is that this country is steadily falling behind other countries in its standards of hospital provision. I feel that the noble Lord, Lord Evans, would perhaps not be altogether averse to that way of stating things. In reference to the teaching hospitals he used language not very far removed from that. At any rate that is the view of the Hospital Year Book.

I have tried to equip myself for this debate by talking to a number of doctors. I wonder whether the great experts present agree with what I am told. I find a strong conviction that outdated hospitals are throwing an excessive strain on junior house officers and nursing staff. I am sure we all agree that it is necessary to provide married quarters for house officers and I have had cases mentioned to me of the breaking up of marriages as the result of inadequate marriage quarters.

As I say, I should like to talk more particularly about mental health. There the noble Earl, Lord Cranbrook, began to paint the picture. We are all aware—and the noble Lord, Lord Moran, explained it to us—that we have entered a new phase in mental health, and these matters were discussed when we had a debate on the Report of the Royal Commission. But we are all aware, and the noble Lord. Lord Moran, does not want me to teach him these elementary things, that the mental hospitals were built when there was a totally different approach to mental disease and old age. They were built largely for the poor, and the least regarded of the poor. Now all elements in the population may be making use of them. We were reminded in the debate on the Report of the Royal Commission on Mental Health that 44 per cent. of the beds in the hospitals at the present time are used for mentally disordered patients—nearly half the beds— and that one boy in twenty born in this country, and rather more than that proportion of women, will spend some time in a mental hospital. The noble Earl, Lord Cranbrook, reminded us that 80 per cent. of patients who are admitted to mental hospitals are discharged within a year and that more than half stay less than three months.

These facts are rightly pointed to by experts like the noble Lord, Lord Moran, as showing how far we have advanced, and that is so. We have, I agree, advanced enormously in ideas and actual progress; but the very fact that the mental hospital to-day has a curative aim imposes a new and heavier responsibility for providing more advanced facilities than in the past, and I should think that a still heavier responsibility has been assumed by the Government through its acceptance of the progressive ideas of the Royal Commission's Report. But if we turn back to the Hospital Year Book we find this: The achievement of a new deal for mental health is dependent on a great deal more than the passing of new legislation … In the hospital field, if the belief of the Royal Commission in the voluntary treatment of mental disorder is to be justified, it will be essential for standards of accommodation, equipment, patient comfort and feeding, and of staffs in mental hospitals, to be brought up to the general run of other hospitals. So that it seems clear that, though some leeway may have been made up, mental hospitals are still, through no fault of their own, lagging behind the rest of the medical world; that they are still the depressed classes of medicine.

We must assume that these matters are in the mind of, the Government, and no doubt the noble Lord, Lord Strathclyde, will have something to say about them. Obviously, what I am proposing involves heavy expenditure, and the noble Lord will tell us to-day that heavy expenditure is not very easy to arrange for at the present lime. I am not going to say more on that now, except that I feel that any Government, irrespective of Party, is not doing its job until it spends much more on hospitals generally and particularly on mental health. I assume, however (and I assume this only for the sake of argument), that the Government cannot be expected to spend much more at this precise moment than they are spending on mental health; but what about reforms which do not cost very much money? I would counsel noble Lords here to read once more the powerful speech made when discussime mental health specifically, by the noble Earl, Lord Feversham, who is Chairman of the National Association for Mental Health, which has done and is doing such an enormous amount in this field.

I should like to remind your Lordships of the emphasis laid by the Royal Commission on the shift from hospital to community care—that is, care of patients outside hospitals. The noble Earl, Lord Cranbrook, was beginning to labour the same point. There is increasing emphasis on forms of treatment and training and social services outside the hospitals which make it possible to discharge patients sooner than in the past. Here, again, it is no good pointing to something which ideally ought to happen. The Government in power have a heavy responsibility for action if mental hospitals and mental deficiency hospitals are to be encouraged to discharge patients who are no longer in need of specialised mental treatment. It may be asked: "What can the Govern- ment do about it, because in many cases is this not the responsibility of the local authority?" All I am asking for is the implementation as soon as possible of paragraph 52 of the Royal Commission's Report—in other words, that the Minister of Health should use his existing powers to make Section 28 of the National Health Service Act a duty, and no longer permissive as at present. This would force local authorities to provide a full community service. I know that a number of enlightened authorities have already done this, but others have lagged behind. The Government cannot, in honour and decency, shirk the responsibility for forcing all local authorities to do their part.

