CONSULTATIVE HEALTH CENTRES

HL Deb 03 December 1964 vol 261 cc1272-92

7.0 p.m.

LORD AMULREE

rose to ask Her Majesty's Government whether they propose to advise local authorities to establish consultative health centres for elderly and other persons. The noble Lord said: My Lords, your Lordships' House has always been kind and indulgent to me when I have got up to speak about the problems and difficulties affecting, aged members of the community, and I trust that your Lordships will not mind at this late hour if once more I inflict a short speech on the House.

One thing of great importance which we have to consider at the present time is to take what steps we can to avoid old people being forced to go into hospital or some kind of communal home. The cost of maintaining a bed in hospital is enormous. I cannot go into that now, but even coming down to a communal home, the capital cost is about £2,000 a bed, and the weekly cost is between £7 and £10. Therefore we have to think of as many ways as we can to avoid the necessity for people going into hospital or any kind of communal home. And the point I want to put before your Lordships to-day is that one of the things that might be done is to establish diagnostic and consultative clinics for elderly persons, which they could visit and see somebody who can help them in their troubles. I do not necessarily want to confine my suggestion to people of 60 and 65. There is no reason why people who are growing middle-aged should not be able to visit these clinics, because often the seeds of trouble in old age come in middle-age. We have seen the value of clinics in maternity and child welfare work since they evolved at the beginning of the century, and it seems to me that there is no reason why clinics such as I am talking about should not do similar good for elderly people.

There is one good example which I know in the borough of Rutherglen, just outside Glasgow—I hope your Lordships do not mind my mentioning it by name. Rutherglen is a burgh of 25,000 inhabitants, densely populated. The clinic was established in 1952. It took a certain amount of time to get going, and it was not until about three or four years after that it became really popular. It was established by the medical officer of health, working in conjunction with a consultant from o le of the big Glasgow hospitals, who is a physician in general medicine and who has a large number of beds for old people. The clinic is in the premises of the local authority, which is convenient, because people know where these premises are. Those who go to the clinic are recommended by their general practitioners. These arrangements seem to me to be a great advantage, because they bring the work of the general practitioner, the local authority, the hospital and the voluntary organisations together in one place for a certain section of the community.

At this late hour I do not want to go into any great detail, but the medical officer of health finds it possible to put one of his social workers in the clinic: one of the health visitors is there, too. She does not have a great deal to do. I think it is rather a pity. One of the troubles with health visitors in general is that they were appointed to take maternity and child welfare only. Then, in 1948, they were given certain other duties for the care of the elderly, but (I do not say that it was their fault) this side of their work does not seem to have gone very far.

During the past eight years, 1,250 people from this one little burgh have attended the clinic. Their ages ranged from 55 to 85, so it has not been dealing only with people of pensionable age. Roughly the same number still visit the clinic, which shows that the need for such a place is just as strong as it was. A certain number are admitted to hospital from the clinic, but not a great number—about 4 per cent. Many others come because they want to have something done to help them—perhaps about a family problem, or to know whether they should go on smoking or not; and a great many things which are not really for a practitioner but which have a strong bearing on the medical side. They can get physiotherapy and chiropody at the clinic. About one quarter of them need chiropody, something which is very important in dealing with elderly people.

One of the great strengths of the clinic, I think, is that those who go there know that they can come to people who know what they are talking about, and they can get reassurance from them. This reassurance is doubly welcome, being grounded on knowledge. I think that such clinics have great value. They would be very useful for lonely people, those who live by themselves in isolation. Often old people might be much more prepared to go there than to go to the hospital or general practitioner where the consultant waiting room can be crowded. The clinics would also be able to do a considerable amount of research into the troubles of elderly people which is difficult to do in other ways.

The point of my question is, why is it that the Ministry of Health have not done more to encourage (I do not mean to direct) local authorities to do the same kind of thing as they have done at Rutherglen? These clinics would not be a great expense. They could be held in the premises of local authorities and there would be plenty of time, because on Monday mothers and babies do not come because it is washing day, and they do not come in the mornings because they want to do their work, so there is plenty of time for the premises to be used for the purposes of the clinic I am suggesting.

