HC Deb 01 May 1946 vol 422 cc159-313

Order read for resuming Adjourned Debate on Question [30th April], "That the Bill be now read a Second time."—[Mr. Aneurin Bevan.]

Question again proposed.

3.39 P.m.

Sir Henry Morris-Jones (Denbigh)

At the adjournment of the Debate last night, I had to sit down after a few disjointed remarks. I hope the House will now allow me to finish my speech. Despite great temptation to the contrary after the night's repose, in view of the large number of right hon. and hon. Gentlemen who wish to take part in this Debate, I promise to be as short as possible in finishing what I have to say. I was speaking about the terms of service under the Bill. It is very unfortunate that the Spens Report, about which we hear so much, is not available to hon. Members now. Neither the public nor the doctors nor the dentists know the terms of service on which practitioners will have to work under this Bill. The Minister did give an indication of his trend of mind. He spoke on the question of capitation and salaries. I was very glad to notice that he laid more emphasis on capitation than on salaries.

He may be interested to know that at the conference in London last night the panel doctors expressed themselves unanimously against any salary at all, and I think they came to a wise decision. It is to their credit that they came to that decision, and I ask the right hon. Gentleman now, whether he will not drop the salary altogether from the terms of service, because the whole medical profession, and those associated with them, regard the salary as placing them immediately in the position of State servants. And so it does. Under these terms the Minister, or any other Minister who comes after him, will have power to vary the salary if he likes. He may make the capitation fee less and the salary more. He may in time make the salary 90 per cent. and the capitation fee 10 per cent., with the result that medical men become more and more tied as State servants. They have a very genuine fear in regard to this matter, and I hope the right hon. Gentleman will give it his consideration.

After all, a salary is not altogether fair in its distribution, because it is given to the inefficient as well as to the efficient. Suppose there are three or four men practising in a small town. There are "dud" practitioners in the medical profession as in every other, and if you give a basic salary to a man who is inefficient or takes no interest in his work, and who may have not more than 100 on his panel, you have to give the same salary to another man in the same town, who may have 2,000 people on his list because of his energy, initiative, resource and interest in his work. The same basic salary is paid to the inefficient and to the efficient. It is not without reason that the medical profession prefer the capitation system. It gives them more interest in their patients, and more incentive to work. It gives them a feeling of a closer personal association with the people themselves. You cannot change human nature. I am told that the world is still very young, and that civilised man has only been on this planet some 10,000 years, but you cannot alter human nature, which demands a personal interest and incentive in work. I trust that the right hon. Gentleman will reconsider the whole question of salaries and capitation fees from that point of view.

Members of the medical profession, the dental profession and similar professions are not sacrosanct. They come into their professions, many of them, on economic grounds. Even a clergyman, I understand, when he takes a living, makes a calculation of what he is likely to get out of marriages and indeed out of funerals as well, so I do not think that a doctor would be unreasonable to take an interest in his capitation fees. The right hon. Gentleman has suggested in the White Paper that, on a number of patients, over a certain figure, it is his intention to make the capi- tation fee smaller. That would be a very dangerous thing to do. The people who came in under this lower figure would be a separate category, different from the main body of the doctor's patients—I presume they would be considered small "capitationists"—and I hope the right hon. Gentleman will consider that point.

I think the right hon. Gentleman was quite wrong on the question of the sale of practices. The medical man, like every other professional man in this country, whether he is an accountant, a lawyer, an architect or anything else, has a complete right to sell his practice, which is the fruit of his endeavour, and represents the goodwill which he has built up. I think it is nonsensical on the part of the right hon. Gentleman to call it a shameful thing. What is it, after all? It is nothing more or less than an introduction. A doctor going to a new district may be many months before he knows anybody, but if he buys a practice, he buys the goodwill and gets an introduction to the people. Under the panel system, when a panel practice is sold, every person on that doctor's list is notified of the change in the practice, and he or she has the right to change. What do they do? They wait to see what sort of a man the new doctor is. They try him, find out what good he is, and if he is not good they change. In describing this free choice as the sale of patients I do not think the right hon. Gentleman is using terms which bear any relation to the facts.

On the question of compensation, I do not wish to say anything about the amount; I do not think anybody could quarrel about the amount, but I understand that the doctors are against compensation altogether. Therefore, I am not for the moment questioning the amount of compensation. What I am questioning is the suggestion that there is any need for compensation. Doctors prefer to retain their practice asset.

Mr. Percy Wells (Faversham)

Is the hon. Member suggesting that the doctors prefer to give their practices?

