HOSPITAL TREATMENT OF CHILDREN

HL Deb 12 February 1959 vol 214 cc185-226

3.24 p.m.

LORD CROOK rose to move to resolve, That, in the opinion of this House it is essential to the future of the Health Service to retain the existing large centralised children's hospitals, alike in the interests of (a) the most efficient treatment of children; (b) the effective continuation of the Register of Sick Children's Nurses; and (c) implementing the policy of education of children in hospitals as desired by the Minister of Education, the Minister of Health and the county education authorities. The noble Lord said: I beg to move the Motion standing on the Order Paper in my name. It is a Motion which I suggest to your Lordships is in no way revolutionary. Indeed, it might well be described as conservative in its origin, because it desires to keep things exactly as they are: it seeks to make no change in the present situation but to keep to the policy at present being followed by Her Majesty's Government.

Your Lordships may well retort: "Why then should you move the Motion?" I move it because of the knowledge that the right honourable gentleman the Minister of Health is considering a large-scale change which would set the clock back fifty to 100 years in respect of the administration of children's hospitals. What is more, he would be doing it not for reasons of policy but for reasons of expediency. In my submission to your Lordships, he would be flying completely in the face of his own declarations recently, agreeing with the recommendations of the Royal College of Physicians. I am sorry that I have to refer once again to that Report, which has been bandied about and discussed in your Lordships' House to a considerable extent in recent weeks, but I am bound to do so, if only to remind your Lordships of the main organisational themes of the Report. I do not want to remind your Lordships only of particular matters which suit the Motion I am moving: I want to remind you of a complete and clear summary of the themes of that Report.

Broadly, as I submit to your Lordships—and I do not think the noble Earl who is to reply for Her Majesty's Government would disagree with me on this—it says that there are four main ways in which children's treatment can be given. It says, first of all, that the most desirable treatment is that in the larger, specially equipped children's hospitals. It says, secondly, that the next desirable is the treatment given in a self-contained children's block. The determining factors there should be the needs of the area, density of population and town planning considerations, plus the fact that the self-contained block would have all the necessary equipment and services readily available. Thirdly, there neither of these is available, treatment should be carried out in a small children's ward. Fourthly—though this is to be avoided everywhere in Britain, if that is at all possible—the children should be treated in the same wards as adults. On this most undesirable fourth alternative the Report says: The proper care of children in hospitals is so different from that of adults that their admission to adult wards is to be deprecated. In fact, it is to the two first-mentioned forms of organisation that the Royal College of Physicians look; and it was for that reason that so many of us interested in this subject were glad to learn last year that the right honourable gentleman the Minister of Health, for his part, on behalf of his Ministry, broadly accepted the terms of the Report.

May I quote further to your Lordships, because I want this to be a factual debate and not a debate on views that I may hold as a Member of this House? In respect of the first choice, that of the special hospital for children, the Royal College say in the Report: There is no doubt that special children's hospitals offer the best service for children, because the staff, at all levels and in all departments, is attuned to the needs of the sick child. Children's hospitals carry with them a tradition of service which cannot lightly be set aside. Then of the second alternative, the separate children's block, they said: In large general hospitals a separate self-contained children's block in close association with the obstetric department of the general hospital is desirable. Where there is no separate children's block, all children should be in special wards in a single unit under the general supervision of a pædiatrician, with a sister in charge who has had training and experience in nursing sick children. A children's unit makes possible such amenities as schooling and facilities for play, etc. A little later in the Report the Royal College of Physicians go on to say: It is unnecessary and undesirable to attempt to provide a children's unit in every general hospital or even in every area hospital, and they make very clear in their comments the reason why they reach this view. Again I quote, so that the views which your Lordships hear shall not be mine: Small units are undesirable because they are detrimental to satisfactory arrangements for the proper care of children, and to the training of doctors and nurses in this field. Units of less than twenty beds are uneconomic, and in closely populated areas children's beds should be concentrated in units of forty beds or more, including beds for both medical and surgical disorders, small units being gradually eliminated. In their later paragraphs, dealing with the medical and surgical staff to be employed the Royal College have this to say: The application and development of special techniques in departments dealing with the investigation and treatment of children is extremely important. These specialist facilities could be fully established only in large pædiatric units. They develop in later sections of their Report their views about the educational and recreational needs of the children. If I may select one important observation which they make, it is this: The happiness of children in hospital can be materially influenced by the opportunities they have for occupation. The use of education in hospital, not only to prevent illness from interfering with educational progress, but also to keep children happy, should be recognised. Provision should also be made for recreation and play.

Those then, my Lords, are not views which I am venturing to express to your Lordships; they are the official views of leaders of the medical profession dealing with children, showing what they think should be the position in the future. I am not, in this Motion, concerned with any attempt to advise the Minister, his officers, his advisers or any board as to future policy. I am only inviting your Lordships to look at the present position. I am desirous of showing that we already have some of these provisions. Over the past 100 years we have built up something that was good before it was taken over by the Health Service, and something which has since been improved further, giving us that of which we can be proud.

I want to try to interest your Lordships for a few minutes in the largest and probably the best-equipped children's hospital in Britain, and perhaps in Europe, a hospital which the Minister of Health has now been invited to close down—not for reasons of general policy, not for reasons of principle, not because he has adequate alternatives, but solely for reasons of financial expediency and to suit other matters. If this move of the Minister were in fact to fit in with proper reorganisation, reallocation and those things which Ministers must undertake if they are to administer an efficient service, then I should not be moving this Motion which is in front of your Lordships this afternoon. I refer to the proposal to close Queen Mary's Hospital at Carshalton, in Surrey. It is just over fifty years old. It is one of those which followed from the pioneering traditions which produced that hospital of great tradition to-day, the Great Ormond Street Hospital, just over one hundred years ago. It has accommodation and facilities for about twice as many children as the Great Ormond Street Hospital, and its situation, with its extensive grounds, is even more fortunate that that of Great Ormond Street or of the other two or three such hospitals which exist in this country.

Queen Mary's well-planned buildings are spread over 100 acres of Carshalton, on what were open downs when the hospital was built, fifty years ago. Since then, Greater London has reached out, and in the hospital's immediate surroundings there are three-quarters of a million population. The Carshalton Council's housing estate abuts upon the grounds of the hospital. The great L.C.C. Estate of St. Helier sprawls south of Merton, Morden: and Mitcham, with the greater part of it in Carshalton. It is one of those areas of Greater London which has developed in population so fast that one of the large general hospitals in this country has been built there. Indeed, I believe that St. Helier Hospital, Carshalton, with its 731 beds, is the largest hospital of modern construction in this country. It was completed only after the war had commenced in 1939. That, my Lords, is the measure of this huge population which has grown up on this area which was once a part of the downs.

In the ten-mile circle around Queen Mary's hospital there live no fewer than 2¾million people. And this great hospital is magnificently equipped. It has a resident physician superintendent, three physicians, six surgeons, ten resident medical officers, a matron, assistant matrons and 300 nurses trained or training in the Special Children's Register, and forty qualified school teachers. Queen Mary's, Carshalton, produces 15 per cent. of the nurses for the Special Register of Sick Children's Nurses. It is the hospital to which other training hospitals send their nurses to secure experience of sick children's nursing; while other hospitals, such as Guy's and St. Thomas's, send their medical students for a short stay in order to secure similar experience.

Patients come to this hospital, my Lords, at the desire of medical men and parents from the areas of twenty-five local authorities, and some from hundreds of miles away, at their own request, by arrangements made by hospital boards in various parts of the country. The reputatian of the hospital is world-wide. It is equipped with every medical and surgical need; and since they took it over in 1948 the Regional Board have built up the hospital's service as a general children's hospital, catering for all types of disease in childhood. The Board decided that Queen Mary's was to be their main pædiatric venture and that they would build up a full range of services, By 1953 it had become clear that this must involve a policy of concentration, in view of the developing excess of children's beds throughout the country. I ask your Lordships to note that as long ago as 1953 it was already clear to those who were studying these matters and were skilled in them that, because of the gradual improvement in the health of children, by reason of their better feeding, advances in antibiotic treatment, and the schemes of injections and the like that were available, an excess of children's beds was developing. But it was because of that that centralisation went on.

The Board appointed a full range of children's specialists, including pædiatricians, a pædiatrie surgeon (incidentally one of the few in any hospital in this country), orthopedic surgeons, anesthetists, pathologists, and radiologists; and they established what is probably the best physiotherapy department in any children's hospital in this country. They did a great deal. They spent capital on the re-equipment of the X-ray and pathology departments; the pharmacy was resited and replanned; many other minor but very useful improvements were made, and valuable capital projects were put in hand. All this work went an, and all this expenditure of capital on development proceeded. The refurnishing of two-thirds of the wards along these new lines had been completed by the date in the summer of last year when, suddenly, there was mooted this idea of closing the hospital.

