§ 7.30 p.m.
§ LORD TAYLOR rose to move, That it be an Instruction to the Committee on the Bill that they should not pass Clause 36 without special attention, and, in particular, should consider whether it is desirable that medical practitioners should be compelled, with a penalty in case of non-compliance, to report to the local authority all cases of housebound handicapped persons living alone. The noble Lord said: My Lords, I beg to move the second of my Instructions. I 851 understand that this is not an opposed Bill. Newcastle upon Tyne, in the course of their Bill, have inserted Clause 36, which introduces something quite new, but on similar lines to the matter we have just been discussing. They wish to make certain social conditions compulsorily notifiable.
§ Newcastle upon Tyne are asking that doctors should have regard to four things when they visit their patients and when all four stars are in conjunction (as it were), then the condition shall be notified. They say that the first thing is that persons must be residing alone in a dwellinghouse in the city; secondly, that they must be substantially handicapped by age, illness or injury or congenital deformity; thirdly, that they must be permanently handicapped—it is not enough to be substantially handicapped for a time; and, fourthly, that they must be unable to leave the dwellinghouse without physical assistance. Given these four conditions, the doctor is compelled to notify the Medical Officer of Health of the existence of such people, whether or not such people wish the matter to be notified.
§ This, again, is an entirely new principle in British public health and in British laws, so far as I know. One can see at once what the Promoters are after and I have a good deal of sympathy with their objective, though not with their proposed method. A number of local authorities keep registers on a voluntary basis of house-bound elderly people and this is an excellent thing to do. They ask the doctors and other social agencies in the town to let them know of housebound elderly people. They collect the list together and, as the names come in, the health visitors can visit these people in their homes to deal with any problems that arise. I have no objection to this. I think that it is an admirable arrangement and something that we should do everything we can to encourage. But the situation proposed for Newcastle is quite different.
§ With compulsory notification, the patient does not have to give permission to the doctor. The doctor does not have to say to the patient, "Do you mind my letting the medical officer of health know you are housebound and 852 disabled permanently, living alone and without physical assistance?" No, the doctor is bound by law, once this goes through, to notify the Medical Officer of Health, even though the patient strongly objects. And there are a number of elderly people living alone and housebound who nevertheless get on perfectly all right and who strongly object to the compulsory notification of their condition to the Medical Officer of Health.
§ Yet there is an enormous number of cases where notification can be very helpful, indeed. My suggestion is that this is something which really ought to be done by voluntary organisation between the Medical Officer of Health of the city of Newcastle and the general practitioners of the town. I cannot believe that if the general practitioner approaches them in a proper way and helps them, they will not help him in every case where he in turn is able to help these housebound elderly people. But to make housebound disability a compulsorily notifiable condition, with the usual rewards and penalties—a 2s. 6d. reward to the doctor when he notifies and a penalty of 40s. if he defaults—is really nonsense. For one thing, it is quite unenforceable. Doctors in Newcastle, unless they wished to, simply would not take any notice of it.
§ It so happens that I know the conditions of general practice in Newcastle upon Tyne very well, and very tough they are. There is an enormous amount of ill-health in working-class areas, many of which are under-doctored. In other words, doctors are working very hard indeed, and if they are called upon compulsorily to notify old people who are housebound, I am afraid that they might react rather badly and not co-operate, whereas, if they are asked nicely by the Medical Officer of Health I cannot believe that they will not be willing to help. So I hope very much that the Newcastle upon Tyne Corporation may think again about this clause and may not press it, but may try to achieve what they are seeking by taking administrative action. And the best administrative action they could take is that recommended in the Gillie Report—to attach a health visitor to every group of three or four general practitioners to 853 work with them. This, I am pleased to say, is something that local authorities are increasingly doing, and wherever they are doing it it has been working successfully. It enables the local authority to know every case of housebound elderly or handicapped people who are not getting help, and it certainly avoids a lot of unpleasantness which may arise through health visitors calling on people who have neither the need nor the desire to be called upon.
§ I hope, subject to any advice that the noble Lord, Lord Merthyr, may give us, that your Lordships will accept my second Motion and will instruct the Committee to pay special attention to this clause, to see whether the Promoters have in mind something which I have not thought of. If they have an overwhelming case, well and good, but unless they have an overwhelming case, I hope very much that this clause may be omitted.
§ Moved, That it be an Instruction to the Committee on the Bill that they should not pass Clause 36 without special attention, and, in particular, should consider whether it is desirable that medical practitioners should be compelled, with a penalty in case of non-compliance, to report to the local authority all cases of housebound handicapped persons living alone.—(Lord Taylor.)
§ 7.38 p.m.
