PRESCRIPTION CHARGES AND MEANS-TESTED BENEFITS

HL Deb 07 July 1971 vol 321 cc1001-43

Debate resumed.

4.8 p.m.

LORD BURNTWOOD

My Lords, I now address myself to the matter of health, within the scope of the Motion before the House. I should have liked to mention various other matters in regard to the National Health Service and provision for health in this country. For instance, there is a need to bring before the attention of your Lordships the increasing anxiety by patients who feel that on being taken to hospital they lose contact with their general practitioners. I believe that the whole system of the somewhat unwieldy, though technically very efficient, district general hospitals may have to be modified sooner or later in favour of smaller hospitals under G.P. control. However, I now want to address myself to the first point in the Motion; namely, the question of cost-related charges for prescriptions.

I am second to nobody in admiring the courtesy and efficiency with which the noble Lord, Lord Aberdare, deals with these questions in the House, so I hope he will not take amiss what I am about to say. In any case, he has more than his fair share of charm. But I felt absolutely outraged by his speech this afternoon, for in essence his remarks about means testing in general, and more particularly about cost-related health charges, seemed to me to be so extreme and reactionary that I was as surprised about his remarks as I was about the original proposal on cost-related charges which was made some months ago by the Government. I do not want to spoil what I wish to do, which is to deploy what I think is a good case against the proposition, by exaggeration, but I am bound to say that if in one hundred years' time people read the noble Lord's speech they will react in much the same way as students of history now react when they read the Reports of Royal Commissions of 140 years ago on the employment of women and children in industry.

I feel that this proposition is outrageous; and I am most surprised at one particular omission in his speech. The noble Lord concentrated I think exclusively (though, of course, I should like to read his speech again) on the economic side of public finance in this matter. There was no enlargement that I detected in his speech on the question of the ethical considerations which should be given to this whole question. Indeed, when I first read about this proposal for cost-related prescription charges I thought it was a sort of sick political joke, and I do not think your Lordships can underestimate the sense of shock with which this idea was received by those of us who have had the Health Service much in our minds over the past 20 to 25 years. I speak with some feeling, because I think I am one of the only two Members in either House who were members of the Committee which in fact saw through the passing of the original, principal Act which established the National Health Service. Be that as it may, the only thing I do not find surprising about this is that the idea, the ethic of it, should be promulgated, if possible, or probably, by this Government. After all, the penalising of the weak and the sick has already been established on the justification that by reducing increased revenue in that way more money can be available for building what one might describe as the hardware in the provision of health facilities for this country.

But, my Lords, the Hinchcliffe Report of 1959 went into this question in very great detail. In point of fact, that Report was engendered by the Conservative Government of the day, and I am very surprised that the findings of that Report should even be questioned at this stage. If I may remind your Lordships, the arguments were deployed for instituting cost-related charges. It was said, for instance, that the patients would no longer want their doctors to prescribe extravagant quantities, since the larger the quantity the more they would have to pay. Nor would doctors be subjected to pressure from patients for necessarily expensive medicines. I do not want to go too far into the ethical question, because I see that there are distinguished members of the medical profession present to-day, and I hope that they will and I count on them to do so—object to the ethical concept of charges, which in point of fact will amount to paying for good health by the purse. But the Hinchcliffe Report threw out the idea of cost related charges, and cited the sort of results which would ensue were they so enforced. There were four main, principal objections, and I will mention the first two: A doctor might refrain from prescribing the more effective cure because it was expensive, or a patient might not present for dispensing an expensive prescription which a doctor might have given him. Those needing very expensive drugs would be hardest hit ". The Report went on: The collection of a percentage charge by the pharmacists would impose an extra burden on them. They would have to work out the cost of every prescription. This would be much more onerous than collecting the shillings ", as they were then, in respect of charges. Moreover, the amount of the charge would be liable to be challenged by patients ". My Lords, prescription charges were bad enough, and I readily discard in the direction of Lord Aberdare the fact that it was the amending legislation of 1949, under the Labour Government, which ever permitted health charges to be made. I accept that. Many of us have been extremely upset and aggrieved that they were subsequently implemented by both Parties. But this is an entirely new concept. The administrative difficulties which have been submitted to the Minister by the chemists—the difficulties in administration not only in the actual dispensing, but the arguments which will follow with patients about the actual charges which are to be made—almost pale into insignificance against the picture that one can conjure up of patients not in the exempted classes, such as old people and young children, but the vast mass of the population, who are in fact in the very low income groups. Drugs nowadays tend to be much more expensive in the first few years after their introduction. Drugs which deal with high blood pressure and matters of that kind, which are extremely expensive, have to be used in large quantities by the lower income groups. They do not come under any provision for exemption; and I think that the whole idea that people should be penalised in this prescribing of medicines is, as I say, intolerable.

LORD ABERDARE

My Lords, I am sorry, but would the noble Lord allow me to interrupt him? He has not mentioned, of course, that there is a ceiling and there is a passport scheme, so that these vastly expensive drugs would not necessarily fall in their entire cost on anybody.

LORD BURNTWOOD

My Lords, it is more than probable that I have missed something announced in the Press. At the same time, when this matter was last raised in another place, in answer to a Question by Mrs. Shirley Williams, the Secretary of State said, in effect, that he had not really made up his mind but that he was engaged (it was some obscure language he used) in a dialogue on this matter with the interests concerned. If there is to be a ceiling, I am glad to hear it, although I comprehend from that intervention that these cost-related charges are now going to be enforced.

LORD ABERDARE

I am sorry to interrupt again, my Lords, but in my speech I said that we were still talking it over with the professions.

LORD BURNTWOOD

So we are now left with the position that, if they are to be introduced, there will be a ceiling?

LORD ABERDARE

Yes.

LORD BURNTWOOD

So we are making a little progress here. Nevertheless, the fact is that if these charges are to be introduced into our National Health Service procedures there will be a sense of public disquiet that a rich man can receive expensive and effective medication because he can afford to pay for these newly-developed drugs, while a postman, for instance, who does not normally come under the provisions for exemptions, will have to do with second best. Now this is a concept which is quite contrary to the original idea of the National Health Service, and I hope that the Government will have another think about it. Indeed, I had thought that, when the original, spontaneous objections were raised to this idea, the Government would gracefully withdraw, but I understand from the last statement which I have just quoted by the Secretary of State, and now the intervention by the noble Lord, Lord Aberdare, that it is still on. I can only say that there will be a great deal of trouble about this. We on this side of the House have struggled against any idea of exemptions per se. We believe that, according to the original concept of the National Health Service, health should not be a matter of any form of financial entitlement.

So, my Lords, I ask the Government to please reconsider this matter. The cost of drugs nowadays to some extent reflects the increasing cost in basic research. We all know the history of cortisone, the antibiotics and the new medicaments for possible conditions of cancer. I leave it to the members of the medical profession in the House now to deal with that. But the whole thing is so absolutely contrary to modern ideas that I ask the Government to reconsider the matter most urgently.

4.20 p.m.

LORD AUCKLAND

My Lords, owing to a long-standing engagement at New Zealand House this evening, I must apologise to the noble Baroness, Lady Phillips, to my noble friend and to the House for the fact that I may not be able to stay until the end of the debate. The noble Baroness need not apologise for having spoken on several Wednesdays, because I am sure I speak on behalf of the whole House when I say how much we enjoy her speeches, whether or not we agree with her, chapter and verse. I should like to associate myself with the sympathies conveyed to her noble friend Lady Scrota and to join in the hope that she will soon be back in fine fettle to contribute to our debates on this subject, about which she has had considerable experience.

The future of the National Health Service as a whole is of great concern to everybody in this country. Many noble Lords on all sides of the House—both those who practise in it and those who, like myself, serve on hospital committees and see what goes on—have a close interest in the National Health Service. My Lords, I must say that this Motion seems to show a curious lack of logic. Of course, prescription charges are something which could be described as anathema to anyone, for people do not become sick from choice, but there are one or two very basic if rather ingenuous facts that we have to face. The first is that the size of our population is greater than ever before. I do not wish to bring in any overtones of racialism, because as a nation we have always integrated people from all walks of life and have always been particularly anxious that they should get the best treatment in the social services, in health and elsewhere. But there comes a time when we must face the question of how we are doing to finance this Health Service, with the present shortage of doctors and of nurses, and with more and more people to look after.

I join with those who pay tribute to everyone who works under the egis of the National Health Service, be it on the medical side, on the nursing side or on the administrative side. I think that there is little in the problem of prescription charges other than that they are a necessary evil. I do not want to make the Party point that both Governments have had to impose prescription charges. In the circumstances, I think it was inevitable. But while it is arguable that cost-related charges set one side of the community against another, I make the contention that this method also ensures that there is some kind of watchdog on these charges. The exemptions from paying prescription charges are pretty considerable. I believe that something like 42 per cent. of the people in this country do not pay them.

