Lords Sitting of 14 February 1962

Preamble
The House met at two of the clock, The LORD CHANCELLOR On the Woolsack.
Prayers—Read by the Lord Bishop of Salisbury

Sherard Falkner, Lord Bishop of Winchester—Was (in the usual manner) introduced.
LORD LEIGHTON OF SAINT MELLONS
Sir George Leigh ton Seager, Baronet, C.B.E., having been created Baron Leighton of Saint Mellons, of Saint Mellons in the County of Monmouth—Was (in the usual manner) introduced.

BERLIN INTERNATIONAL AGRICULTURAL FAIR
2.23 p.m.
LORD WALSTON: My Lords, I beg leave to ask the Question which stands in my name on the Order Paper.
[The Question was as follows:
To ask Her Majesty's Government what are the reasons for the absence of a United Kingdom stand at the international agricultural fair known as the "International Green Week" held in Berlin during the first week of February.]
THE JOINT PARLIAMENTARY SECRETARY, MINISTRY OF AGRICULTURE, FISHERIES AND FOOD (EARL WALDEGRAVE): My Lords, the policy of the Government is to leave it to the initiative of British manufacturers to decide for themselves, as a matter of commercial judgment, whether or not to take part in particular trade fairs. I am informed that no British firm expressed a wish to take part in the International Green Week, either directly or through an agent, and that no request was received from industry for assistance in arranging British participation in this exhibition. If a reason-
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able number of firms had been prepared to take part in the exhibition, the Board of Trade would have been glad to consider helping them to organise a suitable stand.
LORD WALSTON: My Lords, would the noble Earl be prepared to look once more at his information, because there were two British firms represented there in the shape of two tractor manufacturers? What was so conspicuously lacking, however, was any official or general United Kingdom stand, which stood out by its absence in the British Sector of Berlin and was particularly noticeable in view of the representation there of virtually every other country in Europe, even such countries as Israel and the Lebanon.
EARL WALDEGRAVE: My Lords, I am aware that certain tractor manufacturers were present at this show through their international organisations. They were big international firms which have a big British interest. The question of a prestige exhibition put up by the Government would fall to my noble friend the Secretary of State for Foreign Affairs. There are no doubt very good reasons why it is not possible for this country to put up prestige exhibitions at every fair wherever it is held.

COST OF ROAD TRAFFIC SURVEY
2.25 p.m.
LORD TAYLOR: My Lords, I beg leave to ask the Question which stands in my name on the Order Paper.
[The Question was as follows:
To ask Her Majesty's Government the cost per interview of the survey of road traffic users in the greater London area in total and divided into actual interviewing costs and costs of analysis of the material obtained, and the cost per interview of surveys carried out by the Government social survey in total, and analysed in the same way, in each of the latest three available years.]
THE PARLIAMENTARY SECRETARY, MINISTRY OF TRANSPORT (LORD CHESHAM): My Lords, the total cost of the whole survey is estimated at £425,000. The total cost of the home interview part of the survey is estimated

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at £144,000, of which £65,000 is attributable to the actual interviewing and £36,500 to the coding and first stage analysis of the information. The remaining £42,500 is for the drawing of samples and for the preparation of zone plans and a coding index, which are also required for other parts of the survey. On this basis the average cost of the actual interviewing is 26s. per household or about 9s. per person. The average cost of first stage analysis is 14s. 7d. per household or 5s. per person. These figures include expenses and overheads.
It is not possible to make any useful comparison with the costs of recent surveys carried out by the Social Survey Division of the Central Office of Information. The average cost per interview of these surveys varies widely according to the survey technique employed, the number and complexity of the questions asked, and whether the sample is spread over a wide area or concentrated in a more limited one.
LORD TAYLOR: My Lords, I thank the noble Lord for that Answer. Am I correct in thinking that, of the total of £425,000, he has left about £300,000 completely unaccounted for? Could the noble Lord explain where that £300,000, which he described as being outside the scope of the survey, is going to?
LORD CHESHAM: Yes, my Lords, I could do that and, indeed, I probably would have done had it been the information for which the noble Lord asked in his Question. But I feel, since his Question related to the home inter view section of the survey, the £300,000 really ought to be the subject of another Question and does not really arise on this one.
LORD TAYLOR: My Lords, with all due respect, was not the information I asked for the cost per interview of this survey in total? As I understand it, the noble Lord has sloughed off £300,000 by saying that it was not part of the cost of interview or the processing of the data.
LORD CHESHAM: Yes, my Lords; I was quite aware of what the noble Lord had asked and I thought I gave him a quite clear and unequivocal
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Answer—namely, the cost of the inter view. The noble Lord did not ask about anything else. However, I do not want to be unfriendly about this, and may I, in order to help him—although I do not propose to go into any more detail about it—draw his attention to the fact that there are eight different channels of collection of in formation of which the home interview is one. I can be quite brief. We start with home interviews. Then we have interviews of goods vehicle operators; roadside interviews at the boundaries of the survey areas; roadside interviews at the Thames crossings; a study of bus and coach journeys; a study of taxi journeys; a study of journey times and a study of volume counts. Those are all part of it.
THE EARL OF SWINTON: My Lords, may I ask my noble friend whether he could put in the Library—perhaps we have already been supplied with this—a copy of the questionnaire which is being addressed to all these householders so that we ourselves might have some chance of appraising the value of this?
LORD CHESHAM: My Lords, I will certainly consider doing what the noble Earl asks. It also occurs to me that perhaps I ought to put his name on the list of interviewees.
THE EARL OF SWINTON: Do I get the £300,000 if I join the panel?
VISCOUNT HAILSHAM:No; 14s. 7d.!
LORD CHESHAM: My Lords, I am afraid the noble Earl may expect no better result than the noble Baroness, Lady Wootton of Abinger, had last week.

NUCLEAR TESTS ON CHRISTMAS ISLAND
2.30 p.m.
LORD FARINGDON: My Lords, I beg leave to ask the Question which stands in my name on the Order Paper.
[The Question was as follows:
To ask Her Majesty's Government why it has been found necessary to use Christmas Island as a nuclear testing ground rather than the Pacific areas already used by the Americans for these purposes.]
THE LORD PRESIDENT OF THE COUNCIL AND MINISTER FOR SCIENCE (VISCOUNT HAILSHAM): My Lords, for technical reasons, it was agreed between the United States Government and Her Majesty's Government that of all possible sites only Christmas Island would be really suitable for a new series of tests. The Marshall Islands group, in which the United States con ducted some of their earlier tests, is a United Nations Trusteeship Territory. President Kennedy has said that he is anxious to maintain the spirit as well as the letter of the Trusteeship Agreement. Christmas Island has only a small population and is remote from large centres of population.
LORD FARINGDON: My Lords, arising from that reply, I would ask the noble Viscount whether he would not agree that one's attitude towards this facility put at the disposal of the American Government must depend on one's view of the usefulness and also the dangers of this particular testing. There fore I would ask the noble Viscount whether he is aware that many people in this country—and well-informed people—are considerably disturbed and alarmed by the prospect that a territory under our control, and for which we are responsible, is going to be contaminated by these tests, and whether Her Majesty's Government will not reconsider the whole question.
VISCOUNT HAILSHAM: My Lords, as regards the first part of the supplementary question, I would point out that the noble Lord's Question related to the relative advantage between Christmas Island and some other territory. Therefore the first part of the supplementary question does not arise, since the noble Lord's question related to the desirability of the tests at all. As regards the second part of the noble Lord's supplementary question, the noble Lord will be aware that Christmas Island was used as a base for the United Kingdom megaton tests in 1957 and 1958. Precautions were successfully taken then to prevent radio active contamination, and the same will be done again.

UNITED NATIONS FORCES AND KATANGANESE TOWNS
THE EARL OF SWINTON: My Lords, I beg leave to ask the Question which stands in my name on the Order Paper.
[The Question was as follows:
To ask Her Majesty's Government whether it is true that United Nations representatives in the Congo have threatened to occupy with armed forces the towns of Kipushi, Kolwezi, Jadotville and Kamina or any of them; whether law and order are not effectively maintained in these towns at the present time; and whether armed occupation would not be contrary to the policy which the Secretary of State for Foreign Affairs advocated in his last reply to a Question in this House, and likely to frustrate the negotiations in progress between President Tshombe and the United Nations.]
THE SECRETARY OF STATE FOR FOREIGN AFFAIRS (THE EARL OF HOME): My Lords, I understand that the United Nations representatives in the Congo have discussed with Mr. Tshombe the sending of United Nations troops to Kolwezi and Jadotville. I am assured that the intention of the United Nations is to move these troops with the agreement of the Katanga Provincial Government. Such joint action by the United Nations and Mr. Tshombe would appear to be consistent with the Kitona Agreement. Her Majesty's Government have repeatedly said that the role of the United Nations is to assist in a reconciliation between Mr. Adoula and Mr. Tshombe and they trust that nothing will be done to disturb the progress being made in this regard.
THE EARL OF SWINTON: My Lords, while thanking my noble friend for that Answer, which I am sure will be received with great satisfaction in all quarters of the House, may I ask him whether he is aware that there were most substantial reports, I think from Associated Press, on which I put down my Question, and whether it would be possible to make sure that such reports do not circulate unless they have active foundation?
THE EARL OF HOME: My Lords, I think that is perhaps asking rather a lot.

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I cannot control what reports newspaper correspondents send from the Congo or, indeed, anywhere else. I hope there is no substance in these reports; that is why I have laid such great stress upon any action which is taken by the United Nations being taken in conjunction with Mr. Tshombe, because I think it would be an utter disaster if, after these weeks when the fighting has ceased, and when progress has been made between Mr. Adoula's Central Government and the Provincial Government of Mr. Tshombe, fighting were to break out again.
LORD HENDERSON: My Lords, may I ask the noble Earl whether it is not true that the negotiations between the Provincial Government of Tshombe and the Central Government are making satisfactory progress and with the prospect of agreement being reached?
THE EARL OF HOME: My Lords, I have no reason to think that the talks are not making satisfactory progress. The representatives of Mr. Tshombe are in Leopoldville and they are, I understand, working out with representatives of the Central Government and Members of Parliament in Leopoldville the application of the Loi Fondamentale. It is probable, I think, that they will take a considerable time, because constitutional matters are very complicated. I do not want to see, in any other Provinces in the Congo, any action which would upset this peaceful progress.

BUSINESS OF THE HOUSE
EARL ST. ALDWYN: My Lords, in view of the number of speakers in this afternoon's Debate, dinners will be avail able, and I should be grateful to noble Lords if they would "warn in" to the Refreshment Department as soon as possible.
GRIMSBY CORPORATION BILL [H.L.]
Read 2a, and committed to an Un opposed Bill Committee.
LONDON BRIDGE IMPROVEMENTS BILL [H.L.]
Read 2a, and committed to a Select Committee.
WALLASEY CORPORATION BILL [H.L.]
Read 2a, and committed to an Un opposed Bill Committee.

SAINT PETER'S CHURCH, NOTTINGHAM, CHURCHYARD BILL [H.L.]
2.37 p.m.
THE CHAIRMAN OF COMMITTEES (LORD MERTHYR): My Lords, I beg to move that this Bill be now read a second time. Your Lordships will remember that when I moved the Second Reading of the Independent Chapel Mawdsley Street Bolton Bill last week, I made a statement under Standing Order 91 in which I mentioned this Bill as containing provisions dealing with the disposal and development of graveyards. Several of your Lord ships, I know, are interested in Bills containing these provisions, but I suggest that it would be for the convenience of the House if any comments on these Bills could be postponed until the resumed Second Reading debate on the Bolton Bill, when the question can be thoroughly gone into. At the moment, no date has been fixed for the debate, but I will put it down on the Order Paper as soon as conveniently possible.
Moved, That the Bill be now read 2a,—(Lord Merthyr.)
LORD FARINGDON: My Lords, I should like to thank the Lord Chairman for his statement, and for his offer of a debate. As he has said, I am one of those Peers who have been somewhat alarmed by a number of these Bills which have come forward for the con version or decentralisation, or the de-sanctification, whatever you like to call it, of graveyards. Some of us are very anxious about this process. These grave yards, of course, since they are disused, are attached for the most part to old churches and are in the very centres and parts of towns where they form extremely valuable lungs.
This Bill to-day seems to me to have a disadvantage which most of the others do not have. That is that, owing to the fact that the Promoters have a right to build (and I may say at once that the purposes for which they build are not

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such that I should dream of objecting to them: they desire to build, I under stand, a new church hall, a new vestry and other premises required for clerical ecclesiastical purposes), their position vis-à-vis the planning authority is con siderably changed. Instead of the churchyard being zoned as an open space, so that it may not be built on without the agreement of the planning authority, the right to build which will be given by this Bill, when it becomes an Act, puts this particular case in Class 12, under which all the local planning authority can do is to say that they do not like the place, the position or, I imagine, the kind of building, and can indicate some other place where they think it had better be put. But they cannot prevent its erection, and your Lordships will therefore appreciate that the position here is somewhat different from that under other Bills. It is not my intention to contest the Second Reading, but I am most grateful to the Lord Chair man for his promise that we shall he able to discuss this matter.
LORD MERTHYR: My Lords, I am grateful to the noble Lord for allowing a Second Reading of this Bill. In return, I will undertake to provide an occasion for a debate on the Second Reading, as adjourned, of the Bolton Bill, which is somewhat, though not wholly, similar; and I hope the noble Lord will be con tent if he has the opportunity of raising the whole subject in debate on that occasion. As to what he has said this afternoon, I do not demur at all; in fact, he said very much what I said last week, if I may say so. I hope, therefore, that the House will give a Second Reading to this Bill now, on the understanding that we shall have an opportunity for further debate on this subject though not per haps on this particular Bill.
LORD DOUGLAS OF BARLOCH: My Lords, may I ask whether it would not be better to adjourn also the Second Reading of this Bill until that debate takes place, and thereby give the House an opportunity, if it should so desire, of expressing an opinion upon this Bill?
LORD MERTHYR: My Lords, of course the House will in any event have a further opportunity of expressing an opinion on Third Reading. If it should
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be the wish of the House to adjourn this debate I could not oppose it, be cause it would be merely adopting the same process as we did on the Bolton Bill. On the other hand, I hoped that we might give a Second Reading to this Bill, and then, as I have said already, have a full opportunity for debate on a special day. But I am in the hands of the House, and if the House wishes this debate also adjourned, I shall be glad to agree. Perhaps if the noble Lord wishes to move the adjournment of the debate he will do so. But if he does not, I shall assume that he is agree able to debating this matter on a day to be fixed.
LORD SILKIN: My Lords, there is just one short point I should like to make. I am a little concerned that it is possible to put in a Bill a provision which ousts the jurisdiction of the planning authority, so far as planning is concerned. In the normal course of events it is, of course, for a planning authority to say whether the particular area in question is a desirable area for the erection of a building. As a result of the insertion into the Bill of the pro vision which has been mentioned, the planning authority no longer have that power. I hope that the Committee to which the Bill is referred will take that fact into consideration and will consider whether this is a desirable power to have inserted in a Bill. Whether we can discuss this when the Bolton Bill comes up, I do not know, but I imagine that a similar principle will arise there. This is a matter which concerns me, and I am sure must concern other noble Lords. We want to keep the local planning authorities perfectly free to make up their minds on the matter of what is and is not desirable to be erected on a piece of land.
LORD MERTHYR: As I said in my statement which I made on Standing Order No. 91, there are these three Bills dealing with much the same point, though not entirely; and the Nottingham Bill does go a little further than the other two. Incidentally, your Lord ships gave a Second Reading the other day to one of them, the Manchester Corporation Bill, but nobody commented then on this provision. How ever, I have already undertaken that we

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shall have a debate on the third point which the noble Lord, Lord Silkin, has just raised. It is not quite true to say that it deprives planning authorities of all their powers. It does not, if I may say so. But I do admit that it does diminish the powers of the planning authority. On the other hand, these Bills are by no means uncommon in your Lordships' House, and I might mention that this Bill is unopposed. Nobody has petitioned against the Bill, so that I felt perhaps justified in asking for a Second Reading this afternoon. Nevertheless, as I have said, if any noble Lord were to move that this debate be adjourned I should not resist the proposal; I am merely wishing to proceed as expeditiously as possible.
LORD SILKIN: My Lords, I hope that we shall not regard it as a precedent that, because there is no opposition to a Bill, therefore it is not our business to scrutinise it as carefully as if it were opposed.
LORD DOUGLAS OF BARLOCH: My Lords, I beg to move that this debate be now adjourned. I do not want to spend time arguing the matter, but I respectfully submit that it would be very much tidier if this Second Reading were also adjourned. It can come up on the same date as the other Bill, when the discussion will be resumed, and it will leave the House much more in control of the position.
Moved, That the debate be adjourned. —(Lord Douglas of Barloch.)
On Question, Motion agreed to, and debate adjourned accordingly.

LARGS BURGH ORDER CONFIRMATION BILL
Brought from the Commons; read 1,a, and (pursuant to the Private Legislation Procedure (Scotland) Act, 1936) deemed to have been read 2a and reported from the Committee.

THE HOSPITAL PLAN
2.47 p.m.
LORD NEWTON LORD NEWTON rose to move to resolve, That this House approves Cmnd. 1604, entitled A Hospital Plan for England and Wales. The noble Lord said: My Lords, to turn now from the care of the dead to the care of the living, I beg to move that this House approves Command Paper 1604. Those of your Lordships who are familiar with the works of Edward Lear will recall that he made for ever memorable a voyage of adventure in search of a ring which lasted a year and a day. It is exactly a year and a day since I informed this House that, at the request of my right honourable friend, the hospital authorities had embarked upon preparation of their capital programmes over the next ten years. The search was for the Plan which is described in great detail in this Command Paper; and I am very conscious of my good fortune in being the first Member of the Government in either House of Parliament to introduce a debate upon it; because it is no exaggeration to say that January 23, the date on which this Command Paper was published, was one of the most momentous days in the history of the National Health Service and, indeed, in the history of the nation's hospitals. Here now is the opportunity to build a hospital service equal to any in the world and matched, I would think, by very few. The contents of this Command Paper represents the intention of the Government and of the Hospital Service to rise to that opportunity.
My Lords, my right honourable friend Mr. Powell has publicly deprecated any description of this Plan as being his plan. In his view it is a case of a corporate entity, which is literally the whole Hospital Service, saying to the public: "This is what we are planning to do for you over the next ten to fifteen years. We may well be able to improve on our proposals as we go along from year to year. Let us therefore have comments and suggestions ".
Moreover, as was pointed out by Sir Harry Platt in a notable letter to The Times on January 31, this Plan is the public expression of the culminating phase of many years of thinking and planning, which began with the hospital

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services of the late 1930s. Nevertheless, I should not be doing justice to my convictions if I failed to say that my right honourable friend has been at once the inspiration and the driving force behind what Sir Harry Platt has called, the "culminating phase." This Paper bears unmistakably the stamp of his intellect and his imagination and enthusiasm. I trust that your Lordships will not think that, because on this occasion I happen to be his mouthpiece, I ought therefore to have concealed my personal feelings and omitted to give brief credit where it is so richly due.
This Plan is nothing less than a plan for the modernisation of our hospital system. Its purpose is twofold; first, to make clear the sort and size of hospitals which we ought to have if we are to make the best use of the specialist techniques of our time, together with the general practitioner services and the domiciliary services; and secondly to indicate the programme of hospital building which the Government consider will be practicable in the next ten to fifteen years in every part of the country. It is not simply a hospital plan; it is a plan for the hospitals as one branch of the National Health Service. Local authorities have been asked to prepare similar plans for the development of their services in the next ten years, and yesterday my right honourable friend held a conference with representatives of voluntary organisations and of the statutory Health Service authorities to discuss how in the future voluntary ser vices can be used to the best possible advantage. Already hospitals and local authorities receive a, great deal of help from voluntary sources. What we want to do is to make sure that this is developed to the full and that the planning of the statutory services takes proper account of it. Thus, one of the driving ideas behind the plan is belief in the unity of the National Health Service and in the common purpose and mutual sup port of those who work in it and for it.
The Plan is not cut-and-dried and final. The basic assessment, in the first fourteen pages of this Paper, of the future nature and scope of the Hospital Service is one which the Government believe to be sound. But, of course, some of the assessments of need for particular types of hospital are tentative. All of them are open to discussion and
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will have to be tested, and, if necessary, modified in the light of experience. Furthermore, the detailed development programme set out in Appendix A is intended to be, and undoubtedly will be, the subject of much local debate, because hospital development in every area obviously must march in step with the development of community care. But the really important point is that we now have, for the first time, the clear views of the authorities directly responsible for the planning of the Hospital Service—that is to say, the hospital boards and my right honourable friend—on what they think should be done and on approximately how much physical development, how much building, it is reasonable to propose for the next ten or fifteen years. Therefore, the boards themselves, local authorities and all other interested bodies have a clear and coherent programme to work on, discuss, examine, improve and bring to fulfilment.
The programme will always be under review and it will be adjusted to meet changing needs or changing assessments of need. So it is a dynamic plan and not a static one; and it is the intention to carry it forward annually, so that there will always be available an assessment of the amount of work to be started in the next ten years. Perhaps I should say at this stage that although I am moving a Motion inviting your Lordships to approve this Command Paper, I am not, of course, suggesting that your Lordships should be committed to the approval of every detail in this very large and detailed document.
The basis of the Plan is set out in the first fourteen pages of the Paper. It starts with the historical fact that our hospitals were built over a period of time considerably more than a hundred years by a multiplicity of voluntary societies and local authorities. They were built to serve a population very dissimilar in size, distribution, social habits from the population of to-day, and for the exercise of medical and nursing skills very different in many respects from those of the present time. Some of our hospitals to-day are new and well suited to their present functions, but many of them are neither. Nearly half are over 70 years old and one-fifth are over 100 years old.
For perfectly valid reasons it was not possible during the first decade of the National Health Service to do more than make comparatively minor improvements to the buildings that we inherited from the past, though I should point out in passing that these improvements do in fact amount to a substantial addition to the capital assets of the hospitals, as can be seen from the statistical report of progress in hospital building between 1948 and 1961 in England and Wales, which was published on the same day as this Command Paper, January 23.
In those old hospital buildings revolutionary changes have been taking place in methods of diagnosis and treatment. The hospital staffs have adapted them selves to those changes. In many cases the buildings have not. The old team, the original team of doctor and nurse, has been augmented by members of the comparatively new professions supplementary to medicine. To-day hospital staffs can draw upon, and do draw upon, many discoveries in many fields of science, and hospitals have their own specialist teams of laboratory workers. What we want to do, what we must do, is to see that the buildings catch up with the advances in medical techniques that have already taken place.
But, my Lords, these techniques do not stand still. It is a truism that a new hospital, which may have taken five years to design, is out of date when the foundation stone is laid, and it may take another four or five years to complete. But it is better to be five or ten years out of date than 50 or 100. Every new hospital ought to be an improvement upon the one before. That is the principle, and I can assure your Lordships that our hospital planners are very much alive to the need to design hospital buildings which will be reasonably adaptable to varying requirements. To use the jargon of the architects, hospital buildings are regarded as being "envelopes" containing "spaces", the use of which can be varied, or which are designed to permit of extension later, either vertically or horizontally. In the larger hospitals which we are planning for the future there will be much more scope than there is in the smaller hospital of to-day for changing the use of accommodation when that becomes
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necessary in the light of medical or other experience.
It is not only in the design of the buildings that so many of our present hospitals are inadequate. Even more fundamantal is the fact that in many cases their size and their location are no longer right. This is true both of general hospitals and also of special hospitals, particularly psychiatric ones. Broadly speaking, modern methods of diagnosis and treatment indicate that we ought to have larger general hospitals and smaller psychiatric ones. This brings me to the concept of the district general hospital which is the pivot of this Plan. I should like particularly to invite your Lord ship's attention to paragraph 20 of the Command Paper, because that describes succinctly the nature and purpose of these hospitals.
Each of these district general hospitals should be in or near the centre, or one of the centres, of the population which it serves. The great increase in the diagnostic processes and treatments which are available to-day to out patients, and the value to in-patients of regular visits from relatives and friends, make it necessary that hospitals should be easy to reach. On the other hand, there are to-day many more transport facilities available, both public and private, than there were in the days when most of our existing hospitals were built. Therefore, so long as the hospitals are readily accessible by public transport, the actual distance to be travelled does not matter as much as it once did. I should like to say now that the visiting of patients in hospital will be more and more permitted and welcomed at varying times in order to meet the convenience of the visitors.
The pattern of the hospital provision which we believe to be desirable is described, I think with clarity, in paragraphs 20 to 28 of the Command Paper. I want particularly to emphasise the importance which the Government place upon the work of general practitioners. I am sure your Lordships will be aware that for a long time the feeling has been mounting inside the medical profession that the standing and prestige of the family doctor are being diminished, that his role is being devalued, and that the tendency is to look upon him as just a clearing house for the hospitals and the specialists. I hope that the publication