Your Lordships may, quite rightly, ask me, when I talk in general terms about the hospital, exactly what this hospital does. My Lords, it cares, under ideal conditions, for every childhood ailment, from the emergency surgery of the newborn baby to the care of the permanently disabled child. This provision includes special units for the treatment of poliomyelitis, muscular dystrophy, rheumatic ailments, cerebral palsy, and orthopedic handicaps. Throughout all these subjects it is a specialised and specially-equipped hospital. Indeed, I would that your Lordships, instead of merely listening to me offering you words to-day, could have the opportunity of being persuaded by your own vision and your own excitement at seeing what is being done at that hospital: to look in (and this is why I use the word "excitement") at the rooms dealing with the handicapped and see the most modern and advanced system of treatment and care; and to go, in the interests of your Lordships' House, into the cerebral palsy unit—self-contained, with its own dining room, its own dormitory, its own school, its own treatment room—all arranged so that treatment can be fitted in with the continuation of education, which is so much a part of this hospital.

The children are taught on the wards by forty teachers who, from my knowledge of them, I can describe only as "dedicated to their jobs". They are all specially picked; they are either graduates or teacher-trained; and they include those especially capable of giving either education of a grammar school type or education specially for those children who, in addition to the complaints from which they suffer and for which they are taken to the hospital, suffer also the dreadful handicap of being deaf. In this hospital they have achieved in the field of education, as well as in the field of medicine, outstanding examples for the world. One boy, largely immobile, lying on his back and unable to use hands or arms, has passed the General Certificate of Education in six subjects at "O" level, using with his mouth a brush, a pencil, and rubber pads that manipulate an electric typewriter.

The children in that hospital—a hospital quite unlike those that most of us see when we are ailing—can join the Boy Scouts, the Girl Guides, the Brownies, and so on. Thanks to the organisation of a League of Friends—local people interested in the hospital—they are able to go in their own bus (owned by themselves and paid for by local effort; specially designed to take wheelchairs, and driven by voluntary bus drivers) to all manner of amusements and matters of interest; at the one extreme, pantomime and musical events, at the other, educational visits to Kew Gardens or the Tower of London. On one of those lovely occasions which remain in the memory of some of the long-stay patients, they were taken in buses and private cars and deployed along balconies and in shop windows in Epsom, in order to see Her Gracious Majesty pass by on her visit to Epsom College. The children go home to their parents for visits, in private cars made available by the efforts of local people. In fact, and not to keep your Lordships unduly on this point, I may say that they live within the hospital, to the broadest possible degree, the full and valuable life that their parents would like to see them live in the outside world, if only it were possible.

Small wonder, therefore, that medical men and parents ask voluntarily that children should go to Queen Mary's. It is because they know that there the children have the best possible surgical and pediatric treatment, with all those extras which mean not only education but morale to the growing citizen. Since I put this Motion on your Lordships' Order Paper, I have been glad to receive quite voluntary tribute, and much more than tribute, from all the doctors who, of their own volition, send patients to this hospital. The Local Medical Committee for the County of Surrey, by ananimous resolution, has protested to the Ministry of Health against the proposed closure, and has said to him that it does so because this hospital makes provision for the special treatment of children which is unobtainable elsewhere and, in any case, the withdrawal of this accommodation will make it very difficult for general practitioners in a wide area to find hospital treatment at all for their child patients ". On February 5 the honorary secretary of the medical committee for the remaining part of the area, the Croydon Local Medical Committee, sent me this resolution: That this Committee deplores the proposal of the Ministry of Health to close Queen Mary's Hospital for Children, Carshalton, as a children's hospital as it is essential for the treatment of both acute and chronic children's cases which cannot otherwise be accommodated in this area.

My Lords, so much for the medical aspects: may I now turn to the educational ones. Because they are conscious of the unrivalled and unequalled educational service that they are providing in respect of this special problem, the Education Department of the Surrey County Council were astonished when they heard of the proposal to sweep all this away. They wrote to the Minister, since, as many of your Lordships will know, the Minister of Health, jointly with the Minister of Education, had written to hospitals urging the importance of continued education in schools. The Surrey Education Committee said that teaching in general wards is "almost impossible", and even in children's wards in general hospitals the same difficulties applied to a lesser degree. They informed the Minister—and again I quote; they are not my words: For severely handicapped children the services of specialist qualified teachers are needed, but such teachers are scarce and cannot be provided for scattered individual patients. As to education in special children's wards, they said: Even in the best conditions what can be achieved is inadequate.

Then they went on to refer to the larger general hospital, that of St. Helier, Carshalton: The unit at St. Helier which accommodates a maximum of eighty children is the only one in the region of any size. It must be assumed that of this number of children a proportion are either too young or too ill to receive education, leaving probably less than fifty children able to benefit from tuition. This number of children cannot justify a very large number of teachers to educate them. Obviously, with such limited numbers the tuition must, as with the small groups referred to above, have little variety. Aid when it is borne in mind that the children may be aged from two to sixteen years and of varying standards of intelligence and attainments within their age groups, it is clear how difficult it is in such circumstances to make really suitable educational provision for the children. They went on to outline the needs and the solution and to inform the Minister of their knowledge of all the facilities which they were providing at Queen Mary's and how it was completely impossible for them to provide anything like this service anywhere else.

I have endeavoured to give to your Lordships, at the cost of keeping you perhaps a little unduly, a picture of the hospital which it is now proposed shall be abolished. Can your Lordships believe, any more than I can, that the Minister or the Regional Board who have built up this wonderful hospital and have spent all this money and loving care have suddenly felt that everything they have been doing from 1948 to 1958 was wrong? Of course that is not the explanation of the suggested closure. Behind lies one thing only: the lack of provision of capital expenditure to rebuild the Fountain Hospital for Mentally Deficient Children at Tooting. Queen Mary's is to be broken up and everything it stands for is to be destroyed, so that a new home may be found for mentally deficient children at no apparent capital cost.

The Fountain Hospital at Tooting was erected as a temporary structure towards the end of the last century, during an epidemic of fever not expected to last. From its user for that purpose it has changed to a user for the mentally deficient, just as it has changed hands again and again—from the M.A.B. to the L.C.C. and then to the Health Service. Since 1948 the Minister has made a number of promises to rebuild. Indeed he went so far as to select a piece of the hundred acres of Springfield Mental Hospital within the same immediate row of streets half a mile away, for the rebuilding. But whatever the plans, no money has ever been found to honour them. Now the position is that Fountain Hospital is in such a sorry state of disrepair that no Minister could ever find anybody who could carry out any repairs to make them any good at all. Therefore the Minister has either to find the capital to rebuild or to find an alternative way out. The way out found for him is to abolish Queen Mary's and spread these children around in thirty hospitals in the region, none of which is equipped to give the kind of treatment which I have outlined as part of that given by Queen Mary's. And to give even a semblance of the kind of treatment which is given at Queen Mary's in these hospitals to which they would be dispersed would mean an even larger capital expenditure by the Minister than that involved in rebuilding the Fountain Hospital, and it would take a number of years.

Of course the Minister, from his own point of view, has a justification for this suggestion. It is that the number of beds occupied at the Queen Mary's, Carshalton, is now less than it was. Since I am trying to keep this to a factual presentation, it is for me to try to show your Lordships what are the facts. There are in this hospital 550 beds, with 150 in reserve. Of these, no fewer than 400 are occupied at the moment. In the last twelve-monthly period for which figures are available there was a turnover of 4,307 children, aged from a few days to sixteen years. There were performed there 2,019 major operations and 416 minor operations, a total of 2,435, and the number of out-patients treated numbered 11,500.

Let me say to your Lordships straight away that I am not trying to burke the issue. I accept the position put to your Lordships in the Princess Louise Hospital debate on January 28 last, that (I quote the noble Lord, Lord Moran, OFFICIAL REPORT, Vol. 213 (No. 31), col. 892): Clearly, the Minister is faced with the bounden duty of seeing that these beds are properly used. … I accept what the noble Lord said in that debate better than I can say it and with far more authority and right to speak on the facts than I. The noble Lord continued [col. 896]: Now why is it important that a children's hospital should be large? If it is not, it will not he able to compete in the open market for first-class personnel for the accessory departments. The good radiologists and pathologists want to go to a hospital where there is plenty of material. Therefore we come to this sombre conclusion—which I do not think anybody disputes—that the days of small hospitals in every branch of medicine are numbered. They are not economic and they cannot possibly compete for the personnel necessary to run their ancillary departments effectively. That means to say that to get first-rate accessory departments the pædiatric unit of the future should be big enough to supply them itself. To do that it must either be another Great Ormond Street Hospital or, alternatively, it must he a pædiatric block attached to a general hospital which itself has these departments. The noble Lord, Lord Moran, also interpreted the report of the Royal College of Physicians. He said that what the Pædiatric Committee had in mind was not all special children's hospitals, irrespective of size, but the hospital at Sheffield, with 221 beds. What the Committee had in mind was either a hospital as large as that or a children's unit of adequate size—and I quote … it did not matter which, provided two things were supplied. One was that it was of adequate size, and the other that the ancillary departments, mainly pathology, radiology and the like were first rate.

