HOSPITAL PLAN FOR SCOTLAND

HL Deb 29 March 1962 vol 238 cc1134-72

7.2 p.m.

THE MINISTER OF STATE, SCOTTISH OFFICE (LORD CRAIGTON) rose to move to resolve, That this House approves Cmnd. 1602, entitled Hospital Plan for Scotland. The noble Lord said:

My Lords, this paper is the Hospital Plan for Scotland, framed to meet Scottish needs, and it parallels the Plan for England and Wales which your Lordships have already discussed. The Command Paper describes the Government plan for hospital building in Scotland over the ten years up to 1970–71. The Plan represents a new outlook on the sort of hospital buildings we need for the future, and it has been made possible because the Government are able to make a reasonably optimistic forecast about the level of capital investment.

In a way, the Paper also marks the end of the first great period of the national Hospital Service. This has been a period when an immense amount of work has been done in reorganising and co-ordinating the Hospital Service: for what we inherited was a very large number of individual units with little responsibility to each other. It has been a period, too, during which the Service has grown in a way that few people had expected. There have arisen demands for new services which many of the existing buildings were ill-equipped to provide. Many of the buildings that were inherited in 1948 were already old: indeed, for most of the 'twenties and 'thirties. and during the war, very little new construction was undertaken; and since the National Health Service came into operation we have been, as your Lordships know, in a period of restriction on capital investment. Since 1948 the first national priorities have been, of necessity perhaps, education and housing rather than hospitals. Nevertheless, during this period in Scotland something like £27 million has been spent, most of it on renovation, upgrading and minor additions in existing hospitals. But comparatively little has been spent on new hospitals.

It is now generally recognised that the existing buildings cannot suitably house our hospital services as they are now developing. Much of the accommodation is too out-dated to be effectively modernised. Much of it is wrongly sited to provide an effective unified service throughout the country, and much of it is not consistent with our modern standard of living. For these reasons, the boards of management, the Regional Hospital Boards and the Central Department have evolved the plan which is now set out in the Command Paper.

I cannot refer to all the individual projects since there are so many, but I will try to describe the kinds of hospitals for which the Plan provides. Perhaps the most important general decision is about the Scottish teaching hospitals. The programme includes plans—already in hand—for the replacement of Dundee Royal Infirmary, Edinburgh Royal Infirmary, Edinburgh Western General Hospital and the Western Infirmary, Glasgow, and for substantial additions to the other major teaching hospitals, the Royal Infirmary in Glasgow, Maryfield in Dundee, and the Royal Infirmary in Aberdeen. My right honourable friend the Secretary of State has already explained his reasons for taking this decision. We consider that the teaching hospitals have so important a contribution to make to the care of patients, the advancement of medicine, and the teaching of future generations of doctors that they must be seen to be fitted to do the job that is required of them. Scottish medicine has always stood high in world reputation, but we must face the fact that to-day nearly all the Scottish teaching hospitals are housed in buildings which are already old and, because of their massive construction, are hardly capable of being adapted to new uses. So it was decided that the first great attack in new building in Scotland must be on the teaching hospitals. I make this special point because, in our Scottish programme, in the first ten years these teaching hospitals will absorb a very large proportion of the £70 million available.

Another important concept underlying the Plan is that of the district general hospital. This is not entirely new, since in places like Glasgow, Dumfries and Perth there have for many years been district general hospitals. What is new is that for the first time we are seeking to provide each of the main areas of population in the country with the type of service that is possible only in a large hospital of this class. The Plan provides for new district hospitals to be built, for example, in Fife, Lanarkshire, Ayrshire, West Lothian, Inverness and Dumfries, Renfrewshire and Greenock. Each of them should within its own resources be able to cope with all the acute general hospital needs of the area. Some of them will also include maternity provision, psychiatric services, and a special investigation unit for the elderly sick. We believe that this is the way in which we can most effectively provide treatment for the greatest number of patients. while at the same time making the best use we can of the available medical and nursing skills.

The coming of the district general hospital means the end of an era for many smaller local hospitals. I will be saying something later about the closure of hospitals which are no longer essential, but it is the district general hospital which will make redundant a number of the smaller hospitals that at present do some acute work. While these small hospitals have been immensely valuable, they are not something to perpetuate now that we have the opportunity to plan on an area and a regional basis.

On maternity services, we are hoping in the course of the 10-year programme substantially to implement the recommendations of the Montgomery Committee that hospital beds should be sufficient to enable 70 to 75 per cent. of Scottish mothers to be confined in hospital. Some areas are further behind than others, but by the end of the first 10-year building period we hope that the number of beds needed to meet the Montgomery recommendations will have been provided in all areas.

Provision for the mentally ill is one of the subjects exercising the medical planners a great deal just now. With all the new forms of psychiatric treatment, with the early ascertainment of psychiatric illness, and the removal of the barriers to ready admission to mental hospitals, we are hopeful that there may be a substantial fall in the number of patients kept in mental hospitals. For mentally defective patients much has been achieved in the last ten years in providing additional accommodation, and a great deal more will be done in the next ten years.

Another problem now claiming greater recognition is hospital provision for the elderly sick. This problem has its origins in a variety of factors: the fact that more of us are living on into old age, and the burden which is sometimes placed on young families in caring for elderly sick relatives. Indeed, old people are now one of the most important problems facing the Hospital Service to-day. As this new need emerges, there is, too, a changing attitude in the hospitals as to exactly how much can be done for the elderly sick. Because an elderly person is ill, that does not mean that he or she must be bed-ridden for life. All the modern medical evidence shows that if the right kind of care and skill is brought to elderly patients at the right time, most of them can be made fit and well to return to enjoy life, either in their own homes or in the care of their relatives. So we shall be actively encouraging the provision of geriatric assessment units throughout the country, in association either with the district general hospitals or with other accommodation for the elderly sick. It is in these units that the intensive effort is best made to see how far the elderly person can be rehabilitated. Apart from this, we are steadily increasing, and will continue to increase, the amount of accommodation available for the elderly sick. In the more specialised fields, the Plan provides for new units for plastic surgery, neurosurgery and radiotherapy.

My Lords, I have mentioned what we shall be doing in the teaching hospitals to provide up-to-date facilities for the conduct of medical research. In this field we keep very closely in touch with the University Grants Committee, which is responsible for the university interest in medical research, with the Medical Research Council, which has established some important units in Scotland, and with our own Advisory Committee on Medical Research. While the Government can provide many of the major facilities for research in hospitals, they are very fortunate to be able to rely also on the generosity of the various foundations which have medical research as one of their interests. In this context, I am very happy to be able to announce to-day, with gratitude, that the Nuffield Foundation have just agreed to provide a new unit at the Western General Hospital do Edinburgh. This unit will be concerned with problems of replacing diseased tissues and organs, and with research in the related fields of auto-immune disease and cancer. This is a new field, and it is a tribute to Professor Woodruff of the University of Edinburgh that he should have been invited to take charge of the unit. The building and equipment involved will cost about £200,000, and we hope that in association with the other new developments in Edinburgh, this generous support from the Nuffield Foundation will lead to improved and beneficial results in the treatment of patients throughout the United Kingdom.

Now I turn to the Plan from the point of view of the Regional Hospital Boards, which are the Secretary of State's principal agents in administering the hospital services. Up to now, these Boards have done splendid work in reorganising and replanning, the services in the regions for which they are responsible; but up to now they have worked under the difficulty that they could not look further ahead than two or three years in considering their building programmes. The trouble about this kind of limitation is that it is liable to bring about a policy of getting rid of to-day's problem without being able to look to see how this will affect the longer-term pattern of to-morrow. The new Plan will give the Boards the basic data for each of their regions and the basic assumptions on which they can plan forward. They can now go ahead with the long-term planning of the Service, which is one of the main reasons for their existence. Throughout the years of the building programme, all sorts of decisions will have to be taken by the Boards which will affect the future pattern of services. These decisions, if taken on the basis of well-defined principles, will lead eventually to a Service which has a coherent pattern, and to a better Service than we have now.