Sir H. Morris-Jones

What I am trying to say is that the medical profession, as a whole, prefer to retain their goodwill and the right to sell their practices, rather than be given compensation. They hold that view by an overwhelming majority. What is to happen to the man who has bought his practice only a year or so ago? I know one case, a youngish man, only 28, I think he has a small family, and he paid £2,400 for his practice. Under this Bill he will be compensated, probably on the basis of two years' purchase, and he will be compensated by a forced loan. It is a forced loan in the sense that he receives the interest on that money for the rest of his life or until he retires but has no control over the capital—his own—to use it as he thinks fit. It may be 30 or 40 years before he gets the capital. This is the first occasion on which we in this country have seen the establishment of a forced loan on one class of the population without the opportunity of touching the capital.

On the question of the distribution of practices, in my submission the right hon. Gentleman did not establish his case. I have seen the figures. The right hon. Gentleman quoted the differences as between industrial towns and seaside towns, but the figures are equally striking between industrial towns themselves. There are two adjoining towns in Lancashire where there is a great disparity in the number of doctors. But take a town like Bournemouth. I am told that during the war, when they were calling up medical men, the committee set up by the Government to recommend people for selection, received complaints that Bournemouth was over-populated with doctors. They went into the matter and found that a large number of the medical men in Bournemouth were old and retired men and that quite a number of them were men who were sick—suffering from tuberculosis and things of that character—and who had gone to Bournemouth to rehabilitate themselves and get cured of their own ailments. The figures are quite fallacious and if I am able to establish to this House that there is at the present moment a fair distribution of medical men in the country then I submit that the right hon. Gentleman is taking a very serious step in imposing direction on the whole medical profession.

Dr. Stephen Taylor (Barnet)

Surely, as the hon. Gentleman has himself said, there is great disparity between the industrial towns?

Sir H. Morris-Jones

I am trying to establish my case to the House. I know there is disparity between the industrial towns, but the point emphasised by the Government and the right hon. Gentleman is that all doctors are flocking to the seaside and residential resorts. [HON. MEMBERS: "No"] I am saying that that is not the case—

The Minister of Health (Mr. Aneurin Bevan)

The hon. Gentleman ought not to say that. The only seaside town I quoted was Hastings. The others were Bath, Dartford, Bromley and Swindon.

Sir H. Morris-Jones

The distribution of doctors, on the whole, in this country is a fair one. When all is said and done, there is the law of supply and demand, and if the right hon. Gentleman left that law alone the people of this country would be much happier. It is a very salutary law and has been in existence for thousands of years.

Mr. Percy Wells

It is not satisfactory in the case of food.

Sir H. Morris-Jones

I must be brief, because I promised to be. Because of this alleged maldistribution of medical men the right hon. Gentleman is imposing directions under this Bill. There is direction under this Bill both negative and positive. It is the first time that direction has been imposed, under a Statute of this country, on any body of its people as a permanent measure. The negative direction is that no medical man or woman will be allowed, except by the consent of the committee—which will be the Minister —to remove from the place where he or she happens to be when the Act comes into force. They will not be able to remove from that locality without the consent of the committee. Not only that, but no one fresh to the profession will be allowed to go into any area without the consent of the Committee or the Minister.

Dr. Taylor

That is not true.

Sir H. Morris-Jones

Those are the facts.

Dr. Taylor

There is only one ground on which the committee can withhold consent, and that is that there are too many doctors in the area already.

Sir H. Morris-Jones

That does not make any difference to my contention, that it is within the power of the Minister and the committee to refuse consent to any medical man or woman to remove from where he or she may be.

Dr. Morgan (Rochdale)

That has always been so in this country. May I ask a question?

Sir H. Morris-Jones

No. I am exceeding my time. I want to come to the conclusion of what I have to say on this Bill. I have very considerable misgivings about the Government's taking over sickness as a national matter. It will be the death knell of the family doctor as we have known him in this country for generations. I do not think that that is a matter for rejoicing by any hon. Member in any quarter of this House. I am afraid of the dull uniformity that runs through this whole scheme. It may very possibly become a utility scheme with a utility service under which doctors will sign and certify more and more, and be treating less and less and curing less and less, while signing more That is the danger of it. I want the House to remember that here we are not dealing with such nationalisation as, for instance, the nationalisation of the mines. Here we are dealing with the most individual thing in the whole world, the sick and ailing man or woman. We cannot deal with them except on the basis of individual personal interest.

Having said that, I also want to say that we all agree with the aim of the Bill, to bring about a comprehensive health service for everybody in this nation irrespective of class or income. The right hon. Gentleman showed yesterday clear signs that he has benefited very considerably from his study of this matter. He has gained by closer acquaintance with the very great difficulties involved. I was very glad to see him much more conciliatory than I had expected him to be. If he will bring some considerable Amendments into this Bill, to do away with this direction, which is a diabolical thing; to bring about a greater share in the administration of the Bill by the people who will have to work it; to encourage more interest in the voluntary and local hospitals, by allowing them a greater measure of control over their finances, with less central direction; and if he can create a general medical practitioner service, comprising a body of people who will work happily and with enthusiasm, then, I think, he may be able to endue this Bill with life, and so make his mark on the future of this country and make even this Bill workable. If he is unable or unwilling to make concessions I prophesy that the Bill will be unworkable, and that it will not become the Measure which we all desire to see, one which will achieve a real improvement in the dealing with the health of the people.