There is just one point which I should like to put to my noble friend. It was brought out by the noble Baroness, Lady Phillips, and it is this question of the exemption age ceiling for the young. I understand from the White Paper, New Policies on Public Spending, that the age is 15. Leaving aside the contention of the noble Baroness that this affects school children, which it does, I think it is an accepted fact—and many of us who have teenage children will know this—that it is between the ages of 14 and 17 that children tend to pick up some quite distressing illnesses (and I am thinking of glandular fever and rheumatic fever) which need a fairly considerable amount of treatment. This may well mean the use of expensive but necessary drugs. I would ask my noble friend whether he will consult with his right honourable friend about the age ceiling. I think that 17 or even 16 would be a more practical limit.

My Lords, these services have to be paid for; and there is a crying need for new hospitals. Whether or not the saving of £71 million will contribute to building many of those new hospitals is a matter of conjecture, but those of us who have contact particularly with mental hospitals—as I know has the noble Lord, Lord Burntwood—will know how many very old, dilapidated buildings are now in use. An article in The Times the other day instanced two old hospitals where the staff were giving devoted treatment—and one must pay a tribute to the staffs of these hospitals—under extremely difficult conditions. We all want to see improvements made in these hospital buildings and in the amenities of the hospitals themselves, It seems to me that an increase in prescription charges must be looked at in the context of to-day's discoveries, when new drugs are being found: there is a chance now, so we read, of a possible breakthrough for some types of cancer, although one must not raise hopes too highly. If this is so, the question of Health Service charges must be seen in this context.

I would make just one observation about school meals. Of course it is right that children of families with low incomes should be provided with proper and, if necessary, free school meals; but I am not particularly convinced by some of these stories about children going to school without breakfast. This surely is a matter in which we cannot absolve the parents from responsibility. I know that it is argued that increased charges for school meals bring hardship to some families. They do. But there are, as I understand it, some quite considerable exemptions here.

So, my Lords, we must have some yardstick for the provision of these services. This document New Policies for Public Spending is at least a start towards trying to sort these out. One knows that the medical profession has objections to it. It is fair to say that there are medicines which can be obtained from the chemist, over the counter. If that were done it could save a considerable amount of time for the doctors. One hears a great deal about overworked doctors and nurses. Somehow that problem has to be solved. One appreciates the plight of the doctors and I am glad to hear that there is to be consultation. One hopes that it will be quick.

I should like, my Lords, finally, to reinforce the plea which I made earlier to my noble friend about the age limit for the imposition of prescription charges be they cost-related or any other kind of charges. It is important that before they start to earn wages the young should be afforded the best possible help and protection, and the elderly likewise. Having said that, I think that these plans of the Government are a step in the direction of trying to improve the Health Service facilities.

LORD GARNSWORTHY

My Lords, I hope that the noble Lord, Lord Auckland, will excuse me for intervening, but may I say, before he sits down, that he did indicate that he was leaving the debate early. That being so I should like now to address to him a question that I should normally have put later. As I understand it, the noble Lord is defending prescription charges, cost-related prescription charges, on the basis that they will help to meet the cost of the extension of the service. Is he really saying that a special form of taxation should be imposed on the sick to pay for this extension?

LORD AUCKLAND

My Lords, I do not accept that this is a special kind of tax. If we want proper services for the sick, and bearing in mind the number for which we must cater, unless we are to have large increases in direct taxation this seems to me a practical and less damaging way of providing them. But obviously, this is a contentious matter.

4.34 p.m.

LADY GAITSKELL

My Lords, I am grateful to my noble friend Lady Serota for bringing forward this very timely Motion and to my noble friend Lady Phillips for her valiant speech. No one would have guessed that she had to make it at such short notice. The Motion has been phrased in a very subtle way and goes right to the heart of the matter. Here I must disagree with the noble Lord, Lord Aberdare, who did not think that the Motion is phrased in the way I have indicated. The Motion shows that the Government have another peg on which to hang another series of means tests. I do not suggest that a means test is never justified, but I would say to the noble Lord, Lord Aberdare, that it is always a question of the amount, the degree and the trend. The recent series of charges, and increased charges, for various welfare benefits, and the way that it has been sought to justify them by an increase in the number of means tests, seems to me to be a hangover from the Poor Law mentality of the 19th century, and it puts the clock back in respect of our social welfare system in this country.

In the Economist this week there is one of those useful summaries of the different ways in which Britain and countries in the E.E.C. organise their social welfare services. There are differences both in philosophy and also in method. On the Continent the employers bear the major costs; in Britain it is the State. In France and Italy—I notice that the noble Lord, Lord Amulree, referred particularly to France and approved of the method adopted there—family allowances are higher and wages perhaps lower as a result of this system. In Germany, wage-related pensions leave pensioners better off than pensioners in this country, though widows come off rather badly. Because in this country the State bears the major burden the lower paid workers, when drawing benefits, tend to do better. This is a fair picture, despite lots of reservations that many of us might have had of the situation before the present Government took office; but it would not be so true today, despite Government protestations.

My Lords, the excuses are indeed lame and do not stand up to scrutiny. The proposed cost-related prescription charges are strongly opposed by the pharmaceutical and medical professions. The voice of the drug manufacturer is not heard, but perhaps this silence is a reproach to their favourite Government. With no support from those who deal with the prescriptions; with large categories of exemptions and the inevitable administrative costs which result, the economies hoped for by the Government appear to be very small. This will be another case where Tory doctrine does not work out, despite the good intentions.

After all, my Lords, four shillings (or 20p) is a pretty stiff charge for a large number of everyday prescriptions. Already this has increased the watch-dogs on over-prescribing by doctors and by regional medical officers; and to raise the charge even higher would make something of a mockery of a national health service. Various surveys by interested bodies show that the number of prescriptions per head of the population has been fairly constant since the beginning of the National Health Service. The percentage of the cost of pharmaceutical services in the National Health Service has remained stable for many years, although the total cost of prescriptions has risen. The increased costs are due not so much to price rises in the case of existing medicines but because new products have been prescribed. One analysis revealed that 58 per cent. of sales were for products launched since 1960.

It could be shown, my Lords, that prescription charges affect the number and cost of prescriptions. When charges were re-introduced in June, 1968, the number fell, but the average cost rose because doctors tended to prescribe larger quantities when patients had to pay. It appears that the per capita consumption of medicinal drugs is lower in Britain than in most Western countries. This was said by the noble Lord, Lord Amulree. If the Government remain obstinate about raising the charge for medicines still higher, I think that the health of the people might eventually suffer. The list of means-tested welfare measures seems to grow longer every day. Rent and rates have long been subjected to tests. Now, with the abolition of free milk and welfare foods for those under five years old, and the higher charges for prescriptions for dental and optical treatment, welfare measures are a headache for those who have to administer them. Also the variations in income limits for benefit, the different schemes by different authorities, complicate the whole of the new social security pattern and apparatus.

Perhaps the worst aspect of the Government's new style in welfare is the effect on those who have to apply for exemptions and benefits: the way they have to make themselves known. I think that this is where we on this side of the House differ from noble Lords opposite. This selectivity is really a throw-back to a primitive Poor Law attitude, and I am afraid that this is how Continental countries regard our selectivity system. No one can deny that all means testing can be something of an indignity. I feel that the noble Lord, Lord Aberdare, did not show understanding on this matter, when he said that it should not be an indignity. The fact is that people do feel it as an indignity, and that is what matters.

So far, the response, both from individuals and from local authorities, to some of the Government's measures has been something of a slap in the face, such as the revolt by various local authorities, both Labour and Tory councils, over free milk. It is really appalling to hear that in the short period of a year one million children have stopped taking school lunches because of the increased charge for them. The Minister of Education in another place must have found it somewhat difficult to sugar this particular pill.

When we come to the family income supplement for low-paid workers, the much publicised Tory policy to help families of lower paid workers, Conservative remedies have misfired lamentably. I remember the noble and learned Lord the Lord Chancellor (and I am sorry that he is not in the Chamber just now) replying for the Government, I believe at the end of the debate on the gracious Speech, with his usual brilliance and panache. He was indignant that we on the Labour side could accuse the Government of a lack of compassion. I am not setting a 100 per cent. store on Party labels—compassion for Labour and competition for the Tories. But the rigours and practice of Government in action often alters and erodes the credibility of both.

