§ 3.58 p.m.
§ Debate resumed.
§ LORD SHACKLETON
My Lords, I welcome very much the opportunity of replying to the noble Lord, Lord Cohen of Birkenhead, on behalf of the Government, and I am sure all of us, including all those noble Lords who were primarily here to listen to the Statement on the Common Market, have benefited from the noble Lord's wisdom. We are also grateful to him for his tireless promotion of the cause of health education, not least in his capacity of Chairman of the Joint Committee whose Report we are debating to-day. I was about to say that I am a great admirer of the noble Lord, but I think the whole of your Lordships' House would share that view because of his very widely based activities, many-sided, in the field of medicine, and I think the Government and the country were fortunate in having him as the Chairman of the Joint Committee about which he spoke.
It is, I hope, for the convenience of your Lordships that I enter this debate early on, in order to make what I hope will be a fairly short speech, purely on the Government's part and the Government's action in regard to this Report, and later, with the leave of the House, I hope to deal with some of the points raised by the distinguished group of Peers who are to take part in the debate to-day. The fact that in these initial remarks I do not deal with any particular aspect of health is simply in order to help the House by explaining the position of the Government. I am sure we are very glad to see that there are two maiden speakers. Lord Donaldson of Kingsbridge and Lord Garnsworthy, whose speeches we shall look forward to hearing.
1465 One of the difficulties of debating health education is to decide what is health education and what is health, and I am sure this is a subject on which the noble Lord, Lord Cohen of Birkenhead, in his chairmanship of this Committee, was trying continually to steer a sort of dividing-line. But of course it is an indivisible subject, and inevitably, therefore, there will have to be some move across into subjects on which people might say, "Surely that is not health education". We cannot discuss it without looking at it pretty widely.
I think I should be prepared frankly to admit, and I believe your Lordships would, that in the past health education has not always had the priority it deserved. We are all accustomed to the admirable health education that the noble Lord, Lord Hill of Luton, single-mindedly used to give on the radio, and the noble Lord to some extent was a health education policy. But we want to give it a more organised basis than it has had in the past. It has not been as well done as it should have been, and in this I do not in any way impute blame or failure to those people who did labour in this field with little resources and sometimes not much encouragement.
The most important step the Government have taken to remedy the deficiencies was taken last year when my right honourable friend the Minister of Health announced for England and Wales that the Government accepted the Joint Committee's conclusions that increased effort was needed in health education and that the first priority was a new and stronger organisation. He went on to explain that the Government proposed to establish a new Health Education Council for England and Wales, and the scope of this was later extended to include Northern Ireland. Its functions would be broadly as proposed in the Cohen Committee's Report, and its task would be in particular to work out the detailed implications of the proposal in consultation with the local authority associations and the professional and other bodies concerned. I perhaps should make that clear; it is, of course, for the Government to work this out in the first instance, and then for the new Health Council to take on that responsibility, with the Government, as I hope, always behind giving support.
1466 The Government did not arrive at this decision either lightly, or indeed, as the noble Lord, Lord Cohen of Birkenhead, would say, quickly. They did take some time to make up their mind. If I may say so, this is not a purely technical defence; it was in a sense a tribute to the wide range of the work of the Joint Committee. There was a good deal of food for thought and there had to be the fullest consultation with the many interested parties. The Government realised that the decision they were going to take would have a far-reaching effect on people's lives in this country. The work to be done by the new body proposed in the Report would be a preparation for the years ahead, an investment in the future health and wellbeing of the community.
Immediately following the Minister's announcement the Government went into detailed consultations with the local authority associations and professional bodies in England and Wales about the constitution and functions of the proposed new Council, and on questions of staffing and finance. I am afraid the processes involved have taken a great deal longer than the Minister would have wished, but it is obvious that we were laying foundations which we should hope would last for many years ahead and would be of a kind that would be sound from the point of view of the work to be done.
The new Council's main functions will, therefore, be to plan and promote national programmes of health education in selected subjects, to assist local authorities in the development and execution of local programmes, to undertake research into health education techniques and to evaluate the results, and to foster the training of staff engaged in health education. And this is right on the line with those subjects to which the noble Lord, Lord Cohen of Birkenhead, and his colleagues attached importance. It will take over the functions, among other bodies, of the Central Council for Health Education. It will absorb the present health education promotional activities of the Ministry of Health.
At this point it would be right to pay a tribute to the body it replaces, namely the Central Council for Health Education, It has been operational in this field for some forty years and it has made an 1467 admirable contribution to this cause, having regard to financial limitations. I think we should draw particular attention to its role in the training of those working in health education, and its work, too, in sustaining interest in the subject by way of its training courses, seminars and summer schools. It is, I think, very much to its credit that during this recent period of uncertainty over the future direction of health education it has continued its work with the traditional diligence that it has shown over the years.
I should like to turn now to the constitution of the proposed new Council. In their Report the Joint Committee foresaw the Council as having the same sort of relationship with the Government as the Board controlling the Public Health Laboratory Service in England and Wales. In other words—and I quote from the Report:it would, through its constitution, membership and financial dependence, maintain a close working relationship with Government departments, including the education departments, and yet remain freer to experiment, to adopt unusual courses and to take risks".I should like to turn to the particular points on which the noble Lord asked for an assurance, and I am happy to say I can give him a complete assurance on those points that he made in the concluding part of his speech. The Minister had to bear in mind the need for a body no larger than was essential for the effective carrying out of its policy-making and executive functions, while, at the same time, he had to ensure that its membership included the range of qualities, knowledge and experience that need to be brought to the Council's activities. He concluded that it should be made up of 16 members. The Chairman and three members would be appointed by the Minister of Health, and one member each by the Secretary of State for Education and Science and the Minister of Health and Social Services of Northern Ireland. Of the remaining ten members, the Minister would appoint from nominations by the local authority associations—the County Councils Association, the Association of Municipal Corporations, the U.D.C. and R.D.C. Associations—and there would also be one each from nominations made by medical, educational, dental and nursing organisations. But I 1468 should like to make clear that they are not being appointed as representatives of those bodies.
The Minister is making the appointments. Names have been submitted. Indeed, in most cases, if not in every case, the Minister has asked for a list of names from which he has made the appointment. So I hope I have been able to meet the noble Lord on this point. As the noble Lord said, the Minister has appointed the noble Baroness, Lady Serota, to the chairmanship of the new Council, and I absolutely agree with the noble Lord that there could not be a more promising start to the work of the Council than the appointment of the noble Baroness. I do not know whether it is the application of the Addison Rules or the general custom of the House, but it is sad that she feels she is unable to speak. But I am sure this appointment gives us all great confidence. The Minister hopes shortly to announce the names of the other members. Indeed, we had hoped that I should be able to announce them to-day, but the list is not yet quite complete. The expectation is that the Council will begin its work early in the New Year and become fully operational from April next.
I have been referring to the new body as the Health Education Council, but it may be that when it meets it will decide to call itself by some other name, such as the Health Education Board. One of the Council's first jobs will no doubt be to appoint committees or advisory bodies to provide specialised professional advice and help on particular aspects of health education. These of course could include representatives from organisations who are not already directly linked with or specifically represented on the Council.
The intention, to begin with, is that the Council will be incorporated under the Companies Act 1948. Its Memorandum and Articles of Association will prescribe the relationship between the Council and the Minister, and so ensure broad agreement between their respective policies. Although the Council will be expected to work closely with the Health Departments I have the Minister's assurance that he will exercise his power of direction exceptionally and only where he is satisfied that it is necessary in the public interest. As we know, it is rare that 1469 Ministers exercise their powers of direction in this form. We expect that there will be good relations and close understanding and co-operation. This will impose a responsibility, which we acknowledge, not merely on the Council itself but also on Ministers, to understand the work of the Council. Its new independence, therefore, will be real, and it will be freer to experiment and pursue unusual courses of action than would have been the case if health education had remained an entirely departmental function within the ambit of the Ministry of Health.
The detailed financing of the Council is something which remains to be worked out in consultation with the local authority associations and with the Council itself. Until the Council has been able to plan its work and budget it will not be possible to determine exactly what sums will be required. However, the Government fully accept that the major part of any increase in expenditure should be met from Exchequer funds, and they envisage a rising level of expenditure on the work as the Council develops, accompanied by a rising Exchequer contribution. The Government are confident that local authorities will accept the view that it is wholly appropriate—and indeed essential—that they also should contribute at a higher and, if necessary, increasing level, having regard to the extent to which the work of the Council can be expected to supplement and even replace some existing local expenditure on health education.
Experience suggests that centrally directed action in the field of health education in the future will be conducted increasingly through the mass media which can be organised and deployed effectively only by a single central body working on behalf of all those engaged in the field. However, the Government take the view that since local authorities will retain primary responsibility for health education it follows that they should be involved, both financially and otherwise, in responsibility for its central planning and direction. Contributions by local authorities to the expenditure of the Council will be taken into account in the calculation of Exchequer grants to local government, as indeed will local expenditure by the authorities themselves on health education. It will thus rank for 1470 Exchequer grant. It is also hoped that the new Council will attract contributions from industry and commerce and voluntary organisations.
Earlier I described the decision to set up the new body as a most important step. We hope that it marks the beginning of a completely new era in health education. For the first time the central organisation and direction of health education in England, Wales and Northern Ireland will be unified and in the hands of one body alone. The new Council, with greater resources at its disposal, will be expected to carry out a thorough and exhaustive review of all that is being done. What new initiatives will emerge I cannot say, but clearly the new Council! will have very wide scope for making a lasting impression on the health of the nation.
Let me now turn to the position in Scotland. I hope your Lordships will not think that what I now say "unsays" everything I have said with regard to England and Wales; but, as we know, Scotland is a different place; her problems are different, and there are valid reasons for the Scots to tackle their problem in a different way from that in which we have decided to do it in England. The Joint Committee agreed that it would be advantageous to Scotland to have its own self-contained health education body. They envisaged a Board independent in its day-to-day work but accountable in broad terms to Government and local authorities which would absorb the health education functions of the Scottish Home and Health Department and of the Scottish Council for Health Education.
Like the Minister of Health, the Secretary of State for Scotland accepted the Joint Committee's recommendations that increased effort was needed and that for this purpose a new and stronger central organisation was required. He has, however, decided to establish a new Health Education Unit within the Scottish Office, rather than a new body outside it; and he has also arranged for this Unit to work in close association with the Scottish Council for Health Education, which has agreed in principle that, in future, its real role will be to provide training for local authority staff engaged in health education.
1471 The Joint Committee, in their Report, said it seemed to them that cogent arguments could be put forward for entrusting the functions they had in mind for a central body either to the central Departments of Government or to a new body. And in favour of the central Departments they pointed out that health education was an integral part of the National Health Service and should be administered from the same source. The Secretary of State took the view that this was a particularly important consideration in Scotland, and he felt that it would be preferable and would give expression to his own concern to foster health education if the new body were set up within the Scottish Office. There is no reason why different arrangements should not be adopted in England and Wales and in Scotland. As the Joint Committee themselves said, there is much to learn about health education.
This new Scottish Unit will be responsible for stimulating health education, for developing the most effective methods and techniques, and for evaluating results. In due course, it will take on the health education work at present undertaken by the Scottish Home and Health Department and the Scottish Council for Health Education, apart from the latter's responsibility for providing training for local authority staff. In the Unit, staff with appropriate skills in medicine, education and publicity will work together under a Director from the medical field. The staff will be built up gradually, and it is hoped that the principal officers, who are now being recruited, will be in post in time to bring the Unit into operation in April, 1968. Later on there may be added to the staff a nurse and a part-time sociologist and research officer. The Unit will be wholly financed by the Exchequer.
The Director of the Unit will enjoy a considerable degree of autonomy in the conduct of the day-to-day work, and the Unit will be accommodated in premises to be shared with the Scottish Council for Health Education. It will be able to appeal for help from commercial sources. Help will be provided also, in the form of advice, by the Scottish Standing Committee on Dental Health Education, and in due course there will be consultations with the professional organisations to find the right people. 1472 Again, I would pay tribute to the Scottish Council for Health Education which, despite slender resources, has made a notable contribution; and the instructional work will continue. These arrangements have been accepted by the local authority associations, and include an agreement for continued financial support of the Council by local authorities.
THE EARL OF SELKIRK
My Lords, if the noble Lord is leaving that aspect, may I ask whether the Council will be an integral part of the Home Department in Scotland?
§ LORD SHACKLETON
My Lords, I should like to make this clear. The existing Council will continue its activities primarily in the field of training local authority staff. Scotland, unlike England, will have a Unit within the Government Department, under a Director, with a certain amount of autonomy. Therefore the Scottish solution is different from the English one.
I had the impression when listening to the noble Lord, Lord Cohen of Birkenhead—and, indeed, in reading his Report—that he regretted (and I think I regret, as perhaps do the Government now) that we did not earlier recognise the close correlation between the education side and the work of health education. I should like to congratulate the noble Lord, Lord Cohen of Birkenhead, and his colleagues on finding a way of overcoming this difficulty and hoisting it in, possibly not so easily as they might otherwise have done; and it illustrates the great importance of this aspect.
My Lords, I should like to end my remarks by saying something about the school side, because the schools provide unrivalled opportunities for health education. Although my right honourable friends the Secretaries of State have no powers to prescribe the contents of school curricula, which are the responsibility of the local education authorities and schools, they do advise local education authorities in various ways. The Department of Education pamphlet, Health Education, is a handbook of suggestions for the consideration of teachers, and it covers every conceivable topic in the health and education field. It is being revised to take into account some of the more vital topics of the day, such as 1473 smoking, sex education, drug-taking and alcohol. The very special role of the teacher is explained at some length, and also the need for the teacher to have a sound general knowledge of health education principles. Health in Education, another pamphlet issued by the Department, attempts to draw attention to those features of the life of schools which contribute most to the physical, mental and social wellbeing of pupils, and it disseminates information about the ways in which many schools are dealing with personal aspects of health education. The appointment of two members from the field of education to the new Health Education Council in England and Wales and the inclusion of an educationist in the staff of the Scottish Health Education Unit will ensure that there is a real concentration on this vital sphere of health education.
Because we are concerned with individuals, it is fitting that I should conclude my remarks with a reminder that, whatever can be done at national level, the main responsibility for health education must ultimately rest with the local authorities. They are the bodies in the best position to judge the needs of their areas and how these needs can most effectively be met. It is they who employ the staff, such as the health educators, to which Lord Cohen of Birkenhead attaches great importance, and it is this staff who will bring home to the public the ways in which they can achieve high standards of health. The Government's sphere of action is limited. Indeed, I have said nothing at this stage (though I may in my winding-up remarks) about the direct education of all those—whether they be doctors, nurses or others—who are engaged in the field of health education. The Government can ensure that the local authorities receive the support which can most effectively be organised at national level. It was with these considerations in mind that it was decided that local government should have the major voice in the affairs of the new Health Education Council.
This has been far from a complete account of the health education that is currently being undertaken—indeed, it is little more than an introduction to it; but it illustrates the very wide range of activity that will face the new Council as soon as it commences operations. I 1474 look forward to hearing the speeches of a number of noble Lords, and I think it is right that this debate should take place since it will in itself be an important contribution to the health education of this country.
§ 4.26 p.m.
§ BARONESS BROOKE OF YSTRADFELLTE
My Lords, first of all I should like to thank the noble Lord, Lord Cohen of Birkenhead, for the way in which he introduced his Motion. I have for a long time had a great admiration for the work which the noble Lord has done; and I knew that he would give us a fascinating account this afternoon of one of the many subjects on which he is so well informed. His speech was certainly no disappointment to us. I should like also to congratulate the noble Lord the Deputy Leader of the House for the way in which he is able to move from one post to another. At one moment we are, sending him to Aden, and at the next moment we are welcoming him for his part in a debate on health education. It just goes to show what a spendid Deputy Leader he is.
My Lords, it is four years ago this month that the Joint Committee of the Central and Scottish Health Services Councils on Health Education, under the chairmanship of the noble Lord, Lord Cohen of Birkenhead, presented their Report. The Committee had been appointed four years before that and much good work had been done in the tine. In the introduction to their Report they say:We take this opportunity of expressing our appreciation of the great assistance rendered to all those who prepared written evidence or attended our meetings to give oral evidence.Your Lordships will no doubt have picked up the misprint where "to" is used instead of "by"—and yet it may not be a misprint. It may be that all those giving evidence were rendering assistance only to themselves, because four years have passed and neither the Government nor anybody else appear to have, done very much about the Committee's work until the noble Lord initiated this debate to-day, and the Gov-eminent have at last spoken their mind as to what they are intending to do.
I should like at this moment to take the opportunity of welcoming the setting up 1475 of this Council which, I understand, is to come into being in January of next year and hopes to start work in April. I should like to congratulate the Council—which seems to be a somewhat nebulous body which has yet to be appointed—on their chairman. The noble Baroness, Lady Serota, and I, although we sit on opposite sides of the House, for many years have worked together, particularly in the field of health. I have every reason to know how extraordinarily lucky that Council is to have her considerable ability placed at its disposal with her in the chair.
This is yet another Committee or Council or Board of busy people to be set up. There is something to be said for that, but what guarantee is there that whatever the Council recommends will not be left by this Government to suffer the same fate as the recommendations of the Cohen Committee's Report? We spend much time and money in providing education in a myriad of subjects for all ages of our people. We are so busy in the pursuit of academic knowledge with our brains, and technical and practical expertise with our hands, that scant time seems to be left for health education. Most boys and girls emerge from the process of general school education with little information on the subject at all, though many of them may have received instruction in sex. Surely, if we strive after quality in the character and ability of our people, we should also strive after a knowledge of how to develop healthy bodies for ourselves and our children, and how to maintain them in first-class condition throughout our lives.
The Cohen Report described four main types of health education programmes. First, there was specific action; in other words, vaccination and immunisation. Secondly, there was habit or attitude-changing; in other words, avoidance of over-eating, attitudes to mental illness, alcoholism, smoking, exercise and the bringing up of children, all of which the noble Lord, Lord Cohen of Birkenhead, referred to in his speech. Thirdly, there was support for community action and preventive measures; that is, anti-noise legislation, clean air, clean food, fluoridation and good housing. Then, fourthly, there was education to encourage people to consult their doctors at an early stage of illness.
