MEDICAL AND HOSPITAL SERVICES

HL Deb 30 July 1964 vol 260 cc1212-32

2.50 p.m.

LORD TAYLOR rose to call attention to the Medical and Hospital Services; and to move for Papers. The noble Lord said: My Lords, I beg to move the Motion standing in my name on the Order Paper. I must begin by saying that I stand at this Box by false pretences. Your Lordships may have noticed that this Motion originally stood in the name of my noble friend Lady Summerskill, and I was to have wound up the debate after she had spoken. But I received a summons from the Royal College of Physicians requesting me to be there at a comitia this afternoon, and the noble Baroness very kindly agreed to swop places with me. I then re-read the summons, which was in Latin, and found I had misread the date. So here I am, and here is the noble Lady very kindly putting up with my going first.

My Lords, the debate to-day is not only an end-of-term examination of the Government; it is also an autopsy, or postmortem on the Government's stewardship of the National Health Service over the past thirteen years. Whatever criticisms we have, it can at least be said that they kept the National Health Service in being—and that is something. But thirteen years is a long time, and in many ways it has been thirteen wasted years. I do not know how many of your Lordships read the Guardian, but if you do you will have seen a letter this morning from Dr. Coghill, who is a very good physician and who, in fact, is Consultant Physician to the West Middlesex Hospital and is certainly not a person given to alarmist or extremist statements.

In this letter he describes the conditions in the hospital where he works. He says: Priority lists are scrapped year after year as new items of even greater urgency crop up.… Other desperate needs, for which it is a fine point to decide relative urgency are deferred. Paint peels off the walls of the orthopædic theatres; we are short of beds so that patients with head injuries and medical emergencies are admitted to various surgical wards around the hospital; many of our wards are in old buildings originally constructed for Poor Law purposes.… He says that the hospital has only one-fifth of the space for pathology that it ought to have and there is no money for expansion even into a temporary hut. He goes on: Money is so short that serious difficulties take a long time to remedy, and gives an example of autoclaves (which are used for sterilising purposes) that were so obsolete and worn out that even when working they often did not sterilise articles put into them. He goes on to tell this sad story, and I am afraid that the same sort of story can be told in many of the older hospitals in this country, of things which obviously ought to be done and which have not been done.

Our criticism is that in the running of the Health Service Her Majesty's Government have shown mediocrity, lack of vigour and drive, lack of imagination and almost no original thinking whatever in these thirteen years. They have let this tick on and run down. The Ministry of Health have been treated as a second class Ministry, as a stepping-stone for inexperienced Ministers, who as soon as they have begun to know their job have been moved either up and on, or down and out. Of our many Conservative Ministers of Health, I know of only one who really knew much about the Health Service before he came to the Ministry, and it so happened that he was the son of a doctor and came from a medical family. Above all, none of them appeared to see the Ministry as a strategic headquarters for a battle—for the battle for health, because that is what it ought to be. It is impossible to have a strategic plan without a proper study of intelligence reports, and it is here that most of the failures of the Government seem to have started.

Some of your Lordships may enjoy reading Samuel Pepys' Diary—I know I do—and you may have come across a gentleman called Sir William Petty who, I remember, invented a ship with two keels which caused King Charles II a lot of amusement and which was, in fact, launched. He was also a founder member of the Royal Society. I mention him because in 1691 he wrote a book called Political Arithmetic, and in this book he showed that what he called "the very mean science of arithmetic" was the basis of "the government and happiness and greatness of the people".

For the past thirteen years we have been ruled by a Government who have dared to neglect the simple principles laid down by Sir William Petty. I wonder how often our numerous Ministers of Health—whether lawyers, bridge-players or classicists—have opened and studied the Annual Abstract of Statistics, that very important volume published each year by our Central Office of Statistics. Had they done so, I think that the policy they would have followed would inevitably have been very different, and the crisis which our health services will be facing between 1965 and 1970 might well have been averted. Had they done so, they would inevitably have noticed that the population of these islands has increased by 2½ million people in the last ten years but that it will increase by 4 million in the next ten years. Once a Government undertake to provide a universal, comprehensive service for all the people, it is no good just willing or accepting the end without also willing the means.