I should like to say one word—it can be but for a moment—about training. We should all agree that the quality of the service in mental health, as in other spheres, depends on the quality of the workers, and this applies not only to hospitals but also to community care, which should make it possible to reduce the number in hospitals and so make the best use of and provide better service in the hospitals. I am sure that in some hospitals we have every kind of facility, but every encouragement must be given to improving recruitment and training for both medical and nursing staffs in hospitals and for community care. It is a deplorable fact, I am assured by those who ought to know, that there is no generally recognised training for mental welfare officers and duly authorised officers, in spite of the heavy responsibilities of their work and of the fact that these servants of the public have been foremost in urging that suitable training should be provided. There is still a deplorable lack of psychiatric social workers for service in mental hospitals and in out-patient psychiatric clinics.

In the earlier debate various speakers, including myself, led by the noble Earl, Lord Feversham, insisted on the great part to be played by voluntary organisations; and our words, I am glad to think, were endorsed by the noble and learned Viscount the Lord Chancellor. I have already mentioned the most prominent of these, the National Association for Mental Health. There is also the Mental After Care Association, the National League of Hospital Friends, the British Red Cross, the St. John Ambulance Brigade, the W.V.S., the Women's Institutes, the Townswomen's Guilds, Toc-H, the British Legion, youth clubs and, of course, the church organisations. Though I know that the noble and learned Viscount the Lord Chancellor spoke on an earlier occasion on the importance of this work, I hope that the noble Lord, Lord Strathclyde, will reaffirm once more in this hospital debate the importance of the Government's attention to the work of these voluntary organisations, whether they are helping people who are actually patients in hospitals or helping people to find their feet outside hospital, which of course enables them to be taken back into the community much sooner and reduces the burden on the hospitals.

I should like to say a word about research. I do not know anyone who, when he is strongly armed, can provide more crushing replies, always friendly and courteous, than the Lord Chancellor. When we had our last debate I felt unhappy about the answer he gave in regard to mental health research. It was pointed out at that time that the Medical Research Council are spending only 2 per cent. of their funds on mental health. The noble and learned Viscount dealt with that point, but I hope he will not mind my saying that it was not one of the crushing replies which he has administered to me and other critics, and I trust that to-day the noble Lord, Lord Strathclyde, will indicate at least the importance that is attached to research—and to mental health research and not just to research in general.

Finally, one word about the old. The Minister of Health said in November last year that in 1954 a survey had suggested that there were 10,000 old people in mental hospitals all over the country who might be capable of being treated elsewhere. Apparently the total number of patients over 65 years of age in designated mental hospitals is about 45,000. Surely all of us agree—and I am sure that the great doctors who have spoken, such as the noble Lord, Lord Moran, would agree—that the widest possible range of residential services should be developed, so that, if patients do not in fact need the skilled treatments of a mental hospital, they will be able to leave hospital and not be forced to stay there just because there is nowhere else for them to go. I am assured that long-stay psychiatric annexes are a most suitable line of development, and experiments at Oxford and Worthing are proving encouraging. At Worthing, it has been found possible to keep mentally frail old people at home, with the co-operation of the family doctor and a skilled psychiatrist. I hope that that will be carried much further, with the encouragement of the Government.