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of this Plan will correct that impression, and for a variety of reasons I believe that it will. No less than one quarter of the introductory part of this Paper is devoted to the development of community care—that is, to the provision of services for the sick, including the men tally ill, outside hospitals. There have been great changes in methods of pre venting illness. New drugs and antibiotics now enable some patients to be treated in the home instead of in hospital. These factors alone have a direct bearing upon the future scope of general practice and upon the work and activities of the hospital and the local authorities and their relationships one with the other. That is why last summer my right honourable friend's Standing Medical Advisory Committee appointed a sub-committee to advise upon the field of work which it will be reasonable to expect the general practitioner to under take in the foreseeable future.
Some, at any rate, of your Lordships will perhaps recall—I spoke about this on November 29 last year—that the Platt Report recommended that general practitioners should more generally be able to undertake part-time work in hospitals. Consequently, the hospital boards have been asked to review at regular intervals with the local medical committees the extent to which general practitioners are already holding hospital posts and to select suitable ones for them.
The Command Paper explicitly recognises two important facilities for family doctors. First, it envisages that maternity beds will be available for the treatment of their own patients who are undergoing normal confinement. Thus the family doctor will be able to follow up the care which he started in the home, and the patient will have the double advantage of the care of her own doctor whom she knows and the reinforcement, should it be needed, of the full consultant services of the hospital. Secondly, the Command Paper envisages that family doctors will have direct access to the diagnostic facilities of the hospitals. Thus, in many cases they will be able to give treatment to their patients without having to send them into an out-patient consultant clinic. For all these reasons, I hope that this Plan will be welcomed by the general practitioners of this country.
The Plan has nad a pretty good Press. In even more informed circles it has been welcomed as a clear exposition of what we are trying to achieve, and as an indication of a real sense of purpose to improve our hospital buildings. Nevertheless, some questions and doubts have been raised, and I think it may be helpful if I say a word or two about some of them at the beginning of this debate. For instance, it has been questioned whether the money will be forth coming. I think there has been some confusion between the capital cost of building hospitals and the recurrent annual cost of running the hospitals. The capital cost of the programme is estimated at approximately £500 million in the first ten years; the total cost of the buildings to be started (but not all to be finished) within the ten years is put at £707½ million. It is not possible to forecast with any precision what capital sums will actually be available year by year.
Obviously, that will depend upon the state of the economy, the capacity of the building industry and other demands upon the nation's resources, and so on. It may be that over the ten years the total sum may amount to rather more or less than the round figure of £500 million. Nevertheless, the Government consider it reasonable and right to use a figure of that order for the purpose of devising a long-term programme. An average annual capital expenditure over the ten years of £50 million compares with £31 million estimated for the current year and nearly £35 million for 1962–63. It is therefore evident that we are assuming an annual rise in expenditure to well over £50 million by the end of the decade.
Some people have asked how this can be reconciled with the Government's statement that for the next few years the total running costs of the National Health Service as a whole should be contained within a rate of growth of 2½ per cent. Well, my Lords, this figure of 2½ per cent. relates to running costs, not to capital expenditure. The running cost of the Hospital Service is about £450 million. I would suggest, however, that the significant point is not the relationship between total capital expenditure and total running costs in any one year, but the effect which

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this proposed capital expenditure may have on running costs when the new buildings come into use.
This is difficult to assess with any accuracy, but there is no reason to sup pose that anything more than a small annual increase will result. The building programme is not designed to pro duce an increase in the total number of hospital beds. On the contrary, we expect a reduction, because we see a very large reduction in the number of hospital beds likely to be needed for the mentally ill and some reduction in acute beds, partly offset by increases in geriatric and maternity beds and beds required for the mentally subnormal. A substantial part of the building programme is to replace out-of-date buildings and to provide for a more compact grouping of services in the district general hospitals. The standard of service should rise, but the saving in overhead expenses by concentration of work in larger units, and the replacement of old buildings by new ones which can be more economically maintained, will help to keep down the additional running costs.
It has also been asked whether staff will be available for these new buildings. Well, here again, my Lords, I must emphasise that we are planning for an overall reduction in the total size of the hospitals. It is true that the anticipated decrease of some 11,000 acute beds is more than balanced by the anticipated increase of nearly 6,000 geriatric beds and 6,500 maternity beds, and that a continuing increase in out-patient work is to be expected. It is also true that the anticipated very large decrease in the number of psychiatric beds is not likely to be accompanied by an equivalent decrease in staffing requirements, because more intensive treatment will mean higher staffing ratios. Nevertheless, in new up-to-date buildings it should be possible to make more effective use of any given size of staff than in the in convenient older hospitals. For all the principal types of staff the trend of recruitment tends to be upwards, and this plan should in itself help to improve things, because the prospect of working in better buildings, with new equipment, should be a powerful aid to recruiting.
I should like to sum up what one may call the staffing question in four pro-
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positions. First, the Plan envisages a reduction in the total number of hospital beds; secondly, whatever view you may take of the staffing situation as it is to-day, any given number of staff will be more effective in new hospital buildings designed to maximise efficiency; thirdly, if you cannot recruit staff for new hospitals you certainly cannot recruit them for old ones; and, fourthly, this Plan is the best possible recruiting poster because it holds out the prospect of an ever-improving Hospital Service.
Finally, my Lords, I should like to say something about the closure of hospitals. Some of the older or smaller hospitals will still, as the Command Paper explains, be required for other purposes, but inevitably a substantial number of them will become redundant. All these hospitals have traditions of devoted service, and it may well be that the initial reaction of those who work in them, and of the community which they serve, may be one of regret. But I believe that, on reflection, they will accept, and indeed welcome, the natural evolution of a living, growing Service. One of the aims of our Plan is to ensure that the fine traditions of our existing hospitals are carried forward into the future in buildings which will allow all who work in them to put their skills and experience to the fullest use. It has been suggested, particularly by Sir Harry Platt in his letter to The Times, which I mentioned earlier, that where a new, or extended, hospital is to replace an older one the name and traditions should somehow be associated with the new buildings, by the naming, of a block or ward, or by some suitable inscription, as a token of continuity. I feel sure that hospital boards will be sympathetic to this idea.
The staff of hospitals which may be come redundant should not worry about their future. In most cases an intention to close an existing hospital is dependent upon the building of a new hospital or the enlargement of another. In such cases it should generally be possible to transfer the staff with the work; in other cases every effort will be made to absorb those who so wish into other posts within the Hospital Service. Special arrangements, including arrangements for consultation with other authorities, where necessary, will be made for this purpose. I think I should

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make it clear that most of the redundancy of hospitals foreshadowed in the Command Paper is still some years off. Meanwhile, it is absolutely vital that these hospitals should continue to function fully until they are properly re placed. Ample advance notice will be given to staff of any intention to close the hospital in which they are working, and their future will then be discussed with them.
My Lords, I have tried to concentrate upon what seem to me to be the salient features of this Paper, rather than to give your Lordships a précis of it. I hope that I have not taken too long in doing so; if I have, then I may say that I think it will be apparent to those of your Lordships who have studied this document that it contains more than enough material to have enabled me to weary the House with a speech of really in tolerable length. I commend this Command Paper to your Lordships and I am grateful for the privilege of doing so. I am looking forward with pleasure to hearing the comments of the distinguished experts who will be following me. My Lords, I beg to move.
Moved to resolve, That this House approves Cmnd. 1604, entitled A Hospital Plan for England and Wales.—(Lord Newton.)
3.21 p.m.
BARONESS SUMMERSKILL: My Lords, everybody must welcome the re cognition that the Government have given to the whole question of the pro vision of hospitals, and some massive provision must be made if we are to tackle the problem. In the first place, I think this House must thank the hundreds and thousands of unknown men and women on the Regional Hospital Boards, on the local government authorities and on the councils of this country who have made their contribution to the detailed work of this White Paper. I am sure that at this stage we earnestly hope that their assessment of the need for beds in their own areas will prove to be correct. Whether the Procrustean approach of the Minister of Health will survive until the 1970's is another matter.
The noble Lord said that the Press was good. In my opinion, the informed Press on this matter was not good. On this subject, may I read to the noble Lord from the British Medical Journal,
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the voice of the British Medical Association, which, if I may say so, from a political point of view, is a Conservative organisation? What did they say on February 3 after this Paper was published? They certainly have some doubts. They said:
" Regional boards and boards of governors have had to fit their designs into the central plan. This may be tidy but anything tailor-made in Savile Row will not necessarily be a good fit for the men on the spot in the hospital regions of England and Wales."
I might say that this is the first fitting; one certainly does not know what the final fitting will be like.
The fact is that the world of medicine is very conscious that there have been seven different Ministers of Health during the last ten years, and nobody can estimate how many Ministers of Health there will be in the next ten or fifteen years; or, indeed, how many Chancellors of the Exchequer, who will give varying directions to the Treasury about this programme. The fact is that there is not one firm commitment in the White Paper in respect of finance, building capacity or the availability of staff. Indeed, there is a feeling in some quarters that this may be a promissory note which may never be honoured. I must say, reluctantly, that to describe this document as a plan is a complete misnomer. Surely, there should be some degree of probability about a plan, but if you introduce too many imponderables, enter too many caveats, it loses all appearance of reality.
May I illustrate this point? Para graph 46 states:
" It is not possible now to forecast at all precisely what capital sums will be available year by year."
It then states that it is assumed that £500 million will be available over the first ten years. But then it says:
" These figures do not represent commitments and the sums which will actually be come available may be somewhat more or less, dependent on the state of the economy, the capacity of the building industry, and other claims on the national resources."
How nebulous can the Ministry of Health become! What does paragraph 51 say?—
" The staffing of the hospital service … must be the subject of a whole series of studies …"
Studies, my Lords; not decisions, not directions; not directions to teaching

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hospitals saying that we need so many surgeons and physicians of a certain kind. It is studies at this stage, and the noble Lord comes to us and tells us that the thinking on this matter started in the early 'thirties.
LORD NEWTON: The late 'thirties.
BARONESS SUMMERSKILL: I think it is not an over-statement when I say that there are so many imponderables that this Paper seems to be unrealistic. The concept of the district medical hospital is an old one and a good one. But surely any hospital planning must take into account the availability of staff. We had two interesting and informative debates in this House quite recently on the shortage of doctors and of those employed in the professions supplementary to medicine, which revealed to all noble Lords the desperate shortage of doctors in this country; and yet in this paper only one paragraph is devoted to staff. I am not surprised that the noble Lord had to come here and, in some way, at the eleventh hour, try to amend the Paper, and tell noble Lords about what might happen fifteen years hence when he thinks we may need fewer beds. As we are a population which is getting much older, I really do not think there is one working doctor who can definitely say that there will be less need of beds fifteen years hence.
I would remind those noble Lords who were not here during those two earlier debates of a recent report in The Times which showed that in the Sheffield region the proportion of foreign doctors in the Hospital Service has in creased from 51 to 58 per cent. in the past year. Twenty-six hospitals were completely staffed by doctors from over seas. It is a fact that to-day only the reasonably large hospitals can get enough junior medical staff and the small acute hospital seems doomed. There is one interesting outcome of this situation, and as we are all potential patients, I am sure that this will be of interest. If a patient goes into a hospital with 500 beds where Mr. X, the eminent surgeon, has beds the operation will probably be performed by a registrar. If he goes into a hospital with 50 beds, where Mr. X attends also, Mr. X will perform the operation because there is no other staff
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who can do it. That is the interesting position to-day.
When he discussed staff, the noble Lord attached great importance to the change in the form of hospitals, but has he forgotten that in the new hospitals which he discussed the wards will be much smaller and that, surely, there will be no economy there in nursing staff? In answer to a Question in another place on Monday, the Minister said that at this moment in this country there is a short age of 20,000 nurses. The Minister said, "Ah! When we have beautiful hospitals, they will attract staff." I would ask him this: is there any real evidence that new chromium and glass palaces attract more nurses and domestic staff? My experience of life is that it is not the glass or the chromium, or the bricks and mortar, but the people who are in the hospitals—the nurses, the matrons; the people in authority—who attract the nurses.
So I hope that the noble Lord, when he talks about this matter again, will not attach so much importance to the form of the hospitals, in the hope that that will solve his problems. Perhaps he ought to read the Valentine which was sent to the Treasury by some excellent women to-day asking for more pay. I think that that Valentine could be sent by 90 per cent. of the women working in our hospitals to-day. If he had also read to-day that the nursing staff who had asked for a little more pay were to be given only 2½ per cent., in stead of the 30 per cent. they had asked for, perhaps he might have struck a realistic note, and we might have recognised that he understood the staffing problems of some of these hospitals.
The accident service which is envisaged is an excellent idea. Organised on a regional basis, it is proposed to pro vide continuous cover by expert medical staff for 24 hours a day, seven days a week. But where is the staff to come from? I am told that it is impossible to achieve what is proposed, for it would mean trebling the present orthopedic staff of the so-called accident centres. The noble Lord talks about the number of beds for psychiatric patients being reduced; but, while there is a promise that there will be a big reduction in beds for mentally sick patients, the modern, more intensive method of treatment will require higher staffing ratios. What is

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being done to increase the number of psychiatrists in the country? Where are the psychiatric social workers? Every area is in desperate need. Where in this Paper are the plans for the provision of the most essential part of a scheme of this magnitude, the staff?
My Lords, I am not alone in my concern at this lack of planning. May I again quote the British Medical Journal of February 3? It said:
" The problems of staffing are formidable. Mr. Powell and his successors "—
his successors, my Lords!—
" will have to take the picture down and put something better in its place if the ten or fifteen year plan is to come to fruition."
Does the noble Lord say that that is good publicity?
I notice that paragraph 30 of this Paper, dealing with teaching hospitals, reads:
" … the size and location of the individual teaching hospitals and the type of beds must be determined by their function of providing facilities for clinical teaching."
If teaching hospitals are so anxious to provide facilities for clinical teaching, they should take more acute medical and surgical cases, including old patients suffering from congestive heart failure, pneumonia or a stroke, because the majority of students become general practitioners, and it is in the teaching hospital that they should see these conditions. An eminent surgeon was here at lunch to-day, and I told him what I proposed to say, expecting him to tell me of all the reasons why the teaching hospitals should not make their beds available for these complaints. I was agreeably surprised to find that he gave me his complete support.
The noble Lord, Lord Newton, spoke of the general practitioner, and I am very glad that he complimented the general practitioner on his work as the friend and adviser of the family. If the noble Lord feels like this, I should like to know why, in proposing to close some hundreds of small hospitals, there is no suggestion that some should be used as health centres. For the general practitioner should be the directing force in the field of domiciliary services. May I draw the noble Lord's attention to the Lancet of January 27, which, commenting on this White Paper, used these words:
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" The scope and effectiveness of the work which the general practitioner is able to do must have a decisive influence on the scale and type of hospital provision."
It has been repeatedly stated that integrated local authority services, which include services such as home nursing, health visiting and home helps, are an essential part of an effective Hospital Service, for they can reduce the pressure on the hospital beds. Again, the noble Lord said that he attached importance to this matter, and he told us that there was a large section of this Plan dealing with the community care. But has he read it carefully? It says:
" Each local health and welfare authority is being asked to review the present level of its services … and to draw up a long-term plan for future development …"
My Lords, we were told that this was a plan. We were told that decades had gone by during which it had been thought about; but under "Care in the Community" it simply suggests that they should be asked to consider the matter and draw up a plan for future development. I should like to ask: on what basis is this plan to be drawn up? The noble Lord will remember that, when we had a debate on the elderly, I and other noble Lords asked that a register of the elderly should be drawn up in this country. Although it has been suggested that a register of old people should he compiled, only a very few local authorities have so far undertaken this task. I must ask the noble Lord, therefore, if there is not a basis for this review which he has asked the local authorities to undertake, how they are to get on with the scheme.
I come next to building—and I recognise here to-day many noble Lords who were present at the building debate last week. I do not like to mention too many figures, but may I just tell your Lordships what the proposition is? This programme of hospital building involves the provision of 224 new and substantially remodelled hospitals to be started by 1970, apart from 356 other schemes each costing over £100,000. Works costing under £100,000 each are not specified. Now we are told that there is a scarcity of doctors, architects and engineers expert in hospital planning. Last week the Housing debate revealed that there was a vast amount of building to be done, and that there was a serious shortage of builders and labour.

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I would remind noble Lords that the local education authorities are supposed to be midway through a five-year school-building programme; yet last summer they received a circular which cut their minor works programme by one-third and revoked all the loan sanctions already granted except where tenders had been finally agreed. My Lords, what guarantee is there that this will not happen to this programme? Indeed, in the first paragraphs we are warned that there is no guarantee. This programme, as everyone here who has some association with the building world knows, will demand the services of skilled architectural staff. I can envisage little coteries of architects, doctors, nurses and administrators spending endless hours planning their own buildings. I would urge the Ministry of Health to provide some designs for two or three standard units—because, after all, these buildings can be reduced to a few types—and to keep in mind that we are building for the patients and not to satisfy the whims of individualists.
The noble Lord, Lord Newton, mentioned money. He said there are some people—many people, I can assure him—who wonder where the money is coming from. In the earlier paragraphs we have been told there are no commitments. Out of the £707 million total Cost, not more than £500 million is to be spent by 1971. Of course, the longer the scheme takes, the more costly it will become; and how will the present estimate compare with the estimated cost in the 1970's? Who here would dare predict what the cost of a hospital or building would be in the 1970's? In deed, is there any sum mentioned which has any semblance of realism in this Plan?
One newspaper published a picture of the Minister of Health dancing on a pogo stick to mark the publication of this hospital pragramme. Has the former Treasury Minister, who resigned in pro test against Government expenditure, changed his personality? Has there been a metamorphosis from Scrooge to Father Christmas overnight? I suggest that the conversion is a spurious one. The Minister has been careful to introduce so many provisos and allowed himself so many loopholes, that it is apparent he
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is the same man. He has safeguarded the Treasury so effectively that this expenditure may never take place. Your Lordships are not being asked to agree to a Plan; you are being asked to gaze at a mirage which may recede with the years. On this occasion I wholeheartedly support the British Medical Association, and ask the Minister to put something better in the place of this Plan if it is to come to fruition.
3.42 p.m.
THE LORD BISHOP OF LICHFIELD:
My Lords, it will be understood that I do not speak in regard to this matter from any political angle; but obviously a piece of social planning of this character greatly affects the Church, and there fore, from the point of view of the Church, I would say that we most earnestly hope that this kind of plan will come to fruition. If I may also speak as a member of a Regional Hospital Board, I would say that this has come to many of us as a time of great hope, because we have for years had to carry on our work with a great shortage of money. We have had to skimp year after year, and now, to have some chance of putting into bricks and mortar the plans that we have formulated over so many years, is something which gives us considerable hope.
In her speech just now, which I found very interesting, the noble Baroness, Lady Summerskill, asked what kind of guarantee there was that any of this would come to fruition. It is not for me, obviously, to hazard my guess in regard to that, but I would say, speaking as one who has now had experience of work in this field for a number of years, that I and the colleagues who work with me would regard this Blue Book as (as it were) our marching orders to get on with it now as best we can. Further, I would say, as we look at the uncertain future of the world, that I thank God that we are planning and are going forward in hope and in faith that our civilisation is going to endure.
Now, my Lords, this Plan envisages a number of entirely new, and a number of completely modernised, hospitals. I know from speeches I have heard that one of the things that the Ministry and all Regional Boards and Boards of Governors are trying to do is to ensure

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that, hand in hand with the modernisation of the hospitals, there goes the humanisation of the hospitals system. I am not saying that in any criticism of the past. We should be most thankful for the people who, in the past, have worked in very difficult conditions in a spirit of great self-sacrifice, which is a spirit worth preserving for the future. But that we do need further cutting of red tape, and that we do need more humanity in the system, is, I think, clear.
I would urge that, in the form of construction of the new hospitals, this matter of the humanisation of the system should continually be borne in mind. Again, I would agree whole heartedly with the noble Lady when she said that the hospital was built first and foremost for the patient; and that must never be lost sight of. Now, my Lords, I suggest that it is quite possible that, although a brand-new hospital may be erected, when the patient comes into contact with it he or she may find that the atmosphere in it is the impersonal atmosphere of an hotel. We have to create the right atmosphere. I know that that depends primarily on the attitude of the staff to their work; but in addition I am sure there is a good deal in the form of construction which can help in this regard.
May I turn to the question of out patients' departments? Thousands of people go into those departments year by year. Some of the out-patients' departments in our hospitals to-day might be compared with a railway station, and others perhaps to a cattle market—I think maybe a cattle market is the better comparison, because one sees people sitting like sheep in rows, waiting, waiting, waiting. I suggest that all that sort of thing has to be cut out, and I believe it can be. I hope that when the new hospitals are planned, and particularly the out-patients' departments, we shall not find these great halls with all the miserable forms on which the patients sit, but alcoves nearby the various surgeries and consulting rooms of the doctors concerned, so that the patients who are going to be seen by a certain doctor may be grouped together.
Further, as the Minister has said, and, rightly, that he wants to call on voluntary help to the utmost of his ability, I suggest that this is where volun-
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tary help can come in: by having people there who can welcome patients as they come to the out-patients' department, group them by their names, and lead them to the place where they have to wait, and if they have to wait for some time, tell them why they have to wait. I would also suggest that, if we have this system of small alcoves in which there is a little group of people waiting together, it enables the patients, as they wait, to play much better the time-honoured game of explaining to one another their own symptoms, how dreadful they are, and how much worse they are than anybody else's.
Now I come to the main hospital itself. Again, I would plead that this matter of the atmosphere of the hospital should be remembered in the planning. What we want to do at the outset, as the patient arrives nervous, anxious and worried about what is happening to his family at home, wondering what illness he has got, and very worried because he fears the worst about his condition, is to assure that man that he is coming into a place of loving care; not just a kind of factory that is going to turn him out better than he was, but a place of loving care. Therefore, I would suggest, in all humility, that as these new buildings are planned, it might well be thought a practical aid for the creation of that atmosphere that the chapel should be put in a prominent place nearby the entrance to the hospital. I am thankful that I do not have to stand here to-day and plead that there should be chapels in these hospitals; I know now that in any hospital of reasonable size we shall get such a chapel. But I would ask that the question of the place where that chapel is put should be most carefully thought about, be cause I firmly believe that it can do much to create the right atmosphere that we want to have in our hospitals.
May I next turn, in this matter of the atmosphere in our hospitals, to the work that is done by the chaplain? I do so because I think that there would be many who would agree with me when I say that the sight of a chaplain going about his duties in a hospital, in the wards and up and down the corridors, testifies to the atmosphere we want to create and, indeed, is the explanation of every thing that is done there. I would ask