I recognise that some of the decisions taken in the Hospital Plan will cause difficulties for Regional Boards and perhaps also for my right honourable friend the Secretary of State. I refer in particular to the decisions which will involve closing smaller hospitals. We have not attempted yet to decide which hospitals should be closed. This is not by any means only a matter of pounds, shillings and pence. It is just not possible to provide a full service of modern medicine except in a unit which is capable of carrying a certain level of staff and certain facilities in the way of X-ray departments, laboratories, et cetera. There has been, and there will be, reluctance to accept closures. This is very natural, and I sympathise with it: but if we all approach the Hospital Plan on the basis that everybody is going to hold on to everything they now have, and that everything that is now to be done must be additional to what we have already, then the Plan is not viable and we shall not make any headway. The taxpayer has no vested financial interest in favour of closure, for the new and larger hospitals will be more costly to run than those that are closed and replaced. But we have a duty to see that medical and nursing effort is not so dispersed among small units that it is impossible to provide a really satisfactory service in the area. This must be our criterion for deciding whether or not any particular hospital should continue.

This Paper is called The Hospital Plan for Scotland, but the Plan cannot succeed unless the other major partners in the Health Service play their part in association with the hospital developments. The general practitioners are the first line of defence, and we hope that they will be intimately associated with the development and growth of the Hospital Service. The other partners are the local health authorities. The Hospital Plan assumes that the local authorities will play their part in providing the supporting services which are vital to the continued care of patients discharged from the Hospital Service. It is for the local authorities to develop the preventive and domiciliary services which can do so much to make hospital care unnecessary. In the field of health education, the care of mothers and young children, and the care of the elderly in their homes, and in the new field of mental welfare, the staff of the local authorities can reach the people in their homes in a way that the Hospital Service cannot do. They and the general practitioners have a very important joint rôle to play which is complementary to the rôle of the Hospital Service, and we shall do all we can to encourage co-operation between them and the Hospital Service.

So far I have been mainly concerned with the kind of service we intend to provide. Much of the Plan, however, concerns buildings, for before we can provide any really new kind of service we must build the buildings. In the White Paper the assumption has been made that a sum of the order of £70 million will be available for hospital building in the period up to 1970–71. The cost of the projects which will be started during the ten-year period, including those which will run over into the next decade, will be over £90 million. This is a very substantial increase over the level at which we have been spending money during the past few years, and this increase in itself raises an extremely important problem in hospital planning. Sometimes it is difficult for those who are not concerned with the hospital building programme to understand just why it is that the planning of hospitals seems to take so much longer than the planning of other important buildings. There are good reasons for this. No significant new hospital construction has been undertaken in this country since the early 'thirties.

Meanwhile, there have been very great developments in hospital planning and practice throughout the world. Developments in other countries, which we have studied, are of very great interest for our future building programme, but they cannot be copied directly. They have to be reviewed and adjusted to the circumstances of the Hospital Service in this country. Planning a large hospital is not like planning a large office building, with a series of rooms which are to serve more or less similar functions. A large hospital is, in fact, a complex of entirely separate but linked departments, each with its own particular function, and each with a different problem that will change in scope and importance as time passes. So everything must be thought out in minutest detail if the buildings are to be right for their purposes when, and not only when but long after, they are completed.

The Regional Hospital Boards have been building up their planning staffs, and they are gradually acquiring experience in hospital planning. Our architects and the engineers who are to build the hospitals have also had comparatively little experience of hospital building, and it seems worth while in the early large projects to take time to prepare the brief for the architects and engineers in great detail. As experience grows, no doubt the pace will quicken; but it would be unwise to try to rush this process at the early stages and risk getting the wrong kind of buildings. But, my Lords, having said that, I must admit that some of the projects seem to me to have taken too long. We are now strengthening the Board's organisation, and both at the centre and in the Boards much time and thought is now being given to ways of speeding up procedures.

When the buildings are built, we must have the staff. Although the present Hospital Service is able, by and large, to get staff, some anxiety has been expressed about the future needs of these new and more complicated buildings. And there seems no doubt that the new hospitals, with their high level of amenity for patients, will need more staff. But we hope that the greater concentration of resources will meet the need and that recruitment will continue; and I hope that the Hospital Service, by providing the right conditions and the right educational and training facilities, will continue to attract the numbers and quality of staff that it must have.

My Lords, the Hospital Plan, then, is a forecast. It forecasts a Scottish Service, based on the regional centres with their teaching hospitals and other highly specialised units, with, in the areas outside, the large district general hospitals, and continuing in the remoter areas the service provided in the smaller local hospitals. The Service must work in complete harmony with the general practitioners and the local authorities. More immediately, the Plan foreshadows the major reconstruction or replacement of many of our older buildings, with many exciting prospects as the detailed plans develop.

It would be very rash of me to predict that this forecast will anticipate correctly the pattern of things when the first ten years have passed, if only because there are few fields in which advance and change in recent years have been so marked as in medicine. But allowing for the errors of human judgment and the advances of medical science, it must be right to take a longer look than ever before at what seems to be the right thing to do, and then to have geared up our organisation to do it. My Lords, I beg to move.

Moved to resolve, That this House approves Cmnd. 1602, entitled Hospital Plan for Scotland.—(Lord Craigton.)

7.24 p.m.

LORD HUGHES

My Lords, in other places outside your Lordships' House, the general rule is "ladies before gentlemen", and the list of speakers which we have follows that out. But instructions have been issued to the noble Baroness, Lady Elliot of Harwood, and me that we should change places, and we are both much too new here to interfere with tradition. It is, therefore, out of no rudeness to the noble Baroness that I precede her in speaking, and I will remember that her train back to Scotland is earlier than mine. I was very pleased when I entered the House yesterday to see that my noble friend Lord Greenhill had rejoined us after his very lengthy illness, and to hear that he hoped to take part in this debate. When, however, he learned that, due to the activity on the Pipe-lines Bill, we were not due to start this debate until seven o'clock, he realised that he would not be carrying out his doctor's instructions if he remained here for so long, and it was with real regret that he left the House before this debate started. I should say in that connection, on looking round your Lordships' House, that I am reminded of the fact that in another place the day before yesterday it was suggested that your Lordships' House should be abolished. We have not abolished it, but we have jolly nearly emptied it.

In speaking of another place, I should say that if I were speaking there I should probably be adopting a much more critical line with the Command Paper than I propose to do. In fact, shall be, very generally, in approval with the contents of the Paper. In another place I think it would be quite proper that more detailed criticism should be levelled, because, after all, the Members there have both the right and the duty to put forward the interests of their constituencies, and they can do so from local knowledge within their possession which they can readily make available. But in so far as I have any constituency at all—and I doubt very much whether I have any right to say so—it would probably be the whole of Scotland, and I have neither the time nor the resources to gather so much information; and I do not want regularly to appear as the advocate of Dundee General Hospital or the Eastern Regional Hospital Board, because that is the area in which my knowledge exists.

Therefore, I want to confine myself to a general survey of the scene. While it is very easy to be destructive when one talks in generalities, I will try my best rather to be constructive, because I have never felt that destructive criticism was of any great value, here or anywhere else. One of the things which has been said of the Command Paper is that there is nothing in it which is new; that practically everything has been announced already. I think that is quite true, but it is not necessarily a real criticism of the Paper. Rather, I think, is it a criticism of the fact that the Secretary of State for Scotland is not quite so good on the publicity side as the Minister of Health. After all, the Scots preceded the English in this matter by some two years. It is really more than two years since the foundation for this Paper was laid, and if South of the Border it had not suddenly been realised that something of this kind was necessary, probably we should have just gone ahead in Scotland doing these things, without gathering them together all in one Paper. Therefore I think that it is not a fault. but a virtue, that we are merely restating now decisions which have been building up over a period of years, and certainly over the last two years.