THE CHAIRMAN OF COMMITTEES
My Lords, there is just a little more that I should like to say on the Newcastle Bill, because it has at least one difference, as the noble Lord, Lord Taylor, has already said. This is merely a general purposes Bill, like the Cumberland one. The bulk of the Bill deals with the Town Moor at Newcastle, but there are some clauses of general interest and added for different purposes. The Bill, unlike the Cumberland Bill, is an unopposed Bill, by which I mean that there are no Petitions at all against it.
Again, may I say that medical organisations, had they been so minded, could have petitioned against this Bill. May I say here, on the point raised this evening about expert evidence, that the best way of putting expert evidence before your Lordships' House is by calling it before a Select Committee, and the way 854 it is done is for expert witnesses, of whom a great many frequent your Lordships' House upstairs, to be called by the Promoters of the Bill, or by the Petitioners who oppose the Bill. The absence of expert evidence on this Bill is due simply to the fact that it is an unopposed Bill. Had it been opposed, it would have been different and expert evidence could have been given on both sides.
Although I said that it would be difficult to call expert evidence in the absence of a Petition against the Bill, I am reminded that after hearing the debate or argument downstairs, I could adjourn it for witnesses to be asked to come from outside. But much the best way of hearing expert evidence is to have a quasi-judicial hearing, which a hearing upstairs undoubtedly is.
May I say quite shortly that, if this Motion is not passed, this clause would be considered by the Unopposed Bills Committee of this House; and there is no doubt that, there being no precedent for this clause, the Committee would require the Promoters to justify it. The same procedure would then be followed as I have outlined for Cumberland. If this Motion is passed what happens then? Two things could happen. Either the clause would be considered by the Unopposed Bills Committee, being the Committee to which the Bill is referred, or, if I exercised my powers under the Standing Orders, which allow me to do so, I could send the clause upstairs to a Select Committee, in which case the clause, though unopposed, would be treated as if it were opposed. I have power to do that under Standing Order No. 92. Your Lordships may ask which I would do. I would say that my intention has been to consider everything that has been said to-night before deciding that question. I will certainly undertake to do that and then to decide what would be the best course in the interests of all concerned. I think that is all I can add. I am sorry to have addressed the House twice, but as there is a difference between the two Bills I thought I was justified in doing so.
§ 7.42 p.m.
§ LORD SHEPHERD
My Lords, I think I should first make it clear that I am not speaking in any official capacity within my Party. Some time ago I was 855 asked by the Newcastle upon Tyne Corporation, in view of the original Instruction that my noble friend placed on the Order Paper, to explain their point of view. I think, in some ways, it is a good thing that my noble friend has drawn our attention to this particular matter, and I would thank him very much for the terms of the Motion that is now before the House. It draws our attention to what I think is one of the greatest evils that we have in our social system to-day—namely, the results of old age.
For some, old age is a period in which they can enjoy with satisfaction the experiences and achievements of their lives. Some can sit with their children and grandchildren around them, spending the last few years of their life in the best of all circumstances. But there is another side to the coin: those many thousands of old people who live very close to subsistence level, and short of the money which gives them the opportunity of buying the few things that are creature comforts, such as coal and the like. I am sure that my noble friend Lord Taylor is as well aware of them as I am, or any other Member of your Lordships' House is. It is that side of the coin that I should like to have in mind in considering the provisions that the Newcastle Corporation seek within this Bill.
If we just take statistics alone, in 1961 there were in this country 5½ million people over 65; 30 per cent. of them—or 1,650,000—were over the age of 75; and I do not think there is any doubt that this number continues to grow. However, I should like to think, in particular, of Newcastle. Newcastle, as my noble friend Lord Lawson will agree, is not part of the affluent South-East of England. It is condemned with a large amount of slum property; and I think your Lordships will find that many of the old people for whom this provision has been inserted will be found in these old premises of Newcastle, most of them with outside lavatories, certainly no bathroom, and no doubt all with a form of slippery stone step which is very dangerous to an old person. In Newcastle there are 31,000 persons over 65, of whom 10,000 are over 75. In the city alone there are nearly 7,000 women over the age of 60 who live alone. Those figures are taken from the 1961 Census, 856 and I have no doubt that they have increased since that time.
My noble friend Lord Taylor said that doctors co-operate in notifying the authorities when it comes to their knowledge that old people are in need of attention. But in the case of Newcastle (and I would not put this as any reflection on the doctors of the neighbourhood; because, as my noble friend said, they are understaffed in that area), every winter many old people enter hospital, ill-nourished, cold and unkempt, quite apart from their medical ailment; and in many cases the position of these old people has been unknown to the local authority. I had a personal experience not long ago—not dealing with Newcastle, but it rather illustrates the problem—of an old lady of 83 who had lost her husband and her son during the war, and who was living at home and suffering from a severe heart ailment. The doctor sought to get her into hospital, but I understood at the time that she was not exactly a medical case, in the sense of requiring hospital treatment. This old lady lived in a house all by herself, right through the long night, without attention. I do not know why the local authority was not notified, but, as I shall show, under the National Assistance Act, 1948, the local authority have a duty to act when they have been notified. This illustrates the type of case to which the Newcastle Corporation are directing their attention.