Since it is addressed to them, I suppose that our Ministers of Health must have glanced through a volume entitled On the State of the Public Health, by the Chief Medical Officer of the Ministry of Health. But, like Generals without comprehension of the field of battle before them, they could not, I feel, have understood what it was all about. They should have been watching like lynxes one figure, above all: the infant mortality rate, the death-rate of children under one year. This figure, the number of deaths per thousand live births of children under one year, is the best single index of the health of a community and of its health services, and in a good advancing community the infant mortality rate should be going steadily down. In 1958, our figure was 23 deaths per 1,000 live births; in 1959, 22; in 1960, 22; in 1961, 21; in 1962, 22 again. These are good figures, but they are not falling figures. We have been holding our own; but we have not been advancing. Sweden in 1962 got its figure down to 15, which is the lowest for any country of the world. Finland, in those same years, despite its awful climate, got is figure down from 25 to 19 infant deaths per thousand live births.

I want to tell your Lordships something quite extraordinary. Remember that for England and Wales the figure is between 21 and 22. Your Lordships must be rather sick of my talking about Harlow; but Harlow, in a sense, is the prototype of the Britain of the future. In 1959 our infant mortatlity was 19.3; in 1960 it was 12.4. I thought this was a fluke, a sort of statistical accident, because I had not heard of anywhere else having such a low figure. But last year our figure was 9.3 infant deaths per 1,000 live births, as compared with the national figure of 22. There are two other towns of comparable size in Britain with similar figures. One of them is Barking, strangely enough, and the other is a place called Blaby near Leicester.

THE LORD BISHOP OF LEICESTER

Hear, hear!

LORD TAYLOR

I am glad to hear that the right reverend Prelate knows his diocese so well. Blaby must be a very healthy place.

There are quite a number of towns where the comparable figure is in the lower teens, but the record is not so good when we come to the bigger towns, those with over 200,000 population. The lowest of these is Harrow, with 16.3; and next comes Islington, with 19.4. I mention Islington because the people from Islington, and boroughs like Islington, who have been moved out to a decent environment in Harlow have had their infant death rate cut by half. If Harlow can do it I venture to think Britain can do it. Let me tell your Lordships how it has been achieved—and it has been achieved before a single hospital bed has been opened in the New Town.

The New Town has a population of about 60,000, but not one hospital bed has yet been opened there. It has been achieved with nearly 50 per cent.—49 per cent. actually—of our births taking place at home with the family doctors and midwives in charge. I have always had some doubts about the Cranbrook Report, with which I have no doubt the noble Marquess, Lord Lothian, is fully familiar. It urges that at least about 80 per cent. of all babies ought to be born in hospital. I believe that if homes are good, and doctors, midwives and health services are good, it is just as safe for many of the babies to be born at home; and the mothers themselves welcome this. But one had precious little encouragement, until I found what had been happening with us.

It has happened in Harlow because, first of all, a decent home and a good environment have been provided for everybody there, and that is the most important single factor in the battle for health. Like good Socialists we are making a nice fat profit for the Government while we are doing it. Secondly, it has been achieved not by spending £6 million on a hospital, but by borrowing a quarter of a million pounds from the Nuffield Provincial Hospitals Trust to provide the best possible extra-hospital services—that is, the services for the general practitioners and clinics—for the people in the town. Surely this is the right priority.

We have completely integrated our general practitioner service and maternity and child welfare clinics. Each retains its full freedom and identity in a group practice and clinic centre. There are six of these centres now. But our general practitioners in their group practice centres run the local authority clinics for the local authority. They work with the health visitors and the midwives and the district nurses. There is complete coordination, and it is because of this, I am quite sure, that our infant death rate has been so low. However, it has not been easy. We have not had much encouragement from the Ministry of Health, particularly in the early years. But we have had very great co-operation from the county medical officer of health and the local medical officer of health, and it is here that we have to see this co-operation with the general practitioners taking place more and more in the future.