My general reaction to the Paper is one which is completely favourable. References in it to the past are mostly factual rather than opinionative. The statement of aims is excellent. In that connection I can say that Government statements of aims are generally excellent. What is not always so excellent is the extent to which the Government's performance matches up to their intentions; and that is not necessarily peculiar to the present Government, although, in my opinion, they are open to this criticism more frequently.

In the first paragraph of the Paper there is a reference to the 1945 Statement: The first aim of a hospital service must be to ensure that every patient requiring hospital treatment can obtain it without delay in the hospital most suited to his needs.…"— in the seventeen years that have elapsed, it cannot yet be said that we have accomplished that end— the second, that the hospitals are provided with accommodation, equipment, and staff sufficient for this purpose …"— nor can it be said that in seventeen years we have reached the end of the road so far as this end is concerned— and the third, that the efficiency of the service and the standard of treatment will be maintained and enhanced. I have no hesitation in saying that the third aim has been very well carried out. In these years the standard of treatment has improved out of all recognition, and anyone who was making a broadcast in 1945 would not have ventured to predict the developments that have taken place in the standards of treatment and efficiency of the service.

In 1945 (I do not know whether they were more timid or more cautious), they did not put any period to the accomplishment of these ends, and though the Plan before us is a ten-year Plan, it does not say that these aims will be accomplished during the ten years. I have a strong suspicion that we are on a road which has no ending and that the best we can hope to do is to move as far along this road as circumstances permit.

How far will this present programme carry us on? The noble Lord, Lord Craigton, stated, and the Paper says, that the estimated cost is £70 million within the ten years. I am not in a position to say whether that is a fair sum, an adequate slice of the national "cake", because I am not in a position—nor, I suppose, are many Members of your Lordships House—to assess priorities between one thing and another. However, in this connection I am glad to see in paragraph 34 of the Paper that it is laid down that the programme is to be reviewed periodically and that modification and extension will take place as required; that the intention is that there will, in fact, always be an up-to-date ten-year plan. I think that this is one of the most valuable statements in the document. While I do not wish to be unduly political, I cannot refrain from taking the opportunity of saying that I wish that this recognition of the value of planning were accepted by the Government in fields other than the Health Service. It is one which they could follow with great advantage. In fact, if the Pipe-lines Bill had been better planned than it appears to have been, we might have been starting this debate before seven o'clock.

I should also like to say that I like paragraph 34, with its reference to "modification and extension" much better than paragraph 65, which is largely financial. It says at the bottom of the page that … the programme may have to be modified considerably when the detailed schedules of accommodation come to be prepared. It occurred to me that perhaps I was reading "modified" in rather a narrow way, though I do not think so. I looked up in the Library the meaning of the word "modify" and I find that it is: to limit, restrain, tone down"— or, in another connection— to make less severe, or to make partial changes". In paragraph 34 the reference is to "modification and extension", so I think it is fair to assume that in both parts of the Paper "modification" is used in the sense of limiting or restraining, rather than just changing.

In 1965, when we come to talk about the money side, if the only alteration which is suggested is a restriction of the amount of money that may be available, I think it will be a mistake, because our experience over the last ten years has shown clearly that if we set a target of a given amount of money to do a given job we shall inevitably find, before the ten years are up, that it costs more money to do any given amount of work; and even if inflation is kept to a very small figure. it is bound to have some effect on the plan. So I would not accept that the only alteration in this programme should be in a sense a limiting rather than an expanding one.

I have already reached the stage of the only criticisms I want to make, and I might as well deal with them all at the one time. In paragraph 36 it is stated Perhaps the most obvious is that the scale of hospital provision aimed at is based in the first instance on the assumption that hospital treatment and care will be provided only for those who need it, and that the domiciliary services will be responsible for patients who do not need the special services that only the hospital can provide … Paragraph 40 touches on the same theme. If the hospital provision is to be limited to this class, however, there must be adequate home nursing and supporting welfare services for patients who can return home, and old people's homes for those who can no longer live by themselves. As an old local authority man, I feel obliged to draw attention to the fact that this is placing considerable burdens on the shoulders of local authorities, at a time when many of them feel that their resources are strained to the uttermost. So the Government must not feel too disappointed if they find that, under the grants which are now available to local authorities, there may sometimes be a reluctance on the part of some of them to proceed in these supplementary fields as rapidly as the Government would like them to do.

It may be that, before the ten years are up, these burdens on local authorities, will be of a character that will compel the Government to look to the measures of assistance which local authorities are to receive in carrying out these tasks. After all, one of the criticisms which has been laid against the present Government—and it has been raised in another place by Members who are normally supporters of the Government—is that it has shown a very considerable tendency to transfer burdens from the taxpayer to the ratepayer, rather than to effect real economies. It is not an economy to reduce the amount the Chancellor of the Exchequer has to find if, instead, it is placed at the door of the local finance chairman or city treasurer.

In paragraphs 53 to 59 there is reference to bed ratios. and the Command Paper anticipates that in ten years' time there will be reductions in the number of beds required for certain purposes. In making this estimate certain ratios have been taken into account. In so far as these are based on information resulting from a great deal of study by people who are experts in these fields, obviously it would be neither wise nor proper for me to disagree with these conclusions. However, I am bound to mention, and it is admitted in the Paper in another paragraph—I would name it, but I cannot lay hands on it at the moment—that this is not a thing which remains in isolation. These figures can be achieved only if other factors work out as anticipated.

For instance, factors like bed occupancy, turnover of patients, the seasonal use of beds (which we have particularly in pædiatric units, where there is a high incidence of occupation in the winter and a low one in the summer), all have a bearing on the bed ratio, Obviously, if it were guaranteed that as one patient went out of the door, emptying a bed, another one came in to take it up, we could have pretty well 100 per cent. occupancy. But you have to leave a certain number of beds available, say, for the emergency patient, who is sufficiently inconsiderate to be taken suddenly ill and require immediate admission instead of taking his proper place on the waiting list; you can accommodate these people only if you leave empty beds available for them. We are all familiar with the pattern in so many Scottish hospitals where the number left has not been sufficient. In Dundee Royal, Edinburgh Royal, Glasgow Royal and Glasgow Western it very often happens that there are beds down the middle of the ward because all the ordinary beds are full up. All these things have their effect on ratios. I take it that these are as reasonable estimates as can be made of the situation and are not to be taken as the laws of the Medes and Persians.

That, I think, is all I want to say of a critical nature about the White Paper. I agree wholeheartedly with the first emphasis, which is to rebuild, either in whole or in part, the large teaching hospitals. I do so, even though I understand that some £40 million of the £70 million contemplated in the ten years' expenditure will be required for the building and equipping of these teaching hospitals. I think that in themselves they will make the greatest possible contribution to the health and welfare of the people of Scotland, because much of the work which is done there, much of the research carried out and of the experience gained, can be used in other hospitals throughout Scotland. I think, therefore, that while it is one which not everybody in the hospital service in Scotland will agree with, it is the right decision.

I also find myself very enthusiastic about the district hospitals proposal. I think this is a well worthwhile change which is being made. I did underline somewhere in this document a sentence which I thought showed that this was not just a piece of bureaucratic writing, but evinced a real consideration of the needs of the people of Scotland. I cannot find it at the moment, but it does say somewhere in the Paper that it is important not to try to concentrate everything in the teaching hospitals but to have regard to the convenience of people in getting to a hospital reasonably. I think the district hospital will go a long way towards making that possible.

Some of the policies in the Paper which I should also like to commend are the emphasis on the diagnostic aids which are available to general practitioners. I should wish, as I am sure the noble Lord, Lord Craigton, would, that they would make increasing use of these facilities, making their own task so much easier and more satisfying, and being so much more helpful to their patients. I am glad, also, that the opportunity is to be taken for associating, wherever it is possible and where it can be suitably done, general practitioners with those hospitals with specialisation services, such as accident departments. This is something which I think is overdue, and it may well be that we are setting a lead in some of these fields which others may follow.

