HL Deb 26 April 1961 vol 230 cc882-960

4.25 p.m.

Debate resumed.


My Lords, should like to follow on what the noble Lord. Lord Stonham, said when he made a strong plea that we should make the best possible use we can of the hospital beds we have in the country. I want to take up the point he made, but from rather a different point of view—indeed, from a point of view on which he touched. but into which he did not go in any detail. I am going to refer to the effect of the present system upon a number of elderly people in hospitals at the present (time. One of the troubles one frequently finds is that when an elderly patient has been successfully treated in hospital, the moment comes when he or she has to depart. That is perfectly satisfactory if they have a good home to I go to and a family or friends to look after them. But it often happen that these people live by themselves, and it is not proper or suitable for them to go back to live a solitary life, quite frequently, if one is dealing with London, on the top floor of a tenement building, where they have no particular comforts at all.

Therefore, when that situation occurs, one would have thought that by now more use would have been made by local authorities of the powers statutorily given them by Section 21 of the National Assistance Act, which states quite categorically: It shall be the duty of every local authority to provide residential accommodation for persons who by reason of age, infirmity or any other circumstances are in need of care and attention which is not otherwise available to them. Should not the local authorities now be encouraged, or even more than encouraged, to fulfil their obligations under the National Assistance Act, which was passed some 13 years ago, in 1948? I do not say for one moment that a certain amount of good work has not been done by many local authorities. Indeed, it is true that they have done quite a lot, and one has been asked on more than one occasion whether one does not realise that so many more beds are now provided and so many more new homes are open. But that does not impress me at all, because, while I am glad to hear that something has been done, nowhere near enough has been done. There is no point in telling me that 10 per cent. of the need is filled when I want to get 90 per cent., or even 100 per cent., filled.

Here I can give an example from my own experience. In the hospital where I work in the northern part of London I have 120 beds which are entirely filled by people of 65 or over. At the present time, in those beds I have 16 or 17 people who have been accepted by the local authority for admission to accommodation under Part III of the National Assistance Act, but they have no idea when that accommodation will be available. Generally, from my experience in the past, it has been some four to six months before they get admitted to this accommodation. Surely, that is a most unsatisfactory state of affairs. In the first place, these unfortunate people are occupying a bed in a hospital which is staffed by fully-trained medical, nursing and other staff; and secondly—although possibly one should not make too much of this point—it is an extremely costly way of maintaining these people, because, purely by chance, the beds where I work are in one of the teaching hospitals, and the cost of maintaining a patient in a teaching hospital is about £35 a week. It seems to me foolish, wrong and uneconomic to maintain 16 or 17 perfectly fit old people in hospital beds for four to six months, quite unnecessarily, at a cost of £35 a week each. It appears to make no sense whatever, when one is told about the cost of the Service and about everything going up.

I was down in the country about a fortnight ago, and I discussed the problem with one of my colleagues there just to make sure that it was not purely my own experience which was colouring my views. He told me that from about the same number of beds he had in a rural part of South Wales, he reckoned there were 40 people or more who should be the responsibility of the local authority, and not the responsibility of the National Health Service. That is one example from town, and one from the country. They both show an extremely unsatisfactory state of affairs, particularly when combined with the fact that there is enormous difficulty in arranging for the admission of elderly sick persons to hospital. A large number of them cannot get in because the beds which they would normally occupy are filled by people who frankly do not need to be there; they are people who need some kind of care, but not the care of a fully equipped hospital. In that way there seems to me to be a great lack of co-operation between the local authorities and the National Health Service in general.

It makes me rather sad or pleased—I do not know which to feel—to remember that when the National Assistance Bill was being debated in your Lordships' House on April 6, 1948, I brought this point forward. The noble Lord replying for the Government said [OFFICIAL REPORT, Vol. 154, col. 1151]: I am glad to tell the noble Lord that the Government are acutely aware of the importance of this. Obviously, it is necessary that there should be this closely worked out liaison, and that every effort should be made to get the old folk out of the hospitals where, as he said, they tend to stay and retain beds which are needed for other people. It is also essential to encourage traffic the other way. That was said by the Government in 1948, and it is now possible for me, in 1961, to make complaints of the same sort of thing occurring, on practically the same scale, as when the National Health Service first came into force.

There is still, therefore, that extraordinary lack of co-ordination between the health services and the welfare services because, coming back to what the noble Lord, the Government spokesman, said in 1948, that there should be traffic the other way, one now finds in some local authority accommodation quite a number of sick people. Indeed, there is one big institution of which I know in London which has two fully-staffed sick wards, one far men and one for women. I do not mean that they are merely for the people with a trivial illness or who are possibly going to die. Those one would not necessarily want to move to hospital. These are people with a good deal of disability, who should be in hospital.

Where are we going? We are back in the old days of the Poor Law, when we had first-class medicine in the general hospitals and second-class medicine in institutions or workhouses—they are now called by some other, rather grander, name. The wheel is going full circle once more, and I think that is a deplorable thing. One county council near London made a survey of their welfare homes and found that about one-third of the people in those homes should go into hospital, if not for treatment, certainly because they had something which could be improved—some condition which should be investigated. So it seems as if there is something wrong with the whole of the hospital service if we on the hospital side have to keep people in hospital who do not need to be there, whereas the welfare authority cannot get the people into hospital who should go there.

The same thing applies to the mental hospitals, where it is extremely difficult to get people suffering from senile conditions, whose state has become such that they are not fit to be nursed in an ordinary general ward where their habits have become so anti-social that it is impossible to nurse them among people who are more or less reasonable. I do not want to transfer the normal senile person to a mental hospital, but at times it is very difficult not to do so. I cannot give the figures, but it is somewhere between four to six months before such a transfer can be made. It shows that there is something wrong somewhere, because I am sure one will find in some of these mental hospitals people who could be nursed just as well in an old peoples' home and, in the same way, people in an old peoples' home who probably should be in a mental hospital. I do not want to pursue this matter, because I think the noble Lord, Lord Archibald, has had experience of this point and is going to talk about it. But I do agree with him on this. I have found it out for myself, and it is very distressing.

The same thing applies from the housing point of view. As I said just now, there are a number of people who could be discharged, but, by chance, they live on the top floor of a tenement, which makes it very difficult to discharge them. If they could be rehoused in some reasonable accommodation, it should be possible for them to go back and be taken care of by those services to which reference was made in the course of the debate last week. I have found that an almost impossible thing to do. In the last twelve or thirteen years I have been successful in getting one or two people rehoused, but no more than that. That, again, seems entirely wrong, because it means either that people have to be kept in hospital for far longer than they need to be, or that they have to go to some communal home or institution. Quite often they do not want to go there, but they cannot go back to their top-floor tenement because it is not really suitable for them at all.

Some authorities in the country seem to be doing a great deal of good work in this way. There are two types of housing which I have seen recently. One is a group of dwellings in Dorset, at Sturminster Newton, and one in Somerset, at. Wincanton, which are based on the almshouse principle, where people live in accommodation by themselves, but there is somebody in charge who can be summoned by a bell if anything goes wrong. I think you want to make your housing provision for old people—this is not the moment to talk about it in a debate of this sort, but I think it does apply—extremely flexible, where those who are able can live entirely independently and alone, and where they will be able to escape from the clutches of the National Health Service where they do not need to be. Because of these troubles and difficulties, one gets an enormous demand for more hospital beds. I agree that there is a need for more beds of some sort, but whether it is a need for more hospital beds is a point I have raised in your Lordships' House before. I do not doubt that there is a need for a general increase, but not necessarily a hospital increase.

Before I sit down, I should like to associate myself with what the noble Lord, Lord Stonham, said about the terms of service of the medical professions supplementary to medicine. For five years I was President of the Association of Occupational Therapists, and we had a number of discussions with officials of the Ministry and with the Minister himself as to whether the Whitley machinery retainer was the correct thing for these professions. We finally agreed that it was not the right thing, and I should like to associate myself warmly with every word the noble Lord, Lord Stonham, said on that point.

4.40 p.m.


My Lords, I think it is highly desirable that we should have a debate of this nature in which we can question and examine every aspect of the hospital administration, but I am quite sure your Lordships would agree that we must not fail to pay tribute to the very fine men and women who staff our hospitals, and indeed to the whole concept of the National Health Service, which commands the admiration of the world.

I observed this week-end that the Minister of Health deplored the loss of our Empire and waxed lyrical on the English oak which still stood. In my opinion the fact that we have given independence to our Colonies does not diminish our stature in the eyes of the modern world; on the contrary, it is, I believe, an indication of our maturity and our disciplined approach to social trends. Britain surely can continue to command world respect provided we apply ourselves to those things for which we have a special aptitude, and in this I include the organisation of our social services. The Minister of Health can make a great contribution to the Department to which he has been called, and I hope that when he reads this he will forgive my advice. I would advise him to eschew the actuarial approach and cultivate a more sympathetic and understanding attitude. So far I believe the measures which he has introduced have been absolutely disastrous, and when I learn that the executive committees of the National Health Service throughout the country are asking to take a deputation to him, I realise that the repercussions of these ill-considered actions are now being felt. It is a tragedy that there have been seven Ministers of Health in the last nine years and consequently there has been no continuity of ministerial responsibility.

Now I propose to bring to the notice of your Lordships two of the most recent reports upon which immediate action should and could be taken. The first is called Human Relations in Obstetrics, a report published last week by the Central Health Services Council of the Ministry of Health. It is concerned with the growing volume of complaints about the manner in which mothers are treated in childbirth, both at home and in hospital, and I think that it is more than a coincidence that in the current publication of the Lancet there is an article on the maternity services which emphasises the need to examine similar complaints. The Lancet says: Though much safer than formerly, our maternity services have ceased to be our pride and joy. Of course this is not a new criticism. Your Lordships will recall the criticism in the Cranbrook Report. That Report noted the general complaint that there was in many hospitals too little regard for the personal dignity and emotional condition of women during pregnancy and childbirth. They said that women were sometimes left too long alone in labour, and that the staff were said to be sometimes too busy to bother about analgesia.

May I take as the first point, analgesia. It does happen—and I can assure you, as it is out of date, that I am not trying to increase the circulation—that the first small book I wrote in the early 'thirties was called Babies Without Tears. In that I pleaded the case for women to be given analgesia at childbirth. It was then over a hundred years since Simpson gave analgesia, and still the poor women of the country were denied relief at childbirth. Since then, I am glad to say, there has been a tremendous improvement; but in order to be assured that every woman throughout the country is given relief I have asked the Ministry of Health on other occasions to require, when the report on maternity cases comes from the periphery to the centre, that there shall be included in the report the form of analgesia which the woman has been given. Unfortunately I have never been given an assurance that that information would be included.

Nobody can assess how much suffering could be avoided if the hospital staff were more conscious of their professional obligations to relieve the mother's pain. I feel that the mistake women make is not to scream loudly enough. They are often intimidated, and their amazing courage and patience is exploited; and unfortunately many young mothers today read books that convince them that if they breathe in some particular way they will find childbirth painless. They learn their mistake too late. It is significant that most of the authors of these books advocating childbirth without analgesia are men.


My Lords, may I interrupt my noble friend? Was it not a gentleman who invented the obstetric forceps and introduced chloroform? I think we have done our bit.


My Lords, I will not deny to my noble friend that there are exceptional men, but the important point is that we have never lost a man in childbirth yet. I would therefore ask the noble Lord not to treat it as lightly as my noble friend has; I am a little disappointed that he should make the point at this moment, treating it a little lightly. This is a serious matter. As we sit here this afternoon every minute a baby is born in this country. We are talking about the condition of women whose views can never be heard in great numbers in either the other place or in this. Perhaps it is because their voice has never been heard that there is an inclination to disregard recommendations of this kind. I hope the noble Lord, when he comes to reply, will recognise that the report published last week from his own Department was published by people who considered this matter very carefully, and I should like to hear what he has to say about including in the reports of maternity cases a description of the form of analgesia which was used.

The other complaint is that the women are left alone too long, with the frightening effect of hearing other mothers in the second stage of labour, especially if the patient herself is in the early stage. According to British obstetric practice the first stage of labour in primigravidae averages about sixteen hours. Why should not a friend, the mother or the husband, be with the woman during some of this time? When the woman has her baby at home, the relations, the husband, the friend, would regard it as absolutely inhuman to leave her in a room alone without opening the door occasionally to say, "How are you getting on?" Why should we not, therefore, adopt the same human approach to the woman who has her baby in hospital? This is not some curious subjective view of my own. In this debate I am quoting a report which was made by the noble Lord's Ministry last week asking that a different attitude should be adopted.

I would remind your Lordships that during the last few years—it has taken time—visitors have been allowed in hospitals every day to see their friends, and at long last the Platt recommendation that a child should be visited at any time is being put into effect. It has taken a long time. Tradition and custom take time to overcome. But why should we not change our outmoded custom which bears harshly on a woman, at a time when she is in most need of comfort from a friend or relation? I assure your Lordships and the Minister of Health that it will not cost one penny to the Exchequer, but it will go a long way towards lessening the apprehension of the patient.


My Lords, before my noble friend leaves this point, would she agree—I hope she will—that the worst offenders in this respect are, I am sorry to say, the midwives and the nursing staff in these wards, the enormous majority of whom are spinster ladies. They treat the patient in a sort of slaphappy way. I am afraid that is where the trouble lies.


My Lords, perhaps the noble Lord will be a little patient. I am coming to that point. Really, he must not criticise people for being unsympathetic on the ground that they have not had babies. Has he had one? I would suggest that my noble friend keeps quiet a little, because he is getting out of his depth this afternoon.

The Report goes on to say: The commonest cause of dissatisfaction during the ante-natal period seems to be long waiting times, often hours, spent in poor, overcrowded premises, followed by a rapid examination with no real privacy. I would ask the noble Lord, why is the appointment system not operating? He will recall that it is many years ago since the Ministry decided that an appointment system should be established. Surely, it is of paramount importance that the appointment system should be established in every ante-natal department throughout the country.

While the patient's needs, in my opinion, must have first consideration—and I would put them first in my cornments—there is one obvious reason why human relations are not always satisfactory, and that is shortage of staff. I do not need to deal with the point that my noble friend raised just now; the Report deals with it. It says: Overwork and under-staffing will often, of course, make this situation much worse. Some midwives may have their own psychological difficulties to contend with. Over-sensitive women continually working in the labour ward may develop a brusque. insensitive manner to hide their own feelings. The fact is that there is a serious shortage of midwives; yet these women, as the Report describes, because of the very nature of their work should be given ample rest and recreation.

According to the Ministry of Health Circular 59/80, the chief objection to the practice of midwifery in hospitals seems to be the high pressure of work. I would remind my noble friend who has interrupted that the Royal College of Midwives urged long ago that auxiliary staff should be employed to relieve midwives and pupil midwives of duties which can equally well be performed by less skilled people. There is a great deal of evidence that midwives are still being used for domestic work. This week the Lancet says: In one hospital the duties of pupil mid-wives include oiling the ward trolleys; in another a staff midwife spends a morning each week cleaning cupboards and bowls…In many ante-natal clinics midwives do clerical work, even where other help is to be had. Does this mean that all midwives in the country are unemployed; that all midwives who are still efficient and are still comparatively young, have no time to help? On the contrary, of the 70,000 women on the Midwives Roll, about 20,000 have ceased to practice, usually for domestic reasons. Many of these might be prepared to return if acceptable working conditions and hours of duty could be arranged. We give nurses and midwives verbal praise. Every individual, when he or she is a patient, has time to think about the nurse who is ministering to them. Indeed, we give them a plethora of praise. If praise were currency, nurses would be the wealthiest workers in the country. But how, in practice, do we reward these magnificent women who are serving the community in this way?