I have tried to show that even to-day Queen Mary's is using 400 beds. The hospital to which the transfers would be made, if this policy were carried out by the Minister—who, I am glad to say, has already delayed some eight months before finally reaching his conclusion—with a total of about 350 beds, are 34 in number, and the numbers of beds are as follows. There are 3 of 10 beds or less; 15 of between 11 and 20 beds; 12 of between 21 and 30 beds; 1 with 40 beds; 2 with 52 beds and 1 (St. Helier) with 77 beds. The lowest figure desired by the pediatric specialists who co-operated in the Report to which I have referred is forty. I know that if my noble friend Lord Moran were here to criticise me he might well say that I was pitching the figure far too low, in the light of what he had to say.

I want to say a word or two about education in these hospitals. The largest of those I have quoted is St. Helier. I would remind your Lordships that I have already quoted the statement of the Surrey County Council Education Department: that they find themselves unable to provide at St. Helier Hospital what they regard as adequate education. I am not trying to secure that your Lordships should advance to the Minister proposals about how he should organise the Health Service. Of course there will be times when he will re-plan closed hospitals, will open others, and will make changes. If what was involved in the proposals now before him were part of a planned policy to close large children's hospitals, and to proceed to prepare children's blocks of appropriate size, properly equipped and staffed on the lines of the Report of the Royal College of Physicians and the support which your Lordships gave some three weeks ago to the general ideas, that would be another question to be considered on its merits. But that is not the position with which we are faced. Even if it were, it would take years of planning and reorganisation, construction of buildings at capital costs, involving new staffing problems and the like, before this transfer could be carried out in accordance with such a policy. But I repeat that this is not part of the policy. Indeed, I suggest that it is the negation of it; it is an expedient. Until the Ministry have available a policy, let us have things left alone.

I do not want to suggest to your Lordships—and I have tried not to suggest it in what I have ventured to say—that the use of large children's hospitals is the only way to deal with this matter. What I have said is: until we have some other plan, some other way of dealing with this matter, do not let us do away with the one thing we have which is of value to us; do not let us fail to Lind some small amount of money to deal with this problem in front of us. Your Lordships may well say to me: "But there is this gap between the number of beds filled and the number of beds in Queen. Mary's Hospital. What do you say about that?" I say that before the Minister came to suggest this closure the management committee of the hospital had many ideas to discuss with the Minister. For myself, I have a clear answer: I should be content to see the limited number of beds allocated to children in these other hospitals given up. I should be prepared to see certain of the children go where doctors and parents have chosen. For the rest, they should go into Queen Mary's, thereby releasing that number of beds in these thirty-four hospitals. That would help to cut down the long waiting list of adults who are waiting hopefully for operations, and to produce the additional maternity beds which, as the Government reminded us in the debate on the Princess Louise (Kensington) Hospital, are now one of the main needs to which we must pay regard.

I have tried, even at the risk of unduly keeping your Lordships and of boring you, to keep what I have to say completely and utterly factual without making an emotional appeal at all. Nobody knows more than noble Lords here how easy it is to make an emotional appeal when one is talking about children, and particularly when talking about children who are sick and suffering from dire disease. I have based nothing I have tried to say to your Lordships on those considerations. Indeed, the nearest I would come to emotional appeal to your Lordships is to say this. Having fought inside the Civil Service for years to produce decent working accommodation for people serving the State, I was delighted to see in The Times of last Monday week a sketch of the income tax office in Manchester, to be built at a cost of £1,250,000 for a staff of 1,200; and I was delighted the following day to see, similarly in the Press, a picture of the new Meteorological Office, which, at a cost of £1,750,000, will probably try to tell us what the weather is going to be. However, I should like to see one odd million spent on building a hospital. As I walk about and see around your Lordships' House these great towering edifices going up, at a cost of millions of pounds, to provide offices and shops as a memorial to this era, I wonder: can we never find money to build one hospital?

Moved to resolve, That, in the opinion of this House it is essential to the future of the Health Service to retain the existing large centralised children's hospitals, alike in the interests of (a) the most efficient treatment of children; (b) the effective continuation of the Register of Sick Children's Nurses; and (c) implementing the policy of education of children in hospitals as desired by the Minister of Education, the Minister of Health and the county education authorities.—(Lord Crook.)

4.7 p.m.

LORD AMULREE

My Lords, I should like to say a few words in support of the noble Lord who moved this Motion, but I want to include one or two reservations in that support. The first I think the noble Lord himself dealt with. It is that, supposing the terms of the Motion were to be accepted entirely, it would mean that there would never be any possibility of changing the existing plan for children's hospitals in the country. That, I think, is the last thing that the noble Lord would intend; and surely one of the purposes of the National Health Service was that the Minister should be able to make certain changes in the hospital planning of the country as various conditions changed and as new circumstances came along. In the second place, I cannot follow the noble Lord, Lord Crook, entirely, because I do not know well the hospital to which he has referred; although I have passed it, I have never visited it. Therefore I cannot follow the noble Lord in the long and good account of the work the hospital now does. But I am sure it is first class.

I should like to put before your Lordships in rather different language some of the considerations which I mentioned in the debate initiated by the noble Lord, Lord Balfour of Burleigh, on January 28, that is, on the question of whether children should, where it is possible, be taken care of in special children's hospitals, or in the general wards or special wards of large general hospitals. The position is changing because luckily we have fewer sick children to cope with; therefore this will be, so far as one can see, a diminishing problem. However, it is something which I do not understand, and I am rather worried about it, because in the world at large the tendency is for children, where possible, to be taken care of in special children's hospitals. That certainly was occurring in the United States. It is occurring in France to quite an extent, and it is occurring very definitely in the Scandinavian countries, where their hospital planning and construction is admired by most people in the world. In fact there is one big hospital in Stockholm which consists of a large compound—if I may so call it—with a general hospital, a children's hospital, and an old people's hospital, but they are separate blocks. I feel that that is very important.

When the noble Lord, Lord Crook, put down his Motion I thought I would inquire about what was occurring in our Provinces. I got in touch with eleven of the principal undergraduate teaching schools in Scotland, England, Wales and Northern Ireland. They were chosen not because they were teaching schools, but because they were situated in big centres of population where one could get a good idea of the tendency. Of these eleven places, eight had special children's hospitals and their children do not go into general hospitals at all. Four at present have no special children's hospitals; they go into general hospitals in special departments. One town in particular had plans to build a children's hospital as soon as they possibly could, and it was one of the top priorities for the Board of Governors when they got some money. The last place at which I inquired was in the lucky position of having both a large children's hospital and, at the same time, special departments in the general hospital.

It seemed to me that, in the Provinces certainly, the tendency was to provide special children's hospitals. I will not deny that some of the general hospitals had a few children's beds for emergencies or casualties, but I do not think that that will be for long, because it would be simple for the parents and the police in charge of casualties to know that instead of taking an injured child to a general hospital they could take it to the special children's hospital. That is merely a question of planning. The same thing would apply to the parents: once they knew about taking their child to a special of Children 200 children's hospital it would be simple for this procedure to become quite general and not to cause any particular trouble. It looks as if the practice in London is lagging behind what is going on in the rest of the world, and certainly what is going on in the Provinces. In London you have this enormous centre of population where there is no question that it is possible to get the children in certain special hospitals scattered over London so that parents would not need to travel a long way to see their children.

Various references have been made both in the debate of January 20 and in the speech of the noble Lord, Lord Crook, to-day about the Pediatric Report of the Royal College of Physicians. I think my memory serves me aright when I say that the committee which made that report was brought into being because there was a proposal that the children's hospital in Sheffield should be shut down and taken over for other purposes. As a result of protests arising from that proposal, this committee was set up which brought out quite definitely in its report that the right and best thing to do was to treat children in special hospitals, provided they could be of a certain size. Nobody would suggest a little place. This is one of the cases where size counts for quite a lot.

There is a publication, published by the Ministry of Health, called The Welfare of Children in Hospital, which is a Report to the Central Health Services Committee. That deals more with the care of children in hospital, but it says—and I agree—that it would be impracticable to treat all children in specialist hospitals. That is something I should not dream of suggesting, because in the rural areas and small towns where there are no big centres of population children must be treated in the special departments of the general hospital. But I feel that if there is this tendency coming along—and here I speak with the support of many but I will not say the complete body of pædiatricians—we are going the wrong way. I hope that the Minister and Her Majesty's Government will not be carried too far along the lines of changing the big children's hospitals into something else and putting the children in the special departments in the general hospitals.