I like the acceptance of the principle that the normal procedure will be that birth takes place in hospital rather than in the home. It has taken us a long time to reach that position, and I think it is reasonable to say that aiming at 70 per cent. to 75 per cent. of confinements taking place in hospital is, in fact, accepting that principle. But I remember many of the meetings which the Regional Hospital Board chairmen in Scotland used to have, and which it was my privilege to attend, when the chairman of the North-Eastern Regional Hospital Board fought so hard with representatives of the Department because she had a very high incidence of birth in hospital rather than outside. I think it is reasonable that births should take place outside the hospital only where the circumstances lay down that it is a better situation than having confinements in maternity units. This Paper will go a long way towards achieving that.

I was also very happy to hear the noble Lord, Lord Craigton, speak about the value of the geriatric assessment units. As he knows, there is in operation in Maryfield Hospital, under Dr. Taylor Brown, a most effective unit of that kind. He, I think, like me, has seen it in operation, and it is amazing the extent to which old people are enabled to return to a normal life by an application of the special techniques which have been discovered because such a unit was set up in the Eastern Region. I know that before long it will, in fact, be standard practice everywhere.

I should also like to associate myself with the noble Lord, Lord Craigton, in his thanks to the Nuffield Trust for the very generous unit which they are to establish in Edinburgh. Like the noble Lord, I am certain it will be something which is of great advantage to us in Scotland.

The Minister referred to the long time it takes to get new hospitals. I do not know how long it is now since we started talking serious business about the rebuilding of the Dundee Royal Infirmary, but it seems to be almost half a lifetime away and we still have not started to build. The situation, of course, is not so bad as the outsider might think, because, after all, we are building a hospital which is to be used for the next 40, 50 or even longer period of years ahead: the very least we can do is to do everything we can to make certain that when it comes into use it is not already out of date, and that can only be accomplished by a great deal of investigation. I think it was in 1951 that I was one of a party that went to Sweden to see the hospital building programme there, in connection with the building of this Dundee Hospital; and departmental representatives and others have gone to America and European countries other than Sweden. I think we shall be making use in the years ahead of what we have learned there, and it may be that some of the things we are going to do will be ahead of what they have accomplished.

The Paper, as is perhaps reasonable in a Paper which is concerned largely with building, touches only briefly, and the Minister in his speech also touched only briefly, on the aspect of staff. One of the things I learned as long ago as 1951 in Sweden was that that country suffered from the same difficulties in relation to staff shortages as we do in this country. They had difficulty in getting nursing staff and domestic staff. They have been compelled to turn to labour-saving devices in order to make up for these staff shortages. What I liked about the Swedes was the way in which they went about this. Their rules were simple. If a proposal came forward which was workable—that was the obvious first test to be applied—they looked at what it was going to cost. If the sinking fund and interest cost of the proposal were less than the cost of the staff which it replaced, or the staff which it supplanted or made unnecessary, then they went ahead. They particularly used devices which enabled a nurse to do more work than she otherwise would have done—the sort of thing which reduced the mileage which a nurse had to do in the ward in the course of an ordinary day's work.

At that time we saw various types of unit. There was the simple case such as we get in the sleepers, where you press a button which rings a bell in another place, a light goes on, or a flap goes down outside your door. They had that installed, and a nurse could have her attention drawn by a patient and could see right away to which small ward of part of a ward she had to go. We saw in one hospital that they had gone further: they had a two-way system, where it was not necessary for the nurse to go and see what was required. She could speak directly to the patient, and if it was a case of taking a bed-pan along she did so. She did not have to go and find out what was wanted. I do not know how much of that has been done in this country. I do not think there has been much of it. I was told the other day that a two-way system of this kind has recently been installed in the Royal Masonic Hospital, and I hope to have the opportunity of seeing it working there. I think the planning of hospitals is taking that sort of thing into account, and if we are going to be able to make full use of the beds that are provided, obviously we must spend money in these ways or we are going to defeat ourselves before we are finished.

Finally, I want to say a few words about another element of staffing, and that is the question of the salaries that are paid to hospital staffs, and particularly the salaries paid to nurses. A great deal was said about this the other day in another place. There is an amusing cartoon in to-day's Daily Express which shows a nurse loaded up with every noxious device available to a hospital, going into a room labelled "M.P., collapsed after being up all night to vote against increases in nurses' pay". She is saying: "This one is for me!". I think it is a tribute to nurses that, even if they were faced with that opportunity, they would not react in the way the cartoon po[...]trays. Even such an M.P. would receive first-class attention.

I think the fact that we know that that is the position has encouraged us to rely on the belief that we shall always find sufficient girls with a sense of vocation who will come forward and do nursing, whether the reward is a reasonable one or not. In that sense, I think we are quite mistaken. In fact, while a number of years ago the number of student nurses was certainly over 50 per cent, of the total (I obtained these figures only yesterday; I am talking not about Scottish figures, but United Kingdom figures) we have reached a position where the number of students is just equal to the number of trained staff. Having regard to the considerable wastage that is taking place, I consider that that is not nearly good enough. It is all very well to talk about a sense of vocation, but I think we are wrong when we work on the basis that a nurse is a ministering angel who will come along and soothe the fevered brow with her cool hand. A very distinguished, now retired, head of a large hospital in Scotland disagreed with that, and said that in his opinion the really good nurse was one who remembered to warm the bed-pan. We want practical people as well as those with a sense of vocation. Preferably we want people with both of these attributes, but I doubt very much whether we shall continue to get them if pay is put on the basis that it is.

I looked up the Whitley Awards made by the Administrative and Clerical Staffs Council and those made by the Nursing and Midwives Council, and I think it is a poor commentary on the situation that we find that a nurse entering training, probably at the age of 18, receives £299, and then, by her third year, she has risen to a salary of £336, whereas the girl who chooses to enter the office of the hospital at the age of 16 as a clerkess, to be trained as a clerkess, with just such education as she has received at school in commercial pursuits, gets £260. By the time she is 18 she is receiving £330, which is £6 a year less, or 2s. 4d. a week less, than the nurse in training receives in her third year. By the time she is 20 she has, of course, gone substantially ahead of the nurse in training. When the nurse becomes a staff nurse, she goes on to a salary scale of £525, and when she has received six increments and has probably reached the age of 28 or 29 she has achieved the maximum salary for a staff nurse of £656, again £6 a year more than the girl in the office has accomplished. The girl clerk has risen through the ordinary process of just growing older and staying in the position, and has achieved a salary of £650 a year.

I should not wish it to be thought that I am suggesting that the girl in the office is being paid too much, because I know that those who negotiate her salary think they have done a poor job and that she ought to be getting a great deal more. But the girl in the office has the advantage that her salary is arrived at, to some extent, by what is paid in outside employment, what is being paid in the office of the industrialist, the banker and other public boards. They all have their effect on the level of the clerical administrative salaries. After all, the hospital employs comparatively few of these people. But in the nursing field it is the other way round. There is a small nursing staff outwith the Health Service, and there is not this competition. I think we have too long played with this position.

I know it is impossible for the Minister to say anything in this connection to-day, but I feel bound to enter this warning. The Government will only be deluding themselves if they fancy that they can carry on maintaining the service through the years at the level of salaries which is being paid at the present time. If they are prudent men they will take into their calculations the fact at the end of the decade that a great deal more money will be being spent on salaries than is being spent at the present time. After all, the salaries which are being quoted, even if they were going to be comparable only with the office staff, ought to be 15 per cent. more, because the nurse's salary is based on an 88-hour fortnight, whereas the office girl does a 40-hour week. Remember, it is not a 44-hour week which the nurse works. The conditions are such that she cannot guarantee that she will do 44 hours in one week. She may be working 48 hours one week and 40 hours the next, because of the exigencies of the shift system. She is in fact working more hours than the other girl. As has been stated almost ad nauseam, she does it without any payment for overtime and the extra calls on her time that emergencies sometimes create.