The tragedy is that what we have done could have been done in every other New Town or growing community in exactly the same way, but it has not, and I think the lesson is clear. For the next five years our job is to create group practice and clinic centres in every new community, to build them as the houses are being built and not afterwards, and in every old community as it is redeveloped or wherever the opportunity arises; and this must be done with vigour and when the moment offers, without waiting for everybody to agree everything. One has got to strike while the iron is hot. And this can be done at one-twentieth of the cost of providing new hospitals, so surely our first objective should be to achieve this. But I must warn that under present legislation it would be hard to do. We shall need new legislation to do this. It will not cost a great deal of money, though.

Now I want to look at the other end of the scale, at one other piece of political arithmetic. Again going back to the Annual Abstract of Statistics, in the past ten years the number of old people over 65 increased by just over half a million. In the next ten years the number of old people over 65 will increase by nearly one million. There is already a crisis of old people's care upon us, as many of your Lordships who have been concerned with trying to get old people into hospital will know. The crisis is here already and it is going to gel: steadily worse. It is fairly easy to get an old person into hospital if the illness is acute; that is to say, if the person is going to be cured fairly quickly or if, unfortunately, the illness is going to end in death. Thanks to medical and surgical advance, cures in acute cases are far more numerous than they were, and the result is that many more old people are surviving into what might be called the twilight of old age, with paralysis, mental enfeeblement, and so on.

The Ministry of Health Annual Reports for the last three years show that the number of geriatric beds in the country as a whole has gone up by 3,000 but I am sorry to say that the number of beds for chronic sick has gone down by 3,000, so we are exactly as we were, and it is not surprising that the waiting lists are exactly the same. This is a challenge to our hospital services. I do not believe that any of our acutely sick people who need hospital care are not being properly treated in hospital. Sometimes, of course, they are discharged too soon; sometimes they have to leave two or three days after operation in order to make room for other people, and are looked after at home. But I do not think that anybody who needs acute medical care is not getting it. But the chronic sick, the chronic ill and, above all, the old people are really being neglected in a sad and sorrowful way.

Every hospital management committee and every Regional Hospital Board would like to have shining new acute general hospitals. But this is not the first priority. The first priority must be to provide proper care for the old people, and until this is done we must not go on building these great monuments to management committees. May I remind your Lordships that an acute hospital now costs at least £10,000 per bed, but a quarter of this will provide a good bed for a geriatric patient. I get little pleasure from seeing a few new, shiny hospitals going up. Indeed, I would sooner see ten old hospitals properly rehabilitated than one new one built.

If I may give an example, some of your Lordships may know the Moor-haven Hospital at Plymouth. It is a psychiatric hospital. I suppose it was built about 1890. It has been rehabilitated by an extremely energetic management committee and an extremely intelligent medical superintendent, and I would say it is as good a psychiatric hospital as you would find anywhere, although the buildings are old. I do not always agree with my noble friend Lord Stonham, but I usually do, and one of the things I agree with him most tremendously about is the job he has done in his group of hospitals in the East End of London. He is going to speak to us about this later this afternoon. He has upgraded a group of really frightful hospitals by simply fighting, and every time the only way to do it is to fight the Ministry. If one fights one wins through, but it takes fighting to do it.

The Government seem to have placed insuperable difficulties in the way of rehabilitating old buildings in order to spare capital for a few new shining projects, and I think they are fighting the wrong battle in the wrong place. I remember hearing that the noble and gallant Field Marshal Lord Montgomery of Alamein used to teach his officers to study the campaign waged by the late Mr. Aneurin Bevan against the doctors, when he was introducing the Health Service, as a model battle. To-day we are fighting a tougher battle. It is not against the doctors any more; it is against disease and against our own stupidity, our own bureaucracy and our own muddle and feebleness to get things done, with generals, if I may say so, one-fifth as competent as Mr. Aneurin Bevan.