The question of staff is no difficulty at all, except in so far as the employment of one consultant for one session goes. Where the money is going to come from I do not quite know, but there are a certain number of consultant posts which have now joint appointments between the regional health committee and the local authority, and I do not see why one session from a local health consultant, or a regional hospital board consultant, for that matter, could not be given to the clinic.

There are two other points which people say might be difficult. A medical officer of health may be reluctant to set up a clinic because of difficulty—I will not say, hostility—between general practitioners and the public health department at the Town Hall, which one thinks is dying out, but which may pop up in certain quarters. The other thing that might be expensive is transport for these people. At present, I think they all come up under their own steam, whereas if an ambulance service is run for them, this will be expensive. But these, I feel, are not the important points. The important thing is that you must get a first-class consultant coming to see these people; you do not want him to run some kind of second-class medical service for the elderly people, which may well arise if you do not get the first-class set-up.

That is all I want to say. I should now like to put my question again. Can the noble Lord who is to reply give me some idea whether I am talking complete rubbish, or whether there is some very good reason why the Ministry of Health have not done something in regard to the establishment of these things?

7.11 p.m.

BARONESS SUMMERSKILL

My Lords, listening to the noble Lord, Lord Amulree, put his case, I think we are all impressed by the fact that his interest in the aged is as fresh to-day as it was many years ago when he decided to dedicate his life to their welfare.

SEVERAL NOBLE LORDS: Hear, hear!

BARONESS SUMMERSKILL

I only wish I could come here and wholeheartedly dot his "i's" and cross his "t's". Theoretically the noble Lord is right: that any addition we make to our National Health Service, whatever clinic we establish which caters for some category of the population, must do good. Nevertheless, although I sympathise with the noble Lord, I cannot urge the Government to give this plea priority, for the strictly practical reason that in most areas we have not the buildings or the staff available. The noble Lord suggested that we might use the maternity and child welfare clinic rooms. Does he know that in some areas the maternity and child welfare clinic is held in the crudest possible place?

LORD TAYLOR

The church hall.

BARONESS SUMMERSKILL

Yes. I will not give details, because I think it is invidious in your Lordships' House to mention places where clinics are held in such appalling conditions that the mothers fear to take their children there. To think that some of these old people would leave their cosy little warm homes and go to some of these church halls is absurd. Therefore, I think I am right when I say it is not quite so simple as the noble Lord suggests. We should need to have more buildings. At the moment, of course, the Ten-Year Hospital Plan is nothing but a mirage, and the Minister of Health, I understand, is to review the whole question. Therefore I think I am right in saying that it is rather unpractical at this moment to say to the Minister that these clinics should be established.

Then, what of the staff? The noble Lord said that he wants a first-class consultant, and not a second-class one; nothing but the best. It has been said, time after time, that our hospitals could not continue unless we had doctors from overseas. As for other staff, the social workers are desperately needed elsewhere; and our wards are closing because we have not enough nurses.

Nevertheless, I feel that this question gives us an opportunity to focus attention on these deficiencies in the Health Service which threaten to hamper its whole work. What the noble Lord is anxious to do, with his warm, large heart, is to save his children. He is a bachelor (I just cannot understand why women have allowed him to be a bachelor all these years), but he has embraced a vast family—people who have reached their second childhood and who are dependent on him. This vast family of helpless, lonely and many of them unhappy people he is seeking to help, and he wants to save them the sheer misery of going to a large hospital outpatient department and there sitting, sometimes for many hours, among unhappy people who, most of them, are not suffering from trivial illnesses, but from serious conditions.

Why is it that the noble Lord wants to do this? We were hoping that an appointments system would be established in all these hospitals so that this long, miserable waiting would cease. But it seems to me to have broken down in many places. The overcrowded conditions in our out-patients departments which were a feature of so many of our hospitals 25 years ago are now recurring. I would say to the noble Lord that this is not simply due to the failure of assessing the time needed for a consultation, but to the unpunctuality of the consultant.