4.16 p.m.

LORD COHEN OF BIRKENHEAD

My Lords, I hesitate to burden your Lordships with yet another speech on this topic, but may I, at the outset, deal with the question which has been raised once again by the noble Lord, Lord Crook, and the noble Lord, Lord Amulree, on the Royal College of Physicians' report. The noble Lord, Lord Crook, now accepts Lord Moran's interpretation of that report, and the noble Lord, Lord Amulree, is prepared to accept it perhaps a little more wholeheartedly than he did a fortnight or so ago. I would remind your Lordships that that is a report of pædiatricians, and it is unlikely that they would seek in any way to curtail the boundaries of their empire.

Another Report, published only a couple of days ago, was a report to the Central Health Services Council, of which I have the honour to be Chairman, by a Committee of all those interested in the welfare of children in hospitals. Its chairman was Sir Harry Platt, an ex-President of the Royal College of Surgeons. On it were represented distinguished pædiatricians, hospital administrators, general practitioners, those concerned with ancillary services within children's hospitals, and so on. Since the noble Lord, Lord Amulree, has quoted it in part, I should like to read something which is in this Report. In paragraph 15 it says: The guiding principle which emerges for the care of children in hospital is that whilst the child must, of course, undergo the necessary investigations and treatment for the condition from which he is suffering, he should be subject to the least possible disturbance of the routines to which he is accustomed. Every effort should be made by hospitals to preserve continuity with the home during the time the child is in hospital. In paragraph 34, which was quoted in paraphrase by the noble Lord, Lord Amulree, it says: It has been suggested to us that the aim should be to nurse all children in children's hospitals. There are, however, various considerations which make this proposal impracticable. It is not desirable that a child should be removed to a children's hospital which may be far from his home, thus making it difficult for his parents to visit him, when he could be nursed in a children's ward in a local hospital which is in the charge of a children's specialist visiting from a neighbouring centre sufficiently frequently. The greater the distance from a main children's centre, the less the likelihood that the child will be sent to it, and the greater the need for the doctor rather than the patient to travel. When I read the Resolution on the Order Paper, which is couched in general terms, I was under the impression that the noble Lord, Lord Crook, would proceed to debate this matter in general terms, and, having established the proposition in general terms, would then say that the particular instance to which he proposed to refer came within the terms of the general Resolution. But not at all. The noble Lord has debated a particular instance and is asking your Lordships therefore to infer the general from it. As a proposition in logic that fails. On the other hand, if I could establish that there are unequivocal exceptions to that proposition, then I suggest that the proposal as a whole fails.

I have served on a regional hospital board since its inception, and I know the difficulties which confront any regional hospital board when it has to make decisions as to the advice it shall give to the Minister when it runs counter to quite proper and laudable local desire to retain a hospital for the purpose for which it was first intended. There are two hospitals within my region which, I think, exemplify what is the general position. The first is Heswall which, beautifully situated, overlooks the estuary of the Dee and the mountains of North Wales and was established as the prototype of hospitals of which Queen Mary's, Carshalton, was a later example. It was designed to provide, for particular types of case, the appropriate environment, the fresh air, free from the pollution of an urban atmosphere, sunlight and plenty of space for exercise and play. Heswall was established by the late Sir Robert Jones and Dr. Macalister in 1899. It was opened in effect as a separate hospital in 1905, some years before Queen Mary's.

At that time, as the noble Lord, Lord Crook, has rightly said, the major problems with which these hospitals had to deal were the non-respiratory forms of tuberculosis, malnutrition, rickets, cardiac rheumatism, St. Vitus' dance, and chronic osteomyelitis. Again as the noble Lord, Lord Crook, said, these conditions have diminished, due to better houses, with more adequate space and light; to clean food and pasteurised milk; to the welfare foods which were provided during and after the war; to the better balanced diet which children now have, and to various forms of therapy, such as antibiotics, I drugs, vaccines and the like; and hospital needs have also been lessened by other forms of child care which can now be given in the home and thus no longer necessitate a stay in hospital, and by outpatient care, day hospitalisation and other forms of treatment.

Now, my Lords, Heswall has 240 beds. Within the last twenty years the occupancy of these beds has fallen by over 20 per cent., so that a considerable proportion of the hospital now remains empty. I do not propose to burden your Lordships with figures, except one or two which illustrate the magnitude of the decline of certain children's diseases which were treated in those hospitals. If we take a five-year period, say from 1931 to 1936, and compare with it a five-year period twenty years later, and take only a few conditions, we find that tuberculous peritonitis has dropped from 245 patients in the first quinquennium to 8 patients in the second; rickets has dropped from 132 patients to 6 patients; cardiac rheumatism is now 80 per cent. less (there are now 20 per cent. of the number of cases which there were twenty years ago) and the drop in St. Vitus' dance is even greater: it is now only 13 per cent. of what it was previously.

You may ask, but what use then is now being made of the beds that have been emptied by this desirable decline, at which we all rejoice, in many of these children's diseases? The answer is that, as at Queen Mary's, Carshalton, its original purpose has long in great measure been discarded. It is now being used in considerable measure for the treatment of acute conditions, acute bronchitis, for operations for hernia, minor operations such as circumcision and the like. As yet no final proposals have been made by the board of governors, which is responsible for that hospital and for what shall be done in the future. I believe the solution lies in a certain amount of integration and that Heswall might be kept wholly as a children's hospital.

Take the other, take Leasowe, faced by the same problem, faced by a drop in non-tubercular orthopædic conditions, from 193 in 1926 to 10 in 1958. That hospital recognised very early the need for a change in its purpose and it now houses a magnificent plastic surgery unit, a number of adult cases with non-tuberculous orthopedic conditions and also a number of other acute types of children's conditions. This, of course, reflects the experience of the whole country. When you consider that the notifications in the age group up to fifteen, which is, of course, the major age group, suffering from non-respiratory tuberculosis were nearly 4,500 and that they had dropped ten years later to less than 1,000, you realise that the clientele of children's hospitals is, thank God! rapidly and dramatically diminishing. Therefore we must not be Canute-like, blind to the needed change of orientation of many of these hospitals. We must not ignore this changed disease pattern.

I do not propose to discuss Queen Mary's, Carshalton, in any detail, because I have not apprised myself, except through what the noble Lord, Lord Crook, has said, of all the details of this particular problem. I know Queen Mary's at least I knew it in the old days when I visited it on several occasions, and I have no doubt that Queen Mary's is doing a magnificent job on the patients which it has. The noble Lord, Lord Crook, says that it keeps 150 beds in reserve. That, of course, is a euphemism for saying that they are not used, and something else ought to be done to utilise, in our present needs, beds which are kept in reserve. As the noble Lord, Lord Crook has said, the function of the hospital has significantly changed. When I knew it thirty years ago it was a long-stay hospital of the same type as Heswall. When I saw the figures only yesterday which the noble Lord, Lord Crook, had provided, I found that nearly 80 per cent. of the children now in Queen Mary's stay for less than a month, which means that they could be dealt with satisfactorily in acute general hospitals with adequately equipped children's units, and so conform to the desiderata of the Welfare of Children in Hospital Committee's Report.

There is clearly a need, in view of the changing demographic and disease pattern of our hospitals, for a review of the situation. There is clearly a need for all our hospitals and all our regional boards so to do. Some have already done so, such as Leasowe. Others have tried to shelve the issue by admitting to their beds cases which need not have been, for purely hospital reasons, admitted to their beds. It is desirable that in the future a large number of these patients should be dealt with either by home care or by day beds, or by an outpatient clinic. It may very well be that as the result of that review some hospitals which are now children's hospitals will, and should, be retained solely for the purpose of treating children. But it may well be also that a number of these hospitals should, as Leasowe has done, ensure that their accommodation is not wasted but used where there is a great need, as in many adult services. Pædiatric surgery is a type of surgery which can properly be undertaken in a large centralised children's hospital. But also there is a need for plastic surgery units; there is a need for cardiac and neuro-surgical units, and there are great needs—an overwhelming need for beds for the mentally deficient and one which will be increasingly felt in a field which I know that the noble Lord, Lord Amulree has at heart, namely, the care of the aged sick.