1476 The Committee recognised that much health education was already being carried out. They referred to the considerable success which had been achieved in vaccination, immunisation, community X-ray campaigns and screening clinics. They pointed out that there had also been marked improvements in the standard of maternity and child care, in sanitary cleanliness, food hygiene and probably in attitudes to mental illness. They thought that insufficient health education was being directed towards particular groups, notably schoolchildren, teenagers, fathers, middle-aged men and those of limited intelligence in all groups. I wonder whether the Minister, when he comes to speak to us again to-day, could tell us what advances have been made in respect of these groups since 1964. If the National Health Service is truly to live up to its name, rather than being just a national ill-health service, a far greater effort will have to be made to bring health education to all sections of the community. This means dealing not only with physical health but also with mental health, which is equally important.
Much as we may admire the Report of Lord Cohen's Committee for the studious and detailed way in which it deals with its contents, it is a little disappointing in what it excludes and passes over. I regret that the place of hospitals in health education is virtually discounted. This is perhaps less surprising when we note that not a single hospital organisation gave evidence to the Committee. One may agree that in-patient education may necessarily be concentrated on the individual, but in outpatient departments the scope is very different. The number of out-patients grows yearly and, whatever laggardliness there has been in providing hospital beds, everywhere one sees new and modernised out-patient departments.
What is the purpose of health education? Presumably, the answer is to make us more aware of the effects of our everyday actions and environment on our personal mental and physical health. Next, perhaps, we ask who should be responsible for educating us in health matters, and where should they do it? The idea of health educators is a good one and very necessary, and so are the formal courses in schools and colleges, and the public talks and exhibitions arranged by the local health authorities. 1477 But as important, too, is the imparting of knowledge at the point of maximum impact. Courses are already run for expectant mothers and fathers, because they are vitally and immediately concerned with this learning, and consequently courses of this sort are well attended and very effective. It is a pity that courses for potential mothers and fathers, however inexorable the eventual need, are not seen to have the same immediate relevance, and so those for whom they are intended take less interest in them.
A great deal of emphasis is rightly laid upon the health educator, to whom much reference is made in Chapter 8 of the Report. It must also be remembered that people seem to take full notice of the doctor when he speaks to them personally, and of the advice of, say, the sister or the staff nurse. This is likely to be acted upon, whether it is a carefully considered opinion or merely a casual word. Hospital in-patients, indeed, are subject to subtle pressures. Advertisers seek to encourage the sales of patent foods because they are used in hospitals, and in their advertisements we are shown pictures of benign doctors and glamorous nurses. It has often surprised me that the tea firms have not used this tack. There must be more tea made and drunk in hospitals than all the other beverages put together; ergo, the advertisements could well say that it must be the most health-giving drink.
But to be more serious, health education is a continuing and co-operative enterprise. I should regret it if, when we are making slow progress towards practical integration between the three arms of the Health Service, something which is the province of all three was preempted by one or the other. On the detailed account of the setting up of the new Health Council, to which the Deputy Leader of the House referred, I should like to say that until I have had the opportunity of reading the whole of that speech in Hansard it is a little difficult to make full comment on all the implications that arise from it.
The Report rightly dwells on the progress made in combatting tuberculosis, and this is an extremely good example of socially orientated medicine where doctors, hospital nurses, health visitors, social workers and research workers have all 1478 played their part. Patients have been carefully followed up and given help and encouragement throughout their treatment, whether in hospital or at home, and then they have been helped to rehabilitate themselves for their return to the community. Such co-operation is of inestimable value. It is a pattern which should be adopted wherever possible. It is also interesting in that it provides one of the few instances where local authority staff and hospital staff are housed together, and thus work more easily as a team despite their separate administrative accountability. The relevance of this to health education is merely to underline its indivisibility. The only field I know of, in which the lesson taught by co-operation over tuberculosis seems to have been well-learned, is that of mental health where co-operation is being practised between the various authorities.
People are most receptive when they are personally involved and obviously affected, and I feel that hospital out-patients' departments provide a first-class point of contact. Whatever we may piously hope is being done to develop the appointments system in hospitals, we still hear of, and often see, long lines of patients waiting. Some patients, I know, regard their visits to the out-patients' department as something of an outing. They arrive at 9 o'clock in the morning and they stay for the morning, having their "elevenses" from the canteen. Here is a captive audience, and good use could be made of modern methods of getting ideas across to it. Instead of serried rows of waiting patients looking bored, irritated or apprehensive, we might entertain and educate them with film strips, closed circuit television, recorded talks illustrated by photographs or slides, and even attractive posters on the walls, which should be regularly changed, plugging home a point or two of health education after the manner of the wayside pulpit.
If these media are to be used, then additional staff and facilities must be provided and the money to do so made available. In every sense this would be a good investment: first, because better health education would be a preventive measure; and, secondly, because a patient better able to understand what he is being told and advised ought to be a better patient. Then there is the scope 1479 of health education. The Report seems to limit itself to the usual themes for health education as they presented themselves nearly eight years ago.
But is there any major aspect of behaviour which results in patients' requiring medical treatment that ought to be excluded from the definition? If any organisation is to be set up—and we have learned this afternoon that a Central Council is to come into being next year—to implement the recommendations of the Cohen Committees Report, together with any fresh ideas which may emerge as a result of to-day's debate, I hope that it will be flexible and wider-ranging. The old saying, that "Men do not make passes at girls who wear glasses" may never have been true; but it is far less true if girls who do not need glasses wear them as an aid to beauty. Thus it works out that this is a great help to those who are trying to persuade people to wear glasses to improve their eyesight.
In making a virtue of necessity in health education, as elsewhere, we must employ every known device of commercial and inventive ingenuity, and I am quite sure that the noble Baroness will bring her inventive ingenuity into play, together with the help of all these splendid people who are going to be appointed to assist her when the time comes for her Council to come into being.
§ LORD SHACKLETON
My Lords, may I interrupt the noble Baroness? I was trying to follow her very closely, but I was not sure when she moved on from the point. I thought she slightly implied that the Committee's work had not been fully comprehensive, and that there were perhaps other areas of health which they ought to have covered. She then broke into this thing about glasses, and I was not sure whether she was in fact suggesting some field in particular that had been neglected on the health education side.
§ BARONESS BROOKE OF YSTRADFELLTE
My Lords, the answer to that is that the point I had been trying to make was that the whole of the hospital field had been neglected, so far as the Report was concerned.
Accidents in the home and on the road are two of the major causes of "illness", broadly defined, of our time. No educa- 1480 tional plan to help combat these can exclude the health side. The visual horror of a burns unit or an orthopædic ward sears the mind and the conscience in a way that no amount of lecturing can do. I shall never forget the day when I was taken by the Medical Officer of Health of Baltimore, Dr. Huntingdon Williams—who, incidentally, gave evidence to the Cohen Committee—to the Montebello Hospital, just outside Baltimore. Every patient we saw was young, and all were suffering from the results of motor accidents or of diving into too shallow water. Paralysed and crippled—what cruel futures lay ahead for them and their families! Surely it is better to risk wounding sensitive susceptibilities by bringing them into contact with the appalling results of carelessness than to let fine young lives be ruined through ignorance.
We are constantly reading of the growth of drug-taking by young people. This is an evil that has reared its ugly head even more viciously since the Committee's Report was presented. I am sure we are all agreed that we must grasp this nettle and deal with it; and deal with it, incidentally, by using every means of communication necessary to get the measure across, however enterprising or unorthodox these means may have to be. Similarly with the elderly: education for retirement must include its health aspects; and with the population growing older this is a social necessity, as well as a requirement to enable the older person to live his longer life more fully.
My Lords, we must tackle this whole question of propaganda intelligently. And in doing so we must not overlook or sweep aside the splendid work that is being done by the voluntary organisations, such as the King's Fund, the Nuffield Trust, the Queen's Institute, the Red Cross and St. John, to instance only a few. In our attempts to centralise we sometimes run the risk of smothering, by lack of interest, of encouragement and of appreciation, what has been done in the past. Your Lordships will remember the extinction of voluntary help to hospitals in 1948 by the Government of that day. When the National Health Service came into being it was to be State-provided. There was to be no room or scope for the voluntary workers of the past.
1481 Since that foolish suppression it has taken years to rebuild the leagues of hospital friends, as we know them to-day. The good will, enthusiasm, experience and hard work of the voluntary workers of the linen guilds and ladies' associations was killed—and the patients were the losers. I hope very much that, whatever the new Health Council decides to do in the future, it will not repeat that mistake. Voluntary effort is very precious. It springs from the heart; and this country would be a poorer and colourless place without it. Public figures who are looked up to can play their part in this field, as in other fields. One can have no finer preceptor than Richard Dimbleby, whose lasting memorial will be his courage in making us realise that cancer is a problem to be faced up to and tackled, rather than a hideously terrifying word from which to run away.
Three years ago, in a Written Answer to a Question put in another place by Mr. Woodhouse about the number of health education officers employed by local authorities, the then Parliamentary Secretary to the Ministry of Health, Sir Barnett Stross, replied—and I quote:Local authorities organise their health education work in many different ways. I understand that about 50 authorities in England and Wales have designated an officer to take special responsibility, either whole-time or part-time, for organising health education. I am not aware of any special training in cancer education.That was in Hansard of December 16, 1964, at column 101. Can the Deputy Leader of the House tell us whether there has been any increase in the number of health education officers since then, and would he also tell us whether anything is being done to encourage education about cancer?
Finally, my Lords, health education seems to me to need to be organised at two levels, national and local. The former, which must be the responsibility of the Ministry of Health and the Department of Education and Science, should make use of all the mass media available. Those words of mine were thought of before we had the announcement this afternoon of the establishment of this new Health Council, but they link very closely with what is going to happen. The Report has a very full Appendix on the use of the main publicity media available for health education, though I must con- 1482 fess that the comic carelessness in proof reading on page 86 casts some doubt on the validity of the advice. It states that booklets and leaflets can perform a public service when they aredistributed as book makers through the public libraries".At local level, the responsibility must be with the public health authorities and with industry. It would make a great difference if only all industrial firms would show as great concern for the education of employees as the best of them do about avoiding accidents and other hazards to health arising from the work environment. Public health authorities, in co-operation with the hospitals and the voluntary organisations, are particularly well placed to carry out these educational functions. The midwives, health visitors and district nurses are by their employment brought into close contact with all age groups, and this is usually at a time when those they visit will be in a receptive frame of mind to accept advice and instruction from the people who are caring for them.
The Public Health and Education Departments ought to co-operate closely, so that the school health service can extend health education to schoolchildren, who should be taught the principles of good health as part of their regular curriculum. The general practitioner also has a very large part to play in preserving the health, and not merely curing the ills, of his patients—if only the National Health Service gave him time to take advantage of his opportunity. Health education should therefore be treated as a more important subject in the training of medical students, dental students, student nurses and student teachers, and it should always be imaginatively presented. Every public health authority ought to employ a health education officer to act in a supporting role to all those providing health instruction; and the health education officer should be available to advise continually, to co-ordinate effort, to provide training aids as required and to organise, and sometimes conduct, special programmes and campaigns to deal with individual health problems, such as the dangers of cigarette smoking, drug-taking, alcoholism and so on. Research needs to be carried out to assess the results of particular educational activities and campaigns so that the most effective 1483 method of influencing various groups in the community can be ascertained.
Health education cannot be obtained for nothing. Local authorities and hospital management committees must realise that they must budget adequately for it; and it appears from what we have heard to-day that the Treasury also are going to be persuaded to provide some money for this new Central Council for Health Education. In the long run there should be a net saving to the country not only from a reduction of the need for medical and nursing care and from fewer payments of sickness benefit but from the addition of thousands more man-days of useful work in the national effort. The time lost owing to preventable sickness is the greatest single element of waste in our national life. Never do we need to eradicate that waste more than we do to-day.
§ LORD CROOK
My Lords, the noble Lady referred to the lack of voluntary effort. I did not wish to interrupt her at the time, but as one of many noble Lords here who are chairmen or members of Friends of Hospitals I should like to put the question: are there not in fact as many thousands of pounds being spent by Friends of Hospitals in trying to help people inside hospitals now as there were before?
§ BARONESS BROOKE OF YSTRADFELLTE
My Lords, if I may ask the noble Lord to read what I said in Hansard, he will see that the point I put was that whereas in 1948, when the National Health Service came into being, voluntary effort was stifled at the source, since then a great deal of work has been put into the building up of this voluntary effort. As a one-time chairman of a hospital management committee, I shall never cease to be grateful to my League of Friends for the work they did in hours of time and in money collected and amenities presented. I am wholly and heartily behind voluntary effort—and especially in the hospital field.
§ 4.52 p.m.
§ LORD AMULREE
My Lords, before I commence my few words on this subject I should like to associate myself with what the noble Baroness, Lady Brooke of Ystradfellte, has said about the marve- 1484 lous adaptability of the noble Lord who is going to reply to this debate. What he does, and the way he does it, the enormous amount of work that he puts into it and the information that he manages to give us is quite remarkable. I am sorry that she has left her place now, but I was pleased to see that the noble Baroness, Lady Scrota, is going to be Chairman of the new Council. I think she will do it extremely well. One feels that with someone like that in charge, the Council should do a very good job of work.
My Lords, surely the prime object of medicine is not so much to cure disease (for that is evidence of some kind of failure) as to prevent its occurring. I think that is what we have to look forward to when dealing with health education. We were told the other day in the Reith Lectures that it would be a catastrophe for mankind if disease were to be entirely abolished from the world. I do not think there is any chance of that occurring; one finds that when one disease is conquered another comes along to take its place, so that we always keep battling on. The prevention of disease can, I think, take two forms. One is by environmental hygiene, which has done so much good over the last 150 years. The second is by education. That again, as the noble Lord, Lord Cohen of Birkenhead, has said, can be divided into two: first, the kind of education which has resulted in the reduction of diseases like diphtheria by mass immunisation and other such things; and, second, the great deal more that could be done by education on general matters. I think the Report of the Cohen Committee has set the pattern for the latter.
My Lords, I do not want to go over the whole Report. I should like to concentrate my words on two diseases or two conditions which have interested me for a very long time. The first is cancer. Cancer, as we know, is a deadly disease if it is not treated. It took a long time for people to realise that cancer could be successfully treated. That was largely because many doctors merely saw patients in whom the treatment had failed; because those whose treatment had been successful did not come back again. There was a certain feeling of gloom about the whole problem; and this persisted until a detailed follow-up 1485 of patients took place. This began properly in 1929 when the Radium Commission was set up to buy radium with funds subscribed to commemorate the recovery from illness of King George V. The Commission—on which I served as a member at one time—sent radium to various hospitals on condition that they would get complete records of all patients treated. These follow-up reports—and we expected to get about 95 per cent. or more of them—showed us that a large number of patients were being cured of cancer. By "cured", I mean that they remained free of the symptoms and signs for a period of five years after treatment: that is generally accepted by most countries as being evidence of cure. I must say, however, that there are certain sites of the disease where treatment is not promising; and two of these sites are common ones: the lungs and the stomach. But for the others, these follow-ups have revealed a great degree of curability.
I do not want to bother your Lordships with a lot of figures—I do not think they are very impressive when speaking—and I want to quote only one or two. But I should like to talk about cancer in the neck of the womb. One has heard a great deal about this cancer, the disease of cervical cancer, and about what has been done. A long inquiry has been going on which was started before the war by the League of Nations and it is centred on Stockholm. I give only the figures from their Report. Under their scheme, between the years 1952 and 1957 they treated 60,000 patients. They find that of the Stage 1 patients there is a survival rate of about 75 per cent.; and these comprise only about one-quarter of the patients who come for treatment. When one comes to the advanced stages, the recovery rate drops to 8 per cent. The same thing applies to cancer of the rectum which in my younger days, when I first qualified, was thought to be a serious disease with not much chance of recovery. Now if you are treated early there is a recovery rate of 97 per cent.
In the case of cancer of the breast—and this is the last figure I shall quote—the figures are about the same. For early treatment there are 80 per cent. cures; but for late treatment the figure drops to 9 per cent. These are very important and impressive figures when backed by 1486 the fact that it is reckoned that there are about 30,000 people successfully treated for cancer each year in this country. Surely that is a thing on which to base a good deal of education: that this is a curable disease; not entirely curable, but much more than people think.
Certain attempts have been made to undertake education regarding cancer, one at Montreal in Canada where they dealt with a large number of people. The education I am talking about was carried on between 1943 and 1947 and between 1953 and 1957, and there was a great change in the percentage of survival from cancer in the neck of the womb—40 per cent. to 70 per cent.—which showed that education was persuading women to seek medical advice earlier. In Manchester (there is a reference to this in paragraph 75 of the Report of Lord Cohen's Committee) there was an encouraging increase in the number of people who believed that cancer was curable if you came for treatment early, when you first noticed that something was wrong. One of the depressing things about cancer, when you go into the history of people, is that you find there has often been long delay between a patient noticing that something is wrong and the seeking of medical advice. The time may range from six or seven months to ten months.
These are figures which should be improved upon, and one of the questions I should like to ask the noble Lord is whether the Ministry can give any figures for the period of delay or whether they have any such inquiry in mind? Is it proposed to inquire every so often to find whether propaganda and education is making any impact? A good deal of education is being done at the present time and one of the most important centres is at Oxford, where an old friend of mine, Doctor Malcolm Donaldson, has been doing a great deal of good work for a very long time. I think we want more of that, which is why I welcome the idea of the educators who will be able to do more regular work and provide more of that very important education quality.
It is said, my Lords, that if this is done, there will be a lot of people coming and saying that they fear that they have cancer; and that numbers of patients with a cancer phobia will take 1487 up too much of the doctor's time. That has not been the case in places where these methods have been tried, either in this country or in foreign countries. I will not say that there are not one or two people who behave like that, but it is by no means a common thing. In fact, in the United States at one time they used to have "Cured Cancer Clubs" to which people came quite cheerfully, and, so far as I know, these did more good than harm. I am not sure whether they are still carried on.