The figures I give your Lordships to-day I obtained this morning from the best source available, and I assure your Lordships that they are authentic. This is the reward which the country—indeed, an affluent society—gives to these important workers. The student midwife in hospital gets £305 for the first year, with deductions of £128 for board. Of course, she is a girl who is not a qualified nurse. But a qualified nurse who has already obtained her S.R.N.—a very fine woman indeed, because she is prepared to take a midwifery course—is offered £441 as a pupil-midwife, with deductions. This is the utterly stupid and short-sighted aspect: if this woman, who is prepared to stay on and become a midwife, stays as a staff nurse, she will be given £525 a year. In fact, this dedicated woman who offers to become a midwife will lose £84 a year for offering to give her time and her energies to enter a profession which is physically exhausting and demands a great deal of concentration. In other words, there is no inducement to go into midwifery—the very reverse: she loses if she does.

What about her time? The Ministry has recommended an 88-hour fortnight, which is rarely realised. Indeed, I was told this morning that that was quite theoretical and that it must not be accepted as being a realistic description of what happens in a midwifery ward. If a woman who has already proved herself so able in her profession that she is made a ward sister, later on decides to take up midwifery, she has to start at £441 a year. In fact, she has to lose many hundreds of pounds. There is one exception: some of these ward sisters can be chosen and they are seconded. Then they can start their midwifery training at the rate of pay they were receiving when they were sisters. I know that in the days of Florence Nightingale people said, "Ah!, these women are satisfied with 5s. a week because they are dedicated; they have a vocation ". But, in these modern days, are we right to exploit the services of these women? I have told your Lordships precisely what is the picture. Then why do people deplore the fact that midwives are not coming forward?

Now I come to the district midwife and her conditions. She has no fixed hours at all. Day and night—because for some curious reason babies have a habit of coming at night—and at weekends she is on call. Her salary starts at £656 a year. In this space age I would ask your Lordships, when you drive through London, to keep your eyes open. Every now and then you will see a figure in a navy-blue uniform on a bicycle, weaving in and out of traffic with her equipment strapped on to the back of her bicycle. I refer to our midwives who serve us so unselfishly and so nobly. These women, riding bicycles in London, are expected to arrive at their job spotlessly clean, competent, unruffled, and capable of dealing with a family crisis as well as with a confinement; and when we come to examine their wages and conditions we find that they are geared to the Victorian era. I forget which noble Lord said it, but I believe it was the noble Earl, Lord Feversham, who spoke of the low pay of our nurses and said that we must ask the Whitley Council to look into that. I am not suggesting, as some other noble Lords did, that the Ministry used the Whitley Council to stop any improvement in wages and conditions.

I am absolutely certain that what is necessary, and what we must have, is an independent Committee, just as we had when the doctors said they must have an independent Committee. I am glad that my noble friend Lord Taylor, himself a very eminent doctor, agrees with me. The doctors said that, and Mr. Justice Danckwerts was asked to be in the chair. He was able to look at the subject absolutely objectively. He did not have at the back of his mind what other categories in hospitals had, and therefore to gear the amount he recommended to something else. These women, too, need an independent Committee in order that there shall be a complete evaluation of nurses' work. And unless that is done our whole midwifery service will be in jeopardy.

Now I come to the Report (again a very recent one) on the Hospital Inpatient Inquiry for the two years 1956–57. I would remind those noble Lords who have read the Ministry of Health Report that in the last Report, that issued in July, 1960, it was stated that at the end of 1959 the hospital waiting lists had risen to 476,000–33,000 more than in the year before. I know that many questions have been put to elicit the cause of these long waiting lists, but the answers certainly have not allayed the anxieties. This Report, published a week or two ago, makes some revelations which constitute a serious reflection on the organisation of some parts of the National Health Service. I would ask your Lordships to get the Report and read it for yourselves.

Under the heading "Malignant Neoplasms" (that is, new growths), the Report says: Malignant neoplasms are conditions for which there would be general agreement that treatment should be undertaken with all possible speed. It appears that in 1957 approximately 1,100 persons in England and Wales admitted to hospital with cancer waited more than six months for admission; and of course this waiting may sometimes be indirectly responsible for the death of the patient. The Report asks hospitals to keep a very close check on their waiting lists to ensure that no case of cancer is kept waiting for admission any longer than is absolutely necessary. It is possible, of course, that some of these cases which were not admitted earlier were diagnosed as having cancer only after admission. Therefore, whenever any reasonable doubt exists as to the possible diagnosis of cancer, the patient concerned must be admitted as soon as possible. This recommendation on cancer, which was made two or three weeks ago, surely "brooks no delay", and I would ask the noble Lord to tell me what instructions the Minister has given. Even a week's delay in cancer may decide whether or not the operation is successful. Here we have a Report which is so shocking that I find it difficult to believe that a statement was not made in another place on this Report alone.

I come now to another part of the Report, that dealing with "Gynæcological Cases". I remember in another place asking Questions about these waiting lists, and the Minister of the day attempted to reassure me by telling me that most of the people waiting were suffering from some chronic complaint; and that therefore I must not worry too much—that a few weeks did not matter. From this Report we find that out of 184,000 non-malignant gynæcological cases nearly 14,000 had to wait more than six months for admission to hospitals. As the Report quite rightly says: This represents a large amount of human suffering and provides a formidable challenge to the hospital service. That is certainly not an under-statement. And I would say this to your Lordships: of the 14,000 patients waiting six months, 6,700 were suffering from prolapse or malposition of the uterus. These are, in the main, working-class mothers, not eligible for health benefit. They are far from this place, where their voices can never be heard; but they are compelled to do cooking, scrubbing, washing and shopping—indeed, manual labour calculated to aggravate their condition while waiting for an operation. This is the correct picture, as those who wrote this Report knew when they said: This represents a large amount of human suffering. I have endeavoured to bring to your Lordships the real picture of that human suffering, how it is represented in the hundreds of thousands of poor homes throughout the country. I hope that we shall not be told at the end of this debate that this grave situation can be rectified only by the expenditure of a large sum of money on more beds. We have just heard from the noble Lord, Lord Amulree, from his own experience as a doctor, how beds which could be occupied by these people suffering from cancer and gynecological conditions are being occupied by old people who have not had other provision made for them. I would remind the noble Lord that during the winter of 1958–59 hospital physicians assessed the medical need for admission of all the patients in Birmingham hospitals, and they found that 11.8 per cent. of the chronic cases could have been cared for at home.

Again I must emphasise—and it cannot be repeated too often—that capital expenditure does not necessarily determine the quality of the work in any hospital. The service should be measured by the degree of integration between the three parts of the National Health Service—namely, the hospital, the general medical services and the services administered by the local health authorities. If this co-ordination is secured and the emphasis placed on preventive work and the domiciliary service, then the pressure on the hospital will ease.

While this is the policy which should be pursued if the tragic lists of waiting patients are to be reduced, there is little evidence that the Minister is seized of the urgency of the matter; and I want to finish as I began. I realise that the Minister has come into a great new Department, into a world which is a little alien to that which he has known at the Treasury. But I would tell him that there is so much to do in all the fields which have been debated to-day—so much which he himself can do. He is sitting there in the centre. These people who are concerned with administration on the periphery will take great notice if he will personally say a word about these conditions. But unless he does, certain conditions, lack of analgesia at childbirth, long waiting lists while there are plently of beds empty in other places—these things will continue. He has the power, and I only hope that this debate will help him to use it.

5.11 p.m.


My Lords, I am extremely glad that the noble Lord, Lord Stonham, has brought this subject to our attention this afternoon, because it is one that affects the lives of all of us at one time or another. I am very glad to be able to start by paying my tribute to what the Minister has done in regard to the plans which he has outlined in Circular H.M. 61/4. I have the privilege of serving on a Regional Hospital Board myself, and we feel very keenly that, because of this there is new hope altogether. I believe that this will provide, and before very long, new hospitals for old, modernisation of old hospitals, and also new departments. At the same time, my Lords, we must never make the mistake of thinking of the hospital service in terms simply of bricks and mortar, as has, of course, already been mentioned to-day. The hospitals will be able to do their work only if they are adequate both in quantity and in quality.

If we are to have the staff that is adequate in quantity as well as quality we must attract to the work people who have a sense of vocation, and I should like to associate myself with the tributes which have been paid to our staff to-clay. But in arousing this sense of vocation I want to mention one subject which I think has been a very serious casualty as a result of the nationalisation of our hospital service—I refer to Hospital Sunday. In the past, Hospital Sunday was a very great event in the life of the voluntary hospital, and very often the doctors would go out and preach about it in the local churches. The emphasis was, I think, laid primarily on the giving of collections to the hospitals; and, of course, when the appointed day for the National Health Service Act came the need for that disappeared. But what has been lost as a result of the passing of Hospital Sunday to such a large extent is the possibility of preaching about vocation to the work, and in that way arousing a sense of service.

Many of us are very anxious to try to re-create Hospital Sunday to the best of our ability; but what we need is money. It needs quite a bit of money to organise it properly. In the past that was supplied by the Voluntary Hospital Fund, which is now defunct. I would therefore ask whether the Ministry could ask Regional Boards to allocate what to them would be only a very small sum of money to help the churches to organise Hospital Sunday in a proper manner. I would draw attention to what is being done now by the Birmingham Regional Hospital Board and to the plans we are making for 1962. We are trying to have a Hospital Week when the hospitals will be "at home" to the people of the district. What we are aiming at is increasing a sense of local pride in the hospitals. We are hoping that this will stimulate the work of the League of Hospital Friends. We are hoping, too, that this will lead to a sense of vocation in young girls and people like that who come in and see the hospitals and may perhaps be led to work in them. But the point is this: that Hospital Week is going to be initiated by Hospital Sunday.

Mention of Hospital Sunday leads me just to refer to the work of the chaplains. I should like to say how thankful I am that provision is made for them by the hospital service in this country. We have them, and we have salaries for them. But we must not think of these hospital chaplains primarily as being full-time. There are just over 100 full-time hospital chaplains in this country. There are thousands of part-time chaplains, and they are normally, if they are members of the Church of England, vicars of the local parish; or they are Nonconformist ministers or Roman Catholic priests. The point that some of us feel strongly is this: some of these men are being asked to try to do too much. I am afraid that we have a shortage of clergy. We have not all the curates we need in the parishes, and we sometimes find that a vicar is coping single-handed with a parish and with the chaplaincy of a large hospital.

I should like to draw your Lordships' attention to the fact that under the present regulations a hospital, unless it be a teaching hospital, which I am thankful to say is treated separately, cannot have a full-time chaplain unless there are 750 beds occupied by people of the denomination of the chaplain concerned. That means that we shall rarely see a full-time chaplain in a hospital which has under 1,000 beds. As I say I would suggest that sometimes this means asking too much of the chaplain. I hope that consideration will be given to this matter—and I may add that the churches, for their part, are anxiously considering it at the present time. I would just make the point that a chaplain should not be regarded only as somebody who comes in to give spiritual ministrations to people who ask for them. In our view, the chaplain should be regarded as a definite member of the healing team of the hospital; and in these days, when it is increasingly realised how close is the inter-action between spirit and mind and body, surely that is a very desirable feature.

But if there should be co-operation in that way, my Lords, I also suggest that we should have the closest possible co-operation between all members of hospital staff. I believe that greater co-operation is needed between the various branches of the Health Service. For administrative purposes the Health Service is divided into the three branches: the hospitals, the executive councils, and the local health authorities; and, obviously, patients can be handed from one branch to another. The more these three branches coordinate the better it will be for the patient.

From the economic point of view, one of the main duties of the hospitals and of the Health Service is to get the patient back to work just as quickly as possible. I believe that at present valuable time is being lost here. I think that sometimes there is a time-lag before the general practitioner takes over the patient again on his return from hospital. I suggest, therefore, that to correct this we should do all we can to bring the general practitioners more and more into the hospitals. I hope we shall find that increasingly they become full members of the staffs of the hospitals. I would also suggest here that the term "medical assistant", which has, I think, been used in this connection, is not good enough. But if what I suggest is done, then, through the general practitioner, the hospital service can be extended into the homes of the people.

This principle might well apply to the nurses. The nurses who have been tending the patients in the hospitals might well be able to follow the patients into their homes. And, likewise, the local authority nurses could come into the hospitals and take their share of the work there. But, obviously, all this requires staff, and yet more staff. And so, just as the Ministry of Education have been appealing to former teachers to come back and help, I have no doubt that the Ministry of Health will be appealing to former nurses to come back and help. I am one who thinks that we have to do this in moderation. I think that the first duty of a married woman is to her husband and children. At the same time, there are many who can help part-time. I believe that there are a number of trained nurses who have been out of practice for some time and who hesitate about coming back because they think they have become "rusty" and are not used to the new techniques. I would therefore suggest that we should encourage refresher courses for such women as these, and I think it might well encourage them to come back and offer part-time service.

In connection with the remarks which have been made about the way in which the old people are to be found in our hospital beds when, as we know, many of them need not be there, I would suggest that this problem might be alleviated if training courses could be organised for the relatives of the elderly. It is sometimes said that the elderly are left in the hospitals because their families do not bother about them. That may sometimes, I am afraid, be the case; but I think it is also true that there are some elderly people now occupying hospital beds because their families feel that they have not sufficient knowledge to look after them properly. If they were given a training course, of a very simple character, that might well give them encouragement, and lead them to be much more ready to take the old people back and nurse them in their own homes.

Another need which I believe is felt at the present time is that for area key hospitals. We have, of course, the fifteen regions, which are very large and embrace millions of population. The sort of area I have in mind is one of about half a million people. I think it would be very desirable that in each area such as this we should have a central key hospital which would set the tone for all the rest, and to which the others would look for inspiration and guidance; and it would, of course, be foremost in the matter of training. If such a system is built up, I should also like to see an ever-closer link between such an area hospital and the Commonwealth. I believe that one of the chief duties of the Mother Country in her relationship with the Commonwealth is to provide training, and I hope that in our hospitals we shall always make room for members of the Commonwealth countries so that they may come here to be trained as doctors, as nurses and as technicians. That, I repeat, I believe to be one of our chief duties; and the area key hospital might well be foremost in performing that duty.

Finally, my Lords, I would add this reminder: that we must never think of the healing of the sick merely in terms of operations, of the skill and drugs of the physician. The healing of the patient will also depend very much upon the atmosphere of the hospital; and that means that the human relations between the staff and the patients is a vital consideration. The tendency in this modern generation, not only in the hospitals but outside, too, is to rely rather too much on material things: and we must remember that "man does not live by bread alone." I suggest, my Lords, that in our hospitals the spiritual factor will, in the end, matter most of all. I believe that if our hospitals can give a lead in showing that it is the spirit which is all-important, they will do for our nation something that will be a very great service to it.

5.24 p.m.


My Lords, I should first of all like to join in the expressions of gratitude to my noble friend Lord Stonham for having introduced this debate this afternoon. When, a little time ago, my noble friend Lord Taylor was being gently rebuked, and it was being suggested that the was perhaps getting out of his depth, I almost took it as a signal that I should perhaps withdraw my name from the list, because I might be regarded as the one most likely to be out of his depth. I believe that I am the only speaker in this debate who is neither taking an active part in hospital administration in one form or another nor medically qualified. But even the amateur observer may from time to time see things which, in my case, he has a certain duty to draw to the attention of the House on the occasion of a debate like this.