A fortnight ago this House decisively rejected a Motion which sought to disturb a decision about the use of a hospital. So far as I know, no decision has yet been promulgated about the future use of Queen Mary's Hospital, Carshalton. But, in taking any decision, what are the principles which must be followed? The first is that we must look for other possible uses if the need for the specific use for which the hospital was built has so lessened that it has a significant number of surplus beds while there are other groups of the population which are in urgent and dire need of hospital accommodation. The second principle—here I agree wholly with what the noble Lord, Lord Crook, has said—is that we must ensure that if children are displaced from a hospital, they are not deprived of any service at the highest level which shall be necessary for their cure and rehabilitation. These are the principles which I would apply, strictly and objectively, in determining the future of any hospital, whether it be a children's hospital, an infectious. diseases hospital or a sanitorium.

It is perhaps pertinent to remark that the battle here is not always between children's hospitals and general hospitals. The "cold war" has existed for a long time between the children's hospitals and infectious diseases hospitals, because both of them are in sight of losing a considerable proportion of their patients. One of them seeks to establish that what they regard as an infectious disease should be treated in an infectious diseases hospital; the other that the same condition should be dealt with in the children's hospital. I know that the noble Lord, Lord Crook, must be well aware of the fact that there has been a dispute going on as to whether meningitis under the age of 16 is a children's disease or an infectious disease. To me, the concern is an ill child, and it is the ill child who has to be treated.

Let me say at the outset of my concluding remarks that, in my view, it is both dutiful and laudable that a hospital management committee should seek to retain the functions of its own hospital; that it should show loyalty to the work of that hospital. But it cannot view the regional needs with an Olympian detachment. In all disputes", said Sir Thomas Brown, so much as there is of passion, so much there is of nothing to the purpose. The regional hospital board seeks to put the regional needs in perspective, and from time to time it must, through the Minister necessarily change the use of some of its hospital resources to meet changing needs. It has had to do so in regard to infectious diseases hospitals, to sanatoria, to some children's hospitals and the like, and it has to make provision for new and very important and dramatically successful specialities such as cardiac surgery, neuro-surgery, pædiatric surgery, plastic surgery, and the like.

But even the vision and authority of a regional hospital board is confined to its regional boundaries. It is the Minister who has to weigh national needs. It would be reckless folly, I suggest, for this House to concur in the general Motion on the Order Paper and which I remind your Lordships once again this House is debating, and not the specific instance which has been raised by the noble Lord, Lord Crook. It would be reckless folly to impose on the Minister a rigidity which ignores the changing scene of hospital needs and resources. We should in that way tie his hands so that he is unable to discharge his statutory responsibilities in the light both of these altered needs and of changing resources.

House adjourned during pleasure and resumed by the LORD CHANCELLOR.

4.39 p.m.

LORD UVEDALE OF NORTH END

My Lords, I rise to support certain propositions which the noble Lord, Lord Crook, has put before the House, and I am pleased to note that there seems to be a general agreement on the propositions as set out in the Resolution. The Resolution concerns the retention of large centralised children's hospitals on the grounds of ensuring the efficiency of the treatment of children, the registration of sick children's nurses and the education of those children.

LORD COHEN OF BIRKENHEAD

My Lords, may I, with your permission, interrupt just to say that the Resolution says to retain the existing large centralised children's hospitals. I can only interpret that as meaning all the existing large centralised children's hospitals.

LORD UVEDALE OF NORTH END

My Lords, I thank the noble Lord. I could not accept the proposition that any and every large children's hospital should be retained. That, of course, depends on the special circumstances governing the area. But in addition to the general proposition which has met with a large measure of acceptance, the noble Lord, Lord Crook, has brought up a specific instance—the proposed closure of Queen Mary's Hospital, Carshalton, which is now carrying out this work for children, and its replacement—or rather its reestablishment—as a hospital for mentally defective children. These mentally defective children are at present treated at the Fountain Hospital at Tooting.

In view of this debate I visited both the Fountain Hospital and Queen Mary's Hospital early in the week. I was already acquainted with Queen Mary's Hospital at Carshalton, and knew its reputation as an outstanding hospital for the treatment of children. I had not previously visited the Fountain Hospital at Tooting. When I went to the Fountain Hospital, the first thing that was obvious was that this hospital was still accommodated in temporary buildings. These buildings, consisting largely of corrugated iron, were put up in the year 1893 and were expected to last for ten, possibly fifteen, years. They have been standing there and in use now for sixty-six years.

At first, the hospital was employed for the treatment of infectious diseases, but since the period of the First World War, 1914–18, it has been used for the treatment of mentally defective children. It has an excellent medical staff. It has a research department carrying out useful work, and the nursing staff is at a strength of 180. There are in that hospital at the present time 600 mentally defective children. The hospital is overcrowded. There are 50 children in a ward which would be fully occupied by 25. There are no day rooms for the children who can be up during the day. There is a long waiting list for admission to the hospital, and the average time of waiting is two years. Every year 17 children awaiting admission to that hospital die. To show the difficulties of the nursing staff, I may say that, of 600 children in that hospital, 400 are incontinent, and there are only 200 who are capable of training or any form of ordinary education. When I left that hospital, I remembered that a new hospital had been projected for quite a time, and that plans had been prepared for a building on the Springfield Hospital Estate. No steps have yet been taken, however, for the construction of that new hospital, and I felt that the conditions under which the medical and nursing staff were working were a reproach to the community generally.

I then went to Queen Mary's, Carshalton, which I found a very different proposition. That hospital was built in 1909 as a convalescent home for children who had been suffering from infectious diseases. It soon changed its character and became a hospital for children requiring long-term treatment—cases requiring orthopedic treatment, cases of chronic rheumatism and children suffering with chronic nervous diseases. In 1945 it was made into a general hospital for the treatment of children, and began to take acute cases as well as long-term cases. To-day it is exceptionally well equipped for the work that it is carrying out. Most of the cases now admitted remain there for less than one month, but there are some cases, numbering about 50 in all, which remain there for a period of years.

As the noble Lord, Lord Crook, has told the House, this is rather an exceptional hospital in that it occupies a very large area of 100 acres. The buildings are set far apart—a fact which has its advantages, as well as its disadvantages. The total strength of the hospital is 550. The number of patients there is 400. The educational facilities for the children at that hospital are exceptional. The operating theatres, the physiotherapy departments and all equipment required are of the highest order; and it would be a national loss if it were decided that the hospital should close down.

Two points have been raised in this debate. One is that the hospital is not fully occupied; the other is the question of the distance that parents and friends have to travel to visit children in hospital. My own feeling is that there are hospitals with children's wards that would be quite willing to transfer the children's beds to Queen Mary's Hospital, Carshalton, and in that way enable themselves to deal more effectively with the adult cases which crowd their waiting lists. No doubt there are other proposals that could be made without interfering with the essential work that is carried on at Queen Mary's, Carshalton.

The difficulties that have arisen at the Fountain Hospital in Tooting should, I feel, be dealt with by the construction of a new hospital at Tooting. The problem, as has been said already in the debate, is financial; and no doubt that problem is acute with the cost of the Health Service mounting up to something like £700 million a year. But this question of adequate treatment for mentally defective children is really urgent, and this new hospital could be erected in sections over a course of years. They have at the Fountain Hospital a devoted staff, who, if they saw this new hospital taking shape, would willingly continue the excellent work they are now doing in very depressing circumstances.

That, my Lords, is my solution for the present difficulties. Maintain the hospital at Carshalton, the famous Queen Mary's Hospital for Children. Part of the hospital may be used for other things, but maintain the unit. Do not scatter the patients; do not destroy the organisation. But I do think that, whatever expenses may be involved, a commencement should be made with the building of a new hospital to re-house the patients at the present hospital at Tooting.

4.53 p.m.

LORD TAYLOR

My Lords, my noble friend Lord Cohen of Birkenhead was, I think, a little critical of my noble friend Lord Crook for having made his Motion a general one. Yet I think my noble friend Lord Crook was right so to do, and I must say I was charmed by the very quiet way in which he presented his facts. That he did not appeal to our emotions was, I felt, a correct and very right way of looking at this problem. The fact that he put his Motion in general terms enables us to see his particular concern in the perspective of the general problem, and to look at the needs of the sick child in hospital in rather more detail than we were able to do in the last debate on January 28.

The noble Lord's timing was rather good, perhaps not so much from his own point of view as from the point of view of the debate, in that it has very nearly coincided with the publication of the Report to which the noble Lord, Lord Amulree, referred, on the Welfare of Children in Hospital. It is a very interesting Report and I shall say a word or two about it in a moment. In the previous debate there was a good deal of legal argument and some very strong feeling, but I think six general propositions were established about which there is now really very little contention. If I may say so, it was particularly the speeches of the noble Lords, Lord Moran and Lord Cohen of Birkenhead, which established these propositions.

