§ Order for Second Reading read.
§ 4.10 p.m.
§ The Minister of Health (Mr. Elliot)
I beg to move, "That the Bill be now read Second time."
The Measure which I have the honour to bring before the House provides for the earlier and more effective treatment of cancer. No one, I think, can deny the urgent necessity for some means, if it can be found, of bringing more adequate facilities for this purpose within the range of every person in the country. Of course, there is an obvious field for increased research into the prevention, and particularly into the causation of cancer. Substantial progress in this direction has been made in recent years, and the message which we can bring to-day, carefully and anxiously but with hope, is that the records made by surgeons of the histories of the patients on whom they have operated have shown that patients with cancer can be freed from their disease. What is more, treatment both by radium and X-rays has been found to produce some definite action on the cancer cells, which leads either to their destruction or to some change which facilitates their removal by healthy tissues. Indeed, there seems to be a belief that for some conditions X-rays may produce even better results than radium.
But for these forms of treatment to be successful they must be employed when the disease is at an early stage, before it has become deep-rooted. So we must have ample facilities for early diagnosis and for adequate treatment, both of which are lacking in many areas at the present time in this country. For many other diseases it is easy for patients, no matter in what part of the country they live, no matter how remote they may be, to receive modern and adequate treatment for their illnesses, and as a result the mortality from certain diseases has fallen. I am hopeful that the powers which this Bill confers will in time enable us to achieve sensible results even with this terrible scourge of cancer. But we must be careful not to under-rate the size of the problem in front of us.
Cancer has now become the second on the list of fatal diseases in this country. 1644 The annual number of deaths from the disease has been steadily mounting. The total for Great Britain in 1937 was 74,000. Of the total deaths from all causes during the working period of life, that is from 15 to 65, 17 per cent. are due to cancer. Nearly half the deaths from cancer occur when people are still under the age of 65, and about I0,000 occur under the age of 50, when working or business capacity is at its fullest and when the heads of families are most necessary to their children. So it is not, as is sometimes thought, merely an old person's disease. It is a killer and in many cases a killer of people in the prime of their powers. In these circumstances we cannot afford to disregard any inroads of the disease which may be prevented.
The annual death rate from cancer is rising. As recently as 1901 it was 835 per 1,000,000. To-day it is over 1,600 per 1,000,000. The figure has thus nearly doubled in the course of a generation. This increase in mortality is in striking contrast to other diseases where there has been, and still is, a steady fall. In the case of other diseases the mortality curve is trending downwards, but in this disease it trends upwards in a very striking fashion. It is probable that even the figures I have given do not fully represent the mortality from cancer. Medical men do not certify deaths due to cancer as such if they can avoid it. The relatives do not like it to be done. Consequently, it may well be that the figures are even greater than in the picture I have given. But even taking the figures quoted, what they mean is that over 6,000 persons have died of this disease since the King's Speech on 9th November, if the average of the past few years has been continued. The King's Speech seems to have been only a few days ago. Of course, similarly, as the death-rate is not falling, 6,000 more diagnosed or undiagnosed cases have since the same date come into the 100,000 cases that constantly exist in this country to replace those 6,000 victims.
It is not a problem peculiar to this country. Other countries which have registration systems show not merely a high but a rising cancer figure. I have looked out the figures for some countries similar to our own, such as Holland, Switzerland and France. Taking the comparable figures for the period between the quinquennium of 1926–30 and the 1645 present day, we find that the percentage increase in Holland in that time has been 9.5; in Switzerland, 3.7; in France, 3.9; and in this country, 14. It would appear, statistically, that those countries have lower rates of cancer than ours, but it is impossible, for technical reasons, into which I need not go now, to be sure that they have actually less cancer than we have.
Again, it is not, as is sometimes supposed, a disease of civilisation. Among primitive races, among native races, cancer is not at all unknown. In some of those races there are forms of it actually more common than they are among ourselves, although, of course, it is not possible to arrive at any comparable figures of mortality. Still the fact remains that here we have a great killing disease in which the figures are rising, in which the figures are high in this country as compared with other countries, and yet one which is world-wide both among primitive and highly-civilised races. That is the case for tackling this disease out of the many diseases which it might be thought the Government would select to be tackled. Surely this is a disease the statistics of which show how desirable it is that we should, if possible, tackle it and conquer it.
There has been much discussion on whether the increase in the number of deaths means a real increase in the disease. I think there is a general opinion that a good deal of the increase can be explained in other ways. People are living longer, and they are coming more into the regions of life where cancer is prevalent than they did in previous years. In days when half of the population of a great city died before the age of 21, there was very little chance of any one's getting cancer. It is true that the mortality from cancer of certain of the more accessible organs is declining at almost every age—for example, cancer of the lip, jaw and skin. I think that is due, at all events in part, to the effect of treatment, although some of the decline may be due to a lower incidence of the disease in those organs. One recognises, however, that there is an increasing incidence f[...] some organs.
Some forms of cancer are disappearing altogether. Cancer of the skin caused by over-exposure to X-rays is, we may h[...]e a thing of the past. Other skin cancers [...]ue to exposure to certain irritants such as 1646 tar, mineral oil, and so forth, are preventable, partly by avoidance of exposure and partly by preventive treatment of those conditions of the skin which may lead to the disease. I think it is almost certain, too, that some of our health services remove causes of irritation. Dental services, venereal disease services and maternal care services all contribute to the prevention of those conditions which might subsequently become cancerous.
Still, from various inquiries conducted by the Ministry it has been estimated, roughly, that there are over 100,000 persons in the United Kingdom suffering from cancer. Of these, about 10 per cent. are affected in organs for which treatment has not hitherto been practicable. A further 50 per cent. are susceptible at present to treatment by surgery alone, but only if the disease is diagnosed at an early stage. If the disease has progressed too far for such treatment, little can be done for those patients. This group includes cancers of the stomach and intestines which, taken as a whole, account for the largest number of deaths. There remain about 40,000 patients suffering from the disease in easily accessible parts of the body, and for those patients treatment by surgery, treatment by surgery combined with radiation or treatment by radiation alone, is effective, especially in the early stages of the disease. Even when the disease appears to be too far advanced for the treatment to be curative, a great deal of relief of suffering can be given, and, indeed, occasionally cures have been obtained by the expert use of radiation. Certain distressing symptoms can be alleviated and life may be prolonged, and those are great advantages to be gained by the sufferer.
It appears from such investigations as we have been able to make that under present conditions only about a quarter of the patients who could be treated with advantage obtain treatment at centres which are adequately equipped and staffed. By that I mean centres which have expert surgeons, expert radiotherapists and a sufficiency of radium and deep X-ray apparatus. That is not a condition of things with which any of us can be satisfied. Of course, it is true that not all the remaining patients are susceptible to treatment, but more might become so if facilities were improved. For instance, in the large group of intestinal cancers, the symptoms are often 1647 so indefinite that they are neglected until the disease is far advanced. For such cases the problem is not so much the provision of treatment as the promotion of that earlier diagnosis which is absolutely vital.
One further observation is necessary. At many of our hospitals, as those of us who have worked in the hospitals know too well, there are long waiting lists, and the waiting lists at many of our voluntary hospitals have two consequences of terrible importance to the patient who is suffering from, or threatened with, this disease. In the first place, there may be delay in initiating treatment, and that is a very serious matter in this disease. In the second place, very few voluntary hospitals are able to afford bed accommodation for patients who are beyond cure, but whose sufferings could be greatly alleviated by modern treatment, especially by radiation. That, again, is not a situation with which any of us can rest content. It is not enough for us to say that we know how to treat cancer cases—that we can treat them. What we have to say is, "We will treat cancer cases."
There is another cause of delay. A good many patients apply for treatment only at a stage when effective treatment is no longer possible. The reason appears to be that the patients who realise that they are not well, and who fear that they are suffering from what they regard as an incurable disease, wait until the disease is too far advanced. For a great many ailments delay in seeking advice is dangerous, but for cancer it is literally deadly.
This bogy of incurability is one of the things which we want to dispel, and it is one of the things which we hope this Bill will combat. It is a difficulty which our forefathers have grappled with in their time When the bogy of incurability has been dispelled, a great step forward will have been taken. It has been done in other cases. Take the case of tuberculosis alone. Until the middle of the last century there was a similar belief about what was called consumption, that it was an incurable, a mortal disease. People who were suffering from it, or who feared that they were suffering from it, dreaded consulting a doctor. They were afraid of what they regarded as a sentence of 1648 death. With the institution of efficient treatment, however, it was soon noted by the public that patients were being cured of the disease, and so that dread which previously existed has largely been overcome. Diagnosis has improved, the disease can be recognised at an earlier stage and treatment can be promptly instituted. The result has been a steady fall in the annual number of deaths from pulmonary tuberculosis or consumption. I think it is not too much to hope that history will repeat itself in the case of cancer.
It is proposed, therefore, by means of this Bill to attempt to secure that no one wherever domiciled, who is suffering from or suspected by his doctor to be suffering from cancer, will be outwith easy reach of the best available advice and, further, that everyone will be able to obtain admission to an appropriate hospital whether for further examination or for whatever treatment is best suited to his condition. When I say "whatever treatment is best suited to his condition" I mean that. Some fear has been aroused, I understand, that this Bill deals only with a specific method, but that is not the case. It is not a Radium Bill: it is a Cancer Bill. I repeat that again, and it cannot be repeated too often.
§ Mr. Garro Jones
May I ask the right hon. Gentleman to elucidate one point which is giving rise to considerable speculation? He refers constantly to effective treatment. A great many people consider that there is a growing need for provision to be made for those people who are actually dying of cancer. Will the right hon. Gentleman make it clear that there is no intention of excluding those people? Is it intended, particularly in cases where beds in a hospital are full, that people who are coming in for treatment for the incipient stages will have priority of admission to these hospitals?
§ Mr. Elliot
I thought I had made it clear to the House, but if not, I repeat, that our desire is to make available facilities for the treatment of cancer both curative and ameliorative. It is very desirable that people in the later stages of the disease, who cannot in the ordinary course of events be completely cured, should have all the alleviation which modern treatment can afford them. Naturally, cure will, if possible, take precedence of alleviation of the later stages. It is, however, my hope that under the provisions 1649 of the Bill we shall be able to provide sufficient accommodation for both these purposes.
How are we proposing to do it? When we were discussing this question it became very clear that it was very undesirable to set up a whole new service parallel with the existing services. All instructed opinion agreed that we would have to work through the existing machinery as far as possible and, consequently, the existing machinery is the basis on which we are building. We desire to bring into one scheme both voluntary and local government efforts, and we propose to organise the service through the great local authorities who already have the responsibility for public health throughout the country, who are working in so many other fields of public health, and from whom it would be a mistake to divorce this particular attack upon cancer. So, the Bill provides for the organisation, by county and county borough councils throughout England and Wales, and county councils and councils of large burghs in Scotland, of arrangements for the diagnosis and treatment of cancer. Its object is to make facilities for treatment available to all who need them, and to ensure diagnosis in the early stages of the disease, while cure is still possible.
In the London area conditions are not exactly similar to those in the rest of the country, and the problem to be dealt with is less here than elsewhere. The great voluntary hospitals in London are in a position to ensure that for a great many cases of cancer full facilities for adequate treatment will be available, provided the patient attends at a sufficiently early stage of the disease to make it practicable, and the hospitals administered by the London County Council themselves provide, of course, extensive facilities for treatment. Indeed, it might be said that if the whole country were up to the standard of London, there would in fact be no need for this Bill, but so much of the country falls behind the best standards which are available that we must take steps to try to bring up the rest of the country and to provide facilities in other parts of the country equivalent to those which are available for sufferers in London. It has been estimated, for instance, that out of some 11,000 persons in London who are suffering from cancer, nearly 10,000 are receiving some form of treatment, and that is a very 1650 creditable figure, and a figure for which London as a whole, owing to both voluntary and municipal efforts, owing to both local authority and London County Council efforts, deserves the highest praise. That does not apply alone to London, because some other large towns are also in nearly as forward a position.
The provisions of the Bill are that local authorities should submit to the Minister schemes showing their arrangements for ensuring that all these patients shall receive whatever treatment is best suited to their condition. These schemes will be worked out after consultation with the voluntary hospitals in the area, both with the governing bodies and the medical and surgical staffs, with the medical practitioners in the area—there is special reference to them—and with the Radium Commission.
We are not entering upon absolutely unknown ground. A number of progressive local authorities have already practical experience of the factors which make for success in schemes of treatment worked out in co-operation with National Radium Centres. Provision is made for the combination of local authorities in joint committees, and on these joint committees persons other than members of the local authorities can be co-opted. I hope that that provision will make it possible to bring in, for instance, representatives of the staffs and boards of the voluntary hospitals, and it should make it possible for two or more authorities to use one treatment centre.
For instance, it is clear that Wales will be divided more or less between the great cities of the North, such as Liverpool, and the great cities of the South, and that combination would enable the use of these centres. It will also be possible for one local authority to utilise the services of more than one treatment centre. These are, roughly, the objects of the Bill, and I repeat, as I think is clear from my description, it is not a radium Bill, but a Cancer Bill. Although radium is one of the elements in the treatment of cancer, it is only one of the elements, and surgery, radio-therapy, and hospital beds are all items of treatment which are far more important, taken in conjunction, than any one method of attack, however interesting or important it may be.
The proposals will, of course, involve the expenditure of money and will be 1651 financed by local and central authorities in conjunction with each other. The additional liabilities which are imposed on the local authorities by the Bill are to be assisted by grants from the Exchequer. This will be done at first by specific grants to each local authority and later by an addition to the total of the block grant. The expenditure to be taken into account in determining the grant will be the additional expenses incurred by local authorities in excess of those already incurred by them in the year ended 31st March, 1938, on the treatment of cancer. In order to minimise detailed control and examination and to simplify the grant arrangements in respect of local authorities' direct expenditure, there is a provision in the Bill under which the grant may be calculated on the basis of units of expenditure, that is to say as it were, little block grants, to avoid checking-up expenditure on postage stamps, tram tickets, and so on, by the local authorities; but that is permissive and not compulsory, and naturally it will not be put into operation until we have some better idea of what the units should be.
To meet a point made by local authority representatives in all parts of the House, and I think more particularly by the right hon. Member for South Hackney (Mr. H. Morrison), who, I understand, is to follow me, about the undesirability of having the same unit for the whole of the United Kingdom, provision is made whereby different units can be prescribed for different areas, so that we are not to have the same unit applicable, say, to Denbighshire and to the London County Council. I think that meets one of the points at least which have been represented to me by the local authorities.
It is estimated that the Exchequer contribution when the service is in full operation will amount to approximately £300,000 a year for England and Wales and £50,000 for Scotland. It is expected that the scheme will not be in full operation until probably five years hence, because nothing worse could be done for sufferers from this illness than to rush in with powerful new methods of treatment which have not been fully explored. The bottle-neck here, as in so many other cases, will be the provision of skilled men, skilled people, either diagnosticians or 1652 radio-therapists, and I think it will be a matter of some years before a sufficient supply of skilled men has been obtained for the expansion of the service to which we are looking forward.
§ Mr. Herbert Morrison
Can the right hon. Gentleman say whether the £300,000 and £50,000 respectively will be a charge on the Exchequer alone?
§ Mr. Elliot
The Exchequer contribution is half what the united total expenditure will be, and the expenditure by the local authorities is the gross expenditure. They will be the paymasters and will pay out all the sums. The estimate is based on the assumption that in order to meet the more immediate future needs we want three things. We want treatment centres, we want beds, and we want new diagnostic centres. There are 22 treatment centres at present, and we think we shall need some 12 new treatment centres. The 22 treatment centres are situated at hospitals so placed geographically that there are still large areas of the country for which the proper facilities are not reasonably accessible.
There are three principal areas in the country which, I think, are quite inadequately provided for at present. There is a band of country south of the Tyne, that is to say, between the Tyne and the West Riding, there is the whole of north and mid-Wales, and there is a band of country running across England from the Wash to Devon. To provide properly for these areas, we shall need additional treatment centres as well as to expand the provision that at present exists in the 22 centres which are now being used. The largest of the national radium centres are associated with the teaching hospitals of provincial medical schools, and I hope very much that through these channels, as well as others, we shall have a larger number of the experts of whom I have spoken, the expert radio-therapists, because we shall need them to staff the expansion of the existing centres and the new ones to be formed.
It is not necessary, I think, in an assembly such as this, to stress the damage which can be done through the use of these powerful radiation agents by inexpert hands. I have had letters, uneasy letters, from people who fear that this expansion is about to be put into operation rashly or without sufficient professional knowledge to avoid the dangers, 1653 indeed the evils, which to some extent may have been produced in the past. When radium was first introduced for the treatment of cancer, damage to patients was not infrequently done, and deep X-rays also have been productive of a good deal of damage, both to patients and to doctors. They are powerful things, terrible things, dangerous things, but cancer is a powerful thing, a terrible thing, a dangerous thing. A desperate disease needs a desperate remedy, and you must not be deterred merely by the fact that you are using a powerful weapon. You must learn how to use that powerful weapon, for the thing which we are attacking is terribly powerful too.
We want additional beds, and I reckon these to be approximately 1,000 in number at the existing or new centres or in hospitals associated with them, and we want new consultation centres for diagnostic and other purposes. I reckon that somewhere between 300 to 350 of these are needed. In all these cases it will be very necessary to associate the hospitals, the old-established hospitals, closely with these efforts. Patients going in to be examined at an old-established hospital may not realise exactly what they are going to be examined for. Patients going in from the remote districts of Scotland or England, such as Devon and Cornwall, to an old-established hospital such as the Edinburgh Royal Infirmary or some hospital in Cardiff or Swansea, that their relations have known about for a long time, might be rendered desperate if they went into something labelled a cancer hospital or centre or clinic. It would be equivalent to a sentence of death to some poor old lady, say, from Inverness-shire if she was sent a long journey and found that she was to go into some place labelled a cancer hospital. We have to use existing facilities, not merely for the facilities, but for the tradition, because fear is perhaps the greatest thing we have to encounter in struggling against this disease.
The right hon. Gentleman asked me further to elucidate the finance. It is estimated that the Exchequer contribution of 300,000 for England and Wales is based on the assumption that the total net additional expenditure of local authorities in England and Wales will be in the nature of £600,000; that is to say, cost of additional beds £390,000, consultation 1654 centres £350,000, and, say, £30,000 for travelling expenses of patients, because clearly the economic and the humane thing to do is to bring patients into these centres, established, as I say, in great centres of population, and we have made provision in the Bill not merely for travelling expenses for the patients, but for travelling expenses for a companion. To bring some old person a long distance for a consultation the result of which may make a very great difference to him or to her is a very serious thing. None of us, ourselves, would ask any of our relations to undergo it without some person going with him or her for companionship, and the Bill provides for that. The figures I have given bring the total expenditure for England and Wales to £770,000. We estimate that this will be reduced by a certain amount of recoveries from patients. That amount is conjectural, but it has been assumed at £170,000, which gives a total net cost of £600,000 for England and Wales, involving Exchequer grants of £300,000. For Scotland the estimated grant is £50,000. These estimates are, of course, hypothetical.
I turn to points which I was asked to make clear by several hon. Members, including the hon. Member for the London University (Sir E. Graham-Little) and the hon. Member for Consett (Mr. David Adams), in regard to the provision of radium and other radio-therapeutic substances and methods of treatment. They are to be provided for the centres I have mentioned. Neither the Trust nor the Commission will undertake treatment in any way. They will merely be trustees which will hold this valuable element and pass it to the various centres which make application for it. We propose to work through these two existing organisations, the National Radium Trust and the Radium Commission. These bodies were constituted in 1929 by Royal Charter, the Trust to acquire and hold radium and the Commission to manage its distribution. The Trust owns about 20 grammes of radium which it bought out of funds provided partly by public subscription and partly out of a grant of £100,000 from the Exchequer. In addition, it has about 18 grammes on loan with an option to purchase at £4,500 a gramme including containers.
This radium cannot be retained indefinitely on loan, and if it is to be kept 1655 for use here the Trust must be put in a position to pay for it. That situation was causing anxiety to the Trust when I first came into contact with this problem, because these 18 grammes are out on loan and to withdraw them from centres which are using them would no doubt cause a considerable hold-up in the treatment of cancer in this country. Clause 3 provides that the Minister may from moneys voted by Parliament lend the money to the Trust, up to a maximum of £500,000, to enable them to purchase radium and other radio-active substances, apparatus and appliances required for radio-therapeutic treatment. The first charge on this fund will be to put the Trust in a position to pay for the 18 grammes which they have on loan. More radium will be required in order to carry out the expansion for which we hope from this Bill. When the Government decided on the introduction of the Bill they authorised the Trust to negotiate for further supplies of radium before their decision was made public. The hon. Member for Consett reproached me that the decision to embark upon a further development of the cancer campaign was known to the world before we had safeguarded ourselves against the market rising. I am happy to be able to inform him that we foresaw that difficulty and have fully safeguarded ourselves against it.
§ Mr. Elliot
I am coming to that. The Trust secured the option to buy radium up to a further 10 grammes a year for the next five years, with a minimum of two grammes a year for the next five years. I am sure the hon. Member for Consett will be relieved to hear that the price for that was £4,500 a gramme exclusive of containers. The only immediate liability of the Government is for the two grammes a year for the next five years, the cost of which will be about £50,000.
§ Mr. Elliot
A statement in any newspaper to the contrary was inaccurate. Not only in the "Times," but in other papers, and in some medical papers as well, some fantastic estimates have been 1656 given without any authority as to the price at which the radium had been bought and the conditions under which it had been purchased. If the price of radium falls the Trust will be able to take advantage of the lower price for any quantity it desires to buy over and above the 10 grammes I have mentioned. They will, of course, be able to accept tenders from other companies if the price is satisfactory. We have got supplies in the past from the Belgian company, and it is not our desire to tie ourselves up to any one company or another. If the Trust is to be enabled to purchase other forms of radio-therapeutic apparatus and substances it will obviously need to change its title, and it will require also to consider changes in its personnel. I am glad to say that consideration is now being given in order to enable it to carry out its new functions effectively, to a revision of the Royal Charter so as to authorise it to acquire and hold other substances and appliances for radio-therapy in addition to radium, and to provide for any desirable alterations in the personnel of the Trust and Commission.
These are the main proposals of the Bill. Clause r deals with arrangements for the more effective diagnosis and treatment of cancer; Clause 2 deals with the financial means for providing this; and Clause 3 deals with a loan to the National Radium Trust to provide increased apparatus. There are certain points of interest in the remaining Clauses. Clause 4 prohibits the publication of misleading advertisements offering treatment and cures for cancer. I am glad to say that that is merely carrying out the practice of many of the great newspapers to-day. These advertisements are not accepted now by members of the two great newspaper organisations, the Newspaper Proprietors' Association and the Newspaper Society. I am happy to be able to inform the House that they both support the inclusion of this Clause.
§ Mr. Garro Jones
Will the right hon. Gentleman make it perfectly clear that this Clause imposes no penalty or restrictions upon newspapers publishing what they like? The Clause is aimed at the quack who may not be got at at all.