Some time ago I had occasion to go round the wards of one of our big mental hospitals. In passing, I would say that I agree that some wonderful work has been done in the way of upgrading buildings that were old and horrible and seemed almost past any possibility of being made cheerful and attractive. Great work has been done in that. But, going round, I was particularly impressed in the wards for the old people by a slightly different aspect of the prob. fern of old people than that which has been referred to this afternoon. We have had references to those old people who are unnecessarily in hospital because there are not the hostels or other accommodation for them; but what I noticed—and it was confirmed in conversation with the medical staff—was that in a mental hospital ward it was possible to have old people who should not have been in a mental hospital at all but who should have been in a geriatric unit.

These people—old, frail, but clearminded—were in the same ward as those who are so uglily described, I think, as "the senile dements". Some of them, poor souls, were noisy, shouting, confused and, as it has been put, anti-social in their behaviour. I found that a very disturbing combination. Some time later I had occasion to visit regularly, and for quite a period, a purely geriatric ward, away and apart from anything to do with mental hospitals. But, again, in that geriatric ward I found reproduced exactly the conditions that I had seen in the mental hospital ward—in other words, frail, old people needing care and attention, together with those old people whose minds had unfortunately gone and who should have been in a mental hospital.

Now at first glance it looks like a comparatively simple problem of re-classification and transfer, but I have discussed this with a number, at least, of professional people operating in this field, and one caution which was given to me was this: that if, in the big ward, you so organised it that all the patients were the "senile dements", then the strain and burden on the nursing staff would be well-nigh intolerable. It was suggested that possibly another method, other than transfer from and to the respective wards, is the partitioning of the big wards, so that the confused (so to speak) could be at one end; those who are, as is unfortunately the case of some, lucid at one time and a little confused at another could be in a separately partitioned part; and those old and frail only could be in still another part, and that thus there need not be the burden on the old and frail that there is at the present time.

For example, I noticed in the geriatric unit which I visited that it was not only the old people themselves who were disturbed by the shoutings and confusions, but also their visitors. One could watch the visitors becoming more and more embarrassed by the sounds they were hearing, their faces getting stiffer. I believe that sort of experience has a bad tendency in that it discourages visiting; and I think for old, frail people, visiting is very important, and anything that discourages it is much to be regretted. I am not dogmatising this afternoon as to how this problem should be dealt with, but I do say, from my observations, that there is a problem here and that the Regional Boards and the Ministry should certainly take some steps to deal with it.

5.31 p.m.


My Lords, while everyone must welcome the capital programme of hospital construction and reconstruction, its contribution to the hospital service will be illusory unless some means are found to deal effectively with one of the most intractable aspects of that service. I refer to the chronic, and in some departments disastrous, shortage of skilled auxiliary staff. It is, of course, true that where design is good, facilities adequate, and accommodation sufficient, recruitment may be augmented, or at least not positively discouraged; but the extent to which this can be expected to relieve the situation is trifling. The shortage of medical auxiliaries and other non-medical staff extends in varying degrees through all the diverse categories of these vital workers. I cannot stress this forcefully enough. Later I propose to deal with one specific category, but what I shall say applies throughout the whole range of hospital ancillary staff.

The problem of inadequate pay, the consequent failure of recruitment, and the continuous wastage, blights the whole Service. I work in the hospital service and I know this is true. New hospitals may be decreed, designed in conformity with the most modern and enlightened requirements; the various departments may be equipped with all the most desirable scientific apparatus for diagnosis and treatment. But, my Lords, X-ray departments without radiographers, physiotherapy departments without physiotherapists, diet kitchens without dieticians, and pathology laboratories without technicians—to cite but a few from the many—cannot function. There are two inter-related problems: recruitment and wastage. Apart from wastage by marriage in departments where women predominate, such as X-ray departments, the cardinal sanction against recruitment, and stimulus to wastage, is economic. Career prospects in the hospital service fall woefully behind those in industry and, where comparisons are appropriate, those of the scientific Civil Service.

I should like, with your Lordships' permission, to elaborate this thesis in respect of one category of worker—the pathology laboratory technician. I have chosen this category, not because I wish to press any sectional claims but because, as a consulting physician, I am most intimately affected by any laboratory deficiencies, most conscious of their key role in the diagnosis and management of disease, and appreciate their frustrations, having some years ago worked in such a laboratory. I have said that poor recruitment, and particularly wastage, is an expression of economic discontent. That this economic consideration is not so overwhelming as to deprive our laboratories of all technicians, derives from one relieving factor. There are, fortunately, a large number of people who see in the hospital service rewards less tangible, but more satisfying, than can be computed financially. But, my Lords, we cannot, or should not, persist in relying on dedication to staff our hospitals.

The minimum educational requirement for acceptance as a student is the G.C.E., with passes at "O" levels in four subjects, of which one must be a natural science. After three years, during which period he has been paid between £235 and £460 a year, depending on age, the student takes the intermediate examination of the Institute of Medical Laboratory Technology. He takes it in general laboratory techniques. If successful, he is redesignated a junior technician and his pay is increased by £25 a year. Another two years later he takes his Finals in one of the specialist branches of pathology, and qualifies as an Associate of the Institute. His pay is now £595, rising by five annual increments to £720 a year. After a further two years he may become a Fellow of the Institute, either by qualifying in another specialist branch of pathology or by thesis in his own branch. He is now qualified as a senior or a chief technician, and commands a higher salary if he can obtain a post in the appropriate grade. At all levels in the ascent of the professional ladder he may be diverted to industry or to the scientific Civil Service by greater financial reward. But it is in the higher grades that comparison with the scientific Civil Service becomes most blatant. For example, the maximum salary of a chief technician in the 'hospital service is £1,230 a year, and in the corresponding grade in the scientific Civil Service—senior experimental officer—it is £1,800.

My Lords, inadequate pay in the hospital laboratory service at all levels may be held to be largely responsible for poor recruitment. The youth employment service is often reluctant to advise local grammar school boys to enter the service, and headmasters are prone to give the same advice. Similarly, the disparity of pay between the hospital service and the Scientific Civil Service encourages great wastage. Furthermore, it leads to the unedifying spectacle of one branch of the public service competing, and on much more favourable terms, with another for the services of technicians trained and financed by the latter, and essential for the maintenance of their service departments.

This is the kind of thing that is going on. A recent issue of the hospital laboratory technicians' own journal carried an advertisement of a type familiar to harassed directors of hospital clinical laboratories. To save time I will paraphrase it. It invited applications from medical laboratory technicians for a post at the United Kingdom Atomic Energy Establishment at Winfrith, in Dorsetshire. It described the duties as mainly routine hæmatology, and required that the applicant should hold the Final Certificate in Hæmatology of the Institute of Medical Laboratory Technology. The appointment was in the grade of assistant experimental officer. The salary in this grade starts at £640 and rises to £1,055 a year. In the hospital service the maximum salary for one so qualified is £720 a year. Thus, the inducement to transfer from the Hospital Service to the Scientific Civil Service is a not inconsiderable "crumb" of £335 a year.

But the advertisement continues: "There is a possibility of promotion to experimental officer." Here the salary rises to £1,430. No additional academic qualifications are mentioned for this promotion, and in fact none is required. I believe that your Lordships will concede that this is a very substantial carrot for one Government Department to dangle before the eyes of technicians trained by another and financed during their training—a matter of £1,430 against £720. It is only £10 short of double; and that £10 deficit is more than remedied by the additional incentive of housing and house-purchase assistance schemes available to the Scientific Civil Service but denied to the Hospital Service. This is sheer enticement, and unbecoming as between Government Departments.

What is the extent of the problem of wastage from the hospital laboratory service? I have a few figures. In the Wessex region, the losses were 88, out of a complement of 150, over five years. In other laboratories five-year losses were: 26 from an establishment of 24, 28 out of 27, and 26 out of 39. The record five-year turnover is 50 losses from a laboratory with an establishment of 27 in one of the metropolitan regions. These figures are highly disturbing. How can matters be improved? First, by attention to the pay and prospects in the hospital laboratory service, and probably no single measure would be as effective in stimulating recruitment and in curtailing wastage as the equating of their salary scale to that of the Scientific Civil Service. No doubt there would be continuing loss to industry, to the universities and by emigration; but an important leak would have been plugged. I understand that the appropriate Whitley Council have these matters under consideration. I hope that their deliberations will be fruitful.

If, as I hope, the pay structure in the health laboratory service becomes realistic and competitive, at least with that of the Scientific Civil Service, is there any other way of making the service more attractive? My Lords, I believe there is. Your Lordships have heard of the qualifications required of these people before they may enter the service. Your Lordships have heard of the training and of the professional examinations they must pass; and certainly for their most responsible work nothing less would suffice. But when they have qualified, a great deal of their work is boringly repetitive—quite essential work, but none the less repetitive. Here is great scope for automation. Much has already been achieved in this field. When I was a medical student the full preparation of batches of material for microscopic examination would occupy the attention of a technician for ten minutes an hour for eight to ten hours. With automatic tissue-processing, only five minutes is needed to load the equivalent material, and the whole complicated business is carried out automatically overnight—a twenty-fold saving of time. This device is in general use throughout the hospital service. My reason for mentioning it is that formerly, about ten years ago, the cost was something in the order of £400, compared with £150 to-day. Other pieces of apparatus designed to perform different tasks, costly to-day and on that account not in such common use, are available. They will become cheaper as the demand for them increases.

My Lords, the demand should increase. All day throughout the land there are hosts of technicians peering down microscopes counting blood cells, white and red. As I know from personal experience, this is one of the most tedious jobs imaginable. However, these investigations are, quite properly, almost a routine procedure in the full assessment of a patient. The time required by a technician particularly skilled in the visual counting of red cells is about 3½minutes a sample. The error of count when he starts is at least 9 per cent., and the error rapidly increases with fatigue. An electronic counter will do the whole thing in half a minute. The machine, being immune from fatigue, can operate with reproducable accuracy all day, if need be. For white cell counts, the electronic method is twice as quick and twice as accurate, even before technician fatigue becomes a factor.

In biochemistry, there is available a most ingenious machine, the auto-analyser, which can perform in batches some 20 different routine chemical investigations. For instance, it can do 40 blood urea estimations in 40 minutes. It would take a technician, using conventional methods, 21 hours for the same number, and his results would be far less accurate. Comparable saving of time and comparable accuracy obtain in all the other estimations of which this machine is capable. Technicians are spared from dreary routines and freed to occupy their talents in more imaginative roles. It can be argued that such a machine costing to-day £2,000, is justified only where a particular laboratory can, as it were, keep it busy. There is some truth in this, but not so much as cheese-paring finance committees would have us believe. I hope that these will reflect on the easing of technicians' burdens while they are totting up the daily numbers of blood ureas, blood sugars, and so on, which their laboratories are currently estimating. Perhaps they will recognise that in many instances the figures do not in any way represent the number that ought to be estimated, if the laboratories are to continue a service comparable to that of the laboratories in other progressive medical countries in Europe, the United States and elsewhere.

What does this amount to my Lords? It amounts to this. The hospital laboratory service will continue to be starved of recruits and ravaged by wastage unless salaries and other conditions are equated with those of the Scientific Civil Service and unless, this having been done, every possible effort is made to relieve highly skilled technicians of humdrum, dreary routines—and that implies ever-increasing automation. Industry would demand this; it could not afford to be without it—nor can the hospital service.

5.50 p.m.


My Lords, we have just listened to a great expert on the hospital service. I must begin by thanking my noble friend Lord Lucan for changing places with me, and I must apologise to the Minister and to the House generally for the fact that I shall probably have to disappear before most of the later speeches are made. We are certainly all, even those who differ, most grateful to the noble Lord, Lord Stonham, for raising this subject. No one in this House raises the question of hospitals more effectively or with more heart than my noble friend. I never follow anyone quite blindly—no layman, at any rate—but on everything to do with hospitals I follow my noble friend almost blindly. I defer, with almost equal obsequeousness, to the noble Earl, Lord Feversham, in the field of mental health. This puts me initially in somewhat of a difficulty, because these two great masters found themselves in same degree of collision, but as the noble Earl, Lord Feversham, is not here and as my noble friend Lord Stonham is, I will bow before the one who is present and ignore the one who is not.

I am not, however, going to pursue very far the subject that divided them. Nor am I going to speak (though I may take the opportunity of turning to it for a moment later) about something mentioned by the noble Baroness, Lady Summerskill: the noble Lady is not here, and I will ignore those remarks, also. If some of those speakers return during my speech a certain amount of chaos may result, but I will proceed on the assumption that they will not be with us.

I speak on behalf of the National Society for Mentally Handicapped Children, a growing Society, with many branches and about 20,000 members, the parents (though not all parents) of mentally handicapped children, those who used to be called "mentally defective". In saying that I am going to speak on their behalf, I am aware that in this House no one should act simply as an emissary; we all try to put our own views, even Ministers, within the limitations allowed them. But on this occasion I am sure the House will understand if I venture to think that the views of all these parents, without too much alteration from me, will be of some interest in a debate of this kind, when we bear in mind that there are some 60,000 mental defectives of all ages receiving institutional care in hospitals.

The noble Baroness, Lady Summer-skill, referred to the mothers in childbirth whose voices cannot be heard; and that I am sure is true of them. But that is at least just as true, and in the long run even more true, of these mentally defective people, who are human beings like ourselves but have no way of conveying their thoughts. I have often wondered whether there is any other class in the community who are completely incapable of letting us know what they are thinking. People who are mentally ill not infrequently recover, and sometimes they write quite brilliant books. Many famous books have been written in mental homes; and others of course, have been written by people who their friends thought should be in mental homes, Then again at Oxford at one time there were quite a number of "Firsts" obtained from the Warneford. So it is not impossible for people mentally afflicted to convey their views. But for the mentally defective there is this terrible barrier; therefore I feel that their views, conveyed, so far as possible, through their parents, and from their parents indirectly through me, should be of some interest in this debate.

I should like to say a word or two about the shortage of beds. The increased survival of the more severely subnormal has increased the waiting list for admission to mental deficiency hospitals. I asked the noble Earl, Lord Feversham, whether the Minister was excluding mental deficiency hospitals from his general remarks. The noble Earl could not reply to that question before a noble friend of mine, so to speak, swept him on to some other topic, and I do not know what his answer might have been. But perhaps the noble Lord who is to reply will nod if, as I think, the Minister of Health in fact excluded the mental deficiency hospitals from his general observations. I am grateful to the noble Lord, who nods his assent. So this problem, which led to so much controversy between the noble Lord, Lord Stonham, and the noble Earl, Lord Feversham, does not arise in the case of my "constituents". At any rate, there is general agreement that the waiting lists are far too long and that there is an acute shortage of beds. That is endorsed in the 1959 Report of the Ministry of Health, and I honestly feel that there is no one likely to question it.

This pressure on the overcrowded hospitals should be rapidly reduced by the development of small units for those who do not need special medical care and who would benefit enormously from the more personal environment of a small residential hostel or day centre. And this would, of course, reduce the staffing problems about which we have heard so much. All this is provided for in the new Act. We discussed this at great length when that Bill was becoming an Act, and when the noble and learned Viscount on the Woolsack was helping us so greatly in the summer of 1959. I do not say that nothing has been done, but there seems to be a general conviction that urgency is lacking, and we are all, irrespective of Party, demanding a new and rapid acceleration of that programme in setting up these smaller units.

I should like now to say something about a subject which I know is close to the heart and mind of my noble friend Lord Taylor, who is so much better informed about these things than I am and has instructed us in them before—namely, the integration between the hospital and the local authority services. Certainly a mental health service cannot be fully effective until there is much better integration between hospital and local authority services. Here, again, one should not generalise from what may be the small experience of one's own, but I do know of a superintendent of an excellent hospital, which is only a few miles from the capital of a county, whom I found quite out of touch with the medical officer of health and the deputy medical officer of health of that particular county. They were all excellent people, but they did not happen to have met each other; that was the only thing that was wrong. This becomes important if we are planning this tremendous operation under which people will be moved from the hospital to the care of the local authorities. At some time all these excellent gentlemen will have to meet, and, as I am sure the noble Viscount, Lord Waverley, would be the first to agree, the sooner they meet, the better.