I should not like to close on that note of criticism, although it is given rather as a warning than a criticism. Much rather would I close by saying how much I appreciate the terms in which this Paper is written. I think that much more important than the figures that are in it is the concept which lies behind it. But while officially these congratulations may be extended to the Minister, I have a pretty good idea that the Minister did not write this. I do not believe that the Secretary of State wrote it either. I believe I could name the people who had a very great part in it, and I should appreciate it very much if the noble Lord, Lord Craigton, would convey to them, as an old colleague of theirs in the Health Service field, my appreciation of the humane terms in which this document has been compiled. For these reasons it is a pleasure to agree with the Motion put forward by the noble Lord, Lord Craigton.

8.2 p.m.

BARONESS ELLIOT OF HARWOOD

My Lords, I am sure we have all enjoyed enormously the altogether delightful and brilliant speech of the noble Lord, Lord Hughes. He is immensely knowledgeable and has spent many years of his life in local government, and I do not think anybody could have made a more interesting or constructive speech. I am so glad that I stayed here, rather to hear him than to make any contribution myself.

I should like to add my congratulations to the Government on this White Paper. It seems to be a bold and constructive Plan for a new and better Hospital Service in Scotland. Not being an expert on the Hospital Service, although I have now been for a great many years in local government, I was amazed to read, what I had not realised before, that except for the Aberdeen Royal Infirmary no major new hospital has been built since 1914. That conjures up a picture of most amazing historical buildings in which much of the brilliant surgery and medical practice is carried on to-day. So I think, like my noble friend Lord Hughes, that this is a very opportune moment for the Government to announce their plans; and I hope, as I am sure all your Lordships hope, that these will now be carried out as swiftly as possible.

I should also like to agree very much with the way in which the Hospital Service in Scotland is planned to be grouped around the four major teaching hospitals in the great cities; in the Northern Region and in the Southern Region from Inverness. I am sure it is a very wise way of using the skilled staff and teaching staff in those great centres, and I believe that we in Scotland do this much better than it is done in England. At least one noble Lord to whom I was talking earlier in the day (who is also a great doctor) said how much he admired the way in which we use to the best possible advantage the teaching hospitals in Scotland.

I am particularly interested (the noble Lord, Lord Hughes, also mentioned this) in the South-Eastern Region because it includes the four Border Counties of Peebles, Roxburgh (where I live, and where I am a member of the County Council), Selkirk and Berwick. This is largely a rural area, with a number of small boroughs. At present we have quite a number of small hospitals—what, in days gone by, were called cottage hospitals—and these are spread throughout the Border Counties. They are quite effective and serve a useful purpose, but they are not equipped for major operations and medical treatments. They are limited in what they can do, though what they can do they do very well indeed.

But our main hospital (I take it that it is one of the district hospitals referred to in the White Paper) is Peel Hospital, which is some way from Galashiels. It is right off the main thoroughfares, a long way from a railway station and, in fact, in isolation. No doubt that is because it was one of the emergency hospitals built during the war, when hospitals were built in inaccessible places. This hospital comes, quite rightly, under the teaching area of the Edinburgh Royal Infirmary and the great Edinburgh hospitals. The medical service is, I know, excellent in every way, from the point of view of medicine; and of surgery and so on very good indeed. But the hospital is housed in a really terrible series of buildings. They consist simply of wooden hutments, built in the spider fashion of barracks, and the whole place must be extraordinarily difficult to run.

Only recently vast sums of money were spent on it, to put in a new heating system and to try to make new amenities; but, in my opinion, that money would have been far better spent, as it could have been, on providing a district hospital of this kind in either Galashiels or St. Boswell. It would then have been in the same relation with the regional teaching hospitals, but would have been very much easier to run. At present, there must be a tremendous waste of time and energy on the part of the nursing staff, doctors, and so on, in order to run Peel Hospital, and I think it is a great pity that we could not have included in the ten-year Plan a new district hospital on the lines outlined by the Minister and also outlined in the White Paper.

There is in fact—and this is my only criticism of the White Paper—no mention in t of any new hospital for the Border Counties or of any development in the service there. I would beg the Minister to look at this point again. I realise that the amount of rebuilding which is described, and which is so urgently needed in the great centres must be carried out. We must have, as the noble Lord, Lord Hughes, has rightly said, hospitals worthy of the knowledge, skill and the service which is rendered to the community by the nursing and medical profession. None the less, I feel that we in the Border area are at the moment rather left out; we are rather the Cinderella of this Plan. I should like to urge on the Minister and the Secretary of State, bearing in mind that paragraph which Lord Hughes quoted and which speaks about the development and looking at the scheme from time to time to see how it is going on, that someone should look at the Border Counties to see what can be done for them. I must say that I feel that we are worthy of something a little better than being completely left out of this Plan. But that is, I think, my only criticism.

The noble Lord, Lord Hughes, has mentioned, quite rightly the very important point about the pay of nurses. I agree with every single word that he said on that subject. He knows far more about it than I do, but we are, I believe, in danger of losing first-class people—people who would come into the nursing profession—simply by reason of the fact that the remuneration is not nearly good enough for the long years of training which nurses take and also for the devotion which they show to the service. This really is very important indeed. I should like to make one or two other comments about the nursing situation. I believe (the noble Lord, Lord Hughes, did not mention this) that there is a very successful pre-service nursing school in Fife which is a model for the pre-service training of girls who want to go into the nursing service but who cannot get into hospital until they are eighteen. This school takes them from the age of sixteen to eighteen and gives them pre-service training. I am told that it is excellent (I have not seen it myself) and it serves an extremely useful purpose. I think that might be developed in other parts of Scotland.

Then there is the fact that in many of the professions in which women play a very important part (I am thinking particularly of nursing and teaching) there is a very high marriage rate. I believe that one of the things we shall have to do, certainly in these two professions, is to encourage these married people later, when perhaps they have brought up their families, to return to the profession in which they started. I am quite sure that we could get more help in this problem from married nurses and married teachers.

It might be that they would have to be employed part-time, but that again I think ought to be looked at. If we were to make a recruiting drive for State Registered Nurses to help in the Hospital Service I am sure we could get some help, and probably a great deal, from married nurses. It is happening now in a great many areas. I know that in my own area in some of the cottage hospitals the only nurses are part-time nurses who live in the borough and come in and give their services. I believe that that practice could be developed further, and I suggest to the Minister that he might look at it in view of the great importance of nursing in regard to this White Paper.

There is only one other matter that I wish to mention. One could comment on a great many of the aspects of the White Paper, but this is one which, from my experience in local government and on the health and welfare committees, I have found invariably arises; that is, the shortage of accommodation for mental defectives, particularly children. It is sometimes months—I have known it to be even years—before a mentally defective child can be got into a mental institution. This can cause great unhappiness and difficulty in families where probably all the other children are quite all right. If one could investigate the possibilities of providing more accommodation far mental defectives, I think that would be a great help to many families in the community.

The new Mental Health Act, which deals not with mental defectives but with mental illness is one of the great steps forward, one of the great revolutionary plans, put forward by the Government in the medical services, and I wish it every success. It is going to lay upon the local authorities a considerable responsibility in connection with the provision of health and welfare services for mental patients who are well enough to be discharged and to go home, but who must have some care in the community. For this to be provided by the welfare services is bound to place a big responsibility on the local authorities. I am sure it is right that, wherever possible, people should try to live not in mental hospitals but in the community, because so often they become quite all right and can lead an ordinary, normal life. So I welcome this step forward very much indeed. In fact, like the noble Lord, Lord Hughes, I feel that this is an admirable document. I congratulate the Minister and the Secretary of State on putting it forward. All I ask—and this is my only criticism of it—is that the Minister will remember the Border area during the course of the ten years of this Plan.

8.25 p.m.

