MEDICAL AND HOSPITAL SERVICES

HL Deb 30 July 1964 vol 260 cc1242-310

4.20 p.m.

Debate resumed.

LORD AMULREE

My Lords, I was interested when the noble Lord, Lord Taylor, told us the reasons for this coming and going of names upon the Order Paper, because I thought at first it was such a pleasant thought that there were two minds with but a single thought: whether there are also two hearts that beat as one, I am not quite sure. But I am pleased to find out what the answer to the question is.

There are one or two points I wish to raise, because this is the last time we shall meet together for quite a long time, and I think it is important to get one or two things down. The first is the question of hospitals coming under the Ten-Year Plan. I agree with the noble Lord, Lord Taylor, that it is far better at the present time to do a good deal of work on improving what we have, rather than take the not very large sum of money available to build new hospitals when these are not really necessary. I am sure that in some parts of the country it is necessary to build a new hospital, but it is also true that a great deal can be done to improve the buildings we have at the present time.

There are various things which occur to me which could be done, and one of the important ones applies not to the patients, nor to their relatives, but to the hospital staff. One has noticed that people are getting married a great deal younger than they were before the war, and it is important that some arrangement should be made for married quarters for the younger medical staff at hospitals if we are to draw the best of the young doctors to work there. It may sound a rather curious thing to say, but I am sure that one of the reasons why a certain number of young married doctors go abroad is that they find it simpler to take their wives, and maybe their families, with them because accommodation is provided for them, whereas in this country, in the great majority of cases, they have to find accommodation for them outside, which is not necessarily very satisfactory.

The hospital where I work was built in the year 1894. We have done a good deal of work on it since 1948, and it has become quite a satisfactory building. But I would add a note of warning: it cannot be tinkered about with much longer; we have come to the end of what we can do. But there is a great deal more which should be done, because one of the changes which have occurred over the last fifteen years is that not only do the patients want more than they had then, but their relatives want more, and the medical and nursing staff want more. I put the medical and nursing staff third, because I think the patients come first. While I support the noble Lord, Lord Taylor, I do it with a certain amount of doubt as to whether we can carry that situation too far.

There is another point I should like to raise about the hospital services, and that is a matter to which I referred rather briefly when I initiated a debate upon the welfare services in the spring of this year. It is whether the time has not come when we have seriously to think about transferring some of the local authority accommodation (which is supplied under Part III of the National Assistance Act) to the Regional Hospital Boards. My reason for saying that is that if you are dealing with elderly or disabled people, both types of accommodation contain exactly the same type of people. If you go from one to the other, you cannot tell "t'other from which", and it seems a great pity that something cannot be done to bring these two types of building under one authority, because it would save a good deal of trouble in various ways. At the risk of being rather technical, I should like to bring one of them to the attention of your Lordships.

One finds that certain people who have been sick with a long-term sickness, or even a short-term sickness, if they are frail and elderly, come into hospital where, if they are unable to return to their own home, they are seen by the local authority and accepted by them as being fit to go to a local authority home. When they arrive there there is an immediate cry, "Oh, dear! this patient is very frail. He may fall down. We must put him back to bed again, for fear he falls down and breaks his leg." Then they come back in six months' time and say to the hospital, "We have a certain number of bedridden people. Will you take them back again?" One finds a person who has been discharged from one's own wards, well and capable of getting about, lying in bed. That sort of thing—going around in a circle the whole time—does not seem to me to have a great deal of future. That is one reason why I should like to see some transfers of that sort made.

There is another reason, too—and here I am afraid I must go back to the old Poor Law: not that I want to bring the Poor Law back, in any sense of the word. The Poor Law certainly had one good administrative principle. Under the Poor Law there was no barrier between the movement of a person who was sick and the movement of a person who was well. If a man was admitted to one of the institutions—which one does not want to see repeated—there was no trouble if he was ill. He went to the infirm ward, and when he had recovered he went back to the house. That was a very valuable principle which has been lost sight of entirely. At the present time, if you want to exchange a patient, or if I or one of my colleagues wants to transfer a patient to a hospital or institution, or a home run by the L.C.C., it is done on some kind of exchange basis, as if we were bartering the bodies of men and women in some unpleasant way. It does not work. It takes a long time, and it means that a great many people find themselves in the wrong place. That is why I should like to see a good number of these beds transferred to the hospital authorities.

I have given two good reasons, one medical and one administrative. The third one—which may appeal to people a little more—is the economic reason, because if these were under one authority it would in the long run save beds, and would mean that one could cut down on expenses. What made me bring up this matter again was that I was looking at the L.C.C. ten-year plan for the welfare authority. I found two rather worrying statements. One was in paragraph 59, which said: Because of the advanced age of those who enter them, welfare homes will have to include provision for old people, whose infirmity borders on senility or chronic sickness. The second one was in paragraph 60, which used the words. … and further accommodation for old people with a mild degree of senile mental disorder". Those two paragraphs made me feel cold and uncomfortable, because there we are getting back again to the two standards of medicine which we thought the Health Service had abolished once and for all. We are going to get one standard in the Regional Board hospitals, and we are going to get a collection of sick people in the welfare homes. Before we know where we are, we shall find ourselves back to the worst side of the Poor Law.

My Lords, when I mentioned this point on April 22, the noble Marquess who replied for the Government replied to me that (col. 840): Still less would it be right to suggest that the time has yet come for local authority premises to be transferred to the hospital authorities. Possibly the time had not come in the spring; but I suggest to your Lordships that it has corns now, or, at any rate, will come within a very short space of time. One would like to have some more encouraging reply as to whether something of this sort could be done.

There are two more points to which I should like briefly to refer. One is the question of whether more can be done to prevent people from becoming sick. Here there are two things that I think can be done. The first relates to cancer in the neck of the womb, a disease from which about 2,500 women die in England and Wales each year. One wonders whether, by some kind of preventive service, that figure could not be made much lower. I am not going to say that we could wipe it out completely, but there has been a long inquiry going on into the treatment of this disease starting with the League of Nations long before the war and continuing now.

There are records of an enormous number of patients, and one finds that with this disease, supposing it is caught when it is early, 71 or 72 per cent. can be cured. If you catch it when it is late, the percentage of cases cured drops to 7. 1 per cent.; that is, from 71 per cent. to 7.1 per cent. Of the people who do become aware early of the disease only about one-quarter go to their doctor in time. One finds that, taking this disease in particular, and cancer in general, there is quite a long delay between a patient's noticing something wrong and going to consult the doctor. The time is something like four to six months: it varies a certain amount. That seems to me one of the great preventive things that can be done: to try to get people to go early to see their doctor when they have something wrong, and at the same time to encourage people to realise that cancer in certain organs is a disease which is far more liable to successful treatment than a great many long-term illnesses.

The other point I should like to make is that a considerable number of people (I think it is about 4,000 a year) go blind when they are growing old, suffering from some disease of their eyes which certainly can often be cured. I would not dream of claiming for a moment that they can all be cured, but here again this is one of the great pieces of preventive work that can be done. People tend not to worry about their eyes when they are growing old; they think that it is just one of the symptoms of growing old, that one does not see quite as well as one did as one ages. That may be true up to a point, but it is certainly worthwhile going to one's doctor to find out. When people go blind, not only does their world change completely, but it is very difficult at the present time in this country to find places for blind people where they can be taken care of comfortably, provided their family cannot take care of them.

Here again, one wonders whether some provision could be made for old people, when they are worried about this matter, to go to some special kind of clinic where they can consult with somebody sympathetic and kind, somebody to whom they could talk, rather than go to their general practitioner, who may be too busy to see them. What may be said to me—and quite rightly—when I put up that suggestion is that one has to find the staff for these so-called clinics. Where are they to come from; and where is the money to come from to pay for them? I do not think those two points are necesarily of very great substance provided that there is the willingness to get something like that done.

My Lords, the other point I should like to suggest is that we need more work for the chiropodists. There is an enormous amount of chiropody done by local authorities, but this is only for people whose feet have gone wrong. We must get chiropody done as a preventive service, to prevent people's feet from going wrong and from becoming crippled. That would be an expensive service, but it would pay big dividends.

LORD TAYLOR

My Lords, reverting to the question of blindness, was the noble Lord referring to glaucoma or to cataracts?

LORD AMULREE

My Lords, I was referring to both of them, because a good deal can be done for cataracts and a certain amount can be done for glaucoma. A large number of people continue with them without consulting their doctors.

LORD TAYLOR

The point I was seeking to make was that in chronic glaucoma, which produces blindness if allowed to go on in older people, it is perfectly easy for general practitioners to learn to apply a simple instrument to the eye to test the pressure within the globe of the eye. There is no difficulty about this: it is just a matter of learning to do it; and they can learn it in five minutes.

LORD AMULREE

I should like to thank the noble Lord for the support he has given to what I said because I trust that this will go round and that we may get a rather more preventive attitude taken.

There is just one thing more I should like to say. I agree entirely with the noble Lord in what he said about our need for more doctors. What he told us about his friend from India seemed a most terribly depressing story. Because if they do that over there, why cannot we do more here? Durham is a place which is absolutely longing for a school. They have a University there; they have been joined with Newcastle-on-Tyne for a long time. That is now separated; there is all the feeling for a medical school in Durham; there are enough people, and, I should have thought, everything one could possibly want. I am particularly interested because I was a member of a committee which worked out a new medical curriculum, and one would like to see that curriculum put into action. I think it may be put into action at Keele when they finally get their medical school going. One would like to see it done more frequently. I have nothing further to say to your Lordships on this subject except to thank the noble Lord for introducing this Motion.

4.39 p.m.

LORD STONHAM

My Lords, I should like to join with the noble Lord, Lord Amulree, and the noble Lord, Lord Auckland, in thanking my noble friend Lord Taylor for giving us this opportunity of debating this vitally important subject. The noble Lord, Lord Auckland, in his very interesting speech suggested that my noble friend had painted a unreasonably black picture. I am going to discuss just three subjects, in every one of which I have day-to-day contact as a voluntary lay-officer, and I shall certainly be very interested if, in the black picture that I shall paint, the noble Lord chooses to dispute any fact I put forward.

The first subject I want to discuss, on the invitation of my noble friend Lord Taylor, is the Ten-Year Plan from the viewpoint of the chairman of a group of five London hospitals, the youngest of which is 80 years old and oldest of which is 102 years old. The noble Lord, Lord Auckland, said the Ten-Year Plan had been imaginatively conceived. He neglected to add that it had been factually and financially abortive, because the Ten-Year Plan as a ten-year plan is a dead letter. It was, I believe, under pressure from the then Minister of Health, far too hastily drawn up. Anyone who knew anything of what was going on at the time from the standpoint of Regional Boards and their staffs, realised first of all the extent to which they were pressed to deliver their plans, and afterwards the extent to which their proposals, which of course were based on considerable experience and local knowledge, were altered when the Plan was finally printed and presented to the nation.

In my belief, it has failed because of two major faults. It was based, as it were, on national averages. Just as there is no such person as the average man, so there is no such place as the average hospital and no such thing as the average set of conditions. Not sufficient allowance was made, therefore, between the averages for regional and local circumstances. I believe, too, that the cost of the Plan was hopelessly underestimated. What is completely beyond dispute is that we are being asked by the regions, or have for some time been asked in our groups, to forget 10 years and to reconsider the whole matter on the basis not of 10 years but of 25 years. It is at that point, and the complete difference in planning when you are thinking of 25 years instead of 10 years, that I feel we must ask the Government to tell us what their intentions are. My noble friend Lord Taylor spoke about one single bed in a shining new hospital costing £30,000.

LORD TAYLOR

No, £13,000.

LORD STONHAM

I misheard. The figure is £13,000. That, of course, is now. At the time when the next new hospital is built in the plan ten years hence my figure may be nearer to the truth. In any case, £13,000 for a single bed is a very great deal of money. No one grudges the money, I believe, for new hospitals, but we must have a sense of proportion. I do not want to enter any kind of special pleading at all, but I want to give from my own experience the position, which I believe is the same throughout the country—it varies from group to group, but, generally speaking, this is the kind of position which confronts us now that we have to think in terms of 25 years when we were formerly told to think in terms of 10 years. In my view, it requires an entire recasting of investment between new hospitals and existing hospitals. Otherwise, the standard of service is bound to deteriorate.

Much has been said by my noble friend and by the noble Lord, Lord Amulree, about geriatric services in hospitals. One of my five hospitals is a geriatric hospital with 300 beds. It is the main geriatric hospital for several boroughs in London—about five. It was a former workhouse, nearly 100 years old, extensively bomb damaged. We were told that its expectation of life was ten years. That meant that we might put up with things which would otherwise be completely intolerable, because if we had insisted on large-scale expenditure, or comparatively large-scale expenditure, for a period of only ten years it might have been considered not right. Just consider a hospital like that, where there are four floors, a great long building, the wards end to end, 40 beds in each ward, with only one lift in the hospital at one end of the building. The ages of the patients vary from 70 years to 103 years. I have been concerned for some years now—I have woken up at nights—thinking about fire risks; what is going to happen, how do we get them down with one lift at one end of the building for all purposes? The fire authorities say that the provisions for escape in case of fire are inadequate.

In the hospital grounds there is a building, quite a large building, which has not been used for twenty years. In the first year or two after the appointed day £89,000 was spent on repairing the roof. That was more capital expenditure than that hospital had had for years. But £89,000 had to be spent on repairing the roof of a building that was intended to be used and has never been used. Three or four years ago, because of the pressure of space, because of the fact that we have no day space, I wanted to use that building. It would have cost about £100,000 to provide some 100 beds, or say 70 beds and day space—about £1,000 a bed, or, if you like, £1,300, compared with £13,000. The noble Lord, Lord Amulree, knows this hospital very well; we formerly had the great privilege of having him as our honorary consultant there. It is doing a first-class job.