The local authority representatives on the hospital management committee should surely be actively working in the mental health department; and the local authority mental health committee should include a representative of the mental deficiency hospital. That, at any rate, would be one way of bringing the two sides together. I am recording feelings which may not always be justified, but certainly are widely held by those who have the best of reasons for wanting the maximum co-operation. At the present time there seems to be quite often a kind of empire building which makes each side of the equation concerned only with its own authority. Obviously, we have to break down these frontiers between the hospital and the community to the benefit of both, if the great conception behind the Mental Health Act is to mean anything at all in practice. One example to which I would refer would be that the hospital could send children out to the local authority for training; and then, again, the hospital could provide special care units to which parents are able to send their children. You could get the hospital sending these children out to the local authority, and the local authority sending the children to the hospital. I am told that there are many cases where that could be done, and where it is not being done; and I am sure the noble Lord will take note of that.

Certainly the concept of community care involves bringing the hospital itself out into the community. We have to secure this practical integration if there is going to be this pooling of experience and ideas. And I only hope that community care will not prove one of those phrases which in the end is a positive illusion. The noble Earl, Lord Feversham, was quoting Professor Titmuss to great effect. I do not say that this would happen, but we must all be careful that we do not play down or impair the hospital services before the other services are ready. I am sure that everyone agrees about that. There seems to be a possible danger that we may imagine this community care coming into existence long before it does. It is a phrase that is so attractive, and we are all so proud that we are capable of giving community care, that we might sabotage the hospital without putting anything into its place. At any rate, that is a danger to which I certainly think we are all of us alive.

In the field of mental handicap we are most anxious that the industrial units, in which training can be given, whether within the hospital or within the community, should be provided much more rapidly than now. Most of us are aware of cases where the hopelessness of the untrained person is transformed by the training when it is actually brought about. I do not know whether the noble Lord the Minister who is to reply will feel that this subject is within his scope, but if he can say anything about the provision of industrial units for the training of mental sub-normality, then he will undoubtedly cause us all much encouragement.

The subject of research was properly stressed by various speakers, including the noble Earl, Lord Feversham, and the general feeling in my own body is that a special unit for research in mental deficiency is essential if the causes of mental deficiency are ever to be eliminated, prevented or controlled. We are obviously a long way from discovering the truth, but there is this feeling that a break-through might come but will riot unless we spend far more on research. I have a feeling—and I am sure the noble Viscount, Lord Waverley, will correct me if I am wrong—that work in the field of mental deficiency does not occupy a very high status in the medical world. There are some people who devote themselves to it, but for some reason or other most of the leading doctors pass it by. I do not say that he would agree, but I am afraid it is my impression that it is not a question of money—we do not get our share of the attention. Would it be an insult to the very great medical profession to suggest that there is something wrong at the present time about a doctor's thinking that more of these cases cannot be cured? Whatever the reason undoubtedly far too little is done for research in mental deficiency at the present time.

Then we come to staffing, about which others beginning with the noble Lord, Lord Stonham, have spoken with great knowledge. I entirely agree with those who say that nurses are disgracefully underpaid. It is not only the pay; there are all sorts of conditions of service Which could be improved. We feel in our body strongly about the training of mental nurses. We feel that the General Nursing Council has not yet adapted its forms of training to the great changes that have taken place in the understanding and treatment of mental disorder. We may be biased, but as an Association we have no desire for anything except the training which will enable these devoted people to render the best possible service. There has been a tendency, so it seems, to regard mental nurses as requiring ordinary nursing training but at a slightly lower level, instead of appreciating the fact that these nurses in mental work probably need to be more equipped, or to have a stronger vocation, than the average nurses.

We feel, therefore, that the whole approach to the training of the nurses concerned with our children must be revolutionised. I wonder whether the noble Lord, Lord Taylor, and the noble Viscount, Lord Waverley, would agree that the best discipline for mental nurses—perhaps the only discipline one needs—is a proper study and understanding of the methods and procedures of modern psychiatry. That in itself provides the discipline, and we feel that the spirit of the past hangs too strongly over these nurses. There was the famous painter who took his pupils round a public gallery and at one point said to them, "Gentlemen, we are now passing the paintings of Delacroix. Raise your hats, but don't look," We feel that might be said about even so great a lady as Florence Nightingale when it comes to the training of these mental nurses. The noble Lord will tell me if he feels that this is an unfair criticism. Nobody, I am sure, wants to do anything but to train the mental nurses in the best possible way; but, speaking for the patients, we all feel that their training leaves a great deal to be desired, and is a long way behind the times.

I will not at this hour, and with other speakers to come (though I should like to speak about it on another occasion) go into figures to show that, on the whole, on any physical test, the children in the mental deficiency hospitals are treated worse than the children in other hospitals, but I am sure the noble Lord will be sympathetic in principle to the last point which I want to raise, though whether he will be able to accept it here and now in this form, I am not sure. There is a strong feeling among the parents of the mentally handicapped children that they, collectively speaking, or through their representatives, should be taken into much closer consultation with those who run the hospitals. The length of time that their children remain in hospital makes it an even more urgent matter for them than for ordinary parents that there should be this close relationship between parents and the staff.

We are not asking for the impossible. We would not ask for more than the kind of relationship that exists between the head teachers and staffs of the boarding school, on the one side, and sometimes of other schools, and, on the other side, of the parents of normal children who go to such schools. But we feel very strongly that there should be this much more intimate relationship. When it does occur, we cannot accept the overall information and goodwill on the part of the superintendent as something that should lie in his free gift. It should be regarded as a matter of right. The subnormal child and the parents have the same need of adequate preparation before admission to hospital, as has been brought out in various Government Reports, and we feel strongly that this side of the care which so many devoted people are trying to offer—the care for the mentally handicapped—is very sadly neglected, perhaps through lack of emphasis more than anything else.

According to my information, few hospitals maintain a close contact with the parents. There is little to make them feel that the hospital programme is designed to assist, wherever possible, the child's return to partial or full home care, and often there are what are described as rigidly authoritarian attitudes in some hospitals. There is, of course, no justification for attitudes of this sort. It may be denied that they exist. It may be that I shall be told I am simply ventilating grievances; but I feel they are justified grievances, so far as I have been able to discover. While I would not say that 20,000 people cannot be wrong, the 20,000 people who care as much as these people do for their children are likely to have found something fairly solid before they asked me to place it before your Lordships this afternoon.

There are, among the parents of the mentally handicapped, citizens from all walks of life. There is no possible co-relation between mentally handicapped children and mentally handicapped parents. People are apt to assume that I have had at least one mentally handicapped child, and they often spend their time trying to discover which it is, which is not always exactly what my children expect of me. One of my daughters defended me on the ground that if I had not any mentally handicapped children, she at least had a mentally handicapped father That is some justification for my rôle as national Chairman.

The point I am trying to make is that the parents of the mentally handicapped are perfectly normal people, bearing a great load of suffering, and bearing it, as I know full well, with immense bravery. In recent times nothing has been done more to encourage them than the speech of the noble Lord, Lord Grenfell—who is unable to be here to-day—who came out in your Lordships' House, as a Member of this great Chamber, and spoke about his own mentally handicapped child. Perhaps most Members of the House would hardly realise quite what it meant to have someone saying in the House of Lords that he himself had a mentally handicapped child. It seemed to lift a weight off many hearts. There they are, brave people, smiling through their tears, and only anxious to suffer more and sacrifice more so long as their children can benefit.

The last concrete point I want to place before the noble Lord, Lord Newton, of which he has been given some small notice, is the suggestion that wherever possible it should be arranged that these parents of mentally handicapped children are at least unofficially represented on the committees that run the hospitals. I do not say they should nominate people; I just say that the committees concerned with these hospitals for the mentally handicapped should include parents of mentally handicapped children. I hope the noble Lord will be able to-day, or later, perhaps, when he has had time to talk to the Minister, to hold out hope that in fact that will be the Government's declared policy.

I apologise for having to leave the House rather soon, and I apologise also for speaking from one particular point of view, speaking, if you like, to a brief. But I think that the noble and learned Viscount, the Lord Chancellor, would agree that sometimes one has a brief with which one's whole self is linked up. On that occasion the advocate and the representative and the friend are all involved together, and certainly this is a cause which I know has only to be placed before your Lordships to win your sympathy, as we have seen in more debates than one in recent years. I am grateful to the House for letting these points be placed before your Lordships, and I hope the noble Lord will assure us that the mind of the Government is being turned more actively to the problems that confront these parents.

6.13 p.m.


My Lords, first I should like to apologise to the noble Lord, Lord Newton, and the noble Lord, Lord Stonham, for the fact that due to a previous engagement I shall have to leave the Chamber before the conclusion of the debate; I hope that I may have the indulgence of your Lordships' House on that account. From these Benches I should like to pay a warm tribute to the noble Lord, Lord Stonham, not only for introducing this debate at a most opportune time but for the admirable way in which he has. done it. He has spoken strongly, but I think not too strongly, of a very serious problem, a problem to which he has given an immense amount of study and time. We have also listened to a very moving speech from the noble Earl, Lord Longford, who in the field of mental health speaks with such great knowledge and sincerity.

I propose to deal primarily with two matters, children's hospitals and casualties. During the past few days in your Lordships' House we have been discussing accidents of various kinds, accidents in the home and those with which the Road Traffic Bill is concerned. And it is upon the shoulders of the hospitals that the onus of the tremendous casualties, on the roads, in homes and elsewhere, rests. So it is most opportune that to-day we should have this debate.

As I have said before in your Lordships' House, I serve on the board of a children's hospital, and I should like to pay a very warm tribute to all those who care for the welfare of children in hospital. The nursing of children is not easy. A very fine piece of work has been done with the publication of The Welfare of Children in Hospital by a Committee headed by Mr. Platt. I think this is one of the most moving and one of the most sensible papers I have ever read, and the subject matter of it is a justification of the debate in itself, because its recommendations are extremely sound. One of the principal recommendations is for the frequent visiting of children in hospital. I am very glad to note that in most hospitals to-day the visiting of children by parents is very much easier than it used to be. Children who are in hospital do need the comfort and the reassurance of their parents, especially in the early days.

One of the most interesting parts of this Report is the discussion as to whether there should be more children's hospitals or whether there should be more children's wards in general hospitals. I have made some inquiries from doctors, and from one or two hospital secretaries, to ascertain their views on this matter, and almost unanimously they have come out in favour of more children's wards in general hospitals. I know that in my own local general hospital the children are extremely happy and very well cared for. One of the difficulties of a children's hospital is the fact that parents often cannot get in to visit them so frequently. My own children's hospital is in Chelsea, and the one which is near where I live is at Carshalton; and to these hospitals come children from many parts of the Home Counties. For various reasons it is not always possible for parents to visit their children as often as is sometimes necessary.

May I say a word now about casualty departments? I have broached this subject in your Lordships' House before. I would ask the noble Lord who is to reply whether, when these new hospitals are being built—and we have a comprehensive programme, at any rate on paper, for the building and modernisation of hospitals—serious attention will be given to the provision of adequate casualty centres. Many of our older hospitals, especially in London, have extremely cramped and quite inadequate casualty centres; and that makes it very difficult for the doctors, house surgeons and nurses who have to work so hard to clear these casualties. That, I think, is a matter of paramount importance. I was very glad to see in to-day's Scotsman that the Secretary of State for Scotland has told Regional Hospital Boards that they can complete their work on new hospitals and on modernising projects in a single exercise, in place of separate phases. Of course, this will help in the rebuilding of the Royal Infirmary, Edinburgh, the Western Infirmary, Glasgow, and other large hospitals in Scotland which need rebuilding or modernising. But, as I see it, this project will fall down unless more immediate finance is forthcoming. Obviously, the noble Lord cannot answer to-day, because I have not given him notice and it is a Scottish matter. But it may well become a national matter if the policy of the Minister is Ito bring this most desirable scheme into general operation. But finance is going to be the great problem here.

While on accidents, I should like to ask the Minister another question—namely, whether there is to be provision for the setting up of more accident hospitals? At present, I believe there is only one in the country, at Birmingham, which is kept very busy. It has been mooted in a number of centres that there is ample room for the provision of at least one more in the country. With the increasing numbers of accidents of all kinds, in the home, on the roads, and elsewhere, the casualty sections of the general hospitals are being heavily strained.

I turn now to the Mount Vernon Hospital, at Northwood, which, as I said in your Lordships' House two weeks ago, I visited. Here, many accident cases are treated; but here again they are working to a large extent in cramped conditions. In dealing with serious burns and falls, and that kind of thing, plenty of space is needed. In connection with this matter the Ministry of Health have issued some extremely interesting documents regarding the hospital-building schemes. I have looked through these with great interest and care, and I cannot myself see how they are going to work effectively unless more finance is forthcoming from the Government. I presume that the hospitals now under construction will be built, to some extent at least, on the recommendations of these pamphlets; but it is going to be a costly affair.

I should like to pay a tribute to the work of the Regional Hospital Boards: they render great service, often in difficult conditions. They have many problems to consider, not the least of which is finance. In some of the older hospitals a great deal needs to be done, often with little money to do it. I gave the noble Lord, Lord Newton, notice that I was going to raise one specific question in relation to the Hammersmith and St. Mark's Hospital Group. Here a Malayan civil servant was appointed as secretary to the board of governors. There has been a great deal of feeling among other hospital groups about this appointment. I wish to stress to your Lordships that I cast no aspersions whatever, either on the Group or on the gentleman concerned. But with the shortage of hospital administrators of this kind it is an appointment which could be questioned. I should value some comments from the noble Lord on this matter, either after the debate or at some future date.

The hospital building programme covers a wide field. As the noble Lord, Lord Stonham, and other noble Lords have said, some of the pay, particularly of physiotherapists and radiographers, is certainly not what it should be. I believe that top-grade physiotherapists receive something like £760 a year, and the instance which the noble Lord, Lord Stonham, quoted, of the physiotherapist with 25 years' service who could not get a mortgage to buy his house, is extremely disturbing when one considers the responsibilities which are placed on the shoulders of such people. I have spoken to some of the physiotherapists in my own local hospital group. They work long hours, and often have to do private work to supplement their income. I feel that there is a great deal of scope for reviewing this situation. This matter has been raised before in your Lordships' House, but, so far, little has been done.

I feel that on the whole the right honourable gentleman the Minister of Health has acquitted himself very well. He is a man with a practical turn of mind, and it will be interesting to see how quickly developments will take place in this modernisation programme of the hospitals. I understand that it will be two years before work is started on the Edinburgh Royal Infirmary. That is too long. The situation there is acute. I believe that if we are to have an efficient hospital service there are two essential requirements: first, that the ancillary staffs, such as physiotherapists, radiographers and laboratory technicians, should be paid a reasonable living wage; and secondly, that this new hospital building programme should be considerably speeded up.

6.30 p.m.


My Lords, as one who has listened to all the speeches (with one exception) that have been made in this debate, I should like to begin by thanking not only the mover of the Motion, the noble Lord, Lord Stonham, butt everyone else whom I have heard; for from every speech I feel that I have learnt something, and I shall certainly read the speeches fully again in Hansard. The one exception, the one speech I have not heard, was that of my noble friend Lord Amulree. I hope your Lordships will not suppose that there is any serious rift in the Liberal Party; it is only because I was called outside to hear news about the health of a close relation from my home. I am glad that the news is not over-serious, but I had to go.