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that, as these hospitals are planned, his needs should be remembered. For instance, he urgently needs a room in which he can see people. This is of great practical value.
We have heard in the speeches just made, particularly in the speech of the noble Baroness, about the serious question of staffing. I would ask that it should be remembered that it is not merely a question of getting more staff: it is a question of keeping the staff we already have. There are many potentially good nurses who are lost during their period of training because, for one reason or another, they feel that they simply cannot go on with it for another day. I know from personal experience that some of these girls have a deep vocation for nursing. At a time of crisis in a girl's life—and I think that quite a number of new nurses go through a time of crisis—I believe that a good chaplain can be of the greatest assistance in tiding her over such a time, particularly because he stands outside the hospital hierarchy. I think that this matter of preserving our nurses and keeping them in the system is something that is of great imporance and the chaplain can play his part here. But he must have a room in order that he may have the necessary interviews and consultations.
As we think of these new hospitals of the future, I should like to suggest that it is very necessary that we increase the team spirit in the staffs of our hospitals. For they can be so separated into water tight compartments—nurses, radiographers and physiotherapists—all getting on with their own jobs, but often in isolation one from the other, and not knowing what the others are doing. Can we not bring them closer together so that they may work in a real team spirit, which more than anything else will make our hospitals work? May I say how much I welcome the statement made about the new general district hospitals? I think that it is a magnificent idea to have a hospital which is really going to be the mother hospital of all the others in the area and will be the generating force of much that is good. To this district hospital many new people will come to be trained. I am sure that in this district hospital the authorities concerned should do everything they can
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to help these people to come to know one another, so that when they go out to other hospitals they will do so as colleagues and friends, and thus the team spirit will be fostered.
In addition, I am sure that there is much we can still do to make the lives of our nurses more interesting when they are in hospital. I am thinking now of their out-of-duty activities. When a nurse is off-duty, naturally and rightly she will want to go out, to be out of the atmosphere of the hospital, to get a breath of fresh air and a change. Very good! But those of us who have worked in the past as chaplains in hospitals know that sometimes we wished that we could have done more to foster real recreational and educational facilities for the nurses in the hospitals.
Therefore, I think that much could be done in the nurses' homes, by their not being exclusively for nurses and by having other people, radiographers and the like, living there as well. While I know that the home sisters do a very great deal to look after the nurses properly, and some of us are very grateful to the home sisters for what they do, I would add that nurses' homes might well be superintended by a warden, who I hope would be a lady of a wide field of vision and who could help these nurses to have really interesting off-duty activities. All this kind of thing, I suggest, would help hospitals in this matter of staff.
While there is this grave shortage of staff—and I do not seek to disguise that fact for a moment; I know that in the Midlands some of our hospitals would not be properly staffed at all if it were not for nurses from the West Indies and other places overseas, to whom I personally am extremely grateful and who I think are doing a grand job—I am told also that there are more nurses in the country to-day than there have ever been before. Here, obviously, the future planning of hospitals is going to make a tremendous difference. Presumably in the new hospitals we shall have a system of intensive care wards where maximum nursing staff can be brought to bear at the critical moment, and other wards where patients who are not so ill will be found.
Let us see to it, then, that we use our nurses to the best possible extent by

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letting everyone develop her own flair. Obviously, the student nurse has to go round the various departments of the hospital in order to get experience, but after that we shall find that some nurses have a flair in one direction and some in another. One, for instance, may be the better able to use the complicated machinery that she will use under the direction of the doctor. Another nurse may be far better at teaching a patient how to look after himself when he leaves hospital. Presumably, if we seek for a cure when the patient comes in, we have to work for the moment when he goes out again to play a useful part in society. I would suggest that there are also some nurses who can be very well equipped to teach the relatives of a patient how to look after him when he leaves the hospital.
If we are going to make the best use of the nursing staff at our disposal, I would suggest also that we have to make the best use of the machinery of the hospital. This machinery is going to cost an enormous sum of money. The figure of £500 million in ten years has already been mentioned. I am not one who knows a great deal about industry, but I think that I am right in saying that when a firm installs complicated and expensive machinery into its factory, it takes jolly good care to ensure that that machinery is used to the maximum extent. I sometimes wonder if our expensive machinery in the hospitals is used as much as it ought to be. For instance, to go back to the out-patients' departments, in how many hospitals do we find them packed to suffocation in the morning, very much thinned out in the afternoon and completely empty in the evening? I know that this may be awkward for all the staff concerned, but when I think of the cost I am bound to say that we ought to think much more in terms of evening out-patient sessions so as to make use of this machinery, X-ray equipment and so on, to a maxi mum extent. I think further that evening sessions may well be much appreciated by the general public, who may find it much easier to come at that time than at others. But, of course, we can do that kind of thing only if we have sufficient staff; and back we come to the problem with which we grapple: our shortage of doctors and nurses.
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I would agree entirely with the noble Baroness, Lady Summerskill, in the figures which she gave just now. She instanced the Sheffield region. I know the Midlands best, and there it is just the same. The proportion of doctors from overseas is very high. I know that we do not have the number of doctors of our own country that we should like, but I suggest that the training of these men and women who come from the Commonwealth is of the utmost importance at this particular moment. If we do not welcome them here, they will go elsewhere, and they will be welcomed elsewhere with open arms. I believe that this use of the Mother Country as a place of training, to which people can come from the countries of the Commonwealth, or from other countries, and then go back to their homelands, is one of the best ways of keeping the Commonwealth together. So, again, as I think of what is being done in the hospitals with which I am familiar, I am very thankful for all that is being done by these doctors and nurses from overseas; and frankly, I do not know what we should do without them at the present time.
Finally, if I may, I should like to return to the question of the work that is done by the chaplain. I would repeat that really—as I know many other people hold—he is the explanation of all that is done. He can do so much to foster the right kind of atmosphere. I hope it will always be remembered that the chaplain is there in the hospital not merely to care for the sick—though that obviously is one of his great privileges and responsibilities—but is there to be the pastor, the guide, philosopher and friend of the staff, as well. At the present time, with the figures with which we are confronted by the Ministry, he simply cannot do the work. It has to be remembered that in the country to day there are only just over 100 full-time chaplains, whereas there are thousands of part-time chaplains, most of them, so far as the Church of England is concerned, vicars with busy parishes. It is difficult for a man to look after his parish and do part-time chaplaincy in a hospital, as well. He is trying to do fit, and we in the Church, for our part, are doing our utmost to see that the work is done as well as possible. But if the figures are too great, so that

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the calls on his time are too many, he cannot do that work as he should. I hope that in future planning the Minis try will remember the need that we have for a reduction in these figures, so that we can have more part-time chaplains in our hospitals, as I am sure this would help enormously.
So, as I end, I would say we must re member that not only must these new hospitals be as efficient and up to date as possible, but they must have the right atmosphere in them; and if there is any thing that we on the side of the Church can do to help the hospital authorities to make these places really places of loving Dare and human sympathy and kindness, we shall be only too thankful.
4.2 p.m.
LORD AMULREE: My Lords, I am sorry that I was unable to be present when the noble Lord, Lord Newton, began his speech, but I warned him that I should not be able to be here; and I was pleased to find that the earlier business took rather longer than it had been thought it would take and I heard more of the noble Lord's speech than I had expected I should. I am sure that we all, and particularly those of us engaged in hospital work, welcome very much the Plan to give us new hospitals. Whether that Plan will be immediately carried out I do not know, but the know ledge that the Plan is there, and that there is the intention to build new hospitals or to improve all these very old-fashioned ones, gives one great pleasure, and I welcome the Plan very warmly. One of the medical papers the other day, commenting on the Plan somewhat tardily, said that just as women from time to time need new hats, so doctors from time to time need new hospitals. That is probably quite true; but I think there are more solid reasons behind it than that.
There is one point on which I should like to associate myself with the noble Lady and the right reverend Prelate—namely, that we must realise that hospitals are built for the patients and not for the staff. A vast amount of good can be done by a friendly welcome to the patient and an explanation of what is wrong. I remember in my young days, when I was a medical student and a young doctor, it was thought improper
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for patients to ask a question as to what was wrong: they were there; they had to trust and were not told anything. That, in my view, was quite wrong, and I am pleased that it is now going. I hope the new Plan will keep that in mind in the future.
There are one or two rather vague doubts in my mind that I should like to bring to the attention of the noble Lord who is to reply. The Plan says that a large number of hospitals are going to be closed in the next fifteen years—the total number is, I think, 1,250. At the same time, the acute beds are to be reduced by about 10,000 or 11,000. I do not want to refer to the mental hospital beds, as I do not know much about that side of the subject. A large number of district hospitals are going to be built or made with an average of about 600 to 800 beds, and that is something to be greatly encouraged. I agree that for a great deal of treatment centralisation is important; certainly with regard to specialties like neuro-surgery, chest surgery, radiotherapy and for a good deal of cancer surgery, I am sure that a man who can treat 500 patients with one disease in the course of a year is going to be more expert than the one who treats 50. I do not by that imply anything against the man who does not treat so many, but it is a fact that experience does tell. But I wonder whether this will mean that patients will need to travel too far from their homes: because I feel that in many cases the proximity of friends and relatives not only is pleasant for the patients but sometimes shortens their stay in hospital. I mention that merely as a doubt in my mind and not really as a genuine criticism, but I trust that the Government will bear it in mind when these places are being built.
The success of the Plan will very much depend on the way the general practitioner and the local authorities work together. The noble Lord has explained that the general practitioners will be encouraged to come to hospital for various kinds of diagnostic facilities which they require. That scheme has been going on for quite a long time. It causes no particular embarrassment or trouble to the hospital and makes for a much better feeling between the general

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practitioners and the hospital. Where I think the local authority can be of great assistance to practitioners, too, is in assisting them in following up their patients—seeing what becomes of them when they recover, and taking a certain amount of the burden from the practitioners which should by right be on the shoulders of the local authority.
That is where I have my second doubt, because if the local authority are going to play well with the hospitals, they must increase their services considerably. There was a table published in the Lancet the other day which showed that during the course of the last five years the total number of health visitors had gone up from 5,086 to 5,502, an increase of 416. The district nurses, who will be very important, too, have gone up by 350. The only class that has gone up substantially is the home help service. But there again, it is an extremely important service, and the fact that its numbers have gone up by 4,000-odd is not as impressive a figure as it sounds, because it includes people who are doing part-time, as well as those doing full-time work. Those figures are not very impressive, and that is why we should take account of what the noble Baroness said as to whether there will be enough staff to go round, particularly on the local authority side.
May I now come back to the question in which I am particularly interested, the care of old people? I am pleased to see that there is going to be a considerable increase in the number of geriatric beds and departments. I should like to put a question of which I gave the noble Lord notice yesterday—not very long ago I am afraid—and that is: what is the real definition of "geriatrics", and when does a patient come under a geriatric service? It is a thing I have been working at for fifteen years or more, and I am afraid I have found out what is the real answer to that question. If the Government and the Ministry are going to use that service seriously they must know what kind of people they are talking about who are to go into geriatric beds. I am doubtful whether they do know, because we do not say for a moment that it should be all people over 65 or 70, or some age like that. That would obviously be totally absurd. One cannot say that they are to be people coming in for
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rehabilitation who have become stuck in their bed or at home, because one finds that an enormous amount of acute medicine cases comes into the geriatric beds, too. Therefore, I should like to know what the Government feel to be the proper definition of that.
The Plan refers to the establishment of long-stay annexes for old people. I think they should be placed in some of the smaller local hospitals which are not going to be used for other purposes, pro vided there is a good link, from the staff point of view, with the geriatric beds in the big general district hospitals. What one wants to avoid is a repetition of what occurred under the old Poor Law, where old people got tucked in places and were never given proper care, attention and treatment. I think it would be an advantage from all points of view—and I think it is mentioned somewhere in the Plan—if some of these hospitals were used, because it makes it far simpler for the relatives and friends to visit the old people in question.
May I come back for a moment to the local authorities? I am afraid I am going to repeat something I said to your Lordships last year when we had a debate on old people. In order to make this Plan work properly, it will be necessary for the local authority to provide far more beds for the old people who can not live by themselves. Paragraph 39 of the Plan says what proportion of people over 65 are at present being taken care of by the local authority. If we are going to get a really proper geriatric service going we shall find that more accommodation will be required than that. The other thing is that if the total population is going to become older, more people will be unable to live by themselves and will need to go into some kind of common accommodation.
May conclude, if your Lordships do not mind, by quoting for one moment from my own experiences? What I found in going round my own wards a week ago on Friday was that 50 per cent. of the people in them were living entirely by themselves, and, at the same time, the proportion of people aged 75 who come under my care has gone up in the last five years by 10 per cent., from 60 per cent. to 70 per cent. If one has 70 per cent. of one's patients aged over 75 and 50 per cent. live by themselves, there

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is not much chance that when they re cover from their acute illnesses they will be able to go back and live by them selves, even though all sorts of services are laid on. Some may, but some will want some kind of communal provision made for them. That is one of the things I should like the Government to think about very seriously, because it may become one of the instances where these things will not break down, but will run into considerable difficulty.
The last point I wish to make is with regard to what the right reverend Prelate and the noble Lady have said, and that is on the question of shortage of staff. I think I am right in saying that the object behind this Plan is that new hospitals should not contain these large wards which are called, I think, "Nightingale wards", but they should be cut up into smaller wards of four or five beds. Although there is going to be a big reduction in the total number of beds, if you are going to nurse your patients in four- and six-bedded wards you will want more nursing staff to take care of those who are acutely ill; where as in a big ward of 25 to 30 beds a few nurses can keep a very good watch on what is going on because they can see the whole thing in front of them. If there are cubicles there must be far more nurses going round to see what is happening, and I think the larger number of nurses required may well counter act the effect of the number of beds being cut down.
At the same time, what type of nursing is envisaged for these people? I do not think we need a lot of trained nurses. They want one or possibly two, but one also wants people who have a good pair of hands—kindly people who have a vocation for this kind of thing but who do not want to go through the extremely complicated training which a nurse has to go through now, although they are perfectly willing to help and to do the work required. There is a long list of speakers, and I do not want to take up any more of your Lordships' time. I should like to say that I welcome this Plan for what it is, but I think it will not work unless one gets full co operation and support from the general practitioners and local authorities and the voluntary bodies working with them.
4.17 p.m.
LORD BRAIN: My Lords, I should like to welcome this Plan, which I think might fairly be described as a plan of great potentialities. I welcome, too, what the noble Lord, Lord Newton, said about its flexibility, because I am sure that it can realise those potentialities only if there is the greatest possible co operation between the Minister and representatives of all workers in all hospital services. Medicine owes a great deal of its recent rapid progress to the development of specialisation, and as specialties have increased in scope and in number it has been increasingly realised that it is a great advantage for them to co-operate with one another and with general medicine and surgery. I welcome, therefore, the fact that these new district general hospitals will pro vide for that close co-operation between, on one side, the various specialties and, on the other general medicine and surgery.
As a former member of the Royal Commission on Mental Health, I should like also to welcome a proposal for short-stay psychiatric units in every general hospital. We have heard a good deal about the staff problem, which is a very real one in every sphere of hospital work, as we know. One of the difficulties about medical planning in general is that although there is a target, it is both a long-term target and a moving target. Frequently, developments in medicine have outstripped the forecasts, and I think it is only fair to see the advantages against this back ground. It is true that there are far more nurses in the Health Service to day than there were in 1949—about 36,000 more whole-time nursing staff in 1960 than in 1949, and about 21,000 part-time nursing staff, in spite of which, as the Minister said, there are vacancies now for 20,000 nurses of all grades.
The same is true of junior hospital medical staff, to which the Platt Report has drawn attention. In 1949, there were 5,300 in the grades below consultant and consultant trainee—that is, senior registrar—and in 1960 there were 8,700, an increase of about 60 per cent., but the Platt Committee found in 1960 that there were still 873 vacancies. I think it is true that one factor, at any rate, in creating this shortage has been the

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greatly increased demand which modern medicine makes upon staff of all kinds, and the further fact that these greater facilities have been much more wide spread throughout the country and throughout the community as a result of the operation of the National Health Service.
I do not propose to-day to discuss the causes, complex and somewhat controversial as they may be, of these various shortages; but I should like to make one or two suggestions as to the way in which the Hospital Plan may do some thing to remedy them. The question of architectural design is, I think, important, for although small wards may mean a need for more nurses, improved nursing techniques combined with improved design of hospitals can do a great deal to reduce the need for staff, again at all levels. The same is true in laboratories, where we now have machines which can do automatically a good many of the things which needed men and women to do them in the past.
Then I would plead particularly that consideration should be given to the need for residential accommodation at hospitals. I am sure this is most important, and again for all kinds of staff. To-day it is more common than it used to be for medical students to be married. There are many married students, but very few hospitals provide married accommodation for their residents, and it is extremely hard to get accommodation outside. This is very important, too, for registrars. It has long been felt desirable that they should do some of their work in the teaching hospitals and some in the regions and this has been warmly recommended by the Platt Report. Yet to-day it is extremely difficult for married men with young families to move from one area to another and find suitable accommodation there.
The same is true of nurses. There are many instances, particularly of psychiatric hospitals, where there are married nurses, perhaps both man and woman working in the hospital; and yet, if no married accommodation is available, they may be lost to that hospital and have to move to another area. It is not only married nurses, of course, but single people working in the professions supplementary to medicine who, in large towns where there are perhaps several
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hospitals, have the greatest difficulty in finding anywhere to move. So I would suggest that the Minister should consider that he has the responsibility, that the National Health Service has the responsibility, for providing residential accommodation in order that it may both get and keep staff of all kinds.
I should like to say a word about education. The Health Service Acts imposed upon Ministers responsibility for providing facilities for medical education. In those days that work was limited to the undergraduate and post graduate teaching hospitals, and it is still true, of course, that the bulk of medical education is done, and will be done, in these hospitals. Nevertheless, there has been one important change. It is now necessary by Statute that the young doctor after taking his qualifying examination should spend a further year gaining experience in hospital and holding resident hospital posts.
Many of those posts have to be out side the undergraduate teaching hospitals. This has created new responsibilities for universities and other examing bodies and, by implication, for the Ministers, for seeing that the new hospitals which are outlined on the Plan are suitable for educational purposes, for continuing the training of newly qualified doctors. It would, I think, encourage such doctors to stay on for longer periods—as again the Platt Committee recommended—if they were to know that such work would, in fact, be educational. This implies that the staff should take some responsibility for teaching them, that there should be libraries and that there should be, above all, time in which they can read and learn. This, too, I think, would be of great value to the many overseas doctors who are working in these hospitals and who come here to learn. Such hospitals might also fulfil the very useful function of post graduate education for the local general practitioner, who could thus be brought into relationship with the hospital. But I would suggest that we do not want to wait until 1975 for these vital improvements, which would do so much, again, to attract staff and to keep them.
Lastly, I should like to say a word about research. I have not yet been able to find the word "research" in the White Paper. Until recently it might

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well have been argued that the Ministers had no responsibility for research, but there is now a Clinical Research Board which recognises that research may be done in the Health Service, and financial provision is made for it. Research is important. not only as a means of bringing new knowledge, but as the Committees of the Royal College of Physicians have emphasised again and again, as an essential part of the training of specialists, and I believe that the consultant who wants to go on doing clinical research work should have facilities provided for him to do it. But research needs space, and very often space requires to be, not in some remote part of the hospital, but in close relationship with the wards where the clinical work is being done. So I hope that any future hospital plans will make provision for research in under-graduate teaching hospitals and post-graduate teaching hospitals, and, in fact, that every major hospital should have some space provided in which research can be carried out.
This is a Plan which has come from the Minister, and, as I have said, I think that to get the best results it will be necessary not only that he should co-operate with all who have to work in the Health Service but also—as I hope he will—that he will give the greatest possible freedom and initiative to the various hospitals to design and carry out their own plans.
4.28 p.m.
LORD COTTESLOE: My Lords, it is a great personal delight to me, speaking as a mere layman, to be the first to congratulate our new colleague in this House, the noble Lord, Lord Brain, on his maiden speech. No-one who has known Sir Russell Brain as President of the Royal College of Physicians, or in any other activities in the past, could have any doubt that we should have the advantage of hearing him speak to us here very soon after taking his seat in this House; nor that he would do so in the most effective and distinguished way. He justified this expectation on the very day following his Introduction here, and it is evident that we shall benefit greatly from his profound experience and wisdom, and also from his brilliant powers of exposition whenever in the future we are discussing medical affairs.
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My Lords, the Motion moved by the noble Lord, Lord Newton, welcomes the White Paper, and certainly none of your Lordships would dissent from that, despite the suggestions we heard from the noble Baroness, Lady Summerskill (I am sorry she is not here at the moment), or have read in some parts of the Press, that there emanates from it a rather deplorable aura of complacency. I do not think that that charge of complacency can he sustained. It is a charge that rests on the essentially unreasonable complaint that the White Paper does not deal with matters that are, in fact, outside its scope.
The Paper deals with the supply of buildings for the Hospital Service. Involved in the use of those buildings there are, of course, matters of great concern, some of them touched on by most of those who have spoken already this afternoon. For example, there are the grave shortage of doctors, which was brought to the notice of the House in a most impressive speech by the noble Lord, Lord Taylor, when he initiated a debate on the subject recently; the shortage of nurses, of whom, as we have been told this afternoon, there are some 20,000 fewer than the full establishment in the hospitals in this country at the present time; and the shortage of radiologists and physiotherapists, as well as of ancillary staff of various kinds. All these are matters of great concern—and there are plenty of others. But they fall outside the scope of the White Paper, and we cannot blame it for not being something quite different, for not being something that it never set out to be.
Until the requirements of other work a year or two ago made it necessary for me to give it up, I was the chairman of a Regional Hospital Board. In that capacity I found myself for a period of seven years responsible for about 150 hospitals and 36,000 hospital beds. They were beds in buildings of all sorts and kinds, and all shapes and sizes, buildings dating from the time of Waterloo, buildings dating from the Victorian era, Edwardian cottage hospitals, ancient Poor Law buildings and hospitals built between the wars. But those hospitals all had one thing in common: none of them had been built within the last twenty years.