But let us look at what has happened to the proposed family income supplement for low-paid workers. According to the figures recently published by the Department of Health and Social Security, of the 160,000 families originally estimated in need of help who would benefit, 31,000 only have claimed, and of these under 10,000 have been awarded an allowance—that is, 6 per cent. of the original estimated number. Over 10,000 claims were rejected and the rest are being considered. This was the response after an expensive publicity campaign. Two offices had to be closed for lack of claimants. It was originally estimated that the family income supplement would cost £8.6 million. Up to date, spending has been £1.5 million, and I wonder how much of it has been spent on advertising. This is the response to the Labour Party's support for a more comprehensive range of social and welfare services. There is a feeling of indignity, amounting to humiliation, when the less fortunate in an affluent society have to apply and submit to a means test before they get help. This reaction to the family income supplement clearly demonstrates a revolt against the means test ideology. There is no incentive to apply for benefits. More damaging still is the damming up of incentive generally for low-paid workers. This is an indictment of any civilised affluent society.

The European countries can learn from one another, each copying the best of the welfare services in another country. The higher selectivity of the British system is not shared by other countries in the E.E.C., where there is a closer relationship between benefits and recipients' normal income level, according to the Economist again, which also states that the continental worker does better than the British worker on sickness, pensions and unemployment benefit. But apparently on health, the British national health system will tend to serve as an example for other countries to follow. If the Government continue in their means testing and in what I consider rather small, petty economies, I cannot see them setting an example to any European country. Increasing incentives for surtax payers is really no way to improve our welfare services.

4.47 p.m.

LORD PLATT

My Lords, I should like to join with other noble Lords who have expressed their thanks to the noble Baroness, Lady Serota, for initiating this debate, our sorrow that she could not be with us this afternoon and our hope for her rapid recovery. If I were speaking of anyone of less integrity, I might have wondered whether she had contrived the illness to build up a supply of expensive antibiotics while she could still afford them, but I do not think we could think that of the noble Baroness. I am also grateful to the noble Baroness, Lady Phillips, for opening the debate.

In an ideal world, I think most of us would agree, there should be no prescription charges. I think it is true to say that the medical profession was generally opposed to such charges from the beginning of the Health Service, but agreed to them on the ground that there was some truth in the statements that the public were demanding trivial benefits and domestic drugs from their practitioners, so wasting the doctor's time and a good deal of public money, and that a moderate charge might reduce this. I believe that there is still something to be said for that point of view, but I would hope that at this time, when the cost of everything goes up daily and when there is an enormous number of unemployed people, this Government will not still further increase the prescription charges, whether cost-related or otherwise.

I remember the days, to which the noble Baroness, Lady Phillips referred, in the 'twenties and 'thirties when there were really poor people in this country and a great many unemployed. There was the Lloyd George Health Scheme (so-called) for the workers, which did not include the womenfolk, who were also working, and the children. Many women did not go to their doctors or, if they went at all, did not go early enough and did not get treatment for themselves, because they felt that they could not afford it. Fortunately, nobody can say that we have got back to those times. But we are, I think, building up a new poor: not poor in the old sense, like the people I used to see in the out-patient departments, the children with no boots, and who really had not enough soap to keep themselves clean. We are not back to those days. But we are building up a new, large, under-privileged class of people, of low income, who are finding it more and more difficult to live at the standard of living which we nowadays, I think quite reasonably, expect, and who are appalled by the fear or the reality of unemployment, on the one hand, and by the high and mounting costs, on the other, to which they have already had added, as we know, certain charges, such as school meals, dental charges and so on, to be followed shortly by charges to museums. For all these reasons, I hope that we shall not have a higher prescription charge, which will deter people from going to the doctor and make it more likely that they will go and get some cheap, domestic remedy at the chemist's shop, thus putting off the day when they go to the doctor and get the treatment which they really require.

Before I come in detail to cost-related prescription charges, I should like to say that I realise that the Government have to take into account the enormous cost of the Health Service and of prescriptions. But this Government believe in private enterprise and collective bargaining, and presumably should be in a good position to get protection, through negotiation with the drug firms, against excessive charges on their part. As your Lordships know, a Committee was set up some years ago under the competent chairmanship of the noble Lord, Lord Sainsbury, which reported at length on the relationship of the National Health Service to the pharmaceutical industry. That Committee suggested certain measures, which I do not think have yet been fully carried out, as to how the Government might try to reduce the cost of prescriptions.

But let us not forget that a large number of the advances of medicine in my time have come from the drug companies. I have said this before in your Lordships' House, but it bears saying again. The eradication of pulmonary tuberculosis, which is the greatest advance of all in my time, depended originally on a drug produced by a pharmaceutical company. The whole range of antibiotics, after the initial penicillin, have depended on drug firms both for their discovery and for their development. Even penicillin did not become a practical possibility until the aid of the drug firms, or a drug firm, was called in. DDT was the discovery of a drug firm; and the eradication of malaria and other insect-borne diseases has become possible through discoveries by drug firms. The control, or the virtual elimination, of pneumonia, cerebrospinal meningitis and septicæemia—; killing diseases when I was a young man—has been brought about, first of all by the use of the sulphonamides discovered by a chemist working in a drug firm, and later by the antibiotics. New methods of X-ray investigation and anaesthetics have come from drug firms.

It is true that there are good drug firms and bad ones, but the good drug firms spend an enormous amount of money on research, and they run an enormous risk. Perhaps I should say, before going further, that I have no financial interest in any drug firm. But, as I say, they do run enormous risks. They may spend £1 million developing some drug which they think will sell in large quantities—it may be some antidepressant, or something like that, which a large number of people take. It may be that some other drug firm is also spending £1 million on its own drug, and if, for some reason, that drug turns out to be a little better or a little more free from side-effects, or, for reasons difficult to understand, more popular, the first firm may find that it has wasted an enormous amount of its money.

In any case, to control expenditure on prescribing by a cost-related device is, I think, both inappropriate and dangerous. It is bound to influence the doctor's prescribing; and although there are doctors who prescribe extravagantly—and perhaps a few who, one might say, prescribe irresponsibly—there are ways, as we have heard from other speakers, in which the cost of prescriptions by individual doctors is monitored. They can be warned if their average cost is much higher than that of the country in general, and they can be subjected to disciplinary proceedings. If you go to America and start discussing cases with medical colleagues over there, you find, to your utter surprise, because you are so unused to it in this country, that the conversation quite suddenly switches from what the patient needs in the way of investigation and treatment to whether the patient can afford it. I hope that nobody in your Lordships' House wants us to give up our principles and ideals, as embodied in the National Health Service, and go back—because it would be a backward step—to the jungle, as it were, of American medicine.

With a cost-related system there is bound to be a greater prescription and a greater taking of ineffective drugs from the chemists in order to save the patient the cost of the more expensive drugs, which are so often the specific ones which have a really potent antibacterial action or, in some instances, some other specific action. Occasionally you will thus lose the opportunity of avoiding chronic illness by prompt attention at the acute stage, and you will increase the length of quite a number of illnesses. When I was in North Africa during the last war, we had sulphonamide drugs, but there were no antibiotics. We had an enormous outbreak of bacilliary dysentry, and although we were overwhelmed with work we had not, luckily, as your Lordships will see, enough sulphonamides to go round. So I kept a careful note of the cases in which we gave the sulphonamides, and the cases in which we gave the old remedies, which were not so effective, but kept the patient going until nature cured him of his dysentry: and, amazingly, we had no deaths. The really big difference between the two cases was the speed with which we got the disease under control when using sulphonamide drugs and the speed with which we could discharge the patient from hospital and get him sent to a convalescent depot before he rejoined his unit. So I had personal experience of some hundreds of cases of an infective illness and I could see the number of man-days that were saved by the use of a specific drug—an experience which we rarely get on the same scale in civilian medicine.

I repeat, in winding up, that I understand the Government's concern with the cost of prescriptions, and I concede that some doctors are unnecessarily extravagant; but the introduction of a cost-related prescription charge is quite the wrong way to remedy the situation. In addition to the other objections, it cuts across the whole principles on which the Health Service was founded and the principle of the doctor's right to prescribe what he thinks to be right for his patient.

The noble Lord, Lord Aberdare, in his remarks, which he made with his usual patience and charm, referred to the transfer of resources from those who can afford them to those who are in need, and it all seems very reasonable, except that if you have any knowledge of history you remember, as the noble Lord, Lord Burntwood, has reminded us, that similar objections have been made to every single social advance in the last hundred years or more. Also it is an argument which, to my mind, may apply to a person with a fixed income who, whatever he does, is not going to get any more money, and therefore must budget within that amount of money, rather than to a nation like our own, in which no one can say what is the fixed amount that we must spend on health and above which we cannot go. I concede that a Government must watch and see that the amount does not rise too quickly. But, in any case, health is surely an area in which costs can be easily ascertained with some accuracy, whereas the savings and the gains are very difficult to estimate. Thus there is always a danger of false economy.

5.3 p.m.