LORD FERRIER

My Lords, with reference to the remarks of the noble Lord, Lord Hughes, about the Peers in this place, I heard the other day that the Members of this House represent no one but themselves, and enjoy the complete confidence of their constituents. In saying that, I would begin by welcoming this Command Paper and at the same time gently chiding the draftsman for the implication in paragraph 35 that the first principle on which the Plan is based is a new concept. If it were, there would be something revolutionary in the Paper, which of course there is not. How can there be, when it is a continuation of what people have had in mind for so many years? It is difficult to cast our minds back even to the days before antibiotics, to the days before the motor ambulance, to the days before the motor accident, and it is only a hundred years since we were in the days before the anæsthetic, but the effects of modern drugs in the treatment of infectious disease, T.B. and mental illness, are too recent to be out of mind.

The results on hospital planning have been referred to before. The manner in which population patterns and densities have changed is obvious, but are we sufficiently alive—I do not see this from a close study of the Paper—to the future changes which are coming? Do I detect a lack of reference to the changes in population pattern which are to come? These need not be based on crystal-gazing but on facts in terms of industrial development, particularly in the central industrial belt.

As your Lordships know, I am concerned in the pharmaceutical industry, though I do not propose to make more than passing reference to this in my speech. I spent part of my childhood in a doctor's home, and despite a fairly bucolic appearance now I have spent enough time in hospital, mainly with tropical diseases. Only the other day, as the result of an eye injury, I found myself in the casualty department and the following day in the out-patients' department in one of the very latest hospitals in England. In other words, I have been more at the receiving end than perhaps the noble Lord, Lord Hughes, has been at the other end in terms of hospital study.

Further, I live in one of the landward areas of Southern Scotland and am in touch with the problems of the people, of the local cottage hospitals and the nursing services in the neighbourhood. As we all know, hospitals are not only bricks and mortar or concrete and chromium, and the human factor is of paramount importance. I was deeply impressed by the speech which was made by the right reverend Prelate, the Lord Bishop of Lichfield, in your Lordships' House on February 14. I should like to quote (but I must not) a large section of his speech, particularly that part which was an appeal for the humanisation of the Hospital Service. Of course, we know that this is fully appreciated by our planners. But I should like to make two general points. First of all, on the reception of patients, and especially the handling of out-patients, could everything possible be done to imbue in the reception and the office staff some of that undefinable sense of compassion that to me nurses seem to radiate? Indeed, could the administration possibly contemplate a post something like a hostess, such as they have in airports, to look after waiting patients? Has the right reverend Prelate's suggestion, contained in the speech to which I have referred, something in it, that there is an outlet here for voluntary workers in helping with patients who are waiting?

At the planning stage one cannot emphasise too strongly the importance of design. Indeed, the noble Lord and the White Paper itself have emphasised this; and it is clear from paragraph 148 that this is well in hand. May I urge that design at every stage of reception and of out-patients' departments is most important? Perhaps I might again refer to the right reverend Prelate's remarks on the subject, and express the hope and wish that staffing and design can be such that we do not "see people like sheep, waiting, waiting, waiting". To me, there is something infinitely moving about the expressionless mask which our phlegmatic countrymen and women wear as they sit in an outpatients' department.

On the subject of humanisation, may I comment on the White Paper's encouragement to cottage hospitals, especially for the services which they render to old and bedridden people? I would emphasise the point which I think the noble Baroness made, that these cottage hospitals are accessible when they are situated in landward areas for frequent visits by relatives and friends. These visits mean so much to them all, and they are not possible in a landward area if folk are to be involved in long journeys to central hospitals. The noble Baroness touched on the work of cottage hospitals; but I was a little alarmed at that part of the speech of the noble Lord, Lord Craigton, which referred to the disappearance of the small hospitals. He did not mention the cottage hospitals, which I believe, from my own experience, play, and can continue to play, an important part in the care of geriatric patients.

The White Paper does not contain as much reference as I should like to see to the important question of staffing, though the noble Lord developed the subject in his introductory speech. I will not mention nurses, because they have been well dealt with. I would refer particularly to staffing by doctors and by the ancillaries on the doctoring side, such as physiotherapists, radiographers and the like. This subject has been debated in your Lordships' House and in another place, so it should suffice if I say that we must remember that the shortage of doctors is a pressing problem and cannot be put right overnight. As the noble Lord, Lord Craigton said, there must be sufficient staff if the plan is to succeed. One welcomes the last sentence of paragraph 48. But more is needed. It may even be that the National Health Service system may, in some respects, have to be recast. The emigration of too many doctors is a fact—there seems no question of that. It is not only because of insufficient financial reward. Does the Service give a proper sense of fulfilment to the doctors who are working in it? I would beg leave to refer to a quotation from Mill's Essay on Liberty, in which he said: A Government cannot have too much of the kind of activity which does not impede, but aids and stimulates, individual execution and development. As I said, I will not refer to my notes in regard to nurses' recruitment, which has been adequately dealt with. I would mention the noble Baroness's reference and suggestion in regard to part-time work by nurses after marriage—wrongly referred to as "wastage" in some quarters—and remind the noble Lord, if I may, of the point I made in another debate, of the tax angle in regard to the part-time work of a married woman. I personally believe that special provision should, and can, be made if care is taken (though I think more could be done) to allow expenses such as travelling, laundry and even help for the care of children who are left behind, and for there to be superimposed upon it a greater measure of relief when a married woman's income is grossed up with that of her husband for tax purposes.

One other question I should like to ask is, will the Administration do all they can to improve the contacts between general practitioners and hospital doctors, so that patients know of this? —not only to see that the doctors in hospital are in touch with the general practitioners, but that the patients know that they are, and thus do not feel that they have just disappeared into the maw of a completely strange environment, sometimes, in a countryside such as mine, many miles from home.

I now turn from the general to the particular, to the criticisms I have to make about the Western Region Plan. Here the population pattern is most complex; it is changing rapidly and is likely to continue to do so, especially in Lanarkshire and the industrial belt. I believe it would be a mistake to build a new hospital at Motherwell rather than to build one at Airdrie/Coatbridge, and meanwhile to allow the Law Hospital to run down from its present outstanding position in the area. I welcome the statement in the introduction at the top of page 6, where the White Paper says: … in the later years the content of some of the larger projects may have to be reviewed. The noble Lord, Lord Hughes, has referred to another part of the Report where, on the financial side, it is admitted that changes may have to be faced, though my proposal need not necessarily involve additional expense, other than that which might be caused by inflation. I hope that flexibility of this nature can be applied to this part of the Plan. Admitting that Motherwell is a centre of population to-day, and will continue so to be, I feel most strongly that the Strathclyde site is unsuitable for development. With 11-odd acres it is too small; there is not enough room to build while the existing hospital continues its work, and there is not enough room to provide the huge parking accommodation which is necessary to-day and will be necessary in the future.

I am informed—and the noble Lord's researches in other countries will confirm—that it may be that allowance must be made for parking four cars per bed, when it is realised that on visiting days visitors' cars have to be found parking room as well as the cars of the staff. Motherwell is many miles from the Upper Ward of Lanarkshire. Visitors simply cannot travel by public transport; they must travel in their cars, whether they are going to Motherwell or to the Law; and the Law, of course, has 84 acres. The Motherwell area is a centre of heavy industry, with all the smoke and dirt which goes with it, and I am informed any structure there will call for expensive air conditioning and consequent additional expense.

My reference to the Airdrie/Coatbridge area arises from the Cumbernauld development which is going ahead very fast, with its consequent change in the pattern of population. I believe that Airdrie and Coatbridge is the right location for a new major hospital, to be followed by the redevelopment of Law. May I appeal to the noble Lord to look into this aspect again? In passing, may I mention the fact that Law Hospital, despite the temporary-looking nature of its buildings, is a "guid-going" concern, with skilful and happy staff and with excellent training arrangements for nurses; and these intangible factors cannot be sacrificed except in extreme necessity.