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During those seven years I was constantly astonished and encouraged by the magnificent work done by the doctors and nurses, in grim surroundings and in buildings quite unsuitable for modern requirements. And of course it is a fact that the quality of the service given to the patient does not depend primarily on the buildings in which it is carried on: it depends on the quality and spirit of the men and women who work in them. The often-repeated jibe that we have in this country the best Hospital Service in the worst hospital buildings in the world is possibly about as true as such a sweeping generalisation can be; and it is a wonderful tribute, one most richly deserved, to the devoted work of those who are employed throughout the Service.
My colleagues and I during those seven years told, I think, every one of the somewhat rapid succession of Ministers of Health under whom we served that the most serious and the most pressing of all the troubles under which the Hospital Service laboured was capital starvation; that a plan for a decade of building activity on a scale which would begin to make up the arrears of hospital building which resulted from the war years, and were in creased by the inadequacy of new capital work in the post-war years, was the most important and the most urgent of all our needs. That we now have a Minister of Health who is not only able to see this plainly—and it is sufficiently obvious—but is able enough and persuasive enough to get a realistic building programme of the kind embodied in the White Paper, a programme involving some £500 million spread over 10 years and in total more than £700 million, accepted and provided for is a matter of great rejoicing. This Paper does not deserve the sneers of the noble Baroness, Lady Summerskill, in what I am bound to say was one of the most unconstructive speeches I have ever heard.
Such a programme cannot, in the nature of the case, develop its full momentum as quickly as we should like. The limited number of architects with any knowledge of hospital requirements who are available in the first instance, and the limitation of building capacity and of engineers make it impossible that the work should go forward immediately at the fullest speed all over the country.
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But it seems clear that in the next few years at least hospital building can go forward about as fast as such unavoidable limitations will allow; and we must all be profoundly relieved to know that this is so.
This great acceleration of building brings with it the need to face clearly, and to face more urgently than hitherto, some of the more difficult problems of hospital planning and hospital design. The Hospital Service is not something static. It is a great living and growing organism that has, like any other living organism, constantly to adapt itself to the changing world around it. In the battle that is being fought against human disease great victories are being won, and as we gain ground in one part of the vast field the forces of disease fight back in another. As early diagnosis and new methods of treatment overcome the scourge of tuberculosis the incidence of lung cancer increases. Our wonderful antibiotics quickly breed new strains of resistant bacilli. Our modern techniques of immunisation defeat the epidemics that terrified parents when I was a child, yet at the same time the ailments of old age create more formidable problems in an ageing population. Fever hospitals and the children's hospitals are empty, while the geriatric wards are over crowded. Techniques and ideas are developing all the time; we live in a world of flux.
In the matter of hospital planning and design, as in so many other aspects of the world we live in to-day, the rate of change seems constantly to increase. Fifty years ago it was possible to set out to build a hospital with the complete assurance that the requirements that it was designed to fill would remain unchanged or changed but little, until it was completed. Now we can be certain of one thing: that it will be out of date even before it is complete. Some times I have wondered whether new hospital buildings might not be so designed that nothing was permanent except the outer walls and the floors. In this way all the internal divisions would be movable, so that the layout could be varied to meet the changing medical requirements. That idea is no doubt unpractical and unrealistic, but I am quite certain that not enough attention has been devoted to the application to

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hospital design of modern techniques that make for greater adaptability.
I was very glad that the noble Lord, Lord Newton, said something about this matter when he opened this debate, and I hope that the importance of that aspect of hospital planning and design will be constantly stressed. It is at all events necessary that the broad hospital plan which this Command Paper embodies should not attempt to see too far into the future, and that even within its limited period it should be flexible. While one would be glad to see a plan to replace all our pre-war hospitals in the next quarter of a century, in practice the rate of change is so great that a decade is perhaps as far as it can be sensible to try to look forward.
This Plan, then, seems to me, so far as a layman can judge (we have in this House many doctors to give us the benefit of their professional knowledge: I think there are no fewer than seven on the "batting list" to-day), to be, in general, a realistic and forward-looking Plan. Of course, as it goes forward, it will have to be varied and revised from time to time. I have an idea that in the field of obstetrics the climate of opinion will move still further towards the view that all confinements should be in hospital, and that the provision embodied in the White Paper will soon be felt to be insufficient. Although the Plan embodies the modern view of mental illness as a disease generally curable, that should be treated in the psychiatric ward in a general hospital, I do not feel sure that it embodies enough provision, in small and modern units, for the inevitable residue of long-stay mental patients, or for those mentally sub normal, so that the vast and horrible asylums that we have inherited from the past can be done away with as urgently as should be. But these are no more than the casual doubts of a layman who has not the full knowledge to enable him to form any certain judgment.
I am particularly interested in the proposals for the re-grouping of some of the post-graduate teaching hospitals, which are referred to at page 88 of the White Paper and elsewhere, and were more fully detailed by the Minister in answer to a Question in another place last June. These fourteen hospitals, the
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great general post-graduate hospital at Ducane Road, Hammersmith, and the specialist post-graduate hospitals in other parts of London, have associated with them, and providing the medical services for them, the schools and institutes of the British Post-graduate Medical Federation.
The White Paper says that these post graduate teaching hospitals act in their specialties as reference hospitals for the whole country. That is perfectly true. But it goes much wider than that. The Post-graduate Medical School at Hammersmith Hospital and the specialist institutes of the Federation at the specialist post-graduate hospitals—the Institute of Psychiatry at the Maudsley; the Institute of Ophthalmology associated with Moorfields; the Institute of Neurology at the National Hospital; the Institute of Child Health at Great Ormond Street, and all the rest—draw qualified doctors for further training and research not only from the whole country but from the whole world.
The Federation, which is in fact a School of the University of London, last year enrolled 4,000 doctors for higher medical training. About one-third of these came from the United Kingdom; more than 1,500 came from 31 Dominions and dependencies of the Commonwealth, and more than 1,000 came from no fewer than 62 foreign countries—I must not say from China to Peru, because China is almost the only country in the world from whom we have not a student at the present time; but from Japan to Venezuela, from Costa Rica to Nepal. Large numbers come from Australia and New Zealand, from India and Ceylon, from South Africa and the United States of America, from Egypt and Iraq, and from Greece. The work that is done in these hospitals, and in the schools and institutes associated with them pervades the whole world. The knowledge that these doctors from overseas take back with them largely determines the future pattern of medicine in the un developed and underdeveloped countries of the Commonwealth and the world.
It is, therefore, my Lords, as it seems to me, of prime importance, not only for us in this country but also for the world at large, that these post-graduate teaching hospitals should embody the

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latest ideas; that they should be, in their design and their equipment, as modern and as up to date as it is possible for a hospital to be. Not one of them is that at the present time; and some of them, indeed, are in buildings that are utterly deplorable and most seriously hinder and stultify their work.
The White Paper includes proposals for rebuilding some of these hospitals and for improving others; but I doubt whether the full importance and urgency of this particular work is even now appreciated. I hope that when the noble Lord, Lord Mills, domes to reply to this debate (I must express to him my apologies that an imperative engagement elsewhere will prevent my being here to hear him, although I shall, of course, read with the closest interest what he says) he will be able to tell us that we may feel reassured about that aspect, and that every possible effort will be made to accelerate the rebuilding and the modernisation of these post-graduate teaching hospitals so that they may set a standard, as they should be doing, for all the world to see and to follow.
4.47 p.m.
VISCOUNT WAVERLEY: My Lords, first may I add my congratulations to that most eminent member of my profession, Lord Brain, on his eloquent and most valuable maiden speech. I am sure that we look forward to many and frequent opportunities of profiting from his wisdom in the future. In 1959, when I first had the privilege of speaking in your Lordships' House, I urged the need for the immediate launching of a massive programme of hospital construction. The gestation has been disappointingly protracted but the programme as now revealed to us is undoubtedly massive. I welcome its quantity, but have certain reservations about its quality. The concept of the district general hospital to provide comprehensive medical care and supporting services in centres of population must be correct, and the subsequent closure of smaller hospitals, sad but inevitable.
It is, however, about the proposed size of these district hospitals that I am concerned. I fear that Her Majesty's Government may have too doctrinaire an attachment to the notion that 600 to 800 beds is the ideal and that a larger
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hospital may be difficult to administer and, for the patient, impersonal and even perhaps forbidding. Is there really any strong evidence that this is so? I have the honour to be a member of the consultant staff of the Reading group of hospitals. I do not wish to weary our Lordships with purely local statistics. It will suffice to say that anticipated population demands cannot he met by one district hospital in Reading. There will be required 1,200 to 1,400 beds. The present Royal Berkshire Hospital site can accommodate a hospital of this size, and it is the unanimous wish of the consultant staff that it should. The Command Paper, how ever, decrees two district general hospitals for Reading, each presumably duplicating the services of the other, each competing with the other for staff, medical, auxiliary to medicine and lay; and owing to relative professional isolation neither, I suspect, able to provide a service of such scientific quality as could a single, self-contained hospital. If the town of Reading were sub-divided by some physical barrier, such as a wide river, with a capricious and infrequent ferry service, I could understand the need for two hospitals. As, happily, it is not so divided, I cannot. My Lords, I apologise for speaking parochially. My excuse is that I think this to be an example of the particular differing very little from the general.
I should like now to mention a different, but related, matter. I refer to the question of communication. The right honourable gentleman the Minister in another place is a staunch apostle of the importance of communication in the Hospital Service. Reduced to simple terms, "communication" in this context means that patients and their relatives shall know, and if possible understand, what is happening to them. Humanity, of course, frequently determines whether communication between hospital and patient shall be as explicit as between hospital and relatives. My Lords, there is no need for any such glosses or half-truths between the Minister and those whose duties lie in administering the Hospital Service. Indeed, communication must be absolutely frank and free if the Service is to develop harmoniously, particularly when, as at present, the pattern is being set for at least a century.

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Now, my Lords, bearing in mind the Minister's preoccupation with this matter of communication, it could have been anticipated that the Command Paper would contain frequent references to consultation at all levels—and so it does. This, to me, was a most heartening realisation because, if implemented, it implies that the Hospital Plan is less rigid than at first sight might appear, and that within the general framework quite wide modifications to meet local needs would be possible.
I have stressed the importance of full and free consultation, and I pray that it will be forthcoming. I feel, though, that I should stress that, if it is not forth coming. there is a risk of disenchantment in the Hospital Service, of a loss of the present accord between the Minister and the Service, and a recrudescence of that sort of bickering which for so long bedevilled relations between the Minister and family doctors. Remuneration was the trouble there, vexing and often. I fear, somewhat lacking in dignity, but, at least, from the very start always capable of pragmatic solution. If the Hospital Plan goes wrong and is thought to have done so owing to any lack of consultation, there will be no such simple solution. It will not be possible just to scrap it and build afresh. Consultation must be actively encouraged by the Minister. If it is not encouraged, there is danger that hospital staffs, management committees, Regional Boards, and boards of governors may accept a "bird in the hand" rather than risk delays and postponements. Such uncritical acceptance would he detrimental to the Hospital Service. When these peripheral consultations have been completed and deviations within the general framework agreed, considerable savings in time and effort would be established if there were greater devolution from the Minister downwards.
The Command Paper refers to the existing shortages of doctors, architects and engineers skilled and trained in hospital planning. That this is so cannot possibly be doubted. It would appear to me, and perhaps to some of your Lordships, that against such a back ground of scarcity the present Ministry practice of microscopic examination of every plan, even though already agreed
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in principle, displays a prodigality for which our resources are insufficient.
4.55 p.m.
LORD STONHAM: My Lords, I am glad to be the first from this side of your Lordships' House to congratulate the noble Lord, Lord Brain, on his maiden speech, to which we listened with such appreciation and respect a few minutes ago. I hope that the noble Lord will often take part in our debates and give us the benefit of his experience, not only in the profession of which he is such a distinguished member but in other fields in which he has great knowledge.
I am bound to warn him almost at once that in the course of my remarks I shall express opinions with regard to the relationship of the teaching hospital and the hospital world with which he may not agree. He may be tempted to echo what the noble Lord, Lord Mills, said on the last occasion when I addressed your Lordships' House, and that was that I did not know what I was talking about. I am hound to say that the noble Lord, with his customary generosity, softened the blow subsequently by then repeating as fact almost everything that I had said. He left me in somewhat of a dilemma as to whether he was agreeing that neither of us knew what we were talking about, or whether he was softening his early judgment as being too hasty.
I am sorry that the noble Lord, Lord Newton, has momentarily left his place, because I should like to congratulate him on making what I thought was the best speech that I have heard the noble Lord make, either in this House or in another place. I thought that his exposition of the Plan was exceedingly clear and lucid. I felt that in his understand able enthusiasm, both for the, Plan and for his right honourable friend, he some what let himself go and made himself a candidate for the "most sweeping statement stakes" when he said that January 21, 1962, was one of the most momentous days in the history of the Hospital Service. After all, my Lords, the noble Lord did us the favour of giving the figures of expenditure, and I am sure he will agree with me that even the £35 million we shall be spending next year on our hospitals is, in real terms, still less than the level of such expenditure in

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1938. So we have not yet got very far. And, so far as this being the most momentous day in the history of the Hospital Service is concerned, he may well have said that about the day the Conservative Party Manifesto was published in the 1959 Election, because, in capital terms, this Plan does precisely what the Conservative Government promised.
But do join with every noble Lord who has spoken in this debate in welcoming a plan. It is something for which I have pleaded for a good many years in the Hospital Service, and, however much we criticise this Plan, nevertheless we do commend the Minister's enthusiasm and initiative in this matter. We needed a lead. I think, however, that when the Minister, in the noble Lord's words, as it were deprecated the suggestion that it was his Plan, and said that it was really the Plan of the Regional Hospital Boards, it was only a way of paying tribute, a well-deserved tribute, to the exceptionally hard work (I might almost say miraculous work) which they put in in producing a plan in four months, because it had to be in the Minister's hands by May, and the sub sequent eight months prior to publication have quite understandably been taken up by consideration. I say this, because I must emphasise that this is the Minister's Plan. Certainly, of course, he had proposals from the Regional Boards. They sent him their suggestions, but it was for him to accept, reject or amend. He has, in financial terms, reduced the proposals sent to him by the Regional Boards by nearly 40 per cent., as was made clear in another place yesterday.
I would submit, my Lords, that these changes are of a major and fundamental character and that, unfortunately, in places all over the country, the Minister has knocked the bottom out of the hospital world, medical, nursing and lay. Witness the heart-cry in The Times yesterday from Dr. Avery Jones, of the Central Middlesex Hospital, who made it clear that in that hospital, where they have achieved a very great deal in the last twelve years, they feel they will have to depend largely on public charity. And he makes the plea that public contributions should be free of income tax, which would help them. My Lords, that
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is one of the hospitals that will survive. It is not one of the many which in fact began to die the very day that Plan was published. Therefore, it is the Minister's Plan, and such, in my view, are its defects that I submit it can be regarded only as a basis for discussion, which I, for one, am very glad to have.
The first of the defects from which I think the Plan suffers (it has not yet been mentioned, and probably no other noble Lord in the House will agree with me here) is the gross disparity in the financial provision for teaching hospitals as compared with that for ordinary hospitals. Although I was a member of the Standing Committee on the National Health Service Bill, before it became law, I believe that the Labour Government made a bad mistake in 1948, when they decided that teaching hospitals should be financed separately from, and be independent of, the management of the Regional Boards.
No-one would suggest that the Scottish teaching hospitals are inferior to the English, yet in Scotland, where they come under the Regional Boards, they cost far less to run and give infinitely better service to the hospitals in the region as a whole. Staffs of all hospitals, medical, nursing and ancillary, are paid on the same salary scales. They are the same people, with the same qualifications and doing the same job, yet because of the separate financing, and what I regard as the medical "purdah" assumed by the English teaching hospitals, we have a double standard in the Hospital Service. In my view they have failed dismally to diffuse their influence over the Service as a whole.
Everyone recognises that the teaching hospitals have a special job to do which justifies higher staff ratios and some financial cosseting; consequently, their proportion of the limited resources which have been available over the last fourteen years has, rightly, been more than generous. But the opportunity should have been taken, and in my view must be taken, in the ten-year Plan to break down these harmful and artificial barriers and integrate the teaching hospitals into the system as a whole. I think that the quickest and surest way of doing this is to end the separate, and disparate, financing. Unhappily, the Minister not only proposes to continue

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the present system but to make it unconscionably worse.
I would ask the noble Lord, Lord Mills, who is to reply, to consider the figures I am now about to quote, and to answer the point. The Plan proposes that the 473,000 beds in the 2,800 non-teaching hospitals (these are the figures at the moment) shall attract expenditure of £578 million—that is, £1,222 per bed; but the 27,606 beds in the 36 teaching hospitals will attract expenditure of £129 million, which equals £4,673 per bed. That means, my Lords, £4,673 per bed in hospitals already comparatively well endowed, compared with £1,222 per bed in hospitals comparatively ill-provided. I do not think that those figures can possibly be disputed; nor do I think can anyone dispute the two conclusions that I draw from them.
The first is that £4,673 per bed is a fantastic over-provision which we can not and should not afford. The second conclusion is that to spend four times as much on teaching hospitals as on district hospitals is quite indefensible. I think that any one who has had continuous experience, as I have had, over the last twelve years—not only in London but in the West Country—of administering hospitals and knowing something of their comparative conditions, will support me in saying that that almost fourfold disparity is quite in defensible. My Lords, we just cannot allow it, because it will produce two utterly different standards in the same free Hospital Service, and it will create frustration and near-despair in the staffs of ordinary hospitals throughout the country.
In another important aspect—and this time it is not their fault—I will lend the noble Lord my arithmetic if he wants to check—the teaching hospitals give a false picture of the scale of hospital services needed in adjoining areas. For example, the Minister says, quite correctly, that the "London" and "Bart's" draw the majority of their patients from outside the East End of London. But he assumes that, because 25 per cent. of their beds are used by local patients (and in order to be absolutely right with the noble Lord, let me say that I know that 31 per cent. of the "London's" beds are used
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by local patients, though since it is a smaller proportion at "Bart's", my figure of 25 per cent. for the two hospitals together is the correct one) these two hospitals could handle 25 per cent. of all the acute surgical and medical work required for the 570,000 people living in the East End of London. But that is just not possible. Unfortunately, the White Paper acts on that false assumption, and proposes that the present East London total of 2,637 acute beds in ordinary hospitals shall be reduced to 1,586—a reduction of just over 1,000 out of 2,500.
My Lords, the noble Lord, Lord Amulree, mentioned, quite correctly, that under the Plan there is to be a reduction throughout the country of, I think, 10,900 beds. That is in respect of nearly 50 million people, the population of England and Wales. Here in the East End, with only just over half a million people, we are proposing to reduce by 1,000. In other words, it is proposed that 1 per cent. of the people should bear 10 per cent. of the reduction in the number of beds throughout the whole country. I do not know if I am making myself clear to the noble Lord. I will put it again. We are going to lose 10,000 acute beds for the whole country, the whole population. Out of that 10,000, 1,000 are to be in the East End of London, with a population of little more than half a million—in other words, ten times the national average. My Lords, if I did not know the district, and if I were merely looking at things on paper, I should be quite willing to agree that that might be possible; but I do know the district.
Since there are some seven noble Lords who are doctors in this debate, I should like to put this proposition to them. In order to achieve what the Minister wants us to do in the East End of London, we should have to increase our efficiency in the use of beds by 66 per cent. I have before me the figures of a group of hospitals in East London which last year treated to a conclusion 10,117 patients. They are different hospitals, but their bed occupancy varied between a minimum of 80 per cent. and a maximum of 95 per cent. Now if the turnover interval in the use of beds could have been reduced to one day—which, as anyone who knows will agree, is a very high, and possibly unattainable,

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level of efficiency—that group of hospitals could have treated 1,400 more patients last year, In other words, there would have been a 14 per cent. increase in efficiency, which I should regard as the maximum possible from that source—not the 66 per cent. increase in efficiency, which is now demanded by the Minister's Plan.
In fact, my Lords, the Plan would mean a crippling reduction in services, and the waiting lists would lengthen to hopeless proportions. A dangerous situation would arise in emergencies. On page 108, the Command Paper declares that East London has considerably more beds than are required, but I would submit that the enormously long waiting lists in the teaching hospitals would prove otherwise. I made inquiry on this point only this week, and I should like to quote just one or two cases from the waiting lists at teaching hospitals which are always coming to light. First, a patient with varicose veins had been eight years on the waiting list. She had written five times inquiring about ad mission, which proves that it was a live case. Secondly, a patient with a lump in the breast, which most hospitals would regard as urgent—maybe a carcinoma—has been waiting ten months for admission, and has not been admitted yet.
Thirdly, a woman with a painful knee was put on the waiting list for operation for the removal of a torn cartilage in March, 1959. She suffered persistent pain, and eventually, in February, 1962—that is this year—her general practitioner referred her to the local hospital, where she was admitted within a matter of days. Fourthly, a woman with very severe bilateral varicose veins, after having been on the waiting list for four years, received a letter from the teaching hospital informing her that there was no immediate prospect of admission, and advising her to go back to her G.P. and make other arrangements. One consultant surgeon had recently been asked to take 48 cases from the waiting list of a teaching hospital into his general hospital. My Lords, that is not meant to be a reflection on teaching hospitals; I merely mention the chronic state of the waiting lists and the utter folly of suggesting that in adjoining areas there can be a cut in beds of the order which is requested.
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There is another thing: the emergencies. Last month, during the red and yellow warnings, as we call them, they did not have any beds empty. Indeed, they were putting up extra beds. I can assure your Lordships that, in that area, there has been no year since the Appointed Day during which we have not had to put up emergency beds. I do not know the basis of this calculation, but I do know that we cannot tell our patients, "Do not become ill in winter time. Come back when it is summertime, and we might be able to cope with you ". We must treat our patients, or try to treat them, when they are ill; and I assure your Lordships that in that part of London, with the usual respiratory troubles in particular parts of the year, we are always full up. What would it be like if we had only three beds for every five that we now have? I think it would be intolerable. I emphasise these things because the correction of these miscalculations involves adjustments elsewhere. Some hundreds of these beds that I have mentioned are not to be closed altogether, but their use is to be transferred from acute to geriatric cases, and a geriatric hospital is to be closed altogether. I think that must be looked at again, because it just is not "on", my Lords.
The noble Lord, Lord Newton, said that this Plan is dynamic and not static; that it is flexible and subject to annual review. It seems to me that that review will be largely a financial one, to deter mine which parts of the Plan will next go into operation. What I want to know is whether major reconsideration will be possible in respect to different areas or services, or whether, broadly speaking, this Plan is to be regarded as a hospital "Doomsday Book". The point is that, if errors of judgment have been made, they should be corrected immediately the relevant facts have been considered or reconsidered, because it is imperative that the deep disappointment and frustration which the Plan has already caused in certain quarters—and, believe me, my Lords, I speak from knowledge when I talk of the deep disappointment and frustration which has been caused—should, if at all possible, be removed. If it is inevitable—and I can say that I would support it wholeheartedly, with out any parochial ideas, if I could see

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that it was essential for the Service—then, yes, support it; but if there is a miscalculation, if it is foolish, then the correction should be made as soon as possible, before more harm is done.
I think the second defect in the Plan is that, in estimating the bed requirements in relation to population, far too little attention has been given to the variations arising in different areas from varying social conditions. The estimates of beds in relation to population may possibly be justifiable as a natural average, although I think the basis on which the estimates have been made is sketchy in the extreme—four local inquiries, two reports not published and one or two articles or letters in the Lancet. That is about the lot; but I am not prepared to argue that. However, the "average area" is as difficult to find as the average human being For example, there are areas in London and other big cities where overcrowding and bad housing conditions make it necessary to provide higher than average proportions of beds for maternity and geriatric cases. Ten years hence, in the London boroughs of Bethnal Green and Shore-ditch, one person out of four will be 65 years of age or more—one out of four! In Bethnal Green to-day it is one out of five; in ten years' time it will be one out of four. This does not appear to have been properly allowed for. The resulting false premises have led to unsound decisions regarding the building, enlarging, or closing of hospitals.
The greatest error in fact appears to lie in the suggested provision of hospital beds for the aged. We are told that at any given time only one elderly person in a hundred will need a hospital bed. That may be all right for well-to-do residential areas, but in my experience it is far too low for the poorer and more crowded districts. True, it is based on the assumption that there will be wider and fuller provision of services for the elderly outside hospitals, and I know the Minister has taken, or is about to take, the initial step of discussing this with the local authorities. But, my Lords, have you considered the enormous leeway there is to be made up?
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If you look at the figures in the Plan, you will find these facts, which were touched on in a different way by the noble Lord, Lord Amulree. We have only one home nurse for every 6,000 people. We have one health visitor to look after every 8,000 people. These are average figures; it is very uneven throughout the country. We have been told nothing about what will happen with regard to rates of pay or training facilities; they are both ignored in the Report. Where are the people coming from? Who, in the main, are the people who are now health visitors? They are dedicated spinsters—and how grateful we should be to them—of the kind who are not coming forward to-day: they just are not there. It is going to be difficult even to maintain the proportion of health visitors and home nurses. We have one midwife for every 9,000 people. We have one home help to be shared among over 2,000 people. Therefore, it seems vital to insist that geriatric hospitals should not be closed until there has been a large-scale recruitment of domiciliary health workers and a general improvement in health services for old people on the lines suggested in the recent debate, when we asked for a charter for the aged.
Most noble Lords have spoken of the fact that the Plan says very little about staffs. The noble Lord, Lord Cottesloe, said that this was outside the scope of the White Paper; but I hope the Government do not agree with that, because a plan for hospitals which did not plan for the staffs would be no plan at all. Indeed, the Minister does include one paragraph in the Plan about staffs, so we must be on the rails "in discussing the staffs. I think that if nothing is done to remedy the chronic shortage of trained staff in many important departments of hospital work, all this expenditure on new, improved and better-equipped buildings might well be poured down the drain. In the recent debate on the ancillary professional staffs which was initiated by my noble friend Lady Summerskill, I gave official figures proving that our establishments, in adequate as they are, of pharmacists, radiographers, physiotherapists, almoners, laboratory technicians, and so on, were, according to the nature of the specialty and the part of the country,

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anything from 25 to 50 per cent. below strength.
Soon afterwards I received a letter from the North-East Metropolitan Hospital Region—it is not from the Regional Board, but from an official—and this is one paragraph:
" About a year ago we opened an occupational therapy department at the Connaught Hospital, and just as it was beginning to be established, it has had to be closed owing to lack of staff. We are also having to pay 25 guineas a week to a private firm to keep the X-ray department going at Wanstead Hospital."
I ask, what is the use of spending £10,000 or £20,000 on a new department if you are not allowed to pay a reason able salary to trained staff? Where is the economy in paying 25 guineas a week for X-ray staff because you are not allowed to pay more than 12 guineas a week to your own radiographer?
In hospital pharmacies the position is almost desperate, even in teaching hospitals. In Service hospitals they cannot get any at all. The work has to be done by sergeant dispensers with limited training. This is dangerous and foolish and debases the pharmaceutical profession. Essential departments are being closed down everywhere. If the Minister really wants an efficient service in his new hospitals, then new pay scales and improved training facilities for ancillary staffs must be dealt with urgently, as matters of overriding importance.
And we must train more doctors. It is regrettable in the extreme that the Plan contains no proposals for new teaching hospitals. Some district hospitals which have 600 or 800 beds would be eminently suitable. Apart from pro viding badly needed doctors, their presence in the regions would raise the morale of the whole service. Surely we shall not continue to tolerate a position where, but for nearly 4,000 junior doctors from overseas, we could not run our hospitals at all.
Mention was made by the right reverend Prelate of the position in Sheffield. In Sheffield they have not merely a very high proportion of doctors from overseas, but doctors from 29 different countries in their hospitals, including one doctor from China, by the way. The noble Lord, Lord Cottesloe, regretted that there was not a representative from China, but there
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is one in Sheffield. However, some of these doctors require interpreters. Just think, my Lords. What should we say if our wives were going to be examined in such a hospital? As the right reverend Prelate said (although he put the case of a man), she would be nervous, anxious, wanting to know what is the matter with her, and she would be confronted by a young doctor who could not even speak her language and to whom she could not speak herself. It is really extraordinary.
I agree with very much that the Lord Bishop of Lichfield said, and with all that he said on this subject, in what I thought was a notable speech; and how much we welcome having these doctors here! But how utterly wrong it is that we are not producing enough doctors of our own; that is the point. Nearly a thousand of the doctors in our hospitals have only temporary registrations, and we know little or nothing of their standard of training. Despite what Lord Cottesloe said, I think it is as important to have doctors as it is to have hospitals. You cannot have hospitals unless you have doctors. Whatever happens now, and whatever the Government think, we are going to experience a very difficult time over the next seven years, and we cannot start too soon to remedy this desperate situation. Therefore I suggest that there is an imperative need to convert a number of district hospitals into teaching hospitals.
This plan, my Lords, can be accepted only as a first draft. It requires the most careful discussion between Hospital Groups and Regional Boards, and then it should go hack again to the Ministry and the Minister before we go too far with it. If that is done, and we then have a plan which deserves general support and which is likely to take us forward to a comprehensive and efficient Hospital Service, then I think we shall be able to pay tribute to an energetic, a gifted, and a dedicated Minister.
5.28 p.m.
LORD COHEN OF BIRKENHEAD: My Lords, may I at the outset associate myself with the great tributes which have been paid to my noble friend Lord Brain on his most admirable maiden speech, full of wisdom which is born of long