LORD TAYLOR

Hear, hear!

BARONESS SUMMERSKILL

I am glad the noble Lord said that, because it has to be said. In an out-patient department, if a nurse is late she is reprimanded by the sister; and if a sister errs, she is censured by the matron. It seems that nobody reprimands a consultant for keeping patients waiting. What category is there in the country which should have our greater sympathy in this matter than the seriously sick who are kept waiting in our out-patient departments?

The tragedy of old age is that the aged have plenty of spare time, but few friends with which to fill it. The noble Lord, Lord Amulree, quite rightly, mentioned just now that they go to their general practitioner, not necessarily because they have some pathological condition but because they have plenty of time: they want a chat; they want the warmth of human companionship. But what do they find? They find a tired, overworked man or woman, who recognises the old person's condition but has not the time for a long chat or for the frequent examinations which so often reassure the old patient. The noble Lord has described this clinic—I visualised it as he was speaking—with all the diagnostic paraphernalia which is necessary in these days, where the old person is being subjected to a thorough examination, although the doctor knows it is a physiological condition of deterioration and not a pathological condition. Nevertheless, it gives the old person comfort. Of course this would help the pressure on the general practitioner and on the hospital. But I feel it is difficult to establish these things, for the reasons I have put forward.

I say again, at the risk of wearying the House, that the alternative is a comprehensive domiciliary service, for which I have pressed again and again. It should be so comprehensive that the old people in their homes can be looked after by a domestic help; meals can arrive; there can be a chiropodist and physiotherapist, and someone to go in for a chat. I have mentioned this before, but nobody has ever acted on any of these suggestions over the last thirteen years, if I dare mention a period. You could have these married women with spare time, who could be remunerated, to go in and help these old men and women. Let us face up to it: the problem of the future is living too long. What the noble Lord has suggested is very practical if we are to handle this particular problem, and the time may come when he will look back and say: "Well, it has been necessary after all." The situation has deteriorated to such a state that the domiciliary service which I have mentioned is again impracticable, because all the professions which are supplementary to medicine are in such short supply that in most areas the domiciliary service just does not exist.

I was very impressed this morning when I read The Times to see a letter from a matron. Matrons are usually people who shun publicity, shun the Press, never write letters to the newspapers, because they feel somebody in authority might be annoyed. But to-day I find a letter from the President of the Association of Hospital Matrons in The Times. Here she says that the answer to the fact that our wards are closing for lack of nurses, the answer to the fact that the noble Lord's suggestion to-day has to be turned down, the answer to a very limited domiciliary service, is that the country has had its nursing on the cheap. I can only say that what the matron has said about nurses in The Times to-day can, of course, be related to all forms of women's labour in the Health Service. It seems, therefore, that the clinics for which the noble Lord asked will have to wait until the Government can establish a national incomes policy. I am glad that my noble friend who is a member of the Cabinet is so near, listening to me. They will have to establish a national incomes policy in which those who serve the community with such devotion are adequately remunerated. That must be the direction. Our basis of remuneration in the future must be: what does an individual give to the community, whether it is in the factories, in industry, or whether it is in our social services? Let that be the criterion, and then the noble Lord opposite will not come and seek his clinics in vain.

7.22 p.m.

THE LORD BISHOP OF WINCHESTER

My Lords, I cannot claim the professional medical knowledge of the noble Lord who has asked this Question, or of the noble Baroness, Lady Summerskill. I rise only because of my pastoral concern for the care of the elderly. In these days, when we are confronted with so great a variety of human need and suffering, and when so many avenues of service are opened up before us, it is all too easy for the more spectacular forms of service to claim our attention and to attract enthusiastic response. It is all too easy to overlook the needs of a great section of the community that has a paramount claim upon our compassion and our care. There are, indeed, no persons more deserving of the attention and care of the whole community than the elderly.