I may seem to have travelled wider than the Motion, which is concerned with hospitals, but if, as I assume (if only for the sake of argument) there is not anything like as much money to spend on mental health as one could wish, the question then becomes: how can we provide better treatment for those who are in mental hospitals? To some extent that leads on to the question: how can we reduce the population in these hospitals by providing better services outside? I have tried to point to one or two things that could be done constructively. Taking the situation as a whole, no one questions the great improvements that have been made in mental hospitals, as indicated by the noble Lord, Lord Moran; and no one could question the fact that modern ideas of mental treatment are far more advanced than older operations. But I submit—and I think it will be the general opinion of all those interested in the subject—that we shall never discharge our duty to the community without spending much more money on mental health than we seem prepared to do at the moment. That is not to disparage what is being done, within the financial limits; it is excellent and in many cases magnificent. But against the standard of what our present knowledge suggests is necessary, it is only a tinkering with the problem.

I hope the House will forgive me for concentrating on that one aspect, but others vastly more experienced in this field have dealt with other topics. I think that no one who comes to the subject fairly fresh, as I do, can fail to feel that he has learned a great deal from other speakers. I know that when the noble Lord, Lord Strathclyde, replies he will realise that we are all anxious to pay tribute to the hospital service; but we think that there is far more that can be done. As the noble Earl, Lord Cranbrook, said, what matter more than the last ten years are the next ten years; and I hope and believe that the noble Lord will in a moment address us in that spirit.

5.52 p.m.

THE MINISTER OF STATE, SCOTTISH OFFICE (LORD STRATHCLYDE)

My Lords, I should like at the outset of my remarks to associate myself with the tributes that have been paid to the noble Lord, Lord Nathan, for providing us with an opportunity to review the hospital service on what is practically the eve of its tenth anniversary; and I should also like to thank him for the helpful speech with which he introduced his Motion. I want to thank, too, all other noble Lords who have contributed to the debate, and I should like particularly to congratulate the noble Lord, Lord Evans, and the noble Viscount, Lord Addison, or their maiden speeches. I am quite sure that all of your Lordships will look forward to their taking part in our discussions frequently, for indeed we shall benefit from their advice.

I feel that we are fortunate in having in this House so many noble Lords with both knowledge and experience of one or other aspect of the subject we have been discussing. The noble Lord, Lord Nathan, himself brings to bear a great wealth of experience as chairman for many years of the board of governors of one of our great teaching hospitals. I should like to take this opportunity of saying how grateful the Government are, both to the noble Lord and to the many others in similar positions, for the untiring and devoted voluntary service they have given during these first formative years of the hospital service. I think that our debate to-day has shown a lively consciousness of the magnitude of the undertaking and also an appreciation of what has been achieved. The scale of the operation is perhaps worthy of a little thought. The noble Lord, Lord Nathan, spoke on this theme. It may be that some of the figures I shall give will differ from those given by him, and if so he will realise that I am not criticising his figures, but that I have the advantage of figures which are perhaps even more recent than those he has given.

There are in the hospital service in Great Britain some 3,700 hospitals and clinics employing, with their boards and committees, no fewer than 374,000 full-time and 94,000 part-time staff, handling 4¼ million in-patients and some 56 million out-patient attendances, and spending now something like £400 million in a year. It is hardly to be expected that an undertaking of this size, financed from public funds, should not have thrown up many problems during the years in which it has been taking shape; and when we address our minds to these problems, many of which have been raised by noble Lords this afternoon, I think it is right that we should do so with some appreciation of the scale of the undertaking from which they arise.

Before commenting on some of these problems, I should like to turn for a few moments to the achievements of the service, not in any spirit of self-congratulation but because, in my view, it would be grossly unfair to all the many people concerned with the running of the service to give the impression that the Government were so preoccupied with the problems that require solution and the possibilities for the future that they have no time to spare for appreciation of what has already been done. Indeed, several noble Lords have already spoken warmly of what has already been achieved, and I am sure that what they have said will be very welcome to those concerned.