When the National Health Service charges first came under consideration in this House last February, Her Majesty's Government dwelt, with a good deal of emphasis, on their ten-year programme of hospital expansion as a thing highly relevant to the debate. I had the impression at one point that they suggested they could not pay for the development of the hospitals as they wanted unless they obtained some money for the Health Service otherwise than from the ordinary taxpayer. In supporting these new charges, so far as they fell on people who were wage-earning and of working age, I expressed doubts as to their effects on people of past working age and intimated my desire to inquire into the question of these old people. In another debate on these charges this inquiry of mine was welcomed and encouraged in extremely kind language by the noble Earl, Lord Dundee, speaking from the Government Bench. Now that the hospitals are under discussion and the inquiry is concluded I think it will seem appropriate for me to speak, very shortly, both about what that inquiry led to and what it suggests about the growing number of old people, with their growing need for medical treatment, and about how the hospitals can be made most valuable both to the old people and to all others in ill-health.

The publicity given to that inquiry, which was welcomed by the noble Earl, Lord Dundee, including the publicity given in the Press, led to many letters from and about old people. I have received many, and others are still coming in. All those that I had received up to yesterday, when I closed my inquiry, I have sent to one or other of the three Ministers concerned. I had to sort them out for the three Ministers—the Ministers of Pensions, Health, and Housing and Local Government—who are concerned with old people. I sent them, sorted out, to the Minister whose Department they seemed mainly to concern, in the hope that they would be considered on their merits. Those letters, however, were a very small part of my inquiry and of the material I used. Naturally, I read all the books and reports I could get hold of.

But far more important than letters, books and reports were the references to the many debates on old people in this House since 1946, and particularly their bearing on health and how to preserve it. One point made again and again by more than one noble Lord in these debates was the difficulty of discovering old people who are sick in time to give them treatment before their sickness had become incurable. And, let me add, exactly the same point was made to me in, I think, the most important letter of all that I received on my inquiry: a letter from the Chairman of the Women Public Health Officers' Association. Let me quote a few sentences from it: It is my opinion that most medical officers of health and health visitors are very concerned that elderly people are not being visited before the need of social services arises. All too frequently local health authorities and the general practitioner are called in…when recovery is almost, or quite, impossible. The greatest difficulty is to find these old people, especially when they are living alone, without relatives or friends visiting them. It is very common to find, even when help is sought by neighbours or friends, that the aged person either is not aware of the services available or is too independent to seek such help. That is a letter confirming what so many noble Lords have said to me here.

I have embodied the results of that inquiry in a short pamphlet which will be published on Friday at a conference on old people and their needs which I shall be addressing. I feel that it is only courteous to tell this House in advance of the use that I am making of the profound and varied wisdom of its Members. I shall, of course, send copies of the pamphlet to those noble Lords whom I have quoted most often, so that they can read them or burn them as they choose, and to any other noble Lord who may think the pamphlet worth looking at. It deals, of course, not only with what they have said but with special problems of housing and of health.

In preparing for this debate I have read the history of the hospital which I myself know best, St. Thomas's Hospital, where I spent twelve days, on the Health Service basis, before Christmas. They gave me various books about themselves. I was particularly interested to find that the first lady almoner of St. Thomas's, a Miss Cummins, appointed in 1905, after the hospital had been in existence for 800 years and more (for it started at the beginning of the twelfth century), found in the hospital that medicine was often in a losing battle against ignorance, poverty and blank despair. That is sadly true of hospitals in relation to many old people to-day, in 1961.

My Lords, I am not going to say anything more, except to sum up the three points which have been made by speakers before me and which seem to me the most important; and I hope that Her Majesty's Government will consider them most seriously. First, there was the suggestion made by the noble Lord, Lord Stonham, about the importance of providing healthy homes for people who did not need to be in a hospital: those who were not ill enough to be in hospital, but who could not find as good a home to live in outside and therefore stayed in hospital unnecessarily, occupying a bed which might otherwise, and would certainly otherwise, have been used for a real patient. That, of course, is a great contribution which could be made by any organisation which, like those with which I happen to be deeply concerned, is concerned in providing houses for old people. I think that is a task not only for local authorities but, thank goodness!, for voluntary organisations. There are many engaged on it, and their efforts will lessen the burden on the hospitals, as the noble Lord, Lord Stonham, suggested.

My second point is that we should, by organised visiting, discover and treat people—old, solitary people—before it is too late for cure. That is what I have learnt from so many noble Lords in this House, and also from the women medical officers. Then, finally, we should develop more hospitals and have better-paid staff—and that point was stressed particularly by the noble Baroness, Lady Summerskill. I am sorry that I had to go out for a moment during her speech, but I know that it will all stand clear in Hansard, as it stands clear in my mind to-day.

6.43 p.m.


My Lords, I am grateful to my noble friend Lord Stonham for initiating this debate, and I am sorry that circumstances have deprived me of the opportunity of hearing the greater part of it. I had an engagement this forenoon in Scotland. I thought I should be here in time for most of the debate, but the weather and B.E.A. were both against me, and my 'plane arrived two hours late. I must therefore rely on the OFFICIAL REPORT in due course to learn what has been said; and I must apologise Ito your Lordships if anything that I say is a repetition of what has been said before.

I have looked forward to this debate because it is on a subject in which I am particularly interested. Thanks to the successive co-operation of four Secretaries of State for Scotland, I was for twelve years the chairman of a Regional Hospital Board in Scotland, and I should like to say here, as I have said elsewhere, that there is no part of public work in which I have been involved which has given me more satisfaction than the chairmanship of that Hospital Board, even with all its frustrations. Everyone who has anything to do with hospitals knows that in these past twelve years we have had our fair share of frustration—not, I would venture to suggest, because of any deliberate effort on anybody's part, but as a result of the fact that the hospital service inherited a problem which was twenty years out of date because of the effects of the war, the poverty which the voluntary hospitals suffered from immediately before the war and the difficulties of the few years immediately after the war was finished.

I should like to revert from my main topic just for a moment to take up, while it is fresh in my memory, the subject to which the noble Lord, Lord Beveridge, has spoken so well. The last time I spoke I also followed Lord Beveridge, as it is my privilege to do again to-night, and I was very interested in what he said then about his inquiry into old people's circumstances. Perhaps he and other noble Lords will be interested in an experience I had a few weeks ago. I was asked to open something which was called a spring fair, but which was a glorified sale of work, run by the Men of the Round Table and their ladies in the county town of Angus, in the burgh of Forfar. It is not a very big place, but these young men and women have made it their particular piece of social service to look after old folk.

One of the things that they have done is to get a list of people in the burgh of 65 years of age and over, and every old man is visited once a week by one of the members of the Round Table and every old woman (or, should I say, every woman over 65, because they do not consider themselves necessarily old women) is visited by one or other of the ladies. Work is done for them; if something goes wrong with their radio sets the men arrange to have it repaired; and knitting is done by the ladies of the circle. The result is that in this small place the problems to which the noble Lord. Lord Beveridge, has referred are caught in time. Nobody is found seriously ill because their illness has been unknown. I do not know whether there is any way in which what is possible in a small place can be carried out in larger centres of population by voluntary organisations, but I would suggest that in all places where it is within the capabilities of organisations like the Round Table, the ladies' circle or other bodies of that kind, it is a very worthwhile piece of work to undertake.


My Lords, could my noble friend say what the population of Forfar is, approximately?


I should think it is about 8,000, or thereabouts.

I want to speak particularly about some of the things which I learned during my chairmanship of the Regional Hospital Board; and I should like to say how pleased I was to learn the other day of the Government's intention regarding the building of new hospitals in Scotland. I was actively engaged in connection with the new teaching hospital in Dundee—and when I spoke about frustration that was the sort of thing I had in mind. l think it took me and my colleagues three years to persuade two Secretaries of State for Scotland that it was ridiculous to attempt to build a modern teaching hospital on a congested site. It took, I think, another four years before we persuaded the next Secretary of State to let us appoint an architect. Once the architect was appointed, my colleagues and I knew that the battle was won, because, by the very nature of the Civil Service, once a few thousand pounds had been spent on architects' fees the hospital had to be built to justify the initial expenditure. That is one of the hospitals which starts in 1963.

The Secretary of State for Scotland announced the other day that the rebuilding of a teaching hospital in Glasgow and of Edinburgh Royal Infirmary are, together with the Dundee project, to be carried through, not in stages as originally intended, but each in one step—and on these three hospitals will be spent something like £20 million. Now in my own region, the Eastern Region, in addition to the project for building this new teaching hospital, there is the reconstruction of Maryfield Hospital in Dundee, and its expansion by some 200 beds, and the reconstruction of a mental hospital which was lamentably out of date in almost every respect—the reconstruction is of such a nature that, when it is finished, it will virtually be a new hospital. The fourth project in this comparatively small region which has been carried out, and which has been in process now for some three or four years, was the expansion of the Hospital for the Care and Treatment of Mental Defectives. One aspect of the hospital problem is the shortage of accommodation of that kind in Scotland, and I presume the same position applies South of the Border. A fourfold expansion is taking place in that hospital.

It would be wrong if, as one associated with the hospital service for so long, I were not to express gratitude to successive Governments that so intensive a programme is taking place in an area, after all, with a total population of only some 450,000 people. But one of the difficulties of a programme of that kind is whether it can be carried out under the auspices of the Regional Hospital Boards themselves. The schemes are too big for the amount of money which annually is made available for capital projects for any particular board, and in practice the result is that any hospital scheme in Scotland costing upwards of £100,000 must be taken care of by national funds administered by the Department of Health for Scotland, and the balance of the monies available for capital projects is then divided among the five Regional Hospital Boards. The result is that a comparatively small sum of money is available for those other purposes. I should like to suggest that the Government and the Department are in danger of assuming that, because they are doing so well in the provision of a comparatively few and expensive large new hospitals and some reconstruction, everything in the garden is lovely. That is far from being the case. You do not improve the service for all of the people by spending a great deal of money—essential, though it is—if it is concentrated on these comparatively few institutions.

Now, outside of the hospitals which I have mentioned—and I must apologise to your Lordships for talking about this small Scottish region, but my justification for doing so is that I have no reason to believe that its problems are any different from those of any other section of the hospital service in England, Wales or Scotland—the Regional Hospital Boards have 40 other hospitals to look after, ranging in size from upwards of 500 beds to fewer than ten beds. During the current year, and I think in the past year, they have been given, for capital purposes other than these major items, £110,000. That is hopelessly inadequate to deal with the problems, and I should like to suggest to your Lordships that the danger that this scheme is in is that the people in the perimeter hospitals, who are rendering such a necessary service to the community, will fall further and further behind. Because the hospital service is not a static thing. Improvements are taking place every day in methods of treatment and the like, and in the accommodation which is necessary to make that treatment possible.

Not only will those hospitals fall behind, but, what is even more important, it will become increasingly difficult to recruit staff in these essential hospitals, because people will feel that they are in a backwater; that they are working in out-of-date buildings with out-of-date methods; that it will not be possible for them to transfer in due course to the right jobs in other places, and that once they go to these hospitals they will be in danger of being there, if not for the rest of their lives, for very long periods, and perhaps longer than they necessarily want.

I suggest to your Lordships that it is necessary, therefore, that, notwithstanding all that being spent on new hospitals, even more money must be made available for capital purposes. Even if the amount is substantially increased, I know full well that there will still be complaints. I suggested to the former Secretary of State—now the noble Viscount, Lord Stuart of Find horn—that there was no problem in my reasoning which was incapable of solution provided he advanced us at least £20 million. I knew perfectly well that I had no chance at all of getting it. I should like to say, quite sincerely, that I do not believe any Government is in a position to make either the finance available, or, if it were, could furnish the labour and materials necessary, to do in the immediate future all that requires to be done in our hospital service. The most that a reasonable person can expect is that the Government continue to increase, year by year, the monies which are available, so that the arrears may be more speedily overtaken. My only criticism of what has been done in recent years is that the pace of acceleration has been far too slow.

I should like to make a very small suggestion for the better use of monies which are provided. One of the most annoying things about being given an inadequate sum of money is that, because of difficulties out of your control, such as having to wait for materials coming to a site, or because of a temporary shortage of building labour, or because a contractor is not as efficient as he might be, you get towards the end of the financial year and become uncomfortably aware of the fact that, even although you have complained bitterly that the money is inadequate, you are not going to be able to spend it. In my region we took two steps to overcome this difficulty. The first one was reasonably successful, but not completely so. At the beginning of each financial year we deliberately over-budgeted by 10 per cent. Even with that we did not spend all the money that we got, although we could have put in at the beginning of each year at least three times as many projects as managed to get through the priority net.

What took place there, and what takes place, I think, everywhere, was that the Boards had a list of small projects, things costing, perhaps, £300, £500, £700, or £1,000. which, when one got to the end of December and realised that the same position was arising again, could be put speedily into operation and carried out before the end of the financial year. Because the most frustrating thing about these allocations is that if, at the end of the financial year, you have not taken up your capital allocation, it has gone for ever. That, I suggest, leads to a wasteful use of public money, and, in the present circumstances, an inevitable waste. We have tried, and I think probably every Regional Board chairman has tried, to get this altered, but the answer is that the Treasury will not allow funds to be carried from one financial year into another.

Now I do not understand this argument, because that is done in other directions. The University Grants Committee, which is disbursing funds—and I am at the receiving end there, as the Finance Chairman of St. Andrew's University—disburses not on the basis that anything unspent at the end of the financial year comes hack to the Grants Committee, but that it can be carried forward into succeeding years, provided, I understand, it is within the quinquennium. I would suggest that the Ministry and the Department of Health should consider a plan by which monies underspent in the financial year in which they are allocated can be carried forward to the next year, to ensure that the inadequate monies which are available are all spent on projects of first priority and that the items of third or fourth priority do not get into the programme between January and March just to take up the odd £10,000 or £15,000 that may be left. As we are all under an obligation not only to see that expenditure is kept to a reasonable minimum but also to see that what is allocated is wisely spent, it seems to me ridiculous that up and down the country people are encouraged—nay, more than encouraged, required—to do the things which could easily wait another four or five years because this system prevents money being carried forward for use on first priority projects in the first few months of the next financial year. So much for building.

I would also suggest that there is another aspect of our hospitals to-day which ought to be given consideration. Year after year the cost of in-patient treatment in hospitals increases. If all the other things that require to be done are to be carried out, it is essential that we should investigate any ways in which we can provide effective treatment, making the best use of the monies available, for those who are sick and require more than can be received from their general practitioner. An examination is required of more methods of out-patient treatment and of diagnostic services which will stop the expense caused by the use of wards and beds in the acute hospitals. If something can be done along these lines it will enable more effective use to be made of our small country hospitals, our cottage hospitals, and will permit a co-ordination of services between the hospital, the local health authority and the general practitioner which is not always possible at the present time.

If I may use what was said to me by the officer of a Regional Hospital Board, he said something like this. People do not mind travelling some distance from a small town to a large centre where specialist services are available, if they are going to have some specialist treatment. But they resent having to go 10, 15 or 20 miles for what could be regarded as "bread-and-butter" items of treatment. And it would be possible for them to get this easily and speedily in small hospitals near where they live, if we could expand out-patient service for them in this way.

I have had the privilege of reading a document on hospital planning, which is the report of a Scottish group which visited the United States and Canada during October of last year to study hospital planning and building. It consisted of four representatives from Scottish Regional Hospital Boards and two representatives of the Department of Health. They visited a number of the newer hospitals in the United States and Canada, where they studied techniques. I do not know how easily this report can be obtained from the Department of Health, but I suggest to noble Lords who are particularly interested in hospitals that this is a document well worth reading. I presume that some of the recommendations which have been made by this party will be followed up by the Department of Health for Scotland, and possibly by the Ministry of Health also.