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experience and understanding of hospital problems? He has himself written, both eruditely and wittily, on the late Dr. Samuel Johnson, and if I say no more it is because I am now under an exhortation of Dr. Samuel Johnson, which was that you should never speak of a man in his presence; it is always indelicate, and it may be offensive.
The noble Lord, Lord Cottesloe, mentioned that this was a formidable batting list, and I confess that I find myself, as A. E. Housman once found himself, somewhat "betwixt and between": I am obviously not good enough to be an opening batsman, nor am I good enough to be a first-class bowler whose batting does not matter. So, in the position in which I find myself. I must inevitably, I fear, cross a few t's and dot a few i's, but I hope that I shall also erase a few dots and crosses in the process.
Whatever your Lordships may think of this Command Paper, I am sure that we all, even the noble Baroness, should wish to share in the tribute of the noble Lord, Lord Stonham, to the noble Lord, Lord Newton, for his admirably clear and succinct exposition of the principles which underlie this White Paper. For myself, I would add that I welcome them most warmly, despite the animadversions of some who have spoken. May I immediately repudiate what was said by the noble Baroness, that the British Medical Association is a Conservative organisation? I am a past President of the British Medical Association and I know that it owes no Party political allegiance. I do not even know if there is a majority of the Conservative Party in the British Medical Association. All I know is that it would be as wrong to say that the British Medical Association is a Conservative organisation as it would be to say that Parliament is a Conservative organisation.
As has been said, Sir Harry Platt has paid tribute, in his letter to The Times, to the precursors from which this Plan flows. I should like to recall an historic fact. It is that in 1920 a plan was presented to the then Minister of Health by the Chairman of his Consultative Council, the plan known as the Dawson Plan, after the late Lord Dawson of Penn. I would stress that it is from that plan the essence of all successive plans
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for the development of hospitals and the Health Service has been distilled. Indeed, in that plan our district general hospital appeared as what Lord Dawson of Penn called the secondary health centre, with its appropriate association with teaching hospitals and the primary health centres, the general practitioners. I think that it is right, in a tribute to the memory of one who did so much for planning medicine, that I should recall Lord Dawson of Penn's contribution in this field.
It may well be, despite the fact (which I have mentioned on more than one occasion in your Lordships' House) that the conception of the regionalisation of hospitals has not been fully implemented (we still do not have the teaching hospitals and regional hospitals, as the noble Lord, Lord Stonham has suggested, walking the path of progress abreast or arm in arm), that the district general hospital outlined in this White Paper, with its wider hospitals, including acute, psychiatric and geriatric beds, will help to make this contribution in a way which I hope to elaborate in a moment. Though I cannot officially see the Minister from where I am now standing, I should like someone to convey to him the fact that many of us in this House who have been associated with him over the period of time in which he has been in office, recognise his initiative, his drive, his foresight and his complete grasp of the Hospital and Health Service situation from a personal study of the problem.
After all, in scale and in detail and in the complete coherence of the Plan, this is by far the most far-reaching plan of all that have been published. I recall, with some interest, what the Minister said in his earlier major speech as Minister of Health:
" In any given state of society and medical knowledge, there is an ideal application of the available resources which will yield the greatest harvest in terms of health, well-being, comfort, reassurance—in short, of happiness."
I believe that this hospital Plan goes a long way to fulfil the Minister's fundamental credo.
Undoubtedly there will be widespread dissent from its detailed proposals, but I hope that most of us will share the general assent which has been given in this House this afternoon. I expect that

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few Regional Boards or boards of governors would be prepared to accept fully the detailed plans which are posed, and may well feel that some of their own suggestions have been too little heeded but I think that we have to remember—and this is where I doubt whether a detailed discussion of the proposals in Appendix A this afternoon is likely to be productive—that in this Plan all the Regional Board and boards of governors proposals have had to be fitted into a consistent national plan within the com pass of the available financial resources. As the White Paper itself makes abundantly clear, there is still opportunity for the detailed discussion of many of the individual items.
I agree that it is likely that the closure of some of the smaller, of some of the older, of some of the specialist hospitals, which have a long tradition of exemplary and admirable service to the communities in which they are, will attract the most serious criticism. But I feel that we must recognise that, whatever their past contributions, the vast majority of them, in the days of modern medical practice, have outlived their usefulness. They can be used for other purposes—as, it has been suggested, out-patient clinics or diagnostic and follow-up clinics, even, it may be, as general practitioner centres. These are matters which can be discussed, but as acute general hospitals they have had their day. And I hope it will be realised that it is far better that the decisions which had to be taken, which were delicately poised and were Obviously full of emotional content at a parochial level, were better taken at the centre. After all, the Minister is better able to resist the importunate and emotional claims of local interests and local loyalties.
I should also like to say that, when ever it is suggested that a hospital should be closed and there is an outcry, as a rule it does not come from the patients. The potential patients of the hospital are not prepared, as some others who are interested, to say, "This is a poor thing but mine own "and we must retain it. I think that the public is becoming aware that the great range of medical resources which can be brought to their help can so be brought only where those resources are sufficient to provide all the services in general, and many specialist
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services, which are needed to restore the patient to health.
I know, as indeed the White Paper says, that this involves longer distances for patients to travel and for the relatives and friends to visit them. But hospitals must recognise the need for visiting. Many hospitals, I regret to say, are resisting this. I believe that there are few hours in a day in which hospital wards need be closed to visitors. I think there should be daily visiting, except in very unusual circumstances, and that the wards should be open more than once a day—because patients do not want prolonged visiting, but to be visited for a short time frequently. Our own Standing Medical Advisory Committee in the Central Health Council have urged this policy, but I hope that it will be urged again and again from the centre.
I have certain criticisms, but criticisms which I propose to offer, because they are not very profound, in the spirit of the wisdom of Solomon: that
" Having been a little chastised they will he greatly rewarded."
My first criticism relates to a minor point of presentation of the White Paper. I wonder why there is no map in this White Paper to show the regional boundaries and the sites of the proposed district general hospitals, so that we could see at a glance their relationship to the major concentrations of population. It was possible to produce a map in the famous R.H.B. 48/1 on the Development of Consultant Services. We might have had a map which would help poor visuals like myself to obtain a vivid picture of what is proposed.
I also think, with the noble Baroness, Lady Summerskill, that it would have been desirable to have a footnote showing that certain figures were unrealistic to-day. It is not conveying the real truth to say that £8·7 million was spent on hospitals in 1949, and £23·7 million in 1960–61. That suggests an increase of 160 per cent. expenditure, when in fact we know that the cost of hospital building, at a minimum, has gone up in that decade by 60 or 70 per cent., and possibly by 100 per cent. So that the £23·7 million represents about £14 million, and therefore the increase is per haps 65 per cent. To those who think that we are being extremely extravagant in our present proposals, it is worth

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underlining what the noble Lord, Lord Stonham, said; that if we extrapolate the figures of Abel-Smith and Titmus in 1952–53 to the present day, the £10 million spent in 1938–39 is actually equivalent, in terms of real hospital building, to something like £46 million to-day. I stress this only because I think we have to realise that the figures we have seen for the ensuing decade might well not be adequate, if there be this continuing inflationary trend, to complete the programme which is envisaged in the White Paper.
While dealing with finance (and I do this as a member of a Regional Hospital Board and of a board of governors since the appointed day) might I tread, like Ruth, warily, "amid the alien corn," which is not wholly proper to this House, and call attention once again to the defects, as they affect the hospital building, of Parliamentary Accounting and Voting systems. It is, in fact, this annual accounting which makes the problem of building hospitals so difficult. Your Lordships will be well aware how each year one has to estimate; one has to examine the estimates; one has to approve, and one has to vote. And if there is a project which extends over five or six years, it has to be fragmented in such a way that each part fits exactly into the year. Because if one over spends, the poor, unhappy accounting officer of the Ministry of Health has to justify that to the Public Accounts Committee; and if one under-spends, the surplus cannot be carried over—the money is lost. And if the money is lost, it means that the schemes are pro longed; that hospitals which are being remodelled (to use the term in the White Paper) are dislocated for a much longer period of time and there is frustration over new hospitals.
My Lords, I hope that new means will be found to secure a greater financial flexibility in this particular field which will try to ensure that if, for any reason, the preparatory work is delayed, if it is slowed up, yet the total project can be achieved in the given time; and I hat is not possible if money is lost under present conditions. I would, also, as a member of a hospital board, draw attention to some of the defects of the present tendering machinery, and I hope
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that they will be looked at in the light of the Hospital Plan.
I am not unmindful that this is a White Paper, and White Papers, like bishops, despite their aspirations, are not always translated in fact. This White Paper, as has been said, obviously does not commit the present Government; it certainly may be rejected by future Governments. It may well be, too, that the hard facts of the national economy will prevent the implementation, the completion of the vision, of this White Paper. But let us accept that all will go well; let us accept that in the next ten years we shall have started all and completed some of 90 new hospitals and 134 substantially remodelled hospitals. That means that about half the hospitals of this country will be developed over the next ten years.
I hope most sincerely that we shall not have, as a result of that massive project, an undue uniformity of design of appearance of the hospitals, a monotony of appearance of the hospitals; and I certainly hope, with the noble Lord, Lord Cottisloe, that we shall have the greatest degree of flexibility within the hospitals. In ten years the whole outlook in medicine may well change, and there will be greater need. And the one point which I think is absolutely essential is to ensure that these hospitals are not built on restricted sites; because all the hospitals that I have seen built in my own lifetime, up to a very few years ago, were built on restricted sites; and so, I suspect, may be one or two of the present new teaching hospitals. But if that does happen, the result will be that every available square yard will ultimately be used; and the hospital will be a crowded one and not a well-disposed one.
I am also happy to see that something which I emphasised in an earlier hospital debate has been, in this White Paper, considered with great care; that is, the reduction of the number of acute general hospital beds from 5 per 1,000 to 3·3 per 1,000. I hope that the noble Lord, Lord Stonham, will agree that this is not based on one or two small superficial observations; it is, in fact, based, as he will see if he will do me the honour of reading my speech made on November 19, 1959, on very firm studies, many of which are published

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in detail and which showed conclusively that not infrequently hospitals were being used for social as well as for medical purposes. In other words, the patients were being kept in hospital longer than their medical needs required.
I mentioned then, and I will mention again now, a hospital which need not remain anonymous—it is one of the Barrow hospitals—in which a very careful survey showed that one-third of the men and one half of the women were there, having completed their medical treatment, because conditions at home were not proper to receive them. This surely emphasises the role of the local authority. It is no use saying that if four or six members of a family are living in one or two rooms, they should leave hospital immediately their hospital needs have been satisfied, because they will not get the needs at home. That shows how all these services—hospital, local authority, general practitioner and the voluntary agencies—are intimately bound together in providing the service for the whole of this country.
LORD STONHAM: My Lords, will the noble Lord allow me to interrupt? Would he not agree that the example he has quoted is an exception and not an average case, because there could not have been much pressure on the beds of the hospital he mentioned? I should not like him to convey the impression that this was an average case. It must be an extreme case.
LORD COHEN OF BIRKENHEAD: It is much less average than the case of the junior hospital medical officer who was unable to communicate in English with the patient of whom the noble Lord spoke, because these studies have shown in Norwich, Northampton, Barrow, Oxford and elsewhere, that the number of beds required varies between 2 and 3·5 per 1,000 over the population, depending on needs. I thought the noble Earl, Lord Longford, was going to interrupt me, but I can see that he is only drinking one of nature's beverages. Also, I think the dramatic reduction in the number of mental health beds is important—3·3 to 1·8 per 1,000. This reflects the reorientation towards the treatment of the mentally ill which was initiated by the Royal Commission on Mental Health and implemented—statutorily implemented, though not imple-
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mented in fact—by the Mental Health Act, 1959.
I have one caveat. I accept the figures, which are based on the work of Tooth and Brooke, published in the Lancet, which show that in 1975 the number of mentally ill in hospital will be reduced by one half. But it is fair to say that some very distinguished psychiatrists do not accept that view. I myself would have walked very warily over this if it had not been for the White Paper's insistence on an annual review of all these beds. I think that if there are trends which are unforeseen, they can he met after these annual reviews.
The noble Lord, Lord Newton, said that the district general hospital was the pivot, and I believe this to be so. I would use other words: the focus, the linchpin, and so forth; because its wider range of services will meet increasingly the needs of any area. The noble Lord, Lord Brain, said that there had been omitted from the White Paper and the concept of the district general hospital the idea of research, and he himself made some contribution to the use of these hospitals in teaching. I believe that these hospitals have a major and indispensable contribution to make to medical training and research. I believe so for many reasons, one of which is that the quality of the service that is given in a hospital will be far better if the members of the staff are in contact with young, inquiring and inquisitive minds. That is one reason why I think that these hospitals should be used for teaching purposes. Also—and I think this must be said—you will not have the teaching done by members of the staff who are harassed by an undue clinical responsibility.
So, my Lords, I hope that the hospital staff review committees, established after the Platt Working Party Report, will take into account in the sessional assessment of consultants' work in hospitals the time which they devote to teaching. I hope that every district general hospital will undertake the teaching responsibility. I hope that in each hospital there will be appointed one or more tutors who will personally look after the medical education of the junior staff, and give them personal advice. And, I hope, with Lord Brain, that proper accommodation—a library, common room, seminar rooms, tutorial

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rooms and the like—and residence for members of the staff, will be established.
We need not wait until 1975. What I have said about district general hospitals and their rôle in teaching is not a Utopian fantasy, because many of the best regional hospitals to-day are already providing that kind of training facility. Of course, if we are to have a proper communal service of which the hospital must be the focal point, it will, I believe, be necessary to bring on to the medical committees of these hospitals representatives of area general practitioners, medical officers of health and the like; because the concept of "wholism" must pervade the whole structure of hospital and health service.
It must mean taking into account the university medical school, which must play a part in this, and I am sure that the noble Lord, Lord Stonham, will be interested to hear that many teaching hospitals are now feeling the draught. They no longer have a sufficiency either in number or variety, of patients for clinical teaching. The other day I was written to by a board of clinical students of a university hospital, and they told me that
"it is generally agreed that there is an in creasing insufficiency of teaching material in teaching hospitals because first-class hospitals now supply the needs of patients in their own neighbourhood and house special units."
I do not worry about this (although the noble Lord, Lord Stonham, appeared to direct his remarks on teaching hospitals directly to me) because I believe that we must get together over this problem. It is here that I think the teaching hospitals and the district general hospitals can walk the path of progress abreast. Into these district general hospitals we should also admit students, undergraduates, and I should like to see some interchange of staff.
I do not want to discuss the question of general practitioners in hospitals, which has been fully dealt with, except to re-emphasise what the Minister has said about the sub-committee of the Standing Medical Advisory Committee looking into the whole future of general practice. I am quite sure that the interests of the general practitioner will not be lost when I tell your Lordships that Miss Annis Gille, Chairman of the
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General Medical Practitioners' Council, is, in fact, the chairman of the particular committee.
My Lords, may I say this before I conclude? Even if this Plan is incomplete—and, after all, hospital plans are always striving towards their goal, but never reach it—and though we know that unforeseen changes may well occur which will make considerable and in evitable differences to the Plan as the years go along (indeed, we are still with out, as has been said, two important elements of the Plan: the local authority contribution and the general practitioner contribution), in spite of all this, I would urge this House to believe that in this Plan one feels a greater sense of purpose than ever before.
There will be snags and frustration; there will be difficulties of staffing. And may I just interpolate here one point of which I think we occasionally lose sight? We speak in terms of 20,000 nurses being needed to fill the quota; but this is a national need: it does not cover local needs. The needs vary according to the locality, and what we really want to know is how it will be proposed to gear these needs to the individual localities and the new building programme.
Finally, my Lords, may I just say a word or two—because I know it is not only in the Minister's mind but in the minds of his advisers—about the questions raised by the noble Baroness, Lady Summerskill, and the right reverend Prelate the Lord Bishop of Lichfield, on the humanisation of hospitals. There is, in fact, a significant phrase in the White Paper. On the first page there occurs the phrase "Hospitals are for people"; and, indeed, no hospital plan can be concerned with buildings only. Buildings are the framework in which human, sentient beings are helped to return to health. If your Lordships have any doubt about what is being done by the Minister and the Advisory Committee in this field I would ask you to read several Reports on, for example, reception and welfare of in-patients; the pattern of the in-patient's day; human relations in obstetrics; visiting in hospital; noise in hospital. And now there has been set up—and I am very happy to chair it—a committee on communications, the very problem of letting the patient know

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what is going on in hospital and how best to achieve that end.
This human, personal, individual aspect of medical care must never be forgotten. I have said before, and I repeat, that however fine our hospital buildings, however expert our consultant and specialist staff, however modern, ingenious and intricate our diagnostic and therapeutic instruments, all will fail unless we realise that the patient is a human, spiritual, sentient being. There was a little doggerel in the journal of the American Medical Association a week or two ago which urged members of hospital staffs to:
" Pause awhile
" To give the patient one kind smile;
" To stoop a little now and then,
" And shake hands with the race of men."
Some years ago I ventured to quote in this House the words of a national poet of over a century ago. He wrote:
" … True it is that Nature hides her treasures less and less—
" Man now preside; in power where once he trembled in his weakness;
" Science advances with gigantic strides;
" But are we aught enriched in love and meekness?"
My Lords, the Plan which we have before us cannot of itself provide the human touch, and I believe that, if it is implemented fully and in the spirit in which it is intended, then all of us who work in hospitals will be able to answer Wordsworth's question with a more resounding affirmation.
6.4 p.m.
LORD GRENFELL: My Lords, may I, among all the other speakers, congratulate the noble Lord, Lord Brain, on his maiden speech?—and I trust that he will be here very often to speak not only on medical subjects but in all our deliberations. My Lords, I welcome heartily this Plan in general. At long last we have a detailed report on our hospitals showing quite plainly deficiencies and what, within the limits of the financial means of this country, is being done to eradicate them. Not only that, but it is written in language which a layman like myself can understand and appreciate. Her Majesty's Government are at present criticised equally from two camps. In one, we get the angry roar of those who are convinced that the whole of our future has been sabotaged by Government spending; in the other camp we get the equally angry
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roars of those who demand more money for their own particular piece of the national "cake" of amenities, such as hospitals, roads, railways, etcetera. I do not intend to roar, but I would put before your Lordships what is to my mind a real case of priority.
In the report of nearly all regions under the heading "Mental Health", on page 75, there are the words:
" A shortage of beds for the mentally sub normal is a serious problem ".
This is in the Sheffield area. The Report adds:
" There are long waiting lists, the hospitals are overcrowded and the premises of some are no longer suitable for use. There are over 400 subnormal patients in acute and geriatric hospitals ".
It is tragic that the old and the infirm in geriatric hospitals should have to live out their last days among people who are mentally subnormal, whether they he children or adults. In respect of the Newcastle Region—this is on page 36—one finds the words:
" There is a severe shortage of beds for sub normal and severely subnormal patients in the region. Four hospitals are reserved for them but only Prudhoe and Monkton Hospital, which is now being developed and modernised, has the four facilities they need; 200 mentally subnormal patients are in general hospitals, 100 in hospitals for the mentall ill, and 600 in unsatisfactory annexes to the four main hospitals."
I think that here the difference must be stressed between the mentally sub normal and the severely mentally sub normal, the latter being quite unable to help themselves and in need of constant assistance both for feeding and for cleanliness. In the case of the mentally subnormal—and I now speak of child ren—many either are orphans or have been abandoned by their parents and have nowhere else to go; hence hospital beds are a real necessity.
At this stage I beg to ask the first question of which I gave prior notice. Can the noble Lord who is to answer give me the number of mentally sub normal patients at present awaiting admission to hospitals, broken down into two categories: one, adults; and, two, children? It is unnecessary for me to stress again the urgency of this waiting list, but I will remind the House of the terrible mental and physical strain put upon families by these long waiting lists. We have only last week had a debate on housing, and I would ask the

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House to visualise the strain of a family inadequately housed and with the added burden of a severely mentally subnormal child. In saying what I am about to say now I cast no aspersions on the Minister of Health nor his Ministry, as I know they have a very real sympathy with the mentally subnormal, but I do think that we must all be careful that the cause of these unfortunates does not sink into the obscurity it was in prior to the Mental Health Bill and the Mental Health Year. I say this only as I have heard people say, Oh, we had all that in Mental Health Year"; as if all the problems were solved in that one year.
Wonderful work is being done in many areas by the local authorities. One must also admit that in some areas the local authorities have not tackled the problem as they should and little is being done. Apart from occupational centres for children, there is urgent need for special care units which for a period of the day take in severely subnormal children either awaiting admission to hospital or whose parents do not wish to part with them, and thus relieve the parents for a short period of their labours. Hostels also are badly needed for mentally subnormal adults. Her Majesty's Government are, I trust, impressing strongly upon local authorities the real urgency of these matters.
I now return to the hospitals and I wish to say a very few words upon the metropolitan area. According to the Report, the South-West Metropolitan Region take in 2,400 patients from other regions having 6,963 beds. It is expected that by 1975 this region will still be required to accommodate 2,000 patients from other regions. In the children's hospitals a great step forward has been made in the development of Queen Mary's Hospital for Children, at Carshalton, as a comprehensive hospital for mentally subnormal as well as the physically ill. I understand about 300 children have been moved to this hospital from the Fountain Hospital, which is structurally, both inside and out, a terrible case. The Fountain Hospital is being run down as premises are needed for a new hospital which is being moved. I understand, from Hyde Park Corner. The waiting list for the Fountain Hospital and the number of
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patients in this hospital at the end of the year were 50 and 279 respectively. Naturally these numbers fluctuate from day to day. The 50 on the waiting list do not include a list of those from other regions, which was included a few years ago. I have no idea as to the closing date of the Fountain Hospital, but with the present figures in the South-West Region alone, beds must be found for 329 patients in the near future and those are nearly all for severely mentally sub normal children.
On page 156 of the Report I note that St. Ebba's Hospital is under consideration for conversion to a hospital for the mentally subnormal; and I would ask the noble Lord who is to reply this second question. When will a decision be given on this conversion, and will the Minister give full priority to that con version which will go so far to wipe out the large waiting list which is bound to accrue?
I was accused once of always talking on gloomy subjects in your Lordships' House, but this Plan is not a gloomy plan. It is imaginative and gives us far more information than we had in the past; and the remedies, if still inadequate, are a definite move forward in the ever-increasing problem of hospital ser vices in this country. I only hope that the Minister will be able to give a real priority to the case of the mentally sub normal so that many parents can be relieved of a burden that is very heavy to bear.
6.15 p.m.
THE EARL OF LONGFORD: My Lords, I hope the noble Lord, Lord Mills, and the House in general will forgive me if I am not present when the Minister replies owing to a rather urgent engagement elsewhere. I would feel it difficult not to take part in a debate of this kind, as chairman of the National Society for the Mentally Handicapped, which, as I have told the House before, has a membership of some 20,000, mostly, if not all, parents of mentally handicapped children. Naturally I support a great deal of what has fallen from the treasurer of our Society, the noble Lord, Lord Grenfell, who is such a champion of the mentally handicapped. In particular I should like to echo his hope that the cause of the mentally handicapped will not sink back into obscurity.