A large number of people think that more education should be carried out and more publicity given. Questionnaires have been conducted in various parts of the country and the majority of people who were interviewed said that they would like more education to be carried out than is done at present. When the Royal College of Physicians brought cut their report on the connection between cigarette smoking and cancer of the lung, it caused quite an impact, but that has died away. Why cannot the Government do more to encourage people not to smoke? To me it is surprising that if you go to a theatre or to a cinema (I admit that it has to be a theatre where people talk and not one where they sing) you can smoke as much as you want. That seems to me to be wrong. It is something one certainly cannot do in most civilised countries. That people are interested in this question is evidenced by the enormous amount of money which is collected for cancer research. I have the honour to be on the Council of the Imperial Cancer Research Fund, and I am surprised at the way the money for research pours into our funds. It shows that people are really interested, and therefore I do not think that they would be frightened.
My Lords, I have spoken for longer than I should, but I should like to say a word on my second subject, and that is chiropody. As I know very well the feet of some old people are in the most appalling condition. For the most part this would be preventable if they wore proper shoes. I know that it is difficult to get young women (and middle-aged ones, too, it may be) to wear shoes which are not fashionable, but a certain amount of work has been done in this connection and a good deal of co-operation has 1488 been given by the shoe manufacturing firms. They make shoes in a greater number of styles, sizes and shapes. I am sure that this is one thing which the new Council could encourage, because I think that bad feet are a more common cause of old people being confined to their homes than any other form of physical disability.
I very much hope that they may be educated not to wear shoes which have belonged to someone else because their own shoes are worn out. I know that shoes are expensive and that old-aged pensioners live very much on the poverty line, but I would far rather their pensions were increased so that they could buy shoes than that they should need to come to receive treatment for feet which are almost beyond treatment. I hope that these things will form part of the work of the new Council.
§ 5.8 p.m.
§ LORD DONALDSON OF KINGS-BRIDGE
My Lords, I ask for the indulgence of the House in addressing your Lordships for the first time. I find the desire to speak in this debate irresistible owing to my long connection with the pioneer health centre at Peckham, and owing to the fact that in his admirable Report the noble Lord, Lord Cohen of Birkenhead, specifically restated two of the main problems which the Peckham Experiment was set up to invesigate thirty years ago. The noble Lord deals with many other things, but I shall concentrate on only those two points.
The first problem is that of bringing the sufferer to the doctor—to which reference has been made before—to enable him to receive the benefit of early diagnosis and treatment. In this connection we at Peckham were, I think, pretty successful. The second problem is the study of health itself, to which the noble Lord referred and which is, of course, a far more esoteric and difficult subject. We were not particularly successful with this at Peckham because, to be quite frank, we found practically no health to study. I shall say a word or two more about the Centre as I go along, but I should say now that we overstrained ourselves in the harsh post-war period and closed our doors in 1950. But we collected a vast amount of material and have preserved some capital, and I like to think that the Report of the noble 1489 Lord, Lord Cohen of Birkenhead, would not have been exactly the same if we had never existed. I think that some small contribution was made.
It is extraordinary, my Lords, after thirty years to find these two problems still exercising the minds of the noble Lord and his distinguished colleagues. It is extremely interesting that they describe in their Report an experiment by some Birmingham doctors which looks to me like a shot—and perhaps quite a good shot—at doing something about the first of these two problems. I shall come back to that later, but I should like to say now that it is not stirring only in this area. I have evidence of another stirring of this kind which I shall draw to the attention of your Lordships later on.
I turn now to the noble Lord's account of the first problem. He recognises the difficulties confronting ordinary people, diffident, not rich, earning their own living at various levels, in getting to a doctor at all. In paragraph 119 he sets the problem exactly. He speaks of:apathy or disinclination through fear or embarrassment directly to approach a doctor or nurse for advice, or there may be no encouragement or opportunity or encouragement to do so.I myself suffer acutely—and I think it is possible that some other noble Lords may, too—from this fear and embarrassment. I have had no fewer than three valid reasons for going to see a doctor nagging at me for the last three years, and I have not been to see him yet. I have tried to analyse the reasons. They seem to be three—two good ones, and one rather bad. The first is that my doctor is a very busy man, and I am embarrassed at the idea of bothering him with what may turn out to be trifles. I also am a busy man and cannot make an appointment at his surgery, and if I go to his surgery I have to wait sometimes half an hour at the most awkward time of day. Thirdly (and this is one of which I am not proud) the wireless is always playing. I hate that, and I feel shy of coming into a room of mothers and babies who I fancy look at me strangely. I know that this is absolute nonsense, but it has been real enough to keep me from my doctor for three years.
If you add to this neurotic behaviour, the real difficulties of a working man in industry or on the land, who has to beg 1490 a day off from his "boss" before he can go to the doctor, or, if he goes to an evening surgery, has to go home, have his tea and wash and change and turn out into the night, we see that though there is opportunity, in its broadest sense, the noble Lord is absolutely right in what he says about this question of encouragement. None of this applies if anything is seriously wrong with you. I once had a poisoned foot, and I found that all my inhibitions melted away. I limped proudly into the surgery, beamed round at the mothers and their babies, and waited contentedly for my turn to be lanced.
The point I am making and illustrating from my own experience which I think some of your Lordships probably share, is that the present system works perfectly adequately for getting treatment for serious and acute conditions, when the sufferer is aware of them, but it gives no encouragement to somebody who feels well enough but fancies he detects signs of trouble to come; and, of course, these are the people we want to get at. Yet it is a common, though not invariable, characteristic of illness and malfunction to begin small and grow bigger and to be more amenable to treatment in the earlier stages than in the later. Thus we are faced with the situation in which, having evolved truly marvellous methods of curing and only less marvellous methods of diagnosis, we are able to deploy our armoury only when the unfortunate sufferer feels ill enough to overcome his natural reluctance to go to his doctor—when in fact he has become socially incapacitated.
The trouble is that the British medical system was founded on the relationship between the general practitioner and his patients, in which the doctor knew every member of every family by name, and not only by their medical histories, and was a family friend. In modern conditions this system has gone, and gone for ever. This is the price we have paid for a vast extension of the medical services to the population as a whole, but we must do what we can to find means to replace it. As I have said, the Peckham Experiment had as one of its primary aims the creation of something to replace the disappearing world of the family doctor. We went some way towards solving this problem. We took only 1491 families as members, and made it a condition of membership that every member of every family had a regular medical overhaul on joining and periodically thereafter. The Centre was not just a clinic; it was a social club, in which the doctors moved about and made friends with patients, and they were able to build up a link comparable with the old link between the family doctor and his patients.
Peckham has gone beyond recall and we cannot recapture it, but I think we may regret it in this case, because at the time the National Health Service was set up something like it might have been incorporated in it, and it might have solved this problem of the family's relation to the doctor and with it the problem of the early spotting of disease. The Peckham doctors, Dr. Scott Williamson and Dr. Innes Pearse, who conceived and realised the Centre, set themselves this problem from the first, and the system of family membership and of family overhauls seem to have gone most of the way towards solving it. But the problem is as urgent to-day, and however much we may regret the passing of Peckham, we must look for some way of solving it now.
I have spent a long time on the first of these two problems because it is the one to which the solution is much easier. Now I return briefly to the second, which is the Centre's longer-term objective—the study of health. Here we at Peckham were less successful, because, as I said before, we found very little health to study. I am glad to see from the Report and to hear from the noble Lord's lips that he agrees that health is not just the absence of disease. In the paragraph headed "Positive Health" he is bang on the target. He speaks of:… the lives of many people being impoverished by apathy, anxiety, self-pity or lack of physical energy. These people are in striking contrast with those who live a full life and appear always to have the energy to Give of their best. Health education in the future will be increasingly concerned with helping individuals to achieve real health and to adjust themselves more adequately to their environment.We found this again and again in our work at Peckham. We found that people seemed to have nothing clinically wrong with them but were in no sense healthy. Sometimes the doctors found a reason 1492 for it; sometimes they did not. But it was clear that health was not just the absence of disease.
In the course of his Report, the noble Lord has made many recommendations, with all of which I agree, for disseminating knowledge of preventive techniques—immunisation, cervical examination, anti-smoking and so on: and money spent here is certainly money well spent. But though Government can create an environment conducive to health, positive health can be achieved only by the personal response of the individual to the environment. I wrote that sentence myself, but I do not really know what it means. However, these are the things we are trying to find out. What it does not mean is that this response can be produced by hidden persuaders. I am perfectly certain that advertising campaigns are in no way connected with the development of health, and I hope that we shall avoid spending money on advertisements of a vague and uplifting kind.
There is only one agent who can persuade people to invest in positive health, and that is the family doctor. Under the National Health Scheme the specialists have flourished and gone from strength to strength. Rich and poor alike can rely on the best treatment in the world if their affliction is really serious. But if you just feel awful, and there is nothing clinically wrong with you, only your general practitioner can help you; and you will probably put off going to see him as long as I have. So we come back to the same point. The family doctor is by far the most fruitful source of health education in its fullest sense. He has been squeezed by events, overworked and under-valued. It is most important to reinforce his position. But how?
This brings us to the attempt at a solution to which I referred in my opening remarks. To me the most stimulating item in the whole of the noble Lord's Report begins with paragraph 235, where he describes in some detail the procedure of a partnership of doctors in Birmingham. These doctors decided to try to help the patients by what is now known as group training, which means group discussions and lectures, brains trusts and (a very interesting innovation) by involving the local authority health visitors in 1493 the work of their practices. This is something new and it is one of the noble Lord's recommendations which I think must be taken very seriously. Having cleared these ideas with other doctors, these partners began to give some lectures in the waiting room. They found them successful and overflowed into a welfare centre lent by the local authority, and generally got the community moving and thinking about these things in a very satisfactory way. The meetings must have had not only a medical but also a social value. It seems to me that here there is a hint as to how we could do something of greater value than posters and advertisements in spreading health education.
I should like to refer shortly to another instance of the same sort of thing which has come to my knowledge. A group of doctors in the North-East have approached us at the Peckham Centre and told us that they have all local authority support for starting something rather on these lines. I am most anxious that the noble Baroness, Lady Serota, when she takes up the reins, should be free to spend some of her £500,000, or whatever she succeeds in getting, on experimental schemes of this kind. It seems to me that if it is possible to get a group of practitioners who are prepared to co-operate and provide a clubroom with a canteen, and some elementary provision for children, it provides a nucleus from which one can begin to build something really useful, instead of having merely exhortations and propaganda.
This can be approached on an experimental basis, and all the experiments would be different. It is done now with youth centres and community centres, and the new idea which comes out of the Report is that something of this kind might be supported centrally for groups of doctors who wish to make this extra provision for their patients. It is important not to expect too much. These small innovations would not revolutionise the Health Service. But any step in the right direction is valuable, and the idea could spread and help to remove some of the frustrations of the G.P., and perhaps begin to restore to the family doctor his proper role of family friend and guide through the complexities of modern life.
My Lords, I want to thank the noble Lord, Lord Cohen of Birkenhead, for 1494 his Report and for bringing it before the House, and your Lordships for the kind attention that you have given me.
§ 5.23 p.m.
THE LORD BISHOP OF LICHFIELD
My Lords, I should like to be the first to congratulate the noble Lord, Lord Donaldson of Kingsbridge, on his maiden speech in this House. It was a speech which was full of wise counsel and advice, and I am sure we all hope that he will make many more contributions to our debates in the future.
I feel somewhat diffident in intervening in this debate, because I am without expert knowledge on this subject; but I think it is right that someone from this Bench should speak, and as the Health Service is a subject in which I have been extremely closely interested for many years, I ventured to put my name dawn. May I say how grateful I am to the noble Lord, Lord Cohen of Birkenhead, and the fellow members of his Committee for the most valuable Report which they have produced. I think we should go on emphasising this attitude which shows so clearly that health is a positive thing to be sought and guarded, and it is our duty to the community to do that.
As we read this Report, I dare say that many of us felt our consciences troubling us, with its recital of the perils into which we can so easily fall. Speaking as one who in the past used to take a great deal of physical exercise, but who now takes all too little, as I read this Report I began to try to make, at any rate, a few half-hearted resolutions in regard to it. The trouble is that the circumstances of life make it so difficult for many of us. The people who are under the greatest fire in this Report are those who are well represented in this House; namely, the middle-aged, those getting on in years. We come out of it extremely badly. But I am impressed by the fact that the circumstances of life make it difficult for people to take physical exercise, and if they are to face up to the proper guardianship of their health I believe that they have to watch it carefully and see that their duties do not impinge upon it. Not that we should constantly be thinking about our health; I think that is a bad thing. If we do 1495 that, we may fear that we have all manner of diseases. What we need is this change of attitude, and that, as the Report justly says, is not easy.
I noted that the noble Lord, Lord Cohen of Birkenhead, said to-day that people are reluctant to sacrifice present pleasure for future gains. Those words might have come out of a mediaeval religious book. It has been the same all along. We are so reluctant to give up present pleasures for what we know we ought to think about in the future.
I wish now to make one or two brief comments on various items in the Report. First, I would say how impressed I was with paragraph 131, and with one particular sentence where it says that we should regardexcessive noise as challengeable as blasphemy.If we are to take this matter of people's health seriously, I feel that we ought to tackle this question of noise, which I think is rapidly becoming one of the curses of our age. I am not surprised that people who are going to find a new airport on their doorstep, with the screaming of the jets, react violently against it. And if we come into the towns there are the pneumatic drills at work, and the motor-cycles roaring up and down. Sometimes one feels that one could almost shriek because of the noise that goes on and on. I believe that to-day noise is having a serious effect on the nervous system of many people. If we are to take this matter of health education seriously, then I think this is one matter to which we could give our attention. To-day, as I know well in my diocese, many people are living in these enormous block of flats, and I hope that a good deal of thought is given to what, to me, is a most important matter, that of soundproofing, because sometimes you simply have to get away from the noise that other people so thoughtlessly make.
I wish now to say a word or two about the question of immigrants, which is also referred to in the Report. Here I think that we should pay tribute to some remarkable achievements. Again, I see this problem on a large scale in my diocese. People arrive from different parts of the Commonwealth with their different ways of life, and the problem of integration is very real indeed. This 1496 being so, I should like to pay my tribute to the work of the medical officers of health, to whom I think our country owes a great deal. They are people who come into the limelight only when something has gone wrong—perhaps an outbreak of typhoid, or something like that. We so often take for granted what they do for us. In this matter of the integration of our immigrant population, from the point of view of health education, and health generally, I think that the debt that we owe to our medical officers of health in our towns and cities is something that is beyond all praise. I welcome this opportunity of paying my tribute to them.
As in this matter one of the secrets would appear to be the provision of the right kind of training for key people in this work, I should like to draw attention to the fact that the Richmond Fellowship is providing training courses for health visitors, mental welfare officers and others, who especially need to find these new approaches to help the people to generally rethink. It is in the matter of rethinking that we want to get the general public interested, and if we can train the people who work among them by this specialised training I think we shall have rendered a great deal of assistance.
I turn now, quite briefly, to what I think is the vital message of this Report. It is that health is not just a physical or mental affair, but that man needs to be made whole in the whole of his being. That, my Lords, is exactly the same message as is found in the Gospels. It is there made perfectly clear that a man's physical health may suffer through the ills of his soul. Certainly that is true of his mind. So I would ask that there should be trustful co-operation between all those who work on behalf of our fellow men. May I say that I think this is increasingly seen in regard to the work of our chaplains in hospitals. I think that the doctors and nurses are more and more realising how much the chaplain can do to help the patient. But could this be urged on the medical students? Could it be made more plain to them in their time of training that this spiritual factor, allied to the mental factor, is something they should never overlook; because, after all, ignorance of the way in which we can all help one another in 1497 this matter of the health of our fellow men is surely wrong.
May I say just a word or two now about the general practitioner. We had some very interesting remarks on that subject in the speech just made by the noble Lord, Lord Donaldson of Kings-bridge. I would not myself take quite so depressed a view as he did, when he said that the old system had gone beyond recall. I am afraid that very often it has been lost. If a doctor has an enormous number of patients on his list and large crowds coming into his surgery, obviously it is very difficult for him to give the full time to each case which he would like to give. But I would plead that our doctors, our general practitioners, should always try as much as they can to show that they are not too busy for this work. When the Report said that what was needed was fewer prescriptions and more counsel and advice, I thought it was saying something that was profoundly wise. In regard to myself and my own family, I can only say that I have been only too grateful for the counsel and advice that on many occasions we have received from our family doctor; and knowing people as I have done in my clerical career, and the links I have had with many people in my parishes, I would say that many of them, too, appreciate greatly the true friendship of their family doctor, and I hope that would not be lost, because it would be a very great loss indeed.
If I may refer briefly to one other point, I should like to welcome the emphasis given in the Report to the value of marriage guidance. This is something on which many of us are very keen. It surely is very obvious that a happy marriage must encourage mental health and stability. It gives a secure background for the children's early years. The institution of the family has of late been under attack, and in some well-known lectures to which we have just been listening we heard about its narrow privacy and tawdry secrets. What that exactly meant, I am not quite sure, but I believe that the vast majority of the people of this country would be horrified at the idea of the disappearance of the family. Selfish actions which break up the family are very wrong, and I think, therefore, that the Report is very wise when it states that our young people 1498 should be clearly warned of the dangers of wrong behaviour. They should be told in no uncertain terms when they are young what they should do if they want to live a really purposeful, satisfying, useful life, and they should be warned that if they fly in the face of the advice that is given to them they may well find only great unhappiness and disappointment and disillusionment. I know that the young never react very kindly to advice doled out to them by their elders, whom they may not consider to be their betters. I realise that, but nevertheless I believe it true that schools and parents, and the churches, who have these young things in their care, should point out perfectly clearly what is the way in which they should go; and in this matter they should be joined quite firmly by the representatives of the medical profession.