Recently, two or three years ago, we had a very good consultant in geriatrics appointed. He is hopelessly handicapped by reason of these huge wards, where the ambulant patients—those who can sit up—sit in the windows, eat their food, sit all day long in sight of their beds. How can you possibly get the movement you require for elderly people, the movement up? It has been a quite incredible business to make bricks without straw in this place. We cannot alter the exterior, except that every year we win the first prize for that class of hospital for our gardens, virtually in flowerpots except for the garden provided by our ever present fund, the King's Fund—and I am glad to see the noble Lord, Lord McCorquodale of Newton, in his place.

We wanted a day club using the only serviceable hall in that place, which looked like a public lavatory of the old kind, the Victorian kind; we wanted to use this as a day club in which we should have not only people in the hospital now but those who had gone out and other elderly people in the community; in other words, present, past and prospective patients. In that way we felt we should be very greatly reducing the cost. We could not even get a couple of thousand pounds to do it up. We are going to get it now, through the ever present King's Fund, which visited us a month ago. This is a typical example. We know the pressing need for geriatric beds. Here is a hospital where 100 more could be supplied at a cost of £1,000 each, using a perfectly sound building.

Of course, the Ministry is not totally unaware of the changed circumstances, and therefore they have asked Regional Hospital Boards to consult the groups about what priority they would give to the many projects of this kind which have had to be passed by for years and years, and only a few days ago I took the chair at a meeting of that kind. Against the advice of everyone else—but they accepted my advice—I said that my top priority was a new lift and, in case of fire, a means of escape for my old people. That was the top priority in the whole group and that was the one on which I insisted.

I will give another example. In the same group a good former voluntary hospital with 150 beds, with the highest possible reputation in surgery and outpatients departments, also has one lift which was secondhand when it was put in. The lift has been there years and years, so you literally never know when it will work. Sometimes for weeks on end you have to manhandle it. The manhandling stretches up or down, with patients either to be operated on or having been operated on. I am speaking now of senior consultant surgeons having to put up with this, going up one, two or three flights of stairs, because we were not allowed to have another lift. Again, I am demanding a new one, because the hospital is not going to last ten years; it is going to last for 25 years.

In the theatre that we have in that hospital the walls sweat. It is impossible to keep it clinically clean. The consultants in all their fouled clothing have to come out of the theatre, walk along corridors in common use, to cleaning places in order to clean up. The theatre staff has to dress in the theatre sister's office, which is also a store room. And, of course, we need another theatre. I know that this kind of thing could be repeated in regard to hospitals over the whole country.

It was possible three years ago to make a case, and to say, "In ten years' time in your group we are going to start to build a new hospital, and therefore we are not going to do anything with these other places which will not be needed in ten years." That is not going to happen. In 25 years' time, who knows what the shape of the next kind of hospital will be? Who knows, meanwhile, what is going to happen with regard to the grouping of sterilising services, of pharmacies, of pathology departments? In towns or big cities, places like London, virtually something like a factory can supply all these services and developments of that kind.

Of course, we want new hospitals. But when you consider that you can take a hospital for old people with 300 beds which could be made into a good place with 400 beds for £250,000 or less, then there can be only one possible answer. Then there are mundane, humdrum things. You may go to a hospital group and find that every single hospital needs new boilers—£100,000 jobs, or something like that. Again, in some of my hospitals, the boilers were secondhand when they were put in, and we have often been put off. These things will not brook any delay. The Government must do one of two things. They must say that they are going to reconstitute the programme, recast the allocation as between the new hospitals and existing hospitals which are going to last at least 25 years or more; or, alternatively, if they insist that the new hospital programme is going to remain, then they must allocate more money for the other hospitals. That was the first of my points.

LORD AUCKLAND

My Lords, I am grateful to the noble Lord for giving way. Can he say how much these increased costs in the programme are due to increased wages to the builders and others concerned in the construction of these new hospitals? Surely, that has some bearing on the matter.

LORD STONHAM

My Lords, it is just as relevant as my saying that when the Conservative Government took over the pound was a pound, and is now worth nearly 13s. Considerations of that kind should not enter into this argument. Anyone preparing this Plan three years ago should have allowed for an increased cost.

The second point that I want to talk about is the question of the mentally ill when they are released from hospital. I speak on this as the President of the Psychiatric Rehabilitation Association. I would particularly ask the noble Marquess if he would get his Department's book, Health and Welfare: The Development of Community Care, published this month, because I want to refer to pages 112 and 113. I would ask your Lord ships to consider the Government's plan for community care of the mentally ill. We all welcomed the Mental Health Act, 1959. We welcomed, too, the provision which it made for the acceleration of discharge of mental patients from hospital; and welcomed also the intention to increase the local authority services to care for those ex-patients in the community. We have had the acceleration from hospital. The poor devils have been ejected, all right!

I do not want to say that the services are non-existent, but compared with the need they are grossly, shamefully, brutally inadequate, considering that we are talking of people, perhaps the most vulnerable in the world at the time they come out of hospital, who have been psychologically hurt, who have had their confidence completely impaired and who are ejected into the world, many of them, as I shall show, jobless, homeless and even friendless. Not only are the provisions now inadequate, but indeed, as this book, the ten-year Plan shows, there is nothing being done about it. In my submission, the published plans of the Government show that they have not even begun to understand the social implications of mental illness. I first began to study this problem in the community four years ago when the Psychiatric Rehabilitation Association was set up by doctors, nurses, psychiatric social workers and laymen like myself. We started at Long Grove Hospital in Epsom, which the noble Lord, Lord Auckland, knows well and, extraordinarily enough, the catchment area for that Hospital in Epsom is the boroughs of East London 25 miles away. I am not commenting on that, although I have mentioned this in your Lordships' House before. This organisation has not received from the Government a penny piece in four years. We have had marginal help from the L.C.C. and smaller local authorities, totalling something like £1,500 in four years.

We bring the families from the East End to the hospital. We bring the patients out of the hospital into the families. We run daily coaches. We now have six every-day centres, including Sunday—and Sunday is the worst day of the week for people afflicted in this way; and we are endeavouring to do everything for them, which involves lodgings, jobs, advice and even cheap meals. We have had no Treasury help. But this year—I am sorry to have to keep saying this—we had from the King's Fund a grant of £6,000 for a pilot project which will cover the expansion over the next three years of staff and a group centre which we have now got in a church. I cannot say how grateful we are, and what a tremendous amount even a small sum of money like this is achieving. We have also some hundreds of unpaid volunteers, many of them former patients—some, indeed, who have been helped or who were self-helped in the last four years. We had our annual meeting on Tuesday night. I wish your Lordships had seen the audience of about 200, the unbelievable enthusiasm, the self-reliance and the confidence. It proved that individual personalities of psychiatric patients can expand through their taking responsibility not only for themselves but, equally important, for others.

It is becoming clear that when one has been psychologically hurt there are many social processes to be learnt and relearnt. In P.R.A. we claim that, through its programme of concentrated effort, most people can regain their place in society, learn to stand on their own feet, form their own judgment, examine their own prejudices, develop unexpected latent powers, be prepared to give service—in fact to become whole persons even more complete than before. But this has been proved only in one quarter of London. It needs to be demonstrated and applied throughout the whole country, because the relapses are increasing. The numbers discharged to these boroughs in the East End last year increased by 200, and the mental breakdowns of patients in these areas have increased too, often due to the fact that, vulnerable as they are, they are ejected homeless and friendless into a world which many of them feel could not care less. In these conditions of isolation and near despair it is small wonder many of them show a predisposition to relapse.

I would ask the noble Marquess to note that last year 1,301 patients were discharged from this one hospital back to those three or four boroughs in the East End. I repeat 1,301 in one year to one quarter of London. Nearly half were single men and women between the ages of 20 and 39. What incredible waste and cruel folly it is to give them skilled, expensive, psychiatric treatment and then to return them to inadequate housing and to other conditions which would strain the fortitude of the strongest among us! I have mentioned that a large number are single, or widowed, or separated, or without relatives. In those circumstances they scarcely qualify even to get on council housing lists, let alone to secure accommodation. It is therefore imperative that local authorities should make provision to meet this need: that is, hostel accommodation and social centres. The Government must act at once to provide social centres and hostels.

I would ask the noble Marquess, Lord Lothian, to look at page 113 of the Ministry book, which is a mass of 331 pages containing nothing but figures. Section 4 on page 113 deals with capital building programmes, and the noble Lord will see that in regard to the capital programme over the next ten years for the mentally ill the entry is: Social centres or clubs, expenditure for ten years: £1,500. That would not buy one social centre. Then, even more remarkable, in relation to "Hostels"—that is to say, hostels of the kind which are desperately needed—there are three columns and, believe it or not, against "Hostels" no figure at all appears in the corresponding column. There appear merely three little dashes. Why print the word "Hostel" at all in the book if you are not going to spend a penny in the next ten years?

Mr. Bernard Braine, the Parliamentary Secretary to the Minister of Health, last night in another place, in response to a plea by a colleague of mine for more expenditure on these hostels, said that the Government were going to do more, and he assured Members of another place that these figures for hostels were attainable: in other words, a figure of zero. The Government are confident that they can achieve that. The noble Marquess will correct me if I am exaggerating in any way, but I find that that is just incredible. We in P.R.A. have established a link with the Cheshire Foundation which promises new developments, but it is only possible because an anonymous East Ender has given us a house. It would not be possible to do this in any other way. We are going to house people when they come out of hospital, to enable them time to find jobs, or to house them if they have no accommodation at all. Discharge from hospital at so great rate, when the development of community service has not reached the level it should, is a betrayal of the helpless. Therefore there must be far greater participation by the Government, by the community, by employers, by civil leaders, before we can really say that the community cares or that community care has any real meaning. We have shown that miracles can be accomplished, but have made our bricks without straw. We are entitled to ask the Government to supply something in the way of financial clay to help us get on with the job.

I would put this point to the noble Marquess. Does he realise how desperately difficult it is for a man without means, but a man who is mentally capable and fit for discharge from hospital, to leave hospital? To give an example: at Long Grove a highly skilled mechanic had a job waiting for him. He had no home so we found him lodgings, for which one had to pay rent in advance. The firm by whom he was going to be employed had a rule that one had to work a week and be a week's money in hand, which meant that this man had to wait two weeks before he actually drew his first week's wages. We worked out that he had to have £25 for two weeks' rent, meals and the other expenses before he could leave. There was nowhere we could get that. The only chance we had was the N.A.B., but they would give him an allowance only for fares.

So doctors, patients and nurses had a whip round, and the P.R.A. from their benevolent fund helped, just to get one whole man out of mental hospital and at work again. This is intolerable. If the cost of printing this Blue Book, with all its statistics, were just taken and given to the mentally ill, it would do a lot more good than this book will do, and practical good, where it is needed. I ask that there should be special allowances and special fare concessions in cases where, through no fault of their own, parents, relatives and friends have to travel 25 miles and where the therapy of their visits is so helpful to the patient.

Lastly—I am sorry for being so long but I want to make these three points before I sit down—a word on behalf of the mentally handicapped. I am sorry to mention the mentally handicapped in the same speech as the mentally ill, because one of the great problems in my life is to show the public that the two things are totally (different. Briefly, I want to make a plea for some of the problems of the mentally handicapped to be dealt with, and I warn the noble Marquess that I shall be quoting pages 112 and 113 at him again. I heard it said the other day that the Welfare State is an expression of the social conscience of the man in the street, but in the provision of services for the mentally handicapped there is a great yawning gap in the Welfare State, not because the man in the street has not the conscience but because in this field he simply lacks knowledge. But this gap is a reproach both to national and local government. It is not being tackled. There is a tremendous need for education. Deaf or spastic children have often been alleged to be mentally retarded or handciapped and their teachers have afterwards found nothing wrong with them at all. It was simply wrong diagnosis. In exactly the same way a great majority of our mentally handicapped children are culturally deprived, retarded by their own environment and the lack of skilled teachers.

My Lords, the most dreadful thing about the local authority centres—all too few as they are—is that, although the staffs are always warm-hearted, kind, sympathetic and even dedicated, not one in three of them has had any training at all and they are called on to do a job which requires highly specialised, skilled teaching. Children begin to learn as soon as they can see and hear and taste and touch. The only difference is that the retarded learn more slowly. There must, therefore, be early diagnosis so that they can get the skilled teaching which they need, and so that such capacities as they possess may be developed to the full. But so far as severely subnormal children are concerned, not one in twenty has that chance.

I was delighted to read, I think it was yesterday, that Mr. Quintin Hogg, the Minister, announced a new Chair of Child Development at the University of London Institute for Education, with the assistance of a generous endowment from the Spastics Society. We are all delighted to know that, but there is no word about a Chair of Hysteropædics or Retardology, or whatever you like to call it; and there are far more mentally handicapped children than children with other forms of major handicap all put together. My Society, the National Society for Mentally Handicapped Children, to which I was glad to see Mr. Braine paid a very generous tribute last night in the debate in another place, are hoping to raise money for a Chair of Hysteropædics in this country. We are also appealing for funds for an institute for special teacher training, which does not exist. I am not talking about E.S.N. children; I am talking about the training of severely subnormal, for whom perhaps we are 10,000 teachers short. It may well be that the great City of Birmingham and the Midlands towns generally, if they follow the lead of the Lord Mayor of Birmingham, will provide the funds for this teacher training college.