§ Mr. Elliot
It is very desirable that this Bill should be framed and modelled by the House as a whole, and if further amendments are desired there will be an 1657 opportunity for them to be considered. What I want to point out is that we have in this Clause a prohibition of these advertisements and that we have the support of the great newspaper organisations for it. Many of the so-called cures for cancer are harmful in themselves, their danger is that they induce the sufferer to postpone proper treatment, and that is literally deadly. The Bill makes provision for bona fide announcements made to the medical, nursing and pharmaceutical professions, both in regard to the methods of treatment I have already referred to, and others that may be discovered. Clause 5 is the interpretation Clause, Clause 6 deals with the application to London, Clause 7 is the application to Scotland, and Clause 8 is the short title.
There are one or two points which have been raised in objection to the Bill, and it might be for the convenience of the House if I dealt with them now. It has been objected that the weighting of the population which has been adopted for block grant purposes is unsuitable for the present service. The weighting is designed to give effect to the relative needs of various authorities in relation to their expenditure as a whole. Any question of the suitability of the weighting factor is not appropriate to the present Bill. It is a difficult question covering the whole field of local government, about which the right hon. Gentleman who will follow me may have some observations to make. The weighting factor has been accepted by Parliament. It was reviewed less than two years ago, it was accepted by the associations of local authorities, and again confirmed by Parliament. There is a case made that the basis should be something different, but I will leave that to the right hon. Gentleman to develop. We may be able to deal with his points later in the Debate. On the technical side it has been suggested that the Bill provides for too great an expenditure upon radium. I think I dealt with that in the course of my general remarks.
Is the radium at present in the possession of hospitals being used to its full capacity?
§ Mr. Elliot
As far as I know it is. The Radium Commission is responsible for applications made to it for radium to be given or lent to hospitals, and I do not think it would lend radium to any institu- 1658 tion which could not make full use of it. There may be some places where full use is not being made of it, but, taking it by and large, it is being used to its fullest extent.
§ Mr. R. C. Morrison
Are there any prospects of the world supply of radium being increased? It was understood up to a few years ago that the whole of the supply was in the hands of and controlled by the Belgian company to which the right hon. Gentleman referred. He now says that some is coming from a Canadian concern. Can he give any indication whether there are likely to be other sources of supply?
§ Mr. Elliot
I cannot off-hand; I think the original source was the Joachimsthal. In addition to the Belgian supply, the new source of supply from Canada has been greatly developed, and I think, as far as we can see, other sources of supply are available and they show no signs of exhaustion. It has been said that no provision is made for research into cancer. We realise that there is a difference between the world-wide attack on causes that science everywhere is making and this national attack on the disease itself by means of diagnosis and treatment. Great Britain plays a great part in research carried on either under the aegis of the great voluntary organised bodies such as the Imperial Cancer Research Fund, which is directed by the Royal Colleges of Physicians and Surgeons, or by the British Empire Cancer Campaign, which is controlled by a group of distinguished lay and medical persons, or by specialised institutes and organisations such as those of the Royal Cancer, Middlesex, St. Bartholomews, London, Leeds, Edinburgh and other hospitals.
I have already received an assurance from the Imperial Cancer Research Fund and the British Empire Cancer Campaign that they will continue to do their utmost, and I am sure that observation will apply equally to the other voluntary organisations which I have mentioned. There is a field for both organised central and local efforts here, and it would be wrong if either agency should attempt to monopolise the work of the other. I do not need to remind the House of the enormously valuable research carried on for many years by the Medical Research Council, for that body carries on its work with moneys provided by Parliament. Of 1659 course, that indispensable work will be continued and developed quite independently of the present Bill, through its own Council and its own Minister. We shall work in closest association with that body and with the Lord President of the Council in the new developments which may now or afterwards be entered upon. The Medical Research Council, with its own Minister, is not subordinate in any way to the Ministry of Health, but is a colleague of and collaborator with the Ministry of Health, and we shall work together.
Such is the programme which we set before ourselves. It is admittedly a great task and admittedly we are only at the beginning of it, yet our history records other great killing diseases which have been tackled and stamped out. One of the earliest to be tackled was malaria. For years it was a disease which took a terrific toll of life, both in England and in Scotland. In England, the Fens and Romney Marsh were two of the most dangerous areas in the world, and it was said that the fenmen normally used up three wives, going three times to the high lands to replace wives who had died of malaria in that unhealthy region. All over the Lowlands of Scotland there were malaria dispensaries, and it is only within recent times that malaria has been stamped out. Were the attack upon it to be relaxed the disease might recur. Actually within the last two or three years there have been three cases of indigenous malaria arising in this country, the sufferers being people who had never been out of the country. Another disease, not a country disease but a town disease, was the cholera; in the early part of the nineteenth century cholera was stamped out.
We stamped out those two diseases when we did not know so much about their causes as we know about the causes of cancer to-day. These instances are only analogies. Malaria is due to the malaria parasite and cholera is due to the cholera germ, and I am not suggesting that there is anything more than an analogy, but those achievements were accomplished by our forefathers in times when things were not easier than they are now, and when their knowledge and resources were not as great, and it may well be that we shall be able to show that our century can tackle the tasks of peace as well as the tasks of war. In these days, when so much time, thought and trouble 1660 are given, both in this House and outside it, to discussing methods of destruction, one is happy to come before the House with a constructive proposal for saving life and not for causing death, a proposal to improve the conditions of the people and not to reduce them. I welcome very much the reception which our proposals have received, in spite of the fact that there are points on which the House differs, and I hope that the Measure which I have outlined will do something to aid us to attain our object.
§ 5.5. p.m.
§ Mr. H. Morrison
The House will, I am sure, wish me to express our thanks to the Minister for the clear and precise exposition he has given us of the provisions of this Bill and the policy which is behind it. He has made the Bill in most respects reasonably clear, and, moreover, has indicated that he will welcome the collaboration of the House in considering the Clauses without too much rigidity as far as he is concerned but with a pooling of our knowledge on the matter. Whether he suggests that the House should pool its financial knowledge seems a matter of doubt, owing to the rather stern wording of the Financial Resolution which we shall have to discuss later. There was once a Cabinet Minister, who shall be nameless, who made a speech at a Parliamentary by-election indicating that owing to increased armament expenditure the social services would have to suffer, and who, a few days afterwards, said something else which was designed to contradict what he had previously said. I have this impression of what happened in the Cabinet of that time. The Cabinet said to the Minister: "For years on end your Department has had big Bills each year, Bills involving substantial expenditure. We are now living in hard times, armament costs are going up, and you cannot have a Bill which involves big expenditure this year, so you had better look round for something that sounds impressive and will appeal to the public imagination, something which will produce good headlines in the newspaper comments upon the King's Speech, and above all, something which is inexpensive."
The Cabinet having come to that conclusion the Minister did his best, and dropped upon the Cancer Bill, which answers all the requirements, including that of economy, because the cost to the 1661 Treasury will be only the very modest sum of £350,000 a year. Nevertheless, this is a Bill which I am sure will be welcomed by all Members of the House and by all outside who are interested in the public health. Cancer is an exceedingly serious disease, and it is necessary that further steps should be taken for its treatment. I propose to refer to certain of the medical and administrative problems before I come to the financial aspects of the matter, on which the local authorities saw the Minister the other day and on which some of us, at any rate, have strong feelings. On the purely medical side the Bill is very much to be welcomed as being calculated to provide, at any rate, the basis of a serious attack upon cancer. It is true that in recent years considerable progress has been made by medical science in the treatment of cancer and an understanding of the various problems associated with that terrible disease. Particularly has progress been made by means of radium and deep X-ray therapy, and we have improved the means of diagnosis by X-ray examination and other methods.
Unfortunately, as the Minister has said, the disease has tended to increase as the years have passed. It may be that the figures are deceptive. It may be that we are now more accurate in ascertaining the number of deaths from cancer, and it may be, as the Minister has said, that as people are living longer there is a possibility of cancer being, so to speak, a by-product of the longer age to which people live, and if that be so it is, of course, sad. According to the annual report of the Chief Medical Officer of the Ministry of Health the development of the disease is exceedingly serious. He says that the recorded deaths from cancer were, in 1901–5, 867 a year per million living in England and Wales; by 1921–25 the figure had risen from 867 to 1,269, and in 1937 the figure had risen to 1,633. In the course of under 40 years there was, apparently, almost a doubling of the number of recorded cancer deaths per million living.
It is sad that side by side with the undoubted progress made in the treatment and diagnosis of the disease there should have been such an increase in the number of fatal cases, but the facilities for diagnosis and treatment are very expensive, and they have been very largely confined, as the Minister has said, 1662 to London and certain great towns. There are large tracts of the country where the facilities are either completely non-existent or inadequate, and I think Parliament has a duty to see that diagnosis and treatment are available to every citizen in every part of England, Scotland and Wales. At any rate, he should be able to secure treatment within some reasonable distance of his home. The first essential, it seems to me, is to provide means for early and accurate diagnosis, and then to ensure that the best methods of treatment are applied. There must be a judicious enlightenment of the public on the need for seeking medical advice at the onset of the disease, because the results of delay in diagnosis and treatment are undoubtedly serious, and many people who could have been saved succumb to the disease.
Therefore, I agree with the Minister that the public must be told what are the danger signals, and also that the early treatment of the disease is hopeful. There are, of course, difficulties about this because of the fact that doctors do not like to tell patients, and patients do not like to be told, but, nevertheless, the problem is there and it is very necessary to make arrangements for early treatment. Indeed, although there are certain difficulties about it, one is not certain whether compulsory notification by doctors may not be necessary, as time proceeds, in the interests of the patients themselves. Doctors throughout the country ought to be informed exactly how and where specialist diagnosis and treatment can be obtained for their patients. We ought to have such facilities available throughout the country as early as possible, and general practitioners should be informed of where those facilities exist, in order that there may be no lag between the attendance of a patient at a doctor's surgery and the obtaining of specialist advice at one of the diagnosis centres to be established under the Bill.
It is a good thing that newspaper advertisements of cancer treatments and remedies of a doubtful order should be prohibited. It means not only that the patient may suffer harm in the interests of the selfish profit of some quack or other but that treatment is delayed. I hope, however, that the Minister will look into the point raised by my hon. Friend the Member for North Aberdeen (Mr. Garro Jones) as to not only punishing the ad- 1663 vertiser, but prohibiting newspapers, in their own interests, from accepting these advertisements. That would be the most effective way of dealing with them, and if already, as we were glad to hear, the Newspaper Proprietors' Association and the Newspaper Society, representing the London and provincial Press, are agreed upon the principle of the thing, I should think they would not resent an Amendment on those lines being made in the Bill.
With regard to the proposals for the provision of treatment, there are certain matters on which I would like to obtain assurances from the Minister and which, if the Minister could give them, would be welcome. It is desirable and even essential, if we are setting up proper machinery for the diagnosis and treatment of the disease and for the proper working of the schemes that local authorities will submit and the Minister will consider, that both the Minister and the local authorities should insist that only fully equipped and adequately staffed hospitals should be included as part of an official scheme. Approval ought to be the hallmark given only to hospitals where the work is really first class. I am not concerned whether they are local authority or voluntary hospitals. Here it should be remarked that the equipment is more easily obtained from fully trained and experienced medical staffs. There could be nothing more lamentable than for patients to be sent, under these schemes, to centres where the best treatment is not available. In the early years it would be preferable that the number of approved centres should be more limited than otherwise, than that the local authorities or the Minister should be lax by recognising institutions that are not fully efficient for the job in hand.
The gross estimated cost is £700,000 a year, of which £600,000 is for England and Wales and £100,000 is for Scotland. Half of that sum is, of course, to be provided by the local authority. I understand that it is intended that the grant will be in respect of additional expenditure taking place under the Bill and after the introduction of the Bill, and not to expenditure that was taking place be-fore the introduction of the Bill. There is this to be said against it, that the progressive local authority, as, for in- 1664 stance, London and certain other places, and progressive, ambitious and energetic voluntary hospitals that have been doing good work for years, will be to that extent in a less favourable position than the backward local authority or backward voluntary hospital. That is not altogether equitable. The point is felt by the Association of Municipal Corporations, who desire that the matter should be ventilated in the House. On the other hand, I and a number of other people are in a dilemma about it because, owing to the fact that grants to the voluntary hospitals have to be provided through local authority channels with a graduated State grant towards that expenditure, if we were to be successful in obtaining a retrospective payment for the London County Council what we gained in that respect we should more than lose in the additional grants to voluntary hospitals which the Minister is kindly passing to the responsibility of to the local authorities, as, in London, to the London County Council.
That is a real difficulty in which I am and which causes me not to press unduly on behalf of London for payment for past matters. Although there is a maximum to the grant to the local authority as such and no minimum—to which point I shall return with some vigour later on—and no maximum to the grant that the local authority may pay to the voluntary hospitals, it is a pity that local authority rates are being involved in grants to voluntary hospitals. The London County Council, for which I speak in this respect, would prefer that the Minister should make his own financial arrangements with the voluntary hospitals. This financial interlock between the local authority and the voluntary hospitals is embarrassing and is becoming difficult. I in no way wish the voluntary hospitals to pass; they have been doing a great work in London and elsewhere, and we shall be involved in very serious considerations if they should break. I do not want them to break, but it is better in financial matters that they should be dealt with by the State rather than by the local authorities.
If we continue to slide as we are doing we shall have such an interlock between the voluntary hospitals and municipal finance that the complications will be very serious. I am apprehensive that one of these days the voluntary hospitals may be landed against their own will into local 1665 politics and local electoral considerations. It will be a pity if the experience which local education authorities have had in regard to the vexed question of non-provided schools should be repeated in the case of voluntary hospitals, but if the Minister has decided and is going to adhere to his decision that the payment is to be in respect of new services under the Bill and not in respect of past work, it is necessary that he should make that clear in order to prevent any disappointment on the part of the voluntary hospitals, and possible complications between them and the local authorities. It is very undesirable that false hopes should be built up in this matter.
There is one other point in regard to treatment to which I wish to refer. In many centres, Manchester, Birmingham, possibly Glasgow and Dundee, and certainly London and Middlesex, patients from other parts of the country outside the areas of those local authorities will be treated, either at voluntary or possibly at municipal hospitals within one of those areas. None of us wishes to make any difficulty about that point because it is clear that, taking a county of modest populations like Buckinghamshire or Berkshire, both near to London, it may be much more effective for them to make arrangements with the London authority or with Middlesex or with the voluntary hospitals than that they should go to the expense of establishing this expensive treatment for themselves. If they do make such arrangements, it is necessary that the Bill should provide that they must carry the financial responsibility of the treatment of the citizens of the distant county and that the authority concerned should have every right of recovery from the county or county borough from which the persons concerned may come; otherwise there may be further penalisation of the progressive voluntary hospital or the progressive local authority who are doing good work over an area wider than their own. We should like an assurance from the Minister on that point.
I now come to the question of research. Very large sums of money have been subscribed in different parts of the country for cancer treatment and research. There are national bodies such as the Imperial Cancer Research Fund, and the British Empire Cancer Campaign, as well as the funds attached to specific hospitals. It is vitally important 1666 that there should be complete coordination of the work of such bodies with the proposed schemes of the local authorities and I hope that the Minister will be able to give us an assurance on the point. Consultations between the local authorities and those administering the funds should take place when questions of grants are being considered. There ought to be—there must be—no overlapping. The public money to be provided must reinforce the money from voluntary sources and not replace it.
One of the great problems of bringing public money into voluntary funds as a supplementary source of income is to do so without at the same time drying up the sources of voluntary effort and subscription. That is one of the points on which I am apprehensive regarding the rates being behind voluntary hospitals to a rather indefinite and elastic extent—not because I wish in any way to hurt the voluntary hospitals but because of the fact that when public money comes into a service which was previously maintained by voluntary effort there is a tendency for the hitherto voluntary subscriber to say: "I am paying through the rates and I need not pay by voluntary subscription any more." We want the public to supplement the voluntary money and not replace it. Both public effort and voluntary effort have had their place in the combined effort against cancer, and there must be complete cooperation in directing all the money to where it can do most good.
The Bill is necessary, although we have no definite knowledge yet of the cause of cancer. That is the most depressing fact about this terrible disease. Nor have we definite knowledge of the means of treating it, except by the knife, radium and X-ray. It is understood that the Bill makes provision for contributions by local authorities for administering treatment; that is all right, but it makes no provision for local authority contributions for research. I am not asking that the Bill should make such provision, but it is vitally important that the House should impress the Minister, if that is necessary, with the importance of research going on. It is important that research should be adequately financed and staffed because—I have no right to say so—I just feel that it is a disgrace to us and to medical science that although this disease has been going all these years we still do not know 1667 the cause. If we could find the cause we might be well on the road to dealing with the disease itself. Until we know the cause we cannot effectively deal with the disease.
Expenditure upon research, adequately and competently conducted, if there is any hope of finding the cause, is true economic expenditure. If we could find the cause and thereby find the means of prevention, we should save enormous sums of money in diagnosis and treatment upon particular cases. Research must go on, and indeed it ought to be intensified. I trust that the Minister will deal with the matter direct, quite apart from the Bill, and through this House; not through the local authorities, because this matter is better dealt with on a national basis. Of course, it should be a national charge.
Now I come to certain financial considerations in connection with the Bill. I do not quite follow how the Minister makes up his sum of £600,000 for England and Wales and £100,000 for Scotland. That makes £700,000 in all. Out of that the Minister wants to get improved facilities for diagnosis, which will be costly, improved facilities for treatment in many parts of the country and an improved additional organisation all round. He indicated also that he wants to get 1,000 new beds out of that £700,000 a year. My hon. Friend the Member for West Fulham (Dr. Summerskill) has been kind enough to make inquiries for me by telephone as to the capital cost of beds. She informs me that the Middlesex County Council recently constructed a new hospital, I think—
§ Mr. Morrison
The capital cost of the beds, without any equipment is to be £800. I have painful reason to know the figures of new beds in new hospitals, so far as the London County Council is concerned. My hon. Friend also tells me that the Westminster Hospital is actually spending on beds, including equipment this time, £2,000 per bed. Well, 1000 into £700,000 leaves us with £700 a year. It is true that the figures are capital figures, but capital charges on capital expenditure must be met. The mere provision of the bed is nothing in itself compared with the medical overheads and the other associated expenditure. Therefore, I should think that the figure of 1,000 1668 beds within the expenditure of £700,000 for Great Britain, including all the other charges that are to come under the Bill, is a very doubtful figure indeed. I hope that later on some further information may be given on that point. Turning back to the subject of research, a letter from Dr. Howard Willcox to my hon. Friend the Member for Wentworth (Mr. Paling) contains a reminder of something that was said by the Minister of Health when he spoke at the annual dinner of the British Medical Association on 8th November:There are vast resources of knowledge in our laboratories which are not yet carried through to the lives of our people. Let us be sure that we apply the knowledge we have got, and acquire new.I hope very much that that statement of the right hon. Gentleman will be remembered in connection with the research aspects of this Bill.
I come now to the financial aspects of the Bill. In passing, I would draw attention to the fact that the Financial Resolution is very tightly drawn, notwithstanding the discussions we have had in the House and the promise of the Prime Minister that relaxation of these Financial Resolutions would be considered. It will, however, be more appropriate to develop that point when we come to consider the Financial Resolution later on. I would, however, point out that, when the Local Government Act, 1929, was passed, undertakings were entered into, and, indeed, were set out in the Statute itself, that when new obligations were put upon local authorities the matter would be specially considered. Section 135 of the Act of 1929 provides as follows:It is hereby declared that it is the intention of this Act that, in the event of material additional expenditure being imposed on any class of local authorities by reason of the institution of a new public health or other service after the commencement of this Act, provision should be made for increased contributions out of moneys provided by Parliament.The right hon. Gentleman may say, "I am providing these moneys in respect of the increased expenditure out of moneys provided by Parliament," and that is technically true, but, in the case of certain local authorities, the provision he is making can fall as low as 21 per cent., and I do not think that that is meeting the spirit of the provision I have quoted. This is not the first time it has happened, and the Ministry of Health in the last few 1669 years has been a pretty bad enemy of the ratepayers of the country, particularly those of large areas which are placed in certain circumstances. The Ministry came along with the Midwives Bill—a very necessary Bill, imperfect though it was—and in that case also there was a sliding scale, with a maximum at the top and no minimum at the bottom, resulting in the imposition of a very large burden upon local authorities. The Ministry also came along with a Bill, with the principle of which I do not quarrel at all, for compulsory superannuation of local government officers. The Minister made himself exceedingly popular about it, but the Bill contained some rather onerous compulsory provisions, and involved substantially increased expenditure with no State grant at all. There have been other Measures accompanied by the same results.
What is the basis upon which the Minister proceeds, and against which I protest, not only on behalf of the London County Council, but on behalf of the Association of Municipal Corporations and of the County Councils Association? I was the principal spokesman of a deputation on behalf of all of them the other day. The Minister has been subjected to pressure, quite rightly, from the distressed and needy areas, who have pointed out that the grants they were receiving were not adequate in relation to their needs. I am not saying a word against their claims, and, if it were proposed under this Bill to reduce the amount of assistance given to places like Glamorgan, Monmouth, Durham and other parts of the country, I should resist it for myself and on behalf of my hon. Friends. But the Government, having had to concede something to the poorer counties and boroughs and give them additional grants, then said to themselves, "At whose expense shall we give these additional grants? Shall we give them at the expense of the Treasury, or"—cynical thought, typical of the Treasury itself—"shall we give these increased grants at the expense of the other local authorities?" That meant setting the local authorities at war among themselves, for, when authorities whose areas are not regarded as depressed areas come along and demand bigger grants, the Government would be able to say to them, "You want this at the expense of the distressed areas, and you are a heartless 1670 lot. "The doctrine of "Divide and Conquer" was pursued.
The Treasury, with the aid and connivance and backing of the Ministry of Health, which should have been safeguarding the interests of the local authorities, decided that they would assist with greater grants the local authorities in the poorer areas—with which I entirely agree—but that they would get those increased grants at the expense of the ratepayers of the other local authorities. The result is that under this Bill London will get a State grant of 27 per cent., as far as we can tell for the time being, but in some years' time we may get no grant at all. At the same time, we have to make to the voluntary hospitals grants up to a percentage which is not defined in the Bill, and we are not protected against pressure from the voluntary hospitals.
Does the Minister trouble about protecting the ratepayers of London against having to give high grants to other people? Not at all, but he protects himself even against having to give higher grants to the poorer authorities, for he provides that no local authority can get more than a maximum of 85 per cent., and no minimum grant is provided. The Minister will want to set the whole House of Commons against London. That is a very favourite Parliamentary trick, but it will not come off this time, because the facts are against him, and, moreover, it is unfair. When the next London County Council election comes, people will hear how Ministers have helped to put the rates of London up. There is hardly one of them on the Front Bench who is not urging us to spend more money. The legislation of the Minister of Health and his predecessor is putting the rates of London up. The Board of Education, by its scandalous action in London—it seems to have a vindictive hatred of London—has cost us about £8,000,000 so far. They are all in a conspiracy to get our rates up, and yet they join in denouncing us for putting the rates up.