I have addressed your Lordships before now on the subject of the shortage of doctors. Nearly three years ago, on November 21, 1961, we drew attention to the alarming situation which was developing and we warned that it would get worse, and inevitably it has. On Monday last, nearly three years later, the Minister of Health announced that we were going to get one new medical school at Nottingham; but he did not tell us when. I hope that the noble Marquess is going to tell us when this new medical school is likely to open its doors, because that is the thing that matters. The Minister pooh-poohed our proposals for four new medical schools. He said, "We can do just as well by pushing more people into existing, over-crowded medical schools". But I do not see why on earth one should do that. It really is a great nonsense. It is not difficult to create a new medical school. I was talking last night to a professor of medicine from India, and I said to him, "Is yours an old medical school?" He said, "Oh, yes, it is; it was founded when we got our independence, and since then we have founded forty new medical schools." Well, if India can do that, surely to goodness we can do it! We have not had one new medical school since the start of this century: yet look at the growth of our population. I think this has to be put right, and if Her Majesty's present Government will not put it right, then somebody else will have to. I should like to know why they chose Nottingham. It is a most interesting choice. I have nothing against Nottingham. It has a good university and a good hospital. But it is a fact that a new medical school tends to have many of its graduates practising round about it. One would have thought that they would have gone to places where the shortage of doctors was most extreme, where the morbidity was heaviest, where the need was greatest and, incidentally, where the need for the economic stimulation which a new medical school will give was also greatest.

I should have thought they would have gone to Durham, which is one place which is widely canvassed, and I think reasonably so. I should have thought they would have gone to Salford, which is another place that has been suggested, and is still suggested. I hope that my noble friend Lord Peddie will have something to say about the possibilities there. Another place, which I admit has certain disadvantages, but which I myself think is a suitable place, is Norwich. The reason why Norwich is so suitable is that it has one of the new universities which is specialising in the biological sciences, and that would be the essential thing for medical students for the first three years. Exactly the same applies to Keele, where a splendid plan for a new medical school has been drawn up. I think we must ask the noble Marquess to tell us why he or his Department picked Nottingham rather than these other places.

Last year, although the number of general practitioners went up by 260, the proportionate increase in population beat it. The result is that the average list of patients cared for by each doctor went up—very slightly, but it did go up. We all know that a withdrawal of doctors from India and Pakistan would cause a great deal of difficulty. I asked my Indian professor whether there was any likelihood of this happening, and he said, "I think you should be prepared for it: it may very well happen." A withdrawal of these doctors would cause absolute chaos in our hospital service at any time in the next ten years.

The situation is worse than the figures suggest, for four reasons. The first reason is the relative increase in the number of young children and old people in the population. Young children and old people are those who call most on the family doctor's time. As their numbers go up in the population, particularly as they go up relatively, the doctors have less time to give to the rest, and the effect of the shortage of doctors becomes worse. The second thing is that in 1968 the general practitioners of this country will first become eligible to get their full pension under the National Health Service Scheme. Nobody knows how many of them are waiting until then to retire. At least, if it is known, we have not heard of it. If the Minister knows, I think he ought to tell us, because it may well be that there will be an added crisis in 1968.

Thirdly, there is the question of migration of doctors out of England. When I last talked to your Lordships on this subject I underestimated the degree of migration out of England because I had not got any reliable figures. Since then Dr. Abel Smith has published a most important Report, which shows that there is more migration out of Britain than we thought—certainly more than the Ministry thought. Thus, again things are more serious than we expected. You can understand some of this migration. It is fair enough. These young people want to go off to get experience in America. So many young doctors want to do this, and quite rightly so. It would be an entirely good thing if this migration were to developing and underdeveloped countries. We ought to be sending many more doctors to these countries.

However, I am afraid that the bulk of migration seems to be to America, to Canada and to Australia. We cannot stop it. Indeed, if you go to rural America you will find that they have a relative shortage of doctors. Places like Boston are overcrowded. But if you go out to Oklahoma you will find it under-doctored. They are so under-doctored that they have had to make chiropractics legal and have a register of chiropractors to cover the outlying areas, and the doctors have to co-operate with these people who are not proper doctors. There is a shortage of doctors there, and it is only too easy for our young fellows to get jobs there.