We have had compulsory education in this country for 94 years, ever since 1870, and to-day the child with an I.Q. of 100 or so can go to university. But if the child's I.Q. is 30 we are still back in 1874. All parents of mentally handicapped children have a legal obligation to send their children to school for the education which is best suited to them. But tens of thousands of parents of mentally handicapped children cannot do that; they cannot comply with their statutory obligation because the provision of education just is not there. If we found a starving child to-day it would make headlines in the newspapers, but four out of five of the severely handicapped children are mentally starved—250,000 of them. That is merely an estimate based on 4 per 1,000. They have never been counted, as the noble Marquess confirmed to me in a letter he kindly sent to me the other day. He said that there were 65,000 treated in hospital and 29,000 juniors and adults being trained by local authorities, either in their own homes or in local authority centres. That makes a total of 94,000 out of perhaps 250,000, and the rest are hidden away. We have to assess their needs and find out the answer to the question: What useful thing can they do? We need more training centres.

Now I come back to this book about the Government's plans for the next ten years; what they are going to provide in the way of training centres. I refer to page 112. I am keeping to London in this because, generally speaking, London does rather better for these services than other areas, and I think therefore that it is favourable to the Government. But this is what is proposed for a population of over 3 million people, which would contain roughly 12,000 menially handicapped. At the moment, the total places in adult and junior training centres number less than half of one per thousand. In ten years' time there will be places for three-quarters of one per thousand, when the need is for four per thousand—and this is in ten years' time. In ten years' time, if the Plan is carried through, there will be only 1,306 places for adult training. My Lords, we are not now talking about the past; we are talking about a Plan for the future and a Plan to cover the next ten years. The Plan does not even begin to tackle the problem. How right my noble friend Lord Taylor was when he said that the Plan was unimaginative and ill-conceived and did not pretend to deal with the problem. Because it can be dealt with, my Lords. These people can be trained.

I expect the noble Marquess, Lord Lothian, knows of our workshops at Slough where we take people from 16 to 26 with an I.Q. of 35. We reject all but the so-called unteachables, the ineducables. We have to teach them everything; the modest social graces, how to tell a penny from a half-a-crown, how to telephone, how to catch a bus, how to catch a train, and in twelve months many of them are out in open industry. It can be done, and I am pleading for this to be done all over the country. The thousand visitors that we have had at Slough in a year—a good many of them from overseas—have said that it is the only place of its kind in Europe, not because there are not other training centres, but because our workshops entail living in with the work. It is that which is of such tremendous help in showing these people what can be done, and developing their capacities to the fullest possible extent.

LORD TAYLOR

My Lords, could my noble friend just tell us for what kind of jobs these young men and women are trained in his centre? It is a wonderful thing that they go out into open industry, but what kind of jobs can these very low I.Q. subnormals do?

LORD STONHAM

My Lords, there is a considerable variety of assembly jobs. They sit at benches and assemble all sorts of small parts of various things, plastic and metal things. This is not a charity job; this is done on a commercial basis. They are trained to do the job. It is no longer an assumption, but a fact, that over a limited field these people can be trained to do certain jobs as well as people with normal brains, with the great advantage that they take tremendous pride and joy in doing them. The work does not become monotonous to them. They like to go on doing it and they are very proud indeed of doing it. I am sorry that my noble friend did not see the exhibition that we had at County Hall a month or two back, when he could have seen these people working and also some of the extraordinary art work they did.

I was going to say more, but I have spoken over long. However, I ask the noble Marquess to deal with these three fields. I think the worst of the three I have spoken of are the mentally ill, ejected out of hospital without help—and they account for virtually two out of five. That is a shame, and it is an enormous expense, to this country. Next to that class come these 250,000 mentally handicapped, of whom about 150,000 are leading wasted lives, simply because they have no opportunity to get the education which their parents are statutorily obliged to see they get, since it is not provided, and therefore they have no opportunity to develop even the small talent they have. Very truly in education, to them that have shall be given and to them that have not shall be taken away, even that which they have.

5.20 p.m.

THE LORD BISHOP OF LICHFIELD

My Lords, the matter of the health of the nation is obviously of such importance to the community that it ought regularly to be debated in a Chamber such as this. I should like to add my thanks to those already expressed to the noble Lord, Lord Taylor, for introducing it, and also for his interesting and informative speech, which I, for one, much appreciated. The breadth of the wording of this Motion to-day enables one to approach this matter from many different aspects, and the one I have chosen is this.

I wonder whether any of your Lord-ships, on reading your newspaper last Sunday, were as depressed as I was? The signs of the building up of racial conflict between men of different colours seems to be growing, and it is exploding more and more. I, therefore, am one of those who pray most devoutly for our Commonwealth, because I believe that this stands as a great bulwark against this raging sea, and, please God, will lead us through to safer and happier days, with greater understanding. But if the Commonwealth is going to work, it must have practical outlets, and therefore, my Lords, I want to say how grateful I was to see that, in the communiqué of the Prime Ministers' Conference, there was a definite reference to a Medical Conference to be held in 1965 which would enable the members of the Commonwealth to discuss mutual assistance in medical education including links between institutions; the provision of ancillary staffs, the development and planning of health services; and the supply of medical equipment and facilities for research. My Lords, I think that if we can help one another in such a way as that we are really doing our job and making a contribution.

Now this co-operation is something to which I think this nation can make a very great contribution, because we, as a nation, have the practical approach. It may be that men of other races exceed our ability in theorising. But I think that, especially in this world of medicine, other races may be helped by the practical approach which we can give. In his opening speech the noble Lord, Lord Taylor, spoke about the fact that in India several (I think he said fourteen) new teaching institutions had been established for the training of medical students.

LORD TAYLOR

No, my Lords. I think I said—certainly I meant to say—that I was told 35; that is, 35 since independence.

THE LORD BISHOP OF LICHFIELD

I am very grateful to the noble Lord for that figure.

LORD TAYLOR

The number is 35 to 40, and probably the right reverend Prelate misheard me, and thought I said 14, instead of 40.

THE LORD BISHOP OF LICHFIELD

I thank the noble Lord. I think that is what undoubtedly happened. The question I would ask is this: I wonder how often, in the institution of those new teaching schools for future doctors, our competent advisers from England have played a part. I do not know, but I should imagine that, quite likely they have played a large part. But what I know also is that in many places, not only in the Commonwealth countries but elsewhere overseas, some of our leading doctors and administrators have gone out and have played a notable part in helping those developing countries and the under-privileged countries to develop their health services. If we have to export our experience in that way, I believe that we have also continually to try to help here, by encouraging their more junior men to come to this country for the purpose of training. This, I am sure, is vital; and I should like to say how much I agreed with the noble Lord, Lord Taylor, when he said that we should be in difficulty if we did not have such a supply of young doctors from India and Pakistan. Frankly, I do not know how some of our hospitals would carry on.

May I draw attention to the sort of effort that we are at any rate trying to make?—it is organised by the University of Birmingham and the Birmingham Regional Hospital Board. In October of this year there is to be a Commonwealth school to equip overseas graduates to hold house-officer appointments in the National Health Service. Six places are available, and we have had 22 applications for these places. Training will be mainly in general medicine and general surgery as practised in British hospitals, and no special preparation for higher qualifications is offered. Tuition will be provided free of charge, and a house officer's salary will be paid. At the conclusion of the school, those attending will be under obligation to apply for, and, if selected, to accept, a house-officer appointment in a hospital administered by the Birmingham Regional Hospital Board. My Lords, that scheme is only a straw in the wind, but I suggest that it is a hopeful development. Certainly we shall watch it with great interest.

LORD TAYLOR

My Lords, we are delighted to hear what the right reverend Prelate has just said, because as he may remember, this is something we were asking for about two years ago. It is simply wonderful that this should have happened, because these young people do not really know the English morese when they come over, and this will solve the problem, or begin to solve it, so far as the Birmingham Region is concerned.

THE LORD BISHOP OF LICHFIELD

I am very grateful to the noble Lord for the encouragement that he has given to this effort which is to take place.

If we have to encourage the doctors from overseas, as I am sure we have—because, if we here at the centre of the Commonwealth do not help them in this kind of training, let us remember that there are other countries which will warmly welcome them: of that, I am quite sure—we must also do the same in regard to nurses. So far as some of our Midland hospitals are concerned, at any rate, if we did not have these nurses from overseas we should have to shut ward after ward. Of that, there is no doubt. I suggest that we need to give the nurses a sense of purpose and direction; and that is true of the British-born nurses as well. We ought to try to do more to show the S.R.N., when she has completed her training and has been qualified, about the ways in which she can serve the community. Is that shown to her enough?

We have recently had the important Report on the reform of nursing education. Obviously, to implement that report, or even only part of it, would take a long time. However, I do not propose to go into that now.

I should, however, like to mention another report recently produced by the Royal College of Midwives, giving the College's statement of policy on the Maternity Service. We often talk about the great need for more midwives. Are these girls, as they complete their training as S.R.N.'s, given sufficient encouragement at this moment in regard to the midwifery service? It should be remembered that when a girl has completed her training, and has got her S.R.N., if she then has to go into a maternity hospital to learn to become a midwife it is not an easy moment for her. Psychologically, it is at that moment a downgrading. And let us also remember that she will get far less money if she does that than if she goes straight out and does private nursing, for instance. So that if she undertakes training as a midwife it means that she has to make a considerable sacrifice. I suggest that more attention ought to be given to this question of the care of those girls who are ready to go in and train as midwives.

Mention of the nurses leads me to speak of another matter concerning them; that is, nurse wastage. We have heard to-day about the need for more nurses, and so on, as we so often do. In one way or another, as we know, we have more nurses in our hospitals to-day than ever before, but I think the figures of nurse wastage during the period of training are far too high. I believe that we should devote a great deal of care and attention to discovering why nurses give up. I know some of the reasons. Some girls, for instance, find after a year or so that nursing is not their vocation. They, of course, are quite right to pull out. We also know that the age of marriage is much younger than it was, on average, and that may account for some of this leakage; but those are not the only reasons. I suggest that at the present time, for one reason or another, we are losing some potentially excellent nurses.

So far as the Church is concerned we try to urge upon the chaplains that they should play their part in this matter. I know that when a young girl comes to a crisis in her own thinking in her time of training, if there is a good matron she will be able to talk to her, although it is not easy, in a large hospital with hundreds of nurses, with the best will in the world on the part of the matron. If the girl has a good home sister or sister-tutor she will be able to help. It often happens, however, that the girl can find considerable help if she is able at that moment to talk to someone who is outside the hospital hierarchy.

I believe that one of the main jobs of the chaplains should be to try to help the staff in this way; but, as far as the Church is concerned, I am bound to say that we do not feel we get from the Ministry all that we need in this matter. The number of chaplains is still based on the number of patients to whom they have to minister. That is how their salary is assessed and that is how the number of chaplains is assessed. I know that the Ministry say that if the chaplain is appointed for so many patients, that means that he also has, in proportion, a similar responsibility to the staff. That is; all very well; but when you think of the number with whom the man is trying to deal, you will realise that he cannot always give sufficient attention to the staff. It is not so easy. There are many staff not in residence; they come in and they go out. As regards ministering to those who are resident, the chaplain, as far as the Church of England is concerned, is often the local vicar with a big parish to cope with as well. Therefore, I would ask the Ministry again to consider whether they could not help the Church by giving us extra responsibility and assistance in regard to what we ought to try to do with the staff. I believe that a really adequate chaplaincy system could play a valuable part in stemming this nurse wastage which I am sure is going on.

I turn to another aspect. We have heard an interesting account of what is going on in some of the New Towns, and particularly in Harlow. As regards the Health Service, what is undoubtedly needed is the closest possible integration between the three departments of the Service. Therefore I should like to say I welcome the Report, issued, I think, last year, on the development of community care, which encourages the formation of more hospitals and welfare homes. This, if really carried out, would take some of the patients out of the hospital beds; and not only would the people themselves be better off in that type of accommodation but it would also relieve the great strain on the beds. At any rate as far as the Regional Board with which I am associated is concerned—and I think it is quite likely to be true of others—we are beginning to wonder whether we shall not very soon face a serious shortage of beds. I am told by some of my medical friends that, strangely enough, nowadays, as regards sickness and the need for hospital treatment there is not now the summer lull there used to be; the whole thing seems to go along much the same at what used to be a winter level. I do not know why, but it is a fact; and the strain on hospital beds is considerable. As regards our acute hospitals, wonders are done in the rapid turnover and the way in which people are got out of hospital so that the beds are made available. I hope they are not got out too soon.

But if I may return to the question of these New Towns, which I am leading up to, I would point out that here the integration of all the aspects of the Health Service should be seen at its best and finest. In the New Towns we have a blank cheque or a clean sheet or whatever is the appropriate metaphor. We start de novo. Let us see to it that in our New Towns—and in my part of the world we are thinking a great deal about New Towns, and we are getting one in Dawley, Shropshire—the Health Service is the best we can possibly provide by the truest, deepest integration of all aspects of the Health Service. Also, I should like to ask the Ministry whether they are planning a sufficient number of maternity beds in those areas. I am told that there is some reason for thinking the need for maternity beds in areas such as these may be almost double what it is elsewhere. I would therefore plead that in regard to these New Towns we should remember that the maternity beds will be most important.

My Lords, the mention of New Towns leads one to think of building, to which a good deal of reference has been made to-day. And do I not know it! Sitting on a Regional Board one finds the continual pressure of this question: how much for the new hospitals, how much for the old? I think we ought, in generosity, to say that many of the old hospitals have been wonderfully transformed. Let us not forget that; although I know there is a tremendous amount to be done. I think of some of the hospitals that I know well myself, and they are very different from what they were fifteen years ago. But it is not just a question of building. The noble Lord, Lord Stonham, mentioned in passing that in one of his hospitals he needed a new theatre. I can understand that. But what is beginning to worry some of us is the fact that you can have new theatres but be unable to work them flat out because you cannot get the staff. That, also, is a bottleneck. It is not just a question of money. Sometimes the impression is given that you have only to pour more money into it and the whole thing will work out well. But it is not so easy. It is not easy to spend the money; in fact, it is becoming increasingly difficult.