One other particular point I wish to make about the Western area is in regard to the maternity unit for Hairmyres Hospital, which is mentioned in paragraph 75 though I was worried to see that it is not mentioned in paragraph 90 where the future plans for the area are detailed. East Kilbride is already a large community, over 15,000 people, and growing fast, and must be looked upon as a fact. If ever there is a unit which should be near to the folk who use it, I believe it is the maternity unit. Knowing East Kilbride as I do, and speaking as a father of four—and a father's anxieties and feelings are too often treated as a joke—I cannot too strongly urge the acceleration of the maternity unit at Hairmyres. Bellshill, in my view, is too far away for the proper contacts to exist between the maternity unit and the folk it is designed to serve.

If I began my speech with a gentle chiding when I referred to paragraph 35, I would end it by congratulating my noble friend and his Department, as did the noble Lord, Lord Hughes, on the readable, interesting and, to me, almost thrilling draftmanship of this White Paper. I would join with Lord Hughes in his references to those responsible. The Government have set their hand to a major development of an ancient concept, and to that extent can rely upon the sympathy and support of the community. Whether the National Health Service, as we know it to-day, is the best form of service is quite another matter—and it may well require radical revision in some respects.

However that may be, may I, in conclusion, urge my noble friend and the Secretary of State for Scotland to do everything in their power to preserve Scotland from the present malaise in the relations between the Ministry of Health and the medical, nursing and ancillary services? The Ministry seems at the moment to have fallen foul of the doctors, quarrelled with the nurses, driven the pharmacists to desperation, and abused and bullied the pharmaceutical industry. This is not the way to make a creaking structure function smoothly. I urge the Minister of State and his right honourable friend to use all their skill, consideration and courtesy—of all of which they possess in large measure—and to apply as much of the lubricant of human understanding as they can to the conduct of this Department's responsible task in Scotland. With these comments, and a further expression of appreciation not only of the Command Paper but of the manner in which the noble Lord introduced it, I support the Motion.

8.35 p.m.

LORD AUCKLAND

My Lords, before I make my brief contribution to this very important debate, which certainly deserves a larger House than it has at this late hour, I should like to thank my noble friend Lord Craigton and his Department for the help they have given me on this Motion. I should like also to congratulate my noble friend on the admirable way in which he has moved the Resolution, and also to congratulate the draftsmen responsible on the White Paper. Speaking as one who took part in the debate on its English counterpart, I think it has the same admirable traits of clarity and conviction as its English counterpart had.

My Lords, I am, as I have said to your Lordships before, something of an exile from my native country now. I seldom manage to visit it, but I keep in touch with Scottish affairs, largely through the Scotsman and the Perthshire Advertiser, and I have been particularly interested in the progress made with the hospitals in the Perthshire area. I am particularly pleased to note in the White Paper the improvements that are going to be made to the Bridge of Earn Hospital, which in my opinion does some excellent work, particularly on the accidents side.

Something has been said about the remuneration of nurses and I shall not say very much on this subject to-night because there is already a Motion down for debate upon it at a later date, but I should like to bear out what has been said by the noble Lord, Lord Hughes, and by my noble friend Baroness Elliot of Harwood. Of course, while the pay pause is on—and I support the general principles of the pay pause—the hospital services must fall in line, but I should like something of an assurance from my noble friend that when the pay pause is ended the hospital services will be in the forefront of the queue. I do not need to trace the very long hours during which these nurses, the nursing sisters and matrons and other hospital workers toil. The recent smallpox outbreak provides an example. Admittedly Scotland has been mercifully free from that, but it could mean that the nursing staffs in Scottish hospitals would be put to a great deal of extra work.

It is another point with regard to nurses that I should like to make: that when these new hospital buildings are erected and when these new schemes come, adequate provision should be made for really well-built nurses' homes. I have seen a number of nurses' homes in England (I have not visited any north of the Border) and some of those which I have visited are in a really deplorable condition; and while I think the nurses rightly deserve extra remuneration they also deserve decent accommodation. Frequently a would-be nurse with her parents goes round a hospital and meets the matron, and one of the first things they want to see is the nurses' home. If it is an ancient building which lets in water and has other discomforts of that nature, it is going to turn these girls against nursing, even allowing for the fact that nursing is a vocation—and, perhaps, it is more of a vocation than is any other career.

I am not suggesting that nurses should be "molly-coddled". Nurses, and particularly Scottish nurses, would not like that, I am sure. But frequently, particularly in Scotland, hospitals are situated in areas rather more remote than they are in this part of the world and to compensate, perhaps, for not being able to have their share of the bright lights—which, after all, all young ladies like—they should be accommodated in well-ventilated, well-built and well-equipped homes. I hope, and in fact I believe, that the Government will bear that point in mind.

My Lords, I gave notice to my noble friend that I was going to raise the matter of Belford Hospital at Fort William. Fort William is a very busy town and the hospital has to cater for a number of accidents which take place on Ben Nevis and the surrounding mountains and hills. I rather wonder whether the new 52-bed hospital, as outlined in the White Paper, is sufficient. This is a growing area, it is a growing tourist area, and Fort William itself has quite a high population. I would urge the Minister to see if this number is, in fact, adequate.

I gave notice also that I should raise the question of a new hospital between Fort William and Inverness. This is an area which I know quite well, because I lived for a time near Kingussie. The Badenoch area, which covers Kingussie, Newtonmore and so on, is very busy, particularly in the summer, and with the incidence of winter sports and other activities the need for a hospital, perhaps a small hospital, in that area seems to me to be quite important. If not tonight then at a later date I should like to hear the views of the Government on this. The distance between Fort William and Inverness is something like 70 miles. Particularly in the winter the roads can become very, very difficult to pass, particularly the A.9. Therefore, the setting up of a new hospital of some kind, even if it is a small one, is surely a matter of importance.

I was very interested to hear my noble friend Lord Ferrier mention the cottage hospitals. They perform a very fine service in England and in Scotland —I am thinking particularly of those at Crieff and Aberfeldy—and I hope that the Government will not allow the cottage hospitals to die out completely as they are tending to do in this part of the country.

I am pleased to see in the White Paper that the accident and casualty services are being paid adequate attention. It is becoming more and more important, with the increased traffic and with winter sports and other tourist activities, to have well-equipped accident services. I think that this is a practical White Paper. Scotland has contributed much to the world of medicine. I have just been reading a book on the life of John Hunter, who practically pioneered the subject of anatomy. The brothers John and William Hunter—both good, true Scots —contributed much to the annals of medicine, and I am sure that if they were alive to-day they would, as I do—and as I think all noble Lords who have spoken have done—congratulate the Government on this very good White Paper.

8.47 p.m.

LORD CRAIGTON

. My Lords, this has been a valuable debate, and those of your Lordships who have taken part will know that it will be of great value to all those in Scotland concerned with Scottish health. I am grateful to noble Lords for the welcome they have given to the Plan and for their constructive speeches. I may say that I am not a bit worried about the attendance; personally I prefer quality to quantity. I think I should start by adding my regrets to those expressed by the noble Lord, Lord Hughes, that the noble Lord, Lord Greenhill, has not been able to be here to take part in this debate.

The noble Lord, Lord Hughes, said that he did not want to advocate the claims of any area. I agree with him, but I must say that no one speaks with greater authority about Dundee, or the area of the Regional Board of which he was so successful and popular a Chairman. I am also grateful to the noble Lords, Lord Hughes, Lord Ferrier and Lord Auckland, for the kindly thanks and appreciation given to the officials of my Department. I can assure them that I read and, as it were, make "dirty cracks" about these White Papers when they are 90 per cent. completed, but we must always remember that behind us are these loyal and skilled officials who work so hard for the good of us all. I know that they will appreciate very much the mention that has been made.

I must thank the noble Lord, Lord Hughes, too, for his reminder that Scotland was quicker off the mark than England and Wales. This is a point which, perhaps, I was too modest to mention myself. I liked the phrase used by the noble Lord; that we in the Hospital Service are on a road that has no end, and that all we can do is to hurry along as fast as possible. This is how I see the White Paper, and I think he sees it in that way, too. I can assure him that it is our hope, and indeed our intention, that there shall always be a ten-year Plan. In fact, the Regional Hospital Boards will before long be submitting to my right honourable friend proposals for two or three years after 1971.