Looking at the whole picture from the point of view of the central Government, I think one might point to three particular positive features as being specially notable. First there is the point that has already been made by the noble Lord, Lord Moran, when he spoke of the way in which the coming of the hospital service has resulted in specialised medical skill being much more widely available throughout the country. In terms of Great Britain one can get some idea of it by reflecting that the total number of specialists employed in the hospital service in Great Britain at the end of 1957 was not far short of 8,000, an increase of nearly 33 per cent. on the figure even at the end of 1949 when the hospital service had already begun to make its impact. I think it would be fair to say as has already been said by the noble Lord, Lord Moran, that there is no locality now in this country where specialist services are not available within a reasonable distance.

As the noble Lord, Lord Moran, also said, mental health especially has gained from this state of affairs. It is true that we still do not have all the specialists we should like in this field, but I think we all recognise that an entirely new approach to the problems of mental illness has manifested itself in recent years, as debates in this House have shown. While I am not saying that this approach would never have come about without the National Health Service, it is, I think, true to say that the more positive and hopeful treatments and attitudes of to-day have been aided by the wider deployment of skills and accommodation.

The next feature to which I should like to draw attention is the sheer volume of the work that has been handled, compared with the very limited physical expansion that has been found possible. It has been pointed out time and again, as a matter of reproach—and it has been pointed out again today—that no new general hospital has been completed in this country for some twenty years—apart, that is, from one of 156 beds which has been built in Scotland. The noble Lord, Lord Amulree, did not think that new buildings were very important, but other noble Lords took a different view. Nevertheless, in these last eight years we have seen a rise of no less than 29 per cent. in England and Wales, and 43 per cent. in Scotland, in the number of in-patients who have been treated. I do not think I need assure the House that that increase has been achieved without any lowering in standards.

There has been some increase in the number of beds available, a large part of it achieved, not by new building but by bringing into use beds which were formerly idle. But that increase has been only to the order of 6 per cent., and much the most important contribution to the great increase in the volume of hospital work has come from the greater efficiency in management and from the improved methods of treatment. Of course it is quite obvious that statistics cannot show the quality of the treatment and, indeed, those noble Lords who are familiar with current hospital statistics will know that discharges and deaths are lumped together as an indication of the in-patient load. But I really do not think that anyone would suggest that the increase in volume has been achieved by sacrificing medical or nursing standards. I do not want to give the impression that the Government do not consider that new building is necessary. On the contrary, we realise, with noble Lords who have spoken this afternoon, how urgently it is needed. At the same time, I think it is fair to give credit to the doctors, nurses, administrators and all others in the hospital service who, in spite of shortages and obsolescence of much accommodation, have yet achieved so much.

The one other achievement to which I should like to call your Lordships' attention, and which seems to me to be worth recording, is the progress that has been made in the integration of the service. After all, when we think back and remember that in 1948 nearly 3,500 hospitals were taken over—a large number of them completely independent and separate, and others grouped only within a local authority area—we are surely bound to admit that the integration that has been achieved is quite remarkable. I have no doubt that there are still instances where it is far from perfect, but when we speak of the hospital service to-day we know that we are referring to a reasonably coherent entity and not just to a collection of individual hospitals.

(Much progress has been made by the Regional Hospital Boards in planning regional services and relating one part of the Service to another. Sometimes that process has been the cause of heart-burning when it has been found necessary, for instance, to change the use of a hospital to fit it into the modern picture,or even to close a hospital completely. But I do not think anyone could say that the planners have ridden roughshod over local sensitivities or interests. There is more that I could say about what has been achieved, but I still have a good deal of ground to cover in commenting on the various points which have been made by noble Lords who have spoken, and perhaps I may now turn to some of the criticisms which have been made and to the problems that have been mentioned.

Before I do that, perhaps your Lordships would not consider it out of place if I were to remind you that in the review of the hospital service on which we have been engaged to-day we are not exploring virgin territory. A thorough review was carried out three years ago by a special Committee appointed to review the cost of the National Health Service as a whole; and in the Report of the Guillebaud Committee your Lordships will find detailed and considered comment on many of the questions that have been raised to-day. Indeed, such comments as I have to make will often be, to a large extent, a repetition of what that Committee had to say. But in general your Lordships will recall that the Committee had no revolutionary changes to suggest in the organisation of the hospital service, and they recorded the view that the Health Service's record of performance since the appointed day constituted a very real achievement.