3.57 P.m.

The Parliamentary Secretary to the Ministry of Health (Mr. Key)

Rarely, if ever, in a first day's Debate on a Measure of this magnitude can the Opposition in this House have stated so weak a case as that which was stated yesterday from the benches opposite. Rarely, if ever, has a poor Parliamentary Secretary, destined to reply, and seeking material on which to build his speech, listened so eagerly and been rewarded so meagrely as was my case yesterday. I have gone very carefully through my notes; I have looked up the OFFICIAL. REPORT; and I have tried to find, in the objections that were raised, material for the sort of answer I ought to make.

I shall deal with this subject in three sections: hospitals, practitioners and local authorities. First, with regard to the hospital service; what we have to do is to evolve a real hospital service that will give all our people, irrespective of their occupations, irrespective of the area in which they live, the benefit of all kinds of hospital and institutional care necessary to meet their needs. We have got to create a really integrated service. There are those who have said that what we should have done was further to develop our voluntary hospital system, and extend our municipal hospital system. There is no such thing. We have no hospital system. What we have is a number of separate hospitals, voluntary and municipal. Rarely can we find any real coordination between them. Rarely, if ever, can we find the separate units functioning in an integrated service. Overlapping, competition, rivalry—these, in the hospital surveys, have been shown to be common. Cooperation and mutual assistance have been shown to be rare. Such faults as these can be remedied only by the establishment of a nationwide service which will bring within the reach of all, irrespective of their ability to pay, the best possible hospital and medical service we can devise.

We are told that in doing this we ought not to interfere with the individual voluntary hospitals, that they should be left to do their work in their own admirable way, cooperating as far as they wish by providing the type of hospital service they themselves desire, and receiving, if they come up to the minimum standard laid down, appropriate payment from national funds per patient treated, or per bed provided. On that basis, a real hospital system can never be built up. To get a real hospital system it must be planned, and planned not only quantitatively, but geographically and functionally. Moreover, if the service is to be realised, the planning authority must be the executive authority as well. No really efficient hospital service can be provided by the units concerned having the power to determine their own functions within a so-called system, or to decide for themselves the extent to which they will participate. If the planning authority is made the ultimate executive authority, then, having settled the functions of a particular hospital or group of hospitals in the area organisation, it can pass over to smaller managing bodies the direction and control of the institutions concerned. That is the set-up of this Bill.

What, then, are the main objections which have so far been raised against it? First, there is the charge of what has been styled the "mass murder" of the voluntary hospitals, and the confiscation, conscription, or what other question-begging epithets can be coined, of the property of these voluntary organisations. Supposing these terms are right—which I deny—what then? It is right to conscript the labour and lives of men in a war against evil abroad, but it is wrong to conscript buildings and institutions in a war against disease at home. Men may suffer and die in both conflicts, but it will be all right so long as private property and private practices are preserved. We are not standing for that. For whom, and for what, I ask, were these places built and this money given, but for the service of the people of this country in general?

Vice-Admiral Taylor (Paddington, South)

Have they not served the people of this country?

Mr. Key

It is not the opinions of those who are often the self-appointed governors of these institutions which can decide their proper and correct use in the interests and welfare of the people for whom they were provided. It is the will of the people which must decide, and that wish and that will have been definitely made known, and will find proper expression in the Division Lobbies tomorrow. Next, it has been said that what we are here proposing will destroy the local spirit, the local character and the local interest in these hospital services. It has been said, for example—and here I quote: The effectiveness of the hospital, its responsiveness to public feeling, its susceptibility to public criticism, the maintenance of its position as a centre of local interest and welfare and affection—all of which are things essential to human hospital administration—all this will be lost that is, lost under the scheme we propose. I deny that. Every hospital or group of hospitals so related as to form a hospital unit is to have its own committee of management, and the members of that committee will not be black-hearted, black-hatted bureaucrats from Whitehall. They are to be appointed, not, mark you, by the Minister, but by the regional board of the area concerned, and after consultation with a number of local authorities. These local authorities include the local health authority, the local executive committee in charge of the practitioner service, the existing voluntary hospitals and the senior professional staff in the hospitals themselves. You can hardly have a more local body than that. Why should these local citizens, with greater means at their disposal, and greater opportunities for development, do less than their predecessors have done? I am convinced that they will do more. With the growing sense of social responsibility which is so evident in our people today, greater interest, greater initiative and greater participation in the development of our social service will become more potent than ever before.