I agree—and I referred to this in my opening speech—that the Plan relies, as was said by the noble Lord, Lord Hughes, on the active co-operation of the local authorities. I was not in the least surprised to hear from an ex-Lord Provost the usual and quite proper question: "Yes, but where is the money coming from?" All I can answer is that I am sure this problem can be straightened out, if it does arise, as other such problems are straightened out: it is the inevitable and proper conflict between the taxpayer and the ratepayer.

The noble Lord, Lord Ferrier, and my noble friend who has just sat down were worried about the future of the cottage hospitals. Of course, there is no general answer. Some of these hospitals are clearly essential and will have to remain. The coming of the district general hospital may well affect others if they are in the area of that hospital. What I said earlier about the closing or keeping open of small hospitals applies also to the cottage hospitals. The noble Baroness, Lady Elliot of Harwood, who has asked me to apologise for the fact that she has had to go, drew attention to the need for mental deficiency beds. I sympathise greatly with the needs of such patients and, as I said in my opening speech, this is one of the fields in which we have already done much and in which we intend to do a great deal more to provide the extra accommodation needed.

The noble Lord, Lord Hughes, referred to the labour-saving devices which impressed him in Sweden, and very properly, I thought, he wondered whether we were proposing to use in our new hospitals all the modern aids which are available to save labour and to increase efficiency. I can reassure him on this point. The provision of some of the new machinery, like pneumatic tube systems, central dish-washing equipment, call systems for staff, automatic X-ray processing machines and food service equipment seems essential if we are to use our manpower and our womanpower effectively. The only caution I would give—and I think the noble Lord would agree with me on this—is that we should not try to mechanise either to the point at which we set up a whole new series of problems, where we have to replace staff by even more expensive highly-skilled mechanics, or to the point where we substitute machines for effective personal supervision of the patients.

The noble Lord, Lord Ferrier, expressed the hope that we should do everything possible to ensure that our out-patient departments in the new hospitals are designed to cope with the traffic they have to bear. I am glad that he made this point, and I will see that his speech—because he made so many constructive suggestions—is most carefully studied. In general, the growth of the out-patient traffic has been, as the statistics show, one of the dramatic things in the Hospital Service since 1948. The old hospitals were not built with this in mind. We recognise that if the right kind of out-patient departments are provided, not only will patients be seen in proper conditions but we can also take some of the load off the in-patient bed accommodation. We will try also to ensure that patients have to spend as little time as possible waiting to be seen by their doctors, and we can do this by insisting on proper appointment systems. Finally—and this is where the noble Lord's speech will be valuable—the Department's work-study team has made, and is making, a study of out-patient traffic in all its branches, and we hope that the beneficial results of this will be seen in the new departments that are to be built.

Noble Lords referred to staff difficulties, and especially to nursing staff. The facts of the increase—and they are facts —over the years in the number of staff in the service, including nurses and nursing auxiliaries, do not support the argument that pay has been a deterrent to recruitment. But the matter was fully discussed two days ago in another place, and there is a Motion on the Paper in your Lordships' House. So I do not think that in this debate, which is mainly about the Plan, I can usefully add any thing to what has been said by my right honourable friends the Secretary of State and the Minister of Health.

The noble Baroness raised the very important question of the hospital provision for the Borders, and I appreciate the feeling of disappointment that the Hospital Plan for the first ten years does not contain provision for the replacement of Peel Hospital or of Peebles Cottage Hospital. The South-Eastern Regional Hospital Board, who are responsible for setting the priorities in the programme for the whole region, have a very heavy building programme during the first ten years. They decided that their priorities must be, first, the replacement of the major teaching hospitals in Edinburgh, the Royal Infirmary and the Western General Hospital; secondly, the provision of general hospital services in Fife, where no such services now exist; thirdly, the provision of a new mental deficiency hospital in Fife—here again, there is no existing service for this type of patient. And, fourthly, they have decided to build a new district general hospital in West Lothian to replace Bangour, which, like Peel, is a war-time hospital. What tipped the balance in favour of West Lothian were the new developments in that area, including the B.M.C. factory developments and the proposed new town at Livingstone. My Lords, these are the main developments which we hope will take place in the South-Eastern Region in the first ten years and, although there will be continuing expenditure on existing hospitals, including Peel, so far as this is necessary, the South-Eastern Board could not accommodate another major project within the limits of the money available to them.

I should not wish, however, to give the impression that the situation is entirely hopeless so far as the Borders are concerned. The ten-year programme does not represent in any way the end of hospital building in Scotland. Fairly soon now, the Regional Hospital Boards will be presenting the Secretary of State, as I have said, with proposals for new works to be undertaken in the next phase of the programme after 1971, and when the South-Eastern Board come to do this I have no doubt that they will give very sympathetic consideration to the needs of the Borders. Meanwhile, Peel Hospital, like the others of the same origin—Law, Ballochmyle, Stracathro and Raigmore—will continue to provide the valuable services which they have rendered as general hospitals to the communities they serve. The noble Lord, Lord Ferrier, asked whether we were fully alive to the changes that were coming in population and industry. The decision to go ahead with the new general hospital in West Lothian because of the B.M.C. developments and the new town of Livingstone shows, I think, that we are fully alive to the changes.

My noble friend Lord Ferrier mentioned the disquiet in Lanarkshire about the future of Law Hospital. There has been a good deal (that is putting it mildly) of discussion about Law among all the authorities concerned with the future of the hopsital services in Lanarkshire. My right honourable friend the Secretary of State has now said that he approves the proposals of the Western Regional Hospital Board; so I must tell my noble friend that the final decision has now been made. The Board's proposals are to build a new general hospital of some 650 beds at Motherwell, a new hospital of some 400 beds in the Airdrie-Coatbridge area, and to continue acute hospital services at Law on a reduced scale. With beds for geriatrics and for long-term orthopædics. Law will still be a comparatively large hospital of about 450 beds.

I realise that those who were anxious to establish Law as the main general hospital for this area rather than Motherwell will be somewhat disappointed, but after a detailed examination of all the factors which led the Regional Board to their decision the case for Motherwell seemed very strong. Although it was a war-time hospital, as the noble Lord said, Law has rapidly acquired an excellent reputation amongst those who use it, and while it will now change its function to some extent. I have no doubt that it will continue to provide an excellent service. The noble Lord need not worry about Motherwell having priority over the hospital for the Airdrie area: it is the Board's intention that these two should be built at approximately the same time.

The noble Lord, Lord Ferrier, also asked me whether it was the intention to provide a new maternity unit at Hairmyres Hospital before 1965 for the mothers from East Kilbride. On the present programme I am afraid it will be after 1965 before this is done. I will tell the noble Lord why. The Board have taken the view that they should give priority in maternity services in Lanarkshire to those areas where the social and housing conditions are not so good. For this reason, the general practitioner units at Wester Moffat and Strathclyde which will serve the older industrial communities are likely to be the first developments. East Kilbride mothers are served mainly, as he said, by the maternity hospitals at Bellshill and Hamilton. This service will, of course, be much improved when the new maternity hospital at Bellshill comes into use in May or June of this year to replace the old hospital.

My noble friend Lord Auckland referred to Belford Hospital. He asked: was it sufficiently large for the area with 52 beds? I have investigated this and I can assure him that 52 beds is on the generous side—and that is after making proper allowance for the needs of the increased summer population. I take due note of what my noble friend said about nurses' homes, and I am grateful to him for what he said. With regard to the possibility of a new hospital between Fort William and Inverness, I must tell the noble Lord that that is a new proposal which has not come our way. No doubt the Northern Regional Hospital Board will read what my noble friend has said. I am grateful to noble Lords who have raised points in to-day's debate, and I hope that, with these new hospitals, we shall provide a balance of high quality medical care and high quality surroundings in which that care can be given.

On Question, Resolution agreed to.