I welcome the Question of the noble Lord, Lord Amulree, because whether or not the health centre is the best way of meeting the need, there is no doubt whatever about the need of those ser- vices which a health centre would be designed to provide. We can indeed be very thankful for the current provision of services to keep elderly people well and in their homes. This provision is very comprehensive. As your Lordships know, local authorities, with valuable help from voluntary organisations, provide a comprehensive range of services, including home helps, home nurses, health visitors, "meals on wheels", and chiropody. Local statutory and voluntary services between them provide for recreation and home visiting. The criticism of this provision is that it is often fragmented, unco-ordinated, and uneven in its distribution.

I am thankful to say that in my own county, Hampshire, which I think is second to none in its provision for the elderly, there is a very happy and close co-ordination between the statutory and voluntary bodies who are concerned with the care of the elderly. In my county also, as no doubt in many others, there has been a gradual reorientation of the health visitor service, and much of the health visitor's time is now devoted to visiting the elderly rather than the young infants. This seems to me to be a move in the right direction, now that most parents are able to take their children to clinics or to summon the doctor. Health visitors can render real service by keeping a check on old people who may become immobile or otherwise ineffective in seeking the attention they need.

Despite, however, all that has been done by statutory and voluntary bodies in caring for the health of the elderly, a consultative health centre might well fill a gap and meet a very real need. It is now generally acknowledged that everything possible should be done to provide a system of community care which would enable as many people as possible to remain in their own private homes until the need for constant attendance, which cannot be provided always by the family, makes residential care imperative, or illness necessitates removal to hospital. Furthermore, since people are living so much longer after retirement, and physical disability nowadays often preceeds the failure of mental powers, it is very necessary to do everything possible to ensure that lack of physical care does not result in immo- bility and inability to enjoy life to the full for as long as possible.

It is the fact that old people living on low incomes are liable to be housebound because they dc not get sufficient protein and fresh fruit and vegetables in their diet. Often their feet, teeth, eyes or ears need attention which they have not the energy to seek in a doctor's surgery or in the out-patient department of a hospital. This sort of disability might be diagnosed and remedies prescribed if, more often, old people were able and willing to attend central health centres. At such centres, as at, for example, the experimental centres at Dagenham and Twickenham (about which I cannot claim to have any intimate knowledge) elderly people can be given periodic general health checks. They can avail themselves of facilities for testing the heart, blood, digestive tract, sight, hearing, et cetera. They can also benefit by the facilities for chiropody and for obtaining special dietary supplements.

There are, of course, potential disadvantages in special health centres for the elderly. I will just touch briefly on some of them. Bearing in mind that there is already overlapping in the services rendered by statutory and voluntary bodies, the establishment of consultative health centres might encourage further overlapping and still leave had local gaps. It is generally known that shortage of manpower, to which reference has already been made, is possibly the biggest current factor operating against the efficiency of present services. Adding yet another form of care might well aggravate the situation. Secondly, the grouping together generically of everybody over a certain age could be objectionable to people coming within that age group, and it is probable that many elderly people would object to being placed in such a category. Thirdly, it is not necessarily desirable to focus the attention of the elderly on potential physical illness; and the provision of health centres especially for the elderly might do this. Furthermore, such centres might result in the social services for the elderly becoming clinic-orientated, and it is desirable that they should be kept a3 homely and as normal as possible.

It is clear, then, that there is scope for a wide difference of opinion about whether health centres especially for the elderly are the best way of providing certain necessary services, but there is a general consensus of opinion, reflected in previous debates in this House, about the need for these services, and the need for a general improvement in both their quantity and quality. I have reason for believing that voluntary bodies which are concerned with the care of the elderly would welcome a pronouncement from Her Majesty's Government as to whether or not local authorities should be encouraged to establish consultative health centres.

Finally, I would express my conviction that there is a fundamental need for the cultivation in the whole community of a Christian philosophy of old age, so that each old person is valued and cared for with as much enthusiasm as is now devoted to young children. Clearly in this sphere the Christian Church has a special responsibility for leadership, and I am encouraged to know that there is a ready response on the part of the laity of the Church, including young people, when the care of the elderly is presented, as it should be, as a challenging avenue for Christian service.

7.30 p.m.