I believe that in the young people of to-day we have some of the finest young people this country has ever had. They are very idealistic and full of essential social service. We have heard from the noble Baroness, Lady Brooke of Ystradfellte, about the fact that unfortunately some have given way to this dreadful habit in regard to drugs, but I do not think we ought to get things out of proportion. Thank God!, it is only a very small proportion, I believe, who have fallen into that kind of habit. Most of the young people are fine young things. What we have to do, I am sure, is to give them the kind of education which they must have if they are to develop their lives, and it is true that health education is undoubtedly a part of it. But I would say that it is strongly allied with moral teaching, and it is no good saying it is not. They should be shown the clear difference between right and wrong, and I think that if we are muddled in our advice to them we are serving them ill at a very impressionable time in their lives. I should like to say how grateful I am for the support I found on this subject in the words of the Report.
As I end, may I plead for co-operation between all of us—doctors, teachers, parents, clergy. We are all trying to do our best. But do not let us practise in separate, watertight compartments. Let us get to know one another more and trust each other more. If we can do that, I believe we shall be able together 1499 to do a great deal for the true health education of the nation. I feel we must face the fact that if a man is to be able to cope with difficulties later on in life he must learn some discipline. There is no escaping that, so far as I see it. And if we can learn through discipline to discipline ourselves, I believe that in that way we shall develop to the full the talents with which we have been endowed, and thus he of the greatest service to the community.
§ 5.37 p.m.
§ LORD GARNSWORTHY
My Lords, as this is the first time I have risen in your Lordships' House to speak, I respectfully ask for your indulgence. With other noble Lords, I should like to join in thanking the noble Lord, Lord Cohen of Birkenhead, for initiating this debate, and to say how much I appreciated the work and the Report of the Joint Committee of the Central and Scottish Health Services Councils. Health education is a very big subject and I can speak only as a layman, but a layman who has been privileged for some thirty years to serve as a member of local authorities, first as a member of Banstead Urban District Council and for the last fifteen years on the Surrey County Council. Perhaps it is because of that experience that I am very conscious of the vital role local government has played and the scope it offers in the spheres of preventive medicine and health education.
The services which local authorities run are not the most costly items in our National Health Service, but the value we get from them is very great indeed. Through the agencies of their health, welfare and school medical services they have achieved some very impressive results, but to help them maintain and improve the physical, mental and social health of our community a great deal more education is required. While, clearly, much of this needs to be directed at the adult population, I believe that the possibilities within our educational system itself offer a tremendous challenge, and if properly exploited would yield really impressive results.
The 1944 Education Act says:… it shall be the duty of the local education authority for every area, so far as their powers extend, to contribute towards the spiritual, 1500 moral, mental and physical development of the community by ensuring that sufficient education … shall be made available to meet the needs of the population of the area.That would seem to make quite clear that our schools have some considerable responsibility in this field. In some schools health education is taken fairly seriously, but the pattern is patchy, and the subject, as a subject, does not get the place in the curriculum it ought to have. It is true that school curricula are very crowded to-day. Everyone seems bent on hunting a certificate for something or other but education is, or should be, for life, the whole of life, and what is needed to produce healthy minds in healthy bodies, as the noble Lord, Lord Cohen of Birkenhead, put it, is surely of vital importance. Health education should feature not only in primary and secondary schools but should continue right on into establishments of further education. In paragraph 250 of their Report the Joint Committee say:Our inquiries in detail did not include schools".The noble Lord who opened the debate referred to this point. I think it was a great pity that they were not included, for I think it would have been found that in too many schools health education often tends to be everyone's responsibility and ends up as being the responsibility of no one in particular. Any future assessment ought to include detailed inquiries in our schools, for at this level we can anticipate good results from the effort that would be involved.
There are one or two particular matters to which I should like to refer. Antismoking campaigns seem to have an impact on young people where these campaigns are effectively undertaken in schools, but one feels that a great deal more needs to be done. The evidence of available statistics certainly denies that there is any room for complacency in this field, and as witness of that we have the Report of the Royal College of Physicians. I doubt whether many would question the influence of adult example in this matter, and those in close touch with children certainly ought not to avoid their responsibility. One appreciates that advertising on television has been checked, but a great deal of smoking takes place on all television channels by prominent personalities, and I think 1501 it would be a good thing if some attention could be paid to the influence that this may well have on children.
We are told that cigarette coupons are to be banned, but a leaflet in my letterbox only last week stated:The ban doesn't start immediately. There's still time to save for a gift, even if you only start saving to-day.It went on to say that a named brand of cigarette brings the gifts home twice as fast, and that if I smoke 20 cigarettes a day for 41 weeks I can get a Morphy Richards toaster. That is one of the baits that is being held out. But in order to get that toaster I not only take that bait but have to consume 5,740 cigarettes.
My Lords, the Report lays emphasis, in Chapter VI, on the widespread habit of the public of practising self-medication. Probably your Lordships will have seen the report of a statement by the President of the Pharmaceutical Society last Wednesday. He is reported to have said, and I quote here from the Guardian of December 14:There are more than 700 deaths and thousands of casualties each year due to accidental poisoning … The task of teaching the public to live safely with modern medicines has not yet been attempted on anywhere near the scale required … Advertising of medicines should be prohibited.I find that figure of 700 deaths quite staggering.
No-one can read the Joint Report without appreciating what it says on the subject of dental health and fluoridation. I do not wish this evening to be controversial, but it would seem to be desirable that the advocacy of fluoridation should at least match the efforts of the "antis" in this connection. Some excellent literature is available, but it does not seem to get wide distribution. When I think of the masses of literature that I get from the anti-fluoride people I feel that the other side are fighting this matter with their hands tied behind their backs.
There is one other point which I will mention briefly, and which has already been touched on by a number of speakers—it is a matter which I think deserves full consideration; namely, the need for educating people to meet the problems of age before they get old. A great deal of information could be made available to make life for the elderly less burdensome than it sometimes is, and here I 1502 think the rapid development of health centres could be helpful in a very big way.
I know a number of persons who are intimately involved, at county and district levels, in the service of public health and health education. People like Dr. Greenwood, of the Surrey County Council Health Department, and Mr. Powell-Johnson, who is the Health Education Officer for the county of Surrey. Such people have impressed on me that the great and urgent need is the formation of a new and stronger central organisation—a new Health Education Council for England and Wales and Northern Ireland. That Council has already been referred to this afternoon, and it should be formed as soon as possible. I am quite certain that we can look forward with confidence to some excellent work coming from that body under the chairmanship of the noble Baroness, Lady Serota. When this Council is formed I think it is most important (and I hope that we may have some reassurance on this point later) that it shall contain representatives from the teaching profession, in order to ensure that proper emphasis is given to health education in its broadest aspects in our schools.
In paragraph 202, the cost of the Joint Committee's proposals are estimated, as has already been said, to be in the order of £500,000— that is, about 0.06 per cent. of the cost of the National Health Service. Since the Minister of Health, under the National Health Service Act 1946, has the duty to promote the establishment of a comprehensive health service designed to secure the improvement of the physical and mental health of the people and the prevention (and I would underline the word "prevention"), diagnosis and treatment of illness, such a small proportion of the total cost of the National Health Service is a very little from which to expect too much. On the other hand, the more successful we are in the field of health education, the greater the reward.
In conclusion, my Lords, if this debate serves to draw attention nationally to the need for more health education, and, if I may say so, more important, to the need to provide the means for that health education, then I think we shall have even greater reason to be appreciative of 1503 the efforts of the noble Lord, Lord Cohen of Birkenhead, and his colleagues.
§ 5.49 p.m.
§ LORD PLATT
My Lords, I should like to start by adding my congratulations to the noble Lord, Lord Donaldson of Kingsbridge, on his maiden speech, and to say how pleased I am to have the opportunity of being the first to congratulate the noble Lord, Lord Garnsworthy, particularly perhaps because he touched upon a subject about which I hope to speak to your Lordships for a little time. First, let me say that their contributions to this kind of debate, for which this House is particularly noted, have been excellent ones, and we look forward to hearing them again. I also want to thank the noble Lord, Lord Cohen of Birkenhead, as we have all done, not only for his Report and his opening speech to-day, but also for the great work he has done for many years for medicine and medical education.
The question I wanted to address the House upon, fairly briefly I hope, is perhaps the biggest question in health education at the present day. That is the injury to health through cigarette, smoking. Although the present Minister of Health has devoted a great deal of attention to this subject, I think there are still ways in which Her Majesty's Government might do still more. As your Lordships probably know, I have a special interest in this because I was President of the Royal College of Physicians when we produced our now rather famous Report to which the noble Lord, Lord Garnsworthy, and others have referred to-day. I was Chairman of the Committee which produced it, though I always make it very clear that it was Dr. Charles Fletcher who initiated it and did more work than any other member of the Committee. I may also tell your Lordships that we were very particular to put two very heavy cigarette smokers on the Committee as members, and they both gave up smoking before we had finished examining the evidence. I would also make it clear that we did no research into the effects of cigarette smoking, but we examined all the evidence; and although other bodies, including the Ministry of Health and the Medical Research Council, had pronounced on the subject before, it is possible that our 1504 Report had more impact as it was particularly designed to be read by the intelligent public.
As the noble Lord, Lord Cohen of Birkenhead, has already said, the Chief Medical Officer of the Ministry, Sir George Godber, recently referred to the fact that we can be certain that more than 50,000 deaths a year in England and Wales are directly due to cigarette smoking. This he said at a recent World Conference on Smoking and Health in New York last September. He went on to say:From all this we certainty know shat we have to do, but I cannot tell you yet we know how to do it.That is quite true. At that same conference Senator Robert Kennedy was a little more outspoken. He said:Every year cigarettes kill more Americans than were killed in World War I. the Korean War and Vietnam combined, nearly as many as died in battle in World War II. Each year cigarettes kill five times more Americans than do traffic accidents. The cigarette industry is peddling a deadly weapon; it is dealing in people's lives for financial gain.In this country male deaths (or is it perhaps total deaths?—the male deaths, of course, still far exceed those in females) from lung cancer are about 27,000 per annum. That is about three to four times the deaths from traffic accidents, and it is rising by about 1,000 in each year. Deaths from coronary heart disease, the early ones in men of 35 to 54, are two and a half times as common in cigarette smokers as in non-smokers.
There is no doubt at all now that this can be prevented, because, as the noble Lord, Lord Cohen of Birkenhead, remarked, the British doctors, who have changed their smoking habits so that they smoke far less than any other group of people in the population, have, in eight years, reduced their rate of deaths from lung cancer by 30 per cent., while in the general public in the same time it has risen by 25 per cent. So this shows not only that it can be done, that this is a disease that can be prevented, but also that it is not too late to prevent it, and it disposes of the argument of those who say, "I have smoked for 20 years and it is no use giving it up now". Coronary heart disease deaths in ex-smokers are about half those of continuing smokers. The Minister of Transport announced in another place yesterday that the effect of 1505 the breathalyser had been so encouraging that it was possible that as many as 1,200 deaths would be saved in the course of a year if the figures went on at this favourable rate. What I am talking about is the possibility of saving 48,000 deaths.
I should like to say something about the effect of our Report. The first effect of our Report was this: the tobacco manufacturers, who until then had not been known as experts either in cancer or in health education, came on the television screens trying to discredit the evidence. I just ask your Lordships to imagine what would be the public outcry if whisky distillers came on the television screens and said, "Take no notice of this propaganda about drinking and driving. It is only statistical evidence".
The second effect was that within two years the cigarette manufacturers had increased their advertising by 50 per cent., so that in the year 1964 it reached a figure of £15 millions for the advertising of cigarettes alone. It is quite useless to say that this is just due to the increased cost of advertising and the increased tendency to advertise all goods, because the advertising of cigarettes went up far more steeply than the advertising of any other known commodity. At the same time, one large firm of cigarette manufacturers declared openly their intention to promote sales in countries such as Nigeria, in which the smoking habit had never really caught on. I ask your Lordships, can you imagine anything more sinister than that kind of response to evidence that enormous numbers of lives are at stake and people are dying of cancer? And, as we know, much of their advertising was specifically directed at young people.
It is well known that cigarette smoking is a very powerful addiction, as anyone, like myself, knows who has tried, in my case at last successfully, to give it up. Once you are hooked you tend to be hooked for life, and I have no doubt that this is a fact not unknown in the tobacco trade. No one would expect them to stop making and selling cigarettes—indeed, there would be a public outcry immediately if cigarettes were withdrawn from the market—and of course they did not originally know that the goods they were supplying were so damaging. But in the period to which 1506 I have referred the evidence was already quite plain. What shocked me was not only their reaction to our Report, but the fact that it seemed to be accepted as normal behaviour in commercial circles. This I do not believe, because I know many instances in which the pharmaceutical industry, having some evidence, perhaps not very strong evidence, that one of their products may be harmful, has immediately withdrawn it pending further evidence. So you may well say that what I am talking about is not health education, but anti-health education, and I think you would be right.
What have we positively achieved? There are, perhaps, one million fewer smokers than there were before, and particularly smoking has dropped among young men. Although, as Lord Cohen of Birkenhead has pointed out, this was so in 1965, the figures for 1966 were not so encouraging. Above all, there has been a general acceptance of the facts about smoking. There is, I think, much less smoking in train and tube railways than there used to be, much less among professional people, and far less among doctors.
But the need for health education is still great, directed not so much at fear but towards making the smoker the exception to the rule instead of the usual. We must not leave it to the young, because it is well known that children are less liable to smoke if their parents do not smoke. The onus is very much on teachers, both in schools and in universities. Beyond that, I would ask Her Majesty's Government whether they can do anything more to prevent the spending of these enormous sums of money which, as the noble Lord, Lord Garnsworthy, has pointed out, the cigarette manufacturers are spending on sales promotion of all kinds, sales promotion which goes on and on, the measure of its success being judged by the still rising figures of cancer of the lung.
§ 6.2 p.m.
§ BARONESS SUMMERSKILL
My Lords, may I, in the first place, congratulate the noble Lord, Lord Donaldson of Kingsbridge, and my noble friend Lord Garnsworthy, for the interesting form of contribution that they have made to this debate. We hope that on other occasions when what is sometimes called behind the scenes, the "health group" in this 1507 House meets, we shall again have the opportunity of hearing them make knowledgeable speeches, perhaps then on some other aspect. May I also congratulate my noble friend Baroness Serota on the honour—indeed it will be a privilege, as I am sure she realises—of being asked to preside over this important Board or Council or whatever it may be called. I am quite sure that her knowledge of local government will be most important, because we have been told that great emphasis is to be placed on the contribution which local government will make in this field of education. We all know that her name is known throughout the country in local government, and everybody has the greatest of confidence in her.
When I listened to the excellent exposition of my noble friend Lord Cohen of Birkenhead, I was rather struck when he told us who were going to be the educators. I must confess that I deeply regret that we have to rely upon doctors from India and Pakistan to implement some of these recommendations, when there is such a pressing need for just this teaching in their own countries. Meanwhile, so many of our teachers in our own medical schools train men to care for the well-to-do citizens of the United States of America.
Perhaps it is an association of ideas, but I was struck also by the emphasis which has been laid in this Report on the health and habits of over-indulged middle-aged men. I must say to my noble friend Lord Cohen of Birkenhead that I went through this section of the Report and I think it was mentioned about six times. I admit that I am more concerned with the circumstances which are outside the control of the individual, and with the unfortunate victim who has his health or lack of health determined by his field of work or some other circumstances over which he has no control.
However, the Christmas spirit is in the air and I do not wish to appear indifferent to the problems of the plump, middle-aged male. As I read this I thought, "His wife is now seeking a present for him". I am sure that noble Lords here who are doctors will agree with me that perhaps the most appropriate present which can be given are bathroom scales and a long strip mirror. This is the best practical advice that can be given to 1508 this kind of patient. It is advisable in these cases, in my opinion, for the moment of truth to dawn with his ablutions every day. I often find that doctors are a little hesitant about telling this kind of patient the real truth: that his symptoms arise from his indulging in either tobacco, drink or food.
Everyone is at risk, but I should like more emphasis placed on those at risk from industrial diseases and industrial injuries. The adolescent in our factories is a veritable innocent abroad, and our failure to give him adequate protection is a slur on British industry. Indeed, the Annual Report of the Chief Inspector of Factories is a reflection on our society. We had a debate on this matter a year ago. We were promised that something would be done. Little has been done. One of the Parliamentary Secretaries in another place said only two days ago that now more inspectors were being imported and so on. Nevertheless, the disease rate and the accident rate in our factories go up and up.
Again, the widespread disease, chronic bronchitis, is not new, but it is still one of the killer diseases. It is accepted by middle-aged men in our dirty, dusty factories with the same resignation as their fathers and grandfathers did before clean air was recognised as being essential to good health. I speak from experience, because for the last eight years of my time in another place I represented an industrial constituency, and I was shocked to think that in the twentieth century there were men working under such conditions. This is all preventable. Yet what is being done to-day? How are these men urged to demand better conditions? To provide good working conditions calls for expenditure, and the conflict between what is good from the standpoint of health and what is commercially advantageous is still raging fiercely.
Despite the irrefutable statistical evidence of the association between smoking and cancer of the lung—and we thank my noble friend Lord Platt for everything that he has done in this field—the advertisements that we have heard about are designed deliberately to lure their potential victims. We have heard of all kinds of instances tonight. We have heard my noble friend behind me reading from an advertisement. Last week I was in a health group in another place 1509 which is open to Members of both Houses, and the first thing that the chairman read was a letter from the tobacco industry inviting to lunch any Members in the House who would like to go, and no doubt at that lunch those Members would be told that all this talk about there being any connection between tobacco and cancer was rubbish. It is nauseating to think that the tentacles of this particular industry can reach right into the heart of the Palace of Westminster in this way. I regard it as corrupt that this should happen. But what powers have we? All we can do is to keep on telling the potential victims of the dangers.
The Report asks for more sex education, but this is always interpreted according to the attitude of those in authority, whoever they may be. It seems that television has superseded the "birds and the bees" as mentors in the mechanics of conception; but now that premarital intercourse is freely indulged in, is there any evidence that our young people are more stable, happier and less given to means of escaping from reality? While a great deal of newsprint is given over to drug-taking, little is said about the by-products of sexual promiscuity. There is a very serious increase in the incidence of venereal disease in the country, the illegitimate birth-rate is soaring, and all the misery involved for the unmarried mother is still there. Indeed, the treatment of the unmarried mother to-day, despite this permissive society, is broadly similar to that of the less permissive days since fundamentally she is treated as she was before, as an outcast. All the media of propaganda tell our young people that to have premarital intercourse means that you are "with it". I would say that the mental health of the male adolescent would benefit more from talks on the relationship of the sexes in a wide context in order to inculcate a sense of responsibility.
