Lords Sitting of 15 February 1967

Preamble
The House met at half past two of the clock, The LORD CHANCELLOR on the Woolsack.
Prayers—Read by the Lord Bishop of Chichester

LORD MACLEOD OF FUINARY
The Very Reverend Sir George Fielden MacLeod, Baronet, having been created Baron MacLeod of Fuinary, of Fuinary in Morven, in the County of Argyll, for life—Was, in his robes, introduced between the Lord Glentanar and the Baroness Elliot of Harwood.
The Lord Mottistone—Sat first in Parliament after the death of his brother.

MESSAGES FROM THE QUEEN
2.46 p.m.
LORD COBBOLD: My Lords, I have the honour to present to your Lordships two Messages from Her Majesty the Queen, signed by her own hand. The first Message is as follows:
"I have received your Address praying that the Ministry of Aviation (Dissolution) Order 1967 be made in the form of the draft laid before your House. I will comply with your request."
The second Message is as follows:
"I have received your Address praying that the Ministry of Land and Natural Resources (Dissolution) Order 1967 be made in the form of the draft laid before your House. I will comply with your request."

PEERS AND PARLIAMENTARY FEES
LORD INGLEWOOD: My Lords, I beg leave to ask the Question which stands in my name on the Order Paper.
[The Question was as follows:
To ask the Leader of the House whether he considers it proper that a
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Peer should be charged fees by both Houses of Parliament in respect of the discharge of certain of his Parliamentary duties and whether he is prepared to initiate action to rectify this anomaly.]
THE LORD PRIVY SEAL (THE EARL OF LONGFORD): My Lords, no fee is charged to a Peer by either House, so far as I am aware, for fulfilling any Parliamentary duty. As regards the last part of the Question, there is, in my view, no anomaly here which needs to be rectified.
LORD INGLEWOOD: My Lords, may I ask the noble Earl the Leader of the House whether he considers that attempting to amend a Statutory Instrument by the only method open to a Member of either House is not part of his Parliamentary duties? Further, is the noble Earl aware that since I asked a Question about a fortnight ago on this subject I have received a second account for the same amount? This time it is from the Clerk of the Fees of the House of Commons, saying this at the bottom:
"The Clerk of the Fees requests that the above Account may be paid at the Fees Office before Twelve o'clock on Tuesday, the 14th instant, he being required by the orders of The Speaker of the 9th February, 1844, to make a Return to him of the unpaid Accounts at half-past Twelve o'clock on every Tuesday."
It then concludes:
"Payment by Cheque preferred."
THE EARL OF LONGFORD: My Lords, I have a very high opinion of the financial sagacity of my noble relative. When he was my trustee I would always follow his advice, and perhaps he will now follow mine, which is to pay up before worse befalls him.
LORD INGLEWOOD: My Lords, may I ask the Leader of the House, who gave me very little trouble when I was his trustee, one further question? Can he at least give me an assurance that I shall not receive a third account for the same amount from the office of the Lord Privy Seal?
THE EARL OF LONGFORD: My Lords, I hope so, but I am not making any promises. I think the noble Lord is going to be unlucky over this.

DOUBLE WHITE LINES AND THREE-LANE ROADS
2.50 p.m.
LORD WAKEFIELD OF KENDAL: My Lords, I beg leave to ask the Question which stands in my name on the Order Paper.
[The Question was as follows:
To ask Her Majesty's Government what progress has been made with the experiment of alternate off-set double white lines on lengths of three-lane roads, and whether a statement can be made.]
LORD SHEPHERD: My Lords, the experiment with alternate off-set double white lines at selected sites on three-lane roads has been completed, and my right honourable friend the Minister of Transport expects to make an announcement very soon. There have been a number of somewhat premature reports in the Press recently, of which the noble Lord may be aware, but I would not wish to anticipate my right honourable friend's announcement except to say that the experiment has not been so successful as had been hoped.
VISCOUNT STONEHAVEN: My Lords, may I ask the noble Lord whether he is aware that I recently became an accident statistic on one of these unmarked three lane roads, and that had the road been marked with offset white lines there is a 99 per cent. chance that I should not have become a casualty? Is the noble Lord further aware that I was picked up and taken to the Lister Hospital, Hitchin, and that the treatment I received from all concerned was beyond praise? Whatever may be said during the main debate to-day, I should like (quite wrongly, at this moment) just to say that.
LORD SHEPHERD: My Lords, speaking as one who has read in the newspapers recently the criticism poured upon the National Health Service and the hospitals, I am sure the House will appreciate the tribute that the noble Viscount has paid to a particular hospital. With regard to whether the noble Viscount would or would not have become a casualty if white lines had been there is not for me to say because I do not know what the circumstances were. Without anticipating what my right honourable friend may
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say or decide, I think there is undoubted evidence to show that, because motorists have not complied with the rules and regulations governing this experiment, the danger of accidents arising has been increased.
Lord WAKEF1ELD of KENDAL: My Lords, may I ask the noble Lord whether the Statement to be made in another place will be repeated in this House?
Lord SHEPHERD: My Lords, I am not yet aware in what form the Statement will be made. If a Statement is made in another place, as is customary we should repeat it here; but it may well be made in another form.

RHODESIA: GERMAN AND FRENCH TRADE CONTRACTS
2.53 p.m.
LORD NAPIER AND ETTRICK: My Lords, I beg leave to ask the Question which stands in my name on the Order Paper.
[The Question was as follows:
To ask Her Majesty's Government whether it is true that the Government of the Federal Republic of Western Germany have now decided not to cancel existing trade contracts between themselves and Southern Rhodesia; if so, how long these contracts run for, and what this decision is worth in terms of foreign exchange to Rhodesia; and whether Her Majesty's Government can confirm that a £2 million barter deal between Rhodesia and the French firm of Boussac, involving an exchange of French textiles for Rhodesian tobacco, has recently been signed.]
THE MINISTER OF STATE FOR FOREIGN AFFAIRS (LORD CHALFONT): My Lords, the Government of the Federal Republic of Germany have stated that they have not yet taken any decision on existing trade contracts between German importers and Rhodesia. The second part of the Question is therefore hypothetical. So far as the Boussac Company is concerned, we have received reports that the company has entered into a barter deal for the supply of textiles to Rhodesia in exchange for Rhodesian tobacco. As my honourable friend the Minister of State for Commonwealth

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Affairs stated in another place on February 6, inquiries about this are being made. Meanwhile, I am satisfied that the tobacco could not enter France.
LORD NAPIER AND ETTRICK: My Lords, I should like to thank the noble Lord, Lord Chalfont, for that reply. Can he tell us how long the Government now consider it will take for mandatory sanctions to become effective? Would four years perhaps be a fair assessment?
LORD CHALFONT: I am sure the noble Lord will realise that that question does not arise either out of his original Question or out of my Answer, and I could not possibly begin to reply to it.

ROYAL ASSENT BILL [H.L.]
THE LORD CHANCELLOR (LORD GARDINER): My Lords, I beg leave to introduce a Bill to amend the law relating to the signification of Her Majesty's Royal Assent. I beg to move that this Bill be now read a first time.
Moved, That the Bill be now real 1a.—(The Lord Chancellor.)
On Question, Bill read 1a,and to be printed.

THE NATIONAL HEALTH SERVICE
2.54 p.m.
THE MARQUESS OF LOTHIAN THE MARQUESS OF LOTHIAN rose to call attention to the National Health Service; and to move for Papers. The noble Marquess said: My Lords, I beg to move the Motion standing in my name on the Order Paper. First. I feel that I owe the House an apology for the length of time that this Motion has been on the Order Paper. It was first put down, I think I am right in saying, towards the beginning of 1966, but it fell a casualty at the General Election. I hope your Lordships will agree with me, however, that the delay has added to the pressure for a debate on this subject in your Lordships' House. I have deliberately drawn the terms of the Motion widely because there is so much expert medical knowledge in your Lordships' House and it was my hope that as much of this as possible would be contributed to the debate today—and I am glad to see from the list of
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speakers that this hope, I think we can say, is going to be fulfilled. I am aware that this may make the task of the noble Lord, Lord Beswick, who is to wind up, more difficult, perhaps, than it would otherwise have been, but I hope he will forgive me in the interests of having a broad debate on the National Health Service as a whole.
It is frankly my opinion that the National Health Service, which is the vital linchpin in our Welfare State, is gradually accelerating towards a collapse—in fact, towards a real crisis on cost, care and confidence. I therefore thought that, as one of the advantages of membership of your Lordships' House is the opportunity to hear expert opinions voiced, I would venture, having myself had a chance to talk to a great many people on this subject in many and various fields of medicine, first to attempt to analyse what is causing this three-point crisis and then to make some suggestions as to how cost and, particularly, care and confidence in the Health Service can be restored. But, most of all, I hope that this debate will stimulate the Government speakers into telling us how this alarming prospect of the disintegration of the Health Service can be halted—for I think the Government must take responsibility for the present crisis.
First, may I take the cost? I am sure all your Lordships will agree that we are wholehearted supporters of our free National Health Service, but the fact remains that at the present time it is costing something in the region of £1,000 million per year. Under the ill-fated National Plan it was calculated that this sum would rise by something like 4 per cent. per annum, as it had been doing, in line with the 4 per cent. national economic growth. That, I think, is fair enough, although we cannot forget that in some of the more advanced countries in Europe more, proportionately, is being spent on health. But I should like to know what is happening now that the National Plan and its growth target have fallen by the wayside. This seems to be an unfortunate political failure which is affecting the world of suffering (which has no responsibility by way of politics at all), for it is clear that the Health Service costs are continuing to rise. Doctors' salaries, drugs, hospital buildings, new equipment—all these are costing the nation more

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each year, despite the current freeze. That is why I think that the taxpayer has a right to know, first, how Her Majesty's Government mean to tackle all the requirements; secondly, what these will be over the next, say, ten years; and, thirdly, what finance is going to be available.
Also, how are the Government going to avoid the danger that a free Health Service, which is eminently desirable, is achieved only by penny-pinching on the services provided? Indeed, we had an example of this last July, I think, when the Minister said that some important services would have to be unavoidably curtailed. We should have further, detailed information about these cuts. There was at that time, your Lordships may remember, widespread concern in the medical profession. Some of your Lordships may remember a letter from Sir Alexander Haddow to The Times, in which he said:
"Nothing is more unbelievable than reports that the Ministry of Health propose the closure of certain casualty departments."
These cuts, therefore, are a very serious matter, all the more so because there are other instances where proposed economies seem to sacrifice essential priorities.
Surely the best economy we can undertake is to cut down waste. I think that this should be tackled first, because there is no doubt that there is both waste and inefficiency in parts of the National Health Service to-day. For example, one Press report states that something like 30 per cent. of the food used in hospitals is thrown away. This represents an enormous sum in money terms, totalling something in the region of £12 million to £13 million. This money could certainly be used very profitably to finance new equipment (for example, heart-lung machines) or increased salaries where it is considered essential.
There is also the question of time waste, which is a very expensive item. For example, junior hospital doctors spend much of their time acting as clerks and messengers, as was described in an article in the Lancet last year—which does nothing to raise their already low standard of morale. Further, general practitioners find, despite the welcome improvements in their remuneration and in their conditions, that they still have to cope with a very heavy load of correspondence, form-filling and so on. Some of this work is inevitable; but I feel bureaucracy
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tends to flourish under Socialism and that this may be an example of it. There is a case for true economy here, economy in valuable time.
At the other end of the scale we have the vast problem of money which is being spent on buildings and equipment and which is to some extent, I think, being wasted. I saw an instance of this this week in Scotland where the now notorious Ninewells teaching hospital in Dundee is to cost £8 million more than was originally estimated because of technical misunderstandings and delays. Some of your Lordships may have seen in the Daily Mail last week two articles which pinpointed some other examples of this kind of thing. It all seems to suggest that if our administrators were to look after the millions, the thousands might look after themselves. Certainly I am constantly being told that contractors frequently pitch their quotations higher for Government contracts than they do for private ones because they think they will get away with it; and, indeed, they sometimes do.
Even in 1963 it was estimated by the Comptroller and Auditor General that there was an error of from 15 to 40 per cent. in the costing of hospital projects. I doubt very much whether the situation is any better now. It must indicate, apart from incompetence, that much yet remains to be done to standardise the design of components and equipment to save both time and money. So I hope that the noble Lord who is going to reply will give the House some indication of the measures the Government are proposing to take to prevent waste and inefficiency. How is the Minister going to deal with this? Is he satisfied that measures now being taken are being effective?
May I turn now to the crisis of care—and here I am thinking primarily of the patient? We all know that conditions in some of our hospitals are not ideal, from the patients' point of view. It may be due to poor food, or lavatory or library facilities, or just to a lack of general amenities. But certainly in many places—though not all—improvements are needed. Among the difficulties, one of the most important, I think, is how to solve the problem of the shortage of fully-trained nursing staff; for it is often necessary nowadays to delegate responsibility to staff who are only partially trained. I should be interested

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to know of any new proposals which will help eventually to ensure more trained staff; because I think this is something where the patient is the true sufferer.
I should like briefly to mention one particular category of patients, the young chronic sick. There is throughout the country generally a great shortage of beds for these people, with the result that they are taking up badly needed geriatric beds. So far as I am aware, there are no reliable figures for the young chronic sick, and it is therefore difficult to assess the situation accurately and to plan ahead. But I would ask the noble Lord to bring this matter to the attention of his right honourable friend, because I think it is something which should be gone into. Certainly more accommodation is needed. Most of these people suffer usually uncomplainingly and with great courage, from diseases of the central nervous system, like multiple sclerosis. I feel that their particular need should not go by default.
My Lords, may I turn now to the third area of crisis, as I may call it, that of morale? In my view, this concerns primarily doctors and nurses. The tragedy is that although we can rightly claim that we have some of the finest hospitals, and certainly the most dedicated doctors and nurses in the world, the latter to-day are working in an atmosphere of uncertainty and disillusionment. This results in the lowering of morale. And, clearly, a lowering of morale in the caring professions is hardly a good prospect for those who need care, I should like to give one or two examples of this; taking first the doctors.
We are all delighted that general practitioners have now got the increases recommended by the Review Body last April; but I think there are still two alarming factors in their situation. The first is that the numbers of general practitioners are apparently still declining. Between January, 1965, and April, 1966, they fell, in England and Wales, by 250; and in Scotland during the two years from October, 1964, to October. 1966, there was a drop of more than 100. I shall be interested to know the latest figures, and, more importantly, how the Government propose to halt this trend.
It is, obviously, bound up with emigration. It seems that the so-called "drain"
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is beginning to be a stampede. I understand that over 700 junior hospital doctors last year sat the examination to qualify for American appointments. Of course they will not all go to America; and some of those who do will come back. But when we recall that in the previous year only400 sat (though that is a large enough number), and that in the year 1958, I think, only three doctors practising in Britain sat for the same examination, it gives us a pretty alarming picture of the state of feeling among doctors. Last year was certainly in this sense a record year; but it was a highly depressing one both for British patients and for the Treasury, who have borne the expense of the drain.
My Lords, I think that anyone who goes into a hospital to-day, when he notices the high percentage of doctors from overseas, can see for himself, the realities of this doctor drain. But on analysis, and in considering why doctors emigrate, I think that possibly too much attention is paid to the lure of monetary gain. An equally important factor, in my view, is job satisfaction. A doctor becomes a doctor to practise medicine, and in too many cases nowadays doctors cannot do this satisfactorily here at home.
Of course, my Lords, we welcome the increasing number of doctors who are going through our medical schools, but the question is whether there will be enough to offset the effect of emigration and the effect of doctors from the Commonwealth returning to their own countries. What is the Government's estimate about this? What about the four new medical schools which they were demanding so vociferously a few years ago, and which they promised to build? Are there enough clinical teachers for requirements? I am putting all these questions because I think that the House is entitled to have an answer to them.
There is another important and worrying cause for lack of morale among general practitioners, and that is that there is still a lack of properly integrated relationship with hospital services. I believe it to be most important that general practitioners should play a greater part in the well-being and treatment of their own patients in hospital. It helps the treatment, it saves the time of the hospital doctors; and it might indeed

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lessen the routine work-load on consultants, and thereby contribute to the reduction of waiting lists. I think that at the moment some general practitioners feel cut off from the hospitals, and I believe that the need for an improvement here must come from the Minister. The general practitioner is not only a hard-working servant of the public, he is also a responsible human being, which is why so many doctors resent being dealt with as mere medical machines which are overhauled from time to time, or dealt with, as it were, on a computer analysis basis.
I come now to the problem of the general hospital doctors, of whom there are 13,000. They provide the consultants for the future, and there is little doubt that by any standards they are underpaid and overworked. By having to change posts frequently their domestic life is becoming increasingly difficult. It nearly always involves either renting a high-priced flat or house, or an enforced separation of a doctor from his family. Both are invidious alternatives. Therefore, it is little wonder, I think, that doctors contemplate emigration as a solution. The situation here is complicated by another factor, which is that the increase in the number of junior hospital doctors has outstripped the increase in consultant posts, with the result that the promotion ladder has become considerably lengthened in time.
I believe that there is here an urgent problem, and I think the solution lies in a combination of higher salaries and allowances. We are all glad to know that negotiations are at present going on with the Ministry. Better conditions and more consultant pasts are needed, and, I would emphasise, allowances, because if salaries rise, that rise must not, as it were, be cancelled out by a similar rise in expenses.
My Lords, I should like briefly to discuss nurses and nursing, for I think that a great deal has to be done to restore morale. The first point is that there is still a shortage of nurses. I know that the number of nurses in hospitals has increased, which we all welcome, but we must remember that the increase has to some extent been offset by such essential reforms in nursing conditions as shorter hours, longer holidays, and so on. In fact, therefore, more nurses are doing less
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work, which is one reason why we still hear of hospital wards having to be closed down. I think it important that the Government should realise that an increased total of nurses is not, in itself, a matter for complacency. I know that the nursing profession feels very strongly that this is something which should be appreciated.
Secondly, the Salmon Report on the future structure of the nursing profession is, as I am sure your Lordships are aware, pretty far-reaching and revolutionary, and the lack of any statement from Her Majesty's Government is causing under-stable anxiety to members of the nursing profession. I do not wish to discuss the Report on this occasion, but I would ask the noble Lord if, as a matter of urgency, he would ask his right honourable friend to hasten the making of a statement on the Report. I am sure that this uncertainty is causing nurses a great deal of worry. They are working largely in the dark, and this does a great deal of harm to morale. Thirdly, we must not forget that financial considerations also play an important part in maintaining the morale of the nursing profession. To take one very small example of what sometimes happens, it seems inequitable that domestic staff, doing weekend overtime or night duty in hospials, can sometimes earn more than senior nursing staff in the same period.
My Lords, I do not wish to appear too much as a prophet of woe and gloom, and if I have been critical and tried to pinpoint what I believe to be some of the worries and frustrations of people working in the Health Service, it is only because its welfare and improvement, as I am sure your Lordships will agree, is so essential for us all. I am convinced that action by Her Majesty's Government now is essential, because I feel that so far they have been inclined to prevaricate, patch-up and postpone. So may I suggest, with all diffidence, one or two remedies, one or two ways in which the situation can be restored?
First, I should like to see a scale of priorities established, based on actual need rather than on any political desire for shop window publicity. I do not want to bring in politics, but when one considers the priorities of real suffering I still maintain that the removal of the

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prescription charges was a most irresponsible act. It may have attracted votes, but it gave the impression that there is money to burn; whereas we know that the opposite is the case. It is rather like advertising free pillows on a bus tour, when you know quite well that you are short of the means to prevent the engine from actually breaking down. Instead, I suggest a more vigorous approach to costing, a more accurate costing of expenditure, and a ruthless attack on waste and inefficiency from top to bottom. This would enable the money saved to be contributed towards the best available equipment for all those who work in the Health Service.
Quite small sums of money, carefully and thoughtfully spent, often do a disproportionate amount of good both psychologically and physically. I am thinking of such things as decent catering and decent accommodation. A little more spent on redecorating nurses' bedrooms or common rooms, or the provision of decent bathrooms for nurses and patients, would be money well spent, and there is clearly a need for this in many of our hospitals. Surely, it would also save time and labour if dining rooms could be provided for walking patients. All this could help the nurse and make her profession more rewarding. This is vital to what I call job satisfaction, and I think that no detail should be spared in our scrutiny of it, if that can prevent the heart being taken out of nursing, for that is a factor which, of course, affects the patient as well.
Another field of necessary rebuilding seems to me to be that of preventive medicine. Here I would advocate a much more positive approach than I think we have had so far—in fact, a new and dynamic campaign. For preventive medicine is an educational process in which all the modern means of publicity—particularly, in my view, television—should be utilised. We have all seen the effective short film strips which have been made about road safety and accidents in the home. I see no reason why this technique should not be applied to general questions of health.
We must do everything to enlist public interest in cutting down any unnecessary loading of the Health Service. But I think we must also remember that this
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overloading is not only a public responsibility. I was impressed recently, when I was talking to a distinguished Scottish medical superintendent and she said that the concept of preventive medicine reminded us that the Health Service is carrying an increasing work-load of patients for which it was not designed. She called it bluntly, "The price of Britain's moral break-down." She gave the examples of attempted suicides, alcoholics, drug addicts, abortions and people suffering from mental illness. While no one in the Service resents having to cope with this, it seems to be a timely reminder that steps should be taken by legislation and by educationists to prevent as much of this as possible before it hits the Health Service. I would urge that the Minister should discuss this aspect of the problem with his colleagues in other Departments. Otherwise, it looks as if the only answer to accidents and dangerous driving on the motorways is to have a hospital every few yards. Even with more pedestrian ailments, I am sure that preventive measures could cut down what is becoming a dangerous load, and once the public realised that it was in their interests they would gladly co-operate.
In the same way, I am certain that the public would co-operate if it was properly explained when other sensible economies were being made. One instance I can think of, in rural areas particularly, is the hospital car service, which is becoming a very expensive item. I have heard reports from widely separate areas up and down the country. Here again economies could be made without any real hardship, merely by more efficient administration. I believe that people will accept cuts if they know and can see that the money saved is spent on more needed local capital projects, things of which they are at present being deprived, such as a new wing to the local hospital or an old peoples' home or a new operating theatre—things which can be seen by people living in the vicinity.
This brings me finally to a personal suggestion which I think could be considered. It struck me, and I discussed this with several medical administrators, that it is difficult for one man to be both the political and the administrative head of the National Health Service. I think the suggestion is worth