It has been suggested that perhaps not quite enough attention has been paid by the Government to the recommendations of the Guillebaud Committee. I think there are two answers to that. The first, I would suggest. is that to a large extent the Committee's conclusions were against any considerable changes in the existing arrangements; and, secondly, that if noble Lords will study in detail such recommendations for action as were made, they will find that in the majority of cases action has in fact been taken. Where it has not been taken, or not taken in precisely the sense recommended by the Committee, it has been for reasons the cogency of which I do not believe the Committee themselves would fail to recognise.

Several noble Lords spoke on the matter of the teaching hospitals, including the noble Lord, Lord Evans, and the noble Lord, Lord Clitheroe, who devoted almost his entire speech to that subject. It is reasonable that in this House teaching hospitals should find champions, and in view of the importance of these hospitals in the development of medicine it is right that their claims should be pressed. But I also think that we should remember that out of 482,000 beds in the service there are only some 27,000 which are in the teaching hospitals; and they started with a considerable advantage over most of the non-teaching group. The Government have to balance all the claims on the resources available, while they must take care that medical teaching is not seriously prejudiced by lack of funds for hospital development.

The Select Committee on Estimates, 1956–57, in their Sixth Report, recommended something with which the noble Lord, Lord Evans, is not in agreement, but perhaps I may be allowed to quote what they said—namely: Until the standards of non-teaching hospitals reach a significantly higher level the allocation of development and improvement money to teaching hospitals should continue to be strictly limited. My right honourable friend the Minister of Health, commenting on that statement, said he was in general agreement with the recommendation, but that at the same time he was bound to recognise the importance to the hospital service, and indeed to the health of the community generally, of seeing that teaching hospitals took a leading part in the latest development in the treatment of patients. Surely that strikes a reasonable balance. Of the very small amount available for distribution to provide that development and improvement in the year 1958–59, teaching hospitals got nearly twice as much as they would have got if the total had been divided in relation to the number of beds. In the case of staffed beds, the figure has been 7.4 per cent. for teaching hospitals, against 7.8 per cent. for non-teaching hospitals, and that is a difference of 4 of one per cent. which I do not think could be regarded as discrimination against the teaching hospitals. In the new building programme the teaching hospitals would appear to be well represented.

What I have said about the teaching hospitals has been in reference to England and Wales, and perhaps I may, be allowed to say a word about the situation in Scotland. There, of course, both the teaching and non-teaching hospitals come under the control of the Regional Hospital Boards. There has also been criticism in recent years in the teaching hospitals that they have not been receiving adequate capital investment and allocations to enable desirable improvement to proceed. It has been the case in Scotland, in this first decade of the National Health Service, that there has been a more even spread of financial resources over all the hospitals. The result has been to secure a reasonably high standard of service in the Scottish peripheral hospitals, and it is now hoped to be able to devote an increasing share of the financial resources to major developments in the teaching hospitals, and discussion to that end is already taking place between the Regional Hospital Boards and the universities.

My Lords, a good deal has been said also on the subject of capital expenditure. The noble Lords, Lord Nathan, Lord Addison, Lord Lucan and Lord Pakenham, all mentioned that subject. There is an undoubted need for very considerable capital expenditure on the modernisation of old and building of new hospitals. The amounts which can be made available must be considered in the light of the economy as a whole. I think reference was made this afternoon to the fact that the Guillcbaud Committee recommended that £30 million should be spent annually in Great Britain. That has not been possible to date, but I would call the attention of the House to the fact that the Government have increased the amount available in England and Wales from £13 million in 1956–57 to £18 million in 1957–58 and to £20 million in the current financial year; and £22 million is expected to be available next year. In Scotland the respective figures are £2.4 million, £2.7 million, £2.8 million and £2.9 million. The fact that the allocations have been increased is surely evidence that the Government are doing what is possible to improve the situation.