LORD AUCKLAND

My Lords, the House will be grateful to the noble Lord, Lord Amulree, for having put down his Question, and I am sure that on these Benches we all endorse to the full the spirit behind the Question and recognise the stirring work which the noble Lord has carried out with regard not only to the elderly but to all forms of hospital patients and those who are ill. I should like to take this opportunity of congratulating the noble Lord, Lord Taylor, on his appointment as our spokesman for health in this House. In a Government in which not all its spokesmen are necessarily favourably approved of from these Benches, I can assure the noble Lord, Lord Taylor, that he is not in that category, and we look forward very much to his contributions; not only to this debate but to others, because he has himself rendered very valuable work in every branch of the Health Service.

My Lords, I, too, do not have the medical knowledge of the noble Lord, Lord Amulree, or of the noble Baroness, but this is a matter with which all those who are in public life should be very much concerned, and I hope that Lord Amulree's proposal will receive very serious consideration. I am not myself sufficiently technically knowledgeable to know whether it is administratively possible, but, so far as buildings are concerned, I should have thought that the industrialised building system, or even prefabricated buildings, could be erected to serve for this purpose.

The noble Lord, Lord Amulree, referred to Rutherglen. I should like to ask the noble Lord, Lord Taylor, whether the more remote areas would not benefit from this service. I am thinking particularly of the Highlands of Scotland. For example, between Fort William and Inverness, which are about 100 miles apart, there is no large hospital, and there are quite a number of elderly people living in villages and small towns in that area who would benefit by the establishment of one or two, or perhaps more, of these centres, to which elderly people, in particular, could go and receive treatment, such as physiotherapy treatment, instead of having to go to hospital in Inverness or Fort William, which involves travelling long distances. Many of the homes of these elderly people are probably not suitable for treatment of this kind. They may be small homes, and some may not even have electricity, which means that radiography, for instance, would be difficult to administer. Visiting a centre would give them the opportunity of seeing a doctor in private and would give the doctor an opportunity of giving the patient a detailed examination.

There is, as the noble Baroness, Lady Summerskill has said, a shortage of doctors in many areas, but under the late Government the supply of nurses and doctors has increased fairly substantially, although, I would immediately admit, not sufficiently, in certain areas, and we watch the progress of the present Government in this matter with added interest. But with a centre for these old people to attend, a consultant from Inverness, for example, could be brought in perhaps once a fortnight, or even more frequently.

As the noble Baroness has said, some of these clinics are very unsuitable for their purpose, and here I would pay a very real tribute to those who run these clinics, to the doctors and the nursing staff. I have one such clinic in my own village in Surrey which is held in the local village hall. The accommodation is not all that one would wish for, but it is very well staffed, and treatment and examinations are very well carried out. But, as I say, although there is a building problem here, it seems to me that temporary building would be a solution. I hope that these few remarks will have given the noble Lord something to consider, and I would again thank the noble Lord, Lord Amulree, for once again bringing forward a very vital problem.

7.35 p.m.

Viscount ADDISON

My Lords, like the noble Lord, Lord Auckland, I should like to say a word of thanks to the noble Lord, Lord Amulree, for raising this matter, which is, I am sure, very close to your Lordships' hearts. There is a good deal of justice in what my noble friend Lady Summerskill says on the question of what might be described as a division of effort. I did not myself know about the establishment at Rutherglen, but I gather that it would be a purpose-built unit, and I think that if one were to develop this idea—although there may be many places like Rutherglen where it might successfully be arranged—there would be a danger of dividing one's effort and raising even graver difficulties with the staffing situation than we already face.

I should like to say a word in favour of the development of what, for want of a better word, is called the "day" hospital idea; in which there is a consultative clinic attached to, or within the curtilage of, a district hospital, where, of course, you have proper staffing arrangements, radiography apparatus, and all the requisite equipment, together with meals and all the necessary accoutrements at hand. Here elderly people can spend the day, perhaps dropped on the way to work by their children with whom they may be living, and collected by them on the way home again afterwards. They can spend the day receiving any treatment which may be appropriate to their case or getting encouragement and help. They can meet friends and make new ones. I think the Ministry of Health has already given some encouragement to this idea, although I think I am right in saying that they were somewhat against the idea of developing a club atmosphere, which I myself regard as rather desirable. Certainly this method might be pressed forward and it might perhaps be a fairly good compromise solution, speaking in general terms, which would meet the needs of the idea put forward by the noble Lord, Lord Amulree.