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considering that the Minister should have the services of a non-political director-general (or whatever we may call him) of the Health Service, a person who would be responsible to him for day-to-day administration, empowered to co-ordinate the activities of all the branches of the Service within the budget approved by the Government. The relationship would possibly be similar to that which exists between the Postmaster General and the B.B.C. I make this suggestion personally and with diffidence, as I am conscious not only of the highly complicated administrative difficulties involved but also of the great debt which we already owe, and all acknowledge, to the permanent officials in the Ministry of Health for their tireless and selfless services throughout the past 20 years to the National Health Service. I think that their views on a proposal such as this would be most interesting to hear.
To sum up, it may be the Government's view that major alterations in the administrative pattern of the Health Service will to some extent be linked with the eventual recommendations of the Royal Commission on Local Government who are at present sitting; but any Government action on this matter is bound to be still in the pretty distant future. I do not think the Health Service can wait that long. So I am hopeful that to-day the noble Lords who are replying may give the House some indication of the Government's thinking on these general problems, because it is obvious to all of us that, despite the great work that it does—and it is doing great work—all is not completely well with the National Health Service, and that something more than just lack of money is involved.
The Government have now been in office for almost 2½ years—long enough, in my view, for them to have taken stock of the position and to have expanded and improved on the excellent work that was done before then. My complaint to-day is that, except when they have been really hard pressed—for example, by the general practitioners—they have, by and large, let matters drift and have not got down to the job of grinding out the grammar of the whole thing; and this, I believe, has tended to give this feeling of disillusionment and apathy and to lower morale in the Service. I hope that I am wrong about this. Perhaps the noble Lord
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who is going to reply will be able to convince me that I am wrong. I beg to move for Papers.
3.27 p.m.
LORD SORENSEN: My Lords, we are all grateful to the noble Marquess, Lord Lothian, for initiating this debate on the National Health Service, a service which has been of incalculable benefit to those who have suffered from afflictions of body or mind or have needed the means of ensuring good health. I trust that your Lordships will not think it extravagant or provocative if I say that to me it is some compensation to feel that although we have lost an Empire, we have a Health Service of which we can be proud and which can justify the appellation of "Great" to Great Britain.
In the course of my remarks I wish to provide some antidote to the more sombre and morbid aspects of the speech of the noble Marquess. Many other aspects of his speech were helpful. We appreciate them very much indeed and I will see that my right honourable friend the Minister of Health and his colleagues consider them. Many aspects of the Service have been brought to the attention of your Lordships from time to time, but we have not had a debate on the Service as a whole for some time. Therefore, I am grateful that we have this opportunity of making a general survey. Within the limited time at my disposal I cannot do full justice to the subject, and the criticisms, suggestions and inquiries expressed by the noble Marquess and other noble Lords will certainly receive the careful attention of the Minister and his colleagues. It will be impossible immediately to answer every point raised, but my noble friend Lord Beswick will do his best to reply to as many as possible later on.
My own task is now to record, as objectively and concisely as I can, the broad progress made in the development of the National Health Service since its statutory initiation in 1948. Personally, I believe this to be a fascinating and heartening story, as I presume your Lordships will agree, notwithstanding the inadequacies and imperfections of which all of us are aware. Moreover, I trust that this will provide an effective answer to any insinuations or allegations, here or elsewhere, that the National Health service is threatened with collapse or has

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woefully fallen far short of the initial sanguine anticipations. In the more depressing parts of his speech, the noble Marquess referred once or twice to a lack of morale, to collapse and disintegration; and although at one moment he turned aside to say that he did not want to be a mere prophet of woe and gloom, I almost thought, before he said this, that part of my task to-day would be to try and rescue him from the discipleship of the prophet Jeremiah. I am glad that he showed signs that he did not want to be influenced by that particular gentleman.
Most certainly we must not be complacent, but while vigilance, imagination, enterprise, persistent drive and willingness to learn by experience must constantly be exercised, this does not preclude honest recognition of encouraging achievements. I should have welcomed a warmer note or two in the speech of the noble Marquess precisely on that point, for criticism, though valid and natural, particularly on the part of the Opposition, is likely to be more acceptable if there is an appreciation of the positive side as well as of the negative side. I submit that to see how far we have progressed we should do well to contrast the present comprehensive National Health Service of to-day with the wretched plight of many British people at the turn of the century; those who endured grievous burdens of ill-health and suffering, not only because of shameful social conditions, but also frequently because they could not afford to pay for necessary medical attention. Some of us could provide evidence of this from the experience of our own parents. Happily, that form of cruel social injustice no longer embitters human lives or haunts the conscience of a more fortunate minority. For that we can all be profoundly grateful.
None of us is unmindful of the noble efforts of philanthropic institutions and voluntary hospitals in bye-gone years, nor of the fact that in our own age medical knowledge and surgical skill have made an immense advance in preventive and remedial service. Whatever opinions we may have on birth control, certainly we cannot deny that methods of death-control have substantially extended the span
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of human life. As I see it, our National Health Service embodies a now accepted sense of responsibility by the community for all its members who need therapeutic restoration to good health. It receives the support of all political Parties and of the overwhelming mass of our citizens, even though they may seek its improvement and may voice subordinate criticism. Many other countries also have their own form of National Health Service, and in those that do not, or where the concept is resisted, there is growing pressure to emulate our example.
With the assumption, therefore, that all noble Lords, including the noble Marquess, offer their criticism or advice because of their profound desire further to improve the National Health Service, I shall give the House some of the facts and figures that illustrate what has been achieved and what developments have been planned. This will provide material by which we can refute merely ill-informed criticism, as distinct from what is valid and constructive.
First, let me deal with the Hospital Service because that represents the greatest measure of public provision, and also involves the largest proportion of public expenditure. Of the 2,800 or so hospitals which the National Health Service took over at its inception in 1948, many were small, wrongly sited and, worst of all, had obsolete buildings, nearly half having been built in the last century. During the period of post-war reconstruction we had to wait until national resources had grown sufficiently to enable a start to be made in removing this accumulated obsolescence. A national plan for modernising and rationalising the hospital service throughout England and Wales was therefore formulated; and it is quite misleading to suggest that this plan no longer exists. The pattern outlined in the Hospital Plan, and which has already begun to take shape, is to replace numerous small and ill-equipped hospitals by a network of large, modern district general hospitals, each having a wide range of facilities for diagnosis and treatment. Four district general hospitals have already been completed and are in use, and major parts of 60 others, while substantial contributions to 50 more are currently under construction. Hospitals of other kinds will, of course, continue to be required, either to serve areas

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where, for geographical or other reasons, a large general hospital would be inappropriate, or to serve particular purposes.
From 1960 hospital building has made good progress, and more recently there has been a marked growth, both in the programme as a whole, and in the undertaking of really large projects which will contribute to the long-term improvement of the service. Work to the value of £99 million was started in 1965–66, including 18 projects costing over £1 million each, compared with £50 million, or only half the 1965–66 figure, and six projects of over £1 million, in 1962–63. During the 1950s the value was considerably lower and averaged about £15 million a year. Actual expenditure in this year alone is expected to be more than £75 million, compared with a total investment of £336 million during the whole period from July, 1948, to March, 1966. When we speak of investment, I would maintain that this is a splendid national investment, with the dividends accruing in the better health of the people as a whole.
According to present plans, about £1,000 million will be spent on hospital building over the next ten years. At an average expenditure of £100 million a year this will be, in real terms, more than double the rate obtaining just before the last war and more than four times the average for the post-war years up to 1966, that is, £23 million. The experience gained in the highly specialised field of hospital building, and a greater measure of standardisation in both design and construction, to which the noble Marquess referred, will, it is hoped, lead to increased efficiency in the use of resources, without depression of standards. The Ministry of Health has launched two development projects: the first will attempt to design and build two hospitals providing the same standards of service, but at substantially reduced costs; the second aims at the country wide standardisation of complete hospital departments of the commonest kinds, such as wards, operating theatres, maternity and out-patient departments. The evidence is of considerable progress being made, but it is not enough. It has been urgent for years, and now it is being thoroughly and energetically tackled, within the limits imposed upon it. Swifter progress, much as it is needed, cannot be achieved without the necessary
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resources of money, manpower and materials which are dependent on the growth of the national economy.
Turning now to the staffing of the Hospital Service, again there has been a very great quantitative increase. We hear a great deal about staff shortages, which, of course, do exist and are sometimes serious, but little about the solid achievement represented by the great number of staff in post—no doubt because good news is no news.
I present your Lordships with a few other significant facts. We have heard much in the news in recent months—we have heard something of it to-day—about the serious shortage of doctors. In 1949 there were approximately 11,700 medical staff in the National Health Service hospitals in terms of whole-time equivalents. In 1965 the number was over 18,900, and in 1966 over 19,500. The increase since 1949 is about 67 per cent., and even in the last 12 months there has been an increase of over 600 or about 3 per cent. We certainly want more hospital doctors, and my noble friend Lord Beswick will later indicate what is being done to increase the supply, but meanwhile I would say that the picture is not one of steadily declining numbers.
Let us consider nurses, at least in respect of the National Health Service. Here I share with the noble Marquess the tribute he paid to this branch of the Service, as well as to many others. Here we have a particularly good record of recruitment, although we must of course continue our efforts. In hospitals, the overall numbers of nursing and midwifery staff in England and Wales—and all my figures relate to this area—have risen steadily over the years from 148,812 in 1949 to 258,675 in September, 1966. With all the difficulties, there has been this remarkable and encouraging progress. This shows an increase of 47 per cent. in whole-time staff, while part-timers more than doubled—that is, there was a 221 per cent. increase. In the last five years alone, the strength of the nursing and midwifery services, after taking into account the effect of the introduction of a 42 hour week by January 1, 1966, has increased by 12½ per cent. This compares with a rise in the overall working population of the country of 3 per cent.

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Similarly other professional and technical staff in hospitals concerned with diagnosis and treatment have doubled in number since 1948. Nearly 30,000 staff are now engaged in the para-medical professions and as scientists and technicians. Many present technical occupations did not even exist in 1948. Of the long-established professions, I will mention that physiotherapists have increased in number by more than one-third, and dietitians by more than one half. Radiographers and occupational therapists have doubled, and in some categories, such as medical laboratory technicians, numbers have nearly trebled. I forbear to stuff more staffing statistics into the sympathetic ears of your Lordships, though I fear that for public purposes I must deal with some other statistical material. I hope, however, I have made it clear that, perhaps contrary to popular belief, over the years the resources of man and woman power devoted to the Hospital Service have spectacularly increased—much more than the increase in the population. It is not unreasonable to deduce from this, therefore, that the standard of service has also risen, despite what the noble Marquess has said.
Numbers of staff and expenditure of money are not, of course, by themselves decisive. As the noble Marquess has pointed out, efficient and effective use of resources is crucial, and constant efforts are being made to ensure this. The nationalisation of resources—one of the greatest benefits of a National Health Service—has lead to a planned reduction of beds which had increased after the appointed day to a peak figure of 483,000 at the end of 1958. At the end of 1965 they totalled about 470,000. But such has been the improvement in the management of resources that the number of in-patients treated has increased from 2,900,000 in 1949 to 4,800,000 in 1965, an increase of 65 per cent., and the number of new out-patients seen at consultant clinics increased from 6,100,000 in 1949 to 7,500,000 in 1965. New attendances at accident and emergency departments increased from about 4million in 1949 to nearly 7 million in 1965, and this is not simply accounted for by motor-car accidents; industrial and domestic accidents also are far too high. These achievements are due in
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large part to the efforts of doctors, nurses, medical auxiliaries and all the other hospital staff who labour so tirelessly for the sick and injured, and also to the giant strides in medical progress which have, for example, enabled the average length of stay of a patient in an acute hospital to be reduced from 18·2 days in 1955 to 12·7 days in 1965, without there being any deterioration in treatment.
Admittedly there are areas of strain in the Hospital Service; there are bound to be. There are growing pains. Waiting lists have begun to rise again, and totalled 529,000 on September 30, 1966, but this rise must be viewed against the steadily increasing population of England and Wales, and against the background of nearly 5 million hospital admissions each year, and also it may in part be due to increased attention to gynæcological ailments. Patients needing immediate treatment admitted without delay account for half of all admissions. Hospitals are making every effort to reduce waiting lists and are constantly examining the possibility of transferring patients from long to shorter lists, of utilising under-used resources—for example, by making use of operating facilities in psychiatric hospitals for general patients—and of making optimum use of the resources they have.
I turn now from the Hospital Service to local authority health services. These complement the hospital and specialist services and the general medical and dental services, and aim at the cardinal necessity of promoting health and well-being and preventing illness and disability. I entirely share the observations of the noble Marquess in this respect. Where illness and disability nevertheless occur, the local health services aim at providing domiciliary care within the community or in centres or in residential and other accommodation. These services comprise, first, the personal services given mainly in the home by health visitors, midwives, home nurses, social welfare workers, home helps, and the ambulance service. Then there are the facilities provided in residential homes and training centres or social centres for the mentally and physically handicapped. Care in the community by these services supports, and is supported by, the care given by the invaluable family doctor.

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Since the inception of the National Health Service this type of service has expanded considerably. This can be illustrated by the increase in the number of staff employed and by the rise in the level of capital investment. Statistics for local authority staff were not, regrettably, collected from the outset, but the figures now available show substantial increases up to date, and surely this is heartening. Between 1949 and 1966 there was an increase in health visitors from about 3,750 to 5,290, 41 per cent.; in home nurses from about 5,780 to 8,390, 45 per cent.; and in home helps from about 10,510 to 30,240, 188 per cent.
Regarding the home helps, I would interpolate that I know what a tremendous boon they have been to numerous persons who are harassed or infirm or sick in their homes. One hopes that more will volunteer, at least to give part-time work in this splendid part of the service.
Between 1959 (earlier figures are not available) and 1966, the number of mental health social workers increased from about 910 to 1,830, 101 per cent. After a decrease to 1956 the number of midwives increased in the next ten years to 1966 from about 4,650 to 5,200, or 12 per cent. This I think indicates some progress, and in giving these figures I do not seek to imply that all needs are met—indeed I know they are not; and there are many unfilled posts—but the figures do show that the local health services have secured a creditable increase in the man and woman power they employ.
For capital investment in the local community health services the annual amount of loan sanctions recommended by the Ministry of Health has risen over the years from an estimated £1·2 million in 1949–50 to about £9·5 million expected in 1966–67. To these figures must be added capital expenditure by local authorities from revenue and other resources. In recent years this has been running at about £3 million to £5 million per annum on health and welfare. All this registers in general a significant level of improvement and expansion achieved in the capital assets of the local health services. These figures, with those for staffing, reveal that these local services have had vigorous development over the years—a matter for which the country
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should be grateful to the local authorities who plan and run the services.
Time does not permit me to describe the growth of each particular local authority service separately and there would only be complaint if I even started to do so. But there is one group of services that demand special mention because they represent not just an increase in volume but a change in approach as well; namely, the services for the care of the mentally disordered in the community. Having served on a county mental hospital committee for twenty-one years I am greatly impressed by the remarkable progress made in this sphere. These services have grown particularly fast in recent years. Revenue expenditure has been rising by about 20 per cent. per annum and it is expected that this rate of increase will be exceeded in the current financial year. There is now a fuller recognition that the needs and capacities of people suffering from mental handicap or disorder differ more in degree than in kind, from those of others. More social workers, of whom a higher proportion have completed recognised courses of training, are employed year by year, and the development of social work services is doing much to assist mentally handicapped people and their families to understand and cope with the situation with which they are faced.
A number of local authorities now provide residential accommodation to relieve families for short periods of the most exhausting task of looking after their mentally handicapped members; and all of us have had some experience of this type of tragedy in our own homes, ending in the more balanced members of the family breaking down under the strain. There has been a rapid growth in the provision of places in training centres run by local authorities for teaching the mentally handicapped, especially for children, and since 1964 the Training Council for Teachers of the Mentally Handicapped has done much to promote the provision of regular instruction for the teachers who work in these centres, so that the benefits of the latest developments in teaching practice and theory will be available to the handicapped.
I have not so far mentioned the general dental service. There have been considerable improvements in the dental treatment received by the country since

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the inception of the National Health Service. The trend has been steadily towards the conservation of teeth. Whereas in 1935 a sample of National Health Insurance returns showed that 6·15 teeth were extracted for each filling done, and even in 1949 2·36 teeth were extracted for each filling, by 1965 over 3 fillings on permanent teeth were inserted for each extraction carried out. The amount of treatment given to children has increased yearly, and in 1965, 5,815,000 courses of treatment were provided for the 7½ million school children aged 5 to 15 in England and Wales by the general dental service and the school dental service. This is in addition to some thousands of children treated in hospitals. Here again treatment was directed towards the conservation of teeth, and in the permanent teeth of these age groups seven fillings were done for each extraction.
The one branch of the Health Service I have not so far mentioned in any detail is the vitally important one of the family doctor service. We are all well aware of the family doctors' central position in the Health Service. Because this is a service provided by 20,000 individual doctors, comparative statistics for buildings and staffing are not available. There has again been a substantial increase since the early days of the Service, from some 17,000 to some 20,000. There are special problems here, and the special action that has been taken, which we hope will transform the future of the Service, will be described by my noble friend Lord Beswick, who will wind up the debate.
So much for the development of the physical framework for the provision of health services. I feel sure your Lordships will agree that the picture is one of steady development and expansion and emphatically not of decline. In the hope that the lively interest your Lordships will transcend a natural inclination to exhaustion, I trust noble Lords will bear with me while, towards the end of my speech, I give a little more information. I should like to say something of the advances to which all this development is geared and for which it exists—the advances in medical care itself.
Since 1948 scientific and medical research have made wonderful strides forward. The medical knowledge acquired
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has enabled new therapeutic procedures to become available for the treatment of disease, and also new techniques to establish accurate diagnoses so that diseases can be identified at an earlier stage. With the development of more powerful means of diagnosing and treating illness, the medical team is more in a position to help the patient than ever before and to employ methods in which the margin of error is reduced. Similarly there have been considerable changes in the pattern of disease and medical care, resulting from the introduction and development of immunisation procedures for an increasing number of infectious diseases (diphtheria, whooping cough, poliomyelitis, tuberculosis and tetanus), the increasing use of existing antibiotics and the discovery of new ones. The result has been extraordinary changes in the mortality rates for some of these diseases. Whereas in 1948 there were over 21,000 deaths from tuberculosis, in 1965 there were only 2,282. Diphtheria, which claimed 155 deaths in 1948, claimed none in 1965; and finally poliomyelitis, which cause 326 deaths in 1948 caused only 2 in 1965. This, I submit, is part of the dividend to which I referred, as a result of our national investment.
In maternity care the most important developments have been the emphasis on ante-natal care, the need for proper selection of mothers for hospital confinement and the progressive increase in the percentage of mothers delivered in hospital. The maternal mortality rate fell from 1·17 per 1,000 total births in 1947 to 0·25 in 1965 and the length of stay in hospital consultant beds of maternity patients has been falling for the last ten years from 12·1 days in 1955 to 8·6 in 1965. The infant mortality rate has also fallen between 1944 and 1965, from 40 per 1,000 live births to 19 per 1,000. This is relevant, too, to the amazing fact that whereas, when I was a small boy, the expectancy of life was just over 50, it is now 70 years of age.
In relation to psychiatric services, the application of new advances in pharmacology and the expansion in use of electroplexy have revolutionised the pattern of medical care. To-day the accent is increasingly on early return of the patient to community life. Stay in hospital has been dramatically reduced. In the 10-year period from 1954 to 1964 the number

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of occupied mental hospital beds fell from 3·4 to 2·7 per 1,000 population, and there is good evidence that this trend will continue. The psychiatric hospital of to-day needs to be closely linked to other hospitals, family doctors and local authority health and welfare services and, of course, the community they serve.
Modern anæsthetic techniques and the introduction of antibiotics have made great advances. Scientific methods and the use of new materials have led to the development of a new range of surgical procedures, such as open-heart surgery, replacement surgery using human organs and tissues, and intermittent hæmodialysis for renal failure. Hospital authorities are seeking to increase the facilities for this specialised treatment in hospitals with full departments of renal medicine.
Lastly, I would emphasise that preventive medicine is playing an increasing role. Mass miniature radiography for early detection of lung disease is playing a valuable part in the control of tuberculosis, as the figures indicate. In addition, the examination of cervical smears for evidence of cancer of the neck of the womb, about which Questions have been asked in this House, has now reached the scale of more than 1¼ million examinations annually. More, of course, still has to be done. It is probable that other screening tests for early treatable disease will be developed and applied to groups at special risk or even to the whole population.
My Lords, developments in medical science issue from the skill, knowledge and initiative of professional people. The organisational framework of the National Health Service provides the means by which the benefit of these developments is conveyed to the population at large. Because without that their value to us all would be less, it is legitimate to claim some credit for the National Health Service in what has been achieved.
I repeat, we can never be complacent, whether we are professionally or administratively involved. We certainly recognise how much is still to be done, even though we are grateful for so much that has been achieved. Such is the pace of development in medicine that there are always new problems to overcome and new developments to find room for. But
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any suggestion that the morale of the Service is failing because it is being starved of resources, or is being wasteful is, I am positive, ludicrous, even if it is not mischievous. The demand for health services is limitless. All of us would like to see greater and faster expansion, and an even larger share of national resources devoted to health. On this we can all agree. But I am sure your Lordships would not wish to minimise, as I am sure the noble Marquess does not, the really great achievements of the National Health Service in its first twenty years of existence. It is an institution for which, with all its defects, most people have gratitude and of which most people can be proud. Again I thank the noble Marquess for initiating an invaluable debate, and I apologise if I have kept your Lordships too long.
4.5 p.m.
LORD AMULREE: My Lords, the National Health Service, as the noble Lord has said, was instituted about twenty years ago, and I believe it is valuable that from time to time we should take stock of what has gone on. So far as I can recall, there has not been a general debate on the Service since 1952. Various points have been discussed, but there has been no general debate. Therefore we are all very grateful to the noble Marquess for putting down this Motion to-day. I do not want to follow him in the very broad look he took at the Service; nor do I want to follow the noble Lord, Lord Sorensen, in the detailed account he gave of the Service as a whole. But I should like to touch briefly on one or two points which seem to me to be important and in which I am particularly interested. Before I begin, I would say that I do not think that the suggestions that one has seen in the Press and elsewhere, that the Service is in danger of collapse, are really true. There are certain strains on the Service which cause difficulty, but to say that it is in danger of collapse is quite wrong.
One of the matters on which the Government are frequently chided is that they have not produced more modern hospitals in the time the Service has been going. But we must remember that when the Service was introduced in 1948 the Government were faced with the prospect of taking over about 50 per cent. of hospitals which had been Public Assistance institutions, Poor Law institutions,