The noble Earl, Lord Cranbrook, indicated, as I understood him, that capital expenditure was only a third of the level of 1938–39. Perhaps that is a reference to the Guillebaud Report, but I would point out that the Guillebaud Report was referring to capital expenditure in 1952–53; since then the amount provided has increased very much. For instance, in 1952–53 it was £12 million, and in 1958–59, taking Great Britain as a whole, it is somewhere in the region of £23 million.

The noble Lords, Lord Lucan and Lord Evans, made references to the Noel Hall Report. That Report, noble Lords will remember, was concerned with improving the grading structure of the administrative and clerical staff of the hospital service. The various employing associations in the hospital field have been invited to submit comments on various aspects of the Report, and these have not all yet come to hand. Meantime the Administrative and Clerical Staffs Whitley Council is discussing the Report's proposals regarding the grading structure of the general grades, the appropriate pay scale and other related matters. Those discussions have now gone on for some months, but unfortunately it has been impossible to reach agreement. The matter has now been referred to the Industrial Court. The Whitley Council is continuing on other aspects of the Report, and the senior grades (these were the grades to which the noble Lord, Lord Evans, referred) are to be the subject of a fact-finding inquiry. I would add that I have noted Lord Lucan's comments in regard to training.

Another matter which was raised by both the noble Earl, Lord Lucan, and the noble Lord, Lord Amulree, was that of work study. Work study originated in the study of the physical movements required to produce a given product, and its application in that sense to hospitals is somewhat limited, though of course it can be used in such activities as laundries, catering and building maintenance. Work study may be used to mean study of organisation and methods, and that was what was of particular interest to noble Lords who have spoken. That is on a rather broader front. It involves a study of almost any procedure, the examination of the things which have to be achieved and the methods used in achieving them, and the organisation of the establishment in which they have to be carried out. It may use techniques developed on work study. An experimental "organisation and methods" service was started by the Ministry of Health in 1954. Up to the end of 1957 it had completed seventy-eight assignments, and it had another twenty-eight either in hand or waiting. The results of those studies have been very useful indeed, though they do not seem to offer much scope for dramatic economies. I would assure the House that the Government are fully alive to the possibilities of the method and will continue their efforts to apply these techniques as seems to be most beneficial.

Perhaps I might be allowed to say one word on acquisition of space, a matter which was referred to. I think the point made was that hospitals should be enabled to acquire space against undefined future requirements. But, of course, it is policy not to buy land or property for hospitals in advance of requirements. That, I can assure your Lordships, follows the general Government policy not to lay out capital unless there is an immediate need, since the limited amount of capital available must be spent to the best advantage. But that does not mean for one moment that in building new hospitals no space whatsoever is left for future expansion. The objection is to the purchase of whole new parcels of land if there is no likelihood of building on them for some time ahead. I suggest that demands for new space may be balanced by the disappearance of requirements for space for other purposes, and I would also remind the House that to protect land which may be required at a future date for hospital purposes there is the machinery of the Town and Country Planning Acts, under which, of course, as noble Lords realise, land can be defined or designated for hospital purposes in the local development plan.

My Lords, I have been speaking for a very considerable time, but there are still a great number of points to answer, if your Lordships will bear with me for a moment or two longer. I should like to say a word or two on the matter of research, which has been referred to by many noble Lords. The noble Lord, Lord Pakenham, asked me to give an assurance on the subject. Of course, the Government fully realise the importance of research, both in relation to travelling scholarships and otherwise. The Government fully accept the question of travelling scholarships—that is, provided that the purpose of these scholarships can be demonstrated to be rewarding—and hospital hoards have been given a very considerable discretion to grant study leave, whether for travel or otherwise.