The final and most important reason of all why this shortage of doctors is adding a further burden to the work of the general practitioners, is a change of behaviour of the ordinary people of this country about the medical care that they receive. They are demanding more and more what might be called—and it is perfectly reasonable that they should—middle-class medical care. There is nothing wrong with this. I have two friends who work in Sheffield. On the appointed day all the patients whom they looked after had to register with them, and they found that they had 17,000 patients on their lists. Immediately they had to take in three partners to get their lists down to reasonable figures. Of course, they were not looking after 17,000 people properly. The people used to queue up outside the surgery. When they were allowed in they were dealt with almost by rule of thumb. If they looked ill, they were sent to hospital. If they looked reasonably well, they were given a bottle of medicine of the appropriate kind for their symptoms.

Such treatment is no longer any good, and it is a good thing that it is no longer any good. But it means that more and more people, having learned about medicine and what it is about, in part from the television—in fact, largely from the television—are demanding the right to tell their doctor their troubles, to be examined properly, to have what is wrong explained to them, and to be reassured. You cannot do this in three minutes. I personally cannot do it in under twenty minutes or half an hour, and even then I am not doing it properly. Most general practitioners who run an appointments system have to book at eight-minutes intervals. That is the best they can do. It is this pressure for better medicine, rather than a few in considerate patients on whom the Minister in another place placed all the blame, which is really breaking the backs of the family doctors; and there are no more doctors coming along to help.

In regard to these few inconsiderate patients, the doctors have the remedy in their own hands. Just as a patient is free to choose his doctor, so also is a doctor free to choose his patient. The doctor has the right to sack a patient who is grossly inconsiderate. We do not hear enough about that. He has the remedy there. Sometimes certain incon- siderate patients are sacked by one doctor and taken on by another, then sacked again. They go the rounds and, in the end, may even have to be allocated to a practitioner who has to take them. You can be sure that all the doctors in the area commiserate with each other in regard to these particular patients when they go on to somebody else. But there are not a great number of these people. We have to do something temporary. This is a really serious situation and, as I say, it is going to get worse.

There is only one thing we can do temporarily to save the situation, and that is to use nurses at the doctor's surgery to sort out and deal with the minor ailments. This is something quite new in general practice, but it is very familiar to me in industrial medicine where we do it all the time. Our nurses in the factories see everybody. They decide whether they can deal with the condition—and it is usually a case of a minor ailment—and if they cannot deal with it then they arrange for the patient to see a doctor. The patient must have the right to appeal to Cæsar, as it were—that is, the right to see a doctor if he so wishes.

Many doctors are frightened of this idea, because it involves a nominal breach of contract in relation to their responsibility for their patients. This state of affairs must be put right. It is a common-sense arrangement, and one can train nurses to do the work perfectly well. Those of your Lordships who know something about the medical services in Russia will be familiar with the special nurses who are trained for the job there, called feldshevs. In the Sudan the Sudanese Medical Service train exactly similar medical assistants—and very good assistants they are—to deal with the minor ailments and undertake the sorting-out processes. It is no reflection on anybody that one should have people of this kind doing such work and nobody suffers as a result of it. I hope very much that the Working Party which | the Minister has set up will look at this possibility, because it is the only way out of our immediate dilemma.

There are some things which are going ahead satisfactorily. One that springs to mind is the psychiatric hospital. The improvement in the psychiatric hospitals over the past fifteen years or so, as a result of the coming of the National Health Service, has to be seen to be believed. I wish that I could say the same of the after-care of psychiatric patients and about the care of the subnormal, for there it is a very different and sad story. My noble friend Lord Stonham will be saying something about this subject later.

Furthermore, there is virtually no provision for the psychopath. A psychopath is a person who is permanently disordered in his character so that he is a danger or a nuisance to the rest of humanity. We dodged the issue when we dealt with the Mental Health Bill; we did not deal with it properly in regard to psychopaths over 25. There is virtually no provision in psychiatric hospitals for these people, because they need to be dealt with by maximum security. They are the potential criminals, murderers, rapists and so on; and they have to be held in secure surroundings. We have quite rightly opened our mental hospitals, which is one of the reasons why our mental patients are so much better and getting better very much more quickly; but we have not provided the small number of secure beds which there ought to be.