This is not a London issue. The other place they like to quote, when they get tired of London, is Bournemouth. It is not for me to defend Bournemouth. A borough that is capable of returning the hon. and gallant Member for Bournemouth (Sir H. Croft) is not a borough that I am going to get over-excited about. But this is not merely a matter of London 1671 or of Bournemouth. According to Mr. Arthur Collins, the former City Treasurer of Birmingham, and now financial adviser to the Association of Municipal Corporations, out of 83 county boroughs, 52 will receive grants of less than 50 per cent.; and, of the 63 county councils in England and Wales, including London, 19 will receive grants of less than 50 per cent. This sort of thing would not have happened in Scotland when the right hon. Gentleman was Secretary of State. Now he is still a Scottish Member of Parliament running English and Welsh local government, and I beg him to carry to the Ministry of Health some of his old Scottish tradition and capacity for fighting with the Treasury for justice for the local authorities with whom he has these new relations. The story is going round that it is London and Bournemouth who are making the trouble, but, of 146 county councils and county boroughs, 71, or about half, will get less than 50 per cent. grants.
I admit that the case in the counties is not quite as favourable from the point of view that I am arguing as it is in the boroughs, but it is there. It is no use saying that Essex is a county without any financial problems. Let the Government ask the Essex Members about that. But Essex will be below 50 per cent. Lancashire also will be below 50 per cent. In this House the other week my hon. Friend the Member for Westhoughton (Mr. Rhys Davies) and other Members who represent Lancashire constituencies were claiming that Lancashire should be regarded as a Special Area for the purposes of the benefits under the special legislation that has been passed for distressed areas. Middlesex will get less than 50 per cent., and also Hertfordshire, which is represented by the hon. Member for St. Albans (Sir F. Fremantle), and Warwickshire, which includes part of the highly industrialised area around Birmingham, as well as London and Surrey. Then consider the county boroughs. I will not read the whole list of 52 boroughs that will get less than 50 per cent., but here are some that are not by any means rich and salubrious districts: Barrow-in-Furness, Birmingham, Bolton, Bradford, Bristol—I hope the Parliamentary Secretary will remember that when he replies; Berwick, Cardigan, Derby, Dewsbury, Doncaster, East Ham, Halifax, Leeds, 1672 Leicester, Lincoln—the Minister of Agriculture had better remember that; Manchester, Northampton, Norwich, Nottingham, Plymouth, Portsmouth, Preston. Reading, Rochdale, Salford, Sheffield, Smethwick, Southampton, Stockport, West Ham, Wolverhampton. It is no use saying that these are authorities to whose financial interests we can be entirely indifferent. I could have mentioned others, but they are all on my list, which is available for any hon. Member to see.
In these circumstances we want to suggest, and we want an opportunity of doing so on the Bill, that, while the graduated principle is sound and the poorer areas should get the higher grants which they are going to get under the Bill, there ought to be a guaranteed minimum grant of 50 per cent. There is a maximum of 85 per cent., and we suggest that there should be a guaranteed minimum of 50 per cent., and that the additional money required for this, which would not be much, should be provided by the Treasury. I hope that this claim, which I make, not only on behalf of the London County Council, but also on behalf of the Association of Municipal Corporations and the County Councils Association, will be urged upon the Minister, because, if I cannot move my Amendment later, as to which I do not know till I get to it, we shall have to consider what we shall do about the Financial Resolution as a whole, and I hope that hon. Members on both sides of the House will press the Minister to such an extent for financial justice for the local authorities that he will feel that he should give way. I am sorry to have to weary the House with these important and, for the Minister, unpleasant financial points on a day that ought to be for him a day of inspiration to go on with the good work of the campaign against cancer, but the financing of it is of importance. We welcome the Bill. We shall seek to make improvements in Committee, but the Minister and His Majesty's Government may rely on the House giving every cooperation in seeing that this is a valuable and useful Measure when it reaches the Statute Book.
§ 5.46 p.m.
§ Mr. Ernest Evans
I should like to associate myself with the general welcome that has been extended to the main prin- 1673 ciples of this Bill. Any attempt to control the terrible disease of cancer is to be welcomed. The toll of life taken by that disease, the pain it causes those who are suffering from it, and the distress of those who are near and dear to them must demand sympathy. Therefore, we all gladly join in welcoming this Bill, in which it is proposed to make an assault upon that dread disease. Some people have been wondering why this Bill should have received so much emphasis at the present time and should have found so prominent a place in the King's Speech. But the King's Speech is rather like a Budget statement; the authors are glad to find something which will be a bit of surprise, so that the Speech shall not be described as "humdrum." On this occasion, the surprise packet was the reference to the Cancer Bill. There have been a good many discussions, in the House and outside as to whether it was advisable to put in charge of a Government Department a layman or a man supposed to be an expert on the subject with which he would be called upon to deal by his Department. I am not going to offer any opinion on that, but we realise that we have at the present time a distinguished medical gentleman in charge of the Ministry of Health. It may be that the emphasis laid on this Bill is due to his enterprise and experience.
But there is also a practical reason for introducing the Bill at this early stage. That reason is that it will be a long time before the Bill can come into operation. Under Clause 1, the Minister has to wait for schemes to be presented by the local authorities. The local authorities are given one year, and the Minister is given permission to extend that to a longer period. I hope that local authorities will be pressed to present their schemes at the earliest possible moment, and that, should cases occur where longer time is asked for, the Minister will refuse except for very definite and urgent reasons. When the Bill was first published there was a good deal of apprehension in regard to some parts of the financial Clauses. There was a misapprehension that a very large sum was to be spent immediately on the purchase of radium which might not be required, either for facilities which at present exist or for the extension of the facilities which might be made when the Act came into operation. That was a serious apprehension, and I 1674 am glad that the Minister has done a great deal to-day to allay it. As I understand it, the interpretation of Clause 3 is that the complete amount of the loans made by the National Exchequer for the purchase of radium will be £500,000; but there is no intention of spending that, or even a considerable part of it, immediately. The expenditure is to be spread over 10 years, but in each particular year so much only is to be expended as will meet the urgent necessities of that particular year.
In regard to Clause 4, I think there will be general sympathy with the intention of the Clause to prohibit certain types of advertisements with which I suppose we are all familiar. There is no doubt that these advertisements do great harm. They cause many people to indulge in expenditure which they can ill afford in the hope of getting some cure for themselves or their relatives. These advertisements do more than that, as the Minister pointed out. They a re apt to lead sufferers from this disease into buying the sort of goods advertised rather than having recourse to some qualified man, who, even if he could not cure them, would not do them the same harm. Further, there is the consideration of the unspeakable anguish caused to sufferers from this disease by resort to the things advertised. But I am a little doubtful as to the true effect of this Clause, as I am of any legislative provision which seeks to prohibit advertisements. The real remedy is to be found in the spread of education and knowledge. There are many devices that can be used in order to dodge the provisions of this Clause, and the truth is that advertisements of this character will cease to be used only when they cease to pay.
It has been already pointed out that, since public expenditure is involved in the purchase of radium, regard must be had to certain considerations. But regard must also be had to other considerations, one of which is the number of persons qualified to use the radium when it is available. I believe it to be true that the use of radium by persons not qualified may do more harm than good. There are in this country certain hospitals which, I believe, have facilities for diagnosis and operative treatment, but which have no radium or other radioactive substances for treating the disease in its malignant stage. What is the policy 1675 of Clause 1 in regard to those hospitals? Assuming that they have those facilities and a staff qualified for the use of radium, is it proposed that this Bill should facilitate the loan of radium from radium centres to those hospitals, whether they be voluntary or municipal hospitals? If the loan of radium is available to that type of hospital, with that type of equipment and staff, it may be of great assistance, particularly in the initial stages of the disease. I am afraid this is not the intention of Clause 1, because the Minister, in the course of his remarks with regard to Wales, emphasised the importance of this system at present in large centres of population, in North Wales on the one hand and South Wales on the other. He laid stress on "large centres." I am wondering whether there will be any provision under the Clause for the loaning of radium to hospitals of the character I have described. This would avert the necessity of sending people in large numbers to radium institutes, which involves large expenditure and much anxiety, not only for patients but also for their relatives.
There is another consideration which is a little more general in character. The Minister emphasised that this Bill was to be regarded not as a Radium Bill, but as a Cancer Bill. I am glad he emphasised that, because there has been a good deal of feeling that this was merely a Radium Bill, and not a Bill designed to establish a general cancer service for the whole country. The protest the Minister made prompts me to ask what further steps he has in contemplation for dealing with the cancer problem. I am not sure whether it is of lawyers or of doctors that it is said that "when they do agree, their unanimity is wonderful." But it is equally true of both that they very rarely do agree. I understand that it is very rarely that the medical profession agrees now on the disease of cancer, and even on the reliance that is to be placed on radium as the only, or indeed the main, curative means of treatment. Who shall decide when doctors disagree? I am sure I could not decide, and I am equally sure the Minister of Health would be sorry to have the responsibility of deciding placed upon him. Therefore, it is important to secure that other forms of treatment, such as X-ray, should have due consideration and regard, 1676 and that the valuable work done in this direction should not be discouraged.
The Minister of Health protested against the fear that this was to be treated as a Radium Bill; but was there not some justification for that fear? In Clause 1, the one national authority which the local authorities are bound to consult is the Radium Commission. I would be the last to cast, or even appear to cast, any aspersions on the Radium Commission, but it is important to remember that the Radium Commission is in existence for a particular purpose: to deal with radium, and its supply and distribution. It may be a very efficient body—I have no doubt it is—for the purpose of discharging those tasks; but, after all, radium, as the Minister himself says, is only one of the methods of treatment that have to be taken into consideration in dealing with cancer. Why, therefore, in view of the opinion which the Minister himself shares, select the Radium Commission as the only one of a national character which is to be consulted by the local authorities? Does it not look as if the Ministry had a little extra bias in favour of the use of radium, if not as the sole method, at least as the most important of the methods of treatment? It is interesting to observe that the Commission does not include in its membership anyone who represents the radiologists. It does include a very distinguished radiologist, but he is not there to represent that science. He is only there in another capacity. If I am not mistaken, I believe he represents Scotland, and while Scotland is a country containing very learned people who are fully entitled to representation, the particular Scottish member of this Commission is not chosen because he is a radiologist, and in the constitution of that Commission no special representation is given to this particular science.
Therefore, I ask the Minister of Health whether he will be prepared to reconsider the obligations for consultation which he imposes upon local authorities, and that instead they should be invited to consult a commissioner or a committee of a wider sphere and membership, representing not only the Radium Commission, but also many other people responsible for diagnosis and treatment including physicians, surgeons, radiologists and biochemists and others connected with other 1677 methods of treatment. This would extend the function of Clause 1 of the Bill, but I believe that it would help to satisfy the fears entertained by many people and give greater advantage to the consultation which would be secured. There appears to be nothing in the Financial Resolution which would prevent this suggestion from being put into operation.
It would be unfortunate to regard this Bill as a Radium Bill rather than a Cancer Bill, because, as the Minister of Health emphasised, this is a much larger question than committal to any particular curative method. There is one other point I would like to emphasise, and it was mentioned by the right hon. Gentleman the Member for South Hackney (Mr. H. Morrison). This Bill is not designed and should not be treated as a Bill for carrying the financial burden of cancer research work. It is important to emphasise that fact. Fortunately there are a very large number of generous people in this country who subscribe yearly for the carrying on of very valuable cancer research work, and it would be a pity to diminish their support by creating the impression that this is a Bill to enable the Government to accept financial responsibility for cancer research work in the future.
As to the financial provisions as they affect local authorities, it is often said that you should not look a gift horse in the mouth, and I believe that the Minister of Health, when he introduced the Bill, intended it to be something in the nature of a gift horse, but I am becoming a little doubtful as to how far local authorities will appreciate the generosity of the gift he is offering to them. It is important to realise that the grant proposed under the Bill is only in respect of the additional expenditure incurred as the result of the Bill. If the local authority has made heavy expenditure for the treatment of cancer such authority will have little additional expenditure to meet and will consequently have to bear the main part of the burden. On the other hand, the authority that has not done a great deal will get the maximum grant available under the Bill. In one sense that is the intention of the Minister of Health. He wishes to bring the services of the backward authorities into line, but care has to be taken that it does not interfere with, or place an undue or unfair burden upon our local authorities.
1678 The right hon. Gentleman has already drawn attention to the fact that the maximum expenditure is 85 per cent., but that no minimum is prescribed. I am told that the result of this will be that 52 of our 83 county boroughs will receive less than 50 per cent., and some of them less than 30 per cent., and, in the case of counties, 19 will receive less than 50 per cent. This is a matter which requires further investigation on the part of the Minister in order to ensure that there should be no reduction in the grant in any case to less than 50 per cent. I mention this because, quite apart from the financial consideration with which local authorities will be involved and the heavy responsibilities which will be imposed upon them, is obvious that the help of the local authorities is essential. This Bill cannot be put into operation without the wholehearted co-operation of the local authorities, and I hope that co-operation will be available, as it must, if we are to secure success, and, what I am perfectly sure the Minister of Health has in mind—success in making a tremendous assault upon the fortress of this foul disease in our country, and for the success of which assault we all must most fervently hope and pray.
§ 6.7 p.m.
§ Mr. Cooke
I am glad to have an opportunity of saying a few words on this Bill, because in a previous incarnation I was a surgeon. This problem has been quite obviously divided into a lay problem and a scientific problem. From my position I obviously intend to deal largely with the scientific and therapeutic problem, not the lay problem and such points as to whether the road to profligacy and the road to ruin which is being followed apparently by the right hon. Gentleman the Member for South Hackney (Mr. H. Morrison) is due to his own inherent failings, or whether he is being pushed along the road by the Minister of Health. The scientific and the therapeutic problem has been stressed a good deal by previous speakers there are certain parts of it which it is most important one should continue to stress. It has been pointed out that there is no cure at the present time, in the proper sense of the word, for the disease of cancer. There is a cure for the patient, but not for the disease, and that is because up to the present the cause of the disease has not been dis- 1679 covered. It is nevertheless quite certain that by a combination of methods many patients are being cured to-day, and there is no doubt whatever that many more patients will be cured when two conditions are available. First, the possibility of earlier diagnosis and, secondly, the possbility or certainty of earlier and effective treatment.
Every speaker up to the present has stressed, and very rightly, the very important point of early diagnosis, and from a practical point of view I must stress that still further. There is no surgeon who does not recognise that radium, X-ray, surgery, these three, are much less important than the fact of getting the cases known. There is no doubt in my mind that an immensely greater number of patients would be cured if we could arrive at an earlier diagnosis and treatment. How can we reach that stage? It has been pointed out this afternoon that an educational campaign would be necessary. The right hon. Gentleman the Member for South Hackney mentioned that, and there is no question whatever about the importance of that educational factor, but there is also no question about the difficulties. There are many inherent difficulties in this question. To begin with, it is very necessary that, in giving information about this disease and about the necessity of early treatment, we should avoid a thing which is so easy to create, a form of cancer neurosis. All medical men know quite well that although cancer is itself a very serious disease, the fear of cancer is almost as bad, and it is not easy to conduct an effective educational campaign unless we recognise this difficulty and deal with it. As the Minister says, the word "cancer" is naturally a terrible name, and to many people it becomes just a sentence of death.
I think that we can get over these difficulties by stressing one or two things. I believe that they can be got over by stressing the great improvements that have occurred in scientific treatment and by stressing the fact that a very large number of patients can be cured—and cured without operation, which is a thing which people object to—if only they will take steps to be treated and diagnosed, as the case may be, in the early stages. I think that the publicity to which a Debate of this kind gives rise will in itself be valuable—the mere fact of what all 1680 speakers are saying to-day, that there is no question whatever that, if you get cancer in an early stage, in a great many cases it can be cured with operation, and a great many cases without operation. Publicity will be a great help. There is also the Press, which always helps in these matters, and it can be of assistance from time to time. There will often be occasions on which the Press will have an opportunity of giving information on some new method of treatment or possibly some expensive apparatus at some hospital, or some new hospital centre being opened. At the same time they might take the opportunity of delicately pointing out that this gives a great opportunity to people who are prepared to recognise that, if only they take these things in time, they can be cured. I think that in several ways possibly the B.B.C. by means of scientific health talks, in which this particular thing could be gently and delicately brought in, could render assistance in this way.
I am certain that anybody who has had anything to do with this dreadful disease will be with me in stressing the fact that, of all the methods we have been discussing this afternoon, the question of early diagnosis is the most important. We have to get over too, a very natural reticence, and this reticence is very notable in older people and especially in women folk. It is the difficulty they have in drawing attention to something which may be an early stage of some malignant condition but which may actually not be a malignant condition at the time of the diagnosis, and treatment might obviate all the troubles which would arise if they were neglectful. Then there is great reluctance among people to tell their doctors about certain conditions of which they are rather afraid, because they are really not only afraid of mentioning them, but are afraid of the word "cancer" being used. It is not commonly used among medical men, because there are very few people whose disease one is able to tell, nor is it advisable to do it. There are some exceptional cases where it is an advantage to do so, but it is not common. There is very great reluctance on the part of people to see a doctor for fear of the diagnosis that may be given.
A most important thing in relation to the question of fear is the use of quack remedies, and in this regard Clause 4, with the help of the Press, can render 1681 very useful service. In consequence of the weakness of our mental make-up, when people are afraid and obsessed with this sort of dread they are likely to rush to something of that kind, first, because of the fear of the disease, and, secondly, because of fear of the word "operation," which creates a great deal of dread among so many people. I have stressed the importance of early diagnosis because I feel it to be my duty, and I am certain that my fellow medical men will be with me in recognising its importance.
The next important thing is that there should be readily available for the patient for early treatment the resources of the hospitals, the surgeon, the radiologist, the expert in radium, and the nursing staffs. To suggest that there need be any fear of this team of experts is quite wrong. When a patient comes for diagnosis he or she will be liable to see more than one person, but it would be a mistake for people to get it into their heads that they will have to face a team of experts, somewhat like the process of a picture submitted for the Royal Academy having to go before and be judged by experts. It does not work out like that. The consultation in such cases would largely be an exchange of information between the radiologist and the surgeon, not as a matter of quarrel as to the best treatment, but whether the case is one that could probably be cured by some form of radiation, or whether it would require operation first or, as very frequently happens, preliminary radiation for the purpose of making operable a case which was not before operable. There are many cases of operation after previous radiation treatment, and it is important to continue treatment of that kind even long after the operation has been performed.
With regard to the question of training, it cannot be stressed too much that this is a very important part of the Bill and that the Bill cannot succeed unless there is a fully skilled body of people who can deal with the cases in the various centres. I do not think it will be possible under the Bill to give all the increased educational facilities that are needed for the purpose of training people. It is most vital that every opportunity should be taken to give the fullest scope for further education in this direction, because the X-ray and radium are most dangerous weapons. The so-called cure of cancer is a destructive treatment, that is, the 1682 destruction of the cancer, but radium and deep X-rays are also equally dangerous for the destruction of the normal tissues of the patient and of the person who uses them. Therefore, the utmost skilled training must be given.
I should like to say a few words about the suggestion that this might be regarded as a Radium Bill. The Minister of Health stressed the fact very definitely that it has no such intention, and I hope that fact will be generally recognised. It is most important that it should not be regarded as a Radium Bill. In recent months, perhaps years, the value of the deep X-ray, compared with radium, has been increasing in reputation. The X-ray has a certain advantage. In the first place it is much less expensive, it can be applied with a greater degree of safety, it has a deeper penetration, and it can be made more regionally available all over the country. I believe that especially in superficial cases it is more effective than radium. I do not want to spend too much time on the scientific side, but most people know now that radium is used in a variety of ways. It can be used purely locally for superficial cancer. It can be used by the injection of radium needles by operative methods, and it can be used in a form known as radium bombs, which have a deeper penetration. The cost of the X-ray treatment, if it is as effective, is much less expensive and more economical because, as I have said, you can spread the treatment more over the country.
With regard to research, I agree with what the previous speakers have said. That is of the utmost importance. There are two kinds of research. There is therapeutic research, and the Bill will certainly increase the opportunity for therapeutic research, in so far as it increases available beds, encourages the production of radium, the production of X-rays, and the promotion of early diagnosis, X-ray diagnosis, and so on. Every bed that is made available for the treatment of cancer is a source of therapeutic research. In addition to that, there is research of a physical character, but that is largely not in the hands of the medical man. There is great scope for work at the present time in deciding whether deep X-ray is superior to radium treatment. There is an instrument in use called the cyclotion. I do not understand it myself, so I will not attempt 1683 to explain it to the House, but it produces what are called neutrons, which are said to have a penetrating power five times as great as radium and deep X-rays. There are, I understand, only two of these instruments in the country to-day, one at Liverpool and one at Cambridge. It was invented in the United States.
I mention these things to emphasise the fact that scientific progress is constant and progressive, and although at the moment there may be a suggestion that £500,000 should be spent on radium, we must contemplate the possibility that within a year or two something much more important and much more effective will be available. There should, therefore, be every opportunity to use every new process that comes along. It is most important that the research and the funds should be made available not only for radium but for any other treatment that may be equally or possibly more effective.
In regard to hospital work, it must be recognised that a most important thing in connection with cancer is the follow-up observation treatment. When a case of cancer has been treated by operation or radiation the case must be followed up for a period of possibly four or five years, so that if there is the slightest recurrence it can be dealt with at once. Although a case may appear to have been the subject of a successful operation or successful radiation, it cannot be considered cured until a considerable period has elapsed, and one of the most important functions of hospital work is the follow-up treatment. The Minister has linked an important provision with that, by arranging that the travelling expenses of the patients and of friends who accompany them may be paid. Otherwise there might be a great tendency on the part of people who cannot afford the expense, to neglect the second, third, fourth and even the fifth visits which ought to be paid to the hospital, and thereby the great good that has been done may be undone by the later neglect which might easily have been avoided.
On the whole, the Minister of Health has brought in a Bill that will prove magnificent in its effects. It will be of great use, with the help of the factors that I have mentioned. As a final word, because I have stressed it from the first, 1684 I would say that among all the facilities that can be provided, early diagnosis and early treatment are the first essentials of the successful operation of the Act.
§ 6.27 p.m.
§ Major Milner
The hon. Member opposite will not expect me to follow him into the medical and scientific details into which he has gone with so much acceptance, but I join with him in giving a very cordial welcome to the Bill. I am one of those laymen who have for some time taken a considerable interest in this problem of cancer, and I very sincerely congratulate the Minister on this constructive effort. It is a first step and it is often said that the first step is the most important. My only regret is that the Bill does not go as far as some of us would like. There arc one or two preliminary matters with which I should like to deal before coming to the Bill as a whole. There is one curious omission in that there is no definition Clause. There is no definition of the term "cancer." It is extremely desirable that there should be such a definition and that the definition should be in the widest possible terms, so as to include every type of this malignant disease. I hope that in Committee or elsewhere the Minister may think it right to remedy that omission.
A good deal has been said about the submission of schemes by the local authorities to the Radium Commission. I will not go into that matter in detail, but it is a remarkable course of procedure. The usual course is for the local authority, after consulting its local association of medical men, or otherwise, to submit its scheme to the Minister, and the Minister then submits the scheme to or consults with a national body such as the Radium Commission. I think it is quite contrary to precedent for the burden to be put upon the local authorities of consulting the Radium Commission. I should have thought that the proper course was for the Minister to do that and to obtain some general guidance from the Commission, and then see that the schemes of the local authorities fall into line with the proposals of the Radium Commission.