The first is that the need for children's hospitals, or beds in hospitals, is declining and will probably decline still further. The proportion of children's beds occupied is now perhaps only 60 per cent. or even 50 per cent. of what it was. The second is the increased needs in other specialties. The third is that it is impossible to contemplate vacant children's beds remaining unused. The fourth is that such changes of function are bound to be painful, both to lay members of committees and to the medical and nursing staffs involved, and, therefore, those of us who view these matters from outside must, if we are sure it is right, give our full support to regional boards and boards of governors when they have to make such changes. The fifth point which I think was established is that for the efficient technical care of children in hospital large units of beds are essential—not necessarily large units of children's beds but certainly large units of beds—so that there may be adequate ancillary services, particularly pathology, X-rays, physiotherapy and the like. And so the sixth point which has been established is that small individual children's hospitals should probably be the first to be converted to other uses. That was as far as we got in the last debate.

The Motion of my noble friend Lord Crook carries us a stage further. I think that in effect he accepts these six general propositions and then goes on to urge the concentration of sick children in large centralised children's hospitals. He in fact swings right to the opposite extreme from the position adopted by the noble Lord, Lord Balfour of Burleigh, in the previous debate. May I say at once that I think his is a very much better idea, as a general proposition, than that of the noble Lord, Lord Balfour of Burleigh, in such large units we do have the concentration of expertise which is needed. We have doctors who are fully specialist; we can have expert pathology, radiology and nursing services; and, as he has rightly stressed, we have teachers for the chronic children, the long-stay children. There is only one serious disadvantage to his proposal and that is the inevitable increase in distance between parents and children. There is, therefore, quite an even balance to decide here.

During the past ten years there has been a great change in our ideas about the care of the child in hospital. First, it has been realised that admission to hospital for a young child, a little child, particularly, is a fairly frightening experience. It varies greatly with the child. Some are very brave; some are absolutely terrified. Generally speaking, the more secure the child is at home, the greater is its self-reliance on separation from home. The greatest strain is seen in only children and first children, especially if they have over-anxious, over-fussy, mothers, and in children from unhappy or broken homes.

There was in the old days little enough consideration of the child's mental state in the hospital itself, particularly in the tonsil and adenoid wards. Children used to be admitted into these wards on one day of the week and lined up, almost like pigs for slaughter. One would be taken off to the theatre, would come back unconscious and bleeding, in the sight of the other children, and this process would go on until the last poor little one at the end of the line was reached. That sort of thing, thank goodness! is now very rare, if not quite extinct.

A second change that has happened in the last ten years is the realisation that the sudden separation of a young child from its parents, and especially from its mother, can have long-term effects on the child's character and behaviour. This is important, but I do not think it should be exaggerated. It has been very well stated in the Medical World by Dr. Yudkin, who is the consultant pædiatrician of the Whittington Hospital in London—a familiar combination of the Archway and other hospitals at Highgate, and one of the biggest hospitals in the metropolis now. This is what he says: What is known about the effects on young children of a stay in hospital? Certainly harmful effects are frequent, both as regards the immediate situation in hospital and their behaviour for some little time after they return home. They are unhappy, quiet, and sometimes defiant in hospital; often miserable, clinging and irritable at home. In the vast majority of children living in ordinary homes, these effects pass off within a few weeks. It is possible, but by no means certain, that a short hospital stay can by itself produce more serious effects later on. That, I think, is quite a moderate statement, and I think is an accurate one.

Dr. Yudkin goes on to say, however: When young children stay for many weeks or months, the effects are more lasting. These children have lived part of their lives in grossly unnatural surroundings, … If the children come, as they often do, from otherwise normal homes, the effects, though long-lasting, are likely to be overcome, but these children must be classed with other groups of deprived children in any discussion of the long-term effects. And he goes on: Much more research is needed. Now those are both moderate statements of the situation, and one would emphasise that the importance here is particularly where the long-stay child is concerned—the children about whom my noble friend Lord Crook spoke so graphically.

The problem is, then, how to make the admission to hospital as little frightening as possible, and how, while the child is in hospital, to preserve the family ties. There have been two lines of attack on this problem. The first was that of the late Sir James Spence of Newcastle—perhaps the greatest figure in British pædiatrics in the past twenty-five years. He saw the problem, and he created in Newcastle a mothers' and babies' hospital. He converted three houses by joining them together so that it was possible to admit mothers with their babies. There are twelve beds for mothers and babies in this hospital, and also twelve extra cots for babies without mothers: and that has been a very successful institution, of course, for little babies under about two years. Professor Court, Sir James Spence's successor, has continued with it, and, so that the mothers can be in with their babies at the same time, there is now at the Newcastle General Hospital, which is the old former municipal hospital, a unit for the admission of mothers with their babies suffering from the condition pyloric stenosis, which requires surgical treatment. Professor Craig, of Aberdeen, has, I understand, a 12-bed mother and baby unit which is very similar indeed.

Now in this sort of unit there has to be an entirely new approach to the nursing of sick children. The mother has to be taught by the nurse the care of the sick child, which means that the nurse has to become a teacher as well as a nurse. She has to become a demonstrator—somebody who is showing the mother how to do the job. Often enough, it is sufficient to admit a mother and child to the hospital for training in the care of the sick child for only two days and nights: then the mother and baby can go home again, and, with home care, either through nurses or through physicians, it is perfectly all right. The illness is coped with, although occasionally there may be a need to readmit.

That is one line of attack. The second line of attack which has been tried is all-day visiting and any-time visiting in children's wards. This proposition was at first strongly resisted by many people on the grounds that the visits of parents were bad for children; that they upset them; that the children behaved badly after the visits, and so on. But, where-ever it has been adopted, it has been most successful. The mothers come into the hospital and do things for the children. They do not just sit with them; they do things for the children, and, again, learn the technique of nursing sick children. On the whole, this is a more practical way of looking after most of the sick children—and these are, of course, the little children—when they are admitted to hospital, especially where long-stay children are concerned, because it would be uneconomic for mothers to go and stay for many months in the case of a child who is going to be in hospital over a great time. However, it does mean that the children should be admitted to hospitals which are as near home as possible. If the mothers and the fathers visit every day, then distance travelled becomes very important.

We must keep this in perspective, of course. For older children it is not nearly so important. My own children were very interested in this Report. They hold the view that parents are all right in their place, but you do not want them in school and certainly you only want them sometimes in hospital. We have to keep the matter in the right perspective. Again Dr. Yudkin summed it up, I think, very well. He said: There is no doubt, however, that hospital experience is sometimes quite definitely beneficial to a child's emotional development. For the slightly older child who is still desperately tied to his mother's apron strings or for most school-age children the hospital experience, adequately overcome, adds a great deal to their maturity. It is not unusual to hear mothers referring to their child's 'growing up' during the stay in hospital. 'Growing up' always involves overcoming difficulties and learning to be independent, and a humanely-run hospital may give older children opportunities that they have not found at home. It would be ridiculous, of course. to use this as a plea in favour of the older methods. Rather it is important to recognise that the overcoming of difficulties, with proper help, is a real phenomenon in a child's development and should not be overlooked in the planning of hospital and ward management any more than we should overlook methods of preventing the unhappiness of the younger children". I therefore think that the ideal children's unit is beginning to emerge. Children's wards should be part of a large hospital unit, and ideally they should be near enough to home for daily visiting—especially for the under fives and, if possible, for the long-stay children. Equally, it is vitally important to keep the children out of adult wards. Now when is a child not a child? The Report of the Committee of the Central Health Services Council points out that adolescents get very upset and that it is very bad for them—particularly adolescent girls who are admitted to gynecological wards, for example—and I think that fifteen is probably the right age to take. In adult wards they see things and hear things which are really better not seen and heard, and that applies especially to the surgical cases and to the cases of tonsils and adenoids.

A very valuable analysis has been made by my former colleagues at the Nuffield Provincial Hospitals Trust of the number of children now admitted to hospital. Of all patients admitted to hospital, about one in five is aged 0 to 15. Of these children—and these are approximate figures only; they vary a little from hospital to hospital, but not greatly—three-fifths are admitted for tonsils and adenoids. One-fifth are admitted for surgical conditions—appendicitis, accidents, burns, pyloric stenosis and orthopædic conditions. One-fifth are admitted under the care of pædiatricians—that is to say, physicians specialising in children's diseases. The average stay of tonsil and adenoid cases is very short, three to four days only.

Basing myself on these figures, I calculate that in a 400-bed general hospital, the need is for a children's unit of the following size: sixteen children's medical beds, sixteen children's surgical beds and about twenty children's beds for tonsils and adenoids, making a unit of fifty-two in all. That covers, of course, all children up to and including the age of fifteen, which would be more than is usually given in calculations of this sort. That is the ideal unit. It is big enough for full specialisation and for full ancillary services. I think that with fifty beds it is possible to have school-teaching in the wards for children. The minimum put forward in the Central Health Services Council Report, which I suggest might be a little unwelcome to my noble friend, is eight to ten beds, as a unit. I think that this is too small and would result in inadequate service. When my noble friend was giving his figures of the alternative accommodation to which it was proposed to send the Carshalton children, I felt that some of the units probably were too small.