LORD ILFORD

My Lords, I should like to begin, as other noble Lords have begun, by expressing to the noble Baroness, Lady Phillips, our appreciation of the very clear and lucid speech which she made this afternoon. I think we are coming to regard Lady Phillips as a very special exponent of the social services. This is not the first time that I have listened to her, and I hope that it will not be the last. May I also add a message of sympathy to the noble Baroness, Lady Scrota. Those of us who know the noble Baroness in other places know well what we have missed, and I hope that she will have an opportunity of moving another Motion concerning these circumstances a little later.

The noble Baroness, in framing her Motion, coupled the National Health Service with means-tested benefits. We have not heard very much about the means-tested benefits because this afternoon the debate, as these debates frequently do, has tended to creep into a discussion on the National Health Service. I regret that we have not heard a little more about the means-tested benefits. I hope that means that these benefits are not causing any great anxiety and that that view is merely being reflected in your Lordships' House.

I spent 10 years of my life administering various forms of means tests. I hope that what I did was right, but at any rate if my actions were wrong my critics were kind enough not to tell me so. None of us like means tests; but the fact is that the administration of social services, on a scale which is acceptable to-day, to the poorest section of the population is really not possible without a means test. It is not only that the burden of expenditure might otherwise unfairly rest upon other sections of the community, with benefits being paid to persons not requiring them, and it is not only that class of person who would benefit if such benefits were adminstered without a means test. Nothing annoys members of the public more—and I think one discovers this in administering these services—than to en counter some man who is said to be receiving benefits which he does not deserve. Indeed if that happens it brings the whole service into discredit. One has to frame the law so as to ensure that not only is unnecessary expenditure not incurred but also in order to be quite certain that the service is not exposing itself to the criticism that its administration is wasteful and extravagant.

The Labour Party at one time believed that it was possible to dispense with the means test altogether. When they found themselves in office they appeared to learn that certain benefits cannot be separated from a means test, and accordingly the Supplementary Benefits Commission was set up to undertake substantially the work which the National Assistance Board had been conducting. It is interesting to note that the Labour Party found that it is not possible, as they hoped before the Election, to dispense with the means-tested benefit altogether.

There are one or two matters of less importance which have arisen in this debate about which I should like to say something. First of all, there is the question of exemptions. I listened very carefully to the noble Baroness to see whether she could claim that in any one of these major social services there was no exemption, because it seems to me that so long as there are exemptions in a service it is really not possible or fair to claim that the benefit is not readily available to all sections of the population. It is. Although I listened to the noble Baroness carefully, I did not hear her indicate any service in which there was no exemption. Perhaps when the noble Baroness comes to reply she will let me know whether I have overlooked one of the services; otherwise we have to accept the position that the exemption is universal and that all these services are subject to exemption. If they are, it is not right to say that the social services are not extended to all sections of the population—they are. It may be that the exemption is sometimes inconvenient, and no doubt it frequently gives doctors and chemists more work. But when one looks behind those difficulties, the fact remains that the service is exempted in the case of those to whom it would be a hardship. That is one of the major principles to which we should cling in our approach to the social services. We should be sure that somewhere in some part of the service there is an adequate exemption for those who are not able to pay.

Now may I say a word about school meals. Yesterday, in another place, the Minister in reply to a Question gave a very long Answer dealing with the changes which have taken place in recent months in the consumption of school meals. The Minister's statement indicated a considerable drop in the number of meals taken in the schools. Everybody assumed that that drop was attributable solely to the fact that the parents were no longer able to pay the higher charges. Are we right in assuming that? Many of the children who ceased to have their dinners at school have done so because their parents thought that the higher charge was not worth it, and they would rather have the children at home. This is not because there was poverty in the home, but because the parents found it more convenient to have the children at home and did not want to pay the higher charge. Does not that explain why there was this drop in the number of school meals consumed? Of course there were other reasons. The Minister pointed out that it was not uncommon at this time of the year for a fall of that sort to take place, and there may be other reasons, too. But we must not ascribe the whole of that drop to the fact that parents were not able to pay the higher charge.

I should like to refer to the matter raised by the noble Lord, Lord Amulree. He suggested that there may be some form of universal benefit for all forms of social service available in all parts of the country, without the need for a means test. That is a most attractive proposition. It will not work for this reason. In the case of the applicant for supplementary benefits it includes practically the whole of his rent in most assessments. There is an enormous difference in rent levels in different parts of the country. Rents in the North are a great deal lower than rents in the South. The difference in the scale of rents in other parts of the country is even more marked. That fact alone prevents any universal form of benefit. It means that a benefit which may adequately meet the need in one part of the country will not meet the need in another part. In London, where rents are exceptionally high, the scale which would meet the need in other parts of the country would fall far short of what was required. Therefore these proposals, which always recur, about means tests are not practicable.

I wonder how many of your Lordships have realised the enormous size of the new Department which has been created. The Ministry of Pensions and National Insurance was created by the fusion of the old Ministry of Pensions and National Insurance and the National Assistance Board. The staff number something like 70,000 people. It is, indeed, a colossus. Yet this is a Department where success depends to a major extent upon sympathetic contact and cooperation between senior officers and the subordinate staff working in the field. Are we going to get sympathetic co-operation in a Department of this size? If the social services are to reach the poorest sections of the population they must be administered by a staff which has to have special training and special sympathy with the work which has to be done. What is most important of all is that there must be adequate contact between the senior members of the staff and the more subordinate members in the field. I have not the least doubt that the staff in the Ministry will work with the same devotion with which they worked for me when I was at the Board. But it will not be so easy to ensure those conditions in a department of this size. I am certain that the problems of decentralisation and staff handling will have to be studied. I do not suppose that this point will make a very strong appeal to my noble friend. Nevertheless, it is based on a long experience and I hope it will not be disregarded.

5.18 p.m.

BARONESS SUMMERSKILL

My Lords, I should like to join with noble Lords who have already congratulated my noble friend Lady Phillips. I am always charmed by the way that she manages to rise to the occasion when a colleague falls by the way. At very short notice she was asked to appear at the Despatch Box and expound on some complicated question, which she had learned about only the night before, and I congratulate her on her prowess. I am glad to follow the noble Lord, Lord Ilford, because he was Chairman of the National Assistance Board. He has heard the spokesman for the Government charge the former Government with having applied a means test in so many directions. The noble Lord will agree with me that there is a great difference between legislation and administration. You can have a measure on the Statute Book and two Governments can administer it in an entirely different way. Those of us who have served on local authorities well know that the administration of a certain group of councillors, who have a different political approach and who are there to administer the Statute, is entirely different from that of another group, although they have had to direct their attention to precisely the same matter.

First of all, I am going to deal with what I consider is a piece of harsh administration, something which I believe the social historians, when they review the effect of current social legislation on the lives of the people, will roundly condemn: I refer to the decision to abolish the supply of free school milk to children between seven to eleven, cheap welfare milk for expectant and nursing mothers, and for children under five. This was a reactionary decision. I cannot believe that the noble Lord who has just spoken, who administered the National Assistance Board, can possibly identify himself with this measure.

Nature has demonstrated that the most perfect food for a baby is milk. And to deny any expectant or nursing mother cheap milk at this most important time of her life, and that of her infant, indicates a callous disregard for the most helpless in the community. We are told that schoolchildren needing milk on grounds of ill health will receive it. How do the Government define "ill health"? The noble Lord opposite who answered my noble friend Lady Phillips glossed over this matter. If it is a pathological condition they are going to look for, presumably the child will be at home, and as poverty alone will not be a qualification for milk the Government can rely only upon a degree of malnutrition to attract attention. As malnutrition, unhappily, is not accompanied by a rash, it may well go undetected in a crowded school. We hear crowded schools described by teachers—forty or fifty in a classroom. Who is going to diagnose this condition, and when it is diagnosed, will gross malnutrition have developed, by which time the harm will have already been done? I was impressed by the Times Educational Supplement, which asked this question: How many medical officers can ever know enough about a child's background early enough to prescribe free milk?

I was glad to see that the Local Authorities' Association have indicated that if the school health service is not satisfactory they may appoint staff to improve its efficiency, in order if course to ensure that malnutrition will be detected in its early stages. This warning is in line with the Association's attitude to the Government's cheese-paring policy on school milk and school meals. Every local councillor brought up in a poor home is aware of the importance to children of adequate feeding. Therefore, it is not surprising that local authorities in touch with the realities of working-class life are protesting vigorously, and their protests occur all over the country. They are reported in all the papers, from what are considered Right-wing newspapers to Left-wing newspapers. They are protesting at the increase in the price of school dinners and the abolition of free milk for the over-sevens. It is significant that both Labour-controlled and Conservative-controlled councils—Newcastle is an example—want to pay for the milk from the rates. I was shocked to read in my newspaper to-day that in another place yesterday an attempt was made—and I hope it is only an attempt and that somehow it will be defeated—to stop these humane councils from raising a penny rate in order to provide milk and food for the children.