Then there is the question of cost, on which a great deal has been said. There is one curious thing about it. My right hon. Friend made it clear, and the 1685 Minister did not contradict him, that grants will be made only in respect of additional expenditure. There are local authorities, some in my own county, Leeds and Bradford, which have incurred expenditure in connection with cancer. The City of Bradford has a cancer officer. Surely if that cancer officer is continued in his employment, as I hope he will be, and if this employment is included in a scheme submitted by the City of Bradford, the Government will make a grant in respect of the salary paid to that officer? One cannot expect a grant in respect of retrospective expenditure, but there should be no question about a grant for that expenditure if it is part of a scheme submitted by the local authority. In any event the Government ought not to make any grant of less than 50 per cent. to any local authority, I hope it will be more in the case of needy authorities.
The object of the Bill is clearly stated to be the early diagnosis and treatment of cancer. I am rather surprised that no previous speaker has mentioned the one thing which in my judgment, and in that of others much better qualified to speak, would ensure early diagnosis and treatment. I refer to notification, preferably compulsory notification, but, failing that, voluntary notification. I know that are objections on the part of a great many people to compulsory notification, but surely the advantages which have been demonstrated, particularly in the case of tuberculosis, far outweigh the objections and disadvantages. At present there is a conspiracy of silence on the part of all concerned in the matter of cancer. The patient remains in ignorance until such time as a knowledge cannot possibly be hidden from him or her, and frequently such knowledge comes far too late and nothing can be done except for the patient philosophically to bear it to the end.
§ Sir Francis Fremantle
Will the hon. and gallant Member tell us how notification would help this disease?
§ Major Milner
I am proposing to do so. I believe there are to-day many people who would prefer to be told the truth, and if that was done at the earliest possible moment quite obviously those who suffer from this dread disease would understand and appreciate the importance of following instructions and taking 1686 the best advice. If that was done at an early stage of the disease, I am sure there would be a greater likelihood of cure than if the knowledge was kept from them until a much later stage. I think that notification would assist in the maintenance of a statistical survey of the disease, in a proper supervision from the early stages of the treatment, and, in addition, enable a better and a more widely spread experimental treatment to be carried out. The same problems had to be faced in the case of tuberculosis. It became a notifiable disease, and since that time by reason of the publicity given to it and by education there is ample evidence of the beneficial results which have followed upon notification, and I think there should be notification in the case of cancer.
In Leeds in 1925 there were 7,599 cases of tuberculosis, and to-day by notification and the appointment of tuberculosis officers—an example which I think should be followed in the case of cancer officers—that figure has been reduced to 3,046. The percentage death rate in Leeds from tuberculosis dropped between 1925 and the present year from 1.28 per cent. to 8 per cent. whereas the death rate from cancer has risen from 1.5 per cent. to 1.75 per cent. There has been a drop in the cases of tuberculosis and an increase in the cases of cancer. It may be said that compulsory notification would be difficult. In Bradford and other places there are schemes of voluntary notification, and I understand that they are of great help, particularly where cancer officers have been appointed. I hope the Minister will see that in all schemes submitted there will be appointed cancer officers whose duty it will be to keep in touch with cases of cancer and see that the best treatment is given and that appropriate information is kept, as it might be so useful.
It is now recognised among medical authorities that while radium is best in the treatment of cancer it can never become a real cure. I am not at all sure that the lavishing of enormous sums of money on radium treatment, to which so much public attention has been directed, has not hampered the discovery of an aultimate cure in perhaps some other direction. I have been reading the report of the British Empire Cancer Campaign. It is an exceedingly illuminating document. 1687 Some of the figures are appalling in respect, for example, of cancer of the tongue and rectum, and I feel that the Bill should make provision so that other forms of treatment might be accepted and encouraged as well as radium treatment. I think that the crux of the whole problem is the question of research, which is not provided for in any way in the Bill. What are the Government going to do by way of inquiring into the cause and prevention of cancer? At a meeting of the Yorkshire Cancer Campaign held in May last a distinguished medical man, Sir E. Mellanby, said:Medical experts trying to find a cure for cancer are completely flummoxed.Surely the Minister proposes to do something to assist research and experiment? It has already been said that there are a number of voluntary organisations, the Empire Cancer Institute and the British Empire Cancer Campaign. I had a very illuminating experience in connection with the British Empire Cancer Campaign and that experience has led me to think that its operations are very unsatisfactory. I had a case brought to my notice of a medical man who evolved a theory of his own in regard to the cause and cure of cancer. At his own expense he tried it out. On a number of cases which were too far advanced for conventional treatment he obtained extremely promising results. He continued his experiments and obtained really spectacular confirmation of his views, and obtained an improvement in cases which had been given up by other doctors as hopeless. His theories were investigated by a great authority in the country on inoperative cancer, who suggested that he was obtaining results which could not be explained in the light of present-day medical knowledge. Other medical authorities expressed approval.
One of the greatest cancer hospitals of this country said that they would take this particular individual as a clinical assistant in order to try out his theories, subject to one condition, and that was that the British Empire Cancer Campaign would make a grant of £500 a year to the hospital in order to cover the costs of the year's work. A delay of no less than a year took place before any decision was given and then it was that the application was rejected. To this day no reason has been given for that rejection. 1688 It seems to me, as is very often the case, that the medical profession is honeycombed by vested and personal interests, and I hope the Government by this Bill will take steps to control or do away with some of these vested interests. I know that the hon. Member for St. Albans (Sir F. Fremantle), though associated with the work of the Campaign, had no part or lot in this particular matter and indeed has done his best to put it right. The gentlemen ornamenting the council of this particular organisation form a constellation of talent but are almost all specialists. Nearly every one has some particular axe of his own to grind. An oculist would be a public menace if he decided to remove an appendix. A radiologist only understands his instruments and a surgeon is just a surgeon.
The general practitioner has no place in the councils of the British Empire Cancer Campaign, nor has he any place in the Government's Bill. I hope the right hon. Gentleman will see that the general practitioner has a place in these proposals. He is the only member of the profession who has to consider the problem of cancer from every angle and co-ordination of findings is his speciality. It is a curious thing that in the medical professions great eminence does not always mean great inventiveness. The plums are usually awarded to those who are best at applying the knowledge gleaned at great sacrifice by pioneers. I hope therefore that the right hon. Gentleman will do something to help research and experiment. Such organisations as the British Empire Cancer Campaign receiving as they do large sums of public money have a positive duty in my opinion to back up and try out any form of treatment of cancer, however unorthodox, which has any possibility of success and, in view of the very unsatisfactory experience I have related I suggest that the Government should consider taking some form of control over the operations of this body or better still should take over the work altogether as a State service.
Reference has been made to the subject of education. I hope that one result of the Bill will be to educate the public, and to bring about a much more hopeful and active outlook than exists at present. After all, a good many things can properly be told the public to-day. For example, they can be told, even in the 1689 present state of medical knowledge, what are the highly probable causes of chronic irritation and cancer. They can be told something about the detection and treatment of pre-cancerous conditions. They can be told, in plain language, of the desirability—indeed, the absolute necessity—of seeking competent advice and treatment during the early stages of a condition which may eventually prove to be malignant. Above all, they ought to be told the truth of the axiom that cancer is initially a purely local condition and therefore frequently curable by radium or by an operation, or by other means. I hope that this Debate and the Government's efforts will bring to many peoule that hope of life which they have not at present, and that as a result of the Bill there may be a diminution and eventually the disappearance of the scourge of cancer.
§ 6.47 p.m.
§ Sir Waldron Smithers
I wish to join with other hon. Members in welcoming, on humanitarian grounds, the introduction of this Bill. I am sure that everybody will be grateful to the Government. I intervene in the Debate because I have a very close friend and a relative who are in the front line of the battle against this dreaded disease, and who are actively engaged in practical and research work. By letter and in a conversation, I ventured to criticise the action of the Minister in introducing this Bill without consulting the experts engaged in the treatment of the disease, but I am informed by the Minister—and I see my mistake—that the Bill concerns machinery and finance, and does not deal with the methods of treatment of cancer. Therefore, there is still time for me to express to my right hon. Friend my feeling that it is important that the arrangements for treating the disease will be made after the passing of the Bill, and not before its passage. What those arrangements should be, and what are the definite plans of the Government in regard to combating this disease, are questions of vital importance.
I want at the outset to lay down the general principle that the powers under the Bill and the money available ought to be used to treat the greatest number of sufferers. The treatment of cancer is still in an experimental stage, and the Government and the profession are still 1690 playing with fire: but I heartily support the Bill, and beg the Government to go on with their efforts. I should like to give one or two indications as to the way in which I think the Government should proceed. As a result of my close connection with experts, I have been told that new developments in the methods of treatment are taking place almost daily. For instance, only last week, the experts working in one of the biggest cancer hospitals, who had always believed that the point of focus of certain rays was point X, discovered, after much research, that the focus does not point there, but to a slightly different spot. That may have wonderful results in the treatment of cancer. There seem to be three methods of treatment—first, deep-ray therapy; secondly, treatment by radium; and thirdly, removal of the growth by a surgeon. All these three methods have their part to play in the treatment of cancer.
The Minister devoted a large part of his speech to the question of radium, but as one hon. Member has already said, there is in the minds of the public and the profession—perhaps quite wrongly—a feeling that too much insistence is being placed on the use of radium. Before the Government spend large sums of money on radium, I ask them to make further inquiries as to the development of the cure known as the cyclotron, which requires much further consideration. I am informed by one of the biggest experts in the treatment of the disease that the cyclotron may entirely supplant radium. I wish to make it clear that I am not advocating one method of treatment above another, for I have not the technical knowledge to do so.
The main principles which ought to govern the Minister and the Ministry are that the amount of money available should be made to go as far as possible and the method of treatment decided upon should be designed to treat the greatest number of sufferers. I hope that the discussion of these methods will not develop into a dog-fight between the specialists, for all the methods have their place in the treatment of cancer, and I ask that their relative position should be considered in relation to the problem as a whole. The requirements for the treatment of cancer are, first, that there should be improved facilities for early diagnosis, and secondly, that treatment by the most modern methods should be made available to the 1691 largest number of patients. These two requirements can be satisfied only in centres where there are all modern facilities, and where the services of expert surgeons, X-ray and radium therapists, beds, operating theatres, X-ray apparatus and radium and physical laboratories, are available. I am glad that the Minister, in his speech, realised the danger of these methods of treatment being placed in the hands of people who are not expert, and I hope that when he is setting up the centres he will concentrate on having comparatively few and efficient centres, and not many centres where the necessary apparatus and trained staff may not, for the present, be available.
Progress in the treatment of cancer depends upon the co-operation of trained persons, and to put X-ray or radium treatment in the hands of unskilled persons, without the necessary ancillary services, is dangerous. Only last week, I was informed of a tragic instance of that nature, and that is why I speak with great feeling on the matter. The primary consideration must be the protection of the patient to ensure that, in applying treatment, the danger to healthy tissue is not greater than the relief afforded to diseased tissue. One of the greatest experts in the land states that it is his opinion that cancer patients cannot be treated in their own homes. It is for that reason that I welcome so much the provision in the Bill for travelling expenses for patients, and it is an instance of the warm-heartedness of my right hon. Friend that he has also thought of providing travelling expenses for companions. That expert is further of the opinion that there is no case of cancer to-day treated by radium, that could not be treated as well, and far more economically, by X-rays. Another point to which reference has been made is that some provision should be made in the Bill for the after-care and the following-up of cases. The Clause concerning advertisements receives my support, because I believe it will do much to help the expert work to go on.
I should like to make a constructive suggestion with regard to research. I would like to see it made statutory that statistics should be kept of every case at the centres which are to be set up. In time, through those statistics, the progress and success of various methods could be compared. I understand that 1692 at present there is a questionnaire which doctors and cancer hospitals are asked to fill up, but I understand it is very inadequate, and does not result in information being given which can be used afterwards. I suggest that that questionnaire should be redrafted on the advice of experts.
Returning to the methods to be adopted to treat the maximum number of patients, the following figures are instructive. A five-gramme radium unit gives an average individual daily treatment time of 45 minutes; and such a unit is capable of treating about 60 patients yearly. It should be noted that at the present time the number of trained personnel available for using such units is very small. The X-ray apparatus is very much lower in initial cost; its effective penetration is much greater than in the case of radium. With the improved type of X-ray apparatus in general use to-day, the average individual daily treatment time is about 10 minutes; and the number of patients treatable by such an apparatus is not 60, but 250 a year. To sum up this point in one concrete example, the following figures, which I believe to be fairly accurate, have been worked out. Taking an X-ray plant costing £3,000, then to produce the same dose per minute on 'the skin and the same penetration of the radiation with radium, would necessitate the whole £500,000 which the Government propose to spend being devoted to one single radium unit.
On another basis of superficial treatment, one radium bomb will treat 400 cases in one year of a limited type; an X-ray apparatus will treat from 3,000 to 4,000 cases a year of a limited type. From the practical point of view, the group of patients with cancer suitable for X-ray treatment is very much larger than the group suitable for radium treatment. From the economic point of view, X-rays have many advantages over radium, both in initial cost and in the number of patients that it is possible to treat. I want to stress very earnestly that to spend a large sum of money at the present time on the purchase of radium is neither economical nor what is required to tackle the cancer problem efficiently. The "Times" put this point of view in a nutshell in a leading article on 7th December, from which I will quote briefly. It was stated in that article that X-ray treatment is: 1693at least as satisfactory as that provided by surgery or by interstitial radium therapy. It has further this great advantage that the results are obtained without mutilation of the patient…The case histories given in the Report so fully bear out these general conclusions as to exert an effect of surprise upon instructed minds. There is clearly a case here for further research.I have received also a most interesting letter from Dr. Frank Cook, who is Hunterian Professor and Examiner at London University. I showed him the letter which I wrote to the Minister, and in reply he said that he was in general agreement with my observations to the Minister, and that he hoped that too much stress is not going to be laid upon the importance of radium. He has been highly impressed by the results obtained in the radiological department of the Cancer Hospital. Dr. Cook thinks that the terms "Radium Trust" and "Radium Commission" are most unfortunate as applied in connection with this Bill. He makes another very important point and says:The outstanding disease amongst our people to-day and of recent years is neurosis and associated hypochondriasis. I sincerely hope that the Bill in effect will not increase the incidence of cancerphobia, already far too prevalent.Unless this Bill inspires confidence in the public mind and in the professional mind it will do a great deal of harm.
I want to give a few figures from one of our big hospitals, because they are very instructive. They refer to the years 1935, 1936, 1937 and the first II months of 1938. The total attendance of outpatients in the last three years was respectively 48,983, 55,192, and 57,180; the figures for 1938 are not yet available. The number of new cases treated in the radium department for the same years was 200, 235, 174 and 158. The number of new cases treated in the X-ray department was 341, 409, 507, and over 700. To sum up the experience of that hospital, the number of cases most advantageously treated by radium is on the decline, and those most satisfactorily treated by X-ray is steadily rising. I should like to give the total number of patients treated in the X-ray department, being new patients plus old patients receiving a further course of treatment. The numbers for the same years are 680, 937, 932 and over 900. I had a note to criticise the Minister in reference to the Radium Trust and the Radium Commission, but he has 1694 already dealt with that in his speech and has said they will be reconstituted. I do hope that they will be reconstituted, so that all forms of treatment will have a fair hearing and their point of view put.
In conclusion, I want to make one very definite proposal to the Minister, which I hope he will accept. Members of the medical profession in his own Department will be the first to agree that unless they are in daily contact with the treatment of cancer they cannot know as much as practical experts who are daily fighting the disease. The hon. Gentleman who spoke from the Liberal Benches put a question and asked, "Who shall decide?" I would like to repeat that question. Who shall decide to what extent the powers under this Bill and the money provided under it shall be spread over the different forms of treatment? I ask the Minister before deciding on arrangements as to what forms of treatment should be used and how much money should be spent on each form of treatment, to call a conference of experts who are daily engaged in combating this disease. Thus the Minister may be informed of the latest developments and will have expert advice as to the best way to spend the money available so that the maximum number of sufferers can be treated. I submit it is no answer for him to say that he will receive the information and that the Minister of Health and his advisers will then take the decision. I think it will greatly strengthen his hands if he gets together this body of experts and is prepared to take the advice of that body, who have met face to face round the table, and have threshed out as far as they can the different methods of treatment. He will thus ascertain what is the best way to spend the money and to use the powers under the Bill. I should like to congratulate the Minister on producing this Bill. He must feel a proud man to-night to have been privileged to introduce this great and far-reaching Measure.
§ 7.7 p.m.
The Under-Secretary of State for Scotland (Mr. Wedderburn)
I only rise for the purpose of making a very short statement about the position in Scotland, and it will not be necessary to supplement to any real extent the opening remarks of my right hon. Friend. The number of deaths from cancer in Scotland last year was 7,810, which may be compared with 1695 3,635 deaths from all kinds of tuberculosis; but while deaths from tuberculosis are steadily and fairly rapidly decreasing, deaths from cancer are quite as rapidly on the increase. It is estimated that the number of diagnosed cases of cancer in Scotland to-day is over 12,000, and experience in the South-East of Scotland shows that about 25 per cent. of those who have the disease do not seek any kind of treatment until their condition is hopeless, and of the remainder about 40 per cent, do not receive any treatment until their condition is such that the chances of cure are very seriously prejudiced.
The hon. and gallant Member for South-East Leeds (Major Milner) spoke of the necessity, in his view, of notification. Of course, the trouble very often is that people do not know they have the disease until it is too late, and the diagnosis of this disease, to be properly made, needs very special medical knowledge. The ordinary general practitioner in the early stages of cancer may not be able to detect it with any certainty, and one of the purposes of this Bill is that people who are suffering from some complaint which may not appear at the time to be a serious one, but which gives the doctor the slightest shadow of cause to suspect that it might be the beginning of cancer, may be sent free of expense to a consultation centre where they can be examined by highly trained specialists. The chance may not be more than one in 20 that they have the disease, but examination at a consultation centre will greatly increase the likelihood of a large number of cases being detected.
Before the introduction of the Bill my right hon. Friend had a preliminary meeting with representatives of local authority associations in Scotland, and the Department of Health have also had discussions with the local authority representatives, with medical officers of health and with other representatives of the medical profession, and it is generally agreed that the time is now ripe for a determined attack on this disease. There are now in Scotland four radium centres, two of them in Glasgow, one in Edinburgh and one in Aberdeen. The extension of the cancer service in Scotland will probably be based on these four existing radium centres, with the addition of probably one other. From these centres the service will 1696 probably be regionally organised for the whole of the country. The parent centres will be equipped with the most modern diagnostic and therapeutic apparatus, and will be supervised by experienced consultants who are skilled in cancer diagnosis and treatment, and who are competent to assess the relative merits of various different forms of treatment in relation to the needs of individual patients. In addition to these, there will be subsidiary hospital centres, generally in large towns where consultative sessions could be conducted by experts from the parent centre, who would also supervise such treatment as could be carried out at some of the local centres and refer to the parent centre in cases requiring highly specialised resources. These local consultative centres would also be useful for what is called follow-up treatment, that is to say, the periodical inspection of the person who has been cured to make sure that there is no recurrence of the disease.
We propose to set up in Scotland a small advisory committee consisting of persons who have the necessary experience of local government and also of the requirements of treatment. We want this committee for two purposes: to review existing facilities for cancer treatment and the possibility of their expansion, and also to recommend the extent (which is provided for in the Bill) to which it appears desirable that local authorities should combine and act together in agreement among themselves for the purpose of making arrangements on a regional basis. That is of particular importance in Scotland because we have such a large number of local authorities who are responsible for relatively small populations. The accommodation and equipment for radium therapy and X-ray work are very expensive, and it will be very important to avoid needless duplication. There is also a shortage of experts in this specialised field of work, which does, not offer any high rewards to the medical profession, and which only attracts men and women who have a very deep interest in the subject for its own sake. For these reasons it will be particularly necessary in Scotland that local authorities should amalgamate for this purpose on an extensive scale, and we hope that the advisory committee will be able to facilitate arrangements of that kind.
Finally, I wish to refer to the finance of the scheme. The right hon. Gentleman 1697 the Member for South Hackney (Mr. H. Morrison) asked how we had arrived at the figure of £700,000. In Scotland the total expense is £108,000 of which £8,000 is covered by the fees which will be chargeable to some people who may be able to make a contribution, and the remaining £100,000 is made up as follows: A sum of £78,000 is the estimated annual cost of the 300 additional beds which we think will be required in Scotland. The figures which the right hon. Gentleman gave were figures of capital cost. Our estimate is based on the assumption that each bed will cost about £350 a year, which includes both interest charges on the capital cost and the cost of maintenance. Another £20,000 is estimated to be the cost of establishing a number of consultative centres which we do not regard as a very expensive item. I do not think that new buildings will be required, as there is probably enough accommodation available already. The remaining £10,000 is the estimated cost of paying travelling expenses.
As for the rating difficulty, in Scotland as in England the local authorities are inclined to query the distribution of the cost between taxes and rates, but I think it can be said that the burden upon the local authorities will not be very heavy. Twenty Scottish counties and large burghs will receive grants of from 40 per cent. to 60 per cent. of their additional expenditure. Another 21 will receive more than 60 per cent., and only 14 will receive less than 40 per cent. The lowest figure of all is Edinburgh's which is only 25 per cent. We estimate that the total additional expenditure in Edinburgh will be about £10,000. Deducting the grant of £2,500, that will probably leave about £7,500 which represents only one-third of a penny on the rates in Edinburgh. In general I do not think the charge will be more than that. Edinburgh has, as I say, the lowest figure and other authorities receive higher percentages on a scale governed by the block grant formula until the highest figure is reached in Port Glasgow, which receives 85 per cent. If we take the total for Scotland, a penny on the rates brings in about £160,000 for all local authorities, and since the State is paying £50,000 out of the total expenditure of £100,000, that leaves only £50,000 to come from the local authorities which, on the average, is less than one-third of a penny on the rates. In hardly any cases 1698 will the rate be more, and in some cases it will be less, than one-third of a penny, and I do not think it can be suggested that that is an unreasonable or an excessive burden to impose upon local authorities for this very important service.
§ 7.19 p.m.
§ Dr. Summerskill
I join with Members on both sides of the House in welcoming this Bill, because I believe it will make some small contribution to combating this disease of cancer. But it has been regrettable to hear in this Debate speaker after speaker rising to discuss the question of the cure of the disease while feeling that the time has not yet come when we can mention the cause. I listened very carefully to the Under-Secretary of State for Scotland, and I shall leave it to Scottish Members to criticise what he said, but I must make one comment on his figures. I am surprised to hear that in Scotland it is possible to provide a bed for £350.
§ Dr. Summerskill
When I was expressing surprise at the amount I was not surprised at its largeness but at its smallness. Is this capital expenditure?
I thought I had made that clear. That is the annual cost. That £250 includes both the cost of maintenance and the interest charges on the original capital sum.
§ Dr. Summerskill
I thank the hon. Gentleman for his explanation, which certainly does clarify the matter. In England it is difficult to provide a bed under £800 or £900. As I have said, I welcome the Bill because it makes some small contribution to dealing with this problem, but not for one moment do I identify myself with those who hail this Bill as something which will produce startling results.