My Lords, I have said before that the National Health Service is very nearly very good indeed, but under the present administration it has been running without proper direction and with an ever-increasing growth in Parkinsonian circulars and directives. Every time I see a circular from the Ministry of Health I think, "This is not the way to run anything." Then there are cost accountants, unnecessary and valueless clerical records, and an ever-increasing growth of central control. The essence of this administration has been central control when it ought to have been peripheral initiative. On the Regional Hospital Boards and regional management committees many a heart has been broken simply because the courage was lacking to defy central authority in the interests of humanity. We have now to go into reverse, but I warn your Lordships that it will take, not five years but ten years to clean up the muddle which Her Majesty's next Government will inevitably inherit. I beg to move for Papers.

3.26 p.m.

LORD AUCKLAND

My Lords, the House will be grateful to the noble Lord, Lord Taylor, for enabling us to discuss this very important subject this afternoon. It is a pity, in a way, that this is the very last debate of this Session of Parliament and that such a vital subject has to be downgraded, so to speak, to such a time in our Parliamentary phase. But whatever Government take over after October one thing is quite certain: that our hospitals and our medical services will continue to need the maximum attention.

The noble Lord, Lord Taylor, was generally fair in his speech; and, of course, he has one advantage over many of your Lordships in that he is a doctor—and, I venture to suggest, a very able one. But I cannot help thinking that the picture which the Party opposite have painted of our hospital services and our medical services generally is an unreasonably black one, as I shall endeavour to show. The Ten Year Hospital Plan has been received with qualified enthusiasm, and I think would be received with qualified enthusiasm by the Party which is now in power because estimating a hospital plan is a difficult matter. There are so many things to be borne in mind, such as building costs, wage increases for building operatives, the ever-increasing birth-rate, and so on.

I should like first to say a word about hospitals, and to tell your Lordships of one brand-new hospital which I had the privilege of visiting only two days ago. This is the Queen Elizabeth II Hospital, Welwyn Garden City, which started construction in 1958 and was opened by Her Majesty the Queen almost exactly one year ago. It is a hospital of some 320 beds. It is not yet fully completed. The ear, nose and throat unit has yet to be opened, and the psychiatric unit is in process of being constructed.

The first noticeable factor about this hospital is its compactness, coupled with the absence of noise and of clatter and general disturbance. One so often goes round our older hospitals to the accompaniment of a great deal of noise. Let me make it quite clear that the hospital staffs are in little or no way to blame for this; it is frequently the now inadequate size and construction of these hospitals that is responsible. But the Queen Elizabeth II Hospital is designed in a beautiful situation; it overlooks country, for the most part, and the architect and his staff are generally to be highly commended.

One very noticeable feature is the beds. There are many tall people in this country who, when they get into a hospital bed in so many hospitals, are almost doubled up because the beds are not long enough. At this hospital there has been foresight and imagination in providing extensions to these beds. There are also fitted tables on the beds, together with a mirror, so that the patient can see to shave or look at himself or herself if he or she so wishes. Another important innovation, as I understand it, is that the kitchens are on the top floor which also obviates a good deal of noise and, I imagine, culinary smells.

There are, of course, even in this new hospital, shortcomings. One particularly noticeable one is the inadequate size of the physiotherapy department. The reason for this is that the department was originally constructed to take in-patients of the hospital, but now has to take outpatients as well. Quite a number of accident cases, as I understand it, come in because this hospital covers, among other places, Hatfield New Town and Welwyn Garden City, which is an expanding community. The maternity wing has 60 beds. This, in fact, represents 30 from an original maternity unit in the area plus 30 new beds, and I am told that this is a reasonably adequate number for the area which it serves. There is also a delightful children's wing in the hospital.

But, my Lords, I should like here to put one question to my noble friend Lord Lothian, of which I have given him notice; that is, whether he will convey to the Department concerned the need for a separate architects' planning department for the building of new hospitals. I ask that because one of the problems here seems to be that, although consultations are, of course, held with the principal doctors, with the matron and with other vital people concerned with the hospital, they all may have different views. They have to keep to a certain budget, and it is not always easy to effect a compromise. It seems to me that if there were set up a kind of separate department of architects, with special hospital knowledge and with a budget—and a reasonable budget allowing for increased costs—to work to, many of the problems, particularly in the ancillary departments such as treatment rooms and X-ray rooms, could be avoided.