If I speak strongly on this subject it is because I spent four of the most satisfying years of my political life at the Ministry of Food, where I was concerned with prescribing food according to the biological needs of children, mothers, the aged and the sick, and not according to their capacity to pay. Curiously enough, in war time this was accepted. It was accepted that a Ministry should say that the nutritional needs of an individual are of paramount importance, particularly those of our children. We were given a free hand to ensure that the babies, the mothers, the schoolchildren, the sick and those with special diseases were given what they physiologically needed. If it was right then, why is it wrong now? This picture we have of children buying chips and cakes for their midday meal is of course familiar to those who years ago treated rickety children who were fed mainly on carbohydrates.

In the high street of every town in the country we see the lovely, straight legs of these girls in their mini-skirts—

A NOBLE LORD

Hear, hear!

BARONESS SUMMERSKILL

I am glad my noble friend realises it. They are proof of the success of the nutritional policy pursued in our schools during and since the war. In consequence, the hallmark of rickets, namely, bandy legs and knock knees, is found to-day only in the middle-aged and the elderly. That is not because the air has changed; that is not because housing has changed everywhere; it is because we in our great wisdom decided that the most helpless should be fed adequately.

It is suggested that a school means test should be disguised in order to avoid discrimination. It is difficult to believe that some, I suppose, highly intelligent civil servant devised this scheme. The scheme is that a child should take dinner money to school in a sealed envelope; the over-burdened teacher then returns it to the embarrassed child, who has already been informed by a harassed mother of every move in this cruel little game. This procedure is to be adopted in order that the most poverty-stricken—who are showing signs of malnutrition, of course—shall not be discriminated against. I should like those responsible for these variations on the means test theme to study some social statistics. The facts are that children in a small working-class family grow faster and gain more weight than those in large families. The average increase for London children was 2 in height and from 4 to 101b. in weight since the war. Before the war meals were given in schools to only 5 per cent. of children. In 1946, 42 per cent. received meals. It has been proved conclusively that we cannot separate education and child welfare if we are to produce the finest citizens, mentally and physically—and everybody here knows that so often the two go together.

The provision that certain categories—perhaps the noble Lord, Lord Aber dare, will tell me this—of very poor children can obtain free milk is an acknowledgment that children need free milk. But it is no guarantee that they will get it, because unfortunately children are sensitive little creatures and if they feel there is some discrimination in school, whether in the provision of milk or meals, it will be found that for one reason or another they will refuse; they will give some excuse in order not to be shown up in front of their friends. The poor, overworked mother, who I suppose is going to be asked to indicate why her children should have free milk or free food, is already told by the Government to "shop around" for cheap food. Surely, we should put no further difficulties in her way but should give free milk to these children without any further questions.

While the Government have demonstrated that they are out of touch with the needs of children, they have also revealed that they failed to understand the problems of the poor and the sick by the decision to increase charges for the National Health Service. On the subject of cost-related prescriptions, I was struck by the confidence shown by the Minister in another place in his reiterated statement that no charge would be introduced which would deter the patient from necessary treatment. How is the register of those who are deterred from securing advice and treatment to be compiled for his inspection? How is he to know? How can he go into the kitchen of a small home and know what a woman is considering when she says, "Shall I go to the doctor or not"?—because among those people will be the ordinary housewife who, with the rising cost of living, will be reluctant to pay a minimum of 20p and possibly much more, on the cost-related scheme. And when she finally visits the doctor, with a lump or a pain, and is quickly referred to the hospital for an operation, with a kindly reprimand (how well we know it!), "You should have come to see me sooner", it will be little comfort to her and to her family to be told that the Minister had said that no patient should be deterred from obtaining treatment. My Lords, these are just words! How can any Minister at Whitehall know what housewife in Durham has been deterred from getting treatment because of the cost?

Again, how is it proposed to record the number of patients who will be deterred from taking to the chemist a prescription containing two or three expensive items? These people know. They look at the prescription, they know how many items are on it and they know that the crowded chemist at the corner may well contain some of their friends. They are faced with going to the chemist with this prescription which will cost them quite a considerable sum of money, and either paying money which they cannot afford or leaving the shop. They will look at the prescription and say, "I cannot afford this", and they will put it in the fire.

People who are ill cannot choose whether they have a cheap or an expensive illness, and a patient should not be punished for developing a disease which involves more expensive treatment. To be selective among those who are ill is illogical and unjust, and consequently the total cost of the treatment should be shared by the community. Surely it is not surprising that the General Medical Services Council of the British Medical Association has opposed this heartless scheme. And I find it difficult to know why, if all the doctors throughout the country feel that this really is unethical, a patient should either be denied a drug or be prescribed a drug which really is too expensive for him to pay for. How can the Government say that they will administer the scheme in such circumstances?

I believe that this scheme has been conceived because the widespread prescribing of expensive proprietary drugs has been permitted. I have heard the noble Lord, Lord Platt, say half a dozen times what he has just told your Lordships, and he has probably heard what I have said half a dozen times. But these things are written on our hearts. Successive Governments have allowed the prescribing of expensive drugs although a national formulary exists which sets out cheaper alternatives. When I spoke from the Dispatch Box in another place some years ago, I used to take with me what had been sent into my houshold of doctors on one day. I remember on one ocasion holding up at the Dispatch Box six boxes of sample pills and a pile of glossy advertisements. And still they come. Little is done about it. Why. I can never quite understand. I used then to appeal to the Treasury, and I cannot understand why the Treasury does not do something about it.

In 1967 the marketing and promotional practices of the pharmaceutical industry were examined by the Committee of Inquiry in conjunction with the industry and the National Health Service, and the conclusion was reached that the amount of advertising was excessive. Accordingly, it was recommended that a Medicines Commission should be set up to control advertising. The point is that the cost of advertising is met by the National Health Service. Although this Commission has been in existence for 18 months, expensive advertising continues unabated. I had four "glossies" this morning, and the glossy book that we have read about in The Times— the Book of Nobrium—is the illustration of the industry's contempt for the conclusions of the Commission's inquiry.

I listened carefully to what my noble friend told the House. He told us of everything that had been done by the various drug houses in the field of research. What are the facts'? In 1965—and these are the latest figures I have got advertising cost £15 million: a huge sum as compared with the £11 million spent on research. To-day we are asked to save £9 million through depriving children of their milk. Surely nobody can doubt that the milk is of infinitely more value to the welfare of the child than much of the output of the proprietary drug manufacturers that is peddled to the gullible. I want to sum up by saying that here is the striking contrast in the manner in which the Government retreat before the powerful pressure groups of the pharmaceutical industry and permit colossal profits to be made at the expense of the National Health Service, while the unfortunate children, powerless and inarticulate, are deprived of an essential food in the name of containing expenditure.

5.37 p.m.

LORD GARNSWORTHY

My Lords, I think that almost every speaker has expressed regret that the noble Baroness, Lady Serota, has been unable to be with us this afternoon because of illness, but I am quite sure we all feel indebted to her for having tabled this Motion. If I may, with humility and great respect, I would say that in my view the many tributes that have been paid to my noble friend Lady Phillips have indeed been well deserved. While she was speaking she touched on the position that used to obtain many years ago. She was going back certainly to the time when I was at home with my parents, and she said that in those days women could not afford the doctor. I recall that in our family the one person for whom the doctor was never called was my mother. My mother did not have the doctor because the cost would have meant that the amount spent on food or clothing would have had to be cut by the amount of the doctor's bill. Not for one moment do I think that the Government want to take us back to days like that, but certainly those of us who remember them feel fully justified in expressing concern at what appears to us to be the trend of this Government's policy.

The noble Lord, Lord Aberdare, speaking earlier in the debate, spoke in his usual model tones. He did his utmost to persuade us that there is little or no difference between the two sides in this House on this subject. I hope that this debate will make it clear that there is a difference, and that it will make clear that as far as some of us on this side are concerned we have learned a much needed lesson. It is that we ought to be careful before we introduce any policy for reasons of expediency which can be exploited by our opponents when they take office. I think no one will contend that when National Health charges were first introduced it was the intention of the Labour Government or the Labour Movement to maintain them. Indeed, at one point they were able to remove them, and many of us deeply regret that they were reintroduced, again, I think, at the time largely for reasons of expediency. As I say, there is a lesson that some of us have learned, and I hope it will be taken to heart by all those on the Benches behind me.