In Newcastle, apart from the local authority, there are many welfare organisations that co-operate, and are willing to co-operate. But what the authority and the voluntary bodies want to know is the vital information about those persons who are in need of attention. My noble friend Lord Taylor spoke of the voluntary basis. I should much prefer it to be on a voluntary basis. I cannot help but reflect that, in the case of National Assistance, we know that many old people who are in need of National Assistance do not go to the National Assistance Board, because of their pride. They feel that they are asking for charity, although we well know that this is not a charity, but their right. I suggest that they would be willing to take National Assistance if somebody from the local authority or the Board responsible, when they knew that the person was in difficulties, went to the 857 home and said, "This is your right". But it is quite a different thing for the old person to knock at the door and say, "I am in need of attention".
Take the case of loneliness. I think it would be even harder for an old person to go to the local authority and say, "I am lonely; I am unable to look after myself." I believe that that is something the old person would resist to the last. This is one of the reasons why I think that the voluntary appeal does not meet the case. It is true that neighbours and relations could do it. But even relations have a feeling of pride: they would not like to think that they had to go to the authority and say that their mother or father was in need of care and attention. It would be quite different, however, if the local authority came and said, "We know; we have heard; we are sorry. This is what we can do." I think we want a change of emphasis in this relation.
§ LORD TAYLOR
My Lords, may I interrupt my noble friend for a moment? What I was suggesting was that notification by the doctor should be a voluntary act. Is my noble friend objecting to that, or not? It seems to me that the doctor could very properly persuade the patient to allow notification, and the patient would probably not object. It is much better for the doctor to do it as a voluntary act as between willing customer and willing doctor, rather than that both parties should be compelled to do it.
§ LORD SHEPHERD
My Lords, I will reply to that, because I think it is a very serious point. But may I deal with the case of this voluntary registration so far as Newcastle is concerned? They had approximately 32,000 people over 65 at the 1961 census, and at present 11,000 are registered. Not all those 11,000 are persons who are in need of care and attention. They have been registered because of their age, and no doubt visits are made by the local authority through its officers. But there is undoubted evidence of the fact that there are many of whom we are not aware, and who are in need of attention.
My noble friend asked me whether I should not prefer the voluntary system by which the doctor would notify. Certainly I should. I think I would have 858 advised the local authority concerned here to amend their provision, because I agree with my noble friend 100 per cent. that if a person refuses and tells his doctor that in no circumstances is he to be notified, then it is right that no notification should be made. But the power of the doctor is considerable. The doctor does not say to an individual, "I think you ought to go to hospital. Will you please go to hospital?" He does not put it in that way. He puts it in such a way that the person must have very strong objection to going to hospital to refuse. In the same way, if the doctor were to say, "I think you are an individual who is in need of attention", he could put it in such a way that the resistance, unless it was something of very great principle, would not apply.
The local authority do not ask for this provision in any sort of bureaucratic attitude. They do not wish to see wholesale registration. What they would like to know are the names of the persons who are in special need of care. They believe that if this information were available to them, they could use their existing health services far more economically. They could obtain better co-ordination, and perhaps make far greater use of the system and the welfare organisations which are in existence. I do not think the local authority are asking for greater powers, except, of course, that this lays the duty upon the doctor rather than as it is laid under the National Assistance Act, 1948. That Act, if I may refresh your Lordships' memory, in Section 47, lays a duty upon the medical officer of health, where a person is in need of care and attention and is not prepared to go to hospital or to a home, and if he is satisfied that the person requires treatment he goes to the Ministry and gets an order. Therefore, I suggest that here there is a duty laid upon a local authority to see that persons who are in need of care and attention have the services available for their care and attention. Parliament, in its wisdom, has given a power that where a person so objects he may give evidence in front of the magistrates, but the magistrates may make an order. Further, in the same section, if a person wilfully disobeys or obstructs an order, he shall be guilty of an offence and liable on 859 summary conviction to a fine not exceeding £10.
Parliament of the day felt that some compulsion was necessary in the interests of the individual. I have endeavoured to make the case that in the case of Newcastle there may be a need for some compulsion on the doctors to notify the authority when people need care and attention. I must say that I should much prefer the voluntary system, but obviously the local authority feel that this is not sufficient. In the case of Newcastle, I understand that consultations have taken place with the local medical committee, and that it has been discussed and approved by them. This will indicate—and I would not put it higher than that—that there have been discussions with the local doctors, and that they have approved this provision. I may go further and say that the consultant physician in charge of the Newcastle-upon-Tyne geriatric department is also in favour.