LORD STONHAM

My Lords, may I ask the noble Lord, Lord Auckland, whether, when he visited the Queen Elizabeth II Hospital—and this reinforces his argument—he was told that since they started in 1958 there have been no fewer than seven major changes in the plans?

LORD AUCKLAND

My Lords, I was not given that particular information, but I should stress that my tour was a very quick one. It was arranged at very short notice and I had only one hour in which to go round most of the place. I believe the noble Lord may well have made a fair point here. But with the new Hospital Plan—and I believe that the Government deserve credit for the progress which has already been made with this Plan—points like that will, of course, have to be borne in mind. Naturally, if wages of builders go up, then hospital costs will increase.

I should also like to ask my noble friend, in connection with hospitals, how the plan for unrestricted visiting of children is progressing. I believe this to be generally a good idea, but it is obviously essential that in such a matter the matron and the sisters of hospitals should have the ultimate discretion to say whether some visiting should be restricted, particularly when there are children needing a lot of treatment. I may say that another very good innovation in this new hospital is the provision of cubicles in which parents of child patients who are seriously ill can be accommodated for one or more nights. There is one of these cubicles in each ward block.

As I say, the psychiatric wing is still under construction, but I should like to impress on my noble friend the need for a speed-up in its completion. I believe that the policy under the Mental Health Act, 1959, for new general hospitals to have a psychiatric wing is a very good one, but so far some of the progress has been rather slow.

May I now turn to some of the ancillary grades of hospital workers? At the Queen Elizabeth II Hospital they are fully established for radiographers, which is a very good thing. In fact, I am informed that they have turned some applicants away. But, my Lords, with physiotherapists it is a very different story. There is an establishment for twelve and at present they have only seven, including one partly-sighted man. I should like to pay tribute here to the blind and to the partially-sighted physiotherapists, a few of whom I personally know, who do such excellent work.

I supported the noble Baroness, Lady Summerskill, on a Motion which she moved concerning these physiotherapists, when I spoke about their pay. I feel that £700 per year is a miserly sum of money, and I think that the Review Body which is now looking into this matter should take note of the feeling which there is throughout the country on this state of affairs. Many a general labourer can earn almost double this sum, and these people have to do very hard and often very heavy work in lifting heavy people. Many, particularly men, are married with families; and, to say the least of it, it is not easy to keep a family on £700 per year, but that is the state which some of these people are in. As I have said, the radiographers are up to strength here, but this is not the state throughout the whole country; and, with more cars and other mechanised transport on the road, we are, alas! faced with more road accidents, which means more broken bones and more X-rays, and so these people are faced with more work.

May I now say a word about cottage hospitals? Recently my younger daughter had her tonsils removed at our local cottage hospital at Leather-head, and she could not have had better treatment. The operation was carried out by our own doctor; and this is the value of our cottage hospitals. I should like to ask my noble friend to stress to his right honourable friend, even at this late stage in the Parliamentary Session, the need for keeping these cottage hospitals, particularly in the more rural and outlying areas. I know that financially they may be difficult to operate, but for the patient they are an essential need.

There is nothing better for a patient than to have his own general practitioner looking after him, rather than to be sent to a large hospital where he may see one or more doctors. There are, of course, cases where these large hospitals are essential; specialised cases are an entirely different matter. But there is immense value in these cottage hospitals, where patients come under their own doctor and a regular staff of nurses, rather than the often impersonal service of a very big hospital. I am not in any way trying to criticise the big general hospitals, because they do an excellent job. Many are short of nurses and doctors, but they carry on, often in difficult circumstances.

A great deal of play has been made with the pay of our nurses. I would be the first to agree that the pay of nurses, both male and female, particularly in the mental health service, lags behind that of many people in this country. But there have been improvements, and in the case of students it should be remembered that many students pay to learn whereas student nurses are paid, albeit not a very princely sum of money. But what niggles in this connection is the amount deducted for board and lodging, laundry and so on, which I submit is too much. It is for the middle grade of staff nurse and sister that the pay really does seem to be inadequate. It is, of course, too late now to ask the Government to do any particular thing on this score, but I hope that my noble friend will mention to his right honourable friend the feelings which I think many people in this country have on this matter.