LORD PEDDIE

My Lords, with the greater availability of money, would the right reverend Prelate not agree that higher remuneration could be paid which would possibly attract more doctors and nurses to meet that need?

THE LORD BISHOP OF LICHFIELD

My Lords, I am most grateful for that intervention. May I say, in regard to this matter of money, that I appreciate the fact that if you can make the whole thing attractive in that way it would undoubtedly assist. But I am thinking more of money in terms of expenditure on building. You have first to get the money to spend, and it is not easy. Regional Boards may face a situation where they have an allocation and may not be able to get rid of it in the time. I would plead with the Ministry to try to help us in regard to a system by which we can recruit a sufficient number of architects. It is that which I believe would go a very long way to helping us get the money spent in the time.

LORD TAYLOR

My Lords, I should like to ask the right reverend Prelate how far the trouble is the inability to transfer from one project to another. Can he do all the transferring he wants to do, or is he stuck with the money for one thing, another job is ready and he cannot use it?

THE LORD BISHOP OF LICHFIELD

My Lords, I am sorry to say that I have not sufficient information myself to give an adequate answer. I must say that I cannot answer it to-day in that way. But it is the overall picture that worries us of getting money spent for the capital projects. I believe that a sufficient supply of architects who could go out and give consultant advice to the various contractors who are being brought in would go a long way to help remove this difficulty.

But I would say how grateful I am to the Ministry for the way in which, in the planning of new hospitals of any size, they are planning that there should be a chapel. That is much appreciated by the Churches. I would also say how much we appreciate the kind of consultation that we in the Churches have had with the Ministry, not only over that subject, but also over many other things. We have always been received with great courtesy and understanding. We have not always got all we wanted, but, in my view, the Ministry have gone a long way to helping us over the last few years, and I wish to pay my tribute to that to-day.

If I may come again to the other side of the picture, I must ask the Ministry whether they would consider again this figure of 750 patients of one denomination before there can be a full-time chaplain in a hospital. What worries me are these new district general hospitals. I am told that they are going to be, on an average, 800 to 900-bedded hospitals. If that is the case, they will not qualify for a full-time chaplain. These district general hospitals are not really associated with the parishes in which they happen to stand. The patients come from a variety of different places and the doctors and nurses all come from elsewhere. It is an entirely separate community. I do not think it ought to be cared for in that way by the local church. I believe we need a good, full-time chaplain in a hospital of that description, if it is really to do its job and if the Church is to do its job. We feel strongly that if we can get the right men in this service, they can do much to create the kind of spirit that is needed in hospitals.

I am afraid that my remarks have been rather discursive, but there were various points I wanted to discuss. As I end, I would just say this. I am a little worried sometimes lest the nation take all this for granted. I know we get a tremendous amount. I know we need it and we are grateful, or should be very grateful, because it delivers us from much anxiety; but I am afraid that sometimes we just take all this as of right. I am wondering whether that is really helping the community as it should. I know, thank God! that in the Hospital Service there are now more voluntary workers than ever before. Nevertheless, I sometimes wonder lest the Welfare State, with all the blessings that it brings—and I daily thank God for it; I am not a critic—may remove from our people that spark which led to a desire to serve the community, because they saw that intense need which sometimes led to the greatest voluntary services that the country has ever seen.

So I would plead as I end that the voluntary side of this work should be continually stressed. I hope that when Hospital Sunday comes round year by year we shall take the opportunity to stress this call to voluntary service in the hospitals, and also the call to the vocation of full-time service. I believe that in that way we can show the people of this land what the National Health Service really is; and I think they will appreciate it in the way in which they should.

5.43 p.m.

LORD PEDDIE

My Lords, I should like first to join in the appreciation expressed of my noble friends, Lady Summerskill and Lord Taylor, for initiating this debate. While there have been differing degrees of emphasis, there has been unanimity of opinion about the need for, and the value of, the National Health Service. I subscribe to the views expressed by my noble friends Lord Taylor and Lord Stonham, in their devastating criticism of the shortcomings of the National Health Service. I appreciate that most of the noble Lords who have spoken wish to see the Service developed. Even the noble Lord, Lord Auckland, favoured an extension of the Service, provided that he knew where the money was coming from.

I think that most of us, without the aid of a long memory, can appreciate the tremendous difference in the hospital and medical conditions of to-day as compared with the past. I can remember only too vividly the conditions in the old infirmary out-patients' department, with its stone floor and bare walls; its overpowering smell of ether; its long benches, and the shuffling crowd responsive to the notes of the bell—all supervised by a grim-looking elderly individual, who was a cross between a gaoler and a sergeant-major.

These things have changed. I have been in the same out-patients' department recently. There is a more colourful paint on the walls. The patients still have the benches, but they are attended by a younger man, in a better uniform, who wears an occasional smile instead of a continual frown. So we have moved on a little. I must point out, however, that the queues now are just a little longer than they were at the time when I first went there. That may be due to the fact that it was only fear that caused people to attend the outpatients' department a generation ago, when the atmosphere was one of charity, of cold charity, particularly cold in the atmosphere of the out-patients' department.

With the development of the National Health Service we have also seen changes in the important field of the general practitioner. I am not so very old, but when I was a boy the general practitioner was almost a god-like man, feared and respected. In those days, many people who were not "on the panel" were helped by the local doctor, particularly in the industrial areas of the North. The old G.P. was something of a benevolent Robin Hood: he was not particular about soaking the well-to-do in order that he might be able to succour the poor. I feel that the status of the general practitioner, and of doctors in general, is lower to-day than it was years ago, although the demands upon the doctor, and the need for higher skill, are greater than formerly.

Changes have taken place, changes largely in the field of opportunity; and I believe that the Government have largely neglected the opportunities that were presented to the nation by the passing of the "Bevan Act" in 1946. The National Health Service Act laid down new standards of human health and welfare. I honestly believe that no one can deny that, in the years since the National Health Service came into being, we have not seen a development in these services commensurate with the national resources. I believe that the Government have failed in that regard.

What is the position to date? It has been demonstrated by almost every speaker in this debate. Hospital accommodation is utterly inadequate. Doctors are dissatisfied and frustrated. There is no doubt of their frustration—it was to be seen in the almost neurotic statements made at their recent Conference: and they were prodded into those statements by the utter frustration consequent upon the attitude of the Government towards the whole of their Service. And the flow of medical students, according to more than one speaker, falls far short of demand; the supply of nurses has lagged behind the need.

The right reverend Prelate indicated the need for ministers attached to the hospitals to bring about a sense of greater social service among nurses and doctors. I think we could also greatly assist by paying them more adequate remuneration. I remember years ago a friend of mine, a consultant in a hospital in Hull, a devoted doctor but also a man who was quite well-to-do who had made a financial success in his profession, quite seriously discussing with me the question of the payment of higher re- muneration for nurses. He was all against it, because he felt that if we introduced the taint of money into that service something would be lost. I noticed that it did not prevent him from sending in his bill to me when I had to consult him on one occasion. I know that the spirit of service is important, but it should never be used as a justification for paying people inadequate salaries. We should try to avoid the appalling spectacle of groups of nurses lobbying in another place in order to draw public attention to their plight.

I would also point out that in the years that this Government have been in power we have not seen the emergence of any overall national plan. It is recognised that there is a shortage of medical schools, and all speakers have indicated the considerable restrictions placed upon medical research. There is only one section of the community associated with the medical service that has really found a bonanza in these conditions, and that is the manufacturers of proprietary drugs, who are willing to spend as much as £6 million a year on promotions of various kinds to persuade doctors to prescribe their drugs. They are the people who have really gained from the way in which this Government have conducted the medical service over the past thirteen years.

Our hospitals to-day are by modern standards utterly inadequate. One in five is more than a hundred years old; half of them were built over seventy years ago. Frankly, I dislike to cross swords with my noble friend Lord Taylor, but I do not share his view. He finds greater satisfaction in titivating up some old hospitals rather than in seeing the new shining structures. I am sure he has not seen many new shining structures over the past few years. I should like the noble Lord opposite to let me know how many new hospitals we have had constructed over the past decade.

LORD AUCKLAND

My Lords, will the noble Lord indicate how many new hospitals were started between 1945 and 1951?

LORD PEDDIE

I am interested in what the circumstances are to-day and the responsibility of this present Government. It may be the view that men and materials are the great factors that can restrict the building of hospitals. But I was interested to see recently that in the past decade there has been so much energy spent in erecting office blocks, apparently, instead of hospital buildings. There are at the present moment, as quoted in the Press only a fortnight ago, two hundred new office blocks, with 8 million square feet of floor space, standing empty. This is the equivalent of 10,000 3-bedroomed houses and, frankly, I do not know how many hospitals it would represent.

In 1962–63 expenditure on hospital building was £36 million. This year, I agree, it is running at the much higher figure of £66 million. Whether that has anything to do with the impending Election I do not know, but we are at least thankful for the increase in the amount over the past years. But it is far more interesting to observe the expenditure upon hospital buildings over the whole period that this Government have been in office. Since the Government came to power £300 million has been spent on hospital buildings, an average of £23 million a year. In money terms, that is approximately half the amount (the noble Lord opposite may be interested in this figure) that was spent in the 1938–39 period.

It is interesting to observe the comments of the medical profession with regard to hospital buildings. Recently there was a quotation in the Guardian from a report which was intended to be private but ultimately became public, of a survey on the care of the aged in the Birmingham region. That report refers to hospitals which should have been blown up. It is like a lot of slum property, that carried appalling fire risks, that had overcrowding, that were barrack-like buildings and provided degrading conditions for patients; and staff. That was a responsible survey carried out in the Birmingham area.

I would point out another aspect of this problem which I think has not been brought out in the debate so far. It is, as one would expect, impossible under such conditions, with old buildings of this character, to run a hospital or anything else efficiently, and it must make for higher operational costs. The Government in their operation of the National Health Service, judging by the fact that insist on the charging for prescriptions, dental treatment, welfare foods and the like, seem to feel the necessity for running the service, to some extent, as one would run a business. But surely it is bad business indeed, to judge it solely from the commercial standpoint to retain hospitals of this character that are so difficult and costly to operate in such conditions. One observes that the cost of running and maintaining the hospitals is £500 million a year, or approximately half of the total expenditure upon the National Health Service. Surely, on that basis alone greater expenditure in construction of more modern buildings would tend to reduce operational costs with regard to hospitals. I think that is a reasonable proposition.

One can observe to-day the grim contradiction, where we have, according to a recent report, 500,000 people on the hospital waiting list, and yet at the same time there are 10,000 beds empty because of the shortage of doctors and nurses. In the long run the quality of the Health Service is determined by the quality of the personnel, whether they be doctors, nurses or any others who are responsible for the operation of this Service.

I think that a great shortage of doctors has been brought about in the course of this decade. It is not necessary to emphasise further the reasons for this. My noble friend has already given an indication of the accelerated emigration of doctors because of their apparent dissatisfaction with conditions here. I believe there is a need to step up training. As my noble friend indicated, there has recently been an announcement about a further medical school. The medical profession itself has indicated time and time again the need for more training facilities.

My noble friend asked me to comment upon the situation in Manchester. I know quite well that there is, and has been for a long time, a great demand for additional training accommodation. There is but one medical training school in Manchester. Manchester serves a population of 2¼ million within a radius of ten miles, and 11¼ million within a radius of 50 miles, with one medical school, and yet in the Greater London area I believe there are about twelve.

May I also turn to one other aspect which I think is of tremendous importance, and that is the question of research? I believe that the Government are deserving of severe criticism for their lack of encouragement with regard to medical research. Unfortunately, too many people believe that medical research must be associated with vast expenditure upon buildings, equipment and the like. That is not necessarily so. There are many opportunities for long-term and large-scale medical research which could be of enormous value to the community, if only the Government had the initiative, the enterprise and the enthusiasm to encourage it.

I will give one illustration, if your Lordships will bear with me one moment, to show the point I am making, which I believe opens up a vast field of research which is very economical. I am a director of the Co-operative Insurance Society, which two years ago, with the approval of the British Medical Association, made arrangements with a great research project in Europe and America. Under that arrangement—I believe we are the only insurance organisation to undertake it—and with the sanction of the applicants for life insurance, we secured blood samples. Those blood samples are sent to laboratories where careful records of each person are maintained, and will be maintained for years. Ultimately, at the time of death, the cause of death will be noted and the blood samples will be examined for cholesterol level. This may give some indication as to its influence upon coronary thrombosis.

This is a long-term development costing very little, provided that you have the initiative and the interest to provide facilities of that kind. It is quite likely that over a period of years that project will come up with really vital information of value to the community.

The same is applicable in the field of industrial medicine, which my noble friend Lord Taylor knows so well. Large industrial organisations in this country offer in themselves facilities for considerable research. What has been done by the Government in this regard? Nothing at all. It has been left entirely to the enterprise and initiative of individuals. One could go on.

I end on this note. I believe that the G.P. is the basis, indeed the keystone, of a good National Health Service. I know there are some people who see in the ultimate development of the National Health Service a greater concentration upon hospital service. I do not share that view. I believe that to-day, and in the future, the local G.P. can make a great contribution. He can make or mar the health service of the future. Its efficiency and success depend upon him, and I think it is stupid and dangerous to allow his economic condition and social status to deteriorate in the manner it has over the past fifteen years or so.

There is a shortage of doctors. A recent authoritative statement said that there are 16 million people in this country who are living in under-doctored areas. Surely something could be done about it. But what do we do? We have the Minister coming along and saying that he is going to help the medical profession—I paraphrase his statement. He expressed a measure of sympathy with the G.P., and promised to protect him against the time-consuming patients whose lack of consideration causes such a waste of doctors' time. What an appalling exaggeration! Do your Lordships believe that any person in sound health is going to sit in a doctor's draughty waiting room waiting for attention, probably for two or three hours? If there is nothing wrong with him physically, there is mentally, so he should still be in that surgery waiting for some attention. It is utter nonsense to be quoting something of that description as one of the reasons why doctors themselves are rushed off their feet. The cause is not the poor individual who is going to the doctor; it is the fact that there are too few doctors. If we are talking about wasting doctors' time, I would say that the wealthy hypochondriac is more likely to be wasting medical skill and resources than the individual who has to sit in a doctor's draughty waiting room. If noble Lords opposite do not know what I mean, we will take one or two to the East End where they can sit for two or three hours so that they may understand precisely what I am saying.