On this point, if I may digress for one moment—and this is relevant here—I should like to observe that the Divorce Bill which was promised some weeks ago has still not reached the Printed Paper Office. I hope that Mr. Wilson, the Member for South Coventry, and the Government who have helped with the drafting have had second thoughts, or are making fundamental alterations to 1510 make adequate provision for the innocent wife who will be compulsorily divorced. The provisions which have appeared in the Press in my opinion will embitter the relationship between the sexes which no amount of sex education will obliterate. If we are to have sex education, let us now approach these adolescent boys and girls in a more adult way and tell them of the responsibilities which they will have to carry when they are more mature.
I am very surprised to find in this Report no mention of iatrogenic or drug-induced disease. The side effects associated with consumption of inadequately tested drugs present a very grave health hazard, and our medical journals week after week contain articles, and particularly letters, from doctors who have observed these very serious side effects. I do not have to remind your Lordships of the most dramatic of them which focused the attention of the world, that is to say, the thalidomide tragedy. One of the 150 pharmaceutical firms—I repeat, my Lords, 150!—in this country may be fighting against time to get a drug on the market before a competitor captures the patent rights, and such pressures may cause clinical tests to be hurried and awkward results to be ignored. It is not the charge on prescriptions, but a curb on the prescription of proprietary drugs, when there is a cheaper equivalent, which is called for if we are to protect the patient and benefit the Exchequer.
This has been said time after time, year after year, and no effective action has been taken. The innocent, ignorant patient is still absolutely at risk. His little cupboard is full of tablets and powders, all of them unlabelled, which he takes with the same faith as some primitive savage. And yet these are being churned out by those 150 pharmaceutical firms in this country which I have mentioned, all of them competing with each other for profit. I suggest that if we are going to educate the public then we must apply our minds to this very important aspect of health. I am hoping that the Treasury—who I understand are going to look at all the social services in the country as well as the Defence Services—will recognise that tremendous savings can be made in this direction. The facts are that last year nearly half of the proprietary preparations prescribed came from United States-owned companies in 1511 Britain, 27 per cent. from British, 14 per cent. from Swiss, and 10 per cent. from other European-owned companies. The cost of medicines and dressings in the general medical and pharmaceutical services has increased fourfold to £148.9 million in 16 years. Of this expenditure 90 per cent. is for proprietary drugs, which in many cases it is agreed are inadequately tested.
I should like now to deal with another aspect of drugs—and I should say at this point that doctors use the word "drugs" to cover not only what are known in the popular Press as hard or soft drugs, but all medicines, powders and tablets and so on. Great publicity is given to the so-called hard drugs and to the miseries of the addict, yet little public education is given to the need to withhold the so-called psychotropic drugs. While major psychiatric and psychological derangements warrant risks commensurate with their severity, it is for minor neuroses that the bulk of these drugs is consumed; yet little is done to educate the public.
Throughout the country general practitioners are getting to the stage of despair. They can no longer argue, but just hand out prescriptions to individual after individual who tell them the colour of their favourite sleeping tablet and what kind of powders or tablets they want. I suggest that we must educate the public in this matter. Our reputation in this field was given unenviable publicity as late as 1960 by the World Health Organisation, which stated:… in the United Kingdom and British Comonwealth psychiatric teaching in general is still hardly a legitimate part of the medical curriculum, in spite of the repeated requests for improvements which have come from faculty and undergraduates.Therefore I feel we must recognise that the human body is controlled by a very important part known as the brain, and in our medical schools teaching must be devoted to the mind as well as to other parts of the body. I fully realise that prejudice exists. In the First World War psychiatry was treated as charlatan, and it was not until the Second World War that we "sold" psychiatry to the Armed Services. I believe that times are now changing and that we must apply this new knowledge to our teaching.
I was impressed by the Report of the Committee under the chairmanship of 1512 Sir Wilfred Sheldon which recommended changes in the teaching of child care and the provision of special clinics in the surgery. The noble Lord, Lord Cohen of Birkenhead, rightly said that the time to teach an individual is when that individual is a child: as the twig is bent so the tree inclines. While the overburdened medical practitioner cannot undertake further responsibilities, I suggest that there is somebody who is sitting waiting to be called upon, though for some extraordinary reason the Ministry of Health—and I think the Ministry of Health and not the public are to be blamed here—fail to use her services. I am referring to the married woman doctor who is available to offer her part-time services for this preventive work. This is a particular field where she could be used.
It is excellent work for these women. They could teach the children what we all want them to know. It is no good saying to me, "Well, where are they?" I suggest that the authorities should read a book called Women in Medicine, by Dr. Margot Jeffrey and Dr. Patricia Elliott, which was recently published. That comprises a survey of 8,000 women doctors and shows that a great potential remains untapped, because so many of them are unable to find part-time work. It is ironical that the diehards in our medical schools still keep the door only ajar for potential women doctors who might marry and stay and work in this country in the field which we are describing now.
The prevention of disease is work which would be very attractive to them. Yet the potential woman doctor is prevented from getting an education because she is considered not quite fitted, on the ground that her ductless glands are not the ones that are generally contained in the right kind of medical student. I ask noble Lords present who have power in the medical schools to change this old-fashioned attitude. We are surrounded by the medical schools here, and there is only a tiny quota of women medical students in St. Thomas's, Westminster, Guy's and Charing Cross.
A woman may be the most brilliant woman, but she cannot get in. Yet here we are, having the people of our country treated by doctors from India and Pakistan who are desperately needed in 1513 their own countries. What absolute nonsense! But, curiously enough, while these same diehards in the medical schools will not let in the potential woman doctor, they are quite prepared to use their time and energies to train men to supplement the medical services of the United States of America. This is a conservative profession, indeed, and there are certainly no grounds for self-satisfaction, for there are no indications that the standards of medicine in this country cannot be improved upon.
Finally, I want to say this to those who feel that the National Health Service in Britain is, of course, superior to anything else in the world and who say that our statistics stand up to anybody else's. These are the facts. A number of developed countries have been ranked by standardised death-rate, stillbirths, infantile mortality rate and maternal mortality rate combined. In that list, the United Kingdom comes eighth. Countries with better health statistics are, in order of ranking, Sweden, Switzerland, Australia, the Netherlands, Canada, Czechoslovakia and Belgium. In the light of this we must welcome a debate of this nature, for it seems to me that we might well reexamine some of our basic assumptions regarding the prevention and cure of disease.
§ 6.24 p.m.
§ LORD STRANG
My Lords, I propose, if I may, to digress a little from the general course of this debate as it has so far proceeded. In the Report on Health Education, which is the subject of the Motion by the noble Lord, Lord Cohen of Birkenhead, there are a few references to food hygiene education, most substantially in paragraph 51. In that paragraph it is stated:… the precautions which are required to prevent food poisoning or the food-borne infection through the handling of food are subjects about which the public has become increasingly aware in recent years.That is true, and as Chairman of the Food Hygiene Advisory Council (an office to which I was appointed by the noble Lord, Lord Hill of Luton, some years ago) I want to say a few words on this subject.
Food hygiene is a large subject and one that is amply covered by the Food and Drugs Act 1955. Under that Act, the Ministers of Health and Agriculture, 1514 Fisheries and Food issue a series of detailed regulations which have force of law, and a series of codes of practice which are designed to serve as authoritative advice. I would interject here that there is a parallel arrangement in Scotland, which has its own Act and its own Food Hygiene Advisory Council; but of this I am, of course, not entitled to speak.
By Statute, the Ministers are obliged to refer the drafts of regulations and of codes of practice to the Food Hygiene Advisory Council for consideration and advice. That scrutiny is the main work of the Council, but the Council have had other tasks. As a result of the inquiry into the Aberdeen typhoid outbreak of 1964, the Minister of Health asked the Council to look into the whole question of food hygiene education and publicity. The Council were, in particular, to give consideration to the problem of improving the awareness of food handlers of the importance of food hygiene. This the Council did. They duly reported to the Minister, and their Report was published by the Ministry of Health in their Monthly Bulletin.
In their Report, the Council noted the respective responsibilities of the Ministry of Health, of the food firms and of local authorities in this field. They reviewed all the multifarious educational and publicity material already put out from these sources, including the Press, trade and women's magazines, television, radio, the cinema, posters, courses, exhibitions and talks. They attached especial importance to the teaching of food hygiene in schools. They recognised that there has been some improvement in the public's awareness of the need for good food hygiene, but they regretted that public apathy continued to be the greatest single obstacle. They doubted whether nationwide intensive publicity campaigns made any effective impact, unless these were linked with actual incidents. In the absence of keen public concern aroused by actual outbreaks of food poisoning, the subject of hygiene has only a limited news value.
As a result of their inquiry, the Council made a number of recommendations far the future, of which I shall mention only two. First, they thought that the key principles of good food hygiene should be proclaimed in two short and 1515 simple codes, one aimed at the housewife and the other at employees in the food trade. These two 10-point codes—based, I may say, on the model of the Country Code produced by the National Parks Commission—have been framed by the Ministry of Health in consultation with the Food Hygiene Advisory Council. They have been widely distributed by the Central Council for Health Education, and up to date about one million copies have been distributed. I have a copy here, so that your Lordships may see what it looks like.
Secondly, the Council recommended that a meeting should be held with representatives of the national trade organisations, and others, at which views should be sought particularly from retailers' organisations, on ways of improving food hygiene education and publicity. A well-attended meeting was held a little over a year ago in which representatives of trade associations, women's organisations, the Consumer Council and many other bodies took part. A very lively discussion took place. The meeting drew up a list of suggestions upon which action might be taken by the Ministry of Health, by the Department of Education and Science, by the Ministry of Housing and Local Government, by the women's organisations, by the trade associations and by the consumer groups. Action on the lines proposed is now proceeding, and it is hoped that this will make some impact on the public consciousness. But it is an uphill task.
Finally, my Lords, may I say one word about the new Health Education Council? The Food Hygiene Advisory Council welcome the establishment of this new body. It occurs to them that although the Health Education Council will take food hygiene education under its wing, food hygiene education will be only one of the very many matters with which the new Council will deal. On the other hand, the Food Hygiene Advisory Council will continue to be keenly interested in food hygiene education as one of their intimate concerns. The Food Hygiene Advisory Council therefore very much hope that the work of the two Councils in this field may be kept in line. They have proposed that representatives of each of the two Coun- 1516 cils should, on proper occasions, attend meetings of the other Council. In this way the necessary information might be reciprocally shared, to the benefit of the cause which both Councils will have been appointed to serve.
§ 6.32 p.m.
§ LORD RITCHIE-CALDER
My Lords, I welcome this opportunity to congratulate the noble Lord, Lord Donaldson of Kingsbridge, on his maiden speech, particularly, if I may say so, because of a great personal interest which I have. The noble Lord may recall that I, among many others, took an active interest in the Peckham Hill Centre and in that remarkable pioneering experiment which, if I may say so to the noble Lord, has only temporarily lost its way. I also want to congratulate the noble Lord, Lord Garnsworthy, on the contribution he made, particularly because he emphasised the point I would have wanted to make about the enormous importance of stressing health education in the schools.
My reason and justification for intervening in this debate is that I am the President of the Mental Health Film Council. May I say at the very outset how disappointed and rather concerned I am about what seems to me to be the disproportionately small amount of space which this Report gives to mental health. I am subject to correction, but I counted that it gave 40 lines to that subject. I know that all of us here have our deep concerns about this, that and the next things, and that they all add up to the ultimate Report, but this question of mental health is surely preponderantly the most serious matter to which health education has to be directed now and in the future—and more so in the future. Of the 470,000 hospital beds in this country, 200.000 are for the treatment of mental cases; and even although we have now reached the stage of recognising that the sick mind is no more a stigma than a broken limb, and we regard mental cases as we would regard physical illnesses, and even although we have got away from the custodial asylums to increasing out-patient treatment, it still remains true that the turnover of those beds is a very slow business. In fact, the 200,000 beds are the most difficult to empty.
1517 I remind your Lordships that while, with modern preventive medicine and modern pharmaceuticals, we may have got control of the infectious diseases, it will be poor consolation if we have to fill the beds in isolation hospitals with mental cases. May I say—and I hope noble Lords in the medical profession will forgive the expression—that when the bio-mechanics have given us artificial limbs, substitute hearts, artificial or substitute kidneys and other organs (even, as I heard in a seminar in the U.S.A., transistors embodied in the brain to replace failing faculties), we shall still be left with the mind and emotions of the personality which all this is, too often misguidedly, I think, trying to preserve. I do not know what we are really working towards when we are going in for all this "plumbing". What is in fact the creature we are trying to leave behind? Anyway, it adds up eventually—it must add up—to preserving the mind or the personality of the individual.
Nowadays, when we understand so much more than we ever did before about psychosomatic disease—the interplay of body and mind; the duodenal ulcer which is caused by mental stress, or perhaps the mental stress which is caused by the duodenal ulcer; I would not know—a healthy mind in a healthy body has, in terms of mental health, a far greater significance, because, with knowledge, we can do so much more about it. It has now become a social as well as a medical responsibility; but our knowledge also makes us aware of the new hazards, or it should make us aware of them. We know that the stresses of our modern, urbanised and highly-competitive society—including, as the right reverend Prelate the Bishop of Lichfield pointed out, the enormous burden of noise—are increasing the anxieties, the neuroses and the psychoses. We know, too, what the "lonely crowd" can mean—the individual who has lost his identity in the anonymity of an unneighbourly society.
We also know a lot more. Increasingly, and highly commendably, we are regarding mental disease as being without stigma, and as we would regard physical disease. We are discouraging segregation; and, with modern methods, including chemotherapy, we are treating the mentally sick as out-patients—ambulatory cases. But while the treatment may 1518 be so much more enlightened, the old social attitudes die hard in the community. We now recognise that it is not much use removing the patient from the conditions—the work, the family or the group—which broke him down, then bringing him to terms with himself by sympathetic treatment in an institution, and then thrusting him back into the very conditions which had produced the original breakdown. Far better that he should be treated—outside the hospital—in and through the environmental conditions in which he has to accommodate himself. This, I think, is recognised generally now as good practice, and it works—but it works only if his family, his work-mates and his neighbours realise that they are part of the therapy. So there is a vast amount of public education to be done if we are going to persuade people to behave naturally and sympathetically to someone whom they regard as "crackers", or even as potentially dangerous. I suggest that this is one of the biggest problems and biggest jobs ahead of us in health education.
There is another aspect, which has been touched upon by the noble Baroness, Lady Brooke of Ystradfellte, and by my noble friend Lady Summerskill, and that is the dangers of modern drugs—and here I am talking about the habit-forming drugs. In all scientific advance good and evil are the heads and tail of the same penny. The very means—the new drugs—which, under proper psychiatric supervision, can be so helpful to the mentally sick, can through the wrong use become, as we have seen, a social menace. We have seen what happens when drugs like LSD get into the hands of the irresponsible—just for "kicks", or just for psychedelic fantasies. That, I insist again, is an issue which belongs with health education. All the measures which your Lordships or the Home Office try to take legislatively to correct or punish the misuse of drugs will be quite useless unless we get the message across, particularly to the younger generation, who are so much our present worry.
I am saying all this apropos of the functions of the Mental Health Films Council, which we set up in conjunction with the National Association of Mental Health. We regard all that I have been 1519 discussing as part of our job. We consider our job as being concerned not only with these but also with the use of films in mental research, in the professional training of doctors and health visitors and so on. This very remarkable body was set up in 1963 under the ægis of the National Association for Mental Health, and the first chairman of the steering committee was my right honourable friend the Minister of Health, Mr. Kenneth Robinson. We set out to produce films, to help people in the profession to make films for their own teaching facilities and also to select and appraise those films which we regarded as the best in promoting our objects.
Here I must pay a high tribute to my colleagues on this Council, very devoted men and women, who are very heavily committed in the practice of medicine or the new professions of film making, television and so on, and who have given for this purpose a great deal of time and attention. Our complaint is that we have had very little resources. We are not complaining about the lack of money but about the fact that there was so much more that we could have done both in film-making and in television, and so on, if only we had had greater resources.
Regrettably, the main source of our films is overseas. I say "regrettably", not because I am detracting from the value of the films but to remind anyone—and it will be recognised as a fact—that in this kind of problem we are dealing with the cultural conditions, social conditions and personal prejudices prevailing in this country. Therefore, when films are used from sources other than this country, they are not necessarily applicable or, at best, appear unreal. The sources of our films for this very big and important job are, mainly, a very small quantity from the Ministry of Health (through the Central Office of Information), and some from the drug firms—who make some very good films; but with the implication which the noble Baroness, Lady Summerskill, would naturally attach to them. I do not think that the films we sanction would carry any suggestion that we were "plugging" some particular drugs or some drug firms; but, nevertheless, we are dependent on commercially-interested sources. We also receive a great deal of help from local authorities who encourage the 1520 making of films; and, above all, we rely on the inspired amateurs.
There are not nearly enough films of high quality produced in this country, and we are constantly having to make use of old material and of material which we often regard as inappropriate. We have made one or two extremely good films. One was a film called Stress, which dealt with the parents of a handicapped child and made a tremendous impact here and overseas. It was shown at EXPO 67, in Montreal, and it has been retained very widely and shown in Canada and the U.S.A. I must say at this point that we depend for our films very largely upon Canada's National Film Board, and on American sources. Glancing at one page of our release films I find Mr. Finlay's Feelings—not Dr. Finlay's Case Book. This was a ten-minute film. It was from the U.S.A. There follows one from Australia, one from the United Kingdom, one from Canada, another one from Canada, and another from the United Kingdom.
We are at this stage really very ill-equipped to carry out what we regard as our main and, as I think, very purposeful task. Like everyone else, I welcome very warmly the appointment of my noble friend Lady Serota, and I ask her, when she is considering all those things for which others will ask, that she will remember that in responsible hands films can be a very effective method in health education.