Once again I should like to express my thanks to the noble Lord for raising the matter, and I would add my congratulations to those of other noble Lords on the appointment of the noble Lord, Lord Taylor, to the Government Front Bench to speak on this subject.

7.38 p.m.

LORD TAYLOR

My Lords, I think it would be the wish of all noble Lords that I should not indulge in a general discourse on the care of old people but should confine myself rather strictly to answer the questions which the noble Lord, Lord Amulree, has asked and which have been asked by other noble Lords and by my noble friend Lady Summerskill in the course of this debate. I would thank noble Lords very much for their kind words, and I should like to endorse the words of my noble friend Lady Summerskill about the noble Lord, Lord Amulree. I feel that he is a "Dad" with a huge family. Whenever I go to his hospital I feel than he is just wonderful. I may say that I have personal reasons for feeling this, too. We batted together many a time when we were on the same side of the House, and let me assure the noble Lord that we shall be batting together again. But we also have sometimes differed a little, and I am afraid I am going 10 differ just a little with the noble Lord tonight.

Of course, we all agree about the importance of avoiding unnecessary admission to hospital; this is vital. The noble Lord gave us the capital cost of a geriatric bed as £2,000, and its minimum running cost as £7 to £10 a week. I am certain that the latter figure is right; I wish the former figure could be lower. I sometimes think it could be if we could build a little more simply. Then we come to the noble Lord's question of the diagnostic and consultative clinics for old people, and he took as his example the very interesting case of Rutherglen. Here we have a clinic which is a screening unit which sees old people who are nominally fit. They are in a sound physical, mental and social state. They are thoroughly examined, and it takes five hours on the first occasion to examine each one of them—that is a combination of medical time and social worker time, and the rest—and, as a result, a number have things discovered which nobody knew about before and which can be put right.

The noble Lord, Lord Amulree, said the scheme is extended to below the 65-year age group into the 55-year age group, and in eight years they have been able to deal with 1,250 people—that is, 150 new patients a year. That ain't good enough, chum! It just does not make sense to me. I have been doing a care of senior executives scheme for the past 14 years on one morning a week, and I can do two patients a morning, with a really thorough examination. Such a thing is a research project only, which can never be generally applied; you would require all your doctors to do this sort of thing, and not to treat the sick or deal with public health or maternity and child welfare. It just is a non-starter. It is very desirable there should be a few such places where research can be seriously done, and this is what, in my opinion, Rutherglen is; and it is a very good thing. I do not think it would be right, and I believe I am correct in saying—I hope, having read my brief, that I am right in saying—that Her Majesty's Government think as I do and that we should not generally encourage local authorities to establish these places. I am sorry, but I am sure this is the right answer, having regard to all the facts.

Now I come on to my noble friend Lady Summerskill. She really said what I am saying in another way, and we are at one on this. But then she went on to ask, "What should we do about it? What is the alternative?" And the first thing she said was, let these old people be received at the hospital with a proper appointment system, so that they do not have to hang about. And she said that unfortunately the system has broken down. I think she rather generalised about the consultants. In my experience it is 5 to 10 per cent., and probably nearer 5 per cent., of consultants who are extremely bad timekeepers. It is a shocking piece of behaviour. She said there is somebody to "tick off" the nurses; that is the matron. There is somebody to "tick off" the domestic staff, which is the catering officer. There is somebody to "tick off" the catering officer, which is the hospital secretary. But she said there is nobody to "tick off" the consultant if he does not turn up on time.