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built in the nineteenth century; and the first job was to turn these into good modern hospitals. And that I think we may say, is something which has been done with very great skill and, on the whole, with great economy. In most of these buildings the walls and roofs were well built and strong; the builders in the nineteenth century did know the right way to build. Speaking as one who has spent my whole seventeen years in the Service working, together with many of my colleagues, in what were formerly the infirmary or the Public Assistance institution, modernised in a very skilful and proper way, I can say that this has been a very successful policy. The time is now coming when not much more can be clone with these hospitals, but they tided us over very well for a very long time.
Another cause of strain has been the lack of doctors in the Service. The noble Lord, Lord Sorensen, said that the hospital doctors have increased in number. That is true, but they are not quite so important as the general practitioner side, where the numbers have tended to fall. It is a curious thing that a number of new universities have been started in the last ten years, but not a single one has a medical school attached to it and functioning. The Robbins Report did not refer to medical education, because I think it was not in the terms of reference which were put to the noble Lord when he conducted his inquiries. I think I am not completely accurate there: there is one paragraph, or possibly two, in that large Report which mentions medical education. We have been told that there are to be new medical schools at Nottingham, Southampton and Durham, but nothing has yet occurred, and one must not forget that even when a school is started it is at least ten years before a doctor able to practise will come out of that school. One would have thought that Durham, which has part of the school already there, because the Newcastle University has only just split off from it, would have been a place where a school could have been started almost at the present time.
It has been said, too, that even if we train more doctors, it only means that more doctors will be leaving to practise in foreign countries. I do not think that is true for one moment. I think that the
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cause of quite a number of doctors leaving the country is not lack of money or the difference in remuneration received, because I do not believe that my profession is quite so mercenary as all that. It is the overwork, the strain and the lack of facilities generally. I think that if we got more doctors, that situation would be eased.
Again—and this is most important—we ought to know what number of doctors go permanently to work abroad Although it would be difficult to find out, by an intelligent inquiry I think it could be done. It seems to me a most proper and correct thing that as many young doctors as possible should go and spend a year or two in some country where they can get further experience. I think one should encourage that by every possible means, in the same way as one should encourage as many doctors in the developing countries to come to this country, provided they can get proper training and experience when they come here. But we do not know at all what are the total numbers who go abroad and never come back again.
One subject which the noble Marquess mentioned was the care of the chronic sick. That aroused great interest in me, because the first time I addressed your Lordships' House was in October, 1946, on the occasion of the Second Reading of the National Health Service Bill, as it then was. The burden of my speech was the care of the chronic sick, to which the Government made no reply at all. So I should like to come back to this subject again after twenty years, and the type I am referring to, and perhaps the type that the noble Marquess referred to—I do not want to deal with the old people; I have done that frequently in your Lordships' House and probably you have heard all I have to say on that many times—are the young, the disabled, the middle-aged, those suffering from the chronic nervous diseases and those suffering from various forms of arthritis who need a good deal of care and attention.
The National Health Service makes some provision for them. I think there are 400 beds all told, with about another 200 contractual beds. Perhaps the noble Lord will correct my figures later on if I am wrong. But we do not know really what the size of the problem is. We do know that these patients stay in

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these beds, roughly speaking, until they die. Supposing they are well taken care of, their expectation of life can certainly he nearly as long as that of a person living at home.
I must declare some interest in this subject because for a number of years I have been a member of the Board of Governors of the Royal Hospital and Home for Incurables at Putney. This was a big home of about 250 beds which, together with one or two similar homes, was disclaimed by the Minister when the National Health Service first came into being. There we provide an extensive nursing service and a good deal of therapy. There is a large occupational therapy department and a large physiotherapy department. This is not done with the purpose of curing people; it is done with the purpose of maintaining what functions they have, which is most important, so that they do not become too much of a strain on the nursing care. It is done also to encourage their morale and make them feel that something is being done for them.
We have a waiting list there—and I think this must apply also to the rest of the country—of about two years. This does not really mean anything. If you get a waiting list of that length, it means it is much longer really but that people do not bother to put down their names. We have a turnover there of 15 people per annum which comes about through people dying. So you can see that it takes a long time to deal with this problem. These people are the type of patients who demand urgent attention, and one would like to see something more done for them. At present some of them go into welfare homes under the local authority, where they get kind care and attention. But they get practically no medical treatment, and little in the way of physiotherapy, because the welfare homes do not deal with that kind of treatment. One wonders whether it would not be possible to connect some of these beds in the welfare homes with the Regional Hospital Boards, or that some of the staff of the hospitals should have access to them, so that treatment such as is desired could take place.
I do not believe that this would be a costly affair. In the long run it would probably save a certain number of beds—not many, but a certain number. It would
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do one important thing: it would be one step towards breaking down the tripartite system upon which the National Health Service is at present based: that is to say, the Regional Boards on the one side with the boards of governors, and the local authorities and the Executive Councils. That has always seemed to me to be a wasteful and difficult way of doing things, because one sees these bodies run on parallel lines, and, as we were taught at school, one of the characteristics of that is that they never meet but go on into infinity. It is a pity that we have these parallel lines. Any contact made is purely on a personal basis, and not officially. I think if we could get something of that sort to which I have referred it might be a start towards breaking this down. One has got to look forward one day to some kind of regional set-up for the care of people of all sorts. I do not want to go into this subject further, because what happens will depend largely on what is said in the Report of the Royal Commission on Local Government when it appears. I should have thought they would be bound to deal with this among some of the other problems.
I should now like to turn briefly to the care of the junior hospital medical officers, about whom there has been a good deal of talk in the Press, and a good deal of discussion as to their troubles and future. I have a certain sympathy with them in some of their troubles. One of the things I should like to see encouraged is the provision of simple married quarters for these young men and women who have got married. It may be said that it is most improvident of them to get married. I do not agree. People are getting married now much younger than they did in the past. Why should doctors be told that they cannot marry merely because nobody can provide them with a simple room in which to live with their wives? I should like to see more encouragement in that respect. I am told that if you go into some of the more unattractive parts of the country, like the North-West, which does not draw people to it willingly, married quarters are more frequently available than they are down South, where conditions are more attractive to people coming to settle there. Supposing that is true, what can be done in the North can be done in the South. It may be one more case of Manchester

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showing London what is the right thing to do.
Certainly the strain on these young men can be extremely great if they have to keep up two homes. It is no doubt more simple now that they no longer have to pay a lodging allowance if they are compelled by their job to live in hospital. However, I do not understand why they have to pay for their meals instead; because the difference between the amount they have to pay for meals and the amount of the former deduction of lodging allowance is so small that it hardly seems worth commenting upon. I wonder whether this matter could be looked into again in relation to the people who are forced to live in and who have to take their meals in the hospitals.
One must not forget that these young men and women, who work extremely hard, are a unique body of people in this country. They are training in order to get experience in their work, but at the same time they are learning to take on an enormous responsibility which very few people of their age are called upon to shoulder. Therefore, they need very good food to be provided to them by the hospitals, and I do not see why they should be forced to pay for it. As the noble Marquess mentioned, it is a sad thing that in many hospitals such a large amount of food is wasted. On the face of it one would think that it would be a quite simple exercise for a hospital to cater for its population, because it knows exactly the numbers whom it has to feed. This is quite unlike catering in a restaurant, where a fine day may mean very few customers, and a wet day may bring in a large influx of people, and where the whole matter is so uncertain.
LORD SORENSEN: My Lords, what the noble Lord says is quite right, but I am sure he appreciates that the patients do not always eat the food that is provided for them.
LORD AMULREE: I agree that it is not a simple matter, and perhaps one may tend to over-simplify; but that is no reason why the food should not be absolutely first-class.
A further point which troubles some of the younger people in the medical world is uncertainty about the career structure with which they are confronted.
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Many of these young men and women are the consultants of the future, the people upon whom medicine depends. It would appear that in some specialties there are more people training than there are posts for them to fill when they have completed their training. I must say that this is not so in some cases, certainly not in my own field. When I started in 1949 we had four or five consultants in the geriatric field. Now, we have more than 200, so I cannot complain there. But certainly in some specialties that is not the case. One wonders whether the number of consultants is growing as fast as was expected when the plans were first thought out.
I should like to make brief reference to two more points. First, I should like to see some sort of experiment carried out on the preventive side. Would it not be possible in some centre of population, particularly in places where there is a university, for a complete preventive service to be established? Cytological examination of cells for cancer, regular X-ray, health checks on babies and old people, checks on industrial hazards, and so on, could be evaluated properly by a social service department, say, in a neighbouring university which would give some idea, fairly quickly and on a large enough scale, as to what preventive services should be encouraged and what should be left to take second place. It would be difficult to push them all along at the same speed if one did not know which were really important.
Finally, I would join with the noble Marquess in the kind words he said about the Ministry of Health. It is a body which is frequently attacked, by all sorts of people, for not doing its job properly, for being difficult and awkward, and so on. We have at present one of the best Ministers who has ever held office. He is not now on the Steps of the Throne, but he was there a short time ago. Speaking from my personal experience in the various capacities in which I have worked in the Health Service, I have had a good deal of contact with the Ministry and its staff, and have always found them to be friendly, co-operative and prepared to help, and certainly willing to do all they can to improve the Service for which they are responsible. Of course they have certain difficulties. The proportion of the

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national budget available to the health services is not so great in this country as in some other countries, but I would far rather regard the Ministry of Health as my friends, with whom I can argue and discuss, and with whom from time to time I do not necessarily agree, rather than as my enemy who must be fought all the time.
4.27 p.m.
BARONESS SUMMERSKILL: My Lords, I find it extremely difficult to reconcile the statement made at Question Time by the noble Viscount who sits on the Back Bench, when he expressed his warm appreciation of the casualty services—which he himself, having had an accident, experienced—with the speech of the noble Marquess, which was gloomy and despondent, and which in its opening words, as he will see when he reads Hansard to-morrow, prophesied the imminent collapse of the National Health Service. I was very surprised, because the noble Marquess has had a great deal of experience of the Health Service, and he could have summed up the situation a little more constructively. Indeed, his whole approach was destructive—in fact I cannot recall his making one constructive suggestion.
If I criticise the National Health Service, I do it a little as I would criticise my own family. I may appear to be a little severe, but I feel strongly possessive, very friendly, and only too anxious to improve matters. I say to the noble Marquess that his criteria are wrong. The chief criteria which he levelled at the Service was one of cost, but he did not make the very important equation of equating the cost with the human happiness and well-being of the population. My noble friend Lord Sorensen summed-up the whole matter in the last 10 minutes of his speech. He applied the right criteria—the morbidity rates, the mortality rates, the expectation of life, and indeed the increased well-being of the people, their health consciousness, and all those matters. Perhaps I should not say "all", because we are evolving; and in this evolution our social services and our conditions of life have improved. But to a great extent we owe this tremendous decrease in our morbidity and mortality rates to the National Health Service.
I have taken part in many of these debates, and I am going to begin what I am
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going to say with what a noble Lord opposite always calls my ritual dance. Once more I have to say how deeply sorry I am to see the appalling consumption of pills, tablets, powders, and indeed all those medications for which patients go to their doctors. The years have passed, and to-day drug addiction makes headline news. It is now proposed to place stricter limits on over-prescribing, which the Brain Committee believed was responsible for much of the supply of heroin and cocaine. A tribunal is to be empowered to investigate cases of over-prescribing, and the final sanction may be the removal of a doctor's name from the register. He will be struck off the register, which means, of course, that he will be deprived of his means of earning his livelihood. It is a terrible sanction on the medical profession.
Many doctors believe that this development is not surprising, and I am one of them. The drug bill has been rising every year, and I see from the Annual Report of the Ministry of Health that this year drugs will cost us £111 million. Indeed, many patients get these tablets, pills and powders on demand. The pressure on the doctor is such that he finds it difficult to refuse. Also, of course, there is no cessation of the avalanche of advertisements which doctors receive, and their surgeries are still besieged by glib young salesmen recommending their inadequately tested wares.
My answer to this is not to put a 1s. or 2s. charge on the prescription. In view of the high costs of drugs to-day, I do not believe that that would make an appreciable difference. I believe that, while doctors are paid on a capitation basis and are therefore deprived of their real freedom, there will be no effective control on prescribing. I have said on many occasions that the real control which should be applied is that doctors should be asked to prescribe from the National Formulary, which is supplied by the Ministry of Health, and that if they have to prescribe outside that Formulary they should say why. It would appear from the Brain Report that the worst offenders do not adopt a higher moral standard when drugs of addiction are demanded from them. In consequence, we are now faced with further expenditure. We have to embark on fresh

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expenditure to try to remedy the injury done to those dependent on drugs.
It seems to me that the administrators view the Health Service from an entirely different angle from that of the doctors and others engaged in the essential work of healing and preventing disease. While statistics dominate the thoughts of the administrator, the medical worker is motivated first by his vocation. I listened to the noble Lord, Lord Amulree, and heard him describe the lot of the young doctors in the hospitals. What makes those doctors go forward comparatively cheerfully is the fact that they have a vocation. Their vocation comes first, and secondly, of course, they consider adequate remuneration and leisure. Unhappily, the administrator has allowed his calculations to blind him to the importance of this second consideration. The result has been that the Service has excited powerful public pressure, which has manifested itself in an unprecedented threat of strike action from the general practitioners. I think we should congratulate ourselves on the fact that that strike never took place. But, of course, there have been organised protests from the junior hospital doctors. In my opinion, administration is the art of getting people to work cheerfully and effectively together, and this should be a fundamental objective of the National Health Service, as, indeed, it should be the objective of any organisation, any factory, or any profession.
I join with others in welcoming the untiring efforts of the Minister to remove some long-standing grievances. But he should be vigilant, lest there be a tendency—attributable, in my opinion, to a petty and punitive attitude in some places—to perpetuate certain practices. For instance, while it is of course necessary to overhaul the financial structure and ensure that adequate salaries are paid, it is equally necessary to ensure that the doctors—and indeed all the medical workers—have adequate leisure.
THE PARLIAMENTARY UNDER-SECRETARY OF STATE FOR COMMONWEALTH AFFAIRS (LORD BESWICK): Hear, hear!
BARONESS SUMMERSKILL: I am glad that my noble friend said "Hear,
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hear", because I shall remind him of that in the future. Yet it would appear that the general practitioner is still to remain the only worker in the country—in the professions or anywhere else—who cannot enjoy a holiday unless he can find a substitute and can afford £50 a week for a locum. Surely this anachronism should be remedied by providing a locum service, and I hope that that will be done. Furthermore, the decision to encourage ancillary help in a practice, qualified or unqualified, is welcome. The medical practitioner can now employ a woman to help him in so much of the writing and rather boring work which he has to do other than that of medicine. But the doctor is denied the right to employ a fully qualified nurse who happens to be his wife, and this causes some resentment. Again, I would ask my noble friend to bring pressure to bear in the right quarters to see that this ridiculous anomaly is removed.
At long last the general practitioner is to be officially permitted to use a relief service, but if he demands undisturbed sleep every night and relaxation every weekend then he is to forfeit £200. I hope my noble friend will tell me that I am wrong in these figures, but unfortunately I think I am particularly accurate. Therefore, I would ask the Minister not to spoil the ship for a ha'porth of tar. He has had meeting after meeting with the medical profession, and he must be sick and tired of it. Therefore, let his final decision be one which will be accepted happily and gratefully by the whole profession.
A great deal has been said about the hospitals. I confess that when I enter a hospital, particularly one in the Provinces, my reaction is a slight sense of sorrow, tinged with shame, that we have to encourage Commonwealth doctors to leave their countries where they are desperately needed to help run our Health Service. Therefore, it came as something of a shock to me when last week I received an appeal from the British Medical Women's Federation. That Federation is a very old and highly-respected organisation, and in bold type the medical women of Britain ask:
"How can able young women find places in medical schools? How can a married woman be helped and encouraged to return to practice after many years devoted to bringing

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up her children? What new openings can be found for practising medical women whose husbands' work takes them to a new district?"
It seems incredible to think that women have been qualified nearly a hundred years, and yet able young women in this country are denied a medical education; and, moreover, that there is this waste of qualified women prepared to work on a part-time basis at a time of great shortage.
I want to touch upon only one aspect of medicine. The scope of this debate is enormous, and having regard to the serious problems of industrial health which were revealed the other night during a very important little debate in this House I thought I would limit myself to that field. Last year there were 293,717 industrial accidents in this country, of which 627 were fatal. I know, of course, that the Minister of Health is not responsible for the prevention of accidents. Nevertheless, it is the Health Service which must make widespread provision for the victims; and in my opinion preventive medicine should embrace every man, woman and child, wherever they may be and wherever they may work. The victims in these cases are generally young people. Young people are energetic and relatively irresponsible risk-takers. Consequently, the problem of youth in industry is the problem of physical accidents. From the employers' point of view, youth is attractive because it is cheap to employ, especially on easily-taught dead-end jobs.
By far the greater number of young people who enter industry are healthy when they start, but their health may deteriorate; and, of course, there is a small number spread all over the country who are extremely vulnerable and who need careful medical supervision. I am thinking particularly of those who are subnormal though not sufficiently subnormal as to be prevented from going into a factory or workshop, and of the temperamentally unstable, who tend to drift into small, backward industries and get dead-end jobs with unsatisfactory conditions. Some of them have as many as five different jobs between the ages of 15 and 18, and they not infrequently suffer an accident soon after starting work. While I agree that training and apprenticeship schemes should be closely related to safety, the fact is that very often
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the old hands have not the time to teach the young—and there is also the fact that an old hand often becomes a little careless himself, although he knows how to protect himself. So it seems to me that the technical and medical factory inspectorate is the most important single agency for the care of the young in industry.
I should just like to read to your Lordships an extract from a paper in the British Medical Journal of October 1 by Dr. R. C. Browne, the eminent physician and author, entitled "Health in Industry". He said:
"On the technical side the recruitment and training of inspectors and the coverage of factories all need to be improved. More frequent visits from inspectors should be made and, differentially, more frequent still to the especially dangerous parts of factories. The relations between medical and technical inspectorates need consideration, and not only for the reason that it seems very odd that the Annual Report of Her Majesty's Chief Inspector of Factories on Industrial Health is signed by a non-medical man …
"The heads of the medical and technical inspectorate should be of the same rank and should report on a level to the next most senior civil servant up the command chain. Such a change will improve the organisation and increase the impact of health and safety in general as upon young children".
It seems to me that the Minister of Health should be identified closely with the plan for replacing the mid-19th century appointed factory doctor arrangements. Such doctors were appointed when children were rickety and when people had little social conscience, not being concerned with whether children fell into machines or not. Our approach now is quite different. There should be fewer but more highly trained doctors, who would examine fewer healthy young people and more of those vulnerable to accident or disease. Medical care should be concentrated where it is most needed, and only those employed in selected potentially hazardous work would be repeatedly examined, or those who had an employment problem as a result of illness. I believe the time has arrived when the departmental arrangements established to supervise the safety and welfare of young people in a different industrial setting, a different industrial age, should be fundamentally altered in order to reduce the appalling accident and death rate in modern industry.
4.47 p.m.
BARONESS BROOKE OF YSTRADFELLTE: My Lords, we are all indebted to the noble Marquess, Lord Lothian, for introducing his Motion on the National Health Service to-day; and I hope very much that when the noble Baroness who has just sat down reads through her speech to-morrow in Hansard she will glance at what the noble Marquess said, because I really cannot agree with her that he made not one single constructive statement. The last Annual Report of the Ministry of Health mentions the setting up by the Minister of an informal group to help him in considering the long-term future development of the health and welfare services. The Minister wants to have advice about the interaction of the various services one with another. We shall await its findings with the utmost interest.
I hope very much that among the many potential developments of the services which are available for examination they will not fail to study the future of the community health service—a service which was touched on by the noble Marquess when introducing this debate to-day. The most recently published figures show that, in one year alone, this country lost no fewer than 285 million working days through ill-health. This staggering figure, with all that it represents in lost production, underlines the vital need for us to ensure that the National Health and Welfare Services are as efficient as we can make them. Here, I would pay my tribute to those splendid members who have served the Service in the Ministry of Health ever since the inception of the National Health Service Act for the way in which, often in the face of great difficulties, they have continued to develop and allow the Service to grow.
Quite apart from humane considerations, the prosperity of the country demands that our National Health and Welfare Services are as efficient as we can make them. As we have heard this afternoon, hospitals form the most costly part of the Service, and, ambitious though the figures in the hospital programme may seem to laymen, we are frequently reminded that they are barely enough to replace outworn buildings. As a former member of a Regional Hospital Board, and chairman of a hospital management committee, I am only too well aware of
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the truth of that fact. We have got to economise in the use of hospitals and ensure that they house only patients who need the specialised care that can be given only in hospital. The latest available figure for the average cost of treating an in-patient in an acute non-teaching hospital is £61 a week. For teaching hospitals the figure is £76 in the provinces, while in London it is no less than £103 a week. So economy in the use of hospital beds is essential. People do not want to be in hospital if they can be cared for at home. The hospital programme is rightly based on a policy of early discharge. This brings out the need for properly organised health services in the community, which should not be confined to caring for the sick; but should be actively engaged also in preventing illness. That is, I think, a fact with which several of us taking part in this debate this afternoon would agree.
My Lords, can we truthfully say that we have such services at present? I venture to intervene in this debate to-day because I have for some years been Chairman of the executive committee of The Queen's Institute of District Nursing, a committee much enriched by the presence of the noble Lord, Lord Amulree, who for the moment is not in his place but to whose speech earlier we all listened with great interest. This is a body which well over a hundred years ago pioneered district nursing and provided the majority of district nurses up to 1948. Under the National Health Service Act home nursing became the responsibility of the local health authorities, but the Queen's Institute has continued to advise and assist in training and to provide a certificate for nurses qualifying in district nursing. Now that a National Certificate has been established, the Institute intends to cease the award of its own certificate. But it will gladly continue to advise on training, something which, with its long experience and countrywide connections, it is well placed to do. Meanwhile, we plan to devote more resources to those other lines of activity that have been developed in recent years. Foremost of these is operational research to discover, within the changing pattern of community care, what are the needs and how they can best be met.
Secondly, the Institute has set up experimental schemes in training and

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organisation. If they prove successful, they will become demonstration models. One example is the district training of State-enrolled nurses which, at present, is almost exclusively carried out under the ægis of the Institute. Thirdly, there is the provision of a whole field of post-certificate education for nurses ranging from refresher courses (which are particularly necessary for those working away from the hospitals in which most of the advances in medical careare made) to the teaching of administrators, for which there is a crying need in public health nursing.
My Lords, it is the results of our most recent research project which I think are particularly relevant to this debate and to which I should like to invite your Lordships' attention. In November last, we published a Report under the title, Feeling the Pulse. I have a copy of it here. It had a splendid reception from the Press, and I should like to hope that all noble Lords interested in the Health Service will read it if they have not already done so. It is the report of a survey in depth of district nursing in six widely separated areas. It is a disturbing document. Of course, six areas cannot be taken as representative of the whole country. We know many other areas where steps recommended in the Report have already been taken. Nevertheless, the fact that many shortcomings were common to all the survey areas suggests that there is a probability that they are widespread throughout the country.
One of the most striking was the lack of contact between various workers in the National Health field. District nurses seldom met general practitioners. The latter frequently did not even know who was the district nurse who cared for their patients. Most doctors experienced difficulty in getting in touch with a nurse, even if she happened to have a telephone at home, which often enough she did not, and messages had to be channelled through a third person—someone on the staff of the local council office, perhaps. In one area the superintendent of district nursing actively disapproved of doctors and nurses having any direct contact when looking after patients. Contact between doctors and health visitors seemed equally nebulous; and there were some complaints by doctors of
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patients being given advice by health visitors which conflicted with their own. Very few patients were referred from health visitors to district nurses, and vice-versa.
All this fragmentation of effort could not fail to reduce the efficiency of the service offered to the patient. Arising, in part, no doubt from this lack of contact, there was remarkable ignorance among doctors as to the actual qualifications of the nurses available to care for their patients. Consequently, many of the procedures which could have been competently carried out by the nurses were undertaken by the doctors themselves, who were already heavily loaded. Many of the doctors were giving injections, dressing wounds, and similar tasks, which the trained district nurse working on the case was qualified to do. The inquiry showed that the nurses, of whom the majority were State-registered, were largely engaged on tasks which did not require their professional skill and in many cases were not nursing tasks at all. Although many were extremely busy, the time they spent in actual contact with patients was surprisingly small, the remainder being taken up by travelling and clerical work. The load of acute cases, particularly surgical and pædiatric cases, was unexpectedly light.
Where, one wonders, were the "early discharged" patients just out of hospital? Were patients in fact being retained in the hospital because those in charge of them were unaware of the professional expertise and facilities available in the domiciliary services? The survey showed poor contact between the hospitals and the domiciliary services, and this poor contact might have been responsible for such ignorance. If the "early discharge" policy was truly being followed, were patients having to continue to attend the hospital as outpatients, perhaps at great personal inconvenience, or, worse stilt, were they at home lacking the care they needed? This particular question is the subject of the Queen's Institute's current research programme. Meanwhile, whatever may be the reason for the apparent fewness of acute cases, it is clear that the district nursing service is not playing the part it should or could.
So far I have spoken mainly about the care of the sick. But a National Health