§ 6.45 p.m.
§ LORD BROCK
My Lords, this Report is a complex one covering many aspects of health education and many disciplines. I congratulate my noble friend Lord Cohen of Birkenhead very sincerely on the excellent Report of his Committee: it is in keeping with the high standard we have come to expect from him. I feel that I cannot with advantage add anything to the admirable and full presentations and discussions within the Report, but I have one main comment to make, and that is to say how glad I am that the recommendation of the Committee has been accepted and that the Government are establishing a Health Education Council which will further the other recommendations of the Committee in the matter of health education.
We have a Ministry of Health, and I have no doubt that this problem of health 1521 education should, at any rate in theory, be dealt with by them. Many have thought that, in spite of its name, the Ministry of Health is really a "Ministry of Sickness" and that it should so order its affairs as to be a true Ministry of Health. Ideally this should be so—indeed the Ministry of Health does much in the prosecution of health as opposed to the pure alleviation of sickness. Nevertheless, it is difficult not to be impressed with the fact that the Ministry's concern with the management of sickness and disease actually with us is in itself a huge assignment that must, by its very complexity and size, limit the application of its resources to health education.
It is for this reason that I welcome the decision to create a separate Council to organise and administer health education. I note that the Council will be an autonomous body and not a special division of the Ministry. I was interested to hear the argument of the noble Lord, Lord Cohen of Birkenhead, in favour of this. I also noted the statement of the noble Lord, Lord Shackleton: that in Scotland similar work will be done by a separate unit or division of the Home Department.
From the mass of other matters dealt with in the Report, I select only the problem of health education in regard to the harmful effects of smoking. I associate myself with other noble Lords who have spoken of this, not only because of the proven and alarming association with cancer of the lung—alarming to those of us who have to deal with so many tragic cases of death from cancer in persons who should still have many happy and useful years to live—but because smoking causes impairment of health in other ways; and a programme of health education should be concerned with these, as well as with the avoidance of cancer of the lung.
The noble Lord, Lord Cohen of Birkenhead, mentioned that health education is not meant to restrict the enjoyment of leisure and amenities but is intended to allow greater enjoyment and happiness in life. This is well illustrated in the dangers inherent in uncontrolled smoking. When life and health are lost, all is lost. The noble Lord, Lord Cohen of Birkenhead and Lord Platt, reminded us that the Chief Medical Officer's report 1522 for the year 1966 said that at least 50,000 deaths were due to smoking.
In discussing the various means and methods of education, the Report mentions the education of children either by teachers at school or by the mother in the home. These are, to my mind, the two most potent routes to effective influence of the child mind and thence, eventually, to the adult.
§ 6.49 p.m.
§ LORD HILL OF LUTON
My Lords, I join in the expression of thanks to the noble Lord, Lord Cohen of Birkenhead, for the admirable speech with which he opened this debate, and even more for the distinguished Report of his Committee and for the dominating part he played in it—not the least of the many public services he has rendered to the community. I will, if I may, confine myself briefly to one or two points, discarding my prepared speech, knowing that it will become more and more effective the longer it is still in my pocket. The first point is this—the noble Lord, Lord Cohen of Birkenhead, made this point in the later part of his speech. It is in my view of the first importance that we should accept the fact that too little is known about the art and technique of persuasion. Much more research needs to be done if we are to judge the effectiveness of the various media in this, and indeed in every other, field of communication. It is part of the larger problem.
Too little attention is being given to the whole subject of communication in the country. We all think that we are experts in persuasion of one kind or another. Politicians believe that they are superb at influencing people by the presentation of their material. Yet the plain truth is that for the most part this is a field in which assertion reigns. Too little work has been done to find out how it is that attitudes are created; how it is that conduct is influenced. Certainly presentation of the facts alone is not enough. The example, which has been so frequently quoted to-day, of the relationship between cigarette smoking and cancer of the lung affords ample evidence of that. The facts are known; yet the impact of the efforts of education and persuasion has very largely failed. So I welcome that part with great enthusiasm 1523 and I hope that, together with the general research to which the noble Lord, Lord Cohen of Birkenhead, referred, this will remain in the forefront of the new body.
Secondly, I am not as enthusiastic as some about the creation of a new body. Perhaps my attitude is prejudiced by the fact of a long association with the Central Council for Health Education, as a member, as its Chairman and now as its President. I am glad that reference was made to the work of that body. It has in fact an income from local authorities of £40,000 a year, and that is all. There is a self-balancing account on publications, but the contribution of local government has been £40,000. The Council has done some very fine work in educating the educators; in bringing the skills of health education to the people who matter most in health education, and they are the health and other staffs of local authorities. Nevertheless, the decision has been made, and there it is.
I feel a little anxiety about the references to a strong central body; the hint that it might be called a body rather than an agency. I think that one has to go desperately carefully about this. If the strength of this body led to the discouragement of local authorities; if it failed to appreciate that they are the main instruments in the practice of health education, there would be a loss. And there is another lingering apprehension in my mind: it is this. Exhortation in matters of health, as we know, is for the most part a failure. If health education seems to be coming from some central body, some strong body with a link with a Government Department—if that is the impression created, then the influence of such education is likely to be the weaker. It is very important that this new body should, as it were, be an alibi for Government in this matter and not be seen as the instrument of Government.
§ LORD SHACKLETON
My Lords, may I interrupt the noble Lord? I do so because his words carry great influence and what he says is likely to be reported. I hope he will acknowledge that in my speech, in my final remarks. I made it absolutely clear that it is our view (a view which I am sure the new Council, or Board, or whatever it likes to call itself accepts) that the responsibility lies 1524 primarily with the local authorities. That is important. I am sure there is no disagreement between the noble Lord and myself, but I hope he will acknowledge that, so that we do not give the impression that this is likely to go in a way which I think we should all regard as dangerous.
§ LORD HILL OF LUTON
My Lords, I do acknowledge that; indeed I referred to the importance of sustaining the role of local government. But the point I am on now is a rather different and a general one: that it is desperately difficult to be as effective from the centre as from the locality. Here I am thinking not of local government but of the school, the clinic and so on. I would give an illustration of the kind of mistake which one can make. It is many years ago now since I was misguided enough in a broadcast to use the sentence. "Britain needs babies". The reaction to that, in terms of protest, was by far the largest in volume that I ever received. "What in the blazes is it to do with other people?", ran the theme through this protest. "That is our affair, a personal affair, and should not be a matter for pontifical utterances from the centre".
My third point is one about which I have the greatest anxiety, and as the noble Lord, Lord Shackleton, spoke on the subject of finance my anxiety grew. I had hoped that the acceptance of the Report of Lord Cohen of Birkenhead's Committee carried with it an acceptance of some such amount of money as half-a-million, over and above (as he put it in the Report) what is now being spent. But the noble Lord, for reasons I fully understand, was very cautious on the subject, and spoke of discussions with local authorities. It is on that point I want to say a word. We have, in fact, been through this before.
When I first made contact with the Central Council thirty years ago, it was a nearly bankrupt body. The Ministry of Health stepped in with a grant and said, "This must be made stronger, and Government money must be made available". That situation lasted throughout the war, but after the war the Ministry took the view (and I believe it was basically sound although it was painful) that the Government grant should be reduced; that local authorities should 1525 become more and more involved in the work of the Central Council, and that the local authorities should, in fact, pay for it. That painful stage was gone through, and in about 1952 or 1953 the last vestige of Government money was withdrawn. Thereafter the Central Council had to rely on local government contributions.
The point I want to make is this: the view was then held by the Ministry—and I believe it was right—that there should be local authority involvement. Now we are back again. The cycle has been turned, and we are back, and I am glad we are back, to a substantial Government contribution to this central body. I may be wrong, but I believe that, in all the circumstances, local authorities will not show much enthusiasm for sharing; for increasing their contribution. What I hope is that whatever the sum eventually decided upon by Government, it will be plainly stated to this new body that that sum will be at its disposal for this work, whether it be the use of the mass media or for research. Please spare this body from having to go periodically to the Ministry, and through the Ministry to the Treasury, for instalments of money. It is essential, if it is to plan its work properly, if it is to do its research adequately, if it is to engage and use the mass media, that it should know (and this may well be in the Government's mind; I shall be reassured to hear that, if it is true) that the sum will be stated in advance.
After all, the most important single recommendation in this Report is the proposal that from central funds there should be half-a-million pounds added to what is now being authorised. That is the key recommendation. Argument may range around whether the new central body is the right one or not. That is of far less importance than the main issue of a substantial sum of money being guaranteed by the Government to this body. Then I believe it will stand a chance of doing health education in a way and on a scale and based on research that has never been done before. For my part, I warmly wish the noble Baroness, Lady Serota, a happy and successful tenure of what is bound to be a most challenging but important office, and if she were in her place I would urge her to get the cash settled in advance to avoid the risk of the ball being perpetually kicked into the long grass of Treasury discussion. I hope 1526 that the noble Lord, Lord Shackleton, will be more reassuring in the words with which he winds up than in the cautious—naturally cautious, but all the same cautious—words of his earlier speech.
§ 7.2 p.m.
§ LORD AUCKLAND
My Lords, it is a great pleasure for me from these Benches to congratulate the noble Lords, Lord Donaldson of Kingsbridge and Lord Garnsworthy, on their thoughtful and convincing maiden speeches. Like the noble Lord, Lord Garnsworthy, I live in Surrey and I know the distinguished record which he has had, particularly in the field of education, on the Surrey County Council. I am sure it is the wish of the Whole House that those noble Lords should be congratulated most warmly and that we should hear them often in future.
I should also like to express thanks to the noble Lord, Lord Cohen of Birkenhead, for enabling us to discuss this important subject and for his extremely convincing opening speech. I think that the calibre of the speakers has been worthy of a much fuller House. The Report which the noble Lords' Committee produced is a most interesting one, if a little complex. It is so far-reaching that it is not possible to discuss the whole of it in one single debate. I should like to congratulate my noble friend Lady Brooke of Ystradfellte on a very well-delivered speech and also, in her absence, the noble Baroness, Lady Scrota, and to wish her every success as Chairman of this newly formed Committee. She is a mother and a justice of the peace, sharing these distinctions with my own wife, and is extremely well placed to head such a responsible Committee. I was interested in the speech of the noble Lord, Lord Hill of Luton. I remember that some years ago the noble Lord, speaking about children gorging themselves on Christmas Day, said, "Let them eat all they like, but, for heaven's sake, throw them out in the fresh air during the afternoon!"
For this health education venture to succeed, two things are vital. The first is that there should be the widest possible communication with the hospital service, the local authorities, clinics and all the other bodies concerned with medicine and health. The other is that there should be adequate finance, as the noble Lord, Lord Hill of Luton, has stressed. 1527 This debate comes at a time of fierce political heat and I do not want to inject any of that into this debate, but I should like the noble Lord, Lord Shackleton, for whose wisdom I have always had the greatest admiration, to give some assurance, in so far as he can, that if there are to be cuts in the social services this Committee will not be starved of adequate finance. It is a very important Committee, which will try to get at the roots of the problem—to the problems of diagnosis rather than of cure.
I speak among a galaxy of medical talent as a layman whose only claim to take part is that I serve on two hospital committees and I am Vice-President of the Royal Society for the Prevention of Accidents, which has a great interest in this subject. It is vital that the research which is going to be done by this Committee shall be carried on in as unfettered a way as possible. The medical profession has long taken the view that prevention is better than cure and that if diagnosis can be carried out in the early stages of even the most dreaded diseases it can give some hope to those who suffer, and even if it does not lead to the cure of those who suffer now, it may lead to curing sufferers of the next generation. We have all read with interest about the man in South Africa who has had a new heart transplanted. Whether this will succeed remains to be seen; but even if it does not succeed, the fact that he has survived so long up to now is a great triumph for the medical profession and a challenge to further medical research.
Education is perhaps a rather simple word here. As a father of three young children, I occasionally have to say to them, "Have you cleaned your teeth?", or, "Have you washed behind your ears?" There are some interesting points in the Report about dental hygiene. Not only the schools and the dentists have responsibility here, but the parents also. Although children tend to think that their parents are either "square" or fuddy-duddy if they tell them to clean their teeth or, if they wear glasses, to put on their glasses before they watch the television set, nevertheless, if it is done tactfully and patiently, I think it has great effect. If it does, and even if it takes time for this to happen, even 1528 nowadays when children are much more mature they are usually grateful.
I will not mention smoking, because as a non-smoker I should be regarded as being prejudiced, except to say that you will not convince people that smoking is wrong if you keep on telling them it is wrong. What one has to do is to show positively on one or two occasions why it is wrong. I think this is particularly true of children eating sweets, and even smoking.
§ LORD AUCKLAND
And even drinking, as the noble Lord, Lord Sorensen, says. I do not think a small glass of white wine necessarily harms a child if it is diluted. I would not put spirits or other forms of alcohol in this category. But if one tells a child that he must not have this, and does not give a reason, then the child will experiment. If you let a child have two or three sips of wine, so long as it is not too potent, the child may well do as I did as a child; and the only time I ever smoked I had two puffs of a cigarette and was so sick and ill that I never smoked again.
Perhaps I am making the most obvious remark, but it is one that goes through this whole Report, if I say that health is the most precious asset that we can have, whether we are old or young or rich or poor. The Health Service in this country is going through difficult times. There are points about it on which there must be disagreement, not only on these Benches but elsewhere, but those who work in the Service have done a marvellous job, and will continue to do so. In this particular field of health education and of prevention and diagnosis of illness, it is esssential that the good work should continue.
Turning to the composition of this Committee, I hope that the nursing profession will be generously represented. After all, they will have the task of carrying out much of the actual curative work, and I think it is essential that they should be kept fully in the picture. I agree that local authorities should have a paramount part to play, but those who administer the cures, and those who have to diagnose the complaints, should be put more fully in the picture than they tend to be in many spheres at the present time. This is particularly necessary in a time 1529 of great technical change, both in medicine and in every other sphere of healing, and of our life in general. There should be absolute watertight communications between the hospitals, midwives and everybody else concerned with the Committee which is being set up, whether they are actually represented on it or not. I agree very much with what was said, I think by the noble Lord, Lord Cohen of Birkenhead, that the Committee should not, at least initially, be too large.
The noble Lord, Lord Shackleton, mentioned Scotland, and since I have spent a great deal of my life in Scotland, I am particularly interested in the set-up there. At this late hour I would not expect a full reply on this point, but I am a little puzzled as to how Scotland is to be financed in this matter. As I understand it, England and Wales will have this Committee headed by the noble Baroness, Lady Serota, and Scotland will be administered by the Secretary of State, presumably with Treasury funds. It is essential that in Scotland, which is a vast developing area—and with industry moving to Scotland there are necessarily more people going there—the calibre of those who are to administer these funds, should be of the highest quality. I hope the Government will be able to assure the House that the needs of Scotland will be closely considered.
I have given the noble Lord, Lord Shackleton, very short notice of two questions. One is with regard to paragraphs 127 and 128 of the Report, in connection with mental health. I hope the Government will ensure that the Committee have the funds and the personnel to look after the short-term mental health patients who are in hospital for periods of stress and for nervous breakdowns, because I think it is a fact that these days one person in nine in this country has treatment for mental health at some time during his life. I hope the Government will make quite sure that the authorities have the greatest possible help in rehabilitating those people when they come back into society to do a job of work or look after their families.
The second point I wish to raise concerns paragraph 158. There is a tendency these days for young people to take all too little exercise. Riding in a motorcar is more of an attraction than tramping 1530 the hills or walking along the beach. The Report says:There are many ways of meeting individual needs and thus implementing the important truth that in days of increasing mechanisation at work and in the home, which calls for less physical activity, it becomes more necessary to occupy some part of one's pleasure in exercise, preferably in the open air.I hope that the Central Council for Recreation and the youth movements, who already have funds from Government sources, will be kept in close touch with this Committee.
Reference has been made to television and to advertising. I would say just this. Television programmes such as "Your Life in their Hands" and "Doctor Finlay's Casebook", which go into great detail and on which great care is taken to get the programme authentic, have done a lot to reassure people who need medical treatment. So far as advertising is concerned, the Incorporated Society of British Advertisers have done much to cut out the irresponsible facet of the advertising field. The toothpaste manufacturers, particularly, have made it quite clear that the teeth should be cleaned after every meal. My Lords, may I say this, in conclusion. This is a very important body, and I think it may well set new trends to the health of this country. I hope that the Government, and all concerned in it, will give it the widest possible help and support.
§ 7.22 p.m.
§ LORD SOPER
My Lords, I should like to join other noble Lords in congratulating my two noble friends on their maiden speeches, in felicitating my noble friend Lady Serota on her appointment, and expressing my appreciation of this document which has been the subject of what we have discussed this afternoon and this evening. I am the more grateful because I am able to introduce, I think nor unnaturally, into this debate a matter to which I will refer in a moment. But I much regret that I did not have the opportunity of being in your Lordships' House when the noble Lord, Lord Cohen of Birkenhead, introduced this debate. I wrote to him apologising for my unavoidable absence, but I did not have the opportunity of hearing either what he had to say or what my noble friend had to say at the beginning.
1531 I want to talk about alcoholism, and I express a certain diffidence as a Nonconformist parson, for it may be believed in some quarters that there is a residual sense, or almost a complex, with regard to alcohol. I do not intend even to begin a temperance lecture, and I am not concerned at the moment with teetotalism. I believe that a case must be made out that alcoholism is a major health hazard in its own right, or its own wrong. I will not weary your Lordships with evidence, but a little of it will not go astray.
There are at the moment perhaps 400,000 to 500,000 alcoholics in this country, and that total is accumulated largely from male evidence. Very few people know how many women are alcoholics, though I suspect that it is a large number. Reference has been made to mental health. Two years before the appearance of this Report, one out of every four males who was admitted to mental hospitals in Scotland was there because of alcoholism. Alcoholism, I believe, is the fourth major cause of premature death. Therefore, when health education is under discussion it seems to me we are in the presence of a major health hazard which we should take very seriously into account, if indeed health education in this field is not adequate, or, as I believe, has not even begun.