With regard to the matter of clinical research, that is now under the general supervision of the special Clinical Research Board, and there is no lack of encouragement for promising projects within the limits of the resources available. Of course, research has been traditionally regarded by the teaching hospitals, as I understand it, as a proper use for their endowment funds. I think it was the noble Lord, Lord Nathan, who said that the boards ought not to use these funds for other things, such as buildings, which could be more suitably financed by the Exchequer. The answer would give him there is that the teaching hospitals get their fair share of the funds available for building. I do assure the noble Lord, Lord Pakenham, that the Government are really fully seized of the essential need for research to continue.

LORD PAKENHAM

May I interrupt the noble Lord? I am afraid that I was speaking, as usual, too fast, and I did not make my main point quite plain. I was very anxious to submit once more to the noble Lord what was submitted by various speakers in the debate on mental health; that out of the total amount going to medical research far too little is going to research into mental health. I appreciate that the noble Lord cannot give a pledge on the point tonight, but can he assure us that that aspect of the matter will be considered again?

LORD STRATHCLYDE

Certainly. What the noble Lord has said, as he well knows, will be noted and carefully and sympathetically considered.

I should like to turn now to other matters raised by the noble Lord. For instance, he spoke of the need for residential accommodation for old people outside the mental hospital service. Of course, it is a need which applies throughout our hospital service where old people not really in need of medical care and skill have to be accommodated, by reason of the lack of other suitable accommodation. There are two ways of meeting this problem of providing residential accommodation for the old people. One is, of course, by long-stay annexes attached to the hospitals—that is, for patients who are not fit to live in the community but who do not need the full range of hospital care; and the other is that homes should be provided by the local authorities for those who do not need to be in hospital.

I want to tell the House that the establishment of these annexes to hospitals has been recommended to the hospital authorities, and that, despite the limited resources available, some little progress has been made. I am told that there are now about two dozen such annexes, and that they have between them some 2,300 beds. At least this is a start. I am glad also to tell the House that steady progress has been made by local authorities in the provision of small homes for these aged and infirm people, and that since the end of the war some 996 homes have been provided, 68 during the year 1957. In addition to that, the Royal Commission on Mental Laws has recommended that local authorities should make further provision for the elderly mentally infirm who do not need hospital treatment and care. That recommendation is now being considered along with others in the Commission's Report.

The noble Lord, Lord Pakenham, also spoke about the training of voluntary workers. The noble Lord probably knows that a Working Party, under Dr. Eileen Younghusband, has been set up by the Minister of Health to consider the proper field of work in the recruitment and training of social workers at all levels in the local authority health and welfare service. That Working Party began work in 1955, and they have heard evidence from the representatives of mental welfare officers and other bodies interested in the Health Service. That work continues.

The noble Lord also referred to expenditure in mental and mental deficiency hospitals. Of course, it has long been recognised that much needs to be done in our mental and mental deficiency hospitals. I assure the noble Lord that progress is being made. Let me tell him what has been done on the mental side—though he probably knows the answer already. There have been substantial increases in expenditure on mental deficiency hospitals. In 1956–57 32.7 per cent. of all capital expenditure was on the mental deficiency hospitals, compared to 23.9 per cent. in 1948–56. In the period from 1948 to 1957 nearly £18 million has been spent on hospitals of this type out of a capital expenditure of £70 million. Perhaps I might here say a word about staffing, which has been alluded to. Considerable anxiety has been expressed about the intake of nurses. I am glad to say that there is a considerable improvement in that respect. Between December 31, 1956, and September 30, 1957, the number of student nurses increased by some 42 per cent. on the male side, and female student nurses increased in number by 30 per cent. To-day, the rate of recruitment over the whole field has greatly improved and the number of students now under training is a record. That is not bad going, if I may put it in that way. The actual increase in the number of nurses and nursing and midwifery staff in Great Britain between 1953 and 1956 was from 180,470 to 187,697. So we are making a little progress, and one can only hope that it may continue.

My Lords, many other points have been raised, but as I have already spoken at such considerable length perhaps your Lordships will excuse me if I do not comment on them. I have said that every criticism and suggestion which has been offered during this debate will he most carefully considered and studied by the Government. In the answers which I have given to particular points I have tried to pick out those which have seemed to me to be of particular interest.