However, I do not think that the shortage of nurses is entirely due to the pay. What many of the older hospitals lack is decent nurses' homes. I and other noble Lords have mentioned this in this House before, and it has also been mentioned in another place. But I am very glad to see that many of our newer hospitals are being built sensibly, and that attention is being paid to giving nurses a comfortable, homely place in which to live. I am not suggesting they should have lavishly designed bedside lamps or lavishly designed curtains and that kind of thing; but to many, particularly those who may live 200 or 300 miles away, it is a home. Much is being done now for the Regular Forces, and I would ask my noble friend to understand the importance of the application of this principle to our new hospitals and to those which are being remodelled under the Plan. I think this is vital because so often, when a hospital is remodelled, attention is paid to the boiler room, the kitchen or the physiotherapy department, but nothing is done about the nurses' home, and I do feel that from a recruiting point of view this is extremely important.

May I turn briefly to doctors? One of the problems regarding doctors' pay is, of course, that the doctors themselves cannot agree on the system which they would most like. There are the three systems: the salaried service, the capitation system and the pool system. My information, from the many friends I have in the medical profession, is that the younger ones prefer the salaried service while the older ones prefer the capitation system. As I understand it, the average general practitioner's remuneration at the present time is around £2,800 per year, but I should like to ask my noble friend a question, of which I have given him notice. How much is allowed for the rating of a general practitioner's surgery, and how much, if any, is allowed towards the purchase of office equipment? I know that loans are granted for group practice surgeries. In 1963 the figure was £609,000, which is about 50 per cent. higher than in the previous year, but I would question whether loans, interest-free or not, are really sufficient. Provided that a check was carried out for any possible "fiddling", which I think unlikely to happen, I feel there could be some grant from public funds for the mass of new equipment which doctors badly need in view of the progress in medicine which is now being made.

As I have said before, the recruitment of nurses over the past ten years has been quite encouraging—about 3,000 more than in 1953. And I would draw the attention of the Government to paragraph 32 of the Gillie Report, which deals with general practitioners. This paragraph stresses the need for the greater use of the patient's personal doctor during his or her resettlement and convalescence. So often people are sent for convalescence to the coast or to some centre where they get little or no treatment. Yet it is often at the convalescent stage where the treatment really tells.

Regarding the shortage and emigration of doctors, this is a problem, but it is a world-wide problem. Not only from Britain are we losing doctors to other countries; the same applies in America, Canada, Italy, France and other places. It seems to concern hospital doctors more than general practitioners. I have talked to general practitioners of all grades on this point, and it is a point which they stress.

For local health services, such as antenatal clinics and so on, the estimated expenditure for 1964–65 is nearly £97 million, as opposed to £75 million three years ago. This is all part of the £1,000 million now being spent on the Health Service. Whatever the defects of the health services—and there are some, and this is perhaps due partly to the doctors and partly to the patients; there are inefficient doctors and there are awkward patients—I feel that the Government have made a lot of progress on the welfare services generally. I feel that those who criticise should bear that point in mind.

My Lords, if I may, I will now turn briefly to mental health. The 1959 Mental Health Act has removed the stigma of the lunatic asylum and the voluntary patient system is working fairly well. What I feel is unfortunate—particularly in Epsom, where there is a mental health colony—is that a hospital like St. Ebba's, which is an admirable place for the severe and often curable psychiatric cases, has now been turned into a long-term hospital for psychopaths and such-like. I should like the Government to consider very seriously the need for these places where the curable patients can still be sent, pending the building of more psychiatric wards for general hospitals.

To conclude, my Lords, may I say this? Nobody is suggesting that the Government record in the Hospital Service is perfectly good, but this Ten-Year Plan has been imaginatively conceived and on the whole it is working well. I think the hospital which I mentioned is an example. I was very interested to note that in Signpost for the 'Sixties there was little or no mention of how the Party opposite were going to pay for these new schemes which they say they are going to bring into operation for new medical schools they are hoping to start. I am not saying it is not a desirable thing; but some kind of bill will have to be presented to the nation. I think our record will be judged in the light of what the Government have achieved regarding doctors, nurses and the medical services generally.