I should like to take up a point that I tried to get clear when we were dealing with Starred Questions this afternoon, and I hope your Lordships may excuse me for taking up your time. I should like right away to express my gratitude to the noble Baroness, Lady Tweedsmuir of Belhelvie, in that she has written me a note to confirm the figure she gave as to the number of children in Scotland receiving school meals. As I think the House understood at the time, I was after the shortfall as between those who it was estimated ought to be having school meals as compared with those who are in fact getting them; and if I am told that the 120,000 odd who are receiving school meals represent 100 per cent. of those entitled to claim, I shall indeed be surprised. I hope my point is clear. My experience as chairman of a board of governors that covers two secondary schools is that headmasters are concerned at the number of children who ought to be getting free school meals and whose parents, for one reason or another, will not apply.

If I may say so, while on the subject of school meals, both the noble Lord, Lord Auckland, and the noble Lord, Lord Ilford, touched on the 1 million drop in the number of children taking school meals. The drop that has taken place is indeed far beyond anybody's expectations; it goes way beyond the drop that took place in 1968 and 1970, when charges were raised on earlier occasions; and to assume that we are going to get, as it were, back into balance by September of this year is, I think, to express an optimism that is unjustified. May I say that I have been extremely interested in what has happened in my own county, and I find that there has been a tremendous drop, a record drop; and I am told that what has happened in Surrey is nothing like so bad as has happened in some other counties. If one refers to the details published in the Written Answer in another place the day before yesterday, to which the noble Lord, Lord Ilford, referred, it is pretty clear that there are pockets of the country where a very serious situation indeed has arisen in regard to the school meals service.

The noble Lord, Lord Auckland, made some reference to the responsibility of parents. I think we ought to take some note of the fact that a very substantial proportion of the work force in this country consists of married women, and they are not at home to feed their children at midday. They have many calls on their time, and I think it is a little unreasonable for the Secretary of State to suggest that we need have no concern on this; that their mothers know best. It is not so much a matter of their mothers knowing best; it is what their children do while mother is at work. I shall probably be returning to this subject presently. But I do want to make this point: that in so far as the drop in school meals in Surrey is concerned, alongside it there is a quite fantastic increase in the number of pupils bringing sandwich meals from home. May I give the figures that I have before me? In 1968, the number was 3,944; in September, 1969, 5,273; in September, 1970, 7.141 and in May, 1971, 24,014. I leave those figures to speak for themselves, because I think they are impressive, and provide the answer to what seemed to me to be a lack of concern on the part of the noble Lord, Lord Auckland, and the noble Lord, Lord Ilford.

Allowing for the need for some special benefits to ensure a minimum standard of living for all is one thing, but the introduction of means tests over what seems to me to be an ever-widening field is another matter; and the trend at present suggests that it is getting somewhat out of hand. Certainly the people who come just above the level of reduced cost services seem to catch an unfair burden, and I suspect that these include a great many people who struggle to maintain what are known as middle-class standards. I think it is time we showed some concern for those people whose incomes fall roughly between £1,000 and £2,500, because I have a suspicion that we are imposing upon those people who are struggling to maintain standards handicaps which they ought not to be called upon to bear. May I be quite clear about this? For my part, I should welcome a return to the concept of free treatment as of right in regard to all services vital to the maintenance of health, which includes optical and dental treatment, as well as medical, as indeed I would for free milk and welfare foods for expectant mothers and children under school age.

I have suggested that means testing is getting out of hand. It is also getting something of a maze. Two weeks ago I suggested that one needed to be almost a chartered accountant to understand how it all worked out, for each service has a different level of free benefit. My noble friend Lady Phillips referred to this leaflet, Which of these are yours as a right? Free, and, like my noble friend, I obtained a copy of that pamphlet from the Post Office. It shows four different levels. A married couple with one child can get free school meals at £17.25; for free prescriptions, the same family, the income level is £18.10; for free milk and welfare foods for expectant mothers and children under school age, it is £19.30; for free optical or dental treatment, £19.55. The disparities continue for families with children. I wonder how it is possible to justify these different levels? No one can be surprised that one should be asking the question, since they are all on the same leaflet which is handed out.

Whatever may be said in that respect, may I say that I am impressed by a paragraph that precedes those examples, which surely is a warning. It states that these are examples of income at which you "may" qualify. The significant word is "may". You have to till in a form; you have to wait to see what the answer is. You cannot be sure that you are going to qualify until it has been considered by somebody or other in some office. I am told that a quite large number of people think they are entitled and make application for benefit, only to be told that they do not qualify. Indeed, my noble friend Lady Gaitskell gave figures in one particular regard.

There is a different level of income again for a family income supplement. I take the point made by the noble Lord, Lord Aberdare, that if you are drawing that supplement you get all the other benefits, but it is again a different level. In regard to free milk for some children between the ages of 7 and 11, as my noble friend Lady Summerskill said, there is an entirely different standard, and I will come back to that a little later. The introduction of selectivity—as the noble Lord, Lord Amulree, said he preferred to call it—over a wide field, coupled with income tax reduction, has meant more for the childless and those in the higher income bracket (those over £4,000 or £5,000), and the crunch of these charges falls most heavily on those who just manage without entitlement to free benefits. I hope that we shall be inclined to show a little sympathy and understanding of their position.

Cost-related prescription charges have been pretty roundly condemned in this Chamber this afternoon. I have in my hand a copy of the Pharmaceutical Journal for May I. It reports widespread opposition to those charges, and in my contacts with those in the pharmaceutical profession—and I have no interest to declare—I find wholesale and deep felt opposition to them; opposition on grounds of imposed further hardship on the sick, and the burden of work it will impose, as they put it, even if it is workable.

The noble Lord, Lord Aberdare, said that the Government would pay full attention to what the doctors and pharmacists had to say. I hope that they will pay the closest possible attention to what the noble Lord, Lord Platt, has said. I think a fair question to put to the noble Lord is: what do the Government propose to do? Because the advice of the Association is clear. They have told the Government they do not like these charges, and have indicated in pretty clear terms—the pharmacists, at any rate, as I understand it—that they do not regard them as workable. In view of what I thought was a very powerful plea made by the noble Lord, Lord Platt, this afternoon, I think it is reasonable to ask, since the noble Lord, Lord Aberdare, said that the Government would pay full attention, what attention they propose to pay to what is the most serious criticism offered by the profession? As I see it, the extension of means-tested benefits means the further subsidence of inadequate earnings. In addition, it diminishes the incentive to earn more, because higher earnings result in loss of benefits. I really would like the noble Lord, Lord Aberdare, to reply to that point. Just what incentive does he think is afforded the wage earner living on family income supplements if any increase in earnings is lost as a result of loss of benefit? I think that question is very important and pertinent to this debate. It seems to me that, as a constructive and positive attitude, we ought to be encouraging those who seek earnings sufficient to support family needs. May I be excused for saying this in support of that proposition. It is high time that we had an incomes policy that dealt effectively with those at the bottom of the wages scales.

There is also the fact that many of those entitled to claim do not, or will not, claim. It may be that some of them just do not know of their entitlement. Certainly the Government have been spending a deal of money, as my noble friend Lady Gaitskell said, trying to inform people, with apparently not too good a return at the present time. Whatever the potential claimants may or may not know, we know that there are many in need who do not apply. It seems to me that when people get service as of right, there is far less risk of those in need suffering deprivation. By that, I mean that when we all get service as of right and there is no distinction as between one person and another, then those in need will run no risk of being left out.

I touched earlier on the subject of free milk for the seven to eleven-yearolds. Here incomes just do not count; it falls on the school medical officer to determine who gets free milk. As my noble friend Lady Summerskill again pointed out, it does not matter how poor you are: you do not get free milk because you are poor, only because the school medical officer has certified that you should have it. I wonder whether we shall have a school medical officer in some district who will have the temerity to say, "All children between the ages of seven and eleven in our schools ought to have free milk", and I wonder what the attitude of the Government would be if that was done, having regard to their declared intention of prohibiting I.L.E.A. from providing free milk because they think it is a wise and sound policy?

I hope that the Government will think again about this, and think again about it in the light of an article in the New Scientist for July 1 written by Dr. George Lynch and Dr. Sylvia De La Paz, members of the Social Nutrition Research Unit at Queen Elizabeth Hospital. They make the point that a significant proportion of children will be put at risk medically by the decision to withdraw free school milk from the seven to elevenyear-olds except those receiving "medical milk", which is the description given to it by the present Secretary of State for Education and Science. I hope that the warnings these two doctors give in this article will not be treated lightly, having regard particularly to the fact that in 1968 the Committee on the Medical Aspects of Food Policy advised that to withdraw milk from children below the age of eleven would result in nutritional detriment. I do not think that we can afford to ignore what Dr. Lynch and Dr. De La Paz have written, for they indicate that only 32 per cent. of children aged ten to twelve are satisfactorily fed. Some 18 per cent. of primary school children do not get enough calcium, and 28 per cent. lack riboflavin. Those statistics, again, are something of an answer to the noble Lords, Lord Auckland and Lord Ilford.