It would seem, therefore, that the Corporation, when they decided to bring in this provision, carried out some consultation with the local medical service and that they have agreed to it, or approved it. When this clause goes to the office of the noble Lord, Lord Merthyr, or upstairs, I hope the full problem will be understood and examined by the Committee. It may be that the Instruction which the noble Lord, Lord Taylor, has placed on the Order Paper may place this particular provision in jeopardy. We shall have to see. But I am quite sure of this: that if this provision goes, we shall not be as we are to-day. Our attention has been drawn to a serious social evil. Here is a local authority that has tried to find some way of improving its social service. If Parliament rejects it as being the wrong way of doing it, then a direct responsibility will lie upon the medical profession, not only in Newcastle but in the country as a whole, and upon Her Majesty's Government. Therefore, if the noble Lord's Motion for an Instruction has served no other purpose, it has served a most useful purpose in that respect.
§ 8.2 p.m.
§ LORD BRAIN
My Lords, once more I should like to support what the 860 noble Lord, Lord Taylor, has said. I have listened with great attention to the noble Lord, Lord Shepherd, and I can see the attractiveness of the point of view which he has put forward. It is the attractiveness of administrative efficiency. But one can pay too high a price even for administrative efficiency. I think it would be too high a price if it led to the undermining of confidence which one should expect between patients and doctors. Either the thing is compulsory or it is not, and if it is compulsory it is no good representing it as a doctor persuading the patient that he should go and that it is in his interest to go. The confidence in professional secrecy has more than one root, but one obvious root I think is illustrated by this point: that the provision of this clause might well be self-defeating.
As the noble Lord, Lord Taylor, has said many of these old people are very independent-minded and they may get it into their heads, quite wrongly, that they do not want a compulsory visit from a representative of the local authority. That might lead such patients not to call in a doctor, when it gets about that if they have the doctor he will notify their position to the local authority. I think that is a practical point of great importance. I feel quite sure that the right way to approach this problem is, as the noble Lord, Lord Taylor, has said, by the method of voluntary co-operation. If the authority have services to offer which are to the advantage of the patients, and if they make this known to the doctors, I am quite sure that doctors will be only too glad to avail themselves of those services. I hope that when the Committee consider this clause, they will appreciate these difficulties to which I have drawn attention and will not take a step which I am sure would be regarded by the medical profession generally as the thin end of the wedge and as violating this very important principle of confidence between doctor and patient.
§ LORD NEWTON
My Lords, I was not quite clear whether the noble Lord, Lord Shepherd, was opposing the Motion of his noble friend Lord Taylor and, therefore, saying, in effect, that Clause 36 861 of the Bill should not receive special attention. But, for my part, I will agree with the noble Lord, Lord Taylor, that it ought to receive special attention. But here again I express no preference as to exactly what form that special attention should take.
§ LORD SHEPHERD
My Lords, may I make it clear that I do not oppose the Instruction? I think it should go forward. The purpose of my speaking, I fear at considerable length for this time of the evening, was to endeavour to put the Newcastle Corporation's point of view and the reasons for their provision.
§ 8.5 p.m.
§ LORD TAYLOR
My Lords, I should like to thank all your Lordships who have taken part in these two little debates, particularly my noble friend Lord Brain and my noble friend Lord Shepherd. I think he very fairly put the point of view of the Newcastle Corporation. I should like to reiterate that I think this is the wrong way of trying to do the right thing, because I know perfectly well that the easy way out of a situation is to try to put it into an Act instead of providing a service. If the Newcastle Corporation provides enough health visitors and can get those health visitors and general practitioners co-operating, this problem does not arise. It has not arisen—at least this solution has not been suggested previously—and the much better solution is the co-operation between the G.Ps and health visitors. What the noble Lord, Lord Brain, said is absolutely right: if there is a service available to the people and the general practitioners know it is there, they will not be slow in coming forward, because all they want to do is to see their people healthy. I think that what the people in Newcastle desire can and should be achieved, and it should be Newcastle's pride that this is achieved by voluntary effort and voluntary co-operation and not by introducing this compulsory principle.
I have argued my case. I think, on the whole, that you will feel that you would like to accept this Instruction and I hope the noble Lord, Lord Merthyr, will, when he has considered all things, decide that this clause should go to a Committee, my concern being that it should be very 862 carefully examined and, as will have emerged, that this is perhaps a more difficult one than the previous one. There are more obviously two sides to the problem and my concern is that we should have a report from the Committee of their solution. I am not quite sure which of the methods of the noble Lord, Lord Merthyr, will achieve that desired result, but I hope he will bear it in mind. I hope very much that your Lordships will accept my Instruction and that we shall be able to get the matter very carefully and objectively considered in Committee.
§ On Question, Motion agreed to.