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Service, as has been referred to this afternoon, should be as concerned with the preservation of health as with caring for those who are ill. The general practitioner is responsible for the health of his patients; and to discharge this responsibility he should practise preventive as well as therapeutic medicine. He should interest himself in the health education of his patients. But doctors are trained in hospital, taught to be hospital doctors and to look after people who are already ill and in a hospital bed. In spite of what is being done at Edinburgh University and at such places as Guy's Hospital, preventive medicine and the care of patients in their homes has curiously little place in the present curriculum. A doctor may achieve registration and still suffer from ignorance of needs outside the hospital: how patients live, how they can be kept healthy and what services there are to help them when they fall sick. If he stays in hospital posts this ignorance may never be dispelled. Only a small proportion of doctors entering general practice have any special training to fit them for it, and having started off on the wrong foot many are too busy ever to pick up the right step.
A basic requirement for a better Health Service is the revision of medical education. Happily, this is the subject of a Royal Commission, and I trust that its recommendations will include the extension of medical education to cover much in the fields of preventive medicine, social medicine and community health services generally. A broadening of medical education would help to improve health in a number of ways. First, the hospital doctor would be much more closely aware of the daily needs of his patients when discharged to their homes and of the facilities available to meet these needs. Secondly, the general practitioners, knowing the potentialities of the services they can call upon for support, could muster those services to the best effect and stop wasting their own valuable time on tasks that others can do equally well. Thirdly, this new generation of general practitioners should be much readier to organise themselves in a manner which would allow the most efficient deployment of all domiciliary health services.
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Increasingly it is being recognised that the way to provide the closest contact between the various workers in the health field and to prevent any overlapping of effort and the offering of conflicting advice is to attach the public health nurses—that is to say, the health visitors and district nurses—to the general practitioners, so that they can work together as a team. Such a team must have adequate premises from which to work, and at long last there is a heartening interest in health centres. There are still grumblings from some doctors about loss of independence, but this is nonsense, surely, as anyone knows who has visited Witney or Hythe or Harlow (the centre which was inspired by the conviction and enthusiasm of the noble Lord, Lord Taylor, who earlier was in his place in this House).
It is now a known fact that the skill of the State registered nurses carrying out district work is largely being wasted. Many of their present tasks should be carried out by State enrolled nurses who have had proper district training, and I hope that the Minister of Health will go on urging local health authorities to employ State enrolled nurses in the district field. There is still too much reluctance to do so. But it goes further; much of the district nurse's present work is not nursing at all, it is simply doing useful jobs. These should be delegated to home helps and the other auxiliaries such as bath attendants.
It would seem to me that the ideal community health team is beginning to take shape. There are the doctors, and working alongside them is the nursing and auxiliary team, led by a State registered nurse, who might be a health visitor or a district nurse, or both. Under her she may have one or more State registered nurses, depending on the size and nature of the practice, welfare assistants, home helps and other auxiliaries. The leader will be responsible for allocating work to members of the team and she ought to carry out some of the skilled nursing herself. She will need to establish and maintain close co-operation with the social medical workers in the local hospitals. This is to ensure the smooth referral of discharged patients and the rapid provision of any care they may require when they get home.

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My Lords, I have tried to sketch out the way in which I believe the community health service should be developed and how it could enormously relieve the weight on the hospitals. The hospital service is the most glamorous and the most televised part of the National Health Service; it is also the most expensive. But I suggest that the community health services as a whole provide a field where foresight and courageous experiment, and flexible development, are most needed if the people of this country are to have a National Health Service which really lives up to the expectations of those who founded it.
5.4 p.m.
LORD PLATT: My Lords, I rise for the first time to address your Lordships' House, and in accordance with custom I ask for your forbearance. I know that I shall have nothing but your kindness and courtesy. In accordance with custom, too, I shall endeavour to be not too controversial, which may of course be a somewhat difficult thing as we are discussing the National Health Service. I am very grateful to the noble Marquess, Lord Lothian, for introducing and initiating this debate, first, and most importantly, because I think it is a very excellent thing that the defects, such as they are, in the Health Service should be debated in this way, publicly, and, secondly, because it has given me an opportunity of making a maiden speech on a subject which I know something about. That may perhaps be unusual. I should perhaps also say that, as a member of the Royal Commission on Medical Education, I can assure the noble Baroness, Lady Brooke of Ystradfellte, that I have taken note of her remarks. I could enter into the subject a little further, but it would not be non-controversial.
My Lords, I thought that perhaps my main theme would be general practice on this occasion because I think it one of the most important issues we have to face at the present time, not only in this country but all over the world. In different countries we find different solutions, or attempted solutions, to the problems of general practice, all of them under pretty heavy criticism either from the doctors or the patients and, quite commonly, from both. But first I should like to make a diversion into another topic which has been mentioned; namely,
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the junior hospital staffs, because I was at one time a member of a joint working party between the Ministry and the profession which worked, I think I might say, in complete harmony together for two years, and produced a document known as the Platt Report. I should say that there are at least three Platt Reports, but this is the only one that I had anything to do with. I can therefore speak of it without fear of contradiction—at any rate by Platt.
The first thing I should like to do is clear up some misconceptions and fallacies about the number of foreign doctors in our hospitals. I personally regret this, not because I think that they are all bad doctors by any means, but I think it is very bad when almost the whole staff (as is the case in some of what we call our peripheral hospitals, as opposed to the more central teaching hospitals) is composed of foreigners, some of whom have very considerable language difficulties. The first thing I wish to point out to your Lordships is that this is not a problem of our National Health Service alone. It is the same in the United States of America, where in Greater New York more than half the hospital doctors in this intermediate junior stage are foreigners. I understand that there are now 14,000 foreign doctors in the health services (in the hospitals, that is) of the United States of America, only 200 of whom are British. The rest come from South America, the Phillipines and various other places, and often have language difficulties. En passant, I might also mention that the nursing shortage in the United States is extremely acute as well.
My Lords, this is not due, as most people think, to some colossal shortage of doctors in this country. We are short of doctors in this country, but for totally different reasons. It is due to medical progress which has brought about a need for far more people at this particular stage of experience. Your Lordships will understand that, if I say that when I was a medical registrar in a fairly big teaching hospital I was the only medical registrar in that hospital. To-day I suppose that six, or possibly eight, young men are doing the job that I did. I am quite capable of taking this as a matter for personal congratulation, but I am only too aware that it is really due to

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the progress of medical science that we now need far more people at that level to carry out the various processes which modern treatment and investigation require. As these jobs are held for only a comparatively short time, perhaps for two, three, four or five years at the most, if you trebled the number of medical graduates in order to fill these jobs it is quite clear they would then be out of work for the rest of their lives, unless at the same time you created permanent jobs for them to go to after they had spent those few years in hospital. What my working party found—and their Report is still relevant, although we would not to-day write it in exactly the same words—was, first, that we need more consultants in the Health Service, and that they are delegating too much of their work to their juniors. This is, I will not say rapidly, but more than gradually, being repaired. The number of consultants is increasing steadily year by year, and now I believe that one-third of the output of graduates will reach consultant level.
Secondly, these posts will still be filled, quite rightly, by people who come from overseas. So far from bringing them away from countries where they are greatly needed at the present time, I would hold the opposite point of view and say that, especially since India and Pakistan has started their new medical schools and are training a large number of doctors and have not got properly trained teachers (which they cannot have at this stage of the development), it is extremely important that their young men should come over here and learn the standards of British medicine. It may be said that we then send them to some of our worst hospitals, and I am afraid that I would have to agree that this is what often happens. I hope that on the Royal Commission on Medical Education we will be strong in our Report about the whole of the organisation of post-graduate training. I am Chairman of the Committee which is dealing with this but, of course, anything I say this afternoon will not commit the final Report of the Royal Commission. Some posts will have to be filled, as at present, by our own men in training. We hope that general practitioners will spend a longer time in hospital training in future. This will help hospital staffing
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—though it is not done for that purpose, but to improve general practice.
Thirdly, some of these posts should not be filled by temporary juniors at all, but by people who want a long-term connection with the Health Service, usually on a part-time basis, so that they can spend the other part of their time in general practice, in other branches of the profession or in domestic duties. To encourage part-time posts of this kind will be good both for general practice and the hospital service, helping the integration of and better relationship between the two. This is already happening. About 20 per cent. of general practitioners at the present time have some kind of hospital appointment.
Coming to training for general practice, I am glad to say that there is a big area of agreement in all sections of the profession, including the College of General Practitioners and the British Medical Association—who have both put in excellent Reports to the Royal Commission—that the general practitioner of the future should have at least three or four years training after registration before he goes into general practice, and if he wants to stay on longer, this will be a further advantage.
We have not yet considered whether general practice has a future. There are some who may have doubts about it. But if there is one thing which I want to establish more than anything else in your Lordships' minds, it would be that in these days of specialisation, there is an ever-increasing need for the generalist. It is easy to point out that with the growth of knowledge all academic subjects fragment; the undergraduate no longer reads history, but modern history or mediaeval history or ancient history; the chemist no longer studies chemistry, but biochemistry or inorganic chemistry, and the engineer studies civil engineering or mechanical engineering or electrical engineering—and to say that in medicine we must do the same.
It is true that we will have to do something of this kind. Some day we may realise that it is not really necessary for an orthopaedic surgeon to know all the fine structure of the retina, or for an ophthalmic surgeon to know all the bones of the foot. But where the real difference comes in is in this. A man seeking the services of an engineer probably knows

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whether he wants to build an electric power station or a bridge over the River Mersey. A man with a pain in his stomach does not necessarily know whether he needs a physician, a surgeon or a psychiatrist, and he should have a medical man properly trained for the purpose who is a doctor of first instance. I do not think that is a good name for him, but it is a good name for at least part of the job he does. The recent Citizens' Commission's Report in the United States calls him a "primary physician". We might call him the general physician. I think that there is a good reason for getting rid, gradually or suddenly, of the term "general practitioner", which to some extent has fallen into disfavour and conjures up the picture of the old man with his horse and buggy, treating patients for eczema, delivering babies and setting broken bones, which we know is quite out of date.
The practitioner of the future, as we hope to see him, will have a much better training, partly in hospital and partly in general practice, and when this has been completed he will work in a group practice. Within the group there will be some kind of specialisation. A man who has done pædiatrics in hospital will take most of the children's work. But a group practice means much more than five or six doctors working together in a partnership and sharing the proceeds. It means a properly constituted group, which includes health visitors, nurses, and secretarial and receptionist staff, working from suitable premises, often in a health centre and sometimes in the district hospital, and always with ready access to the necessary tools for modern diagnosis in the sense of radiological and laboratory work. Only by maintaining the generalist will the public be protected from some of the worst terrors, inconveniences and indignities of modern medical science. In the United States of America there is at present a great feeling that we have gone too far towards teaching nothing but medical science in the medical schools, and failing to produce doctors who will be pleased to spend their lives giving comprehensive and continuing care to their patients. I hope that I have made out the case for the general practitioner of the future.
Lastly, with regard to the general practitioner, he must have adequate time. We
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shall never attract young graduates into general practice if they see themselves for the rest of their lives seeing a succession of people and giving only a few minutes' attention to each. In this respect, I wonder whether, possibly through the Ministry of Social Security, as well as the Ministry of Health, we could look still further into the question of certification, because, especially in the less attractive districts, where we want doctors, people doing uncongenial tasks come into the surgery in their dozens wanting, not the doctor's advice, but the doctor's signature. This is really not the work that he has been trained for. It may be necessary; but I sometimes wonder whether the country would not gain by having much less certification and risking a little more in the abuse of the services.
I have a practitioner friend in Manchester who went carefully into the question, and he finds that, although he knows full well that there are a few patients who regularly abuse, or try to abuse, the services to obtain sick notes, especially during national sporting events and so on, nevertheless, only a small amount of money is really being wasted in this way because most of the sick benefit goes to a quite small number of people who are chronically sick and disabled. I know that in the matter of certification some advance has been made in the recent discussions between the Minister and the profession, but I still wonder whether something more could not be done, and whether the employers also could not be asked, or told, not to make so many demands, as they often do, on general practitioners for certificates.
In conclusion, I hope that we shall see the defects of the National Health Service, and that we shall look upon them calmly, as matters requiring solution, and as capable of solution only by the joint efforts of my profession and the Ministry. I believe that the Minister's recent statement on dialysis in renal failure is an excellent example of what can come from the collaboration of specialist advice from the profession together with the help of the Administration. I wonder whether it is too much to hope that in the future the same kind of collaboration will spill over, not only to scientific and medical questions, but to questions of the organisation of medical care.
5.23 p.m.
THE LORD BISHOP OF LICHFIELD: My Lords, I should like to begin my speech by congratulating the noble Lord, Lord Platt, on the maiden speech that he has just delivered to this House. In view of his most remarkable record of service to the community, I am sure that we were indeed pleased when we heard that we were to have the privilege of his membership in this House, and I regard it as a privilege to have some share in this debate in which he has made his maiden speech. I feel, also, that I have the right to ask for the sympathy of the House in that it is difficult for the speaker who follows such an expert as the noble Lord, Lord Platt. Nevertheless, on a subject such as this, which impinges so closely on the welfare of the whole community, I hope your Lordships will feel that some contribution ought to be made from this Bench.
As I myself have had the privilege, almost without a break since the appointed day, of serving either on a board of governors or on a Regional Hospital Board, this is a subject in which I have a particular interest, and I should like to thank the noble Marquess for initiating this debate this afternoon. I think it is as well that the country should realise that the increasing demands which are made upon the National Health Service can never be met in full. The National Health Service has uncovered a great measure of human need which hitherto had been unseen. It is, for instance, interesting to note as one goes about how many more people to-day are wearing deaf aids than formerly. This is not because the number of deaf people has suddenly increased; it is obviously because many more people can now be helped in this way. This is an illustration of what I mean. Again, the advantages and discoveries of medical knowledge are now spread everywhere, and are not confined to a few particular hospitals. This means, of course, higher costs: it means that the equipment is much more costly in money, and also costly in manpower. Whatever our political opinion may be, I think that probably all of us will recognise that private enterprise could never have met these demands.
The National Health Service may have its defects; and in this imperfect world, it probably always will. We have, in all
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conscience, heard enough about these defects recently. We are told that we need more money for this and that—and of course we shall all agree. I see that the suggestion has recently been made (it is not one that I personally would advocate) that we might have a national hospital lottery in order to raise more money. But I think the truth is that the limiting factor in our service to the community is in manpower rather than in money, and it is the question of manpower which presents the real problem.
The point has been made in more than one speech this afternoon that manpower in hospitals is now greater than ever before. There are more doctors and more nurses. Moreover, it is obvious that the improvement in the hours worked by these various people means that more people are needed for the same amount of work. That prompts the thought: can computers and automation help us? I should think that it may well prove that, while they will give better service, they may well uncover more work rather than save manpower. Every effort, therefore, must be made to see how manpower can be saved and how greater efficiency can be achieved.
Here I may say that efforts made to encourage married women to return to work in hospitals and the like are not doing particularly well. In the region in which I serve there has been a very small response to the request that went out to married women doctors to see whether they would come back and help. It may be that the tax position has something to do with this. But undoubtedly many of them feel—and I think rightly—that their place is in the home. The trouble is that in this matter we are in a cleft stick. At one and the same time we need the housewives and mothers in the home, yet we are clamouring for them to go out to work.
Let us think of this matter in regard to the grave problem of overcrowding in our mental hospitals. We all know that this is closely allied to the problem of the elderly. With the growing numbers of elderly people, I do not see how the hospitals and local authorities are going to cope with it. They will never be able to solve the problem. We therefore need more families who are ready to care for aged relatives at home. If this is to be

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done the housewife, the mother, has to be at home to do it.
Further, I think the question should be asked whether the houses which are being built to-day are of a kind which can make this possible. Unfortunately, it is true that large numbers of houses which are now being built make it, in my view, impossible. I mention this because I heard this point strongly made at a meeting the other day when we were considering this urgent problem. If you have in a house which is not designed for this purpose a family of children, and at the same time old granny is there, you at once run into very real problems. Therefore, I would say that in all this matter of community care the question of the design of houses may be more important than we sometimes realise. Let us also remember that the tremendous pressure on such an organisation as the National Health Service will undoubtedly be lessened the more we can produce the right type of houses and more houses for the people to live in, because the better the housing accommodation the less disease there will be.
I said just now that really the question of manpower rather than of money was the biggest problem, and I would adhere to that view. But there is one particular aspect of this work in which I believe money at the present time would help, and help very much. I am referring to the supply of pharmacists in our hospitals. At the present time, the shortage of pharmacists in our hospitals is a very serious matter. May I give one illustration from one group in my own Regional Board at the present time? The establishment of pharmacists in this particular group is 11; in post at the moment there are 5, plus 2 part-time. What is the result of this? More and more work is being farmed out to the local chemists.
Of course, the fact is that retailers pay the pharmacists better salaries than does the National Health Service; and the argument, a very reasonable one, is that no matter what the Health Service may pay, the retailers will pay more. But I would ask, is this argument entirely sound? In the debate this afternoon the phrase "job satisfaction" has already been used. I therefore wonder whether it ought not to be used in this particular connection. I believe that if there was
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a reasonable increase in the salaries paid to pharmacists in our hospitals, there would be many who would prefer to go there and do real pharmacy, rather than go into a shop and spend half their time selling cosmetics and the like. I think, therefore, that with the grave problem of the supply of pharmacists, this matter of a reasonable salary increase is something which the Ministry might well consider. I, for one, think it might do much to ease the problem. Also, let us remember that, from the purely financial aspect, it costs the Service much more to have its medicines made up by the local retailer than to produce them itself.
May I next turn to the district general hospital, which is rapidly becoming the nerve centre of the Service? It might well become the centre in a much more marked degree. We often hear it said that there ought to be greater co-ordination between the various sections of the Health Service. If, therefore, Health Service units are established, as I understand is planned, throughout the country, this co-ordination is obviously going to be very much greater. We shall have together our hospital health centre alongside the district general hospital, the local authority social services, welfare services, ambulance services, and so on.
The development of the district general hospital is now being considered by a Special Committee. This Committee was set up by the Minister's Central Health Services Council, and I understand that Mr. Bonham Carter is its Chairman. So far as I am aware, there is no Church representative on this Committee, and I confess I am sorry about this because, after all, for centuries past there has been a very close connection between the work of the Church and the work of the ministry of healing. I would therefore ask the Ministry that the Churches might at least be invited to give evidence to this Committee, because I think the Minister will find they have some very definite views on the subject of the development of the district general hospital and that those views may be of help. These district general hospitals will serve a wide area.
May I touch for a moment on the Church aspect of this matter and the chaplaincy services, with which I am particularly associated? These district

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general hospitals will not have any particular link with the parish in which they happen to be situated. We, therefore, as a Church, do not feel that we shall be able to give adequate chaplaincy services to these hospitals by means of the local parish church trying to do it. We are very concerned about the fact that recently at two centres full-time hospital chaplains had been withdrawn because the numbers of patients concerned apparently did not justify their existence, and in both places it has been shown that the incumbents of the parishes round about simply cannot cope with the extra work of the hospitals. We as a Church—and here I can speak also as a member of the Joint Committee with the Roman Catholic Church and the Free Churches—feel that these district general hospitals ought to have full-time chaplains.
At the present time, however, the Ministry figures make this quite impossible. The Ministry figures are that there have to be 750 patients of the denomination concerned before a full-time chaplain can be appointed. So far as the Church of England is concerned, we find that in hospitals we are responsible at the moment for roughly 67 per cent. of the people there. That means that if we are going to have a full-time chaplain the hospital has to have not fewer that 1,000 beds. I understand that at the moment the plans for the district general hospitals on the whole are that they will not have that number of beds. We think it would be disastrous if on that account we were not able to have full-time chaplains.
It should be remembered that we believe the chaplain in these days can give his best service by his individual work with the sick; not just in holding ward services or in racing round from one bed to another, but in concentrated, careful work with individuals. Speaking, if I may, as one who has been responsible for a large hospital chaplaincy in the past, I would say that if the chaplain can go and visit those patients who are about to undergo an operation, his visits can be entirely worth while; and I know for a fact that many surgeons have greatly appreciated what has been done. But one cannot do that kind of work if one has not time for it, and 750 is a figure which is unrealistic.
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Further, my Lords, what about the staff? Again, we in the Churches feel that the chaplain ought to have a very particular responsibility to the staff. I quite agree that many of the staff will be living out and that they may be associated, if they so desire, with their own parish church. But what about all these coloured nurses in our hospitals? We have heard about the doctors from overseas. What about the nurses? They come here and are not in touch with any local church at all. I believe it is essential that the chaplain should be there to try to help these nurses.
Further, may I draw your Lordships' attention to the serious matter of nurse wastage? I believe that many potentially good nurses are lost because at one time or another in their nursing lives they come on a crisis which they do not feel able to surmount. I believe that a really good chaplain, standing, as he does, somewhat outside the hospital hierarchy, could well be a great help to the nurses at that particular juncture.
If I have seemed to be rather complaining in this matter, I should like to thank the Ministry for what they have done to help us—and I mean this most sincerely. I am indeed grateful that in all our new hospitals we are having chapels. I am thankful that through our joint committee between the Churches we have agreed that there should be one chapel which we shall all use. I am thankful that the Roman Catholics, the Free Churches and ourselves have been able to construct a service of dedication of these new hospital chapels in which we shall all participate; and I am thankful, too, that the Ministry have drawn up a list of furnishings for these chapels which can be charged to Exchequer funds. It is, I think, a generous document. So, while I thank the Ministry for their help, I would at the same time direct their attention to these urgent questions which we in the Churches believe to be so important.
There are just one or two other matters to which I wish to refer. May I direct your Lordships' attention to the matter of communications? These are most important. The National Health Service has been tending to get a bad Press. I do not think we ought to complain about the attention the Press gives to it, because one of the chief duties of the Press is to uncover waste and inefficiency. But I

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believe that lately the man in the street has tended to get a one-sided picture of the position as a result of the kind of picture of the National Health Service which has been so often presented in the Press. This tends, I think, to make him forget the great blessings he receives through the Health Service. For this reason, it seems to me that what we who try to work in the Service must remember is that we must give unceasing care to the matter of communications. Every Regional Board, every hospital management committee ought regularly to consider whether its communications with the Press are as good as they ought to be.
Further, what about communications within the Service itself? Only the other day I was reading of a great commotion in a particular hospital because, it was said, a certain decision had been imposed upon them and no reason had been given. It is desperately easy for people who are in the centre to think that everybody knows what the situation is, that they all realise it and appreciate why the decision has been taken, when in actual fact they do not. Communications, therefore, are worth the most careful attention. If they are well attended to they can prevent any amount of trouble, and in the whole of the National Health Service this matter of communications is absolutely vital.
My final point is a plea that in this great Service the sense of vocation should not be lost. We have heard a great deal lately about hours of duty, and about terms and conditions of service, and the like. If I may speak personally, I was very sorry for the junior hospital doctors when they were caught by the "freeze", and I think the consequences of the fact that they were caught by it will be felt for a long time to come. I am not for a moment arguing for sweated labour, and that we must make reasonable conditions for these young people is something with which I am sure we should all agree. If it took a crisis to stir us up in regard to providing amenities for these junior doctors then I think we owe them an apology.
But, my Lords, when all has been said and done, they are in a profession and, further, in this work what is needed is a sense of vocation, and with that one cannot think first of hours of duty and the like. One has to think first in terms of
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service to the community. This does not only apply to the National Health Service, vital though it is there. I believe that the Church must constantly remember this, and I believe that the whole nation ought constantly to remember it in its approach to its tasks. I pray that we may not lose this spirit of putting service to the community first.
I would end by saying that I, for one, am a great believer in the National Health Service. I personally, and my family, have received much from it, and I am grateful; and I have always regarded it as a real privilege to have some share in the work. I believe it is emphasis on the spirit of service that will give us the driving power to overcome the difficulties which undoubtedly exist in the National Health Service to-day. It is that which will enable us to do much, and it is that spirit of service which will enable us, in this great work, to do our utmost on behalf of the whole community.
5.48 p.m.
LORD COHEN OF BIRKENHEAD: My Lords, I count it a privilege to be among the first to congratulate an old friend and colleague, the noble Lord, Lord Platt, on an admirable maiden speech, wittily and cogently argued, and, as he told us, not wholly free from controversy. I am sure your Lordships will look forward to receiving the benefit of his advice on many future occasions. There are few who are more competent to give it, in many fields apart from medicine. May I now apologise to the noble Marquess, Lord Lothian, and to the noble Lord, Lord Beswick, because I have a firm appointment for a lecture at 7.30 p.m., so I hope that I shall be forgiven if I leave a little early.
The House will certainly be grateful to the noble Marquess, as many of your Lordships have said, for having introduced this debate. It is perfectly true that there has not been a debate entitled "The National Health Service" for a long time, but in the past 11 years, since I have been a Member of your Lordships' House, I have debated most of the matters which have been discussed this afternoon on many occasions under different titles, for, as your Lordships know, the title of a Motion has never restricted those who take part in the discussion from covering a much wider field.