I do not want to make any reference to them, other than to say that I was particularly interested to see that one of the things which is being stressed in American hospitals is the importance of patients being satisfied with the food which they receive in hospital and the stress which is being laid on the opportunity of giving a choice of menu. If you are sick—or if you are well—no matter how good a thing is, if you do not like it, and in a hospital if you have no choice, you either eat what is there, whether you like it or not, or go hungry until the next meal. There is one hospital, also in this famous region, which depends on patients who come from a distance. It was one of the dispersal hospitals built by the Department during the war, and there is nobody who lives close. People come to it from Dundee and other places 20 or 30 miles away. It was difficult to persuade people who needed treatment not to remain on the waiting list of the hospital near to their homes and to go to the excellent hospital out in the country. Strangely enough, after a period of years, it began to get easier to get people to come there, and we found that the news was being spread around that the food at Stracathro was better than at any other hospital in the region: people were encouraged to go there because this, as well as a whole variety of other things, such as the attentions of the almoner, made them feel that the hospital was taking an interest in them as individuals.

When reading this Report, I was also reminded of a visit I made to a small cottage hospital with fewer than 20 beds. On the day of my visit the menu was chalked up on a blackboard. Although there was not a great deal of variety in the lunch, it was being served in eleven different ways to 20 patients. They were all old people. Some wanted meat without potatoes; some wanted meat with potatoes; some wanted potatoes and gravy only, and some did not want any meat or gravy at all. And all this was being taken care of in this small hospital. I appreciate that these are things which cannot be done in hospitals with 100, 200 or 500 beds, but it emphasised to me how important it was to make people in hospital, particularly if they are going to be there for quite a long time, feel that they are individuals and not just cases.

My final point is the importance of research in hospital work and in planning for the future. The Nuffield Trust have been undertaking research, particularly on ward units. I understand that their report, if not complete, is nearly so. I do not believe that they are switching on to anything else. If we are to get the best possible use of the vast sums which will be spent in the next ten years or so on hospital building, it is most important that research continues to be carried out. I think that this is best done by an outside body like the Nuffield Trust. I do not know if there is any other body which will step in to take the Trust's place, but this work cannot be left to the Regional Boards and hospital management committees and boards of management, to be done out of endowment funds, because there are far too many claims on endowment funds already.

On the other hand, I do not think that the best results would be obtained if the work were carried out entirely within a Government Department, because there is too much of a tendency, when research is carried out under Government auspices, for an endeavour to be made to fit the research into a given financial pattern. For example, it is said: "Let us see what you can do in relation to a hospital ward unit at a cost not exceeding so much per bed". That does not necessarily produce either the cheapest or the best results at the end of the day. I suggest that in this matter of research the Government must obviously contribute substantially to expenditure of this kind, because they are one of the principal beneficiaries; I believe that the Boards, from their endowments, could also contribute a proportion of the monies required; and if it can be organised by some voluntary organisation taking particular projects under its wing, then I think we shall obtain the best possible results.

My Lords, there is nothing further I wish to say, other than to reiterate my great regret that I did not hear what was said in this debate before that part of the speech of the noble I Lord, Lord Beveridge, which I did hear. I should like to assure those who have taken part in the debate that I will read every word of the Hansard Report, because, no matter how long I may be away from the hospital service, I shall never lose the intense interest which I have developed through the last twelve years

7.12 p.m.


My Lords, it is an interesting feature of this debate that until my noble friend Lord Hughes rose to speak about new hospital building in Scotland little had been said about the programme of new hospital building which the Government are about to initiate. I believe that the balance of our debate has been right, because inevitably and always most of the hospitals of the future will be the hospitals of the past. We shall have to make do, for many years to come, with the 2,000 or so hospitals that we have, most of which were built in Victorian days. I was glad that my noble friend Lord Hughes quoted the large sum of money (I think he said £20 million) being spent on three teaching hospitals in Scotland. Yet there are the peripheral hospitals, on which nothing like this amount will be spent—though the need there is far greater. And I believe that the good which could he done with even a small proportion of this money is quite disproportionate.

I have often felt how good it would be for any capital allocation for a new hospital to be balanced by equal capital allocation for old hospitals. There is something showy about building a new hospital: there is the foundation stone to be laid; there is the opening ceremony to be conducted; there is local pride and publicity; and there is an announcement to be made in Parliament of a great achievement. Upgrading the old hospital is far less spectacular, but much more important. I sincerely hope that the balance of this debate will be reflected and appreciated by the Ministry of Health and the Minister in his work, and that they will devote as much time, energy and thought to improving old hospitals as they are about to have to devote to trying to build these new hospitals.

I think that my noble friend Lord Hughes was absolutely right, too, in his reference to the extraordinary method of hospital finance which we adopt where capital developments are concerned, and where for the last three or four months of every year we have this absurd rush to spend money on third, fourth or fifth priority jobs, because, due to our extraordinary accounting system, we are not allowed to carry this money forward. My noble friend drew an analogy with the University Grants Committee, and he was quite right in what he said. But the truth is that the University Grants Committee is not subject to Treasury control. The University Grants Committee disposes of £20 million or £30 million every year (perhaps a little less, but certainly money of that order), and the Regional Boards spend about £400 million.

The traditional Treasury argument, which is always "dished up" whenever we speak of this, as it seems to us, apparent insanity, is that Regional Boards cannot exercise their own financial control, as should any public corporation, but must be responsible to the Treasury, because the money they are spending is so great. This seems to me to be the silliest reason. I believe that if Regional Boards were properly responsible for their spending, and were given so much money to spend in their region each year to provide a hospital service, being allowed to carry over whatever they could save year by year, and to conduct their own affairs without Ministry or Treasury control, we should have a far better hospital service and a far cheaper one; and we should certainly get far better value for money. This is the key to getting value for money for our hospital services, to which my noble friend Lord Stonham referred in his splendid opening speech.

My noble friend Lord Waverley showed the folly of not paying properly technicians in the laboratory. It is insane not to pay these people properly, and to have a turnover of over 100 per cent. in technicians in five years. The Atomic Energy Authority offer a proper wage, and off go the hospital technicians. And who can blame them? Again and again in this debate we have heard it said that something has gone wrong with the Whitley Council negotiating machinery; that the machinery is bad, and we must get away from Whitley Councils. I always thought that. I thought it was a foolish thing when we set them up; and, of course, this was the work of the Labour Government.

My old friend Mr. John Edwards devised this elaborate machine of Whitley Council negotiation. It would have been all right if the staff side had been a real staff side. But what was the staff side? They were officers of the Regional Hospital Boards, of the Ministry of Health or of the local authority, where local authority workers were concerned. These people are not free agents; they have not control of the money. The money is controlled by the Treasury, and the only person it is worth while negotiating with, if you are employed by the Government, is the person who is going to "dish out" the money—which means the Treasury. The whole of the Whitley Council machinery is rotten from top to bottom. Many of the fundamental things which are wrong with our hospital service at the moment stem from staffing with those who have not direct negotiating machinery; we have, thank goodness! got this in the medical profession, with the excellent arrangements which have now been made as a result of all the row which the B.M.A. has, quite rightly, "kicked up".

This debate has really fallen into the two main sections of the psychiatric hospital services and the general hospital services. I think, again, that it is right that it should have divided thus. First, I should like to say a few words about the psychiatric services, the mental hospitals. I was interested to hear the little bit of a tussle which developed between my noble friend Lord Stonham and the noble Earl, Lord Fever-sham, on whether the Minister was or was not right in saying that we can reduce progressively the number of mental hospital beds in the dramatic way in which the Minister said it. Funnily enough, I had this very argument with an old friend of mine, Dr. Rees, the superintendent of Warlingham Park, who the noble Earl, Lord Fever-sham, will know was a wonderful superintendent.

It was eight years ago that we discussed whether one should put all one's money, as it were, into psychiatric units in general hospitals, hoping that by so doing it would be possible to get rid of the flow-through of chronic patients to the mental hospital, or whether it was better to improve the mental hospital so that it became a therapeutic community. I think the answer is really to be found in the size of the mental hospital. If we take the mental hospitals of this country we find that they fall roughly into two classes: those with under 1,000 beds, and those with 2,000 or more beds. Quite frankly, my experience of those with 2,000 or more beds is that the only treatment is the bulldozer.

Take Lancashire. Lancashire had a body called the Lancashire Mental Hospitals Board, which provided four or five mental hospitals, enormous places, out in the wilds. The patients from Manchester used to say that it was the journey to the grave. They were not far wrong. Those places are still there; they are still being used. What happened? The county boroughs of Lancashire rebelled at this. They would not face this frightful journey out to these moors, where these terrible hospitals were, and so the county boroughs built little mental hospitals of their own in their own public assistance hospitals. They built about eight or ten 100-bed or 200-bed mental hospitals inside the curtilage of the public assistance general hospital. When the Manchester Regional Board took over, they found that they had a legacy of small psychiatric hospitals already integrated with the general hospitals.

It was in Lancashire that this business started. And a marvellous job they have done; because Dr. Marshall, the senior administrative medical officer, and his colleagues on the Board, agreed that they would upgrade these small 100-bed and 200-bed units and make really efficient psychiatric hospitals out of them inside the existing general hospitals, rather than try to do the impossible upgrading job on these awful places away in the country. That was the beginning of this new conception of the psychiatric hospital as part of the general hospital. It is successful, partly because these units are big enough.

I do not myself think much of the 20-bed psychiatric unit in the general hospital, because a decent psychiatric unit for acute cases needs to have all sorts of things. The patients should not be lying in bed; they should be up and about. They need occupational therapy, a workshop, an art room and discussion group rooms, arid it is very hard to get these if you have a 20-bed unit. I have seen some 20-bed psychiatric units with all the patients in bed, and more miserable places it is impossible to imagine, because it is imitating the general hospital ward. These are not general hospital wards at all. These are little therapeutic communities, and it is essential that they should be so treated. It may be possible sometimes to do it with a very small number of beds, but I say that 80 or 100 beds are needed to get a really good small psychiatric unit inside a big hospital. If we look at the good psychiatric hospital which my noble friend Lord Stonham was describing so beautifully, I should guess—I do not know, I have not asked him—that it is an 800-bed hospital. May I ask my noble friend?


It is 850 to-day, and it ought to be 500.


I was not sure, but my guess was 800, because it is typical of the 800-bed hospital, which usually linked with a county borough. The best usually are so linked for a very simple reason. A county borough is a community which can easily be identified, and it can build a relationship with a hospital which is close and good. Very often it has built its own hospital, of which it is proud, near at hand, instead of its being in a catchment area miles away from the hospital. There is Warlingham Park, where Dr. T. P. Rees built up the hospital in many ways. Mapperley, at Nottingham, is a wonderful mental hospital. Portsmouth is another. You can pick them out; they come automatically. In the good ones, one sees this close relationship to a clear-cut community.

My Lords, it would be an absolute tragedy if, because we went in for these acute psychiatric units, we therefore said that these mental hospitals are necessarily no good. They are wonderful institutions. They are true therapeutic communities: a powerhouse of psychiatric good service. My noble friend has just told me the name of the hospital. It is, in fact, Moorhaven. Dr. Pilkington is, I think, the medical superintendent, and a very fine man indeed. So I hope that the Minister will have a second thought about the extremely sweeping speech that he made, suggesting that they were all to go, and that all ought to go. Let us all hope they will go one day, but we must not destroy good work which is being done so long as there is a need for it. I think if we remember that it will be all right. But we must not press what is a good idea too far.

I was glad that the noble Earl, Lord Feversham, mentioned that interesting paper by Dr. Tooth and Miss Brook in the Lancet, which is a very fine paper indeed. I think the trend is there. It is always a danger to exterpolate too far, to push a series of figures where the curve is coming down or going up, and say that it is going to go on in a straigh' line. Often it describes a parabola, or something else happens. The Minister was guilty of a bit of straight exterpolation, and I think that Dr. Tooth and Miss Brooke were, too. I hope that they are right, and I hope that he is right, too. Even so, I think we shall still have to use the Moorhavens, the Warlingham Parks and the Mapperleys to the best possible advantage for many years to come. I do not want to say any more about psychiatry.

Now general hospitals. The noble Lord, Lord Auckland, referred to these hospital building notes that the Ministry are turning out—and very good they are, too! I would congratulate the Minister on these things. In this particular sphere it is a sign of the very good sense prevailing in the section of the Ministry of Health that is concerned with buildings. We are beginning, therefore, to get sensible guidance to hospitals flowing forth from the Ministry of Health to Regional Hospital Boards, in their difficult job of building new hospitals. But, as I have said, it is far more important that we should be looking at the old hospitals, and seeing how far they come up to the standards laid down in these documents.

I noticed, for example, that in the section on "Wards", they say, quite rightly, that there should be one W.C. for every six patients. I was recently in a very famous London hospital where there was one W.C. for 32 patients, which is fantastic and uneconomic. It means that those patients have to use bedpans. We find that the Ministry—or rather one of their committees—has just produced another excellent report on "The In-patient's Day in Hospital", showing the pattern of the patient's day. It is actually by the Central Health Service Council, by a committee under Miss Powell. It is describing the silly things that happened in the past for traditional reasons or, indeed, for organisational reasons.

One of these things is getting people up too early. Another one is the bedpan round for people who do not need a bedpan and who are far better for getting up. Yet there is nowhere for these people to get up to. It is far better to build a sanitary column, containing four lavatories on each floor, attached to some old hospital which is going to be used for another 50 years, and to repeat that operation a hundred times, than to build a new 200-bed hospital somewhere else. Because we do not really want these extra beds; if we use our old ones properly, we need very few extra beds. All this chat about extra beds is largely eyewash. We do need extra beds in a few places, where there have been movements of population, but if we can get the existing beds good—and we can—the situation will be all right.

A great deal has been said, and very rightly said, about geriatrics; Lord Amulree and Lord Beveridge, and my noble friend Lord Archibald, and many others, have stressed the importance of the care by local authorities of the patients who are going to be discharged from the hospitals. My noble friend Lord Longford spoke of the use of the term "community care" as a sort of catch-phrase. I think it is a catch-phrase. I have never met community care; I do not know what it means. It is supposed to be local authority services to take the place of hospitals for mental patients and for geriatric patients. But it is not there. The noble Earl, Lord Feversham, was absolutely right in quoting this excellent speech that Professor Titmuss made, which was reprinted in the Spectator of March 17. when he told us of the staff of psychiatric workers employed by these local authorities, of the shocking numbers there are, and of how it would take getting on for 100 years, assuming the present rate of progress, to reach the 1948 establishment.

I personally have always believed, having watched the local authorities at work, that the only way we can get proper community care service is to base it from the hospitals. I think it is wishful thinking to say that we can get the local authorities to do it. Where it has succeeded it has come from the hospitals. There are a few local authorities who have made a real effort. York has made an effort; Nottingham has made an effort. In the case of York, I think a good deal of the impetus came from the local authority, but in the case of Nottingham I should have said the prime impetus has come from the hospital at Mapperley. There has been very good integration in the case of Oldham; the impetus has come from the hospital but there has been a good M.O.H.

It is a depressing sight to see the Government pinning its faith on community services which just do not exist. I think at the back of it is the financial situation; if you can off-load the cost of the National Health Service on to the local authorities, who are paid by block grants, that is a bit of saving of Exchequer taxation. It is an extremely short-sighted view. The noble Earl, Lord Feversham, said we should want £10 million for the first year to get these things going. He is quite right, but he will not get it. He has not a hope, because the Government have pledged themselves to use this block grant system, giving an overall grant to local authorities without earmarking for any special purposes. If he could get it, it would be wonderful, but I fear he will not.