I need say no more, except to indicate, as I am sure all noble Lords will agree, that in our own National Health Service we have the means of providing great services to the country. I believe many opportunities have been neglected over the past decade. I can only hope that the opportunity shortly to be presented to the nation, will give us the means to secure far greater improvement in the services offered in the National Health Service.

6.8 p.m.

LORD CROOK

My Lords, I should like to join in the congratulations to the noble Lord who moved this Motion, and to pick up, in particular, one subject to which he referred as a growing problem, that of the treatment of children. I should in any event have desired to take the opportunity of addressing your Lordships on that question, but I have an additional reason, in that there was on the Order Paper for last night in my name an Unstarred Question; but, by arrangements through the usual channels, when the noble Lady put a Motion on the Order Paper I withdrew my Unstarred Question in order that I might include it in to-night's debate. I am referring to the Question which I put down about cystic fibrosis.

For reasons which I will try to explain to your Lordships, I had put down three Questions for Written Answer by the Government in March. Finally, I had a letter from the noble Marquess, Lord Lothian—who throughout this matter has co-operated courteously—telling me that none of the information for which I asked was immediately available. That was chiefly because cystic fibrosis was not a disease to which a specific code had been allocated; and, secondly, because on the question of the prevalence among children no reliable data were available, although it might be possible to obtain some information from hospital in-patient inquiries. The noble Marquess pointed out that whatever was undertaken at my request would mean an extension of work in the Ministry in going back into records to try to find out the information I wanted.

In due course, with others, I met the noble Marquess, and we agreed that I should put down a limited form of Question, to which he was to be good enough to give some reply, aiming at securing that, if we had not the facts and figures of the past, we should at any rate have some collated in the future. It was also the idea that I should have the opportunity of trying to tell your Lordships something of this new problem to children's health—one that has not yet been grasped in this country; the problem of a disease which was first recognised in the United States as recently as 1936 and on which the first comprehensive report was made in 1938. But it was not until this year that finally it has been recognised as a world-wide inherited generalised disorder.

I met the noble Marquess and told him that we were not asking the Government to do things that we were not trying to do ourselves. For, in company with some noble Lords on the opposite Benches, and with the Lord Mayor and others in the City, there has been established a research foundation which will continue to try to find out what is really at the back of this disease, and what kind of cure research might be able to find for it.

The disease is believed to result from a chemical defect which is inherited by the child from both parents, although carriers of the gene in question may, in fact, show no sign of the disease themselves. This mysterious chemical defect causes abnormal secretions of sweat, saliva and mucus. In America it is said that largely because of lung complications this is now second only to cancer among diseases causing death in children under fifteen years of age. They started their research just before the war, and they now have 30,000 cases identified. The problem is one that is now recognised by both State and Federal help, so that in America to-day the amount spent on research is 5 million dollars.

I was most interested in the reference made by my noble friend Lord Peddie to our lack of research, because this is one of the fields in which this country has done nothing. Research is proceeding in the Argentine, Australia, Brazil, Canada, France, Italy, Switzerland and West Germany. Indeed, some ten days ago we had an international gathering in Paris of representatives of all those countries. We want to co-ordinate our own efforts, and we want to get the Government to co-ordinate the efforts of Governments and Ministries of Health throughout the world on this disease.

Those of us who want to press this upon the Government are doing something. We have embarked upon the raising of £50,000 for a three-year programme, and we have already raised some £10,000 in the course of the last three months. We are starting at Great Ormond Street, Queen Elizabeth Hospital for Children, the Brompton Hospital, the University of Manchester Department of Child Health, and the Queen Mary's Hospital for Children, Carshalton, with programmes of about £3,000 to £5,000 per annum each, for a period of three years.

We are going into an unknown field. We do not know any facts, and we are most anxious to urge that the Ministry should try to secure, without that undue amount of overtime which would have been required of the staff for past research into figures, the figures in respect of coming years. In America it has been variously claimed that one in 800 to one in 1,200 children born are suffering from this disease. We are being a little conservative in our estimates from our own medical advisers, but we believe that anything from one in 1,500 to one in 2,000 may well be the number in live births. We not only want statistics from the Government; we are most anxious that the Government should undertake to bring seriously to the attention of general medical practitioners—the G.P.s on whom so much will depend in this matter—something of the nature of the disease, to look for it; because it can be an immediate and early killer if no proper action is taken, or if the disease is not recognised. We should like our research to be co-ordinated with the research of the Government, and the Government's research co-ordinated with that of other Governments.

My Lords, I said that I should have wanted in any case to speak about children's affairs, and the reason for that is that I do not think children are getting a square deal at the moment in the hospital service. In the tragic 1930s, 27,000 children died each year. The figure is now down to 5,000. The reason for the improvement I will quote from the recent document, The Lives of Our Children, issued by the Office of Health Economics: The establishment of the National Health Service in 1948 removed the final economic barriers to medical care, and the Welfare Services, school milk, lunches, and medical inspections, infant and child welfare foods, were made available nation-wide. What has been done in more recent years? Picking up the point about the age of hospitals that has been made by earlier speakers, I would point out that the few major existing children's hospitals were all built between 60 and 150 years ago. Indeed, only one children's hospital has been built in the twentieth century, although in the time that has elapsed since then the whole pattern of treatment of children has changed. As my noble friends on the Front Bench who are medical practitioners well know, in those days one child in six died before reaching his first birthday. Infant mortality is now down to one in 50. But it is also true to say that in those days, in the main, no hospital would take a child under the age of five. To-day, the vast majority of in-patients in children's hospitals are under that age. Yet the provision for children's hospital services, whether in-patient or out-patient, has lagged lamentably in the last ten years as a result of starvation of capital for the hospital service. I suggest that the last ten years are likely to be remembered more for thought than for action, because the position is in fact growing worse.

The analysis of child admissions to hospitals published in the Lancet in 1961 are the most authoritative figures I could obtain, and they show that admissions to nineteen provincial children's hospitals in England and Scotland in 1950 were 65,385 and in 1959, 83,185—a rise of 27 per cent. An increasing number of babies were among those admissions. There is an increasing complexity of investigation and surgical treatment, as my noble friends in the medical profession know only too well. But I do not think we ought to forget that when the babies are using beds in general hospitals this represents a loss of beds for adults who have been lining up, perhaps for as long as a year, for the operation they so badly need.

That something can be done for children the Ministry of Health must know full well from their own records of what one hospital region has managed to achieve. In that region the mortality among newborn babies with congenital abnormalities which menace life, and which need surgical treatment, was 80 per cent. In the first six years following the concentration of such cases into a surgical unit, properly staffed, and well equipped, over 1,000 cases were treated, with an 80 per cent. record of recovery. And the Ministry must know that this one effort in this one region saved 100 lives a year. But, of course, the point of my bringing this to your Lordships' attention was to illustrate what a tragedy it is that this kind of result cannot be achieved all over the country rather than in just one region.

One of the reasons, as my noble friend Lord Stonham said, is that the Ten-Year Plan is dead. I want to recall one place in which I am certain it is dead in respect of children's hospitals. I refer to the Queen Mary's Hospital at Carshalton, about which some of your Lordships in this House now will remember I initiated a debate on February 12, 1959. I am sorry that the new chairman of that hospital, Lord Grenfell, after having a kindly word with me, had to leave before this debate went very far; he has in fact left because he had to go back to the hospital at Carshalton for duties. I know how interested he is in the job that is being done there and how much he wishes that hospital well.

On that occasion, in 1959, I described to your Lordships this wonderful children's hospital with 500 beds catering for all acute and long-term disorders in childbirth. The Minister of that day—not the present one, but the third former Minister—listened in this House. He was impressed, and I want to give him all the credit for stopping the closure of the hospital. Instead, a few months later he announced the amalgamation of that hospital with the Fountain Hospital for the mentally subnormal children of Tooting; it was amalgamated with Queen Mary's, Carshalton, Surrey. Everyone welcomed this first integrated hospital, which was in keeping with the Mental Health Act which we had put through the House in the course of the preceding few months—the Act which would co-ordinate psychiatric and general medical and surgical hospital services. The children were put into temporary converted accommodation for out-patients, theatres, pathology, X-ray, social service departments, physiotherapy, pharmacy and so on.

Everybody of good will knew that purpose built accommodation was to follow. Within the next two years, by the end of 1961, there had been discussions and planning; detailed schedules had been prepared; indeed, the exact siting of the departments had been determined. At the end of 1961 it was understood that the Regional Board were about to obtain Ministry approval for the outline capital programme. That was the position, therefore, just before the beginning of 1962 when the Ten-Year Plan was published. The Ten-Year Plan included the statement that during the period development of Queen Mary's as a comprehensive children's hospital, the first of its kind, would be continued. But in the two years that followed that publication everything seemed to slow up in pace: nothing much seemed to happen. Those of your Lordships who care to look at the new edition of the Ten-Year Plan will fail to find any reference to Queen Mary's, Carshalton, in it at all. There was no notice to the hospital authorities of the apparent abandonment of this Ten-Year Plan. But a capital programme which appeared imminent and which the Ministry of Health so enthusiastically introduced and sang songs of praise about—this idea of a comprehensive hospital—has now in 1964 been put into the limbo of the things to come after 1975. It has been done without a word of explanation even to the hospital authorities running the job.

What kind of planning is it that introduced this world-shaking idea into children's medicine in 1959, and by the end of 1963 has delayed the first phase of its implementation for a further fifteen years, and that without one word of explanation to the people on the spot, struggling with their limited resources to make this great new idea of the Ministry a reality? I could not help being struck by what my noble friend Lord Peddie said about the great new empty office buildings. I look at them, I look at the others still going up, and read with dismay of the planning permission being given for others, using up financial and manpower resources of building in this country, and I begin to wonder whether we have got our priorities anywhere near right in this country.

I read that sealed canisters are being put down in the bottom foundations of some of these new office buildings. They contain coins and newspapers and magazines in order that when in 1,000 years' time somebody looks at the foundations they will find evidence of the kind of civilisation in which we lived in these recent years. I think that what will impress them a good deal more is that during these ten years we could build these great office blocks to stand empty, as they are, while we failed to build the hospitals we so badly needed; and this is why I have been happy to speak in this debate and to declare one person's complete approval.

6.25 p.m.

LORD McCORQUODALE OF NEWTON

My Lords, I must apologise for my unavoidable absence during the early part of this debate, due to a longstanding engagement that I could not possibly miss. Partly owing to the fact that the noble Lord, Lord Stonham, was good enough to refer to the activities of the King Edward's Hospital Fund, I felt that I should like to say one or two words in this debate. As no doubt your Lordships know, the King Edward's Hospital Fund endeavour to arrange, through their visitors, to visit all the hospitals, or at any rate the hospital groups, in the Greater London area, which come into the sphere of our interest. Reading the reports from the visitors, one medical and one lay, one gets a picture of the whole hospital scene in the Greater London area possibly a little different from that of those who are working in one hospital and know the acute difficulties that are facing them in that hospital.

There are, of course, needs and wants everywhere, and a debate of this sort is extremely valuable in urging on the needs and the developments of the hospital world, and in emphasising its short-comings. I am sure that we must do that. On the other hand, I should not like anyone to think that the hospitals of the London area are not doing a wonderful job. One or two of the speeches to-day—let us face it—have had a rather political flavour; and I can understand that we should expect that, so close to an Election. But I should not like anyone outside this House, reading this debate, to get an opinion to the reverse of that. The fact is that the hospitals are doing a wonderful job, and I should like it to go out from this House that the people of this country can confidently commit their nearest and dearest to the care of these hospitals.

We are endeavouring to do in the hospital world a very difficult yet extremely worthwhile job; that is, to combine State ownership and State finance with voluntary control and voluntary effort and voluntary management. I am one who believes that when the history of this country comes to be written a very high place indeed will be given to the name of Mr. Aneurin Bevan for having established that principle of State control plus voluntary effort, because the whole essence of the hospital surely must be voluntary help for our fellow people. The amount of voluntary help that is given—on management committees, on hospital committees, on leagues of friends, on visiting, on help in the out-patients' departments, on entertainment of the patients; in fact in a hundred and one ways—is quite remarkable.

Much help, of course, has been given by the big voluntary organisations which are financed from past and present benefices, such as the Nuffield Foundation, which has done such wonderful work, and the King's Fund, with which I have the honour to be associated. We are endeavouring now to build some new hospitals (many of us would have liked to see some new ones being built earlier), and these will be most welcome. We in the King's Fund are endeavouring to do our share by establishing what we call the "Hospital Centre" in the Edgware Road. By providing a forum for discussions on buildings, and an exhibition showing the latest improvements in hospital layout, in beds and everything else, we are endeavouring to ensure that the new hospitals, when they are built, are as good as they can be.

New hospitals have all the glamour at the moment. But hospitals are not only bricks and mortar: they are live and warm and human affairs. It is the welcome from the nurses and the staff to the patients when they arrive, the food provided, and the consideration shown to each individually, which makes such a difference to those who are in hospital. It is not only these vast, new, shiny edifices which are to-day being acclaimed: our reports show that, by and large, and with few exceptions, this warmth of welcome and care abounds to-day in the hospitals of this country.