We are in danger of producing two nations; those who receive inadequate incomes and who are means-tested for essential services, and those whose incomes are above subsistence levels. But I think one ought to recognise that even among the latter there are many who just get by; on whom the burden of paying taxes, paying contributions and paying again when illness afflicts the home falls heavily. I believe that means-testing offends the sense of dignity of our people and, in addition, the varied pattern of scales now employed makes the whole business an off-putting puzzle to most people. If the Government persist, particularly in regard to cost-related prescription charges, I think that the necessity for a change of Government will be increasingly appreciated. I hope, however, that having regard to the risks involved the Government will not proceed with cost-related prescription charges and will not deprive the 7 to 11 year-olds of entitlement to free milk.

6.2 p.m.

LORD ABERDARE

My Lords, if I may have your Lordships' permission to speak again, I should like to refer to one or two of the speeches that have been made in what has indeed been an interesting debate. If I may go in the order of speaking, I said that I would try to take up one or two of the points made by the noble Baroness, Lady Phillips. One of her proposals was for free prescriptions for women, and she suggested that these should be given at 60, which is their retiring age. I think the noble Lord, Lord Amulree, agreed with that. The noble Baroness will undoubtedly be familiar with the answer: that 65 is the age at which it is considered people require more prescriptions, and it has no relation whatever to the age of retirement. I recognise that many people feel the same, but that is the distinction we make. One has to have regard to a magic figure in all these cases, and why one age is chosen rather than another is a matter for discussion. But the fact is that it is said' that people of 65 and over, whether they be men or women, should receive free prescriptions.

LORD AMULREE

My Lords, may I interrupt the Minister and ask him whether it is not really a question of capacity to pay? Presumably, a woman pensioner who has retired at 60 cannot pay as much as she could when she was in employment.

LORD ABERDARE

My Lords, as I said, the reason for the age which has been chosen is that they need more prescriptions at that time; not that they cannot afford it. But anybody who cannot afford to pay for prescriptions can apply to have free prescriptions, or for a refund of the charge.

The noble Baroness, Lady Phillips, also spoke about free meals, as did a great many others of your Lordships. To put one or two points right, so far as figures and the reasons for the fall-off in the take-up of school meals are concerned, my right honourable friend the Secretary of State for Education and Science made a very detailed Statement on July 5 in the other House, and gave a great number of reasons that are related to this question. Of course, she recognised at the same time that we naturally expected, as a result of increasing the charge, a fall-off in the take-up of school meals; and, indeed, this is exactly what happened when the last Government increased the charge for school meals.

I think the noble Baroness also referred to an article which appeared in the Guardian to-day, and that gives me an opportunity, which I welcome, to put right some of the facts. It was suggested in the article that the estimates had been wrongly made. This is not so. The fact is that the first estimate of 200,000 for the number of children who would benefit was made early this year, and took account of the reduction of sixpence in the standard rate of income tax which had already been announced by the Chancellor in October. But, of course, it could not be foreseen at that moment that the Chancellor would increase the child tax allowance in the Budget, and it is because the child tax allowance was increased in the Budget that certain families have been left with a higher net income than before. It is against that background that the estimate for those children who will benefit is now between 140,000 and 150,000.

But I should like to make this further point. There is no question, as the article implied, that 50,000 to 60,000 children already getting free meals will have them withdrawn. Free meals was a benefit in prospect for certain families which, on the basis of the April changes in remission scale and in child tax allowances, would not have materialised. However, the net income scale for remission of school meals charges will be raised again in September when the supplementary benefits scale is raised, and the 50,000 to 60,000 children referred to will then qualify for free school meals, plus many more.

BARONESS PHILLIPS

My Lords, I am not quite clear about that. Is the noble Lord saying that if you are lucky enough to be getting them already and you have a change in circumstances, you will continue to have the benefit?

LORD ABERDARE

No, my Lords. I am sorry, but it is very complicated and I was not saying that. What I was saying was that these predictions of the number of children who are going to benefit were made without taking into account the fact that there were to be increased child tax allowances. So the number who will benefit has fallen, because there will be that number of families who will be better off. The noble Lord, Lord Amulree, and I think the noble Baroness, Lady Gaitskell, made considerable and effective use of comparisons with European friends. I, too, read with great interest the article in the Economist. This is all very interesting, but it is very difficult to draw exact parallels in these cases. So many of the different benefits in other countries in Europe are covered by various types of insurance schemes, I think that any harmonisation which is going to take place will be a very long and complicated process, and one would hope that in the process of harmonisation it will be the best provisions made in the various countries that will become the harmony.

The noble Lord, Lord Amulree, alrm expressed the view that, in effect, it was better to pay allowances to everybody and recover some of them by means of tax. It is a nice thought, but it does not always work out quite so well as that, because tax does not take back all of the benefit, so that there are a number of people who benefit when they do not really need to. My noble friend Lord Ilford very effectively made the point that of course means-tested benefits of the supplementary benefit type take account of rents, which vary so widely and are such an important part of many people's budgets.

As to the noble Lord. Lord Burntwood, I had great sympathy, if I may say so, with his desire to raise all sorts of matters about the National Health Service. I, too, should have liked to have a debate on the Consultative Document on the National Health Service, but I recognise that this was not possible. I will merely say that I have every sympathy with him in his expressed hope that general practitioners will be more closely allied with the work in the hospitals. Perhaps it would be relevant to say that when we get a unified Health Service, with area health authorities that control the hospitals and the medical health administration, and organise the general practitioners' side, it may be that this will be easier of achievement. I thought he was a little hard in his comments on my speech. I did not think it was quite so reactionary as he seemed to think; and I felt that his speech was rather extraordinary, since he was a member, and a very distinguished member, of the previous Government, which did, after all, restore prescription charges and relied on many of these means-tested benefits that we are discussing this afternoon.

I hope that I have cleared up the matter of the cost-related prescription charge. The fact is that we have announced that we are to introduce a cost-related prescription charge, but we are now looking very carefully at this proposal, following the discussions that we have had with the professions. My right honourable friend has also said that any scheme which is introduced would retain exemptions, would have a ceiling on any single payment and would incorporate the passport scheme, which has worked very well hitherto.

LORD PLATT

My Lords, may I ask the noble Lord a question on that? I am sorry to see that the Government seem to have gone as far as this in their thinking, but when the noble Lord says that there is to be a ceiling, is this the total cost of the things prescribed or of each prescription? You see, to take the simple case of an eye condition, or something like that, it is very usual nowadays for the patient to be given something internally as well as something to be applied to the affected part, to say nothing of one or two accessories that may go with it. Extravagant though it seems, it is quite usual—and I am sure the noble Baroness, Lady Summerskill, will support me in this—to have three or four items on one prescription. So that if the total charge for one of them is (we will say) 30p, or something of that kind—an expensive one—the total cost of the whole lot might be approaching £1, or something of that kind.

BARONESS SUMMERSKILL

My Lords, may I put a supplementary to the noble Lord? We know that the minimum cost will be 20p. Now we are told that a ceiling is going to be fixed. May we know what the ceiling is; how much it will be?

LORD ABERDARE

My Lords, I purposely did not go into this scheme because, as I said, it is still under very deep consideration. We are still listening to the representations which are being made, and we do not wish to make a hasty decision in this matter because it is extremely important. So I do not wish to be drawn to-day into any further details of a scheme on which we have not yet decided.

LORD BURNTWOOD

My Lords, I am sorry to persevere in this matter, but do I understand now that the Government are going ahead with this scheme notwithstanding representations from all quarters, but with a ceiling on the charges to be made?

LORD ABERDARE

No, my Lords. I am awfully sorry; I do not seem able to make myself understood. We have announced that we wish, if we can, to find some means of relating what people pay for their prescriptions more closely to the cost of the prescription; but we have listened and are listening to representations made to us on this matter before we finally make any decision.

My Lords, I was very grateful for the speech of my noble friend Lord Auckland. I think he put very clearly what I had tried to make clear in my opening speech: the difficulty which we all face of making the provision that we should like to make for our social services within the limited resources available to us. The noble Baroness, Lady Gaitskell, as usual, I thought said some astonishing things in a very charming way. She began by taking us to task for the increase in the number of means tests. The increase is one: the family incomes supplement. All the rest were in operation under the previous Government. One other point I thought was not quite worthy of her, and that was when she implied that the reason why the drug manufacturers had not made any complaint was that in some way they were our friends and therefore they stood to benefit by cost-related prescriptions. But they do not. It is to their benefit that all the prescriptions should be free, so that everybody gets what they want however much it costs.

BARONESS GAITSKELL

They have not made their voice heard, my Lords.