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This debate on the National Health Service is timely. A vast canvas has been covered, and I propose merely to discuss, critically but, I hope, constructively, one or two problems. At the outset I want to stress, as most of your Lordships already know, that I am not critical of the concept of the Health Service, and I do not share many of the forebodings which the noble Marquess expressed this afternoon. I believe firmly, that, despite its detractors and despite some admitted shortcomings, the National Health Service has provided for the vast majority of people in this country a much better service of medical care than they could possibly have anticipated before 1948.
There is so much evidence in support of this that, frankly, I regretted the fact that the noble Lord, Lord Sorensen, introduced one or two pieces of supporting evidence this afternoon which it appeared to me were post and not propter. Take, for example, the diminution in the incidence of diphtheria. In 1942 there were 50,000 cases of diphtheria notified in this country, with 2,700 deaths. It is true that the number of deaths in 1948 had fallen to 158 and that recently there have been practically no deaths, and when one occurs it makes the headlines. But that is not due to the National Health Service. It was due to the introduction of diphtheria toxoid, and it has been used since then with great success.
The same is true of poliomyelitis. In 1957 there were over 3,000 cases of poliomyelitis in this country and they created very extensive and severe crippling, though deaths were relatively few. The conquest of poliomyelitis which we now sing in the jubilant strains of victory was in fact due to polio vaccination, and although the polio vaccine was given through the National Health Service we must not attribute it to the National Health Service. The same is true of tuberculosis, tuberculosis of glands and bones and joints, tubercular meningitis, of the alimentary tract, and so on, which are due to infection from milk. This was controlled by pasteurisation of milk supplies before the war, and this continued to be so controlled so that most of our long stay hospitals which were built in the early part of the century were no longer needed for this purpose. And in pulmonary
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tuberculosis the control has been due largely to good housing, better nutrition and the use of chemo-therapy, such as streptomycin, isoniazid and other drugs. This does not detract from the fact that many of these could not have been given in the circumstances in which they were given were it not for the National Health Service. This is why I think it important not to give ammunition to our detractors by indulging in ambivalent claims which can be rebutted.
LORD SORENSEN: If I may interrupt the noble Lord, may I say that I hope I made this clear. But I am very glad for the noble Lord's explanation.
LORD COHEN OF BIRKENHEAD: My Lords, I am sorry I misunderstood, and we shall see in Hansard to-morrow no doubt whether I did. I was very grateful also to the noble Lord, Lord Platt, for mentioning the general practitioner training and the present views thereon, because in 1948 I chaired a committee of the British Medical Association which produced a report on general practitioner training, and recommended that the undergraduate medical course should be a basic medical education with vocational training for medical practice coming later. I was then President of the British Medical Association, and to show the independence of the Association I can merely say that the report was overwhelmingly rejected by the Representative Body and by the Council of that Association. It is satisfying to feel that in twenty years the cycle has returned and that this is now commonly accepted policy.
As to the topics with which I want to deal, the first concerns the Regional Hospital Boards which are responsible for planning hospital and specialist services. As the years have passed those who, like myself and the right reverend Prelate the Bishop of Lichfield have served on Regional HospitalBoards—I have served on the Liverpool Regional Hospital Board since its inception 20 years ago and on the Board of Governors of that City—and indeed the officials who serve our Regional Hospital Boards feel that since the inception of the service they have increasingly experienced more and more frustration. And this is not financial. Most striking has been what a former Minister of Health wrote recently—a greater tendency to monolithic

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centralisation of administration. Your Lordships will not have much difficulty in guessing who that is.
The opportunities for local initiative by Regional Hospital Boards have become gradually eroded, and this has tended to impair the zest and the morale of a vast army of workers who work voluntarily and gratis to administer the Service regionally and locally. Chairmen of Hospital Boards who devote from one-third to one-half of their working time in looking after the interests of the Boards have repeatedly told me in recent years of their frustrations. No one denies that the Service needs central control. The overall planning must be national. But the Regional Boards are charged with planning regional services, and yet there is less and less delegation from the centre so that too many decisions are unnecessarily removed from the Boards who are best fitted to know and appreciate local conditions. For example, in planning a new hospital in one region a project team was set up which included members of the board and officers of the board. They designed a plan which was rejected by the Ministry as being unsatisfactory, and no one complains of that. The Ministry suggested that it might be re-designed on certain lines, and schemes were bandied to and fro between the Ministry and the Regional Board, until after about two years the final scheme was informally accepted. It seems to me that it would have been far preferable if, at an early stage of the planning, the Ministry had provided one of its more senior officers to sit in with the planning and to halt the project team if it seemed to be going beyond Ministry policy.
Let me say, however, that deviations from the Ministry's policy are difficult to determine, because so far as I know no such policy has been clearly defined. Indeed, there can be no fixed ministerial policy in this field because hospital planning and building methods are still fluid. I am glad to see that the Minister is to undertake an experiment, I think in two Regional Boards, Essex and the South-West Metropolitan Regional Board. Hospitals are contemplated at, I think, Bury St. Edmunds and Frimley, in which an attempt will be made to determine how economically a hospital can be built and yet provide the best kind of hospital
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accommodation, how the best value in terms of balance between capital and running costs can be secured, and to test how feasible it will be for the planners and designers to produce a hospital which will satisfy requirements in two different areas and how to speed up the design and construction stages of a hospital. They hope that these hospitals will he in use by 1971–2, and, as I said, this is a commendable exercise.
But it will provide the solution to very few problems. We can never attain the ideal hospital. From conception to completion a hospital, say, of 800 beds, will rarely take less than five years in this country, and very often it is considerably more. But the rate of advance of medical knowledge is such that in five years much of that hospital may be out of date. Five years ago, for example, there was no renal dialysis, which the noble Lord, Lord Sorensen, mentioned. Organ transplantation was in its infancy, and so were the newer methods for the treatment of cancer of various types. And so it is that these new hospitals which are being constructed cannot be based on rigid blueprints. Very often those rigid blueprints simply reflect the views of those who are going to work in them initially. We agree that there must be standardised units, and we also feel that there must be sufficient flexibility of accommodation so that it can be adapted to new needs. I think it right to say that I believe the Ministry recognise this fact.
The right reverend Prelate the Bishop of Lichfield mentioned computers. The Ministry has recognised and accepted the fact that computers have a vast contribution to make to hospital services in the future: in the maintaining and analysis of medical records, in the recording and analysis of laboratory procedures for clinical investigations, possibly even in assisting diagnosis. And I should like to pay a tribute also to the Nuffield Provincial Hospitals Trust, which has established centres in Liverpool, Birmingham and elsewhere to find out what contribution the computer can make to hospital services. What the survey has already revealed, which is of great importance, is that the needs of hospitals vary from place to place, and this is why one cannot have simply standard hospitals the in-provision cannot be confined within a rigid national formula. Account must be

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taken of the location of the hospital, of the demographic pattern of that area: how many old people there are, how many births are expected, and so forth. There are variations in morbidity throughout this country, and these must be noted.
It seems to me that for these reasons it is imperative that we should profit from the knowledge of members of Regional Hospital Boards and of hospital management committees, and do nothing to impair—indeed, do everything to foster—their local buoyancy and initiative; and do it now. This means restoring a wider degree of agency authority and delegation to the Boards. There is need for a booster of morale at Board level. One of the ways in which this might be done is to give a small sum of money, perhaps one-half of one per cent. of their budget, so that they themselves can investigate means of rationalising their resources and so saving on revenue accounts.
But, as has been repeatedly urged this afternoon, the most pressing problem in the Service is not financial but medical manpower. The reasons for this have been given: the increasing complexity of medical diagnoses and treatment, the need for a wider provision of services, and their proper distribution. As the noble Lord, Lord Sorensen, pointed out, we do less than justice to significant increases which have occurred in our medical manpower since the Health Service was begun. But one of the difficulties which has been mentioned is that 45 per cent. of the 10,500 of our junior hospital doctors come from overseas. As President of the General Medical Council I am concerned with the registration of these foreign doctors, and I can tell your Lordships that there is no sign of any decrease in the number of doctors from overseas coming to work in our hospitals. Indeed, it is increasing. Of course, this may not last, and if they did return over a short period to their own countries we should be faced with an emergency.
How can we now obtain the extra doctors who are needed? Clearly, as has been said, an important source is the medical schools; and it is encouraging to note that in the past five years there has been a 25 per cent. increase in the number of admissions to medical schools. In October, 1966, for instance, there were
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2,500 new admissions. But as the noble Lord, Lord Amulree, observed, these will not be ready to give a service to the hospitals for seven, eight, nine or ten years.
There are measures which we might consider in the meantime. They are small, but they will close one or two gaps. I could relate many, but I will instance only one, which was reported in the Lancet a year ago by Cammock and Lee. It is what is called "dual care". Cammock and Lee investigated the practices of 59 doctors in the North Midlands with a total of 150,000 patients, and of these 3,500 had been referred to hospitals. Of the 3,500, 2,200—that is, over 60 per cent.—were having not only hospital care, from repeated attendance at hospital, but at the same time were under the care of their general practitioner for the same complaint. This duality of care clearly can be investigated more closely, and I believe that savings could be made. We have only to remember that it costs £3 10s. to see a new outpatient: and it costs 25s., as a national average, for a revisit. There are, I think, some 13½ million new outpatients a year and some 30 million revisits. So your Lordships will see that the opportunities for saving are there, and I trust that this matter will be further investigated, together with a number of others which I shall discuss on another occasion, as our time this evening is limited.
But our major task, I am certain, is to try to stem the emigration of doctors from this country to settle in countries overseas. It has been said that exact figures are not available. With this, I agree. But there has been a careful investigation by Abel-Smith and Gales which was based on General Medical Council records, and there seems no doubt that the permanent emigrants (I am not thinking of those who, quite properly, spend a year or two abroad to extend their education and training, but of the permanent emigrants) numbered certainly not less than 400; and I note that this figure was accepted in another place on Monday by the Minister of Technology.
Why do they leave? Of course, a few will leave because the financial rewards in other countries are better. Not all have a sufficient sense of vocation to resist the temptations of Mammon. But I do not

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believe that this is the root cause. I believe that the root cause is lack of opportunity in the Service, and a feeling by some of these younger doctors of insecurity of the future. The main loss is among those who have been qualified for three to six years. This is the grade in which they tend to leave. This grade, which is mainly registrars, was originally regarded as the training grade for specialists. Now, of course, only the senior registrar is so regarded. The chances of a registrar's becoming a senior registrar for specialist training are somewhere between one in three and one in four. It varies, but that is about average. After many years of service, a registrar may feel that the future is still insecure, that he may not be one of the four who is to reach the higher rungs of the ladder. Again, it is proper to add that about 30 per cent. of those who leave this country go to the underdeveloped countries where their salaries will be far less than they are receiving in the National Health Service; and, of course, they are badly needed in those countries.
What is the solution? It seems to me that to stem this outflow we need a complete overhaul of our hospital staffing structure. This, of course, is related to schemes of post-graduate training. The principle which I believe must be ensured is that a man—and in deference to the noble Baroness, Lady Summerskill, I will add "or woman"—who has satisfactorily pursued a course of specialist training is assured of a specialist position on the completion of this training. This seems to me to be fundamental if uncertainty and insecurity are to be dispelled.
Perhaps I need not remind your Lordships that at present there are in the hospital service many types of hospital officers—junior residents who are doing a pre-registration year; then hospital officers who are post-registration; senior house officers; registrars; senior registrars, and so on. If a young man decides that he wants to become a hospital specialist, he continues as a registrar. Others who are going into general practice or teaching, or research, or preventive medicine, or administration, or industrial health, will perhaps do two or three of these post-registration house posts and then another period in vocational training. But those who decide to become hospital specialists continue as registrars, and then
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if they are favoured continue as senior registrars for periods up to, it may be, six or seven years. Then, as I have said, after competing with others for the post such a man may be appointed a hospital specialist or consultant; but his chances are only one in four.
If his future is to be assured, I would suggest that all the titles we have been using hitherto should be scrapped, and that in their place there should be established hospital medical posts of increasing annual seniority and pay. Those who enter general practice, public health and the other disciplines which are primarily non-hospital will still hold these posts for a first, second and possibly a third year, but those who choose to become hospital specialists will continue in appropriate hospital medical posts until they have satisfactorily completed their training, which may be as long as seven, eight or nine years, depending on the specialty. On the satisfactory completion of this period they will be promoted to assistant, or junior physicians, or surgeons orone of the other specialties and assigned to appropriate hospitals. They are then assistant specialists taking responsibility under the supervision of a senior.
The assistant physician and others of similar specialist status will not reach the higher general practitioner scales of remuneration because general practice must remain financially attractive, but he can at any time apply to fill a vacancy in a senior post. But after, say, ten years of satisfactory service as an assistant, say at the age of 40, he should enter automatically the senior grade, with its rates of pay and conditions of service in that field. There will thus be no fixed establishment; but there is, of course, none at present. The needs of the various specialties will be generally established, as now.
Clearly, this scheme must be worked out in detail, but it ensures that at the end of his period of training the potential specialist is not left high and dry, as three out of four now are. Such a scheme might add, almost immediately, 300 to 400 specialists to the hospital service per year. The cost would be possibly £1½ million to £2 million a year, though I think probably less. But again, we must not overlook the 400 who have emigrated. True, not all are going to be specialists,

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but each of these, so we were recently told by the Minister of Health, costs £10,000 in training, so the 400 add up to £4 million. It is surely preferable to save as many as possible by a scheme which is sufficiently attractive to keep them here. It is essential to ensure no depletion, indeed to increase the number, of general practitioners.
I share with all those who have spoken on this topic their admiration for the present Minister of Health, who was the first Minister to recognise that remuneration was not the only source of trouble but that conditions of service were to be considered sympathetically, and he worked out with the British Medical Association a scheme which could well cause frustration to disappear in the future and make the future of general practice brighter than at any time in its history. Credit must also be given to the Ministry who during the past years have generously supported post-graduate training and medical research and many other important contributions to the welfare of doctors, not only in hospitals but in general practitioner and preventive medicine services.
I had hoped that there might be time to discuss one or two other pressing administrative questions which I will mention, and which so far in the debate have escaped notice. Are the fourteen hospital regions which were delineated 20 years ago—one has been added since—appropriate for to-day's needs? Should the teaching hospitals and regional hospitals still be separately governed or should they be under the jurisdiction of one body, as in Scotland? Are we proceeding quickly enough with the provision of health centres where complementary services—for example, local health authority, general practitioner and specialist advice—could be integrated? Should ambulance services pass from local authorities to Regional Boards, and so on? There are a hundred-and-one questions which could usefully be discussed, perhaps on another occasion. I am not giving answers to these questions; I am simply posing them.
No-one who has served, as I have, for 41 years as a consultant on a teaching hospital can fail to see the striking difference between the care given to patients in this country before 1948 and after it;
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and, whatever its defects, omissions and blunders—and I should be the last to minimise these—the National Health Service has proved one of the most successful of our social services. True it is, as has recently been pointed out by a former Minister of Health, and indeed by the right reverend Prelate the Bishop of Lichfield, that there will always be a gap between supply and demand; but if we can rationalise supply and set our priorities right, and take steps to ensure that demand more closely represents need, for example by health education—that is a subject of another Motion on the Order Paper—we may well find that our financial resources are not so inadequate as some would have us believe. Even if they are costly, we should never forget, as Ben Johnson wrote of health nearly 3½ centuries ago:
"Who can buy thee at too dear a rate,
Since there is no enjoying the world without thee?"
6.18 p.m.
LORD SOPER: My Lords, the temper and course of this debate hitherto must have given ample gratification to the noble Marquess for initiating it. I, for one, am especially attracted to it because it affords an opportunity of calling attention to the Health Service and away from the somewhat scurrilous misrepresentations of the Service that have been current in the Press just lately. It is to call attention to the essential service itself which I believe is the major contribution for which the noble Marquess hopes, and which I am sure this debate will have achieved.
I should like to put in my pennyworth of congratulation and thankfulness. I began, 41 years ago, a different kind of service from that so eloquently represented by the last speaker, and I testify to the revolutionary change which has taken place in the social services in which I have been engaged in those forty years. To put it quite simply, for me about the most Christian thing that has happened in my lifetime is the National Health Service. When I think of the amount of suffering that was borne by those who could neither afford the time nor the opportunity of curing leg ulcers, for instance, or getting them cured; and when I remember those who went about the world seeing it only as a blur, and being compelled to eat very little more

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than pap because they could not get the adequate treatment for their teeth or for their eyes, I have a profound sense of gratitude for the Health Service, and nothing but contempt for those who, either from irreducible ignorance or cynicism, will seek to depreciate it and to regard it as some kind of unworthy benefaction bestowed on some and unduly enjoyed by those who receive it. I am quite sure of one simple fact: that could we transport some of the cynics back to the conditions in which I first began as a social worker in the Old Kent Road, they would very soon recognise what an immense change has taken place, and, on the whole, how beneficial that change has been.
Nothing will drag out of me any attempt to make statements which involve an expertise which I do not enjoy, but I want to select one field for which I want to set out a case to my noble friend, and to make a plea to him. I hope he will not feel that this is some ritual dance on my part, as the noble Baroness, Lady Summerskill, suggested when she referred to drugs, when I refer again to alcoholism. I have an axe to grind, but I hope I do not qualify for that character in David Copperfield, treating alcoholism as "King Charles's head". I am convinced that it is a major evil, and I intend to go on talking about it, in season and perhaps out of season, because I believe there is very much more that should be done.
In the first place, I think there is very little adequate knowledge in many parts of the community in which we live, as to its nature. It falls properly, I suggest, within the general framework of this debate. Alcoholism has many characteristics, but it is specifically a medical condition. I will venture no further into this field, except to say that one of its characteristics is the recurring blackout and the compulsive drinking, and the condition of slow and inevitable deterioration. It is a matter on which, first of all, accurate knowledge is required and on which accurate experience must be obtained, and it is out of some little knowledge and some long experience that I want to make, very simply and very quickly, a number of propositions.
The first is that if there is to be any adequate treatment of the alcoholic it is useless to talk of him as a moral de-
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linquent to whom spiritual exercises in faith will produce the correct result. He is incapable of responding even to the ministrations of the most ardent Methodist. In the second place, unless he himself is prepared to co-operate in that treatment it is equally foolish to regard him as somebody who can be treated. Therefore, there must be some kind of domestication in which the alcoholic can be encouraged to take the kind of medical treatment which is increasingly made available to him. It is in this sort of case that I would ask the Minister whether he will consider co-operation with local authorities, co-operation with voluntary bodies, in the building of hostels where both the medical treatment needed and the domesticity required to make it applicable can be provided. If that is done, can my noble friend put, or seek to put, teeth into the law, so that those who are alcoholics and who are discovered in extremis, so to speak, may be sent to the hostels?
This is not a sob-story, but I think it is worth recounting. In the hostel for which I am responsible, there was a man who over Christmas became "dried out" and gave every indication that he would remain "on the water wagon". We had no means of keeping him permanently, and he went out. We feared what would happen; and it did. He became hopelessly drunk on a very cold night. He lay on Streatham Common and endured frostbite. He is now lying in the South-Western Hospital with both his legs amputated. Had there been a suitable hostel for that man to go to, a convalescent home to which he could have been sent, I am pretty certain that he would to-day be walking about on his own two feet. My Lords, this is not some sentimental anecdote. I have a preoccupation with this problem, because I have seen what intolerable anguish it causes, and I can see so easily what remedial methods, with a reasonable expenditure of money and co-operation, could be employed.
It is quite foolish to think that by setting up some clinic within a general hospital the alcoholic will have the continuity of treatment or the persuasiveness of application which will secure some remedial process. What has to be done, surely, is to put teeth into the enactments, so that such a man can be sent away, as