Therefore, my Lords, I would say, "Let us encourage, let us praise and let us help all we can those who are ministering to the sick in our hospitals." By means of our training colleges we are endeavouring to help in the administration of these hospitals, by helping the young men and women who are coming into this important task. And I would say, here and now, that the young men and women who are coming forward to the courses in hospital administration are as fine a bunch of young people as one could find anywhere. I believe that on entering the hospitals they will make a remarkable showing.

I would emphasise here that there are more opportunities for voluntary service in the hospital world than have up to now been taken up. Many people respond, but I am quite sure that if only we could get over to the people of this country what opportunities exist, many more would respond; and especially our younger people, who are to-day imbued with a sense of service such as I think many other generations have not been. I believe that we can secure this, and I would urge that means should be found of putting them into touch with their local hospitals or organisations to see what lies to hand. If that is done, I am sure that they will be delighted to be of service.

I was much interested in the remarks of the right reverend Prelate in regard to chaplains. I agree with much that he says about them. Only about eighteen months ago we had a course for hospital chaplains at our administrative staff college. It was a veritable international body of religion. I think that every phase of Christian and Jewish teaching was represented on our course, and the priests and ministers of different persuasions who took part in it got on famously together. With their help we have since tried to hammer out some form of syllabus on what we might class as chaplains' duties, other than spiritual, in the hospital world. I am quite sure that chaplains can play a large part in what I might call the personnel activities in the hospitals. I was, incidentally, particularly interested to hear what the right reverend Prelate said about chaplains helping student nurses through the difficult crises in their career.

I do not wish to keep your Lordships any longer. All I wished to say was that I believe we are going forward. It is right that we should examine our short-comings; that failures and mistakes should be exposed; that new avenues of treatment such as have been mentioned to-day should be explored—and possibly with more speed than is being shown at the present time. But let us also give praise where it is due, and proclaim with pride that our Health Service, our nursing and practitioner training and our hospital treatment is the envy of the civilised world.

6.37 p.m.

BARONESS SUMMERSKILL

My Lords, I have the privilege, on behalf of my noble friends, of making the last speech from this side of the House at the end of this Parliament. I predict that it will also be the end of a long Conservative Administration, and that next time my noble friends speak in this House it will be from the other side of the House. One would have expected this debate to provide some opportunity for us to applaud progress in some field. But, having listened to every speech from this side of the House, I am seriously concerned to learn of the deterioration in the Health Service.

From the other side there have been only two Conservative speakers. There was the noble Lord, Lord McCorquodale of Newton, who came along, quite understandably, at the end of the debate and spoke with pride of the Health Service. But he must admit it is rather curious that, before he arrived, there was only one Conservative speaker on the Back Benches opposite. If the Conservative Party were so proud of the Service, why could not they at the end of this Parliament manage to muster up perhaps two or three speakers to speak on the most important social service in the whole country? The noble Lord, Lord Auckland, said in his opening remarks that he thought my noble friend took rather a gloomy view of the Health Service. The noble Lord to whom we have just listened said that he hoped we should not try to introduce any Party recriminations, or words to that effect. I want to assure the two noble Lords that the remarks I have to make this evening are going to be extracted from Conservative sources, and surely, therefore, they will agree with me that I am not animated by any Party bias. By that I mean that I have extracted them from the recent Conference of the British Medical Association, which is, I can assure them, a Conservative organisation.

I point to the record of successive Conservative Ministers of Health—I think we have had seven. I would agree with my noble friend, having listened to all of those seven, that there was only one, the son of a doctor, who really had any knowledge of the subject at all. I would not say that they were pushed upstairs or downstairs; I would say that they were so out of their depth that they ran away as soon as they could. It is deplorable that in thirteen years we should have had seven Ministers of Health who did not stay long enough to learn their job.

I would ask the noble Lords, Lord Auckland and Lord McCorquodale of Newton, to read the report of the B.M.A. Conference, and they will see that that meeting of doctors culminated in an explosion of indignation. The noble Lord indicated otherwise just now, but everybody knows that the medical profession is a Conservative profession, not accustomed to mixing political broadsides with their professional interchanges. Yet they delivered just recently the most powerful indictment of the Government I have ever known. I think that it should be put on record in this debate.

We have heard so much about the hospitals to-day. The noble Lord in speaking a moment ago had nothing but praise for the hospitals, but has he read that those representing the hospitals at this recent B.M.A. debate accused the Government of a £600 million confidence trick—those were the words used, very different from the language the noble Lord has just used—for this was the sum promised for hospital building? When I mention the names of two gentlemen—and I am sure both would not mind my mentioning their names publicly—your Lordships will know that neither of these surgeons has ever voted for the Labour Party. The attack was led by the two surgeons Mr. Lawrence Abel and Mr. Dickson Wright. I am sure that all noble Lords will have met Mr. Dickson Wright at some dinner or other and have been captivated by his fascinating comments on the world at large. What did these two Conservative gentlemen say? Mr. Abel said: The Government and the Ministry keep on instructing Regional Hospital Boards to put off projects. We were promised the money to build hospitals now, not long after we are all dead. It was promised not for our grandchildren, it was promised for to-day. Mr. Wright said that, while the Government stood still on hospital building, they were putting up "huge palaces for bureaucrats". Finally, the meeting passed a motion in these words: deploring the indefinite deferment by the Ministry of Health of the many hospital building schemes originally scheduled in the 1961 hospital Plan to begin before 1970 and they expressed concern over the inadequate capital expenditure on hospitals. I am quoting representatives not of my Party but, I think, of the other side.

While the doctors deplored this betrayal by the Government, the real victim of this ineptitude is the long-suffering patient who should have first consideration. He waits sick, silent, powerless, completely ignored, as one abortive committee after another discuss their never-ending plans. The urgent need for hospitals is such that a functional approach should be adopted and the buildings standardised. I would not agree with my noble friend when he said that the general management committees are at fault. I think it is the architects who are at fault. My noble friend said that the general management committees want a monument or a memorial. I say it is the architect to whom this applies. The architect can be a very vain man. Architecture is a curious profession. Architects all differ with each other; they all want to have a little baby of their own and all want a better baby than the other man. The architect is longing to have a monument or memorial to himself. Then there is the prima donna on the hospital staff who comes along and says "Let me see the plans", and that morning they are changed. More delay.

Here is the source of delay. The Minister should come along and arbitrate and say, "We have had enough of you people arguing among yourselves." If the Minister does nothing, then the delay will be interminable. I believe that there should be a functional approach and that the building should be standardised. As for all these gems of architecture that these men are longing for, all right! Let them devote themselves, if they want to, to the Palace of Westminster; let them go on arguing for ever about whether it should be modern or Gothic. But for hospitals which are needed, let us have a functional approach, and let the Minister take action and stop this eternal argument.

Undoubtedly those concerned with hospitals at the B.M.A. meeting had nothing good to say of the administration of this Government. As to the general practitioner representatives, one man said that he could not remember a time when dissatisfaction was so widespread, vehement and vociferous. The temper of the meeting was such that one speaker said that it was time to bang on the Ministry table, and he compared their lot with that of the postman; he added what the postmen did about it, and more or less suggested that the doctors should do likewise. This is what we have arrived at after thirteen years of Conservative Government. Undoubtedly, apart from the level of remuneration for the general practitioner, one of the heaviest burdens carried by the single-handed G.P.—and there are plenty of them—is to run a medical service day and night 365 days a year. The strain is intolerable. If the G.P. takes a day off he has to find a locum and pay heavily for his services. As for taking a holiday for a month, well, he cannot contemplate it because his low rate of pay is such that, tied to a medical practice day and night, he cannot afford a month's holiday. In a hospital the doctor has a substitute found for him during holidays and is relieved of all responsibilities.

I should like to hear what the noble Marquess has to say about a salaried service. We were told by the noble Lord, Lord Auckland, that his investigations had led him to believe that the younger men would value a salaried service, but that the older men want to go on with the principle of a capitation fee. The shortcomings of the capitation system could not have been foreseen. I make no apology that the Socialist Medical Association in the early 1930s used to come together and think out the details of the scheme; and we used to think that the capitation system was the right approach. But we have now learnt that the capitation principle encourages the tendency to over-prescribe in order to appease the acquisitive and the hypochondriac.

How I welcome the approach of my noble friend Lord Peddie to this question! I think I have said before—we have had so many debates on this matter and keep having to hammer away at the Ministry on the same question, but the Minister takes no notice at all—that the doctor who tells an obese patient that the best treatment is to reduce his diet and refuses to prescribe slimming pills, may lose the patient and the patient's family. The patient goes out of the consulting room in a huff, and some even say to the G.P. "And I am taking my family away too!" That means three, four, or five cards lost for members of the family, and, of course, a capitation fee is attached to each one. The doctor who gives unlimited supplies of pills to please his patients may get all the fat women in the road on his list. This is not an exaggeration. This is how the capitation fee system works in Britain to-day.

I must confess that it was refreshing to find a representative of the Ministry of Health giving the harsh facts to the B.M.A. meeting. The pharmaceutical industry is now so well represented in both Houses that Ministers in the other place and here are always afraid to grasp this nettle. If I remember rightly, on the last occasion we had four such representatives here. Even the pharmaceutical industry cannot compel them to come here to-day when it is so hot and the holidays are so near. But I was pleased to hear that Dr. J. E. Struthers, a senior medical officer of the Ministry, told the recent meeting of the B.M.A. that one doctor prescribed 800 purple heart tablets a day for a family; another gave a daily supply of 60 sleeping tablets; another a £450 prescription for an anti-T.B. drug for one person, sufficient to last for two and a half years. He went on for a long time showing these abuses of the National Health Service.

The drug industry, he told the doctor—I ask noble Lords just to remember this one figure—spends something like £3 a week per doctor on advertising. Your Lordships all wonder why these amazing prescriptions are written. The pressures on the doctors have never let up. Every week the pressures are greater. These commercial travellers, with their glib tongues, are knocking on the doors of the consulting room all the time. Here are the figures: £3 a week is spent on advertising by the pharmaceutical industry on every doctor in the country, and the drug bill is now £100 million.

In view of all this, it is not surprising that the temper of the meeting encouraged all kinds of ill-digested suggestions, including a payment by the patient. A sum was even mentioned of 10s. for a consultation and a guinea for a visit. The Minister of Health last week in another place—only when pressed, I would remind the noble Marquess, as he will see if he looks at Hansard—promised that he will not introduce a charge. But, my Lords, over these thirteen years we have heard one Minister of Health after another make promises, promises which are written on air, and I feel I cannot attach more importance to this last promise than I have to many unfulfilled promises of the past.

Of course, as the noble Lord, Lord Peddie, said, the suggestion that a charge would protect the doctor from the hypochondriac is unrealistic. The person who insists upon having medicine will go and queue and get his medicine. The small minority who plague the doctor do not take cost into account. If medical advice is once more to e made into a commercial commodity, then the sick and the poor will undoubtedly be the victims. We all know how often the mother with a large family will go to the doctor if she has to pay 10s. each time. How often will the old age pensioners go?

It may be said that there will be a division; that these people will not have to pay. My Lords, coming from a family of doctors, in which I suppose we now have about ten, I feel that we shall simply go back to the old days, when the patient who paid well could knock at the front door and the one who did not pay went to the side surgery. Then, of course, the ones who did not pay were kept waiting while the doctor saw the ones who came to the front door. We have been through all this. This is Dickensian. We thought we had finished with it all. Yet at this conference it was suggested that 10s. should be charged each time a woman takes her child to see the doctor. The Minister should have denounced this question of payment long ago.

I bring up another matter here, because I want to get this off my chest before we adjourn. The Minister will recall that the medical profession suggested a little while ago that they should charge for teaching the use of the contraceptive pill. This was the thin edge of the wedge. Why did the Minister not say forthwith, "No"? I am hoping to hear from the Minister who is to wind up that he will now tell the doctors that there is to be no charge.

My Lords, I am delighted to see that the noble Lord, Lord McCorquodale of Newton, has walked in so late, so that I can say something else which has been worrying me. About three weeks ago the noble Lord quite understandably moved a Motion in this House which was concerned with the explosion of population. He—and I am going to get it right now—as Chairman of the Appeals Committee of the Family Planning Association expounded the theory that universal birth control would solve the problem. I thought I made it quite clear that I believe in birth control, but what I said was that I thought it would be near-criminal to teach primitive women, without medical aid or nursing aid, to use the birth control pill which had not been proven. I want to bring to the notice of the noble Lord that at this meeting Dr. Eric Gerrard, who is the new President of the British Medical Association, vindicated me.

LORD McCORQUODALE OF NEWTON

I saw the report.

BARONESS SUMMERSKILL

I am glad the noble Lord saw it, because when the noble Lord got up—and I could hardly believe it; and Sir Julian Huxley wrote a letter to The Times next day—he said that I was cool about birth control. My goodness me!, of course I support a planned family. I have a son and a daughter. But I think it would be the cruellest possible thing to teach these primitive women to use a pill which has been unproven. Finally, may I just say what Dr. Gerrard said in his presidential speech at this meeting—and I am jolly proud of him that he did. He said that the pill may be harmful and the women who take it are being used as human guinea pigs, and that not only should they be told this but so also should their husbands.

LORD McCORQUODALE OF NEWTON

My Lords, the noble Baroness has referred to me, and no one would blame her for doing so. She will remember that I did not mention the word "pill" throughout the whole of a much-too-long speech. I emphasised that I thought a great deal more research was needed before the proper contraceptive was found which would be suitable for primitive peoples. On the other side, there are a great number of very eminent doctors who do not agree with Dr. Gerrard and the noble Baroness. I am informed by the magazine Time that there are over 5 million women in the United States alone who are availing themselves of this pill, and I wonder what is going to happen.