Applying what I have been saying to the problem of Queen Mary's, Carshalton, I think that the cases as set out in my noble friend's speech fall into two great groups. First, of all, there are the short-stay children, the acute cases, who stay less than a month. Most of them, I suspect the great majority of them, could be looked after in children's blocks in local hospitals, if that was physically possible. I think that that could be done without serious detriment to these children and with one benefit to them—namely, that they would be nearer to their mothers and fathers. On the other hand, the long-stay children present a great and real problem. Before the noble Earl rejects my noble friend's plea, I hope he will look carefully at the problem of the long-stay children at Queen Mary's. My noble friend mentioned that they had a very good poliomyelitis unit. We hope that that will be required less in future as a result of polio inoculations. My noble friend also mentioned that they had a muscular dystrophy unit. There is no reason to suppose that it will be less used. I am afraid that it will continue to be required. Muscular dystrophy is a perfectly awful complaint affecting children, for which no known cure exists. It persists over many years, and it is really valuable to have one or more of those specialist units for an area like London. Again, cerebral palsy requires specialist units to deal with children. The care of long-stay rheumatic children, though these cases are greatly fewer than they used to be, at present presents a real problem; in the case of these children, Queen Mary's has made for itself a special name.

From my noble friend's figures I have tried to work out, I expect quite inaccurately, the number of beds at Carshalton probably occupied by these long-stay cases, for which they are doing such a fine job. I estimate that it is in the order of 200 beds, but I say that very much subject to correction. I feel that whatever happens to Carshalton in future, the important thing is that those units should not be split up and dissipated. I do not mind if the rest of the hospital is used for other purposes. As for acutely sick children, I think it would be a good thing for them to be looked after in their local hospitals. I hope that the work being done for these specialised long-stay children, for whom Queen Mary's has done and is still doing a splendid job, will not be lightly set aside in the future.

5.15 p.m.

THE EARL OF ONSLOW

My Lords, this has been an interesting debate and somewhat unique, because, except for the noble Lord, Lord Crook, who moved the Motion, and I, who am going to do my best to answer him, all the noble Lords who have spoken are professionally qualified to speak on this subject. A fortnight ago, rather on similar lines, we debated the possible future of the Princess Louise Hospital for Children, and, as the noble Lord, Lord Taylor, said, this debate too has developed into a general discussion on the future of the treatment of children in hospitals. But the noble Lord, Lord Crook, as he was good enough to tell me beforehand he proposed to do, devoted the bulk of his speech to the particular case of Queen Mary's Hospital, Carshalton.

Perhaps I may say at once to the noble Lord, and to other noble Lords who are equally interested in Queen Mary's, that at this very moment, more or less, the suggestions put forward by the Regional Hospital Board are being considered by my right honourable friend, and he has told me that one of the reasons why his decision has not been reached before was that he specifically wished to hear what was said by your Lordships on this subject before he finally made up his mind. I hope that that will be some comfort to the noble Lord, Lord Crook, who, if I may say so, has put his case very adequately and movingly, yet, as he said, without emotion.

As my noble friend Lord Dundee said in the last debate, we have to go back to the reasons why these problems over the use of children's hospitals have arisen. The fact is that we are very fortunate in not having to-day so many sick children as we had in the past, and particularly in having fewer long-stay cases; and it is, I understand, mainly the fall in these cases which has resulted in empty beds. I took the trouble to make some inquiries to find out what diseases formed the bulk of long-stay cases in the past. I understand that the diseases in which there has been this great fall are chiefly tuberculosis, rickets and marasmus, which means, when translated, wastage due to malnutrition, and also, as the noble Lord, Lord Cohen of Birkenhead, mentioned, rheumatic heart diseases.

The noble Lord, Lord Crook, quoted the Report of the Royal College of Physicians on the various methods of dealing with sick children, a matter which was mentioned in our last debate. He quoted first the provision of treatment in a children's hospital, which may be a general or a special hospital; secondly, a separate block at a general hospital; thirdly, a children's unit of one or more wards; and fourthly—and most undesirable, as many noble Lords have said—beds in an adult ward. I think it is fair to say that the whole general trend would be to reduce the four possibilities to three; and that, of course, would be the first three. I think everybody is agreed that, except possibly in emergencies, that should be achieved. These hospitals or units may be divided again into two types: that is, units for the short-stay cases, which I visualise would be for things like tonsils, minor accidents and so on; and units for long-stay cases—which we hope will become even fewer—whether they are suffering from some of the diseases I have already mentioned or whether they are mentally defective children housed in special hospitals such as the Fountain Hospital at Tooting.

Unfortunately I am unable to give your Lordships any statistics showing clearly how these children fall into various categories of disease, but I can give the House some rough idea of where sick children are treated. I gather that the last census was taken on the night of April 8. When the count was taken there were nearly 37,000 children between the ages of four weeks and fourteen years in all hospitals in England and Wales. Of these 37,000, nearly 6,500 were in mental and mental deficiency hospitals, and of the remaining 30,500 fewer than 4,000 were in children's general hospitals—that is, in short-stay hospitals for children only, such as Great Ormond Street. In other words, the overwhelming majority of children now receive, and have received for some time, I gather, treatment in units of hospitals which also treat adults, and are not in hospitals for children only.

I would ask your Lordships to consider whether the best informed opinion accepts or condemns this position. The Report of the Royal College of Physicians, published in 1957, to which reference has been made states: There is no doubt that special children's hospitals offer the best service for children "— This part has been quoted before, but I think it well worth repeating— because the staff, on all levels and in all departments, is attuned to the special needs of the sick child and because children's hospitals carry a tradition of service not lightly to be set aside. I do not think anybody disagrees with the statement that there should in certain circumstances be special children's hospitals.

But the Report goes on (it has already been quoted and I will not bore your Lordships by repeating it) to stress the necessity for parents and friends to visit. As has been said by the noble Lord, Lord Cohen of Birkenhead, and others, if you do not have in an area a certain number of these smaller units attached to general hospitals for adults, but have all the children in the area concentrated in one big children's hospital, it will be almost impossible for the average parent to visit. That, I think, is what we all have to bear in mind when consideration is being given to whether a particular children's hospital should be changed from its present use, largely because it is not being filled to its maximum capacity. And that, of course, is probably the first reason why the Regional Board would start to consider whether a hospital should be used for a different purpose. Some noble Lords have suggested that it might be possible to do away with the smaller units and give those to the adults, concentrating then on one big children's hospital. It is open to question however, whether that would not also mean depriving children of opportunities of being visited, something which the experts on both these Committees—not only the one I have just mentioned but also Sir Harry Platt's committee, which produced a few days ago the Report which noble Lords have quoted—regard as of the first importance. I think that that question must be very much in our minds.

The noble Lord, Lord Crook, also mentioned the question of education. The Minister of Health and his colleague the Minister of Education are fully aware that adequate educational facilities should be given to children in hospital. I imagine that children who are in for a short period, having their tonsils out or being treated for an accident or something like that, would not be fit enough to receive instruction and in any case would not be there long enough for any such arrangements to be made. I have not seen, in any of the various Reports, what sort of period expert authority considers children should be in hospital for it to be necessary for them to receive instruction, but, speaking entirely for myself, I presume that it would be something in the nature of at least one school term.

LORD COHEN OF BIRKENHEAD

Perhaps I might quote the Report which, with regard to education, says this: Those in adult wards are specially liable to be overlooked, but even for a short stay a break in education may be positively harmful, and whenever a child is admitted hospital authorities should consider whether he is likely to stay long enough and be fit enough to receive education. So it may be for a comparatively short period, even for weeks.

TILE EARL OF ONSLOW

I am grateful to the noble Lord; that gives us an idea of the educational point of view. In long-stay hospitals, where children are grouped together in large numbers, I understand that it is a much simpler problem to provide the educational facilities than it is in short-stay units. However, I understand that in all cases this matter is being looked into, and that arrangements are being made with the local education authorities so that the statutory obligations of the two Ministers concerned are adequately carried out.

There is one other point the noble Lord, Lord Crook, raised, which was the question of the teaching and training of children's nurses. I understand that at present there are twenty-five training schools recognised for the Sick Children's Nurses Register in which some 2,000 to 2,500 students are being trained. There are nearly 10,000 names on the Register, and the number of trained nurses employed in children's acute hospitals is only about 1,000, which includes general trained nurses. I also understand that every nurse training for the General Register must have at least three months' experience in children's wards. It is unlikely that the disappearance of one training school would affect the numbers that are trained annually for children's nursing. My Lords, I hope that I have answered most of the questions the noble Lord and others have asked, and that he will consider that I have done it reasonably accurately. I certainly have wished to give him all the information I possibly could.