Well, there is somebody. There is my noble friend Lord Addison in his capacity as a chairman of a hospital management committee. There is my noble friend Lord Stonham, in his capacity as a chairman of a hospital management committee. Both of them, I know, have never hesitated to speak sternly and "tick off" a consultant who is not doing the job for which he is paid. That is one of the first and vital jobs of the chairman of every hospital management committee throughout the country: to see that his consultants are doing their jobs properly and serving their patients as they should, and that they are not exploiting their position, as some of them used to in the old days when they were voluntary workers, and a few of them still do.

BARONESS SUMMERSKILL

My Lords, I must ask my noble friend—because I think he paints the system in rather bright colours—if that is so, why are there frequent complaints? I think the noble Lord, Lord Addison, is probably a perfect chairman, but I have known lots of chairmen who have never dared speak to consultants. Why are complaints so rife if the chairmen really do?

LORD TAYLOR

I said they ought to.

BARONESS SUMMERSKILL

Yes, but they do not.

LORD TAYLOR

The sooner they do so, the better. I quite agree with my noble friend. Some chairmen have not got the guts to stand up to consultants, but they should. It is their duty to do so. That deals with the unpunctual consultant.

The next point the noble Baroness raised was in regard to a comprehensive domiciliary service, and here I think she is right. I believe this is what we ought to be aiming at, and it must be based on the general practitioner, because he probably knows where most of the old people are; they are on his list; they are likely to send for him when they are sick, and their relatives are likely to call him in. He probably knows more than any other single person where the old people are. The noble Baroness mentioned domestic help, "meals on wheels", and chiropody—domiciliary chiropody is vitally important for old people, but we are short of chiropodists. She mentioned health visitors for old people. That is vitally important.

Then she made a very important point about lay visitors, the kind of visitor who if one were in prison might be one's voluntary prison visitor. In a sense, old people who are confined by physical disease to one room at the top of a block of buildings in Lambeth or Kennington or Holloway are in prison, and need a voluntary visitor. I can tell your Lordships of an experiment being done in my new town of Harlow which provides a good answer. This is to get girls in their last year at secondary modem schools, when they are full of beans and zest, and some of them not very academically minded, to do social service on two afternoons a week. They do various things, and one thing is visiting old people in their homes and running their errands for them.

It is a splendid thing for the girls, because though they are not academically clever they feel they are wanted. It is splendid for the old people to have a young person taking an interest in them, and they can take an interest in the young person, too, because this is a two-way traffic. I think this is one of the very simple ways in which we can help in taking care of old people, with a continuous stream of these young people, particularly in their final year at school. The less bright girls, and perhaps boys, too, can help, and even some of the bright ones. My children are at Highgate, and some have been doing visiting on the Hill Homes. I think that having young people to do the visiting is very much better in many ways. Middle-aged or elderly people themselves are tired. That is the way we could do it.

With regard to the supply of the other ancillary workers, my noble friend Lord Stonham gave me a copy of a letter he sent to-day to my noble friend Lady Summerskill which shows that there is a steady improvement since the improvement of wages in almost every group of the ancillary workers. So I think things are beginning to improve. I do not say we should take the credit for it; I do not know how much we have done. It may be noble Lords opposite can take credit, but certainly there is an improvement.

Lord Auckland supported Lord Amulree; and we have already dealt with those points. He raised the important question about what to do in remote areas. This presents a problem. These consultative geriatric clinics are really screening clinics to detect disease in relatively healthy people. They are not treatment clinics. They are not social clubs. That is right, is it not?—the noble Lord, Lord Amulree, indicates assent. They are screening clinics. In remote areas you do not want screening clinics. I think you want a general practitioner who can get to people's homes if they are ill, and a day hospital, with an ambulance collecting service to take them to a place if they are disabled yet not ill enough for hospital.

I think that my noble friend Lord Addison was right in stressing the importance of the development of the day hospital for geriatric patients. I remember, not so many years ago, going to McGill Hospital, in Toronto, and seeing almost the first day hospital in the world. It was for psychiatric patients. This was in 1948. It is jolly good news to know that we in this country already have 60 day hospitals for old people. I must say that the Ministry of Health have not been idle, even under the previous Administration. Let us hope that we have many more of these hospitals, because this is a good way of achieving our objective.