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happens with other hostels for which I am responsible where a girl can be sent to a hostel or, if she chooses, to prison. The opportunity is afforded to her, but it is compulsory in the sense that it is an obligation which she has to accept.
I believe that there is, further, a need for some kind of convalescence, or convalescent system, for the man who has been "dried out" and of whom I was just talking. No system of hospitals in this country would regard itself as adequate without the provision of convalescent homes to provide that intermediate period for those who have been clinically ill, or, particularly in cases of acute illness, have been rendered more or less non-effective, and have since been cured, before they are required again to take up their full position in the world in which they will, it is hoped, lead a normal life.
These matters are matters of urgency, and if the Minister is prepared to say that he will consider suggestions and will commend it, then I would make two contributions in terms of money. The first of them is this. I believe that, if it be true that the provision of such hostels and such remedial measures would be expensive, we are already, probably, paying a very much higher price in the total wealth of the country that is being lost. I remember the father of one of the noble Lords who is going to speak a little later on—the great Lord Stamp—saying that on the whole he thought that a 13 per cent. diminution of economic and social effectiveness could be put down to alcohol in general, and I suppose that a large proportion of that could now be put down to alcoholism in particular.
Furthermore, I believe that many of the social amenities within the community are being hampered very largely by the incidence of untreated alcoholism. It will perhaps be within the knowledge of some of your Lordships that there are beautiful gardens and open spaces in many parts of East London which are so contaminated by hopeless alcoholics, particularly in the better weather, as to make them quite unacceptable to anybody else. This is not an exaggeration. It is something which was debated at length in the old London County Council, and the evidence was overwhelming.
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There are many other problems on which it would be proper for me, if I had expert knowledge, to attempt to say something. But on this question of alcoholism, I repeat my own sense of obligation to plead with the Minister that he will agree to set up hostels, for I believe that this is an essential part of a National Health Service and this action would put us all further in its debt.
6.29 p.m.
LORD AUCKLAND: My Lords, I count it a privilege to be the first noble Lordon these Benches to congratulate the noble Lord, Lord Platt, on a maiden speech of great distinction. It was the speech of a man who has given a lifetime of service to medicine, and I know that I echo the views of all sides of your Lordships' House when I say that we hope to hear the noble Lord on many future occasions, particularly on this vital social flatter of health, on which he is so fitted to speak.
It is about two years since the Health Service was discussed in any detail in your Lordships' House, which was when I myself put down a Motion on the hospital services. I was taken to task then, very fairly, by the noble Lord, Lord Taylor, the then Parliamentary Secretary to the Minister of Health, for covering a very wide field rather scrappily—Iam, of course, paraphrasing his words here. To-day, my noble friend the Marquess of Lothian, in an admirable and very convincing opening speech, asked us to cover the whole ambit of the National Health Service. I have given notice to the noble Lord, Lord Beswick, who is to reply, of several questions, and I shall fully understand if he cannot reply to them all, because if he were to reply to the whole ambit of this debate we should be here until the small hours of to-morrow morning.
My qualification, such as it is, to take part in a debate of this kind is that for many years my family have served on hospital committees, both before the National Health Service and after it. My father was chairman of a children's hospital in Chelsea which is now part of the St. George's Group, and I myself served on their house committee for several years. I am also on the house committee of a hospital group, the hospital management committee of which has my noble friend Lord Grenfell, who is to speak

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later, is its admirable and able chairman.
Inevitably, the nub of the whole problem of the Health Service is how it is to be financed. What are the priorities within the Service? What are the priorities within the national economy? Only last week The Times printed an article, one of a series on Government spending at home, entitled, "Pressure on the Health Service". It stressed the fact that expenditure on the Health Service at the present time is in the region of £1,188 million. I have been reading the original 1946 National Health Act which the late Mr. Bevan brought into operation. I was not a Member of this House then, but I have been reading through some of the debates. My noble friends on these Benches and in another place have often been taken to task for opposing that Act, or the Bill as it then was. At this hour, I will not enter into a discussion on the merits or otherwise of that, but, having read through the speeches I think there was very general support for the principles of that Act. It was merely on some matters of detail that the opposition came. All political Parties have had a hand in bringing the National Health Service into fruition to-day, but it is only right and proper to give Mr. Bevan much of the credit for what has been done.
I should just like for one brief moment to touch on the subject of drugs. The noble Baroness, Lady Summerskill, as always, mentioned this fact, and quite properly mentioned it; and, as I understand it, she made a reference to drug salesmen. The small business with which I am currently connected has among its duties the training of drug sales representatives—not on the technical side, but purely on the selling side. I have recently visited three of the leading drug companies and have had the assurance that now very much more attention is paid to the qualifications of these men. They are almost all men who have had medical experience. I certainly would not challenge the noble Baroness in her statement that there are too many drugs in the nation's drug cupboards. This is very true, and there are various reasons for this; but I really think that the drug companies are doing their utmost to make sure that these drugs do not get into the wrong hands, either through
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National Health patients or in less legal ways.
May I touch briefly on the subject of nursing? The problem of nurse recruiting arises right from the very junior grades. I have been in close contact with the Royal College of Nursing, I have been in contact with matrons from teaching hospitals and general hospitals, and I have twice visited the Staff College For Matrons in London to discuss, among other things, this problem. Part of the problem is that in many cases hospitals will not take girls under 18 for student nurse training. That is understandable, because some of the duties which even student nurses have to perform involve responsibility and strain which is hardly appropriate to their years. Many hospitals use cadet nurses. The Hospital near where I live, the Epsom District Hospital, does this, and my wife and I present an annual prize for the best cadet nurse. I wonder whether, in fact, the title "cadet nurse" is completely fair to the girl concerned, because many of her duties are not necessarily connected with nursing. I should think that "hospital cadet" might be a more fitting term, and might even be more complimentary to the girl concerned.
The figures given by the noble Lord, Lord Sorensen, of the increase in nurse recruiting were interesting and, I am quite sure, accurate; but there is a problem here which I think, in fairness, any Government must face: that is, that nursing to-day has become far more technical. There are things such as intensive care units—particularly that of the Leeds Royal Infirmary, which does marvellous work for which they necessarily need quite a large staff. To-day more and more things are done by computer; but one cannot nurse a gravely-injured person by a computer; it needs human hands. This is a problem which the Health Service faces at a time when we are moving into the technological age. We have heard a lot lately about kidney machines, and we read tragic stories of patients needing urgent treatment by these machines having to be selected. I am not blaming the Government for this; I think it is a human problem. It is due possibly to lack of research funds, and this is something which the Government must consider within their finance budget.

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At the other end of the scale, as the noble Lord, Lord Amulree, mentioned, is the question of geriatric patients. I live in an area in which, within a short mileage, there are seven mental hospitals. In one of them, Horton Hospital, is a large geriatric section. I have mentioned in this House before that the patients there are happy and admirably nursed; but many of them are, in fact, capable of home care, provided they can get the necessary nursing. We have heard of the marvellous work of the home helps and of the W.V.S. I yield to no-one in my admiration of these bodies; but if it were possible to provide some kind of Government help to finance a full nursing service for these people in their own homes, it might well prove to be cheaper than keeping them in hospital, taking up hospital beds. We have heard from other noble Lords that there are a good many young people who are taking up geriatric beds. The young people are a special problem here. There are some terrible illnesses, such as muscular dystrophy, which almost inevitably have to be nursed in hospital.
We hear a lot about "wastage of nurses", if I may use that dreadful expression which has become current. One of the problems is that of accommodation. Here, again, I, and other noble Lords, have raised this matter in previous debates, particularly regarding the older hospitals and nurses' homes which are really not homes at all. Again the problem is one of finance; these buildings cost money. Recently a delegation from one of the nursing organisations went out to Finland and studied a number of hospitals in Helsinki, Tampere and other Finnish towns and cities. In Finland, great stress is laid on good accommodation for hospital staff. Many of them live in flats rather than hostels. This gives a nurse a sense of freedom when she is off duty. For the very young nurses, of course, there must be supervision; otherwise parents become worried. Matrons who are friends of mine have come up against this problem of parents worrying about a daughter while, at the same time, the daughter is complaining that she has to be in by 11 p.m. I think flats of some kind could be a solution to this problem and would give the nurse an added sense of responsibility.
The right reverend Prelate the Bishop of Lichfield raised the most important
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subject of communications. We read in some newspapers also lurid details of the condition of some of our hospitals. I have seen some of these hospitals. It is true that they are old buildings; that outside they are grimy; that the stairs are often long, winding and bleak; that inside the equipment is often old; but the standard of nursing is almost invariably high, even when subjected to the greatest pressure. There is a need for Members of this House and of another place to visit more hospitals in their constituencies or in the areas where they live or have businesses. I think that much of the problem here arises because Parliament is remote from those who are closest to the Health Service.
I yield to no one in my respect for those who serve on hospital boards, hospital management committees and house committees. They are public spirited people: they give up a lot of time. If young people had more time they also would serve on these committees. But I think Parliament as a whole tends so fail because of the inability to come into close contact with the matrons, the charge nurses and those who really do the work in the Health Service. We are becoming a nation of rather self-styled public relations officers. In the Health Service there is a need for genuine public relations work to be done on a much bigger scale than at present. Too often we hear of unjust—or seemingly unjust—disciplinary action being taken on junior nurses; we hear of dirty swabs found in patients' stomachs. But we do not hear of the very fine work done in the Service, often by junior doctors who are working 90 hours a week. That is rather taken for granted.
Finally, my Lords, I should like to turn to one or two points regarding the structure of the Health Service. One of the problems of the hospital management committees is that they have only one year's funds to spend at a time. The problem here is linked up with the accounting system which the Treasury has had from time immemorial. It is often very difficult, when you are planning a medium or a long-term project, to do it within the allocation of one year's finances. I do not know whether the Government can give attention to this matter, but it is something which I think is constricting the Health Service very seriously.

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If I may, I would mention physiotherapists. The right reverent Prelate, the Bishop of Lichfield, mentioned pharmacists. There is more and more need for physiotherapy in these days and, as has been pointed out many times before in this House, physiotherapists arc grossly underpaid and grossly overworked. Some hospitals are 50 per cent. below strength. When the wage freeze finally comes to an end, I hope that physiotherapists and ancillary services will be given a share of the cake, because they form a most vital part of the National Health Service.
It is quite obvious that Party politics from either side will not solve the problems of the Health Service. The article which appeared last week in The Times and which I have mentioned puts the matter in a nutshell. There are Party points which must rightly be made, about prescription charges and so on, but nobody would fairly pretend that these will solve the whole of the Health Service problems. I think that the Government, any Government, must face the fact that if we are to continue as a healthy nation, as we are now, and if we are to he a healthier nation, the Health Service must be given a much higher place in the queue, even if it means cutting aid to overseas countries. I am certainly not suggesting that there should be a carte blanche stripping of aid to these countries. But, my Lords, while I deplore some recent statements that the Health Service faces a breakdown in the near future, I feel that in the long term there is a danger that, through financial restrictions, the Health Service will face grave problems.
6.54 p.m.
BARONESS STOCKS: My Lords, I will not waste your Lordships' time by dwelling on the merits of the National Health Service which have been so adequately spoken of. I will only say that I think it is probably the best Health Service in the world and that it has made an immeasurable difference to the health and the happiness of the people in this country. The noble Marquess, Lord Lothian, began with a rather depressing remark when he said that the Health Service is in danger of collapse but the rest of his speech made quite clear that it is not, because one does not devote constructive criticism—as he did—to something which is about to collapse.
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There are two questions that I should like to put before your Lordships. One is the development of deputising for general practitioners which is spreading very rapidly, I think, in many large cities, and certainly is very widespread in the London area. In fact I think that more than 50 per cent. of general practitioners in London depend on it. The way in which it is organised is probably familiar to many noble Lords present. It is run for the most part—indeed, I think entirely—by private agencies which recruit a panel of newly qualified doctors who are available for emergency calls which they receive from a centre while they themselves are ready to respond in radio-equipped cars. The doctors who wish to make use of the service can subscribe to the agency, paying so much (the charges vary of course) for so many nights a week, or so many weekends, or whatever it may be. That system of what I might call contracting out of the National Health Service was certainly not originally intended it was no part of the National Health Service as it was instituted in 1946. It just grew up of its own accord, and had proceeded some way before we knew that it existed at all.
It is a necessary service for many doctors. It is certainly a necessary service for single-handed practitioners who are not, as doctors used to be before the National Health Service, able quite easily to make mutual arrangements with medical colleagues in the same area. Whether it is a necessary service for group practices, where arrangements for a rota system can be made, I am not so certain. I think it is probably over-used by members of group practices, many of whom, of course, do not wish to live in the areas where their daily work is done. The trouble is that though there is now a certain element of control over the agencies and their use by doctors—control, that is, by the executive councils—it is a very shadowy control, and the quality of the doctors employed by the agencies varies very widely indeed.
Some of them are clearly extremely competent young men, in many cases hospital doctors working in their spare time to supplement their grossly inadequate salaries. In some cases they are foreign doctors who have not yet

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fitted themselves into the National Health Service. In some cases they are doctors making themselves useful between appointments; and in some cases, I am afraid, they are doctors who, perhaps for personal reasons, are finding it difficult to get employment elsewhere. But the point is that the quality of the doctors on these panels varies very widely, and their turnover is very rapid. The widespread use of the service does, I think, involve an element of impersonality in the Health Service, because it means that a doctor who uses the service does not know who is going to see his or her patients. I remember a doctor of my own acquaintance, the senior partner in a group practice, who, when I asked her whether she used the deputising service, said, "No, I should not dream of letting my patients be seen by a doctor not of my own choice and whom I knew nothing about".
I am very glad to hear that the British Medical Association are taking steps to rationalise this whole question of deputising, by recruiting a panel of doctors available for such service. Exactly how it is to be done I do not know, and I gather that it is not going to function at all until about April of this year; but when it is under the auspices of the British Medical Association I hope that the Association will end by rationalising the system as it exists now for the provision of deputy doctors for general practitioners.
My Lords, the other feature which I find somewhat disquieting is the existence of mixed practices, by which I mean combined National Health practices and private practices in the hands of the same practitioner. One cannot, of course—one would not wish to—prevent any member of the public who wished to consult a doctor as a private patient from doing so. After all, it is consistent with general consumer choice. If you want to spend your money on what you regard, rightly or wrongly, as a better health service, you should be allowed to do so, as you would be on better education, housing or food. It would not be desirable to prohibit doctors who wish to remain outside the National Health Service and rely on private practice from doing so. But where there is a mixed practice, there is a temptation towards discriminatory treatment in matters of appointments and time spent on patients.
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Many doctors do not respond to this temptation. I know doctors who have mixed practices and who would not dream of discriminating between their private and National Health patients. But not all doctors are of that quality, and faced with the obvious temptation they do discriminate. It may take the form of piling up a considerable list and engaging an assistant or a junior partner, the doctor reserving his own priority time for private patients and relegating as many National Health patients as possible to the assistant or junior partner. This does happen, and the surprising thing is that it does not happen more often.
It may be that this difficulty will cure itself with time, because more and more as young people grow up they rely on the N.H.S., and more and more as old people die the number of those believing that they can do better for themselves by engaging a private practitioner will diminish. It is a problem that time will solve; I do not see how anything else can solve it. The Ministry of Health have so much on their plate already that they could not possibly face the revolt of the medical profession against any kind of prohibition of the right of any doctor to combine private and National Health practice.
Much of the criticism we have been hearing goes back to the question of finance. The noble Lord, Lord Auckland, spoke of priority. We all have our own ideas about priorities. I have been a member of the University Grants Committee and of a hospital housing committee. Sometimes I have been surprised at the contrast between the ease with which resources can be obtained for furnishing student common rooms and providing amenities for undergraduates, compared with the awful effort required to bring up the accommodation of junior hospital staffs to the standards which would be regarded as adequate for teachers in training or undergraduates.
It strikes one that quite a lot of money has been thrown away in cancelling the prescription payments, which could have been maintained without hardship to anybody. I gather that the cancellation has involved an expense of something like £25 million. The saving of that sum would have allowed the allocation of £5 million to the universities, so that they

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could refrain from an increase in fees for foreign students, and would have left a large sum for improving the conditions of junior house doctors and much else. I do not want to raise this question of priorities any further, because we shall probably disagree about them. When it comes to priorities, I do not think that the N.H.S. is fairly allotted as compared with education.
7.5 p.m.
LORD STAMP: My Lords, I should like to express my gratitude, as other noble Lords have done, to the noble Marques for initiating the present debate, particularly as I find myself very much in sympathy with what he has had to say. To many of us in closest contact with medicine, the present condition of the Health Service is giving rise to deep anxiety, and I hope that your Lordships will forgive me if I speak more critically than others have done on this subject.
To me this debate seems to have come at a crucial time. Either steps will have to be taken to meet the obvious defects of the Service, or it will go from bad to worse. I believe, as the noble Marquess intimated, that this issue will assume greater and greater importance in the public mind in coming years. One of the troubles is that the deterioration has been so insidious—we have got along so far, so why worry? We have managed with out-of-date hospitals for so long, we can manage a little longer—and, after all, there are extensive plans for rebuilding over the next ten years, as the noble Lord, Lord Sorensen, has outlined.
The fact is that we have become hopelessly behind in this respect, compared with nearly every other country in Western Europe and North America, and it will take a vast effort if we are to catch up. Professor Miller, Dean of Medicine at the University of Newcastle-upon-Tyne, put the position trenchantly in an article on British medicine entitled "Fifty Years after Flexner" which was published in the Lancet of September 24, 1966. In it, he said:
"It would be hard to find a more telling example of public squalor in an affluent society than the appalling physical conditions under which distinguished physicians and surgeons are expected to teach and practise twentieth-century medicine in some of London's most famous hospitals…It is paradoxical that the two decades that have witnessed the
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greatest scientific advance in the history of medicine have also seen a decline in British hospital building unparalleled during the preceding century…We have only a handful of centres for modern cardiac surgery, organ transplantation, and the treatment of renal disease: we are lagging in these investigative fields. Nor can we offer our patients the benefits that have already accrued from the United States' vast investment in clinical research in these rapidly developing areas of medicine".
I can assure your Lordships that such views are widely felt, and that it would be quite wrong if they were not voiced in a debate such as this.
As has been pointed out in the Lancet, the Government's plans for new hospitals throughout the country have to be considered, not only in the light of the number that will be built in the next ten years, but also in the light of the number that will still continue to be occupied in their present deplorable condition. Those of us who have experienced the intense disappointment and frustration at the delays and cuts in hospital rebuilding announced a year or two ago may perhaps be forgiven if we are not quite so sanguine about the prospects for the future as the noble Lord, Lord Sorensen.
Then there is the problem of the increasing shortage of doctors. Here again the seriousness of the situation must be emphasised. In the Report of the University Grants Committee that has just been published, reviewing university development over the past few years, it was stated that there had been an increase in intake of students to pre-clinical courses of 21 per cent. over the five years to October, 1965. This figure, though, must be considered in relation to the annual net loss of British doctors due to emigration, which is equivalent to about one-fifth of the annual output of our medical schools. It is true that, according to a statement made by the Minister of Health in another place two weeks ago, there will be a further increase in the intake of students to around 40 per cent. for the seven-year period to October, 1967, but the evidence is that emigration is increasing also, according to a further statement made in another place this week.
This very day examinations are being held in London and Edinburgh for medical students and doctors who wish to qualify for hospital practice in the United States. A record number of candidates have notified their intention of sitting. As

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the noble Marquess mentioned, in Edinburgh there is a 100 per cent. increase over the 81 who sat the examination last September. It seems therefore that, in spite of all the talk, we have barely progressed from square one. As in the case of hospital rebuilding, it is the leeway that has to be made up that is a crucial point—a shortage that is reflected in the extent to which we are relying on doctors from the developing countries to run our Health Service, to which reference has already been made, and the appalling conditions of overwork with which many of our junior hospital medical officers have to cope.
In the Report of the University Grants Committee which I have just mentioned it was stated that the expansion referred to was in the main achieved by squeezing more students into existing accommodation and by duplication and triplication of classes. It was also stated that the possibilities of further squeezing up were virtually exhausted, and that the majority of medical school buildings were cramped, overcrowded and obsolescent, and a further increase in student numbers would require major building developments. No special funds were being made available by the Government for the medical schools. The Committee had, therefore, to resort to the General University Fund. So long as the building of new medical schools, and the modernisation of old ones, which are so urgently required, has to compete with all the other projects involved in university expansion, their needs will never be adequately met, and there does seem, therefore, an overwhelming case for a special grant.
The university medical school, with its additional responsibility for teaching and for the training of research workers, on which the whole of the research of the future must depend, has an essential and distinctive part to play. If, for any reason, it does not receive the financial support it should, medical research, as a whole, in the country must inevitably suffer. We are, in fact, still living, as far as research is concerned, on the products of an earlier age when the university medical schools were not suffering to anywhere near the same extent from the handicaps that they are now. The results of the present unhappy situation will only be fully apparent in the years to come. Al-
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ready, though, it is being reflected in some disciplines in a shortage of candidates of adequate calibre to fill important academic posts, and, in general, of research workers in many fields.
It is abundantly clear that the problem of financing the rebuilding and modernisation of our medical schools and ensuring that they receive an income adequate to meet their recurrent expenditure requires urgent reconsideration. These schools, after all, play an essential and fundamental part in our Health Service and must be considered in any review such as we are concerned with to-day.
Another very serious factor that must contribute to the shortage of doctors, and also to the lowering of standards, is the deteriorating position of the clinical teacher. I should like to dwell on this subject for just a moment or two. For a number of reasons, doctors are becoming less and less inclined to take up academic medicine. Professors and other senior members of staff find themselves more and more hard-pressed in teaching the increasing numbers of students, and, with an enormous service commitment of the investigation of patients, they have little or no time for pursuing their research work—and it was on their research record, as much as on their teaching ability, that they were appointed in the first place.
Then there are the inadequate facilities for research in most medical schools inherent in delays in rebuilding that I have referred to, and not least in the inadequate financial provision for research. Every medical school, of course, receives an annual income from university resources, part of which it is intended should be used for research purposes. For many years, though, money available for research has been steadily eroded owing to inadequate increases in its budget to meet rising costs due to inflation, increases in technicians' salaries, additional teaching responsibilities and so on. Many now, therefore, have nothing available for research, and some are running at a large deficit. Recourse has, therefore, to be made more and more to the Medical Research Council. This Council, which has done such splendid work in financing much of the medical research of the universities, is itself feeling the pinch. It has its own research institutes