5.32 p.m.

LORD CROOK

My Lords, with your Lordships' permission I should like to thank noble Lords who have taken part in this debate, and the noble Earl who has just replied for the Government. He rightly said that he and I have cause to be nervous when the only other four speeches were those of eminent medical men, to whose views we shall pay due regard. May I say to those four noble Lords how much I appreciate their intervention—and I say that whether they have accepted the views I have advanced or whether they have not. I am also grateful to my noble friends Lord Amulree and Lord Uvedale of North End, who I knew were going to express views on the lines I was venturing to place before your Lordships. I am equally grateful that such distinguised people as my noble friend Lord Cohen of Birkenhead and my noble colleague Lord Taylor offered their observations. If I may say so, I find in their contributions—which at some points were critical from their point of view—a great deal of comfort for the point of view I have put forward.

My noble friend Lord Cohen of Birkenhead was good enough to say something, as part of his general belief, which I find so impeccable that I could accept it wholeheartedly; and I could apply it completely to the case of Queen Mary's to which I have referred to-day. He referred to the need to see that the children displaced should not lose any necessary services, and that these things must be judged strictly and objectively. I would say to my noble friend that I regard that as complete support for what I have said this afternoon, because if the Minister will strictly and objectively make certain that the children proposed to be displaced from Queen Mary's are sent to places where they will not lose the necessary services, I shall not mind seeing them go; nor will others. But there is no hope that any of us can see that that could possibly be the circumstance at all. So much of what is talked about in so many of these Reports, while it is something we should all love to see, is away in the distance—as far as the first building of a hospital is to-day from where it was when we first talked about it when we had the Health Service debate in this House.

So far as the noble Earl, Lord Onslow, is concerned, I would say to him that I see no objection to placing these children in these large, well-organised blocks in other hospitals. I should not object to it on principle, and I should not object to it in fact. I should like to see it in sonic ways, because it would mean that somebody was bothering to build the blocks in these hospitals and was getting on wish the job that has been put off too long. But the blocks to which these children can be transferred do not exist, and have no hope of existing in present circumstances: they exist only as things that people like to see in Reports. And that will remain so until positive attempts are made to create the kind of service which the noble Lords, Lord Moran, and Lord Cohen of Birkenhead, pictured to us in the debate on the Princess Louise Hospital.

May I say a little about the Platt Report? I was glad to see it published on Tuesday, and to note that my noble friend had had it presented to him last October. He was able to give effective consideration to it and report to the Minister, and the Minister was able to do a thing unprecedented, so far as I know, in Government Department administration. When the Report came out on Tuesday morning I envisaged myself next October or November putting down a Motion to ask Her Majesty's Government whether they had yet had time to consider the Report of the Platt Committee. I visualised the noble Earl who has replied to-day getting up, with his accustomed good grace, and apologising to me that Her Majesty's Government had had the Report for only six months, and that I was completely and unconscionably wrong in daring to ask for considerations to be advanced at that early date because there would be so many more stones to turn over and avenues to run down. That has been my experience in this House two years after a Report has been made.

Therefore, I was amazed to see, the afternoon after publication, that there was already a circulation from the Ministry of Health to rush the Report out to the hospitals, so that they should receive it yesterday morning. Since there is one thing in my reply on which I can congratulate the Ministry of Health, and since it is so rare an event, may I say to the noble Earl how glad we are that at least this Report was given such quick consideration which enabled people to study it when it was not history, but news. It was considered at Queen Mary's yesterday, and, with one or two minor exceptions, every single one of the things recommended has been practised there for a long period of time. There are things in the Report which, had we the opportunity of debating it, I am quite sure I should find people like my noble friend Lord Cohen of Birkenhead, the noble Lord. Lord Moran, and perhaps my noble friend Lord Taylor saying they could not accept.

My noble friend Lord Taylor mentioned the unit of eight to ten children which, according to the Report, could provide welfare. He said that I might well comment that this was not an adequate service. We have only to look at the terms of reference of the Platt Committee to see why there is a difference in figures between those of my noble friend and those of the Royal College of Physicians Pediatric Unit. The Platt Committee were not asked to talk about the organisation of hospitals, but about the organisation of welfare—what to do inside a hospital—and I accept it as completely accurate that they could do these things for nine or ten patients. They were not asked to look at the organisation and administration of Regional Boards of hospitals dealing with a figure of 40 or perhaps 200 patients—the kind of figures talked about when we talked on the Princess Louise Hospital.

The noble Earl replying for the Government just now was given a very nice set of phrases to talk about education—those famous stones "and" "avenues" kind of phrases, to which, whatever Party is in power, noble Lords and Members of another place have become accustomed for so long. Of course, Ministers are doing all they can to see that changes referred to in circulars written some years ago are going to be carried out, whether in education or anything else. The plain truth, however, is that it is the facts that matter. It is not a question of dealing with short-stay patients. It is a question of ability to deal with the matters—whether you have the space; whether you have the facilities. That brings us back again to the building of the block; and until this has been provided, it is not much use doing away with the kind of thing that already exists.

I know that I shall be unpopular, and I know that I must be most careful not to occupy your Lordships' time for too long. I am grateful to the Government that I was given precedence to-day over the Government Business. However, I do want to say this about visiting. First of all, I wonder if the noble Lord who replied for Her Majesty's Government has quite seen some of the relevance of his own case on visiting. If there is a difficulty about visiting at Carshalton in these cases to-day, what will be the position when 600 children who are to spend the rest of their lives in hospital are transferred from Tooting, some miles further out, and 600 sets of parents and friends, already faced with travel difficulties in a central hospital, have five further miles added? I should not like to suggest that the Minister would need to stand first upon one leg and then another.

THE EARL OF ONSLOW

If I may intervene, I think the noble Lord has got it a little bit wrong. What I was trying to put to him was the general principle: that where you could have suitable children's blocks or children's units well spaced about the area, that would be a very good thing from the point of view of visiting, because they would be well and frequently spaced apart so that parents would not have to go far. In general, I was talking about the point in that way.

LORD CROOK

My Lords, I accept the noble Earl's intervention very readily, because I understood that was what he said. I am merely saying that if the people who now visit have another five miles added, all the difficulties of visiting to which the noble Earl referred must be increased.

May I, finally, say something about visiting at Carshalton, because if the Minister has been good enough to put off his determination and is to look at all the facts, I should like to be sure, even at the risk of boring your Lordships for two more minutes, he has all those facts, and that not one is left out. The patients in the hospital come from various parts of the country. They do so because doctors and parents voluntarily send them. There is freedom of choice, and it is wholly because of that freedom of choice that, out of the 350 beds allocated to children in 34 hospitals in the locality, the maximum user at any one time is 60 per cent.

If I deliberately look factually at those who visit Queen Mary's, I would, for any purpose of argument, so as not to make it unfair, eliminate any question of visitation in respect of long-stay cases, because I think there is a complete difference between the two. At the date of the suggested closure, there were 310 acute cases in Queen Mary's. Five came from more than fifty miles away; 53 came from between ten and fifty miles. Of the remaining number, 56 came from the contiguous area to the hospital, and 196 from inside a ten-mile radius. An analysis was made in order to show what the difference in visitation was and there was no appreciable difference. From the contiguous area 80 per cent. of the children, were visited three times or more a week; in the ten-mile area, the proportion was 76 per cent. In the contiguous area, 34 per cent. were visited four times or more a week and for those further away the proportion was 28 per cent. Coming down to daily visiting, 7 per cent. of those admitted from the contiguous area, were visited daily, and 5 per cent. from the ten-mile area.

I should also add, on this point about visiting, that we must not go from one extreme to the other. It is no good our pretending to swing from the point where we try to stop visiting in hospitals to the point where we expect visits every day; because the truth is that parents have other things to do than visit sick children. Many a woman finds the strain of visiting her sick child very difficult if she has two or three others to look after; there is the difficulty of getting baby-sitters and getting meals for the husband. We must not run away with the equally wrong consideration that we expect parents are going to visit every day.

I must apologise for detaining your Lordships so long. I do not apologise for making this a general Motion. I did it deliberately, for this reason. I believe in the proper allocation of Business, as Mem- bers on these Benches, in particular, do. I did not think it right to put down a Motion on Queen Mary's, Carshalton, on its own, something which I know about and would talk about. I had no intention of moving a Motion to go to a Division, and I wanted to put in the Motion something which would do what it has done—that is, encourage noble Lords of great knowledge and great ability on these matters to say something on it, as well as to give me the opportunity of saying to the Minister, "Hold your hand on this matter". That I have done, and with the permission of the House, I now ask leave to withdraw the Motion.

Motion, by leave, withdrawn.