An hon. Member who spoke from the Liberal benches said that he listened to every King's Speech in expectation of a surprise. He said that this year the "surprise packet"—I think those were his words—was this Cancer Bill. Perhaps 1699 I am a little ungenerous, but I regard the inclusion of this Cancer Bill in the King's Speech as being rather in the nature of a grim catchpenny, because I look upon this Bill as a niggardly method of treating a tragic problem. I cannot but deplore the publicity methods adopted by the Minister of Health when he spoke recently on the radio. I listened to that speech, and while I agree that the right hon. Gentleman did not commit himself, I, as a doctor, knew full well that throughout the country in hundreds of bed-rooms there were incurable cancer patients listening to that radio speech, and those people, no doubt, felt a certain hope springing in their breasts. They felt that, perhaps, something was about to be done for them as a result of this Bill.
What are its provisions? The Minister of Health has tried to convince us that this is not a Radium Bill. I remain completely unconvinced. This should be called a Radium Bill. It is not in the slightest respect a comprehensive Cancer Bill. It is proposed to spend £500,000, and one gramme of radium costs £5,000. At a generous estimate it is proposed to set up 25 centres including the centres which we already have, and this very sketchy Bill is, we are told, a mere outline of the machinery to be set up. But we are told nothing of the organisation. I think the Minister of Health was very wise in that, because all these poor creatures throughout the country, who are looking forward to the setting up of these cancer centres, do not know that in this country we have very little personnel with which to staff the centres. Each centre should have one radiotherapist, but I have been told, on very good authority, that throughout the country there are only eight radiotherapists. Of course it is said that more staff will be produced, but I think those who understand this problem know that a radio-therapist canont be trained in a week or a year. A radio-therapist as distinct from a radiologist is an experienced physician who takes up radiotherapy after many years of experience. I feel that the Minister is over-optimistic when he says that these cancer centres will be adequately staffed in five years. I should put it at, perhaps, 15 years.
The question of research has been raised. The Minister has told us that this 1700 is a comprehensive Cancer Bill. Yet here we are in the year 1938, knowing that 70,000 people die every year from cancer, and my profession has to admit that we know really very little of its origin. We do not know whether it is a bacillus or a virus. We cannot, therefore, approach the problem from the right angle, which is the preventive angle. Surely, therefore, any comprehensive Bill to deal with it should include research. I had influenza last week which accounted for the fact that I listened in quite a lot to the radio. I had the pleasure of listening to Sir William Bragg, who explained in a very modest, but tremendously impressive speech, how his brilliant team of scientists had worked during the last four years on radium beam therapy and he held out hopes of a very bright future. But we all know that those scientists cannot go on working and cannot discover the cause of cancer unless their research is financed. That is one of the most important parts of the cancer problem. Yet in this Bill there is not a word about finance for research. It has always, unfortunately, been the case that medical research has been the Cinderella. We find armaments research and industrial research being subsidised while medical research has to go on, year in and year out, on insufficient means. I do hope that the Minister of Health at this stage will see to it that research into this very important problem is not hampered.
What are the other provisions in this so-called Cancer Bill? I find very little but radium mentioned in it, and I suggest that the Minister is not approaching the problem in the proper way. He should, in my opinion, approach it in the light of the knowledge which we have already acquired. I wish to give the House a few figures which, I believe, will prove rather startling and which ought to have been well digested by the Minister before he introduced this Bill. The Registrar-General, in his annual report, divides the people of this country into five social classes, ranging from the well-to-do, who amount to about 2½ per cent., to the unskilled workmen who are about 17 per cent. The significant thing is that as we go down the economic scale, the cancer death-rate rises sharply, and the Minister should remember that. The poorer you are, the more likely you are to die from cancer. 1701 The other figures that I want to bring to his attention are these: They are figures which have to do with survival rates. We divide cancer in these days into three stages, according to whether it is local or whether the glands are involved. A woman doctor fairly recently analysed many cases taken from hospitals throughout the land, and discovered that if a growth is operated on in its first stage, after three years 76 per cent. of the cases are still alive, in five years 66 still survive, and in 10 years 56. In the second stage, after three years 42 per cent. survive, and in the third stage, when the growth has extended, only 33 per cent. survive. What can we deduce from these figures? They mean that if an individual is fortunate enough to be operated on in the first stage, he has a much greater chance of survival than if he is operated on in the second or third stage.
Before I make a deduction from these facts, I want to bring some other statistics to the attention of the Minister. In a report, I think of the Ministry of Health, the different kinds of cancers were classified, and cancers of the skin, mouth, and throat were found to be twice as common among the poor as among the rich. Why is this? First, because the workers are exposed to more dirt and there is more irritation; secondly, because the wealthier you are, the more opportunity you have of getting operative treatment in the first stage. It is an extremely important point. The Minister will tell me that my figures need more elucidation, because he will say that there is still the sweep getting cancer of the skin and the cotton operative getting it also. We know that during the last three years these two sorts of cancer have decreased and that the sweep and the cotton operative have more knowledge and are taking greater care, but the fact remains that the very poorest are in my figures. It will be seen that twice as many people of the poor than of the rich die of cancer of certain parts. Many of the poor are not entitled to national health insurance, and many of them have to go before the district medical officer, who used to be known, in the old days, as the parish doctor and, unfortunately, is often regarded as an official. As a result of this, they postpone going, and many of the very poor workers postpone going to get advice because they are afraid of losing their work. 1702 The point that I want to bring home to the Minister is that from these figures it is obvious that it is the poor who are not being treated in the first stage. It is a horrible commentary on our society that the incidence of cancer in the generative organs of women increases with increasing poverty. How is the Minister going to tackle this? I am speaking of the poor housewife who has certain disquieting symptoms and of her rich sister who has the same symptoms. The rich woman gets treatment immediately, whereas the poor woman has to postpone treatment. On these benches this afternoon we have had speaker after speaker getting up and saying, quite smugly, "Now, what we have to do is to facilitate early treatment," yet I have listened carefully, and there has not been one suggestion how it can be facilitated. I have heard from hon. Members that the solution of the whole problem is to notify cancer, but, as an hon. Member interjected, what is the object of notification? You cannot compare cancer with tuberculosis, diphtheria, and scarlet fever. Let us think for a moment of the poor woman with cancer of the generative organs. By the time she goes to the doctor she may he like one of the 35 per cent. in Scotland whom the hon. Gentleman has just mentioned, who go to the doctor when it is too late. Nobody has suggested to-day how we are to get these people who are suffering to the doctor in time.
I suggest that there is only one constructive way of dealing with this problem. I have spent my life among diseased people. I have had this woman with cancer coming to me time after time, and, as every doctor does, one always tries to put on an inscrutable expression and pretend to the patient that she has not got anything, but one generally, at the end of the consultation, breaks down and involuntarily exclaims, "Why didn't you come before?" Throughout England and Wales and Scotland there are consulting rooms in the industrial areas, and every year into each of these consulting rooms come these cases, and the doctor says, "Why didn't you come before?" You know that the man or the woman is doomed. The Minister of Health is saying, "I come to you with a comprehensive Cancer Bill. You can send the doomed people to these centres." What is he doing to get these people before they are 1703 in the second or the third stage? I say that he is doing nothing. He is certainly supplying a cancer centre where the general practitioner can say to the patient, "Now you must get radium treatment." I agree that that is being supplied, but what is the right hon. Gentleman doing to overcome this barrier which seems to be between the poor woman and the doctor before she gets there? How is he making it easier for these diseased women to get advice in the first stage? There is no provision at all.
This is something which I understand full well, and what I am going to suggest is, in my opinion, the only approach. What is the barrier between the woman who does not go to the doctor and the doctor? It is very easy to say: She is afraid. We have heard a lot about phobia and cancer phobia, but I am afraid I do not pay much attention to it. I believe that "fore warned is forearmed." What prevents the woman who perhaps has a lump, who perhaps has the first symptoms, going to the doctor in the first stage, when we all know that that is her only chance of survival? The barrier is an economic one. That is the answer. You will be told by many people that the woman does not want to know, but the real reason is that the housewife will economise on every penny. She will have some symptom, but she will put it off because she knows that the money is necessary for feeding her children. Everybody knows it. It is a commonplace. The average housewife is the most un-selfish creature. She always postpones getting medical treatment until it is too late.
What is the right hon. Gentleman going to do? I can assure him that in the industrial areas the smallest medical fee is too high. It is this patient for whom we are now legislating. How is the right hon. Gentleman going to get her to the doctor before she is sent to the radium centre? I suggest that you have to get rid of the economic barrier between the patient and the doctor. What I am going to suggest—I know the Minister of Health has gone to sleep—
§ Mr. Elliot
I have heard every word of the hon. Lady. I am listening very carefully to all she says. I do not agree 1704 with any of it, but I am very carefully listening to what she says, and it is a little hard that she accuses me of sleeping.
§ Dr. Summerskill
The right hon. Gentleman does not accuse me of going to sleep, because I have my eyes open. If he agrees with nothing that I have said, then I can assure him that he does not understand the problem. That is the answer. He does not understand the people. He may have a medical qualification, but he has been such a long time away from the consulting room that perhaps he does not even believe me when I say that these women, among whom we find the incidence of cancer much higher in the poor than in the rich, are prevented from going to the doctor because they have not the fee. I can assure the right hon. Gentleman that what I say is absolutely true, and I can prove every word of it. The right hon. Gentleman has not agreed with a word that I have said, and I know very well that he will not agree with my next word, because I know that the only solution of this problem, the only long-term solution, is to introduce a State medical service in the country, so that the people of the country may have a free health service, just as they have free education. I know that there is nobody on the Government benches who will listen to that. It is a kind of Utopia, but we know that that Utopia will probably come during the next 10 years. May I suggest to the Minister of Health, if he will not even contemplate a State medical service, that he would absolutely remove this economic barrier between the patient and the doctor.
My final word—I shall not bore the right hon. Gentleman any longer with these extremely unpleasant details—is that he should consider—and successive Governments have supported this principle—including the dependants of the insured person under the National Health Insurance Act. In 1911 the National Health Insurance Act was introduced. The insured workers can take full advantage of the doctors, but still there are these women, the wives of the insured workers, and the right hon. Gentleman knows that the incidence of cancer among these women is very high and plays a great part in making this terrible total of 1705 70,000 deaths a year. Will he consider including the dependants in a National Health Insurance scheme, so that these women may have an opportunity of consulting a doctor in the very important first stage?
§ 7.44 P.m.
§ Sir Ernest Graham-Little
I would like to ask my right hon. Friend the Minister of Health a question which I put to him some time ago as to what persons or institutions he has consulted who are engaged in research as well as in the treatment of cancer. I have tried to find a possible source of his information. I have had interviews with the president of the radiological section of the Royal Society of Medicine. Anyone who is familiar with conditions in London will know that that society is the fountain head of special knowledge. Its section of radiology, which includes experts from all over the country, deals with this particular subject. There are two hospitals in London which have specialised for many years in the treatment of cancer. The Middlesex Hospital has probably the largest and best equipped cancer department in the country. Westminster Hospital has an equally large section of its beds given to this purpose, and spends £20,000 a year on that part of its work. The surgeon in charge of that department came to this country with special knowledge of radium and his colleagues on the staff of that hospital submit all their cancer patients to his treatment. In particular, cases of cancer of the breast were handed over to him for three years for radium treatment with the result that operation for breast cancer is now seldom done. I think the Minister might have consulted the experts who have knowledge and experience behind them.
Do the poor people who are treated in these hospitals have to pay for the treatment?
§ Sir E. Graham-Little
That is a difficult question to answer. As a rule the fees charged are worked out by the almoner after an inquiry into means. There are few patients who cannot pay something, and it is a very impressive trait in these people that they want to pay, but no patient is refused treatment for lack of means. I cannot help thinking that the Minister is mistaken, no doubt genuinely, in thinking that this Bill will not be re 1706 garded as a radium Bill. I find consternation in the ranks of those who practise this special subject. I have had conversations with many of them, and they say that the net result of the Bill will be to impress upon the public that there is nothing but radium for the treatment of cancer. Unfortunately—and this often happens in Government Departments—the Minister has not overtaken the actual therapeutic position of the treatment of cancer.
Radium is really a receding force rather than an advancing one. It is not nearly so safe as some other treatments, and it requires the most expert and special knowledge. The hon. Member for West Fulham (Dr. Summerskill) suggested that there were eight persons able to give specialised radium treatment in this country. I went through the Medical Directory last night with the president of the radiological section and we reviewed all the principal hospitals in England and Wales, and we came to the conclusion that there were about 25 really expert persons who were capable of treating with radium as well as of carrying out other treatment. It is true that the supply of these specialists must be very small in comparison with the number of radiologists, who do not confine themselves to radium. X-rays are used for many other purposes. There is a livelihood to be made out of X-rays which is not to be made from radium, apart from which cancer is a very depressing thing in itself. My friend at Westminster Hospital has had 4,000 cases under his care in the last 10 or 12 years and he has told me that he would never do that work if he had his time over again.
I would beg the Minister to make certain alterations in the text of the Bill. He says he is giving other methods of treatment a chance, but I find no mention at all of other methods except in Clause 3 where there is a vague reference to radioactive substances. I beg him to include X-ray therapy definitely by name, to include also surgical treatment and facilities for travel in surgical cases as well as in radium cases.
§ Mr. Elliot
All these things are certainly there. Facilities for travel are there. It would be wrong to detail in the Bill all the methods of treatment that might or might not be used. "Adequate facilities" cover surgery and X-rays, and travel 1707 facilities would apply to them as well as to radium. I beg my hon. Friend to dispel the idea that this is a radium Bill.
§ Sir E. Graham-Little
How general that impression is will, perhaps, be evident if I read an extract from a paper which has a large circulation among general practitioners.
§ Mr. Elliot
I am acquainted with that paper, but surely we as informed citizens should not spread misconceptions but do our best to dispel them. If my hon. Friend needs any further assurance from me I shall be glad to give it, but I have repeated more than once that there is no suggestion of cutting out surgery from the treatment of cancer. It would be foolish if I attempted to do it. Do not let us stress that misconception.
§ Sir E. Graham-Little
In the admirable report of the Chief Medical Officer there is an interesting and important chapter on cancer, and hon. Members who are taking part in this Debate would be well advised to read it. One of his most pregnant sentences points out that the advice given in the propaganda of one of the big societies is, "Go and see your doctor as soon as possible." I would ask how likely is it that the doctor will make the diagnosis? That is a vital part of this question. It is the inability, not from any fault of his own, of the general practitioner in many cases to diagnose cancer in its early stages. It is a very difficult diagnosis. I was for 30 years in charge of a department where I had constantly to give that diagnosis, and I know how difficult it is. When there are circumstances in which there is no help, the diagnosis becomes infinitely more difficult. How are we to remedy that state of affairs? It may be said that we should improve the education of the general practitioner. Only this month the General Medical Council has made a new curriculum governing medical education in England. I am very dissatisfied with it, but I will tell the House what it is proposed to teach students in the course of three years. They are to know all that it is possible to know of general medicine, general surgery and midwifery, and in addition certain other special subjects that are named, 3o in all, of which radiology comes last.
Is it possible to make any sort of contribution to the education in radiology of 1708 the practitioner in circumstances such as that? It is a difficult question, but it is one we must tackle because it is the general practitioner who sees the early cases. Unfortunately, the general practitioner is not in love with this Bill. The right hon. Gentleman tells me that he has read this paper. He will see in it a statement that there is general distrust of radium which the Bill treats as the only modern method.
§ Mr. Elliot
What that paper said, I think, is that there is a general mistrust of radium if that is to be the only modern method. That is the misconception which we should do our best to dispel. When the hon. Member quotes a paper which is based on a misconception, and which he is assured is a misconception, he should do his best to see that it is dispelled.
§ Sir E. Graham-Little
My point is that there is this misconception, and that it is unfortunately an important misconception; but I do not think the Bill will dispel it. It becomes even more necessary here than in any other department of medicine that the general practitioner should be more able to recognise the disease. The practitioner has become a kind of sorting machine to the consultant or the hospitals. That position is a very unfortunate one in this connection.
I want to say a word about the methods of management of these centres. I am voicing a considerable section of specialist opinion when I say that the scheme of having this arrangement made entirely through the local authorities is very suspect. In London the voluntary hospitals will be distinctly uncomfortable at the idea that they have to apply to the London County Council for any help under this scheme. Let me give a concrete instance. I cannot speak of it at first hand, but I am assured it is mainly correct. A certain provincial county council decided to present £10,000 to buy radium for use by four hospitals in the county. It was suggested to the four hospitals that the money would be given to them if they handed over their beds to the authority which was going to appoint a specialist officer to conduct the treatment of cancer in those hospitals. The staff of the hospitals said they could not consent to the arrangement, and the four hospitals had unanimously refused to accept the £10,000. 1709 Let me give another instance of the miscarriage of a supply of radium which came under my notice. A certain county hospital was able to make a gift of £6,000 for the purchase of radium for use by the hospital. The staff consisted of four persons, none of whom had any experience in the use of radium. The superintendent was sent to Paris to learn how to treat cases with radium, and in a month he came back an expert in radium-therapy. It is cases of this kind, of obvious inexperience in its use, especially some years ago, which partly explain the distrust of radium which I have cited. I can absolve myself from the charge of being a person prejudiced against the use of radium. About six years ago the Radium Commission of that date proposed to break up the single four-gramme bomb which was in use in this country at the time. A long correspondence initiated by myself ensued in the "Times" protesting against that action, but no regard was paid to it by the Commission, which broke up the bomb forthwith, but two or three years later it was acknowledged that they were quite wrong, and now the big bomb has come into its own more than ever.
In this connection I have a word to say about the Radium Trust. As constituted at the present time it consists of eight or nine extremely eminent persons who, perhaps, may best be described as extinct volcanoes in medicine. Hardly any of them have any recent experience—many of them are personal friends and contemporaries of mine, so that I am in the same category—and are not well acquainted with recent developments in cancer treatment, and are not in a position to decide what treatment shall be adopted when a great scheme like this comes before the public I submit that that is not a very desirable state of affairs, and I hope that the Radium Trust will be radically altered to fit in with the present scheme.
My last word must be about research. I think that research is quite impossible without the resources of a big general hospital. It is impossible to carry out even the minimum of research without a large team to undertake it, and if anyone has any doubt about that view, I ask him to read the report of the Beam Therapy Research, in which it will be seen how many experts are required to supervise that research. The conditions necessary are, I submit, not to be found anywhere 1710 except in the general hospitals, and I would add, the big general hospitals—the voluntary hospitals—more particularly because the staffs in voluntary hospitals are always very much larger than those in any municipal hospitals of which I have any knowledge. What are the lines upon which research might be possible? The prevalent view, and probably the correct, is that the cause of cancer is an ultra-microscopic virus, which means that it has not been discovered by any microscope at our disposal at the present time. Surely the obvious remedy for that is to experiment with better microscopes. There is already a microscope in Germany which has a magnification of 5,000 diameters, which is much larger than any magnification we have in this country; and although it may be a fairy story, I have heard of a microscope and, indeed, I have seen a picture of it, which is said to have cost £50,000 and will magnify 30,000 times. With microscopes of greater power the prospect is very strong that we shall be able to find the actual cause of many diseases which at present are rather glibly described as ultramicroscopic.
I submit that it is in that direction that money should be spent, and freely spent, and I fully agree with the last speaker that provision for that part of the cancer problem, in my opinion much the most important part, has been scandalously under-estimated in the scheme. I can see no provision at all made for it, and I think it is a misfortune that it has not been specifically mentioned. I close with what I fear is a rather pessimistic statement: that I do not think this Bill is receiving enthusiastic support—I will put it as mildly as I can—from either the section of the medical profession whom we call general practitioners or from the specialists, of whom I am one.
§ 8.5 p.m.
§ Colonel Nathan
Any step in the direction of mitigating the scourge of cancer must be welcome, and this Bill is such a step, but, of course, it covers only part of the ground. As my hon. Friend the Member for West Fulham (Dr. Summerskill) pointed out in her very suggestive speech, and as my hon. Friend the Member for London University (Sir E. Graham-Little) added at the end of his speech, this Bill is of a limited character. By its very title it is limited to provision for the treatment of cancer and other 1711 matters in connection with the treatment of cancer. There is, of course, a great deal of research being done, but there is nothing in this Bill which would enable any local authority to expend any sum of money either by way of initiating research or making a contribution towards research. Indeed, the fact that the Bill is so specific as to the matters upon which a local authority may spend its money or exercise its powers, is an indication that everything is excluded save that which is in terms included. I agree with the hon. Member for London University, as I agree with my hon. Friend the Member for West Fulham, that the greatest hope for the future lies in progressive research, and I should like to think that the Minister will be able to give some assurance to this House that the local authorities will not be excluded, as they seem to be by the terms of the Bill, from the possibility of playing a part in research, either by undertaking it themselves, though I doubt whether they have, or are likely to have, the facilities for adequately doing that, or by making some contribution to those who are actually doing research at this time.
I was greatly interested to learn from the Minister that this was not a radium Bill. That was a disavowal which it was very important to have from him. Before I come to another matter I wish just to refer to the Clause, occupying no less than two full pages of the Bill, dealing with the prohibition of certain advertisements. When the time comes for discussing those provisions in detail I think certain amendments will be desirable for the purpose of making it effective. But my real object in rising is this: The hon. Member for London University, like the hon. Member for West Fulham, speaks with a large professional experience. One is a medical man who is a specialist, I think, in these matters, and the other is a medical woman with much and wide experience, and I speak merely as a layman. The hon. Member for London University referred to Westminster Hospital. I happen to be a governor and an active member of the house committee of that hospital. I will not pretend to the House that that gives me any knowledge sufficient to enable me to take the least part in any technical discussion upon this highly technical matter, but it does enable me to make one or two observations on 1712 an aspect of this Bill which falls as much within the province of a layman as of a medical man.
I am astounded to learn that although voluntary hospitals are mentioned in the very first Clause of the Bill, and the Bill contemplates arrangements being made with voluntary hospitals as regards the treatment of cancer, some at least of the most important of those hospitals, some which have undertaken the most important and progressive cancer treatment in the country, have not at any point been consulted with regard to the provisions of the Bill or how it will operate. I speak in my personal capacity, of course, and for no one save myself, but I am in a position to say that neither the Westminster Hospital, nor St. Bartholomew's Hospital, nor the Middlesex Hospital, three of the hospitals which are in the very front rank in the treatment of cancer, has been consulted upon any aspect of this Bill, and as far as I understand it they have had to rely for the whole of their information upon the terms of the Bill and the memorandum by which it is prefaced. It seems all the more extraordinary that the voluntary hospitals have not been consulted when it is borne in mind, as far as the Westminster Hospital is concerned—hon. Members should remember that it is the House of Commons hospital—that it has been carrying on specialised treatment of cancer for the past 10 years and holds one of the largest supplies of radium in the country. It has not been approached in any way with a view to its co-operation, nor has it been told what may be expected of it.
The hon. Member for West Fulham referred to the address given on the wireless by Sir William Bragg with regard to radium beam therapy. The Westminster Hospital is the pioneer in this country in beam therapy, and yet there has been no consultation with it regarding this Bill. It is very much a matter for criticism that with all the experience gained at the Westminster Hospital and also at St. Bartholomew's and the Middlesex—and for all I know the other great hospitals are in a similar position as to ignorance of the terms of the Bill, though I cannot speak about that with precise knowledge—those hospitals should not have been consulted or told how they can help in putting at the disposal of those charged with the administration of the London services the 1713 experience they have gained over a period of years.