Let me adduce two pieces of evidence in support of this last contention. This admirable Report, which ventures over a very large field, entirely ignores the problem of alcoholism. So far as I can see, it contains only two references to the word, "alcoholism". They are on pages 14 and 60, and in neither case is it treated except as an example of unsubstantiated claims in relation to other matters, such as obesity and immoderate smoking. Yet if health education is to be radically undertaken by this new Council, which I am very glad to see is to be set up, how can this supremely important subject be ignored? It will be rather like giving evidence about burglars' kit and omitting any mention of the jemmy. Alcoholism is a major health hazard, and if further evidence that there is a need for widespread health education in this field is needed, may I respectfully refer your Lordships to a 1532 debate in this House almost exactly two years ago, on December 2, 1965. It was on an Unstarred Question promoted by myself, and in it I asked a number of questions. I was pretty sure that the answers could not be given; but various answers were hazarded.
Noble Lords with greater medical experience than I took part in that debate, and they were of the opinion that there might be 35,000 alcoholics in the country. But quite a number had not come across many of these alcoholics; and having consulted fellow medical officers of health, and particularly family doctors, they were unable to compute a larger number than something like 35,000. Moreover, eloquent speeches were made in your Lordships' House which indicated a wide knowledge of drunkenness but no knowledge of alcoholism, as if the two could be confused without irrelevance or detriment to the argument. In fact, it would not be untrue to say that for a great many there was an innocence which at that time was probably creditable, but which, in the light of the problem now, I think, becomes culpable ignorance.
Having said that, I think it is evidence, whatever else can be said about alcoholism—and much can be said about it—that it is a proper subject for any health educative process; and therefore I will venture to delay your Lordships a little by saying something about it. For it is widely assumed that this is in essence a moral problem, and therefore outside the range of this particular Committee, or this particular argument, or this particular debate. I was reared in an atmosphere in which anything connected with alcohol was assumed to be a moral problem. My first religious exercise, so far as I can remember, was attending Band of Hope lectures, accompanied by lantern slides, and sitting in the back row with a pea-shooter. I remember it very vividly. I was brought up to believe that those who drank did it for immoral purposes and should be thoroughly chastised and advised to mend their ways.
The first thing about alcoholism is this. Far from its being a condition within the frame of moral culpability, and issuing in moral turpitude, or indeed being relieved by moral pressures and willpower, it is now beyond dispute 1533 that alcoholism is a particular health condition arrived from, and expressed in, a quite discernible number of characteristics which designate the alcoholic—the "blackout", the compulsive drinking (which does not necessarily mean drunkenness), and the disorder and crumbling of the life of the man or the woman so addicted. It is a health hazard; it is a disease. To continue to try to pump into this particular issue moral obligations and moral exhortations is a sheer waste of time. I say that as a cleric. I have no particular stomach for denigrating the moral or spiritual part, but I think that in the treatment of alcoholism emphasis can be laid on the purely medical attempts to deal with it. But in principle it is a waste of time to talk to an alcoholic about mending his ways, because by his alcoholism he has lost the capacity so to mend them.
The second point about the alcoholic is that he is largely undiagnosed in the early stages because there is a built-in inhibition and a built-in reluctance to admit to conditions which are the early signs of alcoholism and, if not treated at that early stage, can easily develop into the more ragged and the quite disastrous conditions of alcoholism as I know them in the hostels for which I am responsible.
There is an even more sinister aspect to this. A little while ago I happened to take the chair at a day's seminar on alcoholism where it was being said by those more erudite in these matters than I am, and with a wide experience in the field of alcoholism, that there are some people who, by their constitution, react in special ways to alcohol as others do not. I listened with a horrid fascination to a description of those particular symptoms and discovered that I had most of them myself—and I am teetotaller. I felt much like Jerome K. Jerome, who entered the British Museum to consult a medical document on the fact that he might have hay fever and, reading desultorily about other diseases he found that he had the lot, with the exception of housemaid's knee. The difference in my case was that I had many of these pre-determining conditions. It is very lucky for me that I am a teetotaller. There are a great many people who, because of moral quirks and idiosyncracies, because of physical conditions, 1534 are particularly vulnerable to alcohol as others are not, and it is imperative in the early treatment of this problem that it should be so diagnosed. Therefore, there should be the widest publicity for those premonitory signs which are, if they are not recognised and dealt with, almost assuredly the hard road to the complete collapse of the alcoholic.
The third thing is this. Let no alcoholic believe that he is incurable because there is no strict cure. Let him not be despondent; because there is a real prospect of permanent convalescence, and that permanent convalescence, with suitable cushioning, can last him for the rest of his life. If it could be shown by a widespread process of health education that the incipient, early alcoholic can in fact quite quickly be rehabilitated (I am not venturing, heaven forfend!, into fields like apomorphine and antabuse, because I know precious little about them; but I do know the value of putting the alcoholic within the framework of a friendly association with others, into the comfort and assurance of some place where he will be likely to take the kind of treatment offered to him) then I am sure that ample and splendid rewards are there for anyone willing to undertake this work.
This is the kind of thing that is of the greatest importance in health education to-day. And if, as I have said (and I yield to no one in my sense of relevance of these facts and their accuracy). alcoholism is a major disease in this I country, as it is in Russia, in Holland, in the United State of America, then health education ought to be insistent on presenting the facts—though I agree with the noble Lord, Lord Hill of Luton, that you do not necessarily convince people because you tell them the facts; you can often win your case and lose your man. Those concerned in health education should recognise what alcoholism is. They should no longer talk nonsense about it as being coterminous with drunkenness; no longer assume that it is not a wide-scale problem, but should face it, and encourage those who would perhaps tentatively desire some remedial processes to pay attention to the National Council on Alcoholism, which is prepared to give them advice. And the Ministry should be encouraged to adopt the same attitude to alcohol as it is now taking to 1535 smoking. These are necessary and desirable ways of meeting a major health hazard.
It is but a few days to Christmas. I look forward with a certain amount of horror, living and working as I do in the centre of London, to the execrable office parties that will be held on Friday. I regard them as a thoroughgoing nuisance and I have no doubt at all (although I cannot give chapter and verse for this), that the acclimatisation of youngsters in these office parties to alcohol may be one of the pre-disposing causes. If I could make anyone's blood curdle I should be glad to do it now, because I find it a terrifying prospect that there are increasing numbers of youngsters who will be first introduced to hard spirits at parties associated with the Christmas story. Therefore for that reason and the others I have adduced, I hope very much that my noble friend Lady Scrota, when she comes to this most onerous and responsible office, will find a proper place in her work for the presentation of the evidence for the infiltration of knowledge; in fact for education on this issue, as on all the others to which your Lordships have been invited to listen this afternoon.
§ 7.36 p.m.
§ LORD COLLISON
My Lords, I wish to join with the other noble Lords in congratulating the noble Lord, Lord Donaldson of Kingsbridge, and the noble Lord, Lord Garnsworthy, on their admirable maiden speeches. They were most interesting and helpful, and I feel most grateful to those noble Lords. I also wish to apologise to the noble Lord, Lord Cohen of Birkenhead, for the fact that I was not able to be in my place when this debate opened.
This debate is one in which I am interested for a particular reason; and, as it were, this is the mandate for my rising to my feet. Paragraph 132 of the Report reads as follows:Despite the attention of factory inspectors, medical inspectors of factories and appointed factory doctors, there are staggering figures for loss of output, as well as pain and suffering, resulting from accidents in factories. Many of these are due to such causes as failure on the part of management or worker to carry out safety measures, lack of proper safety training and inadequate supervision: In some, fatigue and underlying medical conditions may be contributory causes.1536 This Report was produced in 1964, and since then many of us have been trying to bring about an improvement in this situation. If I may refer to the last Annual Report of Her Majesty's Chief Inspector of Factories, Mr. R. K. Christy, a personal friend of mine, he says, rather sadly:This is the last annual report that I shall be presenting to you and it would have been most gratifying if I could have reported a drop in accidents. Unfortunately I have to report another increase in the number of reported accidents. The 1966 increase, however, was rather smaller than the increase in 1965, and much smaller than the one in 1964. It may be, therefore, that we are reaching a plateau and that the rising trend of recent years is now levelling out. Even if this is so, the 1966 level of 296,610 accidents cannot give us any comfort, and more disturbing is the fact that in 1966 the number of fatal accidents increased from 627 to 701.My Lords, I think it is tragic that the Chief Inspector has to talk in terms of a "plateau". It seems to me that already it is clear that we have not been able to do enough to reduce this toll in suffering and in death which occurs every week in our factories, and I have the greatest possible sympathy with Mr. Christy in the sadness that he feels; and I do see a sadness in that reflection of his in the Report.
It seems to me that the measures we are taking to control accident prevention in factories are not keeping pace with the changes in production techniques and the use of new substances in industry. I know that this is a problem, and one that has to be faced, not only by the Government but also by employers and workers. I know, too, that there is a degree of apathy about this which we are seeking to overcome. I believe that we are achieving some success. Over the past few years we have been organising joint conferences up and down the country, under the chairmanship of people from the Ministry of Labour, and attended by leading members in the area of the Confederation of British Industry and the workpeople's union. I attended one of these conferences only last week in Bristol, and it was encouraging for me to know that although we had 240 people in the hall, from employers and work-people, there were another 240 who wished to come but could not get in because the hall was too small. I am pleased about this, because obviously what we have to do is to get over the need for people to become conscious of 1537 the danger in their jobs, and that means accident-consciousness.
I am convinced, and so is the T.U.C., that one of the most effective ways of reducing accidents, many of which are unnecessary, and also of promoting safety consciousness, is to establish safety committees in all factories of any size and in making other arrangements for joint consultation in the smaller factories. It is a matter for regret that we have not achieved very much success in the development of the safety committees. It is difficult to get figures, and the only statistical information of a general character about the number of safety committees is that which is collected by the district inspectors of factories in the course of their visits and recorded in the factory registers. These figures show that whereas in 1961 there were 2,274 committees in being, in 1964, three years later, there were only 2,664, a very small increase indeed.
Of recent months, and indeed over the past two years or so, the C.B.I. and the T.U.C. have been pushing this question of safety committees among our respective memberships and since 1964 there has been some further improvement. There are still far too many factories that do not have these committees, and the T.U.C., therefore—and I concur with this view—have been forced to take the decision that we can only achieve what we need in this regard if we have legislation. We came to this decision somewhat reluctantly, and I will say straight away that it is no good just establishing a safety committee in a factory because the law requires you to do so. It must work, and people must be interested enough to make it work. Until 1964 we in the trade union movement had pinned our faith in the voluntary establishment of these committees, but in view of the figures I have explained, in 1964 the Trades Union Congress itself passed a resolution asking the Government to introduce legislation to make the setting up of joint safety committees compulsory.
Accordingly, the General Council of the T.U.C. made representations to my right honourable friend the Minister of Labour, who said in effect that he still felt that the voluntary joint consultative machinery was preferable to compulsion. He agreed, however, that progress in developing joint consultation at factory level 1538 had been unsatisfactory and that further information was required. He therefore took the view that the best course would be to give industry a further opportunity to achieve satisfactory results on a voluntary basis, but said that if the opportunity were not taken then the Government would be obliged to take compulsory powers. He said further that if by the time the next major review of the Factory Act takes place sufficient progress has not been made, he will then seek powers to require the establishment of machinery for joint consultation on safety. We are very strongly, and I am very strongly, of the opinion that satisfaction will be achieved only if compulsory powers are taken, and we therefore ask the Minister to undertake a survey of industry to determine just what the situation is with regard to the development of safety committee machinery, because we feel this will give both him and us the information we must have if we are to contemplate legislation in this field.
Another important development in this matter is that the Minister has now replaced the existing Industrial Safety Committee of the Joint Advisory Council for Industry by a new Industrial Safety Council which is manned by representation from the Confederation of British Industry, the T.U.C., and other knowledgeable people. We proposed that that new Committee should, as one of its first jobs, conduct an inquiry into the position with regard to safety committees. We have undertaken such an inquiry and we have, in fact, analysed 260 factories where safety committees exist. The advice we are given by the people in those factories is that the machinery works extraordinarily well. Therefore, we are satisfied that our view about safety committees is confirmed.
I want to stress that it is not only a question of looking to see that legislation is enacted; legislation is important, but it will not do the whole job. One of the most important aspects of these safety committees is that they promulgate this concept of safety consciousness among the workpeople. I would take this opportunity of putting on record my appreciation of the work which is being done by the Factories Department and by the Ministry's safety inspectors. They do a wonderful job in all the circumstances. There are not enough of them 1539 to cover a multitude of factories, and they need to be backed by an extension of research both in occupational safety and in occupational health.
May I now say a word about occupational health? Again, we have been making representations to successive Governments asking for the development of more research in this field, and we are trying to get a number of diseases which we believe to have an industrial origin, and therefore which are an occupational hazard, prescribed. But clearly again prevention is better than cure, and when one recognises that the country loses some 300 million working days a year from sickness and knows that occupation is a factor in that very serious loss of time, it is clear that, quite apart from all the human considerations involved, much remains to be done. For this reason we have, during the past year, persisted in our efforts to secure improvements in the facilities for detecting and preventing, and we have insisted that conditions be improved, and have been insistent that a comprehensive health service is a "must".
It is interesting to know, as we now know, that the highest rates of incapacity were found among the workers in the heavy industries and occupations, miners and colliery-men showing the highest incidence, and these workers also have the highest incapacity rate from bronchitis, rheumatism and arthritis. Those three diseases together account for some 60 million of the 300 million working days lost through sickness each year. The General Council believe that priority should be given to a full-scale clinical and environmental survey on a national basis of bronchitis, and a similar inquiry should be undertaken for rheumatism and arthritis. In addition, surveys should be undertaken particularly in the heavy industries and over the whole range of diseases which especially affect these industries.
Another important aspect of occupational health is the work of the appointed factory doctor service. Your Lordships may be interested in developments which are taking place in this field. In April, 1966, the Industrial Health Advisory Committee of the Ministry of Labour published what we conceived to be important proposals for developing the 1540 appointed factory doctor service. As your Lordships know, the appointed factory doctors are appointed under the Factories Act, and their main duty is to examine young persons under the Act. They also carry out the examination of workers other than young persons required under regulations for particular processes—for instance, under the lead regulations.
We conceive that it is a weakness of this service, in which more than 1,800 general practitioners are employed on a part-time basis, that many of these doctors, because of the short time they spend on this work, have only a limited knowledge of factory conditions, and little or no training in occupational medicine. This is not to denigrate the wonderful work that these doctors do, in addition to their normal services to the community; we hold them in high regard and great respect. This is not a criticism. In spite of the development of the National Health Service and other services, and of the changed demands of occupational health, the Appointed Factory Doctor Service has remained substantially unchanged since 1948. The Industrial Health Advisory Committee Report generally accepts that the service in its present form is not suited to assist the Government to discharge its responsibilities for workpeople's health, and it reports that it feels that it should be replaced by a more integrated and expert medical service with wider responsibilities.
Again, as your Lordships all know, under the present regulations a young person may not be employed in a factory for longer than 14 days unless he is certified by the appointed factory doctor to be fit for the employment. More than half a million young persons are examined each year, but of these less than half of 1 per cent. are rejected. This is a non-selective system which was devised before the introduction of the National Health Service and the school medical service, and we think it follows that a disproportionate amount of medical effort is devoted to perfunctory examinations of young persons, the vast majority of whom are found fit for employment, and we feel that too little attention is given to those who are in need of special attention.
To eliminate unnecessary examination the Report therefore recommends that in 1541 future the examination of young persons should be put on a selective basis, by using the school medical examination in the last year at school as evidence of fitness for employment in industry. Those young persons found unsuitable for some jobs would then be referred to the appointed factory doctor, who would be required to examine and follow up all handicapped young persons referred to him in this way. It is a fact that an amendment of the Factories Act would be required for this change.
The Report also stresses the value of the work of the youth employment service, insisting that as part of the new proposals there must be close cooperation between the appointed factory doctors and youth employment officers. Young persons with health handicaps should, we believe, if those handicaps affect the kind of work they can do in industry be specially encouraged to use the youth employment service. We believe that there must be some integration as between the school medical service, the general practitioner and the appointed factory doctor service so that it can be open to the general practitioner, the employer or the worker himself, either directly, in the case of the worker, or through his doctor, his employer or his trade union, to ask for advice on occupational health problems. Finally, we feel anxious that these recommendations by the Industrial Health Advisory Committee should be taken up quickly by the Government. We are anxious to see development of an occupational health service up and down the country, and of course we think that that development goes hand in hand with an occupational hygiene service.
Again I think your Lordships will be interested to know that we, as a T.U.C. are not simply confining ourselves to what might be termed bringing pressure on the authorities. Next year is the centenary of the Trades Union Congress. In order to mark that centenary it has been decided by the T.U.C. to create a Health Institute. It will be incorporated in the London School of Hygiene and Tropical Medicine, which is part of London University. It will be housed in a new building, to be erected on the fourth floor of the school in Gower Street, which is only a short distance from the T.U.C. headquarters at Congress House. We hope that construction will begin in the sum- 1542 mer of 1968, and we hope, too, that within eighteen months a team of specialists, not only doctors but chemists and engineers, will be at work in the new laboratories, and will have the full resources which we hope to give them for monitoring and testing dust and fumes, industrial processes, chemical substances and the rest.
But to come back to the main point of this debate this evening, the three main objectives of this new Institute are, first of all, to provide a service to trade unions by training a team of doctors and hygienists able to go into industry to investigate health hazards; secondly, to act as a central information centre on all known and suspected health risks in industry—and this is strictly educational—and to undertake the instruction of trade unionists and other non-medical people concerned with occupational health hazards, as well as to stimulate medical education in this field.
At this rather late hour I apologise, my Lords, for taking a little time, but your Lordships will understand the strong feelings that we in industry have about the hazards to which people working in these industries are subjected, many of which we think can and should be dealt with.
§ 7.57 p.m.