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I think that one example of the way in which this cause is neglected is that most people seem to assume that, because I am chairman of the Society for the Mentally Handicapped, I myself must have a mentally handicapped child. It is thought that nobody could possibly take that much interest in the mentally handicapped unless they had a mentally handicapped child. It is a little peculiar if you compare it with other forms of social work. I am also chairman of a society for dealing with ex-prisoners. Nobody assumes I have been in prison—or they may assume it, but they keep it to themselves. This cause has been so much pushed into the corner that it is thought that there is something almost mentally disordered in associating one self with it except for a special reason.
I do not know whether the parents of the mentally handicapped have much reason to draw encouragement from this Hospital Plan. I cannot say that I think they have. So far as the mentally handicapped are concerned, the project is left very vague. If noble Lords will recall paragraph 18, they will know there are various calculations there about the future, and it is said:
" The provision which ought to be made by 1975 is not easy to estimate. On the one hand it is necessary to take account of the waiting lists and of the increased expectation of life of the subnormal and severely sub normal, and to allow for the greater readiness of parents to seek admission to hospital for their children … On the other hand the expansion of community services will avoid or postpone the need for hospital admission in many cases and will enable more patients to he discharged … The net effect of all these factors is impossible to quantify and further knowledge is required about the incidence of subnormality and the improvement in the expectation of life. Provisionally it has been assumed that eventually the factors mentioned above will more or less offset one another, but plans may need radical alteration in one direction or another as time goes on."
I am not necessarily complaining of that way of assessing the situation at the moment, because undoubtedly we are all in the dark.
I feel I ought to apologise for speaking in a debate, where so many experts are taking part, but in fact in the field of mental handicap, though some know more than others, those who know most are perhaps most conscious of the limitations of all knowledge, and therefore I do not necessarily blame the Government for leaving the whole matter so
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open in this long-term planning. But I do blame the Government—and here I am bound to say that I am speaking not only for the unfortunate parents but for a good many doctors with whom I am directly or indirectly in touch—for the absence in this Plan of any operational research. There is no sign of it in this Hospital Plan. The general proposal in the Plan is to close some of the smaller and inefficient mental deficiency hospitals, to increase the beds in some of the existing hospitals, and to build a few new hospitals which are not expected to start until after 1971. The White Paper proposals are to increase hospital places from about 60,000 in 1960 to 64,000 or so by 1975. But there is no attempt, so far as we can see, to integrate planning of the Regional Hospital Boards with that of the local authorities, on whom a large part of the burden of providing community care for the severely sub normal will fall. Therefore, it seems impossible to me for an intelligent parent, or anyone concerned with the problems of the mentally handicapped, to draw much or any encouragement from this Plan.
It is obviously impossible to know how much hospital provision will be required until one knows how much pro vision is going to be made by local authorities or generally under the heading of community care. There is no sign here, at least, that any great steps are being taken to integrate the Hospital Plan or the Regional Hospital Board plan and the plan of the local authorities. That is a sharp criticism which I have found widely held among those most concerned with the mentally handicapped—the lack of integration in the planning as between Regional Hospital Boards and the local authorities.
That great phrase "community care" which we have all subscribed to since the Mental Health Act, while it could represent a step forward, could be a snare and a delusion. It could simply mean "passing the buck". It could mean the Government's simply shuffling out of their own responsibility and leaving it to local authorities to do what, at any rate to some extent, is being done by the Government or by the hospitals at present. Therefore it is impossible to pass any vote of confidence—I am

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not going to the point of passing a vote of no confidence—in any scheme at present brought forward by the Government until we know far more what they propose to do to integrate the hospital and local authority provisions. I must repeat that the last stage could be worse than the first, if the children were turned out of the hospitals and left to the tender mercies of local authorities who have not the staff available, and sometimes have not available the will or the finance, and who therefore are less able than the hospitals at the present time to look after the children.
On this subject of operational research—I will not weary your Lordships with details—I will just mention the kind of thing that is being done in various parts of the country but which is not referred to, so far as I can see, in this hospital scheme; yet it is extremely relevant. For example, two doctors working for the Department of Social Medicine in Manchester have produced an extremely relevant report on the mental health service of the City of Salford in 1960. It has been published by the City of Salford Health Department. From a study like that, it emerges clearly that a very large proportion of the sub normal people at present in hospital could be cared for far more satisfactorily in residential hostels and that new hostels serving a key area might be established and maintained by the Regional Hospital Boards and the local authorities. That is the conclusion reached by those inquirers.
Then, again, our own Society for Mentally Handicapped Children has itself published a study about the needs of mentally handicapped children by the pediatric society of the South East Metropolitan Region. Attention is drawn to the need for continuing care for children needing long-stay treatment, to the severely sub-normal or low-grade child or those with multiple handicaps. That is another suggestion which is being worked out. To give another example, in a recent issue the Journal of Mental Sub -normality describes in great detail the re construction an old hospital. These are all useful studies which are being con ducted. We are entitled to ask and to hear from the Minister at this stage whether the Government themselves pro-
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pose to organise any operational research, either from the statistical point of view or from the point of view of studying the work of the Service.
There are other criticisms that could be made of the White Paper. There is no reference to the problems of the staffs of the mental deficiency hospitals and no examination of the changing work roles of the nursing staff dealing with mental disorder generally, in spite of the fact that most people, like my learned colleagues behind me, agree that the present training syllabus of the General Nursing Council is hopelessly inadequate for this purpose.
One could go on with criticisms, but I will try to be constructive and, at the same time, to be brief. I would say, therefore, shortly, that no plan for the mental deficiency hospitals can be acceptable that does not envisage some such result as this within ten years: first, the breakdown of large hospitals into small units; secondly, the modernisation of mental long-stay hospitals into living units; thirdly, integration between the local authorities and Regional Hospital Boards in the planning of hospital accommodation; fourthly, extensive revision of the training provided for both nurses and those working with the severely sub-normal; and fifthly, the pro vision of special care units for psychotic children and those requiring special treatment which cannot be provided in the existing Service. Those are five points. I would gladly give a copy of my notes to the noble Lord in case he wishes to study these points before he replies. I do not want to develop further arguments to-day. I hope we shall have a complete day to devote to mental health in the not too distant future.
There is a great deal more that could be said from the human point of view. The subject of research was mentioned earlier. It was pointed out by the noble Lord, Lord Brain, who made so striking a maiden speech, that the word apparently does not occur in the Plan at all. That subject appears to be ignored, yet it does not seem to be passible to draw up an adequate Blue Book of this sort without making some careful reference to research and seeing how the mind of the Government is moving.

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I should like just to put one further point before the Minister. The Minister himself is undoubtedly a man of great gifts and seriousness. Some little while ago, during the period of the Conservative Conference, he made a speech which I have quoted myself in a debate on penal reform, in which he said that the prison service of this country was the most neglected of the social services. I could not help wondering, when I read that, what Mr. Butler thought and whether Mr. Butler, who is greatly interested in mental health, might possibly think that more time might be devoted to studying mental health or might have reached a different conclusion. The prison service is much neglected, but so are the mentally handicapped. We in our Society have enjoyed most pleasant relations with previous Ministers. We have not yet been able to make any successful or intimate contact with the present Minister. We must hope that he will prove as interested in mental health as was Sir Derek Walker-Smith, and that with his great gifts and seriousness which I certainly do not deny, he will turn his most remarkable mind to the problem of the mentally handicapped. Certainly no more pressing problem is before him.
Not long ago I read a book written by a woman who had a mentally handicapped child and who suffered many disappointments. At the end of the book even she had to admit that the child was not making progress; yet, in a higher sense, she felt that it was all well worth while. She felt that she and the child were working together towards a full life, even if the child was not becoming any more efficient in the eyes of the world. In that book she said:
" Every day is a stage nearer, and the whole world is our friend ".
I think the whole world is prepared to be friendly to the mentally handicapped and their parents. But the whole world still remains ignorant of the problem of the mentally handicapped, and I hope that this Government, and in particular their most gifted Minister, will give far more attention to the mentally handicapped than has been given in the past.
6.30 p.m.
THE EARL OF ARRAN: My Lords,
this evening we are discussing the future of our hospitals, and it is of course right
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that we should look ahead. But while we are preparing to move on, it might perhaps be not too inappropriate to see how things are going to-day, and to consider how well, or how badly, our hospitals are being administered under the system laid down by the National Health Act. Naturally, one's knowledge of these matters must be restricted to one's personal experience. Mine is that for fifteen years I was a member of a management committee of a voluntary hospital, and for the last thirteen years I have been governor of a teaching hospital. I have therefore had the opportunity of observing both before and after.
I must truthfully report to your Lord ships that, in my experience, the main result of the transfer of responsibility has been the creation of a gap between administrators and patients, a gap which did not exist before. Before 1947 our little committee used literally to run the hospital, which meant doing our hest to look after the personal interests of the patients. To us they were real people; we knew them; we visited them. My father, who was chairman, used to go round the wards every day. The matters we discussed were personal, intimate matters, like complaints about the food, or about the cataract patient in one of the other wards who had fallen out of bed.
To-day it is different. We have a committee of some thirty persons; we have six permanent sub-committees, not to mention ad hoc committees. Our administrative staff has increased since the Appointed Day by 50 per cent.; our meetings are long and tedious (through no fault of the chairman, who is an excellent chairman); and at least one-third of our time is spent in receiving and noting or considering memoranda from the Ministry of Health. The wealth of paper before us is both staggering and disheartening. I do not feel any more that we are dealing with human beings, but with some vast, monolithic commercial enterprise. Our job is simply to administer in vacuo, and, in so doing, not to overspend, and still less to underspend, lest our under-spending be taken by the Treasury as an excuse for cutting down our allocation next year. The personal touch has gone. It is as though we were not dealing with a "him" or a "her", but

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rather with an "it". If the wards were empty, one asks oneself, how many of us would know about it? One wonders how many governors there are who have never in their lives seen a patient.
Let me say that the present arrangements are in the best interests of co ordination and efficiency—those blessed words. That may be, although I would not say that those old-fashioned, dedicated, practical-minded committees of the past made such a bad job of it as all that. They were always short of cash, but they ran their hospitals for a long time and, on the whole, ran them quite well. But whether or not we are more efficient, one thing is certain: in our efforts to create an effective instrument we have once again overlooked the human element. In seeking to improve the quality of the bathwater we have put the baby well and truly down the plughole. This may all seem a little wistful and nostalgic and perhaps a little querulous. But I am not crying "Ichabod!" I am merely wondering how we can make it more intimate while maintaining the present structure of administration.
First, and simplest of all, I would ask the Minister of Health to stop bombarding us with paper. Can we not have a let-up, a sabbatical month in which he sends us nothing at all, leaving us to get on with our job? We really do know how to do it, and do not want constantly to be looking over our shoulders to see whether the Ministry are pleased or cross with us. Could not the Minister have another look at the composition of Regional Boards and the boards of the teaching hospitals? I feel there are too many people involved. Personally, I do not believe any committee can be really efficient if it has more than ten or, at the most, twelve members. Many of the lay members are highly sporadic in their attendance because, like myself, they happen to be very busy men. They come along only four or five times a year; they ask the odd question, they pick up the odd points. But the discussions are not consistent, but desultory; there is no organised pattern. I do not think this is good enough, and one of the results of this absenteeism is that the medical members are sometimes in the majority.
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My Lords, I have the deepest respect for medical men and women, but I believe that, in the last resort, the lay men must have the control, if only because, being outside the business, they can look at it more objectively. In the London teaching hospitals medical members at present average about a third of the membership; at Bart's, the figure is just over a half. Take away the normal quota of lay absentees, and you get rule by doctors, by experts, which is something which I think the Minister of Health has set his face against, and something which I myself, in all humility, think to be quite wrong. For these reasons, then, my Lords, I ask the Minister to consider cutting the member ship of the Regional Boards by anything between one-half and two-thirds. Let them come down to ten or twelve mem bers. I am not going to suggest who should be on the committees and who should not, but let the lay members at least be men and women who would undertake to attend, and attend regularly. Let us have a small, keen and active board, with a practical and at the same time human, interest. Let us get back to the patient.
My Lords, as I see it, the danger of these spendid plans before us to-day (and I know this point has been made before in this debate) is that in the years to come we may find ourselves with the finest hospital system in the world, the best doctors, the best equipment, the greatest buildings, the best and most dedicated administrators, but with the latter completely out of touch with the people whose welfare they are there to look after: the patients.
6.37 p.m.
VISCOUNT ADDISON: My Lords, first I should like to add my congratulations to those of other speakers to the noble Lord, Lord Brain, for a most interesting maiden speech, and to express the hope that we may have the advantage of hearing him again before very long.
I am Chairman of a Hospital Group, and to that extent, therefore, have an interest in the debate, though, unlike the noble Earl, Lord Arran, I am no longer associated with any teaching hospital. For my part, I should like to express a welcome to this ten year Hospital Plan, and I think we have to assume that it

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will go forward. I would offer my congratulations to the Minister and, if it is in order, also to al least one or two of the very able henchmen on 'his staff at the Ministry.
In my opinion, this is about the first time that anything of this kind has been done the right way round. The people at hospital level—that is to say, the men in the field—were consulted first and asked to put up their views, through the Regional Boards, to the Ministry. These views were subsequently collated and acted upon at Ministry level. Up until now it has always seemed to be the other way about. Although a plan of this kind may be said to be long overdue, I think it cannot have been easy for the Minister to have got it thus far at a time of continuing national economic difficulty, and I feel very grateful to him for his efforts. One welcome aspect is the recognition in this document of the need for the plan to go forward subject to reasonable adjustment in the light of experience, because it is not possible accurately to foretell the direction of the advance of medical science even for ten years ahead, or the effect of such advances on procedures and practice in hospitals. Flexibility must therefore be retained, and I think it has, so far as is reasonably practicable, been provided in the Plan.
There are two matters to which I should like to ask the Minister to give special consideration. Both relate to staff, and to some extent both have been referred to earlier this afternoon. First of all, on the subject of the training of undergraduate medical students, I think that normally these young men do three years' clinical training in a teaching hospital. In this atmosphere there are very many highly-qualified doctors and learned professors but, perhaps, comparatively few patients, though these may be suffering from rare and interesting complaints. I think that there is a danger of training becoming over- specialised, and I should like to make a plea for at least up to one year of the three-year period of clinical training to be spent in the somewhat more rough-and-tumble atmosphere of one of the new district hospitals. Here I think a medical student would gain more knowledge of the commonplace and usual disorders, and become more ex-
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perienced in recognising and dealing with them. He would get a more general-practitioner angle to his training, and he might therefore be more inclined to join the ranks of general medicine where shortages exist, especially if a larger number of general practitioner beds are going to be provided in district hospitals, as seems to be envisaged in the Platt Report at present under consideration.
The second matter relates to certain members of hospital staffs, who fall under the general heading of medical auxiliaries. These include radiographers, physiotherapists and various other professional people such as dietitians, who were referred to fairly fully by my noble friend Lord Stonham. All play a most vital part in the make-up of the whole Service. There is an acute shortage of radiographers in some parts of the country, especially in industrial areas, and the reasons for the shortage are fairly clear. The demand has outgrown the supply, and I do not think it is only because of pay. The Society of Radiographers rightly insist that their members be trained in approved training schools, and it is necessary, therefore, to upgrade the various hospitals so that they may meet the required school standard. In my submission, the new district hospitals should be made to qualify as training schools, so that a greater throughput of student radiographers may be dealt with.
It is unfortunate, I think, that recently mobile firms of radiographers have had to be called in in some areas, to try to help deal with the heavy demand. Noble Lords may wonder why it is possible for these firms to employ radiographers who cannot be recruited to the Service. Here, again, I do not quite agree with my noble friend Lord Stonham; I do not think it is entirely a question of pay. I think that these firms employ very many part-time staff on an "on-call" basis. For some reason, this profession of radiographers consists of most attractive and marriage able young women, who no doubt find it convenient to help out their husbands' incomes, at least for some of the time. However that may be, it is up to us, I feel sure, to make it possible for a larger number to be trained, though I hope it will not be suggested that young women of less attractive personality and

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appearance should be recruited as a matter of preference.
The case of physiotherapists is some what similar, but members of this profession normally pay for their own training on the lines of medical students in teaching hospitals. Shortages of physiotherapists are chronic in some areas, and I am sure there is an urgent need to set up regional training schools for these; and also, in this case particularly, to offer greater financial inducements. Dietitians are almost, one might say, in a class by themselves. Training is long, arduous and expensive, and it will be a considerable problem adequately to equip the Service with fully trained members of this highly complicated and scientific profession. I have no short answer as to how it might be done, but I am convinced that their work may play an ever-increasing part in the treatment and cure of disease, as the years go by.
I hope that the Minister will give friendly consideration to the points I have raised, and I would end where I started, with a word of thanks from a Group Chairman to a Minister, who I am sure has tried hard to do something really worth while for the Service at what has been a very difficult time.
6.45 p.m.
LORD AUCKLAND: My Lords, in the course of the debate in your Lord ships' House a few weeks ago on the shortage of physiotherapists and ancillary staffs, I was highly critical of Her Majesty's Government and showed it in the Division Lobby, and I make no apologies for it. But I wish to congratulate the Minister on this ten-year Hospital Plan, and also my noble friend Lord Newton on the very clear way in which he outlined the Plan earlier to-day. Nobody would pretend that it is a perfect plan. Any ten-year plan is subject to alteration for a number of reasons—financial, shortage of building labour, as well as other factors. It is opportune that, after a debate on housing such as we had last week—and an excellent debate it was, too—we should follow it up with a debate on our hospitals. Our hospitals play an integral part in the organisation of this country, and they will continue to do, no matter how much progress, or otherwise,
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medicine might make. This is a thoughtful and sensible document. It is clearly set out. I agree with the views of the noble Lord who suggested that maps of some kind showing these areas should have been included. They would have clarified things even more. I am a little critical as to some of the provisions made for certain areas, but I will say more about that in a moment.
I have also studied a very interesting document on the building of hospitals in England and Wales between 1948 and 1961. The Government have been subjected to severe criticism from many circles, and it has been said that there have been no, or very few, new hospitals completed since the war. Until I studied this document, I myself was among those critics, but I rather feel now that this criticism must be modified, because a great deal of modernisation has already been going on. That is not to say that a great deal more is not necessary, but I believe that in this sphere the Government should be given credit where it is due.
As I have mentioned to your Lord ships on several occasions, I serve on the house committee of a children's hospital in London which may soon be the subject of a considerable upheaval, in that the major hospital—St. George's at Hyde Park Corner—may be moved to Tooting. I will not say any more about that now, because plans are very much in the embryo stage. Building a hospital is very unlike building a house, a flat or a shop. Sites must be found, and this is always difficult. With regard to a hospital about which I shall speak in a moment, I know that there was a great deal of argument about where it should be put. Three urban district councils wanted it to be on one site, and one urban district council wanted it to be on another site, and a number of other people in the various areas had different ideas. However, the site has now been chosen: but that instances the typical difficulties with which those who plan the building of hospitals are faced.
Mention has been made of staffing, and I should like just to elaborate this question. Much is said these days about the pay of nurses—student nurses and the more senior grades—and of sisters and matrons. When I see advertisements in the Nursing Mirror and other papers

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stating that matrons are required for various hospitals, I wonder whether the senior grades are getting a fair share of the cake. It is the matron of a hospital who has to bear a great deal of the responsibility. I think I am right in saying that the average pay of a matron in a large hospital ranges round about £1,300 or £1,400 a year. I should not like to say that this is an infallible argument, and I hope I shall be interrupted if I am wrong, but that seems to me to be an inadequate salary for the responsibility which a matron has. After all, in a large hospital the matron has the welfare of her nurses to look after, very often, and in a small hospital she practically runs it from every angle—not only from the nursing angle, but some times from the catering angle and in many other ways—and she probably also acts as a doctor at times. It is true, I think, that in some cases matrons get a living-in allowance and other allowances, but their pay does not com pare at all favourably when one thinks of ladies in executive grades in business, who, while admittedly they have responsibility, do not have the responsibility of people's lives in their hands. I am not saying that student nurses, physiotherapists and radiographers do not all need more pay. I think they do, and very badly.
I would urge the Minister, in carrying out this new Hospital Plan, to pay particular attention to the provision of really well-built, well-ventilated and well-situated nurses' homes. In the Services one can offer a soldier, a sailor or an airman great financial incentives, but if the accommodation is bad, or if general working conditions are bad, while you may get the numbers you will not get them to stay. That is the cause of a lot of the trouble in the nursing profession at the moment—the number of nurses who come into the profession and the number who do not stay the course. There are various reasons for this. Some talk to their girl-friends, who may work in offices, shops or other jobs, and when they are told of the hours they work and the pay they get the nurses may well feel, "I am not getting a fair share of the cake".
My Lords, nursing is a vocation; it is a dedicated life. I have met a good many nurses in the short time that I
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have been connected with public life. Only recently I paid a very full visit to a hospital in Hitchin—I mentioned this hospital during the debate on the Motion moved by the noble Baroness, Lady Summerskill, and I should like to refer to it again. It is one of the hospitals scheduled for rebuilding. The site has been chosen. It is a very well-run hospital, and a happy hospital. I had a long talk with the matron, who seems a charming and well-informed person. This hospital was built in the early days of the war, or possibly just prior to the war, to serve an area of, I think, some 40,000 people. It now covers an area of, I should think, between three and four times that number. The New Town of Stevenage alone has a population at present of, I believe, about 50,000; and the surrounding towns—Letchworth, Bal dock and Royston—are all expanding towns, as is Hitchin itself.
I should like to ask the noble Lord who is to reply to this debate—and I apologise for not having given him prior notice—whether the Minister will really concentrate on giving the hospitals in the area of the New Towns some kind of priority. I am not at all sure at present whether the needs of these places, even with the ten-year Plan, are going to be met satisfactorily. For example, in Luton, even bearing the ten-year Plan in mind, the estimate by the hospital secretary is that by 1975 there will be a shortage of something like 380 beds. That is on present estimates. As to the maternity sections, I believe that under the new Hospital Plan the Minister is aiming at something like a 70 per cent. intake of mothers into hospital for confinements; but I wonder whether an increase of from 40 to 80 beds in the North Herts Hospital at Hitchin, which is the maternity hospital for the area, will be sufficient.
May I turn for one moment to the subject of building labour? The particular hospital to which I have just referred is suffering from a shortage of plumbing labour and of other types of building labour. That is one of the greatest problems with which this ten-year Plan is going to be faced. I am told that the builders leave after a time because they can get higher pay building houses, but that then some of them come