BARONESS SUMMERSKILL

My Lords, I would just remind the noble Lord that a few years ago—and this was before he went into the birth control movement—when I first mentioned this subject and explained in detail that this pill bombarded the little pituitary gland at the base of the brain, which itself controls the reproductive functions, and when I said that I thought the use of this pill was a terrible thing to teach women, one of the noble Lord's present associates said that the women of the country must not listen to these "fuddy-duddies". So I wanted to prove that Dr. Gerrard was among the "fuddy-duddies" and that a lot of people think he is right. He got up at the meeting to say that the women he is concerned with in this country should no longer be used as human guinea pigs, and I ask why a doctor should be paid for converting a woman into a human guinea pig, which is what is being suggested now. I have not observed that the noble Lord, representing the Family Planning Association in an important field has denounced the pill and supported Dr. Gerrard.

It has been mentioned before—nearly everything that I am saying has been mentioned by one noble Lord or another—that one of the most disastrous consequences of this Administra- tion is the failure to provide sufficient doctors. The fact is, I am told, that in the hospitals North of the Wash 50 per cent. of the staff are now men and women from the Commonwealth, and those men and women are now wanted at home. The Willink Committee made a colossal blunder when it reported on medical students. What was the Ministry doing? The Ministry was dragging its feet. To become a doctor these days takes nearly seven years and the Ministry waited—yes, I am saying "Ministry" and, as a former Minister, I know that one should always say "Minister"; but in this matter I feel that there have been so many Ministers without the necessary knowledge and expertise that the Ministry really is culpable.

All these years they have dragged their feet; all these years they have seen all these hospitals North of the Wash, and many of them down here, staffed by men and women from overseas. And what has been done? Nothing at all. They seem to live from day to day, in a kind of Alice in Wonderland world. Now it is announced, after thirteen years of Conservative Administration, when we are short of doctors, auxiliary workers, midwives, nurses—every worker in the health services—that they are opening a new medical school at Nottingham. My Lords, it takes seven years to make a doctor. What, oh what, a confession of failure!

LORD TAYLOR

We do not know when they are going to open it, either.

BARONESS SUMMERSKILL

Then may I just say this? It is not customary for one professional conference to debate the conditions of service of another group of workers, but it seems that the doctors at this conference were so incensed at the scurvy treatment meted out to the nurses, midwives and auxiliary professions that they ignored this convention and put motions down on the order paper directing attention to the conditions of their colleagues in the other categories of medicine. The right reverend Prelate the Lord Bishop of Lichfield—it is good to hear anything coming from those Benches which is so full of humanity; we do not hear enough of it—said he thought that if the chaplains had a chat with some of the nurses they might stay on; and he asked, "Why is it we have not got more midwives?" I implore him to look at their conditions of service. Does he not know that just recently it has been decided to give a girl who stays up all night an additional 5s.? I think if he will examine the amount paid to domestic cleaners, perhaps those in Lichfield, he will find it is 5s. an hour. But a young girl who stays up all night is going to have a supplement to her wage of 5s.

THE LORD BISHOP OF LICHFIELD

My Lords, if I may just interject, I referred to the fact that when a nurse started her midwifery training she was drawing less than she might have done if she had gone out into private nursing; and I would ask the noble Baroness to remember that I did refer to those conditions of service.

BARONESS SUMMERSKILL

I prefaced my remarks by saying what a nice man the right reverend Prelate was. I can assure the right reverend Prelate that I am so sensitive to what any man says on these matters that I listened to every word he said. But I am taking the 5s. to point out to him that he cannot dismiss the financial aspect of this matter. These girls are young, healthy, 18, 19, 20-year olds, and they are sitting alone all night. How many men would do it? How many Bishops would do it for five shillings a night? So do not let us turn round and say, "These girls have a vocation. Should a chaplain not see them and direct them along the right channels?". They are human beings wanting love, laughter, joy and to go out. They are not some group of dedicated, frosty individuals who get a curious kind of masochistic delight by sitting alone all night and being given 5s. for it. This question of the treatment of these girls is raised time after time. I have observed that every time a noble Lord from the other Benches goes into hospital and has an illness or operation he comes out full of gratitude, but in a few months' time it is all forgotten.

Now what have we heard lately? These nurses and midwives that we are talking about have been waiting a long time in the queue—much longer than the postmen, much longer than anybody else—and what have they been given in the last fortnight, and how many voices were raised on their behalf? They were given an increase of 3 per cent. What do we hear about Ferranti? I hear of there being a violent debate in the other House to-day—I say "violent": I mean that tempers have been aroused—on the subject of Ferranti. Ferranti goes to a Government Department, and the Government Department doffs its hat to him. It is intimidated by him, and it gives Ferranti £6 million profit, or indeed it seems anything he asks for. But when the hardworking, modest little nurse or midwife comes along, then the Government Department parades toughness, saying, "We will show these women", and it demonstrates how carefully it distributes the taxpayers' money by giving them 1 per cent. below the "guiding light". My Lords, how can this be justified? Is it any wonder that these girls, who can go into plenty of other jobs, realise that they are being exploited in the Health Service?

The right reverend Prelate raised the question of the maternity accommodation. I have on other occasions pointed to the failure to provide adequate accommodation for maternity cases, with the result that women in the North-East are being sent home prematurely. I am told that some are being sent home in 24 hours, and some even less. After thirteen years of Conservative Administration, although years ago we were demanding more maternity accommodation, this is the primitive position. If we were in an undeveloped country, I could understand it. I do not think I am putting a Party case. I see from Tuesday's Guardian that the Association for the Improvement in the Maternity Services introduced itself to the Ministry of Health with the comment, in the last three years, far from gaining improvements, we find that the maternity services are hard put to it to cope at all in the face of increasing difficulties. I have only a little more to say, but I see here my noble friend who has had an illness during this Session and whom we are delighted to see at this final Health debate. Before I came here he showed me a letter which he had had from his home town, Weston - super - Mare. Although I have already dealt with hospitals, and because we have such admiration and respect for him, I should just like to bring to your Lordships' notice that in that little town, which has been desperately waiting for 400 beds, individuals are writing to people they think might help them. I have here a letter from Weston-super-Mare, where they were promised a hospital of 400 beds, and it was recently announced that this has been postponed to an unspecified date after 1972. I would ask the Minister, by the way, to take this matter up. Here again is an illustration of the whole Service, it seems, almost grinding to a halt.

My Lords, a doctor is not infallible, but we must proceed on the assumption that he can cure a few, relieve many and comfort all. If this is to be achieved, his door must be left open for the patient without any monetary considerations. He must have the help of a domiciliary team—how often have I said that in the last thirty years?—and a hospital always available. This was the original purpose of the National Health Service, and it is to be deplored that under this Government, after thirteen years of Conservative Administration, one Minister of Health after another has failed to provide the optimum conditions of service. It seems to me that, but for the dedication of the doctors, nurses, midwives and auxiliary workers, the great Health Service of this country might well have foundered under Conservative rule.

7.10 p.m.

THE JOINT PARLIAMENTARY SECRETARY, MINISTRY OF HEALTH (THE MARQUESS OF LOTHIAN)

My Lords, may I first of all thank the noble Lord, Lord Taylor, for giving the House the opportunity to debate the Hospital and Medical Services, and I know he will not mind if I also join with his name that of his colleague the noble Baroness, Lady Summerskill, who was the original proposer of this Motion.

Inevitably, this debate has covered a wide field, and if I were to attempt to answer all the points which have been raised or even to give a comprehensive picture of these services I feel certain that at this late hour your thoughts would be drifting to the delights of a well-earned holiday. I will therefore confine my remarks to the points which I think can usefully be made in order to get these matters into perspective. This does not mean that I shall ignore the suggestions and criticisms that have been made by your Lordships. On the contrary, I shall look at them most carefully when I come to read the OFFICIAL REPORT and shall write to any noble Lord who has asked a question which I have not answered. It seems to me that the great weight of criticism this afternoon—and there has been quite a lot from all sides—has fallen on the two Hospital Plans (one for England and Wales and one for Scotland) and because of this I should like to mention the Hospital Service first.

I must emphasise that from the first the Plans were intended to be flexible. They aimed at spending in England and Wales £500 million and in Scotland £70 million in the first ten years. They gave a broad outline, as clearly as it could be set out in the early stages of planning, of the major work which might be started in ten years. But it was made clear in the Command Papers which described the Plans that the estimates were tentative, and they said in clear terms that the estimates might have to be modified considerably when the detailed schedules of accommodation came to be prepared. The second revision shows £750 million for England and Wales for the next ten years and £105 million for Scotland. It was clearly recognised in the original Plans that they represented only a first instalment of the long-term planning of the Hospital Service. There was never any suggestion that all that was needed would be accomplished within these figures.

A number of your Lordships have made much of the fact, and very understandably so, that a number of the schemes listed in the original programme have been deferred and it has been suggested that less work is now being done than was intended by the Government. This is not so. I myself quite understand the feelings of hospitals whose plans have, should we say, been upset in this way, but it is not true that less work is being done. The total amount of building work has been increased. But more detailed planning has led to certain schemes being deferred within the increased money available.

There are a number of reasons, as I think noble Lords opposite will appreciate. There have been real increases in the cost of some schemes; there have been reassessments of priorities, for example, the bringing forward of schemes which will provide more maternity beds; there have been changes to meet varying local circumstances; and there have been radical changes in the size and scope of some schemes. It is a fact, too, that many schemes in the programme are now very much larger than was earlier intended and will provide, it is hoped, a better service. In fact, the programme is increasing each year. This year, as the noble Lord, Lord Peddie, reminded us, we are spending £66 million on hospital building. In the first three years of the Plan no fewer than 109 major schemes were completed and 72 new and substantially remodelled hospitals, together with 91 other major schemes, were started. About £140 million worth of work is in progress at the moment.

Five new hospitals have been wholly completed in the last ten years and 15 phases of new hospitals have been completed in England and Wales during the same time. Perhaps I may say, in parenthesis, to the noble Lord, Lord Stonham, that my right honourable friend fully appreciates that if large schemes are deferred, changes in the timing of small schemes and in the inclusion of entirely new small schemes to keep going hospitals which will eventually be replaced, may be necessary, even if this means deferring some other schemes. This is one of the reasons why the Plan must be kept constantly under review. It is totally wrong to look upon it as something which should not be subject to frequent change. We feel that it should never become a strait-jacket.

I would take this opportunity of reminding your Lordships that the Hospital Building Programme is one of many large building programmes which rely upon the capacity of the building industry for their achievement. There are limits even for that progressive industry, and if all the work to be done is to be completed within the period allocated it is essential that their sponsors should utilise the best available modern techniques of building and management so as to conserve supplies of skilled labour and to achieve rapid construction despite the difficulties of climate, supplies and, in many cases, geo-graphical location. Of course, I agree there are many buildings that are still out of date, but they are being upgraded, and new equipment is coming forward.

Criticism has been made of the apparent failure to plan services in relation to the population. The noble Lord of course knows well that the hospital pattern which the National Health Service inherited from local authorities and voluntary bodies was largely the product of historical causes. Changing notions of the right place for a hospital had meant that some of them were in the wrong place by modern standards; others, once conveniently situated, were no longer so because of movements of population.

It was made clear in the Hospital Plan that, as a beginning to planning, assessments were made of the probable size of the population, the proportion of elderly people and the birth rate, region by region, in 1975. An attempt was also made to take account, so far as possible, of specific future developments which would affect the local distribution of the population. In addition, standards were set for the relating to the size of the population to be served of the scale of hospital provision which needed to be planned. We recognise that population patterns may change in a way that had not been foreseen at an earlier stage. We are aware that changes in the development of services outside the hospital, in the efficiency of the hospitals, or in needs for, and methods of, treatment may call for a re-setting of the standards of provision, and I think that any charge that our planning has not taken these things into account really cannot stand.

One or two noble Lords, notably the noble Lord, Lord Taylor, brought up the question of new hospitals in contrast to improving the old ones. I think he will be aware that the pros and cons of new building as against improvements to old buildings do not provide an easy solution capable of general application but have to be considered in each individual case. I might point out that the starting of new hospitals accounts for less than a quarter of the major schemes in the programme and about half the major schemes are major additions and improvements to existing hospitals. The implementation of the Hospital Plan will involve the closure of some small hospitals, but (and I would stress this) only where the consequence will be an improved service for the patient.

I am quite well aware of the situation described by the noble Lord, Lord Auckland, regarding the cottage hospitals. I think we all admire the work done in these cottage hospitals. But the welfare of the patient must be the paramount consideration, and to-day the patient goes into hospital to be treated not always only by one doctor, whether physician or surgeon, but by other specialists—radiologist, pathologist or anæsthetist. The value to the patient is in the team, and the team needs to have at its disposal complicated and expensive equipment. To work efficiently for the benefit of the majority of the patients, it must spend the major part of its time at its base.

I think that it would be true to say (and we have heard a lot about this to-day) that at this point in time the general practitioner service is under greater scrutiny by the profession itself, Parliament, the Government, Press and public alike than at any other time since the inception of the National Health Service. As your Lordships are aware, the profession have submitted a claim for an increase in remuneration of about £900 a year. This claim is at present before the independent Review Body. I know that your Lordships will not expect me to make any comment on remuneration while the matter is under consideration by the Review Body. The wide publicity given to the pronouncements at the recent British Medical Association meeting in Manchester indicates the general interest in this subject at this moment.

The fact that the Working Party set up by my right honourable friend the Minister of Health is about to issue a first group of papers on matters of concern to the profession illustrates the need to look closely at the terms of service of the general practitioner service. I shall not, I think, be guilty of giving away any secrets if I now say that the Working Party will be publishing interim papers to-morrow. I know that all of us would like to know what success is likely to be achieved by this co-operative effort between the Health Departments and the profession. But it is too early to make judgments of this kind. The Working Party is confronted with a tremendous number of problems, some big, some small, and it may be some time yet before significant progress can be recorded. However, the reactions of the general practitioners to these first papers will be awaited with great interest by all concerned.