This off-loading of patients from the hospital into the community is a very good thing if it can be done. I think we want to encourage keeping people at home, whether it be old folk or psychiatric patients. Do not let them go into hospital if it can be avoided, and when they are in, let them come out as quickly as possible. But do not ask general practitioners to do any more. There are too few general practitioners, and the supply of general practitioners is going down rapidly. This follows another Committee decision made about six, seven or eight years ago. This was the Committee on the Supply of Medical Manpower. My noble friend, Lord Cohen of Birkenhead, was a member of the Committee, the Willink Committee. It made a mistake. I must say I did not realise it had made a mistake until about a year or so ago, when we began to see the awful effects of its mistake. If you make a mistake when you are producing a simple item in a factory you can retool in about three months. If you are producing a motor car it takes two years. If you are producing a doctor, retooling takes at least six years or possibly seven. So we are bound now to get the doctors who have been in the pipeline, as it were, for the past six years, and we know we are going to be short because the Willink Committee made a recommendation, and the Government accepted it, to cut the intake into medicine by 10 per cent., which was absolutely fantastic.

What has happened? The general practitioners are worked off their feet. We know they cannot do better work until we can reduce their list sizes. It is the only way they have to do better work, because they have got too many patients to look after, and they are begging that we should reduce the list sizes. They say, "Why does not the Government reduce the maximum list and keep our salary the same, and we shall be able to give better service". They are absolutely right. There are a few large-list men who always make a great fuss and say they can look after 3,500 perfectly properly. But 99 per cent. of general practitioners will tell you that this is nonsense; and they are, of course, quite right.

If you push back the psychiatric patients too early on to the general practitioners you are facing them with an impossible job, especially if there are not the social workers available—and it is the same with geriatric patients. The hospitals are finding themselves in an increasing jam over staff. The Ministry, quite rightly, set up a joint Working Party under Sir Robert Platt to have a look at the problem, and here is their Report, Medical Staffing Structure in the Hospital Service. They say, "Let us bring the general practitioners in to help us out". A very good idea, because there is lots of work they can do. But they cannot come in; they cannot do any more. They are working in their surgeries at night, doing rounds all day. surgeries in the morning; a lot are doing industrial work, midwifery clinics and so on, arid they cannot come in. The right reverend Prelate, the Lord Bishop of Lichfield, mentioned the rather silly name proposed by the Committee for the general practitioners in this book, namely medical assistants. We used to call people senior hospital medical officers. That Committee proposes a new title of medical assistant. It is to be a career grade for those who do not quite make the grade as specialists. As a matter of fact, they will not be medical assistants. They will be standing on their awn; there is no question about that. You cannot, in a hospital, be a medical assistant; you have lo take responsibility for patients, and in fact they will.

This Working Party Report suffers from one defect, and it is a defect very common to Government documents: that is, that the people who wrote it are almost all teaching hospital staff. There is inadequate representation of the peripheral hospitals and the ordinary day-to-day hospitals of the Regional Boards where the great bulk of British medicine is now done. They were referred to by the noble Lord, Lord Hughes. It is not a bad Report; most of it is very good. Where the Working Party went wrong was because they did not know what life was like in these peripheral hospitals. One thing they have shown, and that is that a quarter of all the junior staff in our hospitals now is non-British. Our hospitals are relying on doctors from the Commonwealth, particularly from India and Pakistan. If you go into any hospital I'm the provinces the chances are that the casualty department will be manned by somebody who can hardly speak English.


And in London.


And, my noble friend Lord Stonham says, in London. We are being helped out by these excellent people who come over here. But it is not very satisfactory, because they are coming here to learn and not to do the job for us; and they are not able to give the service they ought to give because they cannot understand the patient, and in medicine that is an elementary essential. So the standard of work done is not all it ought to be, although these excellent people are saving our bacon, so to speak, because without them our hospital service would collapse. We are not getting the standard of work and they are not getting the standard of training they ought to have; and again it flows back to this fantastic decision of the Willink Committee, to cut the entry to medicine, and to the persistence in this of the Government, although I believe they have an interdepartmental committee looking at it now, and I hope they will get on and look quickly.

Now just a word about casualty departments, to which the noble Lord, Lord Auckland, referred. It is extraordinary that, until recent months, nobody has made any sort of study as to what goes on in casualty departments. Casualty departments are places into which anybody can drift—you can walk in because you cannot find a general practitioner, you can walk in because you have hurt yourself at work, or you can be carried in by an ambulance. So a hotch-potch of patients arrives in these casualty departments—some serious cases, some minor, some trivial. It is inevitable that this is so. If the minor and the trivial involve considerable delays in industry, it does not much matter, but speaking of the serious cases, that is a most serious matter.

In first aid and ambulance work our teaching is that any patient who is seriously injured must be brought to hospital within half an hour in order that the treatment for shock and blood transfusion can be started right away. The average time for an ambulance to get a person to a hospital in London is, I think, about 21 minutes, which is very good. But once there, they hang about for hours in the casualty department. The chap concerned cannot be found; he is doing something else. At present the casualty departments are just not properly staffed. One surgical colleague of mine, knowing what would happen to him if he were involved in a car smash, and knowing the varying service available, has suggested that he should have tattoed on each of his limbs the appropriate hospital to which he should be taken in the event of that particular organ being injured—and, knowing one's hospitals, that is not a bad idea. So we have to do something about casualty departments, to try to improve a few and to make them suitable for dealing with the really serious casualties, while not getting rid of the little ones which will deal with the light work.

That brings me to the whole question of staff deployment and the proper use of staff, which was such a key point made by my noble friends Lord Stonham and Lady Summerskill. We must use our staff properly, and we have not got to design our hospital structure in such a way that we penalise good work. We pay for inefficiency. If we pay a man on the size of his department he will try to make his department bigger in order to get more money. That is just common sense—anyone would. We must pay him according to the amount of work his department has to do in terms of population. Believe me, you can build up the waiting list if you want to, and if you are really enthusiastic—"No patient ever refused for operation"—if you are really out to make a case for yourself. It is vitally important that there should be in each hospital a continuous process of planning to meet human need and not to meet administrative or medical ambition, either of which can cause a lot of trouble.

My noble friend Lord Stonham stressed the question of staphyloccocol infection in hospitals. This is another case of a Government Report becoming a bible. There is the Cranbrook Report, which we are always hearing about, saying that about 80 per cent., I think, of midwifery should be done in hospitals. If one looks at the composition of the Committee one finds that it is composed largely of obstetricians, who are quite certain to say that there should be plenty of midwifery in hospital. Yet, given any good community with good housing, 50 per cent. of midwifery can quite well be done at home, and is welcomed by the mothers who do not have to leave their families. In our experience, if they are given the choice—and there are many examples where they have been given the choice—one finds that, given good housing, at least 50 per cent. of maternity cases can be dealt with in that way satisfactorily. Does my noble friend wish to intervene?


My Lords, my noble friend has humanity as well as wisdom. I would ask, who is to look after the family while the mother is having the baby?


My Lords, the answer is, theoretically, the home help, and dad. Anyway, we are seeing the folly of pushing, or trying to push, all these people back into hospital in case of staphy-loccocol infection in children. I must say that unless it is a jolly good hospital, there is something to be said for home delivery on purely safety grounds. My noble friend Lady Summerskill was absolutely right about this question of the need for humanity, and the need for teaching humanity to the staff and to everybody who is dealing with the expectant mother. We have seen the same thing happen with the children. There used to be this terrible regimentation of children in hospital. Somehow, we have got over that, as a result of the recommendations of the Platt Committee, and I think that most hospitals are now fairly humane. We want to have a little more humanity in the maternity ward. But there is one point: namely, that the mothers themselves are often apt to gossip endlessly about the details of their confinement. It is a little depressing for any of them who do not want particularly to gossip, or who may not yet have experienced it. My noble friend Lady Summerskill probably will have had the same experience in the maternity wards. It is a question of building up a different kind of morale and a different kind of approach.

Well, I have been very sketchy in my observations, and most amateurish in what I have said, and I am sure, in many respects, inaccurate. But I have tried to be provocative, and I hope I shall provoke my noble friend Lord Newton and perhaps the Minister and his Ministry.

7.47 p.m.


My Lords, we have had some powerful speeches this afternoon, and some fairly long ones. I do not think that is surprising when one considers the qualifications of those who have contributed to the debate. We have had speaking no fewer than four members of the medical profession. At one time there was going to be a fifth. Unfortunately, he dropped out. Then, among the many Members of your Lordships' House who have taken part, we have had (without putting them in any particular order) the Chairman of the National Association for Mental Health, the Chairman of the National Society for Mentally Handicapped Children, the former Chairman, until very recently, of a Regional Hospital Board, the Chairman of a hospital group management committee and a member of a board of governors, the author of the Beveridge Report, and the right reverend Prelate the Lord Bishop of Lichfield, who told us that he was a member of a Regional Hospital Board.

As I say, we have had a veritable feast of oratory and I have enjoyed it very much. I have listened to every speech. But I am a little concerned that your Lordships may feel that, among this galaxy of stars who have shone and twinkled with the brightness of their own knowledge and experience, I may, as it were, be no more than a cold and lifeless planet reflecting the light shed upon me by my right honourable friend and his Department. So I should like to say that my interest in this debate is not just an official one, because for ten years I was a member of the management committee of a large mental hospital group. I had to give pit up only recently. when I was appointed to the task of speaking on behalf of my right honourable friend in your Lordships' House. I was also at one time a member of the mental health sub-committee of my county council, which, of course, had to deal with the problems of the mentally handicapped, the mentally subnormal. If the noble Earl, Lord Longford, were here I should he only too pleased to tell him at some length that we were extremely successful then in co-operating with the hospitals to whom we sent the children and, indeed, the adults, for whom we were responsible.

The debate has covered a very wide field indeed, as it was bound to do, and I am in this dilemma. If I speak for too long I shall displease those of your Lordships who do not like long speeches, at any rate from the Government, at this time of the evening; and if I do not speak long enough I shall incur the displeasure of those of your Lordships whose speeches I have not answered. I will therefore try to strike a balance between these two extremes, and hope to be able to succeed. And, if necessary, of course, I will in due course write to noble Lords about points they have raised which I have had to ignore.

Although, as I say, the debate has ranged very wide indeed, those who have spoken have mainly been concerned with what one might call the long-term hospital plan of my right honourable friend: whether it is a good plan or whether it is a bad one, and whether it is calculated to provide full value for money, which so many of your Lordships, quite rightly, wish to see. So I should like to begin by discussing that and to take as my theme a sentence from my right honourable friend's speech to the National Association of Mental Health, about which so much has been said already in this debate. The sentence is this: The essential idea is to get on to paper a picture or statement of the pattern of hospital provision which we think right and practicable for this country in the mid-1970s. May I first point out that in the last few years there has been very considerable capital growth so far as the hospital world is concerned. For instance, the estimate of capital expenditure for 1958–59 was £20 million in England and Wales; for this coming year, 1961–62, it is £31 million; for 1962–63 it is £36 million; and by 1965–66 it is hoped to achieve £50 million. I suggest to your Lordships that that is quite an appreciable increase.

The Hospital Boards have been asked to prepare by May 31 programmes showing the work they would like to start in the 10-year period. Hitherto, it has not been possible to plan for more than two years ahead. For the first five years they have been given a financial framework in which to plan; and for the later part of the period they are asked to make an estimate of what is needed and what is practicable. Longterm planning will, it is hoped by my right honourable friend, help Boards, first, to decide the order of priority of future work, and, secondly, to organise the technical resources which they must have, both to undertake an expanding programme and to keep it going and sustain it. The intention is that, at any given time, there will be a firm plan, so far as possible, for five years ahead. For the later years it will be more adaptable in order to allow for developments. There are going to be new methods used to expedite the expanding capital programme and to try to ensure that value is obtained for the money spent. For instance, the maximum cost of new projects which Boards can undertake without prior Ministerial approval was doubled last February from £30,000 to £60,000.

When the preparation of a scheme is approved, a date for the start of building will be indicated so that the authority can carry this scheme straight through to completion in the knowledge that it will not be held up when preparation of the plans has begun. A system of cost limits is to be introduced in connection with a series of building notes, which the Department are now publishing; and this will obviate detailed examination of plans which conform in design and cost to the indications given in the building notes. My right honourable friend's Ministry is making available a great deal of planning information, and this is being done principally in these building notes. The noble Lord, Lord Taylor, was polite, I might almost say enthusiastic, about it; and I, in turn, would like to be enthusiastic about his building notes, of which he was kind enough to send me a copy, entitled "Hospitals of the Future", which he published in the British Medical Journal last September.

Of these building notes some eight have been published already. Number 1 has sold 4.500 copies and there is a second edition being printed now. About thirty of them, all told, will be published in quick succession. They will be revised as often as necessary to keep them fully up to date, in the light of experience and changes of technique and medical developments, and so on, and they will cover the main aspects of hospital planning and design. In due course, the Ministry will also be issuing building bulletins on selected departments, which will be even more detailed than the building notes. Furthermore, another series of publications will come out entitled Hospital Abstracts, and they are based on the contents of the many periodicals, books, reports and other material on hospitals and hospital services published in various countries.

The Ministry's own design and development unit is also itself designing a new out-patient department to be built at Walton Hospital, Liverpool, and a kitchen at Kingston Hospital, as practical demonstrations of its research work. The main object of all these measures is to tackle the immense task of hospital capital development as quickly and efficiently as possible. The need is to replace on modern lines accommodation that is obsolete, to re-site hospitals or to provide them, to meet the medical needs of the population, now very differently distributed, and to rationalise units at present uneconomic by having hospitals of the right size and in the right place. That, as succinctly as I can put it, is the basic aim of my right honourable friend, and I think it is, in part, an answer to the case presented by the noble Lord, Lord Stonham, in his speech, although I do not think it is the complete answer.

As regards the present progress of building, there are over 200 major schemes at the present time in the programme in the course of planning and construction. They include 43 new hospitals and six new dental hospitals. Ten new hospitals are partially complete and in use; seven are under construction; and 26 are at various stages of planning. As well as new hospitals, the programme of major schemes includes large new units and major extensions of many hospitals. I have a long list of them here. Furthermore, in addition to the major schemes, Boards' own programmes are achieving improvements in existing hospitals, which are helping to produce the maximum increased services from the resources available already. For example, considerable attention has been devoted to the development of outpatient work, because to-day the emphasis is on keeping the patient, if possible, out of a hospital bed altogether, and, if he has to be in one, on getting him home as soon as it can safely be managed.

My Lords, I understood Lord Stonham to argue, although it is a very long time ago now (or it seems to be a very long time ago now), that he is not convinced of the need for a large number of new hospitals because he thinks that more could be done by obtaining a quicker turnover in existing beds and in reducing the number of unused and under-used beds. I think that was the purport of his argument.

One of the most striking trends in hospital statistics recently has been the upward trend in the number of courses of in-patient treatment, while the volume of resources in terms of available staffed beds has been practically at a standstill at 475,000. The total number of courses of treatment rose from 3.65 million to 4 million, or by 10 per cent. In 1960 the figure rose to 4.1 million, and the percentage occupancy in 1959 was 87 per cent. But generally it must be right, of course, that we should make the best use we can of the resources we have, and riot hang on to those for which the need is past. The National Health Service Advisory Council for Management Efficiency has turned its attention to the problem of bed use, and some very good advice on this subject has been given in a circular from the Department and in a Report by a study group of the Hospital Administrative Staff College.