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back to the hospital because, although their pay is somewhat lower, they get more security of employment. I hope that the Minister will carry out a comprehensive study of these problems of building labour, because otherwise one can visualise plans getting very much behind-hand.
Now may I say a word about mental health? My noble friend Lord Grenfell made what was a very moving speech on this subject, and he mentioned a hospital in which I have a particular interest—St. Ebba's Hospital at Epsom. I have known the medical superintendent there for several years now, and great concern is being felt by the staff at that hospital about their future. About a year ago, a medical research centre was set up at this hospital, and the hospital is now threatened with being changed from one for the treatment of curable, short-term patients to one for the long-term, incurable grades. It would not be in order, my having given no notice to the Minister, to form any opinions to-night; but I may put down a Question on this particular subject, because it is giving a great deal of concern.
Next I would say a word about the geriatric section of the community. I spent some time going round the geriatric department of the Lister Hospital at Hitchin. They were very happy there, although they were in surroundings which were not so pretty; but the patients were being well cared for. When the hospital was rebuilt on the Stevenage side of Hitchin, I understand that the geriatric department remained on the old site. My Lords, I hope that when these new hospitals are built or transferred, the needs of the geriatric patients, the old patients, many of whom have served the community well, will not be overlooked.
Lastly, little reference has been made in this Report to children. I hope that the recommendations of the Platt Report on the welfare of children will be carried out by every Hospital Group. I was very interested to hear the noble Lord, Lord Cohen of Birkenhead (I think it was), stress the importance of short visits. Children do need visits. They need to have the knowledge that their parents are still there. No matter how good the treatment they get, it is
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their parents of whom they think, and I hope that attention will be paid very conscientiously to more spread out visiting hours. My Lords, I do commend this Report. It is proof, once again, of the imaginative virtues of the present Minister of Health. It is a practical Report. I am sorry that I did not earlier congratulate the noble Lord, Lord Brain, on his excellent maiden speech; and also the right reverend Prelate, the Lord Bishop of Lichfield, on his excellent speech. I hope that this Report will be adopted.
7.5 p.m.
LORD UVEDALE OF NORTH END: My Lords, I am sure we shall all agree that our hospital system can be improved, and that we shall all welcome the Plan that has been so ably put be fore us this afternoon by the noble Lord, Lord Newton. I venture to make a few remarks because I have been a resident in hospitals for over forty years, and at the same time I may say that I have never worked in a Ministry of Health hospital; so that I bring a free and unprejudiced mind to the subject.
In this Plan we learn what is immediately before us in the matter of the building of hospitals. The sum of £188 million has been spent on improving hospitals since the inception of the National Health Service. I cannot recall that during that time any number of new hospitals have been built. I believe there has been one finished, and perhaps one or two started; but no doubt the noble Lord who answers for the Government will tell us more about that. At any rate, the money has been spent in improving, extending and maintaining the hospitals which we now have with us. This work of maintenance and extension, we understand, is to go on, but to it is to be added the building of new hospitals. It is expected that by 1970 or 1971, nine new hospitals will have been built; and that by 1975, 200 new hospitals will have been built and will be in operation. In addition to that, 134 schemes have been submitted for reconstructing hospitals. In 356 cases, there are to be grants of over £100,000 to each hospital for improvements; and there are also to be grants of less than £100,000 for an indefinite number of hospitals. In 1975 we understand that

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buildings under construction and renovation will involve an expenditure of some thing like £707,500,000.
My Lords, these are large figures, and in dealing with them we must remember that hospital needs are not the only call upon the resources of the nation. We have facing us a National Debt of £27,000 million. We have as a first priority to provide for our Services, especially as we do not wish all to become, as one noble Lord said, incinerated, in which case the Hospital Plan would be of no avail. We had a debate a little while ago in which demands were made for the building of 400,000 houses each year. The professors at our universities and the teachers in our schools are not silent and education, of course, cannot be neglected. While all these demands are going on a large section of the community is demanding a higher standard of living, and is coupling with that demand for a higher standard of living another demand for a reduction in working hours—a very strange combination, it seems to me. However, the Minister of Health is obviously very optimistic with regard to British industry, and his opinion is that it can successfully carry all these burdens. We can only hope that that will prove to be the case.
Having agreed that a plan of this sort is to be carried out, we then turn to the question: what is required in the way of medical treatment? Here again we have the answer in the Report. It is well stated, and I do not think that anyone can challenge the figures: for every 1,000 of population, 3 acute beds; 0·85 beds for maternity cases; 2 beds for the mentally deficient; 1·4 beds for geriatrics, and so on. This is the basis on which the calculation is made of the number of beds required in the community and the division of hospitals into sections.
The next question which comes be fore us is: what type of hospital are we going to build? The recommendation is that they should be general hospitals of from 600 to 800 beds. That is a very sound figure, which allows of treatment of most of the different classes of disability and disease. Above 800 beds, a hospital tends to divide itself into communities, and it becomes difficult to run
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it as a unit. It may be that some hospitals will not have so many as 600 beds, but it is supposed that they will not have fewer than 300. We already have hospitals with a large number of beds, some with 1,000 beds and more. Generally speaking, they were built at the end of last century or at the beginning of this, by hoards of guardians, municipalities or county councils. I hope that in our building operations, we shall not take example from these hospitals, but take warning from them.
Visiting one of these hospitals, one is struck first by their repellent appearance—so much so that, in general, if one sees a particularly ugly building, one usually describes it as institutional. Another thing that strikes one about these large hospitals is their great spaciousness. A little while ago, I was talking to the superintendent of a hospital that was established by the Middle sex County Council, and he said that walking briskly from his headquarters to the reception room of his hospital took him eight minutes. In other words, when he goes from his headquarters to the reception room and back he has walked for over a mile.
If we take a hospital like Queen Mary's Hospital, Carshalton, which is for 720 children, we find that the area on which that was first built was 120 acres and the area on which it now stands is 100 acres. Within the boundary of this hospital are miles of roads and paths. This passion for spaciousness in these old hospitals also applies to the wards. One finds that they are 30 feet thigh. But while these hospitals must have been extremely costly, the little extras that mean so much for the com fort of patients are often lacking—such things as floor covering, good furniture, adequate lighting and first-class sanitary accommodation.
I hope that the hospitals that we are to have will be of this type, with these advantages. There will be a central block, which will the eight storeys in height, the height of each storey being 10 feet. At the end of the hospital will be the out patients' department, which will be a single-storey block. Between the out patient block and the central block will be the accessory services, such as the dispensary, the X-ray department, the physiotherapy department and the

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clinical laboratories, so that these departments can be used by both in patient and out-patient departments.
The ward of a modern hospital is rather complicated. First of all, there is the main ward, which should have two rooms separated from the general ward for the isolation of patients and for special treatment. There should be a sister's room; a doctors' room, with records; a linen and store room; a soiled linen room; a room where the friends of patients who are detained because of severe illness can wait; a day room for the patients who are ambulant; a kitchen; lavatories (which should have extractor fans), and a sluice room. I venture to think that the windows of the wards should be made of aluminium. There should be a uniform floor covering over the whole hospital, which should be cleaned by mops.
The general appearance of the hospital can be made artistic by the use of suit able materials, and by having a true sense of proportion (that is where you get your artistic effects in a modern building), and around the hospital there should be a well-kept garden. The appearance of the hospital should be attractive instead of repellent. Not only do we find wards such as I have indicated in a modern hospital, but we also find theatres. I would suggest a theatre for every 60 surgical beds, and also special theatres for ear, nose and throat cases, and for gynæcological operations. Each theatre should have pressurised air conditioning, with the flow of air from, and not towards, the theatre. If the hospitals are of this type, then they will be such as I hope to see going up in this country.
Apart from these large hospitals, we must remember the smaller hospitals which will become redundant. Some of these can be turned to special use, and can be used as neuro-surgical hospitals, plastic surgery hospitals or for deep X-ray therapy; and some of them can be used for geriatrics. But no doubt a number of them will be closed.
I want to add a word about general practitioner hospitals. These can do a great deal to relieve the pressure on the general hospitals. They satisfy local sentiment; they eliminate the difficulties of travel to the larger hospitals, and
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excellent work can be done there, pro vided that they can from time to time call on the services of the specialists from the larger hospitals. Then of course, there are the local authority ser vices which can do a great deal to relieve the pressure on the general hospitals by supplying the home nurses and the home helps, with the health visitors visiting the home. A short time ago, as some of your Lordships are well aware, the medical profession was circularised by the pharmacists to the effect that it was better that a man should be nursed at home and get cured on a bottle of medicine costing 8s, rather than that he should lie in bed in a hospital costing the State £30 a week. That argument was put forward forcibly in the circular.
Finally, I would say that we are all anxious to see an improvement in our hospital buildings. We are hoping that the programme which is being put for ward this afternoon will be carried out; and if it is, we shall have taken a great step in the direction of more efficient treatment for the sick of this country.
7.27 p.m.
LORD BURDEN: My Lords, this Hospital Plan has in the course of the debate this afternoon, quite rightly, received its full measure of commendation. On the other hand, again quite rightly, criticism has been forthcoming; and it is, I take it, also the purpose of this debate that the Minister should hear what noble Lards think of the Plan. I hope that at this late hour I may be forgiven for saying a few words on a problem with which I am concerned in my contact with a hospital management committee, would, first of all, declare an interest in that I am the chairman of the Run-well Hospital Management Committee. Runwell Hospital is a mental hospital, situated in Essex, at the present time providing accommodation for over 1,000 patients.
The hospital was built with the co operation of the Southend county borough council and the East Ham county borough council. I well remember the circumstances which at the time made the building of this hospital at Runwell imperative. East Ham mental cases were being provided for by Essex County Council hospitals, but unfortunately, the pressure on the accommodation in the Essex county hospitals was

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such that the Essex County Council officers threatened to bring East Ham cases to, and leave them on, the steps of the Town Hall unless the East Ham Council set about the problem of building accommation for their old mental cases.
The hospital was opened by the late Sir Kingsley Wood in 1937. It is of modern design and lay-out, and since 1937 (perhaps I may be forgiven for saying this) it has established a national and an international reputation. It is the latest hospital to be built within the region of the North-East Metropolitan Hospital Board. In fact, until quite recently I believe it was the last mental hospital to be built in this country. Clinical work of the highest quality, in conjunction with special departments, has always been a prominent feature at Runwell Hospital. Fundamental and clinical research of the utmost importance in the fields of biochemistry, neuropathology, neurophysiology and psychology is in progress. Over the years this has led to ties with the University of London, the Maudsley Hospital, the Medical Research Council, the Mental Health Research Fund, the Dowager Lady Peel Trust, the Beit Memorial Fellowship and the Nuffield Provincial Hospitals' Trust. A regional training scheme for clinical psychologists has been devised by the head of the Department of Psychology and two students are at present working for a Ph.D. degree in this department.
Notwithstanding this unique contribution in the field of mental health, the Minister's Hospital Plan envisages the closing of Runwell Hospital when pro vision can be made elsewhere. Two reasons are given for this. First, the hospital is badly sited and, secondly, extensive repairs are necessary. It would be quite wrong for me to argue on these points this evening, but both these points, as well as many others which the Runwell Hospital Management Committee consider of vital importance, will be dealt with by the Hospital Management Committee in representations to the North-East Metropolitan Regional Hospital Board, and perhaps it may be necessary afterwards to go direct to the Minister.
In regard to a special and local problem of this kind, I think it would be quite wrong to attempt to debate the
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pros and cons this evening. But I was glad to hear that the Plan can be considered flexible; it can be considered, if the circumstances warrant it, as subject to modification, and so on. Therefore, with a Motion before your Lordships' House to approve the Hospital Plan, I considered it necessary, and my duty to the Hospital Management Committee to say these few words while the Sword of Damocles apparently hangs over their heads.
7.35 p.m.
LORD TAYLOR: My Lords, I should like to begin by adding my word of congratulation to the noble Lord, Lord Brain, on his maiden speech. I was brought up on two rather tough text books, called The Diseases of the Nervous System, and Recent Advances in Neurology by W. Russell Brain, and I cannot honestly recommend them to your Lordships as light reading. On the other hand, I can recommend to your Lordships a book called Tea with Walter de la Mare, which Lord Brain wrote some years ago, and which is one of the most delightful books I have read, in the real tradition of Sir Thomas Browne and the other medical scholars.
We are now really very strong in your Lordships' Houes on the medical side, but we are considerably stronger after yesterday, and we are delighted that Lord Brain should have joined us. The spectrum of medical Peers is now truly remarkable, ranging from Lord Malvern at one extreme to Lord Adrian at the other. I think probably Lord Brain comes a little nearer to Lord Adrian than to Lord Malvern, but it shows, I think, that we have done very well. I think he is the tenth medical Peer of the first creation and there are three hereditary Peers who are medical, so we are well represented. We are grateful, and even more pleased, that we should now have added to our numbers the noble Lord, Lord Brain. We hope that we shall hear a great deal from him. I was thinking of that Royal Commission on Mental Health, and how valuable it would have been to have had his help when we were debating the Mental Health Bill. But he was on another Royal Commission on Marriage and Divorce. So we look forward to hearing him on a wide range of subjects.

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It is rather a compliment to your Lordships' House that Her Majesty's Government should have decided to give us the first go at this Hospital Plan, and we have responded nobly, as to numbers anyway. I do not think the Government can complain that we have failed to put up a sufficient number of speakers. The interest is certainly here. I think seven of our speakers to day are doctors, but every one has had some intimate connection with the health services. It is most encouraging to hear so many who are experts speaking on this Plan. But it was a reception of modified rapture, rather than universal rapture, and the Plan has, not unnaturally, been subjected to considerable criticism, ranging from detail such as the point made by my noble friend Lord Burden, to much more general criticisms about which I shall have to say something in a minute.
I must begin by agreeing with my noble friend Lady Summerskill, that this is not just a Minister's Plan, as indeed the noble Lord, Lord Newton, said. It is a Plan from the Regional Hospital Boards, in the first instance, and a whole lot of people all over the country have played their part and have all deserved congratulations. May I, in passing, say that I agree with my noble friend Lord Stonham, in that I thoroughly enjoyed the speech of the noble Lord, Lord Newton. I thought it was one of his best, but that does not mean I agreed with everything he said, because I certainly did not.
Many people have contributed to the Plan, and the remarkable thing about it was the speed at which it was done. I think some of its defects spring from this speed. Regional Boards and management committees were asked to make their report in, I think, about four months, and then the Minister had about six months; yet the problem has been there for over ten years or so. It has been a very quick operation. Still, better a quick plan than no plan at all.
As I see it, the Government's job was first, to call on the Boards to prepare their plans; second, to lay down certain general principles; and then, third, to approve or disapprove the Board's proposals. As my noble friend Lord Stonham said, only about 40 per cent. of the Board's proposals were cut out. That
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is natural enough, but we cannot, I think, be quite sure it is the right 40 per cent. I should be interested to know whether that is the correct figure of the amount that had to go. With the first of these processes, that of the job of calling on the periphery to prepare plans and the laying down of general principles, I have not any great quarrel; though again one can always criticise details and wonder whether the Government are right. As regards bed numbers, for example, I suspect that in most circumstances the Government are probably right, but the problem is very difficult, and, particularly in this matter of psychiatric beds, one wonders with the noble Lord, Lord Cohen of Birkenhead, whether the Government have not been over-optimistic.
There is a very good case—the case presented by Dr. Tooth was an extremely convincing one—but it demands assuming that present trends go on in the next ten years—that is the assumption on which the Plan is based. We hope it will be all right, but we cannot be absolutely certain. What is more important is that the total number of beds envisaged at the end of this period is half of what was envisaged as regards acute beds when the National Health Service was started. This tremendous change in the conception of the number of beds we owe largely to the work of the Nuffield Provincial Hospitals Trust, who have been pioneers in making studies of what bed numbers are required in relation to the population. In a series of very intelligent reports their research workers have studied this problem; and I am sure the officers of the Ministry of Health would be the first to agree that that was so.
The philosophy as regards the number of beds is, I suspect, about right, though I am not sure about mental deficiency beds, as the noble Lord, Lord Grenfell, and my noble friend Lord Longford were saying. But the expectation to reduce the number of beds, as is proposed, depends entirely on increasing the number of staff and especially general practitioners, because it pushes more work back on them. I entirely agree with what the noble Baroness, Lady Summerskill, said: that the implementation of this Plan is completely dependent on having more general practitioners and more staff in hospitals to actually fewer patients, because unless

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we have that it cannot be done. And it is dependent also, of course, on the development by local authorities of the necessary supporting services. But it is a fair beginning and I do not think we should sniff too much at the Plan. As a Plan it is very much better to have it than no plan at all.
If there is a philosophy on the total number of beds and the allocation of beds by specialties, I do not think there is any real philosophy on the allocation of money for captial development on a basis of need. Nor do I think there is any real philosophy yet worked out about hospital construction. The Plan shows some very interesting and instructive anomalies. Appendix C shows the cost of schemes starting in the ten-year period, analysed by region and expressed in pounds per head of the population of those regions in 1975. This invites us to see how much each of the hospital regions is getting in terms of population. It is a very brave thing to have done, and I congratulate the drafters of the Report on having been so remarkably frank. On a basis of need, considering the hospital regions I should have expected that Newcastle, Sheffield, Leeds, Manchester, Liverpool and South Wales would be the top regions needing most, for three reasons: they are the areas of higher morbidity, the areas where there is most illness, for very obvious reasons; secondly, they are the areas of greatest dilapidation of hospital build ings—they have the worst old hospital buildings; and they are the areas of the greatest dilapidation in housing, which is why the Minister of Housing has just announced a massive attack on their slums, in which, of course, he is quite right.
But this has a great effect on hospital admissions, because a great many admissions to hospital are social rather than medical, or a mixture of social and medical, simply because of bad home conditions. Therefore, I should have expected the greatest amount of hospital building expenditure to be in these northern regions, plus South Wales. In fact, we find that Liverpool and South Wales are at the top of the tree: Liver pool, with £21·2 per head of the population, and South Wales with £17·4 per head of the population. The rest of these most needy regions are all at the bottom —£13·1 to £13·3 per head; they are at
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the bottom of the league, as it were. The two best regions, apart from Liverpool and South Wales are Oxford and Wessex, and they get £16·4 and £16·3, nearly a quarter more of capital spending per head than those northern regions, except the two I mentioned. Wessex—the little, new region created about Southampton and a very good little region—if you take the whole ten-year period is getting £4·8 million more, and the Oxford region is getting £5·2 million more, proportionately, than any of the northern regions, leaving out Liverpool. These two are the two best regions, in terms of housing and general health and in terms of hospital provision. It is a strange anomaly.
Now let me say at once that I am not blaming the people of these regions for this achievement. They have done very well. But it is not fair, it is not really right, and something has gone wrong somewhere. I think I know where it has gone wrong, and I propose to tell your Lordships, because it is a very instructive thing. Wessex and Oxford are the two smallest hospital regions. They are both outstandingly good and outstandingly efficient, and have out standingly good senior administrative medical officers. In both, the forward planning has been more efficient than anywhere else and they have had more schemes ready than anywhere else. That is not entirely because they were more efficient, but because they were smaller and because, therefore, their senior officers were better able to cover the region and get their plans done. It exemplifies the old Biblical saying: "Unto him that bath shall be given; unto him that bath not shall be given rather less."
This arises from the method of allocation of these new hospitals for capital development. It is done on the basis of the central study of individual schemes submitted from the periphery. That means the more and the better schemes you push up from your region the more you are likely to get. That is what has happened. I have always thought that the allocation of money for capital development should be central but the decision how to spend the allocation should be peripheral: that is to say, the Ministry should divide up the cake of capital spending according to the needs of the regions and the regions

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themselves should then decide how they were going to spend it. It has worked quite the other way round. Our present method puts the last word on new buildings with the Ministry, with the above result. It is not that there is too much central control but that central control, as such, is wrong.
I should like to see each region decide its own scheme of priorities, on the basis of further grants with carry-overs from year to year. There will have to be a formula, which would involve a combination of population morbidity in the region and the obsolescence of the buildings; it would not be difficult to work out, but I know there is little hope of getting it. Yet it is the only way of getting a full deployment of intelligence, skill and cunning in the planning of our Health Service which the Minister of Health called for in his remarkable Lloyd Roberts lecture. So much for the allocation.
Secondly, I turn to the philosophy of hospital construction, about which this Report says very little; yet the whole thing turns on the philosophy of hospital construction. One was very worried some years ago about the apparent squandering of money on the building of hospitals; and I pressed that the Ministry should draw up a series of model schemes for hospitals and hospital planning, as the Ministry of Education did for schools. The Ministry of Health have done this and during the past two years they have issued a series of hospital building memoranda which set out details of how to plan a hospital laundry or out-patient department or what-you-will, and they begin to give the sort of guidance which architects and planners must have. I would say that it is a very good thing indeed. There is one defect. They have not very many pictures. I have a great friend who is an eminent architect and he said to me one day, "Architects cannot read. They only look at pictures". And there is a lot in that. These things are full of reading, with very few diagrams. They would be improved if they were a great deal more diagrammatic, if they are to get over to the architects.
I do not think that the Ministry have yet thought through the problem of hospital building. But it is essential to do so if we are to get value for money,
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and, indeed, if we are to get any hospitals at all. I am very glad the noble Lord, Lord Mills, is to reply, because I hope that from his industrial experience, he will turn his mind increasingly to what is in essence an industrial problem. The problem of hospital building must be faced exactly like any other problem in industrial production, and I hope he will have a look at the way these things are done at present and will see in what ways they go wrong—because they do go wrong rather alarmingly.
Perhaps I may give an imaginary example. If hospital A, containing 1,000 beds, costs£10 million, that represents £10 million allocation of building skill, raw material and labour which is not available for hospitals anywhere else. If hospital B, containing 1,000 beds, costs £6 million we have £4 million left to use somewhere else, and we have the hospital more quickly because its construction does not take so long. Once the cost passes a couple of millions, the tendency seems to be to let things rip; and the Whole system of control seems to go if you get the figures high enough. When I was a civil servant I used to notice that the bigger the sum I asked for the easier it was to gat. If I asked for £50 for some wretched typist I could not get it; but if I asked for £200,000 for a social survey I had very little difficulty. The same thing seems to happen in this allocation of monies for new hospitals. If the cost is up to £4 million or £5 million, people do not seem to mind whether it is £4 or £5 million. Yet if it is down to £30,000 or £40,000, they will quarrel over £3,000 or £4,000. This is fundamentally wrong.
I have been going through the second part of this Report called Progress Report 1, which is a very valuable document, and a very instructive one, too. Throughout this debate there has been a series of questions addressed to the noble Lord about the finality of this Report—whether it is the last word; and we have been told, "Oh no, it will come out every year, revised, brought up to date". That is a splendid thing, but I am not sure Whether it is the Command Paper which is going to come out, revised every year, or the Progress Report. I hope that it will be both. And it is right that it should be both,

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because the Progress Report is no more than saying what has been done to implement the Plan. I am sure we all desire that the Plan should not be the Law of the Medes and Persians; that it should be highly adaptable—though we realise that, if we say that, there is at once a danger of all sorts of misinformed local pressures being applied. We know that, and we feel sure the Government will resist—and they will have the support of the great majority of us in resisting—misinformed local pressures which are not concerned with doing everything possible to provide the best 'possible service. At the same time, this Plan may well contain mistakes. So it must be flexible, and it must be adaptable; but, as I say, that should not be the sign for everybody to have a go at it, as it were, in order to try to get it altered.
My noble friend Lord Waverley was putting up a strong case for a 1,200 bed hospital at Reading. The case against a 1,200-bed hospital is pretty strong, and it is the case against any very large organisation. Those of your Lordships who have had to deal with factories of different sizes will know that after a certain size morale tends to fall in a factory and that the liability to strikes in a single unit tends to rise steadily; the emotional satisfaction of working in an organisation, I think, goes down after a certain point. I do not think this figure of 800 suggested by the Ministry is a haphazard figure. I think that Scandinavian experience—where they have built very big hospitals; they are really more like factories than hospitals as we understand them—is that they lose the personal touch and all the human and humane things about which the right reverend Prelate the Lord Bishop of Lichfield was speaking. I do not think I would support my noble friend Lord Waverley in feeling that that was the best way to deal with Reading. I mention the point because, while one feels that there are many things on which the Ministry should stand firm in this Plan, they should nevertheless be ready to listen to all the arguments and to consider them on their merits. It may be that I am wrong and the noble Viscount, Lord Waverley, is right.
I come next to the actual new buildings described in this document; and it is on this point that I should like the
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noble Lord, Lord Mills, to have a further look at it. I do not expect him to give an answer to-day—I know that he can not; and it would not be fair to expect it—but some very remarkable things are happening in hospital building at the moment. There is a tremendous variation in the cost of hospitals which have already been built. A number seem to range at about £10,000 per bed, which is a terrific sum of money. For example, the West Cumberland Hospital, stage 3, main ward block, shows a cost of £2·66 million for 260 beds; Wexham Park, Slough, £3·01 million for 296 beds; Hillingdon Hospital reconstruction, £2·9 million for 210 beds; and Huddersfield General Hospital £4·88 million for 520 beds. Those are the high limits. When we take the new teaching hospitals, some of them are a little above, some a little below. But these are alarming figures; and when I see figures like these I cannot help comparing them with the building of a new town. We build a whole new town for 50,000 or 60,000 people for £30 million. When one thinks of a hospital costing £10 million, as some of them are scheduled to cost—one-third of the cost of a whole new town—I do not know what is happening.
The second group runs at about £5,000 to £7,500 per bed. For example, the Welwyn and Hatfield Hospital is costing £1·67 million for 315 beds, and the figures for the Harlow Hospital are about the same. Then there is a third group which is much down—£2,500 to £2,000 per bed, or rather less. This is not a strict comparison, because some times the figure relates only to ward blocks. Even so, the extra should not constitute four-fifths of the cost. There are a couple which I have here: for Llanfrechfa Grange Hospital, stage 2, the cost for 250 beds is just over £500,000; while Southmead Hospital has a ward block for under £2,500 per bed.
Then there are the very low figures, mostly for psychiatric blocks. Here we come down to about £1,000, or slightly more, per bed. So the range is from £10,000 to £1,000, and some even down to £750 per bed. One such case is Cell Barnes Hospital. There are even some general hospitals which are on these low rates: for example, St. Nicholas' Hospital, at Woolwich—£90,000 for 133 beds; that is, £680 a