The Westminster Hospital authorities are engaged upon building a great new hospital. The building and equipment are in an advanced stage. The hospital will be complete, according to present plans, in the early part of next year. At present there are 21 cancer beds, and there is a highly-skilled staff of physicians and technicians who are working in specially constructed and specially equipped laboratories. This unit could be doubled within a very short space of time if the hospitals were called upon to take any part in the service. Within a few months, all the arrangements of the new hospital will have been completed. This hospital will have been finished and opened. If, at that last moment or afterwards, it should be asked to make arrangements for additional accommodation, there must necessarily be a great deal of avoidable difficulty and expense.
I should like to ask the Minister what voluntary hospitals have been consulted and what has been their attitude in those consultations towards the provisions of this Bill. If some voluntary hospitals have been consulted, how is it that the Westminster Hospital, St. Bartholomew's and Middlesex have been excluded from the consultations, although I suppose they rank as high as any hospitals in this matter? Is it that the Minister has developed the scheme out of his own inner consciousness without consultation with those who have had great experience, and, if so, how comes it that advantage has not been taken of that experience in the framing of the Bill which has, in many respects, so much to commend it?
§ 8.17 p.m.
§ Sir Henry Morris-Jones
In common with nearly all who have spoken on the Bill I should like to congratulate the Minister on its production. I am rather surprised to find that the Bill is arousing a little controversy. The hon. Lady who spoke from the Opposition benches is not here now or I should like to have taken up with her the latter part of her speech. The hon. Lady seemed inclined to take rather a party view, or a Socialistic view, at all events, of the subject. She attempted, for example, to suggest that the poor suffer more from cancer than do the rich, but that suggestion is not justi- 1714 fied by the facts. I speak as one who has been in general practice, a large practice, for over 20 years, and I may say without the slightest hesitation that there is nothing to establish the point made by the hon. Lady that cancer is a disease that attacks any particular class. Cancer attacks irrespective of class or section of society, or even mode of living, so far as I know. I am rather sorry that the hon. Lady introduced that point.
§ Mr. Rhys Davies
Will the hon. Member pardon me for interrupting? He said that he had been in practice. I understand that he was in practice in Colwyn Bay for 20 years. If so, will he say whether there are any poor at all in Colwyn Bay?
§ Sir H. Morris-Jones
I am afraid that the hon. Member will have to revise his view of the town in which I had the honour to practise for many years. Like other towns it contains a large number of poor. They are with us, unfortunately, wherever we are. The town contains a poor as well as a rich population, and there is no question that there were ample opportunities there of finding out and definitely establishing the fact that the incidence of cancer among the poor is not in larger proportions than among the rich. On the point made at the end of the last speech, I take it that the Minister has not so far taken any hospital into consultation on the subject. I see by the provisions of the Bill that these consultations are to take place after the Bill has become an Act. Clause 3 (1) makes that point quite clear.
I would like to lay stress on and to commend for consideration to the House the aspect of the Bill touched upon by the hon. Member for London University (Sir E. Graham-Little), as to the investigation of disease at the beginning. The House should not confuse investigation of disease with research. The general medical practitioner is the front and first line of defence and attack on disease in this country and in any country. He is the man who sees the case first and who is consulted by all classes of the population—so far as we may speak of classes of the population. There is no specific mention of the word "investigation" in the Bill but, to my mind, it is quite as important as treatment. I want general medical practitioners to be in a position 1715 to send any case of which they are in doubt to a hospital not only for treatment but for investigation. As the hon. Member for London University stated, diagnosis of cancer is an abstruse, difficult and complex matter. I do not want general practitioners to have any feeling of chagrin or to be upset in any way if a case which they have sent for investigation proves not to be one of cancer; all the better. Unless facilities for investigation are coupled with those for treatment there is a danger that the Bill will be weak in this aspect of dealing with the cancer problem.
I am glad that the Minister mentioned the question of various counties and of the centralisation. We in Wales are suffering under some disabilities in that respect, particularly in north Wales, where there is an attenuated population, largely agricultural, and there are no big towns. We should like to retain our system of treatment in Wales itself because we are sufficiently confident that we can deal with almost anything we like within our Principality, but we are handicapped in the sense that we have a thin population, largely in the six northern Welsh counties and the counties of Mid-Wales. I am sure that the Principality will co-operate under this Bill to see that cases from those counties go to the large centres in England, like Liverpool or Manchester, or even Chester. I hope that the Minister will see his way to enable expenditure to be met from that point of view. It is a long journey for some of these people in the rural villages of Wales—say an old lady who is very poor—to travel to Liverpool or Manchester, and I take it that adequate provision will be made to meet that expenditure.
In my view, the House has been rather debating too much, if I may respectfully say so, the various aspects of treatment—radium, X-rays, surgical operation—which do not in particular arise on this Bill. It seems to me that the Minister has ample provision in the Bill to enable him to consult with all those involved, both lay and professional, in such a way that the best advice is secured in the interests of those who are suffering from this dread malady. I welcome the Bill; it is a Bill in the right direction, although there may be difference of opinion from some points of view on its financial provisions. I feel sure that the House will 1716 pass the Bill and expedite its becoming an Act.
§ 8.27 p.m.
§ Mr. Tomlinson
After listening to so many medical men who have spoken with knowledge of the subject of cancer, one wonders whether a laymen—and very much a layman—dare say a word in this Debate. But I was interested in the speech of the hon. Member for Denbigh (Sir H. Morris-Jones), in that he was questioning the facts, as I took them, that were put before the House by the hon. Member for West Fulham (Dr. Summerskill). I think the figures that the hon. Lady quoted proved conclusively that, as the incidence of the disease rose in, if not the working-class population, at any rate the poorer class of the population, the lower they were in the social scale. My hon. Friend did not suggest that cancer did not attack all classes of society, but she emphasised, and I think it needs emphasising, that the economic position of the individual has to be considered in connection with the question of treatment. Even in Colwyn Bay, where there may not be so many poor people as there are in some of our districts, the hon. Member for Denbigh must be aware of the reluctance with which poorer people visit the doctor.
I am not able to speak with knowledge of the skill which the doctor exercises, or of the subject of cancer, but, on the question of the economic effect on those people who have to visit the doctor, I claim to be able to hold my own with any Member of the House, and I say without fear of contradiction that many of the poor people who, too late, visit the doctor, are compelled to put it off until it is too late because of their economic circumstances. I agree that at the same time there is a fear, and one of the things which I hope this Bill will be able to do is in some way to dispel the fear of cancer, if it can be done, by seeking to encourage visits to these clinics, if that is what they are, when they are set up, by all who are in the least suspicious that they may be so affected.
My principal reason for intervening in the Debate was, however, to criticise and to ask for an amendment of the Financial Clauses of the Bill. It seems to me that the National Government and all its Ministers are infected by the same virus—I believe that that is the medical term.
1717 In all their legislation affecting local authorities, at any rate since I came into the House, they have worked upon the principle of placing a premium on reaction. I find nothing in the Bill that is going in any way to recoup the local authority that has been doing the pioneer spadework in this direction—that has, if I may so say, set the pace for the Ministry of Health. I was speaking this morning to two of the principal medical men in the Lancashire County Council, and one of the things that they put to me—I am glad to say that it has been dispelled since I came into the House—was that the Bill only deals with radium. Why, they asked, cannot those methods which they have been adopting and which they believe to have been successful—X-ray methods and so on—come into the picture more than they appear to do in the Bill; and why should not the expenditure which has been undertaken by these public authorities be considered when the Minister is making grants?
An authority that has done nothing hitherto will come under this scheme, and anything that is now done by it will be additional to the expenditure before the passing of the Bill; whereas the authority that has been going ahead with its work, that begins, as it were, halfway towards the mark when the Bill passes, is going to receive only a percentage of the additional expenditure involved by the passing of the Bill. That is not nearly good enough; it is what I call putting a premium on reaction. We have seen it with regard to the Government's attitude towards housing; we have seen it with regard to the nursing profession; we have seen it with regard to fire brigades; every piece of legislation introduced, during the last 12 months at any rate, dealing with local authorities, has worked on this principle of putting a premium on reaction instead of rewarding the progressive authority—the authority that has been doing the work which the Minister now, by the introduction of this Bill, wishes to be a necessity.
In the second place, I suggest that the method of dealing with the financial problem is not a right or just one. One cannot go into all the implications of the complicated formula under which these grants are to be made, but I know that, as a consequence of the way in which the average weighting factor is used, the 1718 Lancashire County Council will receive something between 20 and 30 per cent. Again I say that that is not nearly good enough. In a county area like that of Lancashire, you have a great many districts which are distressed in the true sense of the word, even though the whole of the county council area may not be so distressed. But the distressed districts in the county area have to meet the county rates; there is no weighting factor in the sending out of demand notes for rates. There are many distressed areas in Lancashire—places like Darwen and many others of the non-county boroughs. particularly in North-East Lancashire—whose grant will be only 21 per cent., and who, therefore, will be called upon to pay 79 per cent. of the additional cost. This is another case of the poor helping the poor. I am not objecting to their helping, but I think it ought to be on a more equitable basis. I think the least that the Minister can do is to see that, even if these factors are taken into consideration, no local authority shall receive less than 50 per cent, of the additional charge which will result from the passing of the Bill. When we are asking for their co-operation and looking to them to provide the facilities, and when we know the circumstances of the case, we ought to see that they receive what is being regarded as reasonable—a minimum amount of 50 per cent. I hope that in the further stages of the Bill we shall have some promise from the Minister to reconsider these financial Clauses with a view to doing justice to the local authorities.
§ 8.36 p.m.
§ Mr. Storey
I want to support the restriction which my right hon. Friend proposes to impose on advertisements. While the Press is rightly jealous of any restrictions on its liberties, no reputable member of it wishes to stretch liberty and take licence. For a long time all reputable papers have, on their own initiative, refused to insert advertisements which offer treatment and hold out a hope of cure for cancer. What has been the voluntary practice of the majority should be enforced on the few who are content to profit out of such advertisements. That is not only a personal view; it is also the view of the Newspaper Society, which represents the whole of the provincial newspapers in this country. It has ex- 1719 pressed its entire approval of the proposed restrictions in this Bill.
I not only welcome these advertising restrictions, but I welcome the Bill as a whole, because I feel it is an essential step in building up an efficient health service in this country. I would add that, although the duty of securing that facilities are available is placed on the local authorities, the Minister has made it quite clear that these facilities are not to be based on the narrow limits of local government boundaries. An efficient health service cannot be built on such narrow limits. It must be based on the best means of meeting the country's hospital and health service needs, and it will necessitate the co-ordination and cooperation of the voluntary hospitals and local authorities. The voluntary hospitals at the present time are engaged in reorganising themselves on a regional basis, and they are prepared to do all they can to co-operate with the local authorities in providing a proper health service for this country. I hope the Minister will give them his full support in their reorganisation, because I feel that if he does he will find a valuable means of bringing about the co-ordination and co-operation which is so essential between local authorities and voluntary hospitals, which will not only be of great use in all health services, but in meeting this special problem.
§ 8.40 p.m.
Mr. David Adams
As a member of a local authority of many years standing, and one who has had the privilege of serving for many years on a municipal health and hospitals committee—that of Newcastle-on-Tyne—I cordially welcome this Bill. I have felt, indeed, that the time is more than ripe for a general extension of this service which we in Newcastle have brought up to as near perfection as we could, with the cordial appreciation of the city council. When one observes that the Ministry of Health figures indicate that only 27 per cent. of those afflicted with this disease were treated in hospitals where adequate provision was made for such treatment, and that 73 per cent. of those afflicted did not receive such treatment, but were treated either in their own homes or in institutions where little or no provision had been made, it is quite clear that the hour when 1720 the Ministry of Health has taken action is very late.
Belated as the Bill is, in my opinion it is a fairly thoroughgoing Measure. It provides diagnosis and treatment for the first time to large numbers of victims of this disease. Great centres are to be more adequately used and new centres created. While there is a lament that there may not be the personnel needed for distribution among the new centres to be created, if the other centres are pursuing the same course as Newcastle they are specialising deliberately in the creation of additional technologists for service elsewhere. On the question of notification, I feel that the Bill ought to be still further strengthened by making this compulsory, as in the case of tuberculosis and ophthalmia in children. In those cases such notification is obligatory upon the medical practitioner. Very valuable information would be obtainable even if it was optional upon the local authority to make it compulsory or not, because from certain individual centres a great deal of valuable information can undoubtedly be obtained.
No figures have been quoted in this House as to the amazing increase of this disease in this country. Perhaps in some cases it may be due to better diagnosis. In 1926 there were 55,870 deaths from the disease; in 1931 the number was over 62,000; and we have learned this afternoon that last year there were no fewer than 74,000. The increase from 1901 to 1936 has been by no less than 50 per cent. It is quite clear, therefore, even allowing for the fact that cancer is being certified to-day as the cause of death in many cases in which previously it would have been certified as being due to associated causes, the rise in this disease has gone on with such rapidity as to be one of the most startling features of our modern hurrying existence. No less than one quarter of female deaths between the ages of 45 and 65 are associated, after careful investigation, with cancer. The proportion in the age groups mainly affected is increasing as the facilities for diagnosis progress.
As far as Newcastle-upon-Tyne is concerned, for 10 years past the very closest attention has been given to this disease and to-day the Royal Victoria Infirmary and Newcastle General Hospital both possess installations to treat cases thoroughly. I think that I am justified 1721 in taking some pride in having had something to do with this matter in that we have spent £9,000 for the purpose of the building and the equipment for this X-ray therapy, and there will be an annual charge of £1,500. That is genuine public spirit because we were not looking to the central authority to make any contribution either to our capital cost or to imburse us for the annual cost of running this institution. In the year 1937 we treated 237 patients for a total of 9,859 days, at an estimated cost of approximately £3,000. The question of a model scheme has been raised, and I scarcely know, speaking personally, to what the Minister really referred, but I should say that on Tyneside, with its large medical school, no difficulty would be found in formulating as comprehensive and as ideal a scheme as may be required by the Ministry.
There has been some comment by one hon. Member this evening as to the views of the medical practitioners upon this scheme, and I believe that every Member of the House has been supplied with the letter to which he referred from the medical practitioners' journal. The main claim in that is that under the Bill it is not likely that proper team work will be instituted. I fail to observe the justice of that condemnation. Team work is absolutely imperative. You require the joint labours of the medical practitioner,' the consultant, the surgeon, the radiologist and the laboratory technician. We are not likely at any time to find the one man expert as in the case of venereal disease and in tuberculosis.
It may interest the House to know that in Newcastle we found that there was a reluctance to consult medical practitioners. We discovered that in no less than 11 per cent. of the cancer deaths, the victims apparently had either left their disease entirely without report or at a very late stage they consulted a medical practitioner. We discovered also the very remarkable fact that one-third of the fatal cases in Newcastle were resistant to all forms of treatment, surgery, radium, deep X-ray therapy, even in most cases when early diagnosis and treatment had been sought. It is a very interesting fact, but it demonstrates and proves to me, and probably to the House, that further research is imperatively required.
We have not reached the key of the problem as yet, I was privileged to visit 1722 the Rockefeller Institute of New York last year, and I made a special point of having a short conference with two of the professors dealing with this disease. To sum up their observations, while they imagined—they could only use the term "imagine"—that they were drawing somewhat nearer to the original source of the disease, they still were in the dark, and were hoping, one might almost say, against hope, in view of the vast sums that were being expended and the illimitable resources that were placed at the disposal of that institute. And yet the key to the origin, and perhaps the proper method of dealing with this disease, had not been found. With regard to the more potent methods of treatment, I was advised that the cyclotron apparatus recently constructed in America which bombards the tissues with neutron particles is the one which is particularly receiving the consideration and attention of the experts. That statement has been made already in the House to-day, but I was privileged to hear it from the lips of one of the professors.
The new expenditure with respect to the grants will not be cheerfully borne by authorities in the Special Areas, like Durham, even if they obtain the maximum amount of grant as indicated in the Bill. This will be quite insufficient, and it will require the greatest pressure to be brought by the Act upon such local authorities to make them engage in additional expenditure even for this purpose. County Durham, as I stated in this House last week, is so driven by the spur of poverty that the different authorities in that county have already had a conference to determine whether or not they have not reached the absolute maximum of their capacity to spend any additional sums. I look upon this as being one of the weaknesses of the Measure, and I hope that the question will receive the further consideration of the Government. As the hon. Lady on these benches stated—and there cannot be any dispute about it—the incidence of this disease is greater among the poverty-stricken section of the community than among the better placed. That is admitted, I think, on all sides of the House. Poverty is the cause of at least half the necessary expenditure upon all public health services.
1723 The Bill gives great benefits and financial advantages to those authorities which, unlike Newcastle, have been slumberous and have neglected their responsibilities towards their community. The provisions of the Bill, as far as finance is concerned, are not retrospective, but only applicable to the new services, and I hope that that will also receive consideration by the Ministry in Committee. The eight-year period for experiment before the expenditure is duly embodied in the block grant is very satisfactory. The complaint has been made frequently that when the block grant has been fixed the Minister's representatives have come down upon the local authorities—certainly they did it so far as we were concerned—and virtually insisted upon new and additional expenditure entirely outside the amounts allowed under the block grant. Therefore, this eight year period will give the authorities sufficient time to know just what the amount of their financial liabilities will be before the amount is finally embodied in the block grant.
With regard to the production of radium, I observed in yesterday's Press that it is to be produced in Britain, and that our only seam, which has been lost for 25 years in a disused mine, near Lostwithiel, in Cornwall, is to be worked again. I hope that will receive the sympathy and good will of the Minister and the Radium Trust in their further purchases. We are depending largely upon the Belgian Congo, Czechoslovakia and Canada. If we can develop the production of that most valuable mineral in this country, a very splendid step will have been taken in connection with the work on which we are engaged. I was very gratified at the statement of the Minister when he indicated that the purchase of the additional radium that will be required will be obtained at a relatively low market figure. He told us that while the market price was £5,000 per gramme, he had taken an option at £4,500. Statements have been made in the medical Press that the Minister had permitted the price of radium to rise substantially while he was seeking to develop the cancer service in this country, but we have the assurance from the Minister that that statement is wholly inaccurate.
The Bill, in the nature of things, is not a perfect one. It is only a step, but it certainly is a step that ought long ago to 1724 have been taken, and I am certain that the municipalities whose finances will permit them, will work it wholeheartedly. While the origin of the disease may not be known, we certainly do know, as we have learned in Newcastle, that certain cases of cancer, particularly of the lip and the tongue, can be treated without surgical operation, and as far as our experience goes, we have had perfect cures. Let us hope that those results can be extended throughout the country. A step has certainly been taken by the Minister of Health in the right direction. If the Bill can be improved in Committee on the lines indicated and a more generous outlook can be adopted towards the poverty-stricken areas, the Minister will have performed a very good day's work in bringing forward the Measure.
§ 9.0 p.m.
§ Sir F. Fremantle
There are one or two subjects to which I would refer. Not least, I want to thank my right hon. Friend the Minister of Health for his admirable statement, and the right hon. Member for South Hackney (Mr. H. Morrison), who made what seemed to me a perfect speech from the Front Opposition Bench on a non-party measure, keeping up his proper attitude, with one or two points of criticism, but at the same time helping us to pass a non-controversial Bill. We have heard a great deal about the question of non-consultation by the Minister with the interests concerned, before the Bill was produced. I think that has been a bit overdone. I have spoken to many of my friends at hospitals and institutions who feel aggrieved that they were not consulted; but my right hon. Friend would not have been unaware of the general lines on which he would have received advice if he had held those consultations. It is not as if he was laying down in the Bill the details of what is to be done. He is laying down the general lines, and with regard to those general lines none of the different bodies who have been represented to us to-day as objecting because they have not been consulted, would oppose the Bill. I think the Minister has, to a certain extent, himself to blame for the fact that there has been such an outcry that the Bill has been produced on the lines as if it were a radium Bill. Although it is called a Cancer Bill, it is recognised everywhere that the reason for the secrecy was the proposed purchase, or the option to purchase, radium. There- 1725 fore, that seemed to be the centre of the proposal in the Bill. Indeed, in the Preamble of the Bill we find that it is:To make further provision for the treatment of cancer, to authorise the Minister of Health to lend money to the National Radium Trust, to prohibit certain advertisements relating to cancer, and for purposes connected with the matters aforesaid.In the local arrangements that are to be made Clause 1 (3) says:Before submitting arrangements to the Minister under this section a council shall consult—
It was, therefore, only natural that people should have flown to the idea that this Bill was primarily one for treatment with radium. I am not sure that it was not the view of the Cabinet that the use of radium was a nice new toy, or some new thing to be brought forward. I am, however, sure that the Minister would not tumble to that. He did not defend himself as well as he might have done. He might well have referred to the fact that the lines on which he now recommends this Bill to the House were laid down in a Memorandum on the provision of radio-therapeutic departments in general hospitals, issued by his own Ministry in March of last year, one paragraph of which states:
- (a) the Radium Commission; and
- (b) such committees or other bodies as the council considers to represent both the governing bodies and the medical and surgical staffs of the voluntary hospitals providing services in or for the benefit of its area."The effective treatment of cancer now demands the partnership of three highly specialised forms of therapy—surgery, radium and X-rays.It is clearly laid down in the Memorandum that that is the actual proposal of the expert adviser on the staff of the Ministry. The Memorandum goes on to say:To be adequate for the treatment of cancer according to modern methods, general hospitals should possess facilities for treatment by all three methods.The third paragraph says:Full radiation facilities are uneconomic in small hospitals; the number of beds a general hospital should contain if it is to make reasonably full use of radiation treatment facilities is of the order of 300.That is the basis of the Bill, and I am sorry it has not been brought out before that these are the lines on which the Bill has been framed. It is for the general public to know why we cannot now say that treatment for cancer must be by one method alone. In a report of the Medical 1726 Research Council, of which I have had an advance copy, there are summarised the reports from all the research centres, and there is an interesting table set out showing the relative frequency of surgical and radiological treatment in the research centres. By surgical treatment alone 27 per cent. of the cases have been treated, by radiation alone 31 per cent., and by X-rays alone 23 per cent. That shows that in the research centres and hospitals, where you have the most up-to-date methods of treatment, the figures are fairly easy as between the three different methods of treatment. That, again, is a reason why the Bill should not be called a radium Bill, but a Bill for the treatment of cancer in the best up-to-date way.
I am generally in agreement with the hon. and gallant Member for South-East Leeds (Major Milner) on these questions, but there are one or two points in his speech with which I must disagree. He made a rather bitter attack in one particular case on the British Empire Cancer Campaign. The British Empire Cancer Campaign is only a research body, and therefore does not come under the Bill at all. It was founded in the Harcourt Rooms of this House by Mr. Godfrey Locker-Lampson about 15 years ago as a body devoted to the promotion of research in the prevention and treatment of cancer. Ever since then different proposals for the treatment of this disease have been brought before a special committee of the Campaign which is called the Investigation Committee, who welcome and examine all the supposed cures for this disease. They are examined by scientists. This particular committee is presided over by a chairman who is an operating consulting surgeon, who says that as he is not a scientist himself he can distinguish between the different scientists on the board. They considered the particular case mentioned by the hon. and gallant Member and turned it down on the ground that there was not sufficient reason to show that there was any further value in pursuing that method. I hope, however, that the Minister will have this case brought before him and will inquire into it. I am sure that the British Empire Cancer Campaign would be only too delighted to have such an investigation. There is really nothing in it. Obviously, they are not restrained from giving funds for research if there is a really good case for research.