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and units faced with similar rises in costs, and is becoming less and less in a position to help university needs as it has done in the past.
Charitable foundations and funds have also done much to help the universities in this difficult situation, but their support, like that of the Medical Research Council, is only on a temporary basis. Unlike the Medical Research Council grant, there is not even a guarantee that the university will provide funds for a project to be taken over if it shows continuing promise. Without the certainty that the research—which usually must be planned on a long-term basis, including the taking on of research and technical staff—can be continued, workers are becoming increasingly unwilling to apply for such grants. As a result, ideas become stillborn.
It is not possible, my Lords, to over-emphasise the depressing and discouraging effect this state of affairs is having on our academic medical scientists, and it is one of the main reasons why they decide to emigrate. The only solution is a more realistic assessment of the cost of medical research and the provision of an adequate, continuing and independent source of income to the university schools for this purpose.
While on this subject, I should like to mention a booklet which is being published next week by the National Fund for Research into Crippling Diseases, an organisation that has performed an outstanding national service in collecting funds from the public, which are very largely used to support university medical research. This publication, which is a record of the proceedings of a conference that was held last year, is entitled Medical Research—Whose Responsibility?, and is one that everyone who is interested in the problem should make a point of reading.
Yet another deterrent to entry into academic clinical medicine is the present disparity between the salaries of consultants in academic medicine and their counterparts in the Health Service, to which reference has been made in recent months in another place. In spite of the increases which have recently been agreed upon in the salaries of clinical teachers, this disparity has not been removed.
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My Lords, the subject we are discussing this afternoon is so extensive that no one speaker can touch on more than one or two aspects of the problem. I have concentrated on university medical and teaching research as it is one facet with which I am particularly concerned. It is also, as I have said, of vital importance to the whole future of the Health Service. I hope that the Government will take these criticisms in the spirit in which they are meant. We all have the same aim. In conclusion, the problem of putting our Health Service on a sound basis is vast and complex. As the noble Lord, Lord Auckland, has said, it involves a reassessment of our priorities with regard to national expenditure; our priorities within the Health Service, such as the extent to which we meet essentially present-day demands at the expense of those of the future; the elimination of waste from the Service, as the noble Marquess emphasised; and the promotion of efficiency. If the present debate can contribute materially to this end, it will have been abundantly worthwhile.
LORD PLATT: My Lords, may I make just a short intervention? I happen to be the chairman of the Clinical Research Board of the Medical Research Council. We give away millions of pounds, and a lot of it goes to long-term support of research. It is not correct to say that it is very largely on a short-term basis. I left the Medical Research Council in 1957 and rejoined it in 1964, and the enormous increase in the grants that we are giving was the first thing that struck me when I returned to it.
LORD STAMP: I agree with what the noble Lord has said. At the same time, I think he would agree that a tremendous amount of research cannot be carried out because of inadequate finance. I agree that the Medical Research Council is helping tremendously, but there is a limit to even what they can do.
LORD PLATT: I agree. I was only speaking for the Medical Research Council.
7.20 p.m.
LORD RITCHIE-CALDER: My Lords, I, like everyone else, am grateful to the noble Marquess, Lord Lothian, for introducing this discussion. I would draw

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your Lordships' attention to the fact that we are discussing the National Health Service. A great deal of emphasis has naturally been on the aspect of the national sickness service and the ways in which we can deal with ill-health. The Preamble of the World Health Organisation's Charters says:
"Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity."
One of the important things in the whole conception of the National Health Service, so far as I have been in any way connected with it—and that was while it was still a limited service in the 1930s—has been the emphasis on the Health Service, while the whole of the criticism has been on the sickness service, and quite properly. The object of the National Health Service is to secure health, but in all its work it has to cope with sickness and with the failures of our social efforts. Because we are certainly a long way from achieving complete "physical, mental and social well-being."
In this aspect I think lies the basis of a great deal of the criticism of the Service. Many of us feel—I am including myself—that there are aspects of the Service which are manifestly inadequate; and I am glad that the noble Lord, Lord Stamp, preceded me and emphasised the fact that a great deal of research and teaching of clinical medicine is probably inadequate. But I would not say—and I am glad that the noble Lord, Lord Platt, intervened—we are in fact starving medical research in any sense of the word. Whatever the priorities may be, the amount of work, as well as money, which is going into medical research is very substantial and is manifest in my own university. I have not done a national survey to find out what is happening in other universities, but I would say that at the moment the extent of research and its speed is something it would be very difficult for a national health, or a national sickness or a national medical service to absorb very quickly.
I know that, by comparison with what the National Institutes of Health in America are spending, what we spend in this country may be inadequate, but, by golly! (if I may use that expression in your Lordships' House) I would not compare the application of the Health Service in this country to what is happen-
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ing in the United States, where they are not absorbing the enormous expenditure which is in fact being spent in the United States National Institutes of Health. That is to say, the research is certainly not becoming available to the mass of people in America in the way in which we have, through our National Health Service, made our advances accessible to the people of this country.
We have only to consider this, which is the experience of many of us. I do not remember one single social evening I spent in the United States when the question of the cost of medicine in the United States did not come up. In every case—and I was not, I assure you, moving among the poor or the Medicare classes—these were people certainly in the upper middle-class bracket who were themselves concerned about how they could not afford to be sick. This is a preoccupation in America, in the way that the weather is a preoccupation in Britain. I personally go round the world boasting what I regard as one of the best of all Britain's achievements, and that is our National Health Service, without any question whatever. Except in some dug-out places, perhaps, in the United States, it is not even denied when I am going round that we have this Service as one of our great achievements. Indeed, in the social sense it is probably our greatest. I would follow the noble Baroness, Lady Stocks, in saying that education is important, but I believe that we can only educate on the basis of a sound and healthy population. Therefore this is one of the priorities.
One thing I would emphasise is this. At this point I am afraid I have lost my partner in the ritual dance—the noble Baroness, Lady Summerskill—but I would follow her to this point. I seriously believe, having been an author of a book on pharmaceuticals and the pharmaceutical industry—that we are in fact now in danger of getting "instant medicine". That is to say, owing perhaps to the pressure on the doctors, the general practitioners and so forth, they are over-prescribing to a degree which I think is quite wrong. I think we have probably stimulated drug-taking, in the sense of the habit-forming drug-taking, because of this over-prescribing.
The second point is that they (I use the word "they" pejoratively, referring

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to the bad doctors; the conscientious doctors do not do this) get rid of patients by giving them a certificate or a prescription to get them out of the surgery. I am quite certain, from my own direct experience in this matter, that in fact people are being given dangerous drugs with a lack of responsibility which is the measure of. I would say, a decline in our medical ethics—I do not want to be savage, because this is a reflection on a minority of a very devoted profession. But I agree with the right reverend Prelate, and with Donald Soper, that one of the most important factors in this business is a sense of vocation. I wonder how many doctors to-day have lost or sacrificed that sense of vocation.
I was brought up in a very curious way because I was a crime reporter in the slums of Glasgow, and therefore had a great deal of rather scarifying, dramatic experience, and I saw all that poverty and crime and malnutrition meant. But, my goodness! I did see devoted slum doctors, devoted to a degree that was utter self-sacrifice. I may say that I sat at the feet of one of them with a great deal of devotion because he was almost a Schweitzer of the East End of Glasgow. I listened to him. And now I hear complaints from doctors about the lay bouts in their surgeries; about people simply coming into them out of the rain or cold, people coming in malingering. I think of what it would have meant to him if he had had the opportunity, which he kept asking for, to see people in the early stages of disease, when he could diagnose and treat. He would never have thought of anyone who came to see him as a lay-about or a malingerer. A malingerer to him was someone who had to be looked at because, if he was malingering, there was a good reason for it.
My criticism of the medical profession is that they are in their protests to-day conceding what has been admitted on both sides of the House to be the denigration of the Service—a Service which I regard as superb in every sense of the word when it comes to the measurement of what it ought to be doing. Here we have falsifying—we have plenty of it. There are the criticisms of how the Service works; there are ways in which we ought to improve it. But, my Lords, the Service stands above any other service
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that I know in the social services of the world.
7.28 p.m.
LORD SOMERS: My Lords, we have had an extremely interesting debate, and I am sure that everybody who has listened to it is very grateful to my noble friend Lord Lothian for having initiated it. We have had the benefit of a great deal of expert knowledge, and it would seem almost impertinent for a complete layman like myself even to speak on this subject at the end of such a debate. But there are just one of two things I should like to say.
I felt, when I was asked to join the list of speakers, that my knowledge—my inside knowledge—of the Health Service was so sketchy that I consulted a friend of mine who is a general practitioner in the Service, so many of my opinions will also be his. My first question was this: Are general practitioners overworked? The answer, of course, is that in some districts they are; in others they are not. It rather depends on the type of patients whom they have. Those in the better-off areas, the better educated, probably do not go to see their doctor unless it is absolutely necessary to do so, whereas those in the rather poorer, less well educated areas, will probably go on the slightest excuse. Therefore one has a variation. But on the whole my friend seemed to think that they are not too badly off.
At the moment, there is a ceiling of 3,500 patients, and we have heard from the noble Lord, Lord Sorensen, that for a population of about 50 million there are about 20,000 general practitioners. That works out at an average per doctor of 2,500 patients, which is quite a lot short of the ceiling. Here I would say that I agree heartily with the noble Baroness, Lady Summerskill, that something should be done to find a locum tenens so that a family doctor can get away for a holiday, and I was most interested to hear the system suggested by the noble Baroness, Lady Stocks.
My next question to my friend was: Are general practitioners underpaid? Again, my friend in the medical profession did not seem to think so, and I believe that this is largely due to the most ingenious system by which they are paid. In case any of your Lordships

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do not know how this works, I should like to explain it. They are paid in three bands—the first of 500 patients; the second of 500 to 1,500; and the third of 1,500 to 3,500. For the two outside bands, the smallest and the largest, they are paid 15s. per patient, but for the middle bands they are paid 25s. per patient. This is most ingenious, because one can realise what a beneficial effect it has for a doctor who, say, has 3,000 patients and is getting a little older and feels he wants to cut down on his work.
LORD BESWICK: I wonder whether the noble Lord will allow me to interrupt him? Perhaps I may say that I shall be dealing with a new system of payment which is already coming into operation.
LORD SOMERS: My Lords, I have heard that a new system is under consideration, but the system that is at present in operation has certainly made it possible for a man to take a partner and give him half his patients yet not lose a great deal of his income. I also asked my friend about patients having to wait before their case was attended to. He told me that there is a slight difference between surgery for acute cases and that for chronic non-urgent cases. The acute cases are dealt with promptly, but the non-urgent cases have to queue up in rather a long waiting list. I think that was pointed out by my noble friend Lord Lothian.
Another question which occurred to me was the fact that in the National Health Service there is no award for merit; that is to say, a poor doctor gets exactly the same as a very good one. Fortunately, in the medical service there are very few poor doctors, but my friend pointed out to me why this is the situation. Merit awards actually exist, so far as hospital consultants are concerned, because they are constantly under the eye of their colleagues, and it is well known in the profession who deserves a merit award and who does not. But who would be able to decide about the general practitioner? Nobody knows about his work except his own patients, and those patients probably do not know any other doctor, except possibly one other in the same partnership. So it is quite impossible for anybody to say whether or not a merit award should go to a general practioner.
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On the whole, my friend seemed to think that the present system was working well and was of great benefit to the community. There is, however, just one point on which both he and I agree, and I should like to bring it forward this evening. It has already been referred to by my noble friend Lord Auckland as a Party political matter, but I am not putting it forward as such: I am putting it forward purely as something which will benefit the community. I refer to the reintroduction of prescription charges. I earnestly hope that the Government will consider this, because their abolition has meant a loss to the Health Service of about £2 million a year, which could well be used for modernising hospitals, for building new ones and for research work and other things.
After all, my Lords, a prescription charge is not a great weight on any patient. If they happen to be chronic patients who have to get a prescription once a week, perhaps some system could be introduced so that they could be relieved of the charge. But to have to pay a shilling, or even a little more, every time one goes to the doctor for the prescription does not seem to me in these days of comparative wealth—or lack of poverty, shall I say?—to be a great burden; and it would do so much good. Throughout the debate we have heard of the difficulties caused by lack of money in the National Health Service, and it seems to me this would do something to improve the position.
LORD AUCKLAND: My Lords, may I just clear up one point about these prescription charges, since my noble friend has referred to them? My views on this subject are well known to the House, but I think in fairness I must again stress that within the ambit of the Health Service as a whole prescription charges do not form a very large part.
7.39 p.m.
LORD NAPIER AND ETTRICK: My Lords, I, too, should like to thank my noble friend Lord Lothian for putting down this Motion and for giving us the opportunity of having such an interesting and wide-ranging debate this afternoon. I should also like to add my congratulations to the noble Lord, Lord Platt, on his maiden speech—quite one of the best that I have listened to in over twelve

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years' membership of your Lordships' House. This is such a vast subject that I find it difficult to know where to start, and even harder to know where to stop. However, I assure your Lordships that I shall restrict myself to no more than 10 minutes. I should perhaps add that I am a complete layman on this subject, but it is a subject which fascinates me.
In my view, the National Health Service was conceived for a poor society emerging from the effects of a devastating war. It must surely be true to say that at that time no-one could have foreseen the rise in general affluence which has taken place over the past twenty years. However—and here I must disagree with the noble Baroness, Lady Summerskill, though I agreed with a lot she said—I believe that, due to a sense of general dissatisfaction with the Service felt among the members of the profession itself, the whole system could be in danger of breaking down. This must not be allowed to happen. The National Health Service, in some form or another, is now a vital part of our Welfare State.
I myself am certain that the main trouble stems entirely from shortages. I am advised that the ideal number of National Health Service patients for a general practitioner is about 2,000 to 2,500. The average figures to-day rise well above this. In areas like the Midlands and the industrial North they can be as high as 5,000 or more. In the rushed conditions under which he is compelled to work the average general practitioner has had to develop a kind of sixth sense, to know instinctively when to hand out a certain treatment and when to delve deeper. This is a form of instant medicine which doctors themselves naturally do not like.
If I may refer for one moment to the problem of hospital doctors, the United Kingdom still has, I believe, a very good name for medicine and surgery, and it follows that post-graduates come from all over the world to study and work in this country. They benefit, and so do we, and we are grateful to them for the services they give us. Nevertheless, it is this influx of post-graduates which is keeping the National Health Services hospitals operating—and, in some cases only just! What is going to happen in the not too distant future when many of these coun-
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tries will have developed their own postgraduate training? It seems to me that a large part of our supply of overseas doctors will dry up. Is it appreciated that about 50 per cent. of the total number of junior hospital doctors are from overseas, and that in some provincial hospitals the proportion is as high as 95 per cent? Doctors' messes or dining halls have been described to me as looking and sounding like a gathering of the United Nations. Moreover, this problem is not confined to doctors alone; it applies equally to nursing staff.
The public at large are, I think, basically unaware of the magnitude of the problem; and if they do know about it, very few seem to care. Contact with hospitals is usually rare, so the issue is not brought home to enough people at the same time to cause an impact. I believe that we are beginning to realise the dangers of the high rate of emigration. I am told that about 25 per cent. (I think the noble Lord, Lord Stamp, said 20 per cent., and he may be right) of the total output of our medical schools are leaving this country, and the signs are that this figure is on the increase.
Why is this? I believe that many general practitioners find the National Health Service too restrictive to-day. Abroad, they are given greater opportunity to practise medicine as they were taught it. They can reasonably expect to have fewer patients. Their earnings will undoubtedly be better than in the United Kingdom—though I am told that this is not in itself a major factor. As for the budding specialist, some see little future here, and let us not forget the ease with which a qualified doctor can find work overseas.
Much has been said about abuses, and I think that the activity of a small minority may have been given undue prominence. Nevertheless, people have been shielded from the costs by twenty years of free medicine, and, like everything free, it will tend to be abused and taken for granted. The doctor who genuinely tries to combat the demanding patient merely loses that patient off his list to another doctor who is prepared to acquiesce; this, in blunt terms, involves a loss of income to the conscientious doctor and a gain to the other sort. Generally speaking, even intelligent people are

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abysmally ignorant of the cost of medicine. A person has to be nearly forty to-day to remember having had to pay a doctor's bill. A whole generation has grown to adulthood with free medical services—all taken for granted. People consult their doctors over the most trivial things, things that their grandparents would hardly have bothered the chemist about. They get sunburnt on the Costa Brava and then ask for calamine lotion on the Health Service. I cannot help wondering whether the Service in its present form does not perhaps encourage an irresponsible attitude to health matters.
I should like for a moment to consider the appalling problem of hospital beds. A few months ago it came to my ears that a very old lady over 80, whom I have never met, and who is entirely dependent on her old age pension, had been waiting for close on two years for her eyes to ripen so that she could undergo an operation for the removal of cataract. Your Lordships will probably know that this operation cannot be undertaken until the sight has gone. About four months ago she was told that her eyes were ready; she was to all intents and purposes blind. She was then told that there were no beds available, and with the length of the waiting lists being what they are she was further told that it could well be two years before anything could be done. I was appalled. I pointed out that in two years' time this old lady might well be dead. Was this the best the Health Service could offer? Why should she have to wait for two years in total darkness just because she had not the where-withal to pay for private treatment? I laid the facts before her M.P., and I am glad to be able to tell your Lordships that as a direct result of his personal intervention in this case a bed was made available within 10 days, the operation was carried out successfully, and this old lady has had her sight restored. I mention this story only because I believe it to be right that people should be aware of the facts.
Where does the private patient fit into all this? He constitutes about one-fifth of the total consultations that the average general practitioner undertakes in a year. I will tell your Lordships, if I may, what I think the private patient is doing: he is simply buying his doctor's time, time to
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take a proper case history, time to examine and make a diagnosis, and time to explain. Where there is time things are not likely to go wrong, but where time is short and consultations are hurried things can go wrong, and if this happens the patient blames the doctor and not the system. Herein, to my mind, lies much of the reason for the medical discontent at the present time.
My Lords, whether we like it or not, I feel that medicine is now completely tied up with politics. Any improvement in the National Health Service is going to cost more money, and more money has got to come from taxes. Conversely, any modification towards greater personal responsibility for health and away from a totally comprehensive Service will involve greater personal expenditure. At the moment, the doctors are clay in the hands of the Health Minister of the day. They do not know their own minds. I am firmly of the opinion that some sort of financial arrangement between doctor and patient is essential. I entirely support the view of the noble Lord, Lord Snow, who, when writing in the proceedings of the Royal Society of Medicine, said that the doctor must become the patient's personal friend, like Dr. Cameron or Dr. Finlay. In the case of the less well off, money could be provided by the State to give to the doctor, but you immediately establish a personal relationship.
I hasten to add that I am not for one moment suggesting a system such as is in force in the United States, where treatment is dependent on the purse, and where a whole family can be ruined by medical bills. But there are countries where State supervised insurance schemes work very well indeed—Canada and Sweden, to mention only a couple. As we all know, membership of organisations such as the British United Provident Association are growing at a great rate. A wide variety of people, by no means all well-to-do, recognise the value of such schemes. Many firms insure their employees so that the necessary operation can be carried out at the most convenient time for all concerned, and not just when the name comes to the top of a long waiting list. There is, of course, absolutely no tax relief on such subscriptions.
During the proceedings in another place on the 1966 Finance Bill, the Party I

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support moved an Amendment which proposed that tax relief should be available to all who make payments to contractual medical treatment insurance schemes. The relief would have been broadly on the same rates as that now given for life assurance. The Government rejected the Amendment. I cannot for the life of me understand why. Do Her Majesty's Government appreciate that there are a very large number of people—I am told it could be as high as half the population—who would contract out of the National Health Service and make their own arrangements if their contribution to the National Health Service by way of tax and stamps were refunded, or suitable tax relief were granted? But naturally many cannot afford to support their own private case and compulsory cover. Can the Government really say that the National Health Service contributions give good value for money when compared with a B.U.P.A. type of insurance policy? I am not sure. I therefore ask the Government whether they will undertake to look at this whole problem again more sympathetically than they have done in the past.
This brings me to another point—and I have nearly finished. In my view, the total abolition of prescription charges was an example of perfectly genuine and thoughtful Socialism going off the rails. However, the Labour Party leaders in their wisdom decided that this was the right thing to do. I therefore have no hesitation in putting the further question now: What about the charges for dental treatment, appliances and spectacles? We were promised in the Labour Party Election Manifesto of 1964 that all these charges would be removed. Perhaps the Minister, when he comes to wind up, will tell us when the Government are going to take some action—or have they perhaps had second thoughts?
I have one final suggestion to make. I assure your Lordships that I have had no prior consultation with my noble friend Lord Lothian. We have both arrived at the same point completely independently. I believe that the medical profession as a whole desperately wish to be less tied to the State. Is there any reason why the Government should not create a Health Corporation—an independent one—something, perhaps, on the
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lines of the British Broadcasting Corporation? Psychologically, such a move could, in my view, be a powerful influence for good. Will the Government consider it?
7.52 p.m.
LORD GRENFELL: My Lords, the House will know of my interest in the National Health Service, in that I am Chairman of the Fountain and Carshalton Group of Hospitals, so kindly mentioned by my noble friend Lord Auckland. In passing, I should like to pay a sincere tribute to the officers and committee members of all hospital management committees for the way they look after their chairmen. They see that they work exceedingly hard, but they back them up in every way.
I have a few points to raise which are relevant not only to this debate, but I believe are of importance to the country as a whole. Some years ago the Ministry of Health asked us at Queen Mary's Hospital for Children to plan a psychotic unit to take primarily 20 and eventually 40 children. Plans were laid, and we were all ready to start building when the clamp came down and no money could be found for this unit. I am informed that this unit could be filled immediately if it were opened; and there is a sad demand all over the country for places for these unfortunate children, who are causing their families a great deal of distress.
Within this group also comes the autistic and the mentally disturbed child. I have knowledge of the first through a school at St. Ebba's Hospital at Epsom and a home at Banstead run by the Invalid Children's Aid Association for autistic and non-communicating children. We have at St. Mary's a ward for mentally disturbed children. It is difficult to understand why these children suffer in this way, as many of them have a high IQ; but it seems that some shock in early youth, such as the loss of a parent or a breakup in the family, may be one among many other factors causing the child to become non-communicating and withdrawn from his or her fellow beings.
The treatment is difficult and expensive, as a vital link of confidence has to be forged between teacher and child in order to make a breakthrough which precludes

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large classes and requires a high teacher-student ratio. It is not only the lack of facilities during school age which is so disturbing, but there is the fact that when the child reaches school leaving age, having shown some improvement, there is nowhere for him or her to go except back to the family which, maybe, was the original source of the trouble. Hence, the last stage of that child is worse than the first.
I have urged time and time again—and here I walk with Lord Soper—that the situation regarding hostels and sheltered homes for all types of mental disorders should be carefully considered. Under the Mental Health Act the provision of these is laid at the door of the local authorities, and I have now come to the conclusion that this was a mistake. The requirement for hostels in our country is so widespread that it has become a national problem and, as they require to be residential, I believe that the responsibility should be transferred to the Hospital Service. I could clear a lot of beds at Queen Mary's Hospital, Carshalton, and at St. Ebba's Hospital, Epsom, if hostels were available; and hence I could bring in more young patients from my waiting list, which is sadly long. All these patients are, of course, at home and, being severely abnormal, are a great tie on the family.
I talked over this question with my noble friend Lord Macpherson of Drumochter, who cannot be present today and who, the House will remember, told us he had a brain-damaged child. We came to the conclusion that a number of cottage hospitals which, if the rumour is true, are likely to become redundant, would be ideally suited as hostels where care and treatment could be given to all categories of mental disturbed and mentally subnormal persons, who cannot return home and who are unable to take their full place within the community. For these people the situation is urgent, and I hope that Her Majesty's Government will give careful consideration to my request.
There is one matter of hospital financing which I feel needs definite clarification. Again this was touched on by my noble friend Lord Auckland. I have given the noble Lord opposite notice of this question. Hospital management
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committees, through the Regional Boards, are given a sum of money yearly for the purpose of financing the day-to-day administration, apart from the capital expenditure which is financed by the Board. In my group the amount is in the region of £1·8 million a year, and I believe that the House will agree that this sum is comparable with the turnover of a reasonable business, and the spending of this is a large responsibility for the chairman and members of the hospital management committee.
It will be appreciated that any firm would wish at the end of the year to put money to reserve should this be possible, and there can be no doubt that this is sound policy. But for some reason we in the Hospital Service are not allowed to do this, and if we are under spent at the end of the year we are unable to carry this money over to the next year; in fact, the money is forfeited. I know that the official answer will be that money is allocated on a yearly basis. But as stocks can be carried over, surely we should be able to carry over money for such things as maintenance on buildings. We have got this half done, and we should be able to carry that money forward.
As this is the policy, there is an inevitable temptation at the close of the year to spend money quickly. I believe that if we were able to carry this money over it would assist us greatly in major schemes of maintenance which are vital to the long-term efficiency of any hospital. I am not saying in any way that we shall always be under-spent, but it would be a great incentive to chairmen and committees if we could feel that any money saved by good husbandry would be available to us in the next financial year for urgent requirements. I hope that the noble Lord will not only give some consideration to this, but also give us the reasons for this procedure, which I believe is detrimental to the Service as a whole.
I now turn quite briefly to the subject of nursing. The General Nursing Council at the moment lay down that should a student nurse take general nursing she does a course of three years, and should she decide after that to take up psychiatric nursing she will have to do another 17 months' student course in order to qualify. In view of Ministry