My Lords, I must say something, I think, about the long-term planning of hospital services for the mentally ill, and about the estimate of what was likely to happen which was made by my right honourable friend in his speech to the National Association of Mental Health. I was very glad to hear my noble friend Lord Feversham say that his Association, at any rate, supports the blueprint (those were his words) of my right honourable friend's plan. My Lords, I want to make it quite plain (because the noble Earl, Lord Longford, was in some doubt about it) that in his speech my right honourable friend was not concerned at all with hospitals for the subnormal, but with hospitals for the mentally ill; and his estimate was based not on pious hopes of what may be achieved but on a statistical projection based solely on what did, in fact, happen during the years 1954 to 1958. Of course, the main reason for the dramatic changes which my right honourable friend foresaw is the development of improved methods of treatment, many of which are very recent indeed.


Would the noble Lord allow me to interrupt him? I am quite sure he would not wish there to be any doubt on this point. I did not refer to the question of the mentally subnormal, but I should like to point out that, in his speech, the Minister said: Far from contemplating the certainty of a heavy run-down in numbers, we have here to reckon with the increase which flows automatically from the increased expectation of life of the subnormal …. In other words, he envisages not curtailed facilities, but possibly extended facilities.


Yes. I am going to say something shortly about the mentally subnormal, but what I was concerned with was that part of the Minister's speech in which he talked about this coming statistical decline in the number of beds needed in mental hospitals: not, as I was trying to make plain, in hospitals for subnormal patients.

I had intended (though I will not do so now) to go into some detail and to explain how this statistical projection was worked out, but at this late hour I think that is one of the things which I had better leave out, even though I had wanted to devote a good deal of attention to it. I will simply say this, if I may: that on balance it is quite clear that over the coming years there will be a large, progressive decline in the number of beds needed for mental illness, and this must be taken into account in planning; but plans will be sufficiently flexible to be adjusted if, for example, the reduction in bed needs does not come about as quickly as expected.

My Lords, mention has been made of the effect upon staffing. I recognise that reports of a likely reduction in the number of hospital beds have given rise to some anxiety on the part of mental hospital staff—a point that has been referred to in this debate. The Minister, however, wishes me to emphasise that there are no grounds for such anxiety, because a reduction in the number of beds does not mean a reduction in the psychiatric hospital services. A greater amount of active treatment will be given in a smaller number of beds, and there will be no reduction in the opportunities for the special skills of the psychiatrist and the trained mental nurse. It is only long-stay beds that will be affected by the decrease in the total bed needs, and these are precisely the beds where staffing is lightest at present. The amount of active treatment being given is increasing, and the demand for beds for short- and medium-stay patients, which already have the highest staffing levels, will, if anything, increase. Finally, there is the need to deal with overcrowding and nursing shortages, which are still problems with some hospitals. So, my Lords, mental nursing is certainly not a dying profession.

In his speech, my right honourable friend described cogently, and I think graphically, all the factors, physical and human, which militate against new thinking about mental hospitals and the treatment of mental patients. I believe that unless everyone who is in a position to do so does push the change, then change will not come; and I am quite certain that my right honourable friend is right to stress this theme. Indeed, if he did not do so he would probably be failing in his duty as Minister.

The noble Earl, Lord Longford, spoke to us, in a moving speech, about hospital accommodation for the subnormal, and their care. My Lords, there has been an appreciable increase in the number of available beds in hospitals for the subnormal. For instance, between 1954 and 1959 the number of staffed beds increased from 54,561 to 58,904. There are also a number of large schemes in progress, or in the planning stage, which are designed to relieve the pressure on hospital beds where it is most acute. On the other hand, despite these efforts, the increase in beds has not been accompanied by a decrease in the number of patients awaiting admission; and I think we have to recognise, as my right honourable friend said—and I quote his own words: When we look at the future provision for the subnormal, the prospects for change must seem far less dramatic—certainly if we discount, as we prudently ought, the chance of some medical break-through on this front. The noble Earl, Lord Longford, as we know, is Chairman of the National Society for Mentally Handicapped Children, and I am sure that local authorities and hospitals are glad to have both the constructive suggestions of the Society and, of course, their criticisms, too. I understand that its membership has increased, and that is something that is most pleasing. Of course, the views of parents are welcomed by these hospitals, and one hopes that parents support the "League of Friends", which most of these hospitals have. That is perhaps the best way, I should think, by which the parents could make their views and wishes known. The noble Earl suggested that there ought to be a parent of a subnormal child on each management committee. My Lords, that is an interesting suggestion. It is, of course, a matter for the Regional Hospital Boards whom they appoint to hospital management committees, but it may be that Lord Longford is not aware that only a small proportion of patients in these hospitals, perhaps 12 per cent., are under the age of 16.

Cross-infection in hospitals has been mentioned by the noble Lord, Lord Stonham, and I think by the noble Lord, Lord Taylor. The importance of this subject was recognised by the appointment in 1957 of a special sub-committee of the Minister's Standing Medical Advisory Committee, under the chairmanship of the noble Lord, Lord Cohen of Birkhenhead. The sub-committee's report was published; copies were sent to all hospital authorities, and they were asked to consider urgently how the recommendations in that report could be implemented. It is recognised throughout the hospital service that this is a subject, on which constant vigilance is necessary, and hospital authorities were advised to set up control-of-infection committees and to appoint control-of-infection officers for each hospital.

As regards the problems of cross-infection in maternity hospitals, I am in the presence of three distinguished doctors here and would not, as a layman, discuss the merits of a highly technical research project. I am referring, of course, to the article in the Lancet. But maternity hospitals are no different from others with regard to the urgency of solving this problem of cross-infection. It may be that the high turnover of patients is a factor which needs examination, and it would be my right honourable friend's hope, indeed his expectation, that all hospital authorities with maternity hospitals or departments in their charge would be aware of this and similar studies, and would be vigilant to improve their own performance, whether the local situation compared with that described in the article or not. My right honourable friend has recommended that hospital authorities take the initiative in establishing with the local authorities and general practitioners in their area maternity liaison committees which could usefully discuss common problems of this kind. My right honourable friend understands that such committees are now common, and he is inquiring into their functioning in circumstances where no committees yet exist.

My noble friend Lord Auckland, and my noble friend Lord Taylor, raised the question of the hospital casualty and accident services. I know that there has been for some time disquiet about the organisation of these services, and this disquiet received a great deal of publicity last autumn, following the Report of the Nuffield Provincial Hospitals Trust. Before the Report was issued, the Standing Medical Advisory Committee of the Central Health Services Council had appointed a sub-committee, under the chairmanship of Sir Harry Platt, to consider the organisation of hospital casualty and accident services, and to make recommendations regarding their future development. The Platt Committee is looking at the whole field and has a lengthy task. It is examining statistical and written evidence, and when it has made its report the Standing Medical Advisory Committee will consider it. The provision of adequate accommodation is, of course, one of the main problems, as my noble friend Lord Auckland recognised.

My Lords, my right honourable friend's Department will be issuing a building note to give interim guidance to all hospital authorities on the design of casualty and accident departments, pending the outcome of detailed studies and the Report of the Platt Committee. I understand that when the hospitals are being phased now, the great majority of out-patients of casualty departments are in phase 1. The noble Lord, Lord Taylor, referred to the publication of the Pattern of the In-Patient's Day. This is a first-class Report, which has had a generally favourable reception, and the hospitals have been asked to study it. I do not think I need say any more about it.

The noble Baroness referred to the Standing Maternity and Midwifery Committee's Report on "Human Relations in Obstetrics." This report says, in brief, that there are widespread complaints that mothers are not considerately treated in maternity hospitals and departments, and the noble Lady elaborated on that theme. My right honourable friend has commended the Report to the hospitals, and has asked them to discuss it with their staffs and to report on initial action by July 31. He has stressed that much devoted work goes unpublished, though not unrecognised, and the general approach of the Report is one that commands attention elsewhere in the hospitals, and outside them. Nevertheless, he does not believe that a general charge of inhumanity can be brought against the staffs of maternity departments. It is clear, however, that the human approach to the running of hospitals and the giving of treatment is of great importance, and that it is essential to look to these points.

The noble Lord, Lord Amulree, and many others of your Lordships, discussed the obligations of the local authorities to carry out their responsibilities of caring for the old; and reference has been made to the joint circular of my two right honourable friends to the local authorities, which calls on housing, health and welfare authorities to plan together, in conjunction with voluntary organisations, to ensure that the needs of old people are fully met. It is perfectly true that the ideas concerned in this circular are not new, as has been pointed out to us. But the circular fulfils two useful purposes: in bringing the ideas together in one document, and in reminding the local authorities where their duties lie. The question to ask individual local authorities is how far they are, in fact, carrying out the suggestions in the circular, even though the suggestions are not new; and your Lordships have indicated pretty clearly this afternoon that you attach very great importance to the carrying out of those functions.

I might point out—and I think this would help to answer the question which my noble friend Lord Feversham put to me—that the capital investment programme for local residential accommodation has gone up pretty sharply. For instance, the average capital available for loan sanctions during the three years between 1956 and 1959 was £2.6 million, and the estimate for 1961–62 is £10 million; so they are getting a lot more. On the housing side, which my noble friend, Lord Amulree was particularly concerned with, the recently published White Paper, Housing in England and Wales, emphasises the priority which the Government attach to satisfying the demand for special housing for old people. Some progress has already been made, but authorities are now being encouraged to step up the pace of the provision.

Now I come to the question of the Whitley system of pay and the ancillary professions, because they have been discussed by so many of your Lordships, I would ask your Lordships to be realistic about all this. To-day, because we have been discussing hospitals and the medical services, I have been told that these people ought to be paid very much more money. If we had been discussing education, I should have been told that the teachers ought to be paid very much more. If we had been discussing the police, I should have been told the police ought to be paid more.


They have had their rise.


I know that, but I should have been told they should get more still—I am certain of that. If we were discussing the Armed Services, no doubt we should be told that the retired members of the Forces ought to be paid higher pensions in order to encourage recruiting. You must be realistic about this, my Lords. I have heard that sort of thing so often.

May I also point out to your Lordships that, whatever you may say about salaries, there have been many gratifying increases in the numbers of these auxiliaries in the last ten years? For instance, the number of dieticians has gone up by 25 per cent.; the number of medical laboratory technicians (in whom the noble Viscount, Lord Waverley, was particularly interested) has increased by 54 per cent.; occupational therapists by 93 per cent.; physiotherapists by 23 per cent.; radiographers by 55 per cent.; and remedial gymnasts by 53 per cent.

There has been considerable criticism of the Whitley system, a form of collective bargaining for which, as the noble Lord, Lord Taylor, said, his Party was responsible. It works very well on the whole, and if it were to be jettisoned, as has been suggested. I really do not know what could be put in its place which would work more satisfactorily, nor has any noble Lord suggested in this debate a system which would convince me would work more satisfactorily. The object of the Whitley negotiations is to determine salaries which are fair and reasonable, having regard to the duties performed, in relation to the salaries of persons doing comparable work elsewhere. As the hospital service is a public service the appropriate comparisons are with other public services. Industry is concerned only with its immediate needs Salaries in the hospital service are determined on the basis that they are applied uniformly throughout the service as a whole. Any attempt to compete with the salaries offered by industry would have no other effect than to raise the bidding, and, in the end, the result would he to bring no benefit to the hospital service and to increase the cost put on the taxpayer.

We recognise that over the country as a whole there is a great demand for persons with professional qualifications, university degrees and technical skill and experience of all kinds, not only in the hospital service but also in other public services, and, of course, in industry. Nevertheless, in my right honourable friend's opinion and in mine, the hospital service gets a fair and reasonable share of the available pool. What we are concerned with is the size of the available pool. There are not sufficient young people to fill all the available posts. Since 1948, the hospital service has had to staff an expanding service at a time when other services were also expanding. I hope that the bulge in the birth rate, the effects of which are beginning to show themselves, will produce more recruits in the coming years. Staffs are predominantly female and wastage through marriage is high, as the noble Viscount, Lord Waverley, said.


My Lords, I do not like the word "wastage".


I apologise to the noble Baroness. There has been a steady growth in the number of technical staff employed in the hospital service, as I hope your Lordships will have noted from the figures which I gave earlier.

I am afraid I have covered barely half the topics I had intended to cover because they 'were' mentioned by noble Lords, but I feel that the moment has come when the time factor should begin to operate, and I. hope that your Lordships will agree. I will write to noble Lords with whose points I have not been able to deal. Finally, I should like to say this. A few days ago my noble friend Lord Taylor and I had a discussion about the objects and usefulness of debates of this kind. I think that my noble friend will agree that on the whole this debate has fulfilled what we thought its object ought to be. I would add my thanks to the noble Lord, Lord Stonham, who initiated the debate, and to those noble Lords who have contributed. I have certainly enjoyed listening to them very much. Of course, I will see that proper attention is taken of everything that has been said. At the same time, for a reason which I think will be apparent to most of your Lordships, so far as a great deal of this debate is concerned it is not necessary for me to say, in the time-honoured phrase, that I will bring the points to the attention of my right honourable friend.

8.25 p.m.


My Lords, the noble Lord, Lord Newton, was kind enough to refer to those of us who have taken part in this debate as a galaxy of stars who have shone and twinkled, and exempted himself from the galaxy on the ground that he was a layman. In the end, he in his winding up speech revealed himself as a minor planet. One of the pleasantest things about your Lordships' House is the complete confidence which we repose in each other. This is exemplified by the way in which noble Lords make their speeches and then depart to keep urgent appointments elsewhere, in the comfortable knowledge that in to-morrow's OFFICIAL REPORT they will read nothing but good said about them by those who mentioned them after they had departed. I am not going to break this happy rule.

The masterly and comprehensive winding-up speech of my noble friend Lord Taylor has left me with little to say, except to express my grateful thanks to all noble Lords and to my noble friend Lady Summerskill, who have taken part in this debate. I agree with the noble Lord, Lord Newton, that it has been a useful debate, ranging widely, and one which I believe will repay the careful study which I feel sure it will be given. I am sorry that the noble Earl, Lord Feversham, has gone, because I should particularly like to thank him for being virtually the only noble Lord who disagreed with me in this debate.


My Lords, I think that I ought to be included among that number.


I am sorry, I take it automatically that the Minister winding up would disagree in some particulars.


My Lords, I cannot accept that either.


My Lords, I would also thank the noble Earl, Lord Fever-sham, for the manner of his disagreement, because I think that we shall find, when we read his speech to-morrow, that I am correct in thinking that he agreed with the Minister's broad principles and thus disagreed with me, but agreed with me in all details and thus disagreed with the Minister. I am content, if all my detailed suggestions are adopted, to let the broad principles take care of themselves.

I was pleased that every noble Lord who spoke supported what was said about the old people, and I was glad that the noble Lord, Lord Newton, could assure us that local authorities are being encouraged to step up the pace. We shall look on this with interest. I was rather disappointed about what the noble Lord said about salaries for ancillary staffs, particularly when he said, "You must be realistic". When a poor chap is receiving £l.230 for precisely the job for which he can get £1,800 in another Government service, then it is being realistic when he leaves the hospital service and goes to another branch of the Civil Service to do the same job. It is the same with industry. I hope that this matter will be looked into much more seriously, because we cannot go on efficiently in the hospitals without these people.

I am grateful for the other assurances which the noble Lord gave. It will be a great relief to people in mental hospitals to learn that plans will be sufficiently flexible for adjustments to be made, if reduction in bed needs does not prove to be as great as expected, and that mental nursing is not a dying profession. I think that they really needed some assurances on these matters. I hope that the debate has proved useful and that, as it is studied as the months go on, we shall see something practical coming from it. I ask leave of the House to withdraw my Motion.

Motion for Papers, by leave, withdrawn.