§ Major Milner
Do I understand the hon. Member to say that the case in question was investigated? I assert without fear of contradiction that no steps were taken to investigate it, none of the cases were seen, and although the treatment was recommended by the hospital authorities no steps to investigate it of any kind were taken by the British Empire Cancer Campaign. I challenge the hon. Member to contradict it.
§ Sir F. Fremantle
Again I say that there was sufficient reason for the British Empire Cancer Campaign to say that there was no value in further pursuing that particular case. If there is any question about it, it is not for us to discuss it in this Debate, but I hope the hon. Member will bring the matter before the Minister of Health, who, I am sure, will look into it impartially. Obviously, it is a fraud on the public if the British Empire Cancer Campaign have turned down for insufficient reason any particular form of investigation.
Another point on which I do not agree with the hon. and gallant Member for South-East Leeds is that he wants a definition of "cancer." I hope he will not pursue that. It would be quite impossible to give a definition. I do not think it is possible logically to define any disease until you know the cause; then you can define it. The hon. and gallant Member and also the hon. Member for Consett (Mr. David Adams) referred to the question of notification. You cannot notify a disease unless you have something definite to notify. The hon. Member for Consett said that there was a great volume of knowledge, but there will be a great volume of knowledge under the Bill when reports are kept of every single case, which I hope will be one of the first results of this Bill. I hope that we shall get properly formulated reports of all cases so that we can get the fullest knowledge that is possible. We get most of it to-day, but under the Bill we shall get it in a proper form.
But who is to notify? Is it to be the medical man? How can he notify when it is quite indeterminate? The hon. and gallant Member suggested the analogy of tuberculosis. Tuberculosis is definitely notifiable because you find the cause of the disease—the bacilli in the serum. Until you get that you cannot be certain that it is tuberculosis. There is no such 1728 means of identifying cancer. The right hon. Member for South Hackney—and on this non-party Bill I hope I may call him my hon. Friend—said that if we know the cause we shall know how to prevent the disease. We found out the cause of tuberculosis. Professor Koch did 48 years ago, and we do not yet know how to prevent tuberculosis. I admit that we are getting on, and if all milk were pasteurised we might be able to get on a good deal faster.
§ Mr. Deputy-Speaker (Sir Dennis Herbert)
I hope the hon. Member will keep to the matter under discussion.
§ Sir F. Fremantle
The right hon. Gentleman used that as part of his argument, and it was the only slip that I found in his speech. The hon. Member for West Fulham (Dr. Summerskill) suggested, apparently, that it was known that the disease might be due to bacillus or virus.
§ Dr. Summerskill
I am afraid the hon. Member misunderstood me. I said that it has not yet been discovered whether it is due to bacillus or virus. I pointed out how important it is to have more research.
§ Sir F. Fremantle
I apologise to the hon. Member. It is quite as likely that it is due neither to bacillus nor virus, but that it is what the Minister described on another occasion as "pathological Bolshevism." What happens is that the cells of the body appear to be absolute Bolsheviks; they get loose from the society of one another and from all the restrictions that keep cells in their place, and run amok. The latest reports on research show how those engaged in research work are getting down to understanding and investigating the actual laws of cell division, cell restraint, and so on.
Reference has been made to the fear of cancer among the people. How is that fear to be prevented? Some hon. Members have said that knowledge must be spread among the people, by means of the Press, and so on. That view is diametrically opposed to the idea which the Minister expressed to-day, that nothing should be done to frighten people, 1729 What we have to do is to spread knowledge of the treatment and an understanding of the organisation without, in so doing, causing people to fear that possibly they may be suffering from the disease. There is only one way in which both these things can be done. Naturally, the first thing to do is to get a proper organisation, for knowledge of it cannot be spread unless it exists. Having established such an organisation, there is only one way of meeting the case—a way which I think has not been sufficiently dwelt on in the Debate—and that is through the general medical practitioners. It is of no use getting the views of the most distinguished scientists, the hospitals, institutions and local authorities as to how this purpose can be achieved, for it will have to be done through the general practitioners, whether they have a panel, private or hospital practice.
The general practitioners are the persons to whom people go when they have something wrong with them. If the general practitioners are given the job of making the fullest use of this new organisation, they will known how to persuade the people who come within their purview to go to the hospitals. The general practitioners will know, in their kindly way, how to suggest such a course, perhaps without mentioning the actual ailment. It will be a difficult matter, because it may be that the people concerned will have to go 20, 30 or 50 miles if the organisation is to be sufficient to cover the ground, although I hope that in general the distance will be less. In any case, it will be the general practitioners who must carry the burden. Many of them, I know, will not be very good at it, for we know that in the profession there are some who are clumsy, slack, overburdened, and some who are tired and weary, but it is the general practitioners who must be asked to do this work.
Is the Ministry consulting the organisation which represents the general practitioners? It may be that the Ministry is doing that, but I ask the right hon. Gentleman—and perhaps the Parliamentary Secretary, when he replies, will be able to give an assurance on this matter—that the British Medical Association, as representing the medical practitioners, shall be consulted, if they have not already been consulted, concerning the 1730 terms in which this scheme is to be worked out. It is true that, as regards the details, there is a provision in the Bill that the local authority shall consult with the local organisations of medical practitioners, but the scheme of the organisation must be laid down from the centre. The Ministry consult the best people in the land, and through their inspectors, they get a good idea of the local authorities' work; but if the general practitioners are to be consulted, it will require special efforts on the part of the Ministry.
The Ministry ought to consult the British Medical Association, and any other associations representing the general practitioners, on the question of how to approach these men on the subject. It will be very difficult, as they are busy men, but the Ministry ought to get into touch with them and ask for their help. I am afraid that is something which is seldom done either by this Government or by any other Government. It is, for instance, a pity that it was not done when the Government were considering Air-Raid Precautions. The representatives of the general practitioners ought to be consulted—as the House resolved when it adopted a Resolution which I moved only last week—when the Government are devising these things, as well as when they are organising and administering them.
Therefore, I conclude by making this suggestion. The general practitioners ought to be brought into the scheme from the beginning, because it is on them that we must depend. If that is done, I do not think we shall need a great deal of Press publicity on cancer, although, by all means, let there be Press publicity as regards the organisation and research. As this Bill does not provide for research, let us hope that Press publicity will touch the hearts of some of those people who are able to provide large amounts of money for research. For more and more research is required. It is research that is most needed. We must not expect big results from this organisation, or from any organisation; it will be able to give a certain amount of relief and help, and bring about an improvement on what goes on at present. But we do want an enormous increase in research by the proper people, and treatment by the proper people. Very few people exist in this country who have had proper training to enable them 1731 to give radium treatment and X-ray treatment. One of the greatest things the Minister could do—and I hope he can do it under this Bill—is to see that provision is made for the proper training of medical men who are in this way of business in the latest methods of radium treatment and X-ray treatment. I believe it will be possible and wise to set aside some particular place and build up a school for treatment of these people. Those who are qualified to give the treatment are at present a small number, but by that means the number would be increased. I believe that if we do not expect too much at once and are patient, we are setting up in this Bill a ladder by which we can gradually climb to the ideal of an eventual complete treatment of every case with at least a considerable amount of success.
§ 9.27 p.m.
§ Captain Elliston
I have listened to the speeches of many of the critics of this Bill this afternoon and have not changed the opinion I formed when I first saw it, that we are much indebted to the Government for presenting to us the first national scheme for dealing with the great scourge of cancer, which is responsible for the terrible mortality rate of something like 60,000 a year. But worse than that is the unspeakable suffering that we know accompanies this disease. There has been a conflict of opinion to-night between the medical Members of the House and the laymen as to exactly what the Government had in their minds when they framed this Bill. We have been told of a mysterious conspiracy and have heard the Bill described as a Radium Bill. The Government believe that there are several agencies for the treatment of cancer and that in a high percentage of cases death can be prevented, or can be postponed, by early radium treatment or X-ray treatment or surgery. No scheme could be complete without radium treatment; and unless you acquired an option on the purchase of radium from time to time it would be impossible to safeguard the Radium Trust against a rise of price.
The very fact that you will have cancer units in many hospitals will mean a continuing trial of treatments, varying in each neighbourhood perhaps, but representing the progressive opinion of the profession.
I propose to refer to the subject which has already been emphasised, and which 1732 I think is the matter of outstanding importance in this campaign, that is, the securing of an early diagnosis of the disease. I should like to refer to what has been done by several local authorities in this connection. I was very much surprised to hear the hon. Member for West Fulham (Dr. Summerskill) suggest that the poor have been deliberately denied advantages and facilities which were available for their more fortunate fellow citizens, and I should like to draw her attention to what has been attempted in several areas in the effort to combat the disease. As long ago as 1926 the Greenwich Borough Council formed the first cancer clinic. Everything possible was done to advertise it. The health visitors talked about it at the maternity and child welfare centres, it was mentioned in the newspapers, and it was the subject of lectures and meetings. The people were begged to come on the least suspicion of a cancerous condition. Throughout the years that clinic was open never more than 20 cases came to it, and of these very few were early cases of the disease. And so after a long trial that clinic has disappeared. It has been replaced by what is called a special clinic for women, and it is hoped to secure early treatment for certain conditions. But in that case you had a serious effort made to induce people to accept advice and diagnosis and they took no advantage of it.
Much the same thing happened at Leicester in the following year 1927. A clinic was started in that town, and in the first year there were 60 cases. There again tremendous propaganda work was done. The Leicester Royal Infirmary co-operated, placing all its facilities, its staff and its consultants, at the service of the clinic. But the people would not go there, and the number declined gradually each year until in 1933 the clinic had to be closed. The same thing happened in the borough of Willesden. In Willesden a clinic was opened in 1929. It was called a clinic for early diagnosis. Everything was done at the maternity and child welfare centres and through the local newspapers, but the result was most disappointing. The work still continues, it is true, but the medical officer of health has said that he believes that people will not come because cancer is not painful in its early stages. He says the cases which go elsewhere are not always given 1733 such adequate examination as to convince them that they must reach the hospital in good time.
We have heard to-night about cancer-phobia. I do not know whether it is better that people should be scared by cancer or that they should die of the disease, but if you do not tell the people what to do in its early stages how do you think this great problem is to be tackled? I am told by medical officers who are experienced in this work that it is the people who are afraid of cancer who go to the doctor and who, curiously enough, are found in the majority of cases not to have the disease. In any event, I find many town councillors, medical officers, health visitors and others interested in this problem ail agreed that this matter of early diagnosis is of fundamental importance if any serious campaigning against the disease is to be undertaken. It will be necessary to have diagnostic clinics available at convenient centres everywhere, so that people can reach them easily. It is not necessary to erect new buildings or take new premises. Let us have the clinics in places to which the people are already accustomed to go. For instance mothers to-day are accustomed to go to the maternity and child welfare centres, and they would be much more likely to avail themselves of the proposed facilities, if the clinics were at those centres than if they had to go to some other place.
I had intended to refer to the importance of the family doctor in any campaign of this kind, but that point has already been dealt with by my hon. Friend the Member for St. Albans (Sir F. Fremantle). Without the aid of the doctor you will not be able to do much good. People may fight shy of the clinics, and they may fight shy of examination at the hospitals, but when they go to the doctor, he can overhaul them and pass them on to the hospital for that complete diagnosis which only the hospital can give, and that will be a very important step in the right direction. In accepting the responsibilities which this Bill will place upon them, the first work which the local authorities will require to undertake is an investigation into the reasons why people decline to accept advice and treatment. The causes are not well known and many medical men are considerably mystified as to why people who are in this condition show such a reluctance to seek advice. It 1734 all comes back to a matter which has been discussed in this House several times during the past few years, namely, the need for the health education of the people.
This reluctance to accept treatment is not only to be found in connection with cancer. In connection with diphtheria, complete immunisation against the disease, which would save the lives of many children, is offered and people will not avail of it. Here we have 60,000 people dying from cancer every year and many of those people have refused to accept the advice which is placed at their disposal and which would involve no cost to themselves. The Empire Cancer Campaign has done fine work in this connection already. Lectures have been delivered under its auspices in all parts of the country. I hope that the Central Council for Health Education, which has the approval and support of the Minister of Health, will always regard this part of their work as of great importance and that they will take up this subject of cancer.
There are two provisions in the Bill which I welcome very much, first the provision of travelling expenses for unhappy people who have to make long journeys to these centres, and secondly, the provision suppressing the advertising of quack remedies for cancer, just as has been done in the case of venereal disease. I am glad that now, in regard to these two matters, we are putting some limitation to the exploitation of the public by the sale of remedies which are frequently of no value.
§ 9.40 P.m.
Mr. Vyvyan Adams
Like my hon. and gallant Friend the Member for Blackburn (Captain Elliston), but unlike many hon. Members who have spoken to-day, I am not a professional expert. But I do not think that I, or any other layman who takes part in this Debate need offer any apology for his intervention. Like all other laymen and all professional people, and indeed like all our constituents throughout the country, each one of us runs at least one chance in eight of being destroyed by this disease. Most unfortunately it seems to be a growing chance. I venture to reiterate the plea which has been made by several hon. Members, including the hon. Member for West Fulham (Dr. E. Summerskill) and the hon. Member for London University 1735 (Sir E. Graham-Little) in favour of greater research and more financial aid for research. I do not think that research, particularly in relation to cancer, should be random, haphazard or fortuitous. Research is never wasted. Even negative results are valuable in that they deter people from turning over particular stones and exploring certain avenues. They save time and allow others to concentrate on the promising fields.
The Under-Secretary of State for Scotland after giving the figures for his country, which, it was remarkable to note, tallied exactly with English experience, argued against notification. I wish to advance one or two further arguments in favour of notification, and, indeed, I almost dare, layman though I am, to predict that the legal notification of cancer will come within measurable time. The case for notification seems to be expressed in the short maxim "Leave nothing to chance." Fear, slackness, ignorance—all conspire to make a legal obligation on the doctor and the public to notify, desirable both in the interests of the public and in the interests of the profession which, surely, wants to destroy this disease or at least reduce its incidence. I wish that suspected cases in each locality—and the locality in question may be large or small—could be reported under a legal obligation to a cancer officer for each of those localities. We have heard several times to-day that the ordinary general practitioner is often unable to make the diagnosis. No blame can be placed upon him for that. He cannot be expected to do so and therefore he should be assisted by an expert in each area. The hon. Member for St. Albans (Sir F. Fremantle) to whom, as he is a medical man, I am rather diffident to reply, asked what would be the object of notification. The object would be to give the cancer officer, whose appointment I propose, the chance to effect a cure in the early stages of the disease.
§ Sir F. Fremantle
Why is it necessary to have the publicity of a public notification in order to do that? What is the object?
If my hon. Friend had been listening to the earlier part of my observations he would have heard what I said on that point, but I will repeat it. Where a general practitioner suspects a 1736 case of cancer he should automatically, and under a legal obligation, report it to an expert cancer officer in each area. The hon. Member said that it might not be possible to verify cancer by a germ. Again, as a layman, I hesitate to reply to him but while you cannot define cancer, just as you cannot define an elephant, I have known many medical men who were fully able to recognise cancer when they saw it just as anybody, lay or professional, is able to diagnose an elephant when he sees one. The diagnosis may be a good deal less certain than diagnosis in a case of tuberculosis but, however good or however bad the diagnosis, no diagnostician can ever claim that he is infallible. What Parliament, at least, can do is to insist on medicine and surgery having the best possible chance in their struggle against the disease. That is the object of notification. Even my hon. Friend will hardly contend that, to-day, every curable case of cancer comes to light in its early stages.
We have all welcomed this Bill with greater or lesser enthusiasm. The Minister of Health was given a perfect opportunity to unite administrative ability with scientific knowledge and that opportunity he seized, as we expected him to do, with his usual avid brilliance. But I would suggest that in the respect which I have mentioned, the Bill falls short of what might be done. On 8th November the Minister, who made to-day such a brilliant and comprehensive speech in introducing this Bill, said to the British Medical Association:There are vast resources of knowledge in our laboratories which are not carried through to the lives of our people. Let us be sure that we apply the knowledge we have got and acquire new.That quotation is from an after-dinner speech. Nevertheless, the statement contained in its first paragraph is, if I may be allowed to say so, entirely accurate. But this Bill does not fulfil the aspiration which followed. Some 16 years ago tuberculosis was made a notifiable disease. To-day that complaint has lost half its terror. The treatment is applied early. The public has been made aware that it is no longer incurable. Tuberculosis will soon lose its position among the chief killing complaints.
The Minister to-day gave a number of figures. I would like to bring the matter a little nearer home, if I may be some- 1737 what parochial, and give the experience of the City of Leeds, where we have a medical service of which we are particularly proud. In that city in 1925 the number of tuberculosis cases was 7,599; in 1937 tuberculosis cases in the same great centre of population had fallen to 3,056. Here are some very significant figures which I am going to give, and they happen to contain a very strange numerical coincidence. The death-rate from tuberculosis in 1925 in the City of Leeds was 1.25, and that from cancer at the same date was precisely the same. By 1937, last year, the tuberculosis death-rate had fallen to 0.88, but during the same period the cancer death-rate in Leeds varied from 1.25 to as high as 1.72, the peak figure, which was reached in 1936. 1.72 represented a gross total of no fewer than 843 deaths in a single year in a city of just under half a million inhabitants.
The cancer death-rate throughout the country has over this same period of time shown an increase that has been steady, ruthless, uniform, and sinister. Over the period that I have mentioned, from 1925 to to-day, it was 1.34 in 1925 and had risen to 1.63 in 1937. I should like to give the precise figures, which have not been given so far, over this same period of time of the cancer death-rate. I am afraid these figures will sound rather tedious, but the regular rise is most remarkable and depressing. In 1925 it was 1.34, in the next year 1.36, then 1.38, 1.42, 1.44, 1,45, 1.48, 1.51, 1.53, 1.56, 1.59, 1.62, and last year 1.63. Those figures have emerged over the last 13 or 14 years or so in spite of the researches of Gye and Barnard, which were thought at the beginning of that period to be opening a new chapter in the battle against cancer.
These figures represent an obstinately rising volume of the most agonising suffering. In so far as this Bill can be expected to alleviate that torment, every man and woman must acclaim it. But is everything possible being done? I think not, and I would respectfully again suggest to my right hon. Friend that he should make this disease notifiable. The public are not at the present moment fully aware of the possibilities of curative surgery. They are reluctant—naturally—to run the risk of hearing what they think is bound to be a death sentence. I am told that in certain country districts the superstitution is sometimes vigorously 1738 entertained, even to-day, that cancer is infectious. With so much perfectly intelligible terror of cancer prevalent everywhere, it is no use, I suggest, vaguely to hope that the public are going to avail themselves of treatment and at a satisfactorily early stage. There must be for this dread disease the same degree of compulsion as for tuberculosis. That compulsion has enabled us to wage a war, and in fact an unexpectedly and highly successful war, against tuberculosis, and—I am using the language of my right hon. Friend—compulsory notification is the way to dispel what he described as "the bogy of incurability."
Although cancer is now far more fatal than tuberculosis, this fact is of interest, that the proportion of cancer patients to tubercular patients offering themselves at hospitals is less than one to two. The same fears inhibited the tubercular patient before compulsory notification. To-day he knows that his chances are increased by that compulsion of the law. I submit that compulsory notification by the general practitioner to the cancer officer in each specified locality would have two clear advantages. First, it would be more fair to the medical profession, who would then have a true picture of the vast problem before them, for at present they are, to some extent at least, working in the dark; they would have a much better chance than they have to-day of early and accurate diagnosis. And it would also, in the wider sense, save the lives of thousands of men and women. Their main hope to-day, as we have heard from every side of the House, lies in early help, and I suggest that the law should insist upon their having it.
§ 9.54 P.m.
§ Mr. Rhys Davies
I have listened to practically the whole of this Debate, and I do not remember a discussion in which there was so much unanimity, at any rate since the present Government came into power. I am wondering after our experience to-day whether one Scotsman in the Cabinet might not give a hint to another Scotsman, so that the other may not get into trouble. If the Minister of Agriculture were here, he might learn a lesson from the right hon. Gentleman on how to conduct himself in public life. This Bill has been welcomed in every part of the House, and perhaps the right hon. Gentleman will be glad to know that it is not our intention 1739 to divide on it, but when we come to the Money Resolution he will find that our attitude is not quite so agreeable. My right hon. Friend the Member for South Hackney (Mr. H. Morrison), who is a leading figure in the London County Council, will have more than a word or two of criticism to say to him when we come to the Money Resolution. I hesitate to speak on a technical subject of this kind when there are so many learned technicians about, but I notice that when I know least about a question I become eloquent. But that, by the way, is not a failing peculiar to me.
Let the House notice what has happened in connection with this Measure. Most Members will be old enough to remember that Parliament and the municipalities never thought it wise to intervene in connection with diseases unless they are infectious or contagious. They confined themselves for decades to the principle that other ailments belonged to private practice. Cancer is neither contagious nor infectious, and now the State decides to intervene in order to try and combat this terrible disease. We on this side welcome any movement, however small it may be, by which the State brings its efficient machinery to aid the municipalities, through the social services to assist sick people who cannot fend for themselves.
The hon. Member for Denbigh (Sir H. Morris-Jones) was annoyed by a statement made by the hon. Member for West Fulham (Dr. Summerskill), and he was terrified lest her speech should give the slightest sign of Socialism. He thought it was unfair of her to say that the poor suffered more from cancer than the rich. He said he had been in medical practice for 20 years and could not find anything in his experience to substantiate that point. The hon. Gentleman has been in medical practice in Colwyn Bay, which is packed with retired ladies and gentlemen from Manchester and Liverpool, and where the medical practitioners themselves retire from practice and enter politics after they have been attending to them for only about 20 years.
§ Sir H. Morris-Jones
The point which the hon. Member makes rather substantiates the argument I tried to put before the House. If, as he says, Colwyn Bay is full of rich people—which is not, as a 1740 matter of fact, the case—then I had ample opportunities of finding out the number of cancer cases among the rich.
§ Mr. Rhys Davies
If I cannot convince the hon. Gentleman in the English language, I shall have to try Welsh, but I would not be reported then, and that of course would be fatal to publicity. As I stated, we welcome this. Measure because it is a contribution to that principle of State intervention. The hon. Member for West Leeds (Mr. V. Adams) urged the compulsory notification of this disease, but I doubt whether Parliament has ever been asked to, or whether it ever will, compel the notification of any disease unless it is either contagious or infectious. I think that that principle will always hold good, because it is necessary that there should be compulsory notification only when the health of the community is at stake. Cancer, I understand, is neither infectious nor contagious. I approach this problem, however, from a different angle altogether. I have been secretary of an approved society for 26 years, and I think I may speak for all the administrators of approved societies when I say that we have no information whatever about this problem, although we deal with the 17,000,000 insured population of the country. I do not want to offend the medical profession. Indeed, I think the House ought to congratulate them on doing such excellent work in connection with cancer. I speak with some little knowledge of that, because I live almost on the doorstep of the Holt Radium Institute in Manchester.