During the course of this debate a number of speeches have drawn attention to the shortage of doctors. Those who have studied the OFFICIAL REPORT of last Monday's debate in another place on the Family Doctor Service will know that my right honourable friend then announced that a new medical school is to be provided at Nottingham, where a new hospital of about 1,200 beds and a school with an intake of 100 students is visualised. In answer to the noble Lord, I understand that the site at Nottingham was chosen on the recommendation of the University Grants Committee, but I do not myself know what led them to this conclusion.

LORD PEDDIE

My Lords, can the noble Marquess say whether any consideration was given to the claims of Manchester?

THE MARQUESS OF LOTHIAN

My Lords, I am afraid that I do not know which towns put in claims, but I know that the Committee considered them at various times. Whether Manchester was included in this consideration, I do not know, but I will get in touch with the noble Lord later about this point.

My right honourable friend also announced during that debate that it had been agreed that the existing medical schools should be expanded to increase the annual intake of British-based students by about 150 by October, 1966. This means that by October of that year, there should be some 400 extra British-based medical students in our existing schools. This is a significant increase when one considers that the autumn in-take of British students into our medical schools in 1963 was 2,153, and that figure itself was 20 per cent. greater than the 1960–61 intake. We are considering the possibility of making further increases in the longer term.

The noble Lord, Lord Taylor, mentioned the Abel-Smith Report on Emigration. The Abel-Smith study highlighted another aspect of the problem of doctor shortage. It concluded that between 1955 and 1962 an annual average of about 390 British born and trained doctors left this country and had not returned by July, 1962. Independent studies recently completed by my Department confirm this figure, but it is not a true figure of net emigration of British doctors. By that I mean that the figure does not take into account the fact that some of the doctors who left in each of these years will return to work here. As the Abel-Smith study shows, about one-quarter of British doctors abroad had some sort of intention of returning to this country. But I do not wish to give the impression that we are happy with this situation. My Department are still studying emigration and have secured the B.M.A.'s agreement to sending a special questionnaire to a sample of doctors. They are also studying the rate of immigration which was outside Abel-Smith's terms of reference.

I feel that I cannot leave the subject of medical manpower before reminding your Lordships of a few simple facts. In 1951, the number of general practitioners in Great Britain was about 19,500. By 1963 the number had risen by 18 per cent. to about 23,000. In 1951, approximately 48 per cent. of the population were living in under-doctored areas; by 1963 the proportion had fallen to 19 per cent. In 1953 the numbers of hospital doctors of all grades was 16,000; by 1963 it had risen to 20,000.

I would say a word here, in reply to the noble Lord, Lord Taylor, on the question of infant mortality. I have no doubt that the high degree of co-operation in Harlow, to which the noble Lord has referred, between the various services for the care of mother and child has made a substantial contribution towards the low infant mortality rate achieved in 1963. I think that this is a matter on which Harlow should be very much congratulated. Such co-operation is in accord with the advice which my right honourable friend the Minister of Health has received from the bodies that advise him and which has been circulated widely to all branches concerned of the National Health Service.

The infant mortality rate for England and Wales in 1963 of 21.1 infant deaths per 1,000 live births is the lowest reached so far, and it reflects the constant efforts on the part of all concerned to secure that mothers understand the importance of taking advantage for themselves and their children of the services freely available for them. But there are factors affecting the infant mortality rate about which we need to know more. Apart from the variations which occur from locality to locality, there is the well-known regional variation. The rate is consistently lower in London and the Southern and Eastern parts of England than in the Midlands, further North and in Wales. There is no simple explanation of the regional variations, but my right honourable friend the Minister of Health hopes that a special study which the Registrar General is to make of infant deaths in the twelve months up to March, 1965, will contribute data of value to inquiries. There is, in addition, a special study of post-neo-natal mortality being carried out by the Ministry of Health, with the co-operation of the medical officers of health of Bristol, Birmingham and Gloucestershire.

I should like, if I may, to depart from the general to concentrate on the particular, and will attempt to satisfy, or at any rate answer, a number of noble Lords who were kind enough to let me know in advance some of the points they were going to raise during the debate. In answer to the noble Lord, Lord Crook, I would confirm what I have already told him in conversations which he mentioned we had had: that the Government have at present no information from nation-wide records about the incidence of cystic fibrosis. We are aware of the estimates that have been made in America and here, which suggest that about one child in every 2 to 2½ thousand born has this disease. This would mean that at present 350 children are born with it every year in England and Wales.

The disease has not so far been identified in the national statistics of cause of deaths, but thanks to the attention the noble Lord has already drawn to it the Registrar-General has now made arrangements specially to extract statistical information about the deaths which doctors certify as being due to the disease, and to obtain information about children admitted to hospital with the disease. The reliability of this information must be dependent on the extent to which doctors are aware of the disease and able to identify it. It is probable that, in the past at least, doctors will in many cases have certified deaths as being due to chronic lung diseases when they were really due to this condition which may have gone unrecognised. It has to be borne in mind that any one general practitioner is not likely to see more than one case in a lifetime's practice. I hope that what the noble Lord has said to-day and what I have said will draw the attention of general practitioners to this problem.

When there has been time to accumulate sufficient records of this condition to provide a basis for statistical analysis, we shall be glad to provide statistical data to those who are interested in this disease and may be able to use it. My Ministry and the General Register Office would also be willing to offer to those interested what help they can in tracing cases of this disease. I can also assure the noble Lord that the Medical Research Council have supported research on the genetics of the disease and are willing to consider providing support for any further worthwhile studies. It is sad that in the present state of our knowledge cystic fibrosis cannot be prevented; nor can it be cured. The prognosis in individual cases depends upon the severity of the symptoms and the age at which they appear, but I am glad to say that in recent years the outlook has been greatly improved by early diagnosis and modern treatment.

LORD CROOK

My Lords, before the noble Marquess continues, may I save time by thanking him for his courtesy and kindness?

THE MARQUESS OF LOTHIAN

My Lords, I am obliged.

The noble Lord, Lord Amulree, raised a few points, and I hope he will forgive me if I reply only briefly to one or two of them. The care of the increasing numbers of frail old people is admittedly a very large and growing problem and, as I said in the debate on the Welfare Services on April 22, its implications are being examined. A number of studies of the services needed for the elderly have been made, are in progress, or are planned. For example, in the autumn of this year the Government Social Survey will be carrying out the pilot study of the needs of old people for special housing, community care services (including residential homes) and hospital care which the National Corporation for the Care of Old People has agreed to finance; and if the pilot survey is a success, the National Corporation will consider its extension to a number of other areas.

It would, in our view be a mistake to think that the undoubted difficulties of caring for the elderly would be solved or even eased if what we call Part III accommodation were in the future to be administered by the hospital authorities, as Lord Amulree suggests. The noble Lord said that this is really what I said the last time, but it was not timed well. I am afraid I cannot give him any better answer to-day. For one thing, while this would abolish one boundary line, that between residential accommodation and the hospitals, it would create a new and very difficult one between care in a residential home and care just short of that provided by a residential home—for example, in special housing with a warden and supporting domiciliary services. But I assure the noble Lord that this is a matter that we keep under consideration.

LORD AMULREE

Does not the noble Marquess think that the Government or the Ministry should encourage local authorities, certainly in the London area, to be a little more forthcoming and amiable in their approach to the subject than they are at the present time?

THE MARQUESS OF LOTHIAN

I will take note of what the noble Lord says on that point. On the noble Lord's second point about which he let me know, I would agree that we must strive for an economical employment of domiciliary visitors both to save skilled man and woman power and to avoid an unnecessary number of visits to the home. The functions of health visitors, home nurses and social workers, though related, are, however, distinct and, as I said in the previous debate, true progress lies not in seeking to merge their differing functions, but rather in ensuring that each makes her own particular contribution; and not in seeking to roll several domiciliary visitors into one, but rather in securing that all work together and towards a common aim.

The noble Lord, Lord Stonham, in a most eloquent speech, if I may say so, raised a subject in which I know he is deeply interested, and in reply to him I would say that local authorities have been encouraged to develop their health and welfare services, including those for the mentally disordered, and are doing so rapidly. The increasing number of available places in purpose-built training centres for the mentally subnormal, in day centres for the mentally ill and in hostels, together with authorities' plans for further expansion, are proof of this. There is, as the noble Lord knows, much scope for experiment, and new experience is being gained all the time. He asked me a question some time ago about the projects initiated by the Carnegie Trust. This is the sort of thing that we welcome and encourage, and there are many experiments being carried out by local authorities, as he knows, on their own initiative.

In general the pattern is to provide separately for the mentally ill and the subnormal. This is true not only of training and rehabilitation but also of hostel provision. Nevertheless, experience has shown that provided it is done on a selective basis, small numbers of mentally subnormal adults can work alongside the mentally ill, and small numbers of the mentally ill alongside the subnormal, to their mutual advantage. This is the present view, but this is a field where our knowledge is very incomplete and we must be prepared to reconsider our approach in the light of increased knowledge.

The services for the mentally ill after discharge from hospital are admittedly not complete. There is a need for more social workers, more places in day centres, and better liaison between hospitals, local authorities and general practitioners—in fact, very much what the noble Lord was pointing out to us. But the social workers are being trained in greater numbers. The number of places in day centres is planned to increase from the present figure of about 600 to nearly 3,000 by 1974; co-operation between the various branches of the service is a delicate plant which cannot be forced to grow more quickly than human nature will permit, but it is growing. The Department have recently issued guidance to hospital authorities on how to improve the effectiveness of hospitals for the mentally ill. This memorandum, of which copies have been sent to local health authorities and Executive Councils stressed again the need for this co-operation and set out a number of specific instances of the forms it should take.

We recognise that the Psychiatric Rehabilitation Association is doing useful and worthwhile work in supplementing what is being done by the local authorities. So are several other voluntary bodies: the work of the Mental After-Care Association and the Richmond Fellowship in helping to rehabilitate people who have suffered mental illness comes to mind. The Ministry welcome these contributions to the common effort and take every opportunity to encourage the statutory and voluntary bodies to work in close co-operation with each other.

Various other points were raised during the debate, but I do not think I can answer them all. My noble friend Lord Auckland asked me about physiotherapists. It is true that there is a shortage, but I understand that the numbers are now higher than they have been. The number started increasing again last year, and it is hoped that this will continue. There is the question of their pay. As my noble friend knows, a substantial claim over the pay of physiotherapists is in front of the Industrial Court at the moment, and he will not expect me to refer to that at the present time.

LORD AUCKLAND

My Lords, can my noble friend give any indication as to how long this settlement will be in coming to fruition? It has been under consideration now for quite a long time.

THE MARQUESS OF LOTHIAN

No, my Lords. I am afraid that I cannot, off the cuff, give my noble friend an answer on that point. But I will let him know as soon as I can.

The noble Lord also raised a point concerning unrestricted visiting by parents to children's hospitals. I understand the indications are that this is now going very well, and we are now doing everything we can to see that visiting of this sort is entirely unrestricted. If the noble Lord goes round, I think he will find that this is the case. I should also like to thank the right reverend Prelate for his most interesting speech. I was especially taken up by what he said about Commonwealth medical co-operation, and the need to encourage doctors to come here. He also asked me if I could do anything to help in the provision of more chaplains. May I assure him that I will look into this question for him and let him know?

Before I sit down, I should like to say this. Despite what we have heard, not so much to-day perhaps, but sometimes, I think the House will agree that in the National Health Service this country has something that is unique and the envy of the world. Gratitude has a short memory, but many of us, if we cast our minds back, can remember what life was like before the N.H.S. We now have only to compare ourselves even with other prosperous, rich countries to realise what terrible economic disaster to a family a serious illness can bring. I should like to second what my noble friend Lord McCorquodale of Newton said in paying a tribute to the late Mr. Bevan as the architect of this Service. But there is nothing good that cannot be made better; and although much remains to be done to chisel it into a perfect shape I think we must be proud of it; for, as a doctor said to me the other day, "Never before has so much good medicine been brought to so many people." I think that is a very apt comment on the Service.

Many of the suggestions and criticisms made by noble Lords to-day have been most constructive and most sincere. Nevertheless, it does; great harm when people in the country continually carp and complain about the Service concentrating, like some critics of art, always on the blemishes, and forgetting the masterpiece; because I feel that if the spirit in the National Health Service was as bad as some people made out, it would not be the excellent Service that it undoubtedly is. That is why I should like to pay a sincere tribute to all those who work in the National Health Service, not only the paid staff, but also members of boards and committees, voluntary workers and, if I may be allowed to say so, the officials in my own Ministry. We owe them all a big debt of gratitude. I have myself seen, this past few months, in hospitals, homes and clinics up and down the country, something of the dynamic and dedicated efforts that are achieving so much in the relief of the abiding problem of human suffering and ill-health. I am certain, my Lords, that in terms of human happiness, and in removing from the minds of men and women the fear that ill-health and disease used to bring, the National Health Service is one of this country's finest achievements of recent years.

7.44 p.m.

LORD TAYLOR

My Lords, I should like to say "Thank you" to the noble Marquess, Lord Lothian, for a nice winding-up speech. Of course, he will not expect us to agree with all he has said, but he makes the point that as soon as we get a good Minister on the other side, if this Parliament were to go on, he would be moved somewhere else. He would be made First Lord of the Admiralty and we should be landed again. My noble friend says that the noble Marquess made a better speech than usual, but I would not be so presumptuous. I thought he made a nice winding-up speech. I should like to thank all noble Lords and Ladies who have taken part in the debate. I am sorry there have not been more speakers from the other side. We are also grateful to the right reverend Prelate for his very interesting speech. On behalf of my noble friend Lady Summerskill and myself, I would thank all who have spoken, and beg leave to withdraw what is really our Motion.

Motion for Papers, by leave, withdrawn.