LORD ABERDARE

They have not made their voice heard; but this is not for the reason that the noble Baroness thinks. What she never tackled, and what the noble Lord. Lord Garnsworthy, if I may say so, did not make clear to us, was how noble Lords on the other side would intend to pay for the rapidly increasing cost of these prescriptions. We have heard from all sides of the House, and from the noble Lord, Lord Platt, that more and more money is required to pay for more and more expensive medicines; and, somehow, these have to be paid for. Not only that, but the noble Lord, Lord Garnsworthy, went even further. He wanted all health benefits to be free, and a great many welfare ones, too. He must accept that this would increase taxation.

LORD GARNSWORTHY

My Lords, it is not a question of increasing taxation. The Government have chosen to reduce taxation, and in order to reduce taxation they are imposing additional charges on people, many of whom I suggest, can ill-afford them.

LORD ABERDARE

My Lords that is not putting it the right way at all. The reason for the charges is to find extra resources for the health and welfare services. But if the noble Lord is really considering having no prescription charges, no charges for health services and no welfare charges, I hesitate to think how much he is going to put on income tax when, if he ever does—and I hope he does not—he gets back into power.

My Lords, I took very careful note of the views of the noble Lord, Lord Platt, on prescription charges, and particularly on cost-related prescription charges, and I am grateful to him. I do not want to intervene between him and the noble Baroness, Lady Summerskill, on the question of the pharmaceutical industry, except perhaps to say that I find myself rather more in sympathy with the noble Lord, Lord Platt, on this matter than with the noble Baroness. Not only have these pharmaceutical firms done a great service in many ways, as the noble Lord, Lord Platt, described to us, in the development of new drugs but we ought not to forget that they have also been very considerable exporters, and have earned a lot of foreign currency for this country. But, having said that, of course, it is true that we still operate the voluntary price regulation scheme which was introduced under the last Government, and which keeps a check on the prices charged.

The noble Lord, Lord Ilford, from his long experience made his usual wise contribution to this debate. I was grateful for his assistance in pointing to the need for means tests provided that there are proper provisions for exemptions. He drew attention to the size of my Department, and rather thought that his remarks might not appeal to me. I must say that they rather did appeal to me. I am quite sure that there are very great advantages in Health and Social Security being amalgamated, because it means that the Secretary of State can take an overall view of cash arid care when dealing with this problem. I also take his point of the need for the human administration of social security benefits. I can assure him that this is very much in the mind of the Department. As he knows very well, it is very largely dealt with in local offices, and I have on many occasions paid tribute to the staff of those offices. I think that they deal with the claims on them in a most humane way.

The noble Baroness Lady Summerskill, made a powerful attack on what we did about school and welfare meals. She referred particularly to her experience when she was doing extremely good work at the Ministry of Food. She asked what was the difference. The difference was that in those days food was very desperately short. It had to be provided we had to see that those who needed it got it. Do we really now need to supply free milk to all children over the age of 7? We are a very well-fed community. Are there not other priorities? We can differ on this—

BARONESS SUM MERSKILL

My Lords, the noble Lord could argue as logically that in view of the fact that people are so very much better off to-day they should pay for their own education. Why do not the Government say that? The Government know that they cannot say that because education is of fundamental importance to the country. So are healthy workers. Welfare and education go together.

LORD ABERDARE

My Lords, as I said at the beginning, we believe in a mixture of benefits, some free where they apply to large classes of people—and everybody is in need of education. But I wonder whether all children over 7 really need milk? I do not know that all my children do. I wonder whether every child really does.

LORD RAGLAN

My Lords, I am sorry to interrupt and add to the number of questions which the noble Lord has to answer, but I think my noble friend Lady Summerskill has a point of substance here. I remember asking a question in your Lordships' House five or six years ago in relation to cases in Scotland, in Glasgow, which arose out of deficiency, cases of rickets—

SEVERAL NOBLE LORDS

Order, order!

LORD ABERDARE

My Lords, I am sorry, but the noble Lord has not made a speech in this debate and it is unfair of him now to do so. Would he like to ask a quick question?

LORD RAGLAN

My Lords, I was leading up to my question. How are the Department of Health going to ensure that deficiency diseases like rickets are not going to reappear with the abolition of free milk?

LORD ABERDARE

My Lords, I have made it clear that we are depending on the school health service in this. The Committee on the Medical Aspect of Food Policy has a watching brief on this.

The noble Baroness, Lady Summerskill, also challenged me on the fact that we had said we would ensure there was no deterrent on people going for their medicines on prescription. What my right honourable friend had in mind was a scheme under which there would be exemptions for those who could not afford it, or a maximum charge, so that certainly it would never be more than that maximum charge for that particular item. Furthermore, there is the season ticket system which is so effective at the moment, so that anybody can limit his prescription cost now to something in the region of 7p per week.

BARONESS SUMMER SKILL

My Lords, I am sorry to interrupt but this is a very important debate. Does the noble Lord realise that the season ticket system is attractive to individuals suffering from some chronic disease and to hypochondriacs? What we have to consider is the sort of person such as my noble friend Lord Garnsworthy referred to, his mother: the woman who every day will say, "I will not go to the doctor, for it will cost at least 20p, and perhaps 40p or 50p." How can the noble Lord opposite know whether they are deterred or not? They are the people who eventually become outpatients and wait to be seen by the doctor, only to be told that it is too late.

LORD ABERDARE

My Lords, the noble Baroness has made her point and I have made mine. I think that there are various safeguards by which we can continue to look at any new scheme. We shall provide for the noble Lord's mother.

LORD GARNSWORTHY

We do it ourselves.

LORD ABERDARE

My Lords, the noble Lord, Lord Garnsworthy, made various points. He went back to refer to the position in Scotland about which he had asked earlier. My figures for England and Wales show that something over 80 per cent. of those eligible for free meals are claiming them at the moment. He talked about National Health charges being introduced by his Party for reasons of expediency. I should not say that "expediency" is a very good word. I should say, "for practical reasons". But I would also say that nobody supports Health Service charges for their own sake. We do not believe in them as some sort of doctrine; that they are a good thing. But when looking at the priorities, when trying to provide health services and to make available the free services required, we are driven back partly on to taxation and partly on to charges—just as were the last Government. It is the balance between these that noble Lords are perfectly at liberty to criticise. I would suggest that we are always going to have a balance between how much one pays through tax and how much through charges.

The noble Lord made a great number of other interesting points. I have dealt with his desire for free treatment which I thought was a little Utopian. He mentioned the document that we both have and the different levels of income which ensure free provision. This again is what the Labour Party had: different levels of qualifications for different benefits. We have done better. We have increased the amounts. As I have tried to explain, we are bringing these benefits together so as to make the family incomes supplement the passport to the other benefits. We have tried to make simplification wherever possible. Finally, he mentioned some of the research by Dr. Lynch. We have not yet had all the details of his research; but my right honourable friend the Secretary of State said yesterday in the House of Commons that when this report is published it will be referred to the Committee on the Medical Aspects of Food Policy and fully and objectively assessed.

If I may end as I began, there are many demands on us. We need to use the resources we have to the best advantage. We have all had to rely partly on taxation, partly on charges and partly on the provision of free facilities to help those less fortunate. We can go on adjusting the balance between taxation and charges and free benefits as much as we like wherever we think the best balance lies. But in the end it comes down to a balance and we have to find the best one. My Lords, I very much welcome this debate.

6.30 p.m.

BARONESS PHILLIPS

My Lords, I should like to thank all noble Lords who have participated in the debate. There has been a great galaxy of that talent in which your Lordships' House is so rich. We have had speeches from ex-Ministers; people concerned with hospitals as governors, and people with knowledge in the medical profession. Each speech produced new ideas and confronted the Minister with questions to answer. I am sure that I speak for all noble Lords when I pay tribute to the noble Lord, Lord Aberdare, for his patience and the meticulous way in which he has answered everyone who put a point to him. We greatly appreciate it, and the fact that he spoke twice in the debate. I did not accept the explanation about the woman of 60 when it was given to me originally; I still do not accept it, and I shall come back to that later.

LORD ABERDARE

My Lords, perhaps the noble Baroness will accept it when she reaches the age of 60.

LADY PHILLIPS

My Lords, it seems more likely that it will be when I get to the age of 65, and I am sick.

I was heartened by the fact that the last debate which I had the privilege of introducing in your Lordships' House referred to retirement pensions, and shortly afterwards these were increased. I am now relying on my Patron Saint, who sees me in good stead in most things. Since the Government appear still not to have completely made up their mind about cost-related prescription charges, and are under heavy pressure, I hope that ultimately they will decide against such charges. I thank all noble Lords who have participated in this debate, and on behalf of my noble friend Lady Serota I ask leave to withdraw the Motion for Papers.

Motion for Papers, by leave, withdrawn.