My noble friend Lord Addison asked, "What about the club atmosphere?" This is a difficult matter. I think there is something in what he says, provided that the place is not too "clubby" and has constructive activity. People suffer from disuse atrophy if they do not do things—if they just sit around television, drinking cups of tea all day long. That is not really the function of a day hospital for geriatric people. They must be got moving. They do not at first like to be got moving. They must be kept moving intellectually, and doing things and making things, and not just sitting about like the rich tourists that we were talking about just now.

LORD DERWENT

Not even if they want to?

LORD TAYLOR

Well, "Sometimes I just sits; I just sits and thinks outside the pub, but I also do my ploughing." Surely, the answer is that it is a bad thing to sit about all the time. I imagine that even the noble Lord, Lord Derwent, will agree with that. I do not think that my noble friend Lord Addison raised any other points that I have not covered—

VISCOUNT ADDISON

My Lords, the only point I should like to make clear is this. Since last April I am no longer chairman of a hospital group; but it was not because I was rude to the consultants.

LORD TAYLOR

My Lords, I am sorry that my noble friend is no longer a chairman. I am sure we are all sorry—even the consultants. When they have been "ticked off", they generally do not mind it too much either.

I want to say one word in general about how this work should be undertaken. I am sure that the basis of the proper care of old people is a really good general practitioner service. If you start having special clinics for everybody you end up with nothing. You hive off the old people; you hive off the infants; you hive off the maternity, and you hive off the diabetics—that is the latest one. You hive off the people with eye complaints; you hive off the skin people, and you hive off industrial medicine. There is nothing left. You have a series of second-rate consulting clinics, because there are not enough first-rate consultants to go round.

I have spent the past fourteen years trying the reverse; trying to get the general practitioners working in groups in good buildings, themselves running the ante-natal clinics and child welfare clinics, with the health visitor working with them, with the health visitor doing not merely this but geriatric health visiting as well—doing the lot. I am sure that is the right answer. It is not so difficult to do, it does not take so long, and it does not cost so much. Thirty thousand pounds will build a six-doctor health centre, and at 6 per cent. that is paid for by the rents which the doctors and the local authorities and the dentists pay for it. It could be done in any new community.

My noble friend Lady Summerskill mentioned the problem of appointment systems. In my experience, more and more good general practitioners are running an appointments system, and making it work. They are most ready and willing to give up time in the afternoons to have a special appointments period for older people. I have known many general practitioners who have made it a habit, when things were a little easier in the summer (as they used to be in the old days, but not so much now), to do a special old people's round and to visit the old people at home, they being not under active treatment, but just to see that they were all right. They take their blood pressures when things are quiet and calm, and see that they are getting enough to eat.

That brings me to the last point I want to mention. The right reverend Prelate the Lord Bishop of Winchester mentioned one matter, and I am going to say only one thing about it. He spoke of the Twickenham Clinic, where Dr. Maddison is the M.O.H. There he has carried out some investigations which are in some respects somewhat controversial. But there is one finding with which I hope everybody would agree: namely, that if you visit old people and examine them in their homes—just taking a sample of old people—you find not a lot of gross malnutrition, but quite a lot of under-nutrition; old people who are not getting enough to eat and not getting the right things to eat. On the whole, this is not due to lack of money, though sometimes it is. It is much more due to ignorance, apathy and loss of appetite; to physical disabilities in obtaining, preparing or eating food. Things like ill-fitting dentures and such small things can make all the difference between health and ill-health, and the steady beginning of a physical decline.

That means that our next generation of doctors must be trained to deal with minor things in old people. It is all very well knowing about awful cancers and so on. But what matters are the simple things, the little things, and watching all the time for little things going wrong. If the doctors do that; if they visit their old people regularly, and if they have not got too much work to do—and that means if there are enough doctors, which, in turn, means if there are many more medical schools than there are at present—then I think we shall get a proper service for old people; and I do not despair that we shall make a jolly good foundation in the next few years.