May I return now to a point I endeavoured to make at the outset of my remarks? As your Lordships know, I come to this Box as the spokesman for Her Majesty's Government. In seeking to draw attention to the achievements of the hospital service and to answer criticisms of it, I may have given the impression that I am concerned only with claiming credit for the Government. That is far from being the case. If I have given that impression, may I repeat that the Government realise fully where most of the credit for what has been done belongs—namely, with the thousands of people who are engaged in the day-to-day running of the service: those who give their services as chairmen and as members of boards and committees, many of whom are included among Members of your Lordships' House; the doctors, whose medical skill is the foundation of the whole edifice; the administrators, nurses and all those other members of the hospital staff who are engaged in this great service. Nor am I forgetting the many voluntary workers who give so much of their time to help the hospitals in a variety of ways, through Leagues of Friends and otherwise. I am sure that the whole House will join with me in paying the most sincere tribute to all those people for the work that they do. For my part, I can assure your Lordships that the Government will do everything they possibly can, while maintaining the health of the national economy, to enable the service to consolidate the progress that has been made in these first ten years and to make further advances in the future.

LORD CLITHEROE

My Lords, before my noble friend sits down, may I ask him if he will be so good as to make one point clear about which I was not quite sure from his reply? When he was talking about teaching hospitals he created a certain amount of alarm and despondency in my mind by quoting the fact that the Minister of Health had associated himself with the rather depressing and, I thought, reactionary Report of a Select Committee in another place. Could the Minister give us some assurance that he still believes that it is the policy of Her Majesty's Government that the teaching hospitals should keep in the lead?

LORD STRATHCLYDE

My Lords, I should have thought that the noble Lord could accept that in view of the fact that expenditure on the teaching hospitals has been increasing year by year.

LORD CLITHEROE

I thank my noble friend.

6.29 p.m.

LORD NATHAN

My Lords, I am not at all certain that the two statements last made by the noble Lord opposite are not the two most important of his most interesting and valuable statement—I refer to his reply to the noble Lord, Lord Clitheroe, and also the praise which he bestowed upon that vast body of persons outside your Lordships' House who are so closely concerned with the work and the service of the hospitals. I am sure they will read what the noble Lord has said with the greatest satisfaction.

I feel all your Lordships will agree that I should express to the noble Lord who has spoken for Her Majesty's Government appreciation of the charm and the fullness of the statement he has made, to which obviously he has given a great deal of trouble. If some of the promise was a little arid, that was disguised by the charm of the presentation.

This has been a memorable debate in the history of hospitals. It has been conducted at all times and in all parts of the House in an atmosphere of friendly good will and of appreciation of what has been done by all concerned in the Health Service, from the Ministry downwards. We are all partners in this. To-day's debate has been memorable for the fact that five of the speakers were drawn from the medical profession and distinguished in one branch of it or another. The veteran, Lord Moran, brought all his long experience and authority to bear on the discussion. We have heard the noble Lord before and have learned to assess him here. But we have not before heard the noble Lord, Lord Evans, and I am sure that everyone who heard his speech will have acclaimed him and will regard with satisfaction the fact that the first of what we hope may be numerous speeches in your Lordships' House on subjects coming so much within his province was made in this debate on ten years of the Health Service. Personally, I have an especial satisfaction in commenting on the maiden speech of my noble friend Lord Addison, for I know my honoured friend his father would have rejoiced to think he was making so successful a speech on such a subject in this debate to-day.

Your Lordships will not wish that I should in any way prolong this debate. I believe it has been useful and will bring satisfaction to those engaged in the hospital services. I took note of what was said by the noble Lord about taking into account also the various suggestions and criticisms which had been made but had not been referred to in his reply; and of course we rely upon the Ministry to give due consideration to all these matters which have been put forward in a spirit of good faith and good will and in conformity with our common purpose. Once more I thank the noble Lord, and beg leave to withdraw my Motion.

Motion for Papers, by leave, withdrawn.