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bed, compared with £10,000 a bed. This range is really quite extraordinary. May I say that it is not confined to hospital building. I understand from my friends in the contracting industry that hotels cost at the moment from £3,000 to £7,000 per bedroom, and they do not know why. I doubt whether our friends in the Ministry of Health know why there is this tremendous range in the cost of hospital building. Clearly it is some thing that needs looking at closely, be cause every time we build one of these immensely expensive hospitals we are taking out of circulation far more building labour and operative skill than is justified if we can do it in any way more cheaply.
When one looks closely it seems that there are two types of hospital beds. There are the primarily social beds, where the medical services do not need to be elaborate—the psychiatric, the geriatric, the midwifery and the convalescent beds. Then there are those which are primarily medico-social, which are expensive—the traumatic, the accident, the major surgery and the major medicine beds. But even these need not be as expensive as they are. The tendency is to put both kinds of bed in the same ward block, to build a great slab block and put them together. That makes the beds which are not themselves expensive as costly as those which are. That is one of the ways in which things go wrong. To be fair, it may be due to the fact that the site is limited, and certainly often the architect likes to build a great massive affair—it adds to the interest of his work.
The Report says that there is still a scarcity of doctors, architects and engineers expert in hospital planning, and that their numbers can only slowly be increased. I would add that there is little incentive to the most efficient con tractors to engage in hospital building at the present time because of the present system of competitive tendering. The lowest tenderer is by no means the most efficient builder, and these are not profitable jobs because of the enormous number of variations which occur in the course of building. Contractors are said to like variations because they can charge extra for them; but in fact they do not like them, because every variation
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leads to a whole series of delays in the building work, and they have to stand off the plasterers while they get in the electricians to make an alteration, or whatever it may be. So variations are not popular with the most efficient contractors.
I am certain that if we are to achieve this programme we must get away from the conventional tendering system, and must associate the builder with the architect, even in the planning phase. By so doing, it is often possible to cut costs—for example, the traverse of a crane may often be the determining factor in the height or size of a building. There is nothing wrong in that, yet if the architect has the first go without the builder he will not realise this. In industry and in office building it is now usual to associate builders and architects from the start. And I am all in favour of that.
I hope that the Government will also look closely at the new techniques in package building, and will at least experiment in associating building con tractors with architects in a few, at any rate, of these new enterprises—for ex ample, the Joint Ministry of Health and Medical Research Council Research Hospital at Wembley which is at present being planned. And there are many more possibilities. I should say here that I have a special interest in the building industry. Medically speaking, I look after a contracting firm, and I also look after a number of building firms, through the Harlow Industrial Health Service.
Then, my Lords, there is a need for much better preparation and detailed briefing of architects before the architects are called in; and there is need for a whole time co-ordinating officer who acts as the client and consults all the users, the doctors, and finds out what each needs, puts it into a proper form, and sees how it all fits together. This co-ordinating job, if properly done, is certainly a whole-time job; but it is so much better than having an endless series of committees. If one has committees, with a number of doctors serving on them, invariably one finds that rows and difficulties develop over the plan, which gets altered. Here only one person sees each person individually and finds out his real need, arid then welds all the needs together. That

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is the only way I know in which to get speed into this matter.
There is need for the architects to consider the real needs and wishes of the clients, rather than the current architectural fads and fancies, such as the vast glass curtain walls and Venetian blinds exemplified in the Swindon hospital, where it was possible to see from passing buses the patients being examined. Then, the architects having gone oil these curtain walls, they turned to slit windows—tiny little slits close to the ceiling, and about 6 inches wide. The latest thing is louvres—everywhere they are fitting louvres. Then there is a thing called the new brutalism—that is, untreated exposed concrete or steel girders. There is nothing in these things; they are just fads and fancies. We must get the architect to listen to what the client wants, and to do that is extremely difficult. They are actually taught at architectural schools, "You must not give the client what he wants, but what you, the architect, think he needs". Surely, if the client is paying he has the right to have what he has found by experience he needs. He is usually right, though the architect is equally right to show him the alternatives.
This Report has come at a difficult time when we are much pre-occupied with the impending shortage of doctors and the existing shortage of medical auxiliaries. It has also come at a time when the National Health Service has been under a most unjust and quite uninformed criticism from Professor Jewkes, and Dr. Lees, of the Institute of Economic Affairs. The criticism is based on an attempt to apply nineteenth century pre-Keynsian market place economics to a great social service, with political and moral implications. Judging from the columns of the British Medical Journal, the effect of all this criticism on the doctors has been disastrous in terms of morale.
Fortunately, these attacks have been extremely well answered in this week's Lancet by Mr. Gordon McLachlan, Secretary of the Nuffield Provincial Hospitals Trust. He points out that these attacks are a mélange of slender fact and gross opinion. He says—and he is quite right—that the National Health Service is no longer an experiment, but a complex of highly organised, highly diffused services (by which he means
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there are people all over the country taking part in the running of them, administratively and technically), that they are giving the patients a higher standard of treatment than ever before, and that the doctors are enjoying a greater degree of clinical freedom than ever before. But, he says, so vast a thing will never be perfect down to the last detail. In part, delays occur because there is so much consultation all the way up and all the way down. But it is the price we pay, not only for a measure of lay democracy, but also for a measure of medical democracy. He goes on to say that reforms and improvements are bound to be pragmatic, in the best British tradition.
A few weeks ago, when discussing the position as to the supply of doctors, I described the situation as a pretty ghastly, awful picture ". That, I think, is quite true. But I was not describing the National Health Service. This shortage is not due to the National Health Service, because there is no lack of would-be medical students. The bottle-neck is at the medical schools. The truth is that the National Health Service is very nearly very good indeed, but its administrative machinery is still, in many respects, cumbersome and slow. I would therefore commend to the Minister the suggestion of the noble Earl, Lord Arran, that the size of Regional Boards and hospital management committees should be reduced from 30 to 10, and I would also suggest that the number of sub-committees should be considerably cut down.
The time that is wasted by administrative staff in servicing these sub-committees, instead of doing their work, is simply appalling. I do not know how they do it at all. Many of the people on these committees are inevitably "passengers". There would no doubt be many heart burnings if they were to go, but I think that one could get over that by creating regional advisory councils, which might very well be elected alongside the Regional Boards in which the general principles of the thing could be discussed. But to attempt to administer an organisation with commit tees of 30 all the way through seems to me a very strange method. I would not, in the normal way, put my money into something that involves these very large managing committees. If we are to

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achieve the Hospital Plan, it is to improvements in the administrative machinery that we must look, and it is here that the intelligence, the skill and the cunning for which the Minister called are required—and they are required on his part.
I should like to remind my medical friends that public grumbling is the worst possible way to win friends and influence people and to achieve results. I was greatly struck by a letter from a doctor that appeared in the British Medical Journal, showing the other side of the picture. The doctor wrote:
" Sir, what is all this about a pretty awful, ghastly picture? I have seen just about enough of doctors busily bleating away on paper like so many Inland Revenue sheep instead of doing something about their lot. There is nothing seriously wrong with general practice in this country if it is approached in the right way. The money is very fair, professional status is as high as we ourselves insist it should be, and our interests are most adequately looked after by the British Medical Association.
" I entered general practice as an assistant in early 1959. After six months' assistantship in the Midlands I moved to the pleasant area of Kent."
It happens to be Sandwich.
" Now, alone, I have a practice of over 1,600 and still growing. This together with other medical perquisites achieves an income of a little over £3,500 per annum. Late calls (after 11 a.m.) in the past month numbered fourteen and night calls (after 11 p.m.) numbered one. These figures are about average.
" At the age of 31 I am in a position to assure colleagues that organisation, personality, and attention to detail (in that order) leave the single-handed man sufficient time for personal interests like shooting, swimming. free-lance journalism, looking after an acre of garden and a flock of laying hens, carpentry, photography, eight hours a night for sleep, and a minute or two to write letters to the British Medical Journal.
" To sum up, the general practitioner can have elegant living in return for hard work. And who could ask for more than that?"
That, to my mind, my Lords, is the spirit of the great majority of general practitioners in this country. But it is not the spirit of the great majority of hospital doctors. Something has gone wrong on the hospital side as regards morale, and I believe that the main thing that has gone wrong is the slowness of the administrative machinery. I think the Minister really must look to see what he can do to speed things up for the future, and let the mills grind a little more quickly. I am sure it is in the spirit of
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this letter that the Hospital Plan must be tackled, if we are to translate this paper plan into actual reality.
8.17 p.m.
THE MINISTER WITHOUT PORT FOLIO (LORD MILLS): My Lords, this has been a very valuable debate and we have had the great advantage of hearing from many noble Lords who have had experience as doctors and as administrators, in hospitals and in public health work. I was very impressed with the maiden speech of the noble Lord, Lord Brain, and I hope it will often be our privilege to listen to him. I will deal presently with some of the matters he put forward.
The Plan we have been debating is not an end in itself, but not only is it a beginning as regards building a large number of new hospitals and reconstructing others; it is a beginning to a great deal of new thought. The contributions we have had to-day will add greatly to the gradual evolution of the Plan over the years. I should like to emphasise that the Plan is a beginning, because I think there may be some feeling that it imposes some kind of straitjacket from the centre. That is not so. The Plan is the best view which can be taken of the development of the Hospital Service, but we recognise that it will have to be adapted to meet changing circumstances. It is intended that the Plan should be reviewed and carried forward annually. This progress report (of which the noble Lord, Lord Taylor, did not quite know the colour) will be with him every six months. This Plan is not the answer to all the questions, but it is the basis for further studies. Its importance is not that it lays down a firm rule from which there is no deviation but that it sets the framework of future planning and enables those who have to do the work to move forward with a large view of their objectives.
I think it is right that we should have such a Plan and, as such, I believe it has been generally welcomed to-day; although I must except the reception which the noble Baroness, Lady Summer-skill, and the noble Lord, Lord Stonham, gave to it. Otherwise, I think it has general acceptance. It would be surprising if a plan of this kind did not contain elements of controversy. I cannot hope to answer all the detailed points that

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have been put forward, but I will do my best to deal with those that seem to be the most important. I do not propose to deal with questions regarding individual plans and individual hospitals, though if any noble Lord who put for ward such a point wishes to have information on it, I will see that it is supplied. The Plan is built around the concept of a general hospital. This is so because the developments of modern medicine and the interdependence of the various branches of medicine make it inevitable, if the best treatment is to be available for all the patients.
I will now try to deal with some of the points that have been put forward in the debate. The noble Baroness, Lady Summerskill, paid tribute to the very many people who have been concerned in various ways with the making of this Plan. I was glad that she did so because, while the Minister obviously takes responsibility for the Plan, it is founded on the work of many devoted people. Then the noble Lady concentrated on the criticisms of the Plan. She said that there was no commitment here at all; and that is quite true. How can there be a commitment? How do we know what we shall be able to do in ten years' time? I think it is quite right that that should be stated. However, the Paper puts forward plans which, in the opinion of the Government, they will be able to carry out. The Plan is obviously affected by many things, and not least by the wishes of the Regional Boards themselves as to what form they think their development should take.
The noble Lady made some valuable suggestions regarding teaching hospitals, and she suggested that there should be some designs for two or three standard units. The noble Lord, Lord Taylor, touched on that subject at some length, and with some force. Of course, this is a subject to which the Ministry of Health are paying great attention. It is obvious that there are valuable results to be gained from a study of hospital needs. But that does not mean, I think, that we should have a uniform pattern throughout the whole Hospital Service. The needs in the various districts are different, and the ideas of people who have to run these hospitals and services are also different. Perhaps the noble Lady would like to consult with the noble Lord, Lord Uvedale of North End, who
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told us exactly what form a hospital should take. Then we might get some thing worth while on that subject.
I would say to the noble Lady that, in her criticism of this Plan—because she did criticise it very severely—she should take heed of what the right reverend Prelate the Lord Bishop of Lichfield had to say. He said: "I look upon this as our marching orders to get on with the work." I think that was a very fair and proper thing for him to say. The right reverend Prelate also said that modernisation should go hand in hand with the humanisation of the system. I believe that that is fully realised. The good work which the chaplain does is fully realised, and the question of proper accommodation for the chaplain is no doubt one which will be kept in mind by those responsible for designing and building hospitals. The right reverend Prelate said that the atmosphere of the hospital is very important and that it should be a place where one expects to get—and feels it from the moment of going there—loving care.
He also commented, as did the noble Baroness, Lady Summerskill, and several noble Lords, on the question of staffing. As this subject has been discussed twice quite recently by your Lordships, I do not propose at this hour to comment on it in detail. I would, however, remind your Lordships that one of the main recommendations of the Platt working party on the medical staffing structure in the Hospital Service was that there should be a review of medical staffing in hospitals; and Boards, in carrying out the review, have been asked to assess the numbers of doctors needed at each level, both immediately and over the next five years. In order to help secure a uniform standard in all regions, the Minister of Health has appointed a central panel of consultants to act as assessors in the regions. Until this review is complete, it will not be known what staffing changes may be necessary. When these assessments are available, they will be considered in consultation with representatives of the medical profession.
It is one of the advantages of this Plan that it enables us to take a longer view and to look at staffing with a better indication than has ever been possible before; to look at the service which it is intended to provide and the needs of the Service. The concentration of treatment

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in a smaller number of units, of adequate size, situated in well-populated areas, should enable more effective use to be made of the skills of available staff. Of course, it is quite true that no Plan can be effective unless there is an adequate staff, but I should not like noble Lords to think that this side of the problem is being at all neglected. It is obvious that if a hospital system or service is going to succeed, it must be adequately staffed, and the needs of the staff and the services studied.
The noble Lord, Lord Amulree, put several questions to me and I will briefly deal with them. He asked what we mean by "geriatric" in the Hospital Plan. The footnote to the passage on geriatric beds, on page 5, says that they
" include both those required for active treatment and rehabilitation and those required for longer stay."
However, they do not include the number of beds for young patients suffering from chronic illness. Geriatric departments in practice deal with the chronic sick, mainly elderly, who are in for assessment, and with elderly patients needing intensive treatment of a kind more suitably given in a geriatric department than in acute wards. I will write the noble Lord quite fully on this subject, because there is a lot to say about it. He talked also about general practitioners. I think the importance of the general practitioner is fully recognised, as is the fact that his work can be made far more effective by increasing the supporting services at the hospital. It is intended that in the future, far more than in the past, hospitals should provide access for general practitioners' patients to the diagnostic facilities, especially pathology and radiography, and that this should be done without the need for intermediate reference to the consultant.
The noble Lord, Lord Brain, in his maiden speech, to which I have referred, mentioned that architectural design as well as improved nursing techniques can reduce the requirements of staff. That is quite true. He also referred to the question of residential married quarters. Not only is that under consideration, but the attention of hospital boards has been drawn to the desirability of dealing with it. I
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was struck very much indeed by the contribution the noble Lord made to the subject of education. On the question of research, which the noble Lord also raised, I may say that it is intended that the new hospitals should be fully equipped to carry out research work, which is so valuable.
The noble Lord, Lord Cottesloe, I was glad to see, said that the charge of complacency could not be sustained. I was sorry that he had found it necessary to give up the chairmanship of the Regional Board to which he had devoted so much time. He paid a tribute to the Minister, and said that this was a realistic programme. He pointed to the change in techniques and circum stances, and said that we live in an age of flux. He suggested that we should not try to peer too far into the future, but that, having provided the framework of a plan, that plan should be flexible—as, indeed, it must be. He also pointed out the importance of post-graduate teaching hospitals. The noble Viscount, Lord Waverley, told us that in 1959 he had suggested that work of this character should proceed. The noble Viscount said that there was no evidence that 600 or 800 beds—
VISCOUNT WAVERLEY: My Lords, I asked whether there was any such evidence.
LORD MILLS: I am sorry if I mis took what the noble Viscount said. If he will look at paragraph 20 of this Paper, he will find that it states that some hospitals might be larger. The noble Viscount also referred to the question of consultation.
The noble Lord, Lord Stonham, who I am glad to see is in his place, told me that in our last debate I had said that he did not know what he was talking about. I freely admit that in this debate he does know what he is talking about but I should like to tell him that, after our last debate, I looked for him to try to make some small friendly amends, not for being wrong but for being so outspoken. The noble Lord paid a very deserved tribute to the Regional Boards, and to others who had contributed to the Plan. I should like to make it quite clear that, while this Plan was worked on by a great many people—and all Regional Boards and

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others put forward their views, which were then co-ordinated into a general Plan—the Minister and the Government do take responsibility for it.
The noble Lord referred to the question of teaching hospitals, and gave me some figures regarding costs and the cost of beds, but I was not able to deduce much from that except the facts themselves, because I was quite unaware—he may be aware—of the condition of the buildings, the reconstructions that were necessary, the age of the buildings and so on. In addition to making several individual comments on matters about which he knew, and about which I have already said I do not intend to reply directly (though I will answer them by letter if he wishes), the noble Lord drew attention to the question of geriatric beds and asked what wouldd happen if certain of these hospitals were closed. I think the answer is that nothing will be closed until adequate provision has been made elsewhere.
The noble Lord, Lord Cohen of Birkenhead, made a very welcome tribute to the Minister. I found his speech to be most realistic, interesting and helpful. I felt that he was in agree ment—in fact he said the same words—with the preface to this book, to which I should just like to draw your Lord ships' attention. The preface says:
" Hospitals are for people and this plan will give to the public, whom the hospitals exist to serve, the opportunity of judging for themselves, on a national scale, the lines on which this service is intended to develop."
The preface also says:
" The hospital authorities will be alert to modify present proposals or bring forward new ones, as the needs of their areas change or new methods are developed. The intention, therefore, is that the programmes set out in this Paper shall be reviewed and carried forward annually, so that at all times they represent an up-to-date forecast of the work to be started in the next ten years ahead."
That will give plenty of opportunity for criticism as it goes forward.
BARONESS SUMMERSKILL: My Lords, could I ask the noble Lord if that means that it will be published every year, and that we may have an annual debate on the subject?
LORD MILLS: My Lords, if the Plan is going to be revised every year, it will certainly be published, and there will certainly be opportunity for debate.
LORD STONHAM: My Lords, may I pursue the point raised by my noble friend? Obviously, in another place even if there were no special opportunity there, they can debate this on the Estimates. We do not have quite the same comparable opportunity, but obviously, as has been shown by this debate, there is considerable experience in this House, and we ought to have an opportunity for discussion.
LORD MILLS: It is up to any noble Lord to draw attention to it when it is published. As I was saying, the noble Lord, Lord Cohen of Birkenhead, made what I thought was a very realistic speech, and I was particularly interested in what he said about visiting hours. I am sure that the Minister will pay due regard to the points he made about lack of maps, not building on restricted sites and other matters, all of which are of considerable importance. The noble Lord said one thing which I should like to repeat. In this Plan one feels a greater sense of purpose than ever before.
The noble Lord, Lord Grenfell, welcomed the Plan and said he was not indulging in an angry roar, on the basis either that the country was spending too much or that its citizens were not receiving enough. Then he asked me two questions. The first had to do with the mentally subnormal waiting admission to hospitals, and he asked me if I would give the figures for adults and children. The number of adults over sixteen was 2,716, of which 1,783 were non-urgent cases. The number of children under 16 was 2,871, of which 1,138 were non-urgent. The present shortage of beds is real but paragraph 18 of the White Paper mentions some of the factors which may affect demand during the next few years and the reasons which have led to the proposal to provide an additional 3,780 beds. Of course, the expansion of community services is of particular importance in this respect, but plans will be changed with experience, or if new information shows that to be necessary. With regard to the question of St. Ebba's Hospital, I propose to write to the noble Lord about that.
The noble Earl, Lord Longford, put a number of questions to me about the subject of hospitals for the mentally subnormal and said that no plan would

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be acceptable which did not envisage the breaking down of all large hospitals into small units; the modernisation of mental long-stay hospitals; integration between local authorities and the Regional Hospital Boards in the planning of hospital accommodation; extension of the training provided for both nurses and teachers working with the severely sub normal; and the provision of special care, units for treatment of children and those needing special treatment which cannot be provided in the existing training centres. The need for co-ordination between the plans of the local authorities and the hospitals fully accepted, not only by the Ministry but by the local authorities and the hospital authorities. That is again emphasised by paragraphs 18 and 38 of the Command Paper, and in Circular 2/62, in which the local authorities have been asked to prepare their own long-term plans. So I am rather surprised that the noble Earl did not think that this question of the men tally-handicapped had been sufficiently dealt with in the Paper.
The training of teachers for the mentally sub-normal, both in the local authority centres and in hospitals, has been reviewed during the last two years by the Standing Mental Health Advisory Committee of the Central Health Services Council, and their Report is now being considered. The noble Earl, Lord Longford, also told me afterwards some thing of the good work being done by the National Society for the Mentally Handicapped.
The noble Earl, Lord Arran, has already been mentioned as having drawn attention to the amount of paper work and to the size of the boards, and suggesting that they should be cut. I will see that those suggestions go to the Minister. The noble Viscount, Lord Addison, welcomed the plan and congratulated the Minister. He said that, for the first time, the question was tackled the right way round and the regional administrators were consulted first. I should like that to be well under stood, because I think that there is an idea that this is a central plan and that the regional people were not as fully consulted as they should have been.
The noble Lord, Lord Auckland, asked whether the hospitals in the
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New Towns would be given priority. I cannot say that they will be given special priority, but I am sure that the needs of the New Towns will have the special care of the Regional Boards and of the Ministry. The noble Lord, Lord Uvedale of North End, gave general support, some valuable criticisms and suggestions, and a plan for the general district hospitals. So far as the noble Lord, Lord Burden, is concerned, I will write him, if he wishes, about his particular case, but meantime I should like to thank him for his support of the White Paper.
In a speech which interested me very much the noble Lord, Lord Taylor, ex pressed what he called "modified rapture" at the Plan. I did not know that there were degrees of rapture. The noble Lord drew attention to a number of matters: to the tremendous change in our ideas about the number of beds, owing to the good work of the Nuffield Provincial Hospitals Trust, to the estimate for mental beds and mental sub normal beds, to the question of staffing and to the need for more general practitioners. I accept those points of view. Of course, it is necessary to have adequate staff, as I said before. The noble Lord criticised the amount of expenditure proposed in different regions. There I found myself at a loss. He must have been doing a lot of work to see the condition of buildings and sites in the different regions, and thus be able to give the House the comparisons he gave to-night. I myself have been lazy and I do not have that information.
LORD TAYLOR: My Lords, I have spent a good deal of time in the past ten years travelling the regions for one reason or another. I think that it is fairly well known that, by and large, the Northern hospitals are even more dilapidated than are the Southern.
LORD MILLS: My Lords, I am sure it depends on a great many factors which have to be taken into account and I am glad that the noble Lord is able to say with such assurance that the allocation has gone wrong. I am sure that if it has, it will have attention. The noble Lord gave us a learned talk on what he called the philosophy of hospital construction. I have already referred to this and said that this was a subject which

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is having increasing study because, of course, we must not waste money. It must be used in the best way to give us the best possible service we can get. I am sure that the Minister will have regard to what the noble Lord had to say about the cost of hospitals. The noble Lord concluded by referring to the slowness of administrative processes, the size of boards, the number of committees and so on.
I would sum up by saying that the Plan we are debating to-day is a signpost for the future. It is a promise of an up-to-date hospital service, of which I am confident we shall all be proud. As time goes on, the details will be modified; changes will be made. But we have now what we have never had before—that is, a plan for the whole country, following a pattern which is coherently thought out, capable of execution and worthy of the hospital tradition which it will embrace.
On Question, Resolution agreed to.

TELEGRAPH BILL [H.L.]
Reported from the Joint Committee on Consolidation Bills without amendment, and committed to a Committee of the Whole House.
VEHICLES (EXCISE) BILL [H.L.]
Reported from the Joint Committee on Consolidation Bills, with amendments, and committed to a Committee of the Whole House.