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policy, it would appear that there would be great value in being able to switch nurses from one side to the other, should this be desired. From my experience there are many who would like to take up psychiatric nursing but who are deterred by the extra time as a student nurse; and I believe that this is also true if the wish of the student nurse is to move from psychiatric to general nursing. I am convinced that it would be of great value to the Health Service if the General Nursing Council could devise an initial course which would combine the two, and hence have nurses who would be qualified in both categories and could take up nursing on either side at their will. I hope that Her Majesty's Government will consider this with the General Nursing Council, as I am sure that it would be of great assistance to the nurses and to the groups which have mental and general hospitals under their administration.
Finally, may I make another plea, as I did when I initiated the debate on the Mental Health Act, for honours for medical, nursing and other hospital staff who have given a lifetime to caring for the sick? I went through the last New Year's Honours List and I saw only one sister who had been honoured with a decoration. I am still of the opinion that such a gesture to the hospital staff would be a wonderful morale-raiser, and, after all, would cost only the price of a medal.
8.4 p.m.
LORD BESWICK: My Lords, may I first reiterate what has been rightly said about our indebtedness to the noble Marquess, Lord Lothian, for making this useful debate possible? I personally speak with a real sense of humility because I know so comparatively little about a subject on which so many who have spoken know so much. The debate has ranged widely, and about that none of us could complain. However, it means that I cannot possibly answer all the points which have been raised; but I confirm that comments and criticisms will be carefully studied, not only by myself but by those who have high responsibility for these matters in the Ministry of Health.
Several noble Lords and the noble Baroness, Lady Brooke of Ystradfellte, paid tribute to the officials of the Ministry of Health. I myself should like
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to take this opportunity of saying that within the short time I have had association with them I have come to admire very much the keenness and the zeal they show for the National Health Service. May I also express appreciation to the noble Lord, Lord Amulree, for his kind words about my right honourable friend the Minister of Health. I thank him all the more because I know that those references are so justified.
I should like, at the outset, to join with others in congratulating the noble Lord, Lord Platt, on his maiden speech, and to echo the words of the right reverend Prelate in saying how fortunate we have been that the noble Lord was able to make his maiden speech in this debate, having to his credit, as we all know, such a long history of service to the profession and to the Health Service. We greatly look forward to further contributions from the noble Lord, not only on this matter but on any other subject on which he seeks to address the House.
I want to deal particularly with the future of the Health Service, but before I do so I should like to pay my tribute to what has been done in the past. It seems to me that sometimes we have been so busy in spurring ourselves on that we have scarcely time to stop and see how much ground we have been covering. Several noble Lords, among them the noble Lords, Lord Platt, Lord Amulree, Lord Cohen of Birkenhead, the right reverend Prelate, and my noble friend Lord Ritchie-Calder, with their knowledge of these matters, have told us, in what I thought were inspiring terms, about what had been achieved. But, as I say, I want to deal with the future.
First I would claim that, far from facing collapse, we are now poised for a great leap forward in the National Health Service. The noble Marquess, Lord Lothian, and others, have discussed in general terms the alleged excessive cost of the Service and have spoken of waste. Certainly total costs are high, but, as my noble friend Lady Summerskill said, they are not high in relation to the service given or in proportion to our national resources. I am not quite sure what line the noble Marquess took on this, and I should not like to argue on an election platform that we should devote a smaller proportion of our national resources to our health services. No doubt some waste

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can be found, but this is true in any large organisation. My case, however, is that we get increasingly good value for money spent, and I will seek to substantiate what I say.
First, there is the more intensive use of hospital beds. Leaving aside psychiatric and long-stay beds, the average stay of a patient in hospital has droppen by almost one-third in 10 years, from 18 days in 1955 to just under 13 days in 1965. The trends towards a shorter stay in psychiatric and long-stay beds are similar. The annual number of patients treated per bed has increased by just over one-third in the same 10 years. Improved management has been a contributory factor to this, as well as new medical techniques, equipment and materials, including of course the use of drugs. Additionally, a considerable and growing proportion of hospital capital has been devoted to improved diagnostic facilities, such as pathology and X-ray.
Significantly, over the last eight years the cost of treating an in-patient for the total length of his or her stay has actually fallen in real terms. I recognise that it might be more economical in some cases to spend more intensively to secure an earlier successful outcome of treatment. But if we take this reduction in cost, together with improved quality and sophistication of treatment, I think we can claim that there has been a real improvement in efficiency in the hospital services.
Secondly, the Ministry of Health has made a special study of the question of food costs in hospitals and has consequently been able to advise authorities about the cost of provisions and standards of catering for patients and staff. This has already yielded results. Thirdly, improvements have been made in costing systems which will give hospital management more useful data about running costs. This additional information, providing as it will a better basis for management decisions, should enable these complex units to be administered with even greater efficiency.
As resources increase for hospital building new techniques are being used to ensure extra value per pound spent. All the hospital buildings in this country are now planned and designed within a framework of national guidance. Rooms
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and spaces, and increasingly equipment too, are designed to a common dimensional pattern. There are national standards of provision and costs for all but a few of the individual departments of the hospitals. My noble friend Lord Bowden the other day was telling us—almost taunting us—about pioneer work carried out in this field by the Defence Department of the United States. In this country the pioneering work has been done by the National Health Service.
The noble Lord, Lord Auckland, and the noble Lord, Lord Grenfell, referred to the difficulty of managing the financial affairs of hospitals within a national budget. They were particularly concerned about capital expenditure on hospital buildings and equipment. The point here, of course, is that the hospital building programme is financed from money voted by Parliament, but I recognise that difficulties arise on occasions when expenditure on individual building schemes fluctuates. I sympathise with the hospital authorities who find it difficult to match their targets each year. I cannot give any undertakings on this matter, but the Ministry of Health are aware of the problems and are exploring the possibility of applying some other form of control to the hospital building programme, consistent, of course, with the Parliamentary accounting system.
Clearly, it is not only important to get the most efficient buildings; their efficient use is also vital. Here the training of managers and supervisors is being practically encouraged. There are over 500,000 people working in the Hospital Service. If they are to do their work effectively, and to find satisfaction in it, the Service can neglect no opportunity to help in the development of their talents for supervision, management and organisation at every level. Increasing attention is being paid to staff training. There are experimental management courses provided by the Hospital Administrative Staff College of King Edward's Hospital Fund and by the Nuffield Centre for Hospital and Health Service Studies at Leeds University. Both of these courses have been running for some time, and the National Staff Committee will shortly be publishing details of revised recruitment and management development schemes for the Hospital Administrative Service. The

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Salmon Committee, as the noble Marquess said, made some important and valuable recommendations on management training for nursing staff, and the implementation of these will be a matter for a statement which the Minister of Health hopes shortly to be making.
The noble Lord, Lord Platt, made a modest reference to his Report—a Report which was referred to the other day as being the "Bible of the Department" in these matters of hospital staffing structure. In that Report, and again this afternoon, the noble Lord recommended strongly that the doctor who followed his year as a provisionally registered houseman by engaging in hospital work for a further period, would usually become a better doctor and be better fitted for whatever branch of the profession he might ultimately serve. The current discussions with the profession will fully cover the point which the noble Lord has made in the Report and again to-day.
The noble Lord also referred to the opportunities for general practitioners in the Hospital Service. Negotiations with the profession are nearing completion on the pay and conditions of general practitioners wishing to undertake part-time work in the Hospital Service. Discussions between the Minister and representatives of the professions began on December 19 of last year and still continue. I cannot anticipate the outcome, but I can say that they cover a very wide field (including the subjects of overwork, married quarters and time off duty). These negotiations concern all grades of hospital medical and dental staff, as well as the problems associated particularly with the junior grades of staff. The importance attached by the profession to ensuring that the interests of the junior doctors are kept to the fore is underlined by the fact that four of the negotiating team of nine appointed by the profession are themselves doctors in the training grades.
I should like to say a word about what is euphemistically called in one of my briefs "the work load of hospital doctors", which might very well be called the work over-load. With every year the volume of work in hospitals seems to increase. It may be measured to some extent by the actual figures of hospital patients, although they in themselves do not reflect, as the noble Lord,
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Lord Platt, said, the increasing burden falling on hospital and other professional staff due to the increasing complexity of medical care. Obviously, it is in the interests of us all that the hospital doctors, particularly those resident, should have time not only for rest and recreation, but for study and other professional activities. Particularly in the junior grades, there is a special need for time to prepare for higher degrees. There ought to be within the reach of every doctor a centre of post-graduate activity. Since 1964 this has been recognised as an essential feature of the Hospital Service, and much welcome development has already taken place.
The noble Lord, Lord Amulree, rightly spoke about the importance, so far as hospital staffs were concerned, of having suitable residential accommodation. To-day, in all the new hospitals under construction, we are building good accommodation for single doctors, and married quarters are being provided as a matter of course. In existing hospitals, Boards and hospital management committees have been urged to do everything they can to improve and to expand their present accommodation for young doctors, and wherever possible for their wives and families. We have to face the fact that these older hospitals are especially difficult to bring up to modern standards, but efforts are being made to provide more residential accommodation for married doctors by adaptation of existing premises and by acquisition of houses and flats.
The noble Lord, Lord Amulree, also referred to the cost of meals to the junior hospital doctors. As he knows, the new charges stem directly from the report of the Review Body on Doctors' and Dentists' Remuneration and were agreed in detail with the profession. The Review Body made it clear that their recommendations on pay assumed that these new principles governing meal charges would be observed. Pay has now been increased from October 1, 1966, with substantial increases for junior doctors. Charges for meals are 1s. for tea, 2s. 6d. for breakfast and 3s. 6d. for midday and evening main meals. I do not think that these charges can be considered excessive. Doctors required to be resident pay less for board and lodging than before, since their lodging will be free.

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For the voluntary resident, the new charges for accommodation are less than the previous all-in charges, although I agree that charges for meals could resultin a net increase in payments for meals and accommodation together, depending on the number of meals taken in the hospital.
The noble Marquess was, I thought, especially gloomy when he discussed the position of the general practitioner. The truth, I would say, is that there is an entirely new spirit of expectation among the general practitioners to-day. Since the British Medical Association produced their charter for the family doctor service in March, 1965, discussions between the Government and representatives of G.P.s have continued virtually without stop. They have been marked by the publication of three reports of the joint discussions, by the report of the Review Body on Doctors' and Dentists' Remuneration, by the passage of a new Act of Parliament, and by amendments approved by Parliament to the regulations and terms of service which apply to general practitioners. This of itself, I should have thought, would merit the kindly words which have been expressed about the activities of my right honourable friend, especially when one realises the economic climate in which he has had to operate.
The purpose of these negotiations, as I ventured to put to the noble Lord, Lord Somers, has been to provide a new contract for the family doctor, and to help him make the best use of his time and skill for the benefit of his patients, as well as for his own satisfaction. The new contract has introduced a new system of payment, designed to take into account the differing circumstances of individual doctors and to encourage various features of general practice. The old system was based almost entirely on capitation payments, giving the doctor no encouragement to develop and improve his practice except in terms of the size of his list of patients. The new system, whilst still retaining an element of capitation, is much more refined and, inevitably, more complicated. There are higher capitation fees for elderly patients, and there are special payments for visits made to patients at night and for items of service representing public policy—vaccinations and immunisations and the taking of cervical smears. There are additional
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allowances for practising in groups, and for practising in areas which have been seriously short of doctors for years. For the younger doctor there are payments if he has undertaken certain preparatory training for general practice, and there are payments increasing in amount as the doctor devotes more years to general practice.
For all doctors with a list of patients above a minimum size there is a basic practice allowance which recognises the basic obligations and other expenses in looking after a practice. All doctors are now to have the rent and rates of their practice premises fully reimbursed, and up to 70 per cent. of the salaries of their ancillary staff, such as receptionists and nurses, is to be repaid to them. A scheme of outright grants from the Government is available towards the cost of improving practice premises, and the General Practice Finance Corporation, which was set up for the purpose of facilitating this, will be making arrangements in order to implement it before very long. The present-day family doctor is thus practically encouraged to provide modern practice premises and to employ supporting staff to relieve him so far as possible of non-medical work. He is encouraged to practise with colleagues in groups so that he can have relief from the continuous responsibility for his patients and can enjoy periods when he is not on call. And there is some measure of recognition of the particular services he provides for his patients in the payment for night visits and for some items of service. I shall be extremely pleased to discuss with my noble friend Baroness Summerskill just how far these changes go to meet the very proper points which she put forward about the present difficulties of the general practitioners.
Not all these changes may appear very significant in themselves, but in total they represent the first major review of the doctor's contract in the National Health Service since 1948—or, indeed, since 1911. The immediate purpose of the changes is to help the doctor, but in doing this, and in giving him a greater satisfaction in his work, they provide an improved service for the patient. I was greatly interested in what the right reverend Prelate said about the motivation of service, and I can only quote

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the words of a general practitioner who lives in my street, who said to me this morning, "It is now up to us". I hope that, now they have this new charter, the doctors will in fact accept the challenge to serve which is posed to them in the terms that are now agreed.
Dentists have not been forgotten in the present series of discussions. Indeed, a Working Party of officials of the Health Departments and representatives of the British Dental Association, set up after a series of discussions, begun in January, 1966, recommended a number of changes in the administration of the general dental services. As a joint report of these discussions is to be presented by the Association's representatives to the General Dental Services Committee next Friday, your Lordships would not wish me to anticipate the Committee's consideration of the report by giving details of the proposed changes to-day. I can say, however, that, although the changes are in no sense revolutionary, they are regarded by the members of the Working Party as a useful step in the evolution of the general dental services.
In a number of ways, therefore, there are prospects of considerable improvement in the conditions under which doctors work in the Health Service. None of this will solve our problems, of course, unless new doctors continue to come forward. In passing, I should just like to say that I do not accept the arithmetic of the noble Lord, Lord Stamp, about the extent to which emigration will upset the entry of new students into the profession. I think that when the effects of these new changes become apparent we shall have to see just how great is the difference between those coming in and those who may, for their own good reason, still want to leave. But I agree with him that if we are to seek to improve the service, if we are to keep up the level of the number of doctors, we must have sufficient places in the medical schools. There is no shortage of applicants for places: the principal bottleneck is the shortage of places themselves.
The University Grants Committee have already taken steps to increase the annual intake of British-based pre-clinical students from 1,788 in 1960–61 to about 2,360 in the autumn of 1966.
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This increase will be reflected in increased output over the next five years. The University Grants Committee are providing for medical school expansion which will increase the annual intake of pre-clinical students above the October, 1966, figure of 2,363 by about 340 in the next four years. In addition, a new school at Nottingham, to which reference was made, will provide for a further intake of at least 160. The Royal Commission on Medical Education is giving close attention to the question of medical manpower needs.
The noble Lord, Lord Amulree, has referred to disabled persons who need nursing care and treatment to maintain their existing physical functions. The majority of such persons would almost certainly be the responsibility of the hospital service and would fall within the category of the younger chronic sick. Some special units for these patients already exist, but my right honourable friend is at present arranging to carry out a survey on a national basis of the younger chronic sick in hospital, and when that survey is complete he will consider what further guidance he might usefully give to hospitals about their care.
Where the need for continuous nursing care is not essential and it is not practicable or desirable for the handicapped person to live at home, it would fall to the local welfare authority to provide, either directly or by arrangement with a voluntary body, suitable accommodation. The authorities already accommodate many severely handicapped younger people. Their plans for the next ten years include 50 small homes specially for this group, and these are now beginning to come forward. But it is not enough to seek ways of providing for the chronic sick in hospitals and residential homes. The proper place for anyone is his own home, if he wants to be there and if the services he needs can be provided there. In this matter I am sure we must all pay special attention to what was said by the right reverend Prelate the Bishop of Lichfield.
The right reverend Prelate asked me about the possibility of giving evidence to the Committee independently appointed by the Central Health Services Council. If the Churches wish to offer the Committee evidence relevant to their task,

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there seems no reason at all, so far as I can see, why they should not do so. Possibly the right reverend Prelate might himself care to approach the Committee and offer to give evidence. With regard to the other points which he made about the chaplain service, possibly I can write to him about these.
My noble friend Lord Sorensen has already referred to the development in the community health services. Satisfactory as is the development up to the present time, I agree with the noble Baroness, Lady Brooke of Ystradfellte, that there is clearly a need for a great deal of development and expansion in the future. On this we have the encouragement and hope offered by the latest revised plans of the local health authorities covering the period up to 1975–76 and published as Cmnd. 3022.
The latest version of the local authority 10-year plans clearly looks forward to a substantial measure of expansion. For staff employed to give personal services in the home and in the ambulance service, the planned increase is from about 68,000 in 1965 to about 94,500 in1975—an increase of almost 40 per cent. On capital investment the plans envisage a total expenditure on health projects of nearly £167 million over the 10 years. There is in addition planned expenditure of £178 million on welfare projects (mainly residential accommodation for the elderly). The figures I have given for staffing and capital investment, I think the noble Lady will agree, augur well for the future.
There are two particular topics I should like to say something about in looking to the future of the local authority services. First, the community services for the mentally disordered. A substantial number of places in centres for teaching the mentally handicapped have been provided, but there is still a considerable need for more places, especially for adults. Local authorities'10-year plans go some way towards meeting this need, though not in every case as far as we would wish. The Training Council for Teachers of the Mentally Handicapped of which the noble Lord, Lord Grenfell is a member, will we hope continue to promote the provision of training for the staff of these centres. More residential
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accommodation will be required. Helpful, too, will be the continued development of a more enlightened public attitude towards mental disorder. I was moved by what the noble Lord, Lord Grenfell, said on this subject. I am sure that what he said will be carefully studied.
The other topic on the local authority side which is of special importance for the future is that of co-operation between general practitioner and local authority services. The greatest scope for this, perhaps, is in the support which the local authority nursing services can give to the family doctors.
Nursing and medicine in the community are moving steadily closer together. This accords with the hopes expressed by many speakers in this debate. Already in many parts of the country local health authorities and general practitioners are co-operating in experimental schemes under which local authority nursing staff are closely associated with group practices. It is widely recognised that patients within the family are best served by a team, led clinically by the doctor, and including local authority skilled staffs and experienced in community nursing. The concept of the community medical and nursing team is a most encouraging development, and the means by which it can best be implemented are under consideration in many areas.
Health centres, of course, are a particularly valuable way of facilitating local authority family doctor co-operation, and the new and growing interest in health centres has exciting implications for the future. Indeed, progress has been considerable. By 1964, only 21 health centres had been opened. But in the two years since then 9 more have been opened; 13 more are being built; plans have been approved for 27, and 30 more are under active consideration. All of us here are, I know, interested in the provision of modern, first-class medical care in the community. To achieve this objective, we need the active participation of keen, forward-looking general practitioners backed up by excellent facilities such as those now being provided in health centres. The large number of health centres now being planned reflects the growing readiness of the general practitioner and local health authority branches of the Health Service to work

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together to their mutual advantage and for the benefit of the local community. The latest plans of local health authorities envisage that nearly 300 health centres will be built by 1976. This is a development which we warmly welcome and wish to foster.
The subject of co-operation between local authorities and family doctors brings me naturally to my final topic. It is true that the National Health Service has a tripartite structure. But each of these parts of the Service has close connections with the others, and within the present tripartite structure, co-operation has been growing and new forms of organisation of services have emerged. Nevertheless, I would not myself seek to argue that when our predecessors legislated for the pattern of the Health Service, over twenty years ago, they got the right answer for all time. It would be remarkable if they had. I think my right honourable friend the Minister of Health would like to keep an open mind on this question of whether, or when, there might be reconsideration of the administrative structure. Certainly more could yet be done by better arrangements for co-operation and co-ordination between authorities, both of long-term plans and day-to-day operations, and there is scope for experiment in new patterns of organisation of services, and a great deal of research is going on in this field. Moreover the structure of local government, with which the hospital and family doctor must closely co-operate, and through which an important part of the health and welfare services are administered, is being reviewed by Royal Commission. I know that my right honourable friend will study with care not only the implications of all these reviews but also the suggestions that have been made to-day.
My Lords, I am sorry we have transgressed into the late hours, but I have endeavoured to describe some of the problems and opportunities that lie before our National Health Service. There is nothing here for despondency and everything for hopeful confidence and resolution. The debate, I hope, will press those concerned with the National Health Service to still further achievement. I thank again all noble Lords who have
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taken part in this debate. I should like to think that we can send out from here, despite all criticisms, a message of good wishes and thanks to all those who serve in the National Health Service; to those in the operating theatres, in the hospital wards, in the surgeries and the clinics; to all from the Minister down (or up) to the humble porter who pushes the trolley along the hospital corridors; and to wish them well in the services they give to us.
8.39 p.m.
THE MARQUESS OF LOTHIAN: My Lords, at this hour I do not intend to add anything further to what has been said, except to agree with the noble Lord, Lord Beswick, that I think this has been a valuable and useful debate. Its greatest value has been to show the real depth of feeling and concern in all parts of the House for the future well-being of the National Health Service. I think this is a matter of great encouragement. I should like to echo the noble Lord, Lord Beswick, in hoping that this message will go out to all those who are working in the Service.
I should like to thank all noble Lords and noble Ladies from all sides of the House who have spoken and I should like, particularly, to add my tribute to the others concerning the maiden speech of the noble Lord, Lord Platt, whom I hope we shall hear again on many occasions. I should like to thank the noble Lord, Lord Beswick, particularly for winding-up in such a comprehensive manner. I think that if he reads my speech to-morrow morning he may find that it was not quite so gloomy or unconstructive as possibly he thought. However, he has to some extent comforted me, although he has not yet entirely convinced me. With that, I beg leave to withdraw my Motion.
Motion for Papers, by leave, withdrawn.

EXPORT GUARANTEES BILL
Brought from the Commons endorsed with the Certificate from the Speaker that the Bill is a Money Bill, within the meaning of the Parliament Act, 1911; read 1a, and to be printed.
LOCAL GOVERNMENT (TERMINATION OF REVIEWS) BILL
Brought from the Commons; read 1a and to be printed.

PROCEDURE OF THE HOUSE
Fourth Report from the Committee: made, and to be printed.
House adjourned at twenty minutes before nine o'clock.