The problem of diagnosis is obviously a difficult one. In the offices of the approved societies the medical certificates tend to show that when the panel doctor is not certain of a disease he has a convenient way of calling it "influenza." Most of the certificates for one week may bear just the one word "influenza." I do not blame the doctors because sometimes they do not know themselves as yet what is the real trouble with their patients.
With regard to the problem of fear, I am not imbued with the idea of carrying on a raging propaganda campaign about cancer. The best propaganda to induce sufferers to submit themselves to treatment is to assure them that there is hope of cure. If you convince a person
1741 who thinks he is suffering from cancer that there is hope for him, you need not do any other publicity. I must pay tribute to that treatment provided for a man I know personally. He had cancer on his lip and he has been completely cured. He is satisfied that he is cured, and he rejoices in a semi-humorous way because he does not need to shave any more for the rest of his life; the radium destroyed all the growth on his face. That is a little tragedy mixed with good humour and I am sure that other hon. Members will know of similar cases.
The one volume that interests me above all others that come from Government Departments is the annual report of the Chief Medical Officer of the Ministry of Health on the state of the public health. It would serve a useful purpose if more people turned to its pages for information about diseases. According to that report the figures which the hon. Member for West Leeds gave for Leeds are just a picture for the country as a whole. Since the State and the municipalities attacked tuberculosis, for instance, the mortality figures have gone down year by year. Most hon. Members who have sat on municipal corporations will remember that they were told some years ago that it was not the business of municipalities to interfere in a disease of this kind. I am proud to think therefore that the State is now accepting the philosophy that cancer, one of the most dread diseases of all, is to be attacked by the vast machinery of the State and the municipalities. I am delighted at the change in the attitude of mind of Members of all parties in this connection. I have by the way seen a colony of people suffering from the worst disease known to man. When I was in Iceland some years ago, I visited the leper colony there and I was glad to know that the Government of Iceland were dealing with the problem of leprosy, reducing the death rate, and that they hoped in 10 years time to bring about its total extinction. I am not without hope that this Measure will tend to have the same effects upon cancer in this country. I might say that without being a medical practitioner, or a surgeon, or a radiologist. We are told that nowadays we live 15 years longer, on the average, than people did 50 years ago, and consequently it is fair to assume that cancer is in part at any rate a disease of longevity; 1742 as people become older they are more likely to suffer from it.
A word ought to be said as to the provisions already in being in several parts of the country. I am informed that in Lancashire, outside the boroughs, there is a scheme in existence very much like this one, but that it applies only to persons in receipt of public assistance and not to the whole of the community. We welcome the provisions in this Bill, therefore, for making any such scheme applicable to the whole of the community; but when I come to consider the case of Salford, a borough with about 300,000 inhabitants, where they already have in being the whole of the machinery which would be provided by this Measure, I wish to know how it comes about that Salford will not receive, apparently, a penny piece under the financial provisions of the Measure unless it does some additional work to that which it is doing at the moment. That is a very serious criticism of the Bill, and I trust that when we come to the Money Resolution the right hon. Gentleman will be able to say something more hopeful to us than we have already heard from him.
As one who is keenly interested in vital statistics, and who measures the civilisation of every country by those statistics, I feel that in our own country we are making extraordinary progress in dealing with most diseases. But cancer is the one curable disease—old age, of course, is not curable I suppose, not even under a Tory Government—among the 10 or 11 main categories of diseases in which there is an annual increase in the mortality rate. We ought, however, to remember that during the last 10 years there has been an increase of 36 per cent. in the numbers of those over 65 years of age in the population, and I return again to the point that I think that cancer is very largely a disease of old age; at any rate, it does not afflict the young to the same extent. The right hon. Gentleman told us that there are 100,000 cases of cancer known at the present time, and that only a quarter of those cases are receiving treatment. That is the crux of the problem, I take it.
I think my hon. Friends will agree with me in welcoming the provisions whereby the travelling expenses of cancer patients will be paid, but I do not like the assumption in the Bill that patients are to be 1743 asked to contribute something in return for services rendered to them. The right hon. Gentleman knows as well as I do that the well-to-do person who can afford to be treated by a specialist or in special institutions will not be among those affected by the Bill. In the main they will be those who are too poor to pay anything towards the cost of either diagnosis or treatment. I was a member of a large local authority for 10 years and know of instances where the education authority tried to get money from parents in respect of services rendered, and to my amazement it has been found that the expense of trying to get the money returned has exceeded the amount they were able to collect. Therefore, I ask the right hon. Gentleman whether it is not possible to eliminate those transactions altogether from this Bill. If he wants to do the big thing in this connection let him be the big man and wipe out that provision altogether.
Like most hon. Members, I naturally wish the Measure well, but since I have been here I have learned that it is one thing to pass an Act of Parliament but quite another thing to get it implemented. Acts of Parliament in relation to health, as in relation to everything else, are just instruments which can be utilised if the community are disposed and willing. Somebody asked me the other day—and I cite this as a parallel—why he did not get justice in the courts of law. My reply was, "You are too poor to get justice." [HON. MEMBERS "No"] Oh, yes, too poor. It is true that the law would deal with rich and poor alike, but unless I have the money to pay to put the law in motion I cannot get as much justice as the person who is able to pay. The same consideration applies very largely to the health of the individual, and therefore I hope the right hon. Gentleman will be good enough to consider again whether he can relieve people of any payments at all, making the service, as he indicated it would be in his speech, a real public service. I am glad once again that Members of all parties in the House have given a welcome to this Measure, and I trust sincerely that it will help to achieve the objects which the right hon. Gentleman has in mind.
§ 10.14 p.m.
§ The Parliamentary Secretary to the Ministry of Health (Mr. Bernays)
The 1744 hon. Member for Westhoughton (Mr. Rhys Davies) spoke with his characteristic eloquence, and I am sure that that eloquence was not due, as he suggested at the opening of his remarks, to any lack of knowledge of the Bill, because all who heard him must agree that he spoke with both knowledge and authority. I was very much impressed by the point he made with regard to cancer that the best propaganda is the hope of recovery on the part of the patient. I am sure that is the case, and we shall all agree with him, I feel, in looking forward to the time when cancer will be as unknown in this country as leprosy. I think he made a little too much about the question of the recovery of expenses from patients. If a patient is too poor he will not pay anything. Recovery is not open only to those who can afford to pay for it.
At this Box a short time ago it was part of my melancholy duty to unfold to this House the plans which the Government had for the protection of men, women and children in the case of air raids—which we pray may never happen. It is a special pleasure to me to-night to be able to discuss the question of how we can deal with the casualties, not of war but of peace, and of normal life. On behalf of my right hon. Friend I would say how much he appreciates the response this Bill has had from all parts of the House. The interest taken in it is a clear indication that he will have great assistance from hon. Members in the Committee stage in moulding the Bill as a House of Commons Measure. The Bill represents a new and important addition to the campaign which is ceaselessly being waged by successive Governments for the conquest of disease, and the disablement associated with disease. We believe that in this Bill we are on the threshold of something big. The health progress of the last generation affords remarkable evidence of great progress, and hon. Members can take some pride at the part that legislation has played in that progress.
Take, for instance, the plague. There is no need now for a prayer in the Anglican Liturgy for a time of plague. I suppose that improvements in sanitation services have had a great deal to do with that change. I remember that even in my childhood it was common to see men and women pitted with the ravages of smallpox. I looked up the 1745 records at the Ministry of Health this morning and found that there were only three cases of small-pox last year in the whole country and that none of them was fatal. In pulmonary tuberculosis, the death-rate has declined by 46 per cent. since 1911. But cancer remains unconquered, and it has grown more formidable every year. It is against that disease that we are seeking in the Bill to mobilise all our resources in an offensive all along the line of treatment and diagnosis for all. I stress particularly those words "for all." I am afraid that I found it very difficult to follow the words of the hon. Lady the Member for West Fulham (Dr. Summerskill) when she argued that the poor were not receiving treatment. It is the whole point of this scheme that it applies equally to all classes and to both sexes. I fully admit that probably in the present time the rich do have a better chance of treatment for cancer than the poor, but we have brought in the Bill in order to remove that difference, and in order that all classes may have an equal opportunity of diagnosis and treatment.
§ Mr. Bernays
I am afraid that it would be out of order for me to discuss that subject.
Hon. Members do not disagree with the principle of the Bill. It is upon details, and particularly the financial details, that criticism has centred. The most sustained attack has been made upon the finance of the Bill. I will, therefore, try to deal with that aspect of the Bill first. The right hon. Member for South Hackney (Mr. H. Morrison) dealt with the matter with great moderation—at any rate great moderation for him, as I know his feelings in regard to the financial aspect. He seemed concerned about what our election cry would be in 1940, but I can assure him that on this side we do not consider electioneering, at any rate 18 months before the election.
His main argument, as I understood it, was that we are really producing social reform on the cheap: that the Government were constantly placing statutory burdens on the local authorities and then claiming the credit for the reforms which the local authorities carried out. I am quite willing to meet that argument. Is 1746 it really suggested that, while the responsibility for carrying out the service should rest on the local governments, the greater part of the burden of finance should rest upon the central government? That, really, is an attack on the roots of local government. Local government is one of the bulwarks of democracy, and I am sure that the right hon. Gentleman would be against the encroachment of the central government, against a rigid, standardised control by an impersonal bureaucracy. But local government can only remain a bulwark of democracy as long as it retains in some degree—and, I believe, in a very substantial degree—the power of the purse. Destroy or damage that, and the local authorities cease to be responsible instruments of government, and become the lifeless agencies of an all-powerful central executive. I am sure the right hon. Gentleman would not wish that to happen.
The principle has long been established in this country, so far as the health services are concerned, that their administration is a partnership between the local authorities and the central government, and I do not believe that hon. Gentlemen opposite, in spite of their theoretical adherence to Socialism and complete State control, would really depart from that principle if they came into power. In this Bill we are proceeding on the well-established principle of the division of finance on the basis of a 50 per cent. contribution by the State towards the total sum incurred by a new health service. The right hon. Gentleman argues that some authorities will receive considerably more than others, and that is perfectly true; but surely that is fair and just. I have here a table of the estimated percentage—
§ Mr. H. Morrison
The hon. Gentleman will forgive me, but I made no complaint about that at all. He will recall that I made no complaint that the poorer areas should receive more than the better-off areas. But I say that there ought to be a minimum below which any area should not fall.
§ Mr. Bernays
I am coming to deal with that point next, but first of all I want to establish the principle. I have here a table of the estimated percentage grant for county borough councils and county councils. In the case of the county 1747 boroughs, Merthyr Tydfil heads the list with 85 per cent., and Bournemouth is at the bottom with 21 per cent. I do not think the right hon. Gentleman would object to Bournemouth being at the bottom. In the case of the county councils, Monmouth is at the top with 85 per cent., and London and the Home Counties are at the other end with 27 per cent. or more. The same point was strongly stressed by the hon. Member for the University of Wales (Mr. E. Evans), but I do not really think he has much to complain of, so far as Wales is concerned, in regard to these grants, because under the Bill only Cardiff will have less than 50 per cent., and even Cardiff will get 49 per cent.
Coming to the point made by the right hon. Gentleman, he made what he thought was a strong case about the position in which London is placed under the Bill. I suggest that it cannot really be contended that London has been harshly treated. After all, London is the richest town in Europe; and particularly is her wealth evident in the size and variety of her hospital accommodation, of which the hon. and gallant Member for Central Wandsworth (Colonel Nathan) spoke. It has been, perhaps, unfortunate for the country that the benefaction of wealthy men has been so much concentrated in London and not spread more over the industrial districts, where a great portion of that wealth has been made; but that is the fact, and the efficiency of London's hospital accommodation is the result. It is evidenced also by the estimate that has been made that 90 per cent. of the cancer patients in London are already receiving some form of treatment, many of them in voluntary hospitals. This Bill is concerned only with additional expenditure, and I suggest that that additional expenditure in London cannot be a serious burden. I have had inquiries made, and it is estimated to be somewhere in the region of £60,000 a year. That is the equivalent of a rate of one-fourth of a penny. Even if you double or treble it, it does not become a very serious burden.
I admit that this is not only a London point. Several hon. Members have asked, "Why not a minimum grant? Clearly, if the better off local authorities received 5o per cent., and the harder-pressed authorities as much as 85 per cent.—and the right hon. Gentleman has 1748 reinforced in his interruption the point he made in his speech that no one would suggest that the worse-off authorities should receive less than they are getting now—then the total Exchequer assistance would be not 50 per cent. of the total expenditure, but something in the nature of 70 per cent. That is a position to which the Government cannot agree. The Government decline to depart from the principle of the block grant, by which contributions are made from the Exchequer by reference to the relative need based on the weighting formula. Not only was this principle accepted and the method of calculating Exchequer contributions established with the assent of Parliament in 1929, but the whole subject was under review two years ago and a Bill was laid before Parliament which continued the revised formula for another five years; and I think I am right in saying that that Bill passed through this House without amendment and without a Division.
In face of all those facts, I am sure the great majority of hon. Members realise that it is unreasonable to expect the Government to make an alteration in the apportionment in the case of cancer, in which it is peculiarly appropriate, in that the largest proportion of grant will go to centres where the treatment of cancer is least advanced. The right hon. Gentleman the Member for South Hackney also put this question: Cannot the grant be related to each local authority's total expenditure instead of its additional expenditure? The right hon. Gentleman quoted the evidence of Section 135 of the Local Government Act, 1929. It is upon that Section that we take our stand, for that Section states that it is the intention a that Act, in the event of material additional expenditure being imposed on any class of local authorities by reason of the institution of a new statutory service, that provision should be made for increased contributions out of moneys provided by Parliament. That is precisely what we are doing. We are giving half of the total additional expenditure. The right hon. Gentleman accused us of betraying the spirit of the Act of 1929, and I contend that we are carrying out that Act both in the spirit and in the letter.
Considerable and powerful arguments have been addressed to the Government on the question of those local authorities who 1749 vices. I would ask hon. Members who have made no provision for cancer serraise this question to consider the argument that generally the local authorities who have done little or nothing in the development of a cancer service are the poorer authorities. The expenditure of these authorities under the development of a cancer service will be proportionately higher than that of the authorities who have already a service, and the temporary grant, therefore, will be proportionately greater. When the Exchequer assistance is merged in the block grant, all will share in the increased block grant under the normal method of distribution, the additional money being distributed according to the relative capacity to meet increased expenditure as indicated by the weighted population.
There were a few financial questions raised by the right hon. Gentleman the Member for South Hackney, who argued that the Minister should make direct grants to the voluntary hospitals. For the Minister to do that would really be contrary to the whole spirit of the administration of the health services; it would result in the setting up of dual responsibility. I think he will agree with me when I say that there are many local authorities, perhaps the majority of local authorities, who do not take his view of that question. He raised also the question of the right of recovery of the cost of their treatment from patients who come from outside the area of the local authority and are treated in the organisations of that local authority. It is not the intention of the Bill that the London County Council, for instance, should pay for the treatment of patients who come from outside their area. If Berkshire or Buckinghamshire send a patient to a London voluntary hospital, then, clearly Berkshire or Buckinghamshire must pay for the treatment. It is for the London County Council to see that they pay only for their own patients, and clearly it is a matter of arrangement and of organisation for the London County Council.
I come to one or two of the general questions that were raised outside finance. The hon. and gallant Gentleman the Member for South-East Leeds (Major Milner) and my hon. Friend the Member for West Leeds (Mr. V. Adams) raised the question of notification. The main purpose of notification is for the prevention of the 1750 spread of infectious diseases; it is really only made statutory for the protection of society. You cannot notify a disease until you have diagnosed it, and once cancer is diagnosed there is no need for notification. Notification is the switch by which you set in motion the machinery of treatment. What we are trying to do in this Bill is to create the machinery of treatment.
The hon. and gallant Member for South-East Leeds and, I think, my hon. Friend the Member for St. Albans (Sir F. Fremantle) argued that the general practitioner ought to have a place in these proposals. I suggest that he does, in fact, have a place. He is the first line of attack in this problem, as he is in all problems of disease, and we are out to strengthen his hands by providing him with expert consultative opinion for his patients. There is also a duty in Clause 1 (3) laid upon the local authorities to take the representatives of the medical profession in each area into consultation, and those representatives will include representatives of the general practitioner.
My hon. Friend the Member for Chislehurst (Sir W. Smithers), and the hon. and gallant Member for South-East Leeds, asked why we were lavishing £500,000 on radium. We are not proposing to do that. The Trust are not pledged to buy any more than two grammes of radium a year, so that their actual commitment does not amount to more than £50,000. That has to be taken with the sum required for the radium now in the possession of the Trust, the initial payment for which will become due in a few weeks, amounting in all to £80,000, so that the actual commitments under this Bill are only £130,000. Therefore, by no means all the £500,000 has been earmarked already. The balance will be available for additional radium as it is required, and also for all the other requirements of radiotherapy.
We have been asked why this Bill, a Cancer Bill, mentions radium at all. Well, radium is the one element in treatment where the supply does not keep pace with the demand. Its high cost and relative scarcity make it suitable for specialised purchase, control and distribution. I can assure the hon. Member for the Welsh University (Mr. E. Evans) that it is certainly not our intention to 1751 press radium on the medical profession. He asked who will decide when doctor's disagree. Certainly not my right hon. Friend. There is no intention in the Bill and no intention on the part of my right hon. Friend to stereotype in any way the method of the treatment of cancer. That is a question for the specialist. We have been asked, further, why we propose in Clause 1 to consult the Radium Commission. The answer is a simple one. Because they were set up for that specific purpose of consultation, and clearly it is wise that we should consult them, because they have accumulated a vast amount of experience. The question of extending the functions and the personnel of the Radium Commission so that they may deal with other forms of radiation treatment is, as my right hon. Friend said, now under consideration.
The hon. Member for Chislehurst and the hon. Member for the London University (Sir E. Graham-Little) urged consultation with the leaders of the medical profession. The hon. and gallant Member for Central Wandsworth expressed surprise that consultations had not taken place before the Bill was introduced. Let me give him one reason why consultations did not take place which, I am sure, will appeal to him as a business man. If my right hon. Friend had announced the introduction of this Bill before he was ready for it he would, in fact, have sent up the price of radium, and when he came to get an option on radium he would have found that the price had been raised substantially against him. Therefore, it was not possible to have prior consultation. But what really matters is not so much consultations about the introduction of the Bill as consultations about arrangements which will be made under the Bill, and I can give hon. Members who have raised this point the fullest assurance that my right hon. Friend will keep in the closest touch with the medical profession and those skilled in the newest methods of remedy. In fact, there is a statutory duty under Subsection (3) of Clause 1 for local authorities to consult with the representatives of the medical profession. The hon. Member for the London University raised the point of a formal conference with the medical profession.
§ Sir E. Graham-Little
My point was for a conference with the expert members of the radiological profession.
§ Mr. Bernays
My right hon. Friend will, of course, be willing to consider such a conference if a desire for it is expressed by all the interests concerned. I am sure he will not expect me to give him a definite announcement on that point to-night.
The right hon. Member for South Hackney stressed the importance of research, and I can only repeat my right hon. Friend's assurance that he has consulted with the great institutions of research already in existence and has received from them an assurance that every effort will be made to maintain and extend their work. It is true, as the hon. Member for West Fulham suggested, that there is no grant specifically for research in the Bill. I would suggest that the establishment of statutory services for the treatment of cancer open out new opportunities for research in the additional practical experience which will be obtained from the increased number of patients who will now be treated. A new team of cancer specialists will, we hope, emerge as a result of the Bill, and their investigation into thousands of cases spread over a number of years will provide a growing accumulation of records and statistics which cannot but be of value to research students.
The right hon. Gentleman asked whether there was not a danger that Government action might tend to dry up the sources of private charity. There always is that possibility. There is always a danger when public money comes in at one door that private subscriptions may go out at the other, but when my right hon. Friend saw the heads of the research bodies, representatives were included of the voluntary hospitals, and he received assurances that so far from diminishing their efforts they would try their utmost to increase them. It is satisfactory to recall, in this connection, that many sanatoria for tuberculosis are still being carried on by voluntary subscriptions, although a statutory duty has now been laid upon the local authorities to take steps to provide the necessary sanatoria for the treatment of tuberculosis.
1753 My hon. Friend the Member for South Hammersmith (Mr. Cooke) asked whether we have sufficient cancer specialists available for the centres. I am sure everyone was delighted to hear my hon. Friend say, in his most interesting speech, that in another incarnation he had been a member of the medical profession. I was particularly interested to hear that, because it was the firm of doctors with which my hon. Friend was associated in those days who were responsible for bringing me into the world, and I hope my hon. Friend does not regret the part he played in that. In reply to his question whether we have sufficient cancer specialists available for the centres, I cannot definitely say "yes," but once it is known that there will be new openings in this field, we are confident that more people will train and equip themselves for the work. There are, indeed, already signs that this is happening. I hope this will be of some assurance to my hon. Friend the Member for St. Albans. With the establishment of this service, after all, an assured future for cancer specialists comes on to the horizon, and I am sure that the new attractions will induce students to take up specialist cancer work.
It is, of course, inevitable that in a Bill of this kind the question should be asked, "Why cancer? Are there not other health services where the need for assistance is as urgent, if not more urgent?" Of course, there are many other health improvements which might be taken in hand. The Government have to consider the means they have available at any one time. The question of priorities is not confined to the Defence Services, but exists at the Ministry of Health too. We had to make a choice from competing claims, and I think my right hon. Friend advised the Government to choose cancer because, as he said, cancer is a killing disease, and the question of treating it is one of urgency. It is a terrible thought that only one quarter of those who suffer from cancer are, in fact, able to go and receive expert treatment. It is, also, not merely a question of the actual sufferers from cancer. Many thousands more believe they have cancer, and though their fears may be entirely groundless, in many cases they suffer the tortures of the condemned. I am informed that a proportion of suicides are due directly to the fact that the people who take their life believe they are afflicted with cancer.
1754 This Bill will enable these people, whatever their position in life, to put their anxieties to the test by seeking an expert medical diagnosis, and we hope, too, that it will spread the news that cancer in its early stages does yield to treatment. There is no doubt that many people are afraid to confess their symptoms because they feel that if they do so, they will receive sentence of death. After all, one of the favourite situations in the Edwardian novels was the scene where a man was informed by a great Harley Street heart specialist that he had only six months to live. I believe such a verdict is never given in Harley Street now, because so much more is known about the condition of the heart. It is the same with tuberculosis. There was a time when "T.B." was mentioned in frightened whispers, but now a patient confidently goes to the sanatorium, and in a great number of cases he emerges cured. What we aim at in this Bill is to do for cancer what has been done for tuberculosis, and I believe that by so doing we shall lift a load of anxiety from thousands of homes.
§ Question, "That the Bill be now read a Second time," put, and agreed to.
§ Bill read a Second time.
§ Bill committed to a Committee of the Whole House for To-morrow.—[Captain Hope.]