§ LORD SHACKLETON
My Lords, I shall not spend much time on congratulating noble Lords on what has been a most interesting debate. There has been quite a flow of compliments from a number of noble Lords, all, or nearly all, well deserved. I would particularly join with all my noble friends and noble Lord generally in congratulating the two maiden speakers, the noble Lord, Lord Garnsworthy, who displayed a great knowledge and, to my mind, delivered the perfect maiden speech—well informed, based on personal experience, short and absolutely relevant to the subject of the debate and my noble friend Lord Donaldson of Kingsbridge, who again brought a great deal of knowledge and indeed some extra enlightenment, to the debate. I should very much have liked him to develop further the future development of the Peckham Health Centre and, even more, to have seen the correlation between the subject of this debate and the pioneer work with which he has been involved. Both noble Lords 1543 brought great knowledge, and charmed the House as well as contributing to our general enlightenment.
Some noble Lords, including the noble Baroness, Lady Brooke of Ystradfellte, were kind to me. I am not going back to 1948. I hope that this is a debate in which we are not going to dig out certain matters and slam one another. She may feel strongly about some things—there are things that we feel strongly about. I do not propose to follow her in that. But I was grateful for her kindly remarks and the encouragement that she has given, and I am sure that my noble friend Lady Serota will also have appreciated all that was said about her, both by the noble Baroness and by other noble Lords. Before I finish I should like to deal with points made by the noble Baroness and the noble Lord, Lord Hill of Luton, on the fundamental question of the relationship of this new Central Council with the community, but I shall reserve that to the end, since I agree that it is important that we should understand this particular aspect.
I now turn to certain aspects of health education which were discussed, and I am conscious that we are fortunate that the rather carefully prepared briefs have been far more effectively reproduced by other noble Lords. Indeed, the first of the issues I had meant to talk about was the subject of smoking. There is no doubt about the sense of urgency conveyed by noble Lords on this matter. Many noble Lords, including the noble Lord, Lord Cohen of Birkenhead, the noble Lords, Lord Platt and Lord Brock, and my noble friend Lady Summerskill, felt that somehow we are not getting enough urgency into the matter. I must say that I find a certain amount of depression that we are allowing people to encourage young persons and our citizens to kill themselves in this way. There has not yet been enough social or psychological research into what makes people smoke cigarettes. In fact, very little is still known on this subject. There have been spot-check surveys on advertisements and the Government's social survey is at the moment carrying out an investigation. Nor do people know how difficult or how easy it is to give up smoking.
1544 I was interested to hear the noble Lord, Lord Auckland, talk about what one says to children. I speak as someone who gave up smoking cigarettes when I reached 60 cigarettes in one day—I admit that this was actually on the day of an election count, and I have never smoked a cigarette since that day. I admit that I smoke a pipe, but it goes out all the time, which is very much easier. I believe it is easier to give up cigarette smoking than many people realise. Having tried so many times before, only when I gave that final little push did I realise how much easier it was to do.
Since the parallel question of self-control comes into this matter, I am inclined here to refer to Lady Summer-skill's reference to the indulgent male and the tendency to obesity. Of course, one of the first consequences of giving up cigarettes is enormous putting on of weight, and since that time I have had to take off two stones. I think that further research on the motivations in these matters is of importance. Meanwhile the Government are stepping up their campaign. There is a mounting force behind it, and the general pressures, both social and otherwise, are having a considerable effect—but still nothing like enough effect. I can only say that what has been said to-day is certainly something to which I will draw the attention of my right honourable friend, since I know how strongly he feels on this subject and upon the need for greater efforts. I will leave the subject there, for I feel that it has been fully deployed.
I should like to touch on a matter which has not been quite so fully discussed—although a number of noble Lords, among them the right reverend Prelate, the noble Lord, Lord Garnsworth and Lord Ritchie-Calder, referred to it—the subject of mental illness. That is a particularly delicate area for a central body to conduct operations in, using mass media. It is the area par excellence where a more personal approach is needed, but it is true that a greater awareness of the nature of mental illness has created rather more tolerance and understanding—but still astonishingly little. It amazes me how many people, even those with experience of 1545 mental breakdown and neurotic conditions in their families, are still unsympathetic to others and unaware of the responsibility which rests upon the community. This again comes back to school education, the personal responsibility of parents, and the counselling of husbands and wives by the Marriage Guidance Council and Family Planning services. There is much more that can be done in this field. I was interested to hear the right reverend Prelate mention the Richmond Fellowship, which is doing such striking pioneer voluntary work—voluntary work of the kind which must still continue to grow up in pioneering the way, even when, as we hope, the local authorities and the State move more fully into the matter.
The noble Lord, Lord Soper, gave us a very interesting, sympathetic and clear account of the problems of alcoholism. Again, it is clear that this a subject in which health education must play a more active part. His differentiation between drunkenness and the alcoholic was most interesting, and I myself have had friends who are alcoholics and one would never know that they were so. One of them recently, very bravely, wrote an article in a Sunday supplement, saying, "I was an alcoholic". It never occurred to his friends that he was in fact an alcoholic. The fact that this was not mentioned in Lord Cohen of Birkenhead's Report is not a reflection on him or on the Report. Clearly, it would have been possible to produce a Report which was rather more of a catalogue than an indication of further work. The noble Baroness, Lady Serota, is sitting very close to the noble Lord, Lord Soper, and will have full opportunity to put this subject on the agenda for early consideration by her Council. It is again, however, an aspect of personality problems and raises issues which also come into the field of mental health.
Reference was made to drug dependence and drug abuse. I listened to what was said, conscious of the great need for action. I have listened on other occasions to my noble friend Lady Summerskill talking on the problem of drugs, on screening, of the dangers of dependence, and indeed on the dangers of simple medicine addiction, as opposed to what most people think of as real drug addiction, though perhaps I should say 1546 medicine "dependence" rather than "addiction." At the moment an examination is being carried out into the findings of inquiries recently carried out by the Ministry of Health and the Department of Education and Science conducted by local authority professional officers. The Advisory Committee are shortly expected to issue their advice to the Government. So far as school children are concerned—I do not wish to prejudge the conclusions—the report is likely to be a good deal less alarming than some people may have feared. This is not to minimise the intensity of the problem among those who suffer from it, but it is a matter on which we shall await that report with interest.
The noble Lord, Lord Strang, spoke about food hygiene and expressed the hope that there would be close cooperation between Baroness Serota and his Committee. He is sitting a little further away from my noble friend Lady Scrota than my noble friend Lord Soper is, but I do not doubt that they will be able to work out a satisfactory measure of co-operation. Clearly, it is highly desirable that there should be that sort of co-operation.
I should have liked to speak at great length on this subject of food hygiene. It is interesting what a continuing part my noble friend Lady Summerskill has played in these fields, and I remember her determination back in 1946 and 1947, when she was Minister of Food, to get universal pasteurisation. I remember being rather impressed as a new M.P., and thinking that at last somebody was doing something about it. It has now been done, and the fact that there is more work to do should not minimise the achievements in this field, and the further work which I am sure the noble Lord, Lord Strang, and those who are active in this field, will undertake. In the last twenty years there has been real progress in this field, in regard to the manufacture, treatment and preparation of food and milk, and also in regard to its handling in shops and under retail conditions.
Again, we had some interesting discussion on industrial health and on the industrial medical factory service. I listened to my noble friend Lord Collison with a mixture of great interest and slight frustration, because he was embarking on a field of very deep interest and one in 1547 which I have been involved. He linked it skilfully to the subject of industrial health training. In the Commons he would just have been in Order, but I am not quite sure whether it is possible for me this evening to discuss the whole of the factory doctor service, or even the question of accident prevention. But that it is of the greatest importance no one would doubt.
It is striking what enormous variety there is in industry between the good employer and the employer who is, not bad but unimaginative. This is a personal view, but I have always thought that one of the areas for further advance in the Health Service is in industrial conditions. This is one of the areas where it will be possible, without doing the overworked general practitioner out of a job, to lighten his load. A firm with which I was associated had first-rate doctors, and also a sister in every branch, who would deal not only with actual accidents and troubles but with daily incidents, such as colds, headaches, and so on. That sort of thing is possible on the part of enlightened employers. Of course, when the Bill comes before us, as no doubt it will—it may be that my noble friend Lord Collison is better informed than I am as a member of the Government about the progress of that Bill—it will change the basis of the factory doctor service. But that it is right to do so I have no doubt. Here, again, both he and my noble friend Lady Summerskill talked interestingly on this subject.
The time is late, Many worthwhile things have been said, but I shall deal with only two or three other points. We were all interested in what the noble Lord, Lord Amulree, had to say on the subject of cancer education. I hope that this, again, will receive publicity. It is a matter which was dealt with in the Cohen Report, and it will no doubt receive further consideration. He asked me certain questions, but I think in the interests of time, unless he particularly wants me to do so, I shall not deal with them now but will let him have that information.
One of the subjects which I had expected to receive more discussion, which I think the noble Lord, Lord Hill of Luton, referred to and which came out indirectly 1548 in other speeches—it was certainly the main subject of the Cohen Report—is the need for field studies as an aid to evaluation of health education. Field studies are singularly difficult to get carried out because of the shortage of people who are competent to do them. Having been involved in a number of field studies in different areas which were carried out by competent sociologists, I was appalled by the inadequate or unsatisfactory nature of the results. This is something on which a great deal of experience, as well as professional training, is also necessary. It is an important matter if health education is to be effective and if we are to understand the nature of the problems and the attitudes that surround them. That is why the Government Social Survey has carried out field studies into the problems of venereal disease and smoking and health, and the Central Council for Health Education sponsored the inquiry by Mr. Michael Schofield into the sexual behaviour of young people. The results of those studies have been used to inform the health education that is carried out on these important problems.
I was asked by the noble Lord, Lord Auckland, whether there would be cooperation between other Government bodies—and I think he meant Government bodies in the field of physical recreational health—and this new Central Council. I would give an absolute, categorical affirmative. To my mind, it is inconceivable that bodies such as the Central Council for Physical Recreation, or the Scottish Council, or any of those bodies would not become important allies of the Central Council. There is such a clear link, especially in the field of physical activity to which the noble Lord, Lord Cohen of Birkenhead, and his colleagues attached such importance. Certainly, again, although the noble Lord is sitting opposite my noble friend Lady Serota, she will have heard what he had to say, and, of course, having a debate here is one way of making sure that the Chairman of the new Council really knows what we think she ought to be doing.
The noble Lord, Lord Donaldson of Kingsbridge, and other noble Lords, very rightly pointed to the important work of general practitioners in this field. As I made clear in my opening remarks, I was at that stage speaking primarily about the 1549 role of Government in this matter, but it is absolutely true that the greatest amount of education is done by doctors, by dentists, by midwives and by nurses. I remember my own doctor making me hold two 14 lb. weights to show what I was-unnecessarily carrying around. That was a very effective form of health education, and I am sure that the sort of work which health centres and groups of doctors are able to carry out is quite fundamental. It is a matter of time.
When I was Air Force Minister and was treated by the Air Force, it was very noticeable to me that I had more dental health advice because the dentists were keen and less heavily worked than my National Health dentist, who is equally keen, equally good, but does not have time to do it. Clearly, one hopes to see more leisure and more scope for doctors to do that sort of thing. It is vain to expect more than a certain amount at the moment, but, even so, it is striking how much is being done.
I will not now go into the subject which aroused Lady Summerskill's understandable anger—that perhaps is not the word; "indignation" is the right word, I think—which was with regard to the attitude to women doctors. I was not sure whether she was being critical of the Government or of Nabobs of the medical profession. But we listened to what she had to say, and I certainly should be very happy to talk to her at some time about the importance of industry, of Government and of others making full use, part-time, of the trained woman-power that there is in this country—and this applies both in the professions and, indeed, in industry. It has been my view—indeed, I am sure—that it is sometimes easier to get high-calibre women part-time to do certain jobs which otherwise would be less well done by lower-calibre men who are full-time. Not that I would suggest for one moment that you will not find equally high-calibre men, but they are doing perhaps more important jobs, which require full-time work. I am sure my noble friend will at least accept this as a reasonable approach to her.
§ LORD SHACKLETON
Perhaps I did not make myself as clear as I wanted 1550 to. I can only say that I shall read what I said in Hansard tomorrow with interest, and, if necessary, will supply a correction.
My Lords, I should now like, in conclusion, to refer back to the basic role of this new Council that is being set up. The noble Lord, Lord Hill of Luton, made some wise remarks, both as to its role, and indeed as to its financing. He was sympathetic, in that he did not expect me to say to-day how much money the Council was going to receive from the Government, but certainly, so far as a quick calculation made by myself is any indication, I reckon that three-quarters of the finance in future will come from central Government funds; and this will provide a stability. But if we are to rely on local authorities—and I am sure this was the burden of speeches from all quarters of the House—this is an area where, whether the central Government are operating through a semi-independent body like the Council of the noble Baroness, Lady Scrota, or whether they are operating through their own Government Department, they should be very careful not to attempt to take the whole thing on. Here I agree so much with the noble Baroness, Lady Brooke of Ystradfellte, that this is something in which local authorities and individuals engaged in this field professionally have the biggest part to play. But there is clearly an important area—and this was well spelt out by the noble Lord, Lord Cohen of Birkenhead, in his Report—where Government can both provide the sinews for the work and stimulate the initiative. I think the proposals that have been put forward by the Government represent the right sort of compromise between conflicting principles, and that they are no worse for being a little bit delayed or for following so closely the recommendations of the noble Lord, Lord Cohen of Birkenhead.
§ 8.24 p.m.
§ LORD COHEN OF BIRKENHEAD
My Lords, may I at the outset express my thanks to those who have taken part in this debate? I confess that when I saw the list of speakers, formidable as it was, I was very encouraged, because I believed that at last an interest was being taken in health education; and I have been delighted that there has been such a unanimity of approach to the problems of health education. I am grateful also for the very generous expressions about 1551 myself and my Committee, and the work that it has done. I think I can say that nothing has been said this afternoon which in any way runs counter to the recommendations of the Report. There have been one or two minor criticisms, and perhaps at this hour I should not reply to them, but I think it might be advantageous if I reply very briefly to one or two.
First, there were the observations of the noble Lord, Lord Shackleton, that health education had somewhat vague boundaries. That, of course, is true, and the whole of the first chapter of our Report is devoted to what is health education. That it was rather vague we realised, but we were a little comforted when we saw a review of the Report in the New Statesman of May 15, 1964, which said:Few would quarrel with the opening sentence of the Report, 'It is difficult to fix precise boundaries to health education.' The Committee has attempted the task none-the-less, and has largely succeeded in giving shape and definition to a nebulous subject.That observation was written by the present Minister of Health, Mr. Kenneth Robinson, when he reviewed the Report before he became a Minister.
I must say that, purely on basic grounds, my preference would be for the word "Council" to be in the name of the body, rather than "Board". I have unfortunate recollections of certain boards, and I prefer "Council", because I believe it is counsel which the Health Education Council will be giving. I am not disturbed that Scotland has decided to have a somewhat different administrative structure from that to be set up in this country. It is very good that there should be experiment in this field. It will provide a valuable opportunity for comparing results and methods; but clearly there must be communication between them.
Of course, in the Report one has not referred in detail to a large number of subjects. After all, this is not a textbook on health education: it is a Report on health education. Let me say that if alcohol is mentioned as one of the subjects, then all the rest of the Report, which deals in general with the methods of health education, with the techniques of health education and with the material for health education, applies to alcohol; and I can reassure the noble Lord, Lord Soper, that I am very conscious of the 1552 important part which alcoholism plays in disturbing the health of the community. In fact, I initiated, and am President of, the Merseyside Council on Alcoholism, a progenitor of the National Council on Alcoholism, which the noble Lord adorns. May I also say, with reference to general practitioners, that one chapter of the Report does deal with the general practitioner and health education.
The noble Baroness, Lady Brooke of Ystradfellte, referred to what she felt were two misprints in the Report. One was, I think, "to" instead of "by", but I think that if she reads this sentence as I am now going to read it she will find that "to" is the appropriate preposition:We take this opportunity of expressing our appreciation of the great assistance rendered to all those who prepared written evidence …",and so forth. With regard to the other misprint, I apologise. It is the only misprint that I myself found in the Report, and I should like to say that it was not the result of any Freudian lapse or of wish-fulfilment. Again, I would say to the noble Baroness, Lady Brooke of Ystradfellte, that the reason the place of hospitals is not included in any detail in the Report is simply that we have referred to doctors and methods in general.
The noble Lord, Lord Amulree, referred to cancer education and the fear which may be associated with it. Our duty is to frighten people to life; we do not frighten them to death. Much has been said about the role of the medical officer of health. He is discussed in the Report very fully. After all, the Royal Society of Health, over which I had the honour to preside, is largely peopled by medical officers of health and their staffs.
My Lords, there is very little further that I wish to say, except this. I believe that perhaps one of the difficulties about the smoking campaign has been that we have constantly referred to diseases such as lung cancer, bronchitis and heart diseases. Young men and women think that the possibility of developing these diseases is extremely remote. I believe we ought to emphasise the effect which cigarette smoking is having on them at present, particularly if they are athletes, if they run or play rugby. This is a more immediate effect of cigarette smoking.
1553 The noble Baroness, Lady Summerskill, provided the appropriate present with her bathroom scales and her long strip mirror for what the Daily Mirror once called "the tubby hubby". I think it will be effective. There are several paragraphs dealing with medicines and medication in the Report, and I agree that we must deal with health education in the undergraduate curricula. There is more psychiatry being taught at present than the noble Baroness realises; and in the recommendations of the General Medical Council which have recently been published psychiatry occupies a very important part. I think I must say the same to the noble Lord, Lord Ritchie Calder. Five paragraphs were devoted to mental health. We had two distinguished psychiatrists on our Committee. But I should like to make it clear that health education cannot achieve any more than contemporary knowledge will allow it to achieve. In the field of mental health we are still looking for causative factors which might usefully be mended by appropriate health education.
I am grateful to my noble friend Lord Hill of Luton for what he said about the Report, although I do not agree that money is the main proposal. I think that far more important is the Health Education Council and the functions to which it will be devoted; and then the money to support those functions is of great importance. I am grateful to all noble Lords who have spoken, and I am grateful to the noble Lord, Lord Shackleton, for what he has said and also for the attention he has given to the Report. I beg leave to withdraw my Motion for Papers.