It is also said that we shall have restricted the powers of local initiative and robbed them of the means of meeting local needs by the confiscation of their local funds. That is the exact opposite of the truth. This scheme provides that the regional boards with their local management committees are to enjoy a high degree of independence and autonomy within their own field. Each of the regional boards will have at its disposal an appropriate share of the present endowments of the voluntary hospitals, which are to be transferred into a central hospital endowments fund and redistri- buted according to the need of each region. The regional boards will be able to spend this money, or hand it over to local management committees to spend as they think best, without any kind of detailed instruction or restrictive regulations from the centre.

Commander Maitland (Horncastle): rose

Mr. Key

It is my statement which I am making. I will have clarified it by the time I have finished. I have had a great deal of experience in teaching youths who are not ready to understand and appreciate. Before I have finished, I think that I shall have given my class the sort of lesson they are wanting.

Mr. Peter Thorneyeroft (Monmouth)

Is it in Order to describe the Chair as an inexperienced youth?

Mr. Speaker

I do not think the Parliamentary Secretary said that the Chair was an inexperienced youth.

Mr. Key

I have an appreciation of the English language, and I should not apply those words to the Chair. In addition, as the White Paper states, the regional boards can receive gifts or legacies and hold property in trust for any purpose connected with the hospital services which they control. Moreover, the boards, and under them the hospital management committees, will have a very considerable amount of financial freedom so far as administration is concerned. At the beginning of each financial year they will prepare their annual estimates. Their budget of course will have to secure approval, but when once it has been approved, it will be for the Board to spend the money, put at their disposal by the Exchequer, as they think best, up to the limit of the sum that has been approved. There will be a wide discretion concerning that global sum, and not, as some critics tell us, central control over the detailed items of financial expenditure.

On the other hand, it has been asked, "Why not take over the local authority hospitals? Why not use the local government geographical distribution, the local government managerial machine, for what, in fact, would become a greatly improved local government service?" I answer: Because of existing geographical areas and the functional distribution that is administratively impossible. I have been a keen participater in local government for many years. and yield to no one in my admiration for its services and my desire to see them extended, but we must not blind ourselves to the fact that, whatever else has been done in local government, as an administrative machine, particularly in so far as its area basis is concerned, it has not kept pace with developments in communications and transport. We have not made its sphere of operations grow with the character of the services we have developed nor with the means and needs for wider areas of administration. This, however, is not the time to deal with the reorganisation of local government.

What we have to consider is the proper planning and provision of a hospital service, and I say, definitely, that the present local government machine cannot provide that service. The areas are normally not adapted to it. We need much wider catchment areas, now that specialised institutions and consultant services are to be made available to all the people. The present separation of the county and county borough services, particularly the separation of the county borough services from those of the county in which it is situated, means that in any hospital service, based upon existing areas of local government, the real focal centre of such a hospital service for the county would not be really available because it would be under separate, and definitely segregated, county borough control. It is said that by the creation of elected joint hospital boards these difficulties can he overcome. I do not agree at all. Greater difficulties would, in fact, be created, because of all bodies the indirectly elected joint board is in my opinion administratively the most hopeless.

Mr. Willink (Croydon, North)

Would the Parliamentary Secretary say why an indirectly appointed regional hospital board is better?

Mr. Key

Yes. I propose to give the reasons for that as I go along. As I say, local differences, local jealousies, local rights and claims are intensified by joint boards. Unified needs, unified advantages are minimised by them. The attention of the members is centred purely on local interests and not upon the general development of a wider service. People appointed to the regional hospitals boards will not be there merely as representatives of local authority interests, but will be selected for their knowledge of hospital needs and hospital problems and will, therefore, be interested in hospital development, and not retarded, all the time, by considerations of a local character, particularly the incidence of local taxation.

That leads me to a further most important point. This hospital service is to be a national service, available to all, and to develop such a service dependent, if administered through the local government machine, at least in part on local taxation, would either place an undue burden on those areas where the needs for this service are greatest—the most poverty stricken, the most highly rated and the most lowly assessed areas in the country—or it would be insuring that in those areas the standard of service provided would not be equal to that in the more financially favoured districts. To that we cannot agree. We are pledged to a general national service, available to all upon equal terms, irrespective of individual needs or local financial ability. Geographically and administratively, functionally and financially, the local government machine is not equal to our task. Hence our need to make one which will fill the big purpose which we have in view. What, ultimately, may become of the local government set-up I do not know, but of this I am perfectly convinced, that we cannot allow our hospital service to be crippled by making it conform to the present restricted areas of local administration, nor can we make its evolution wait on some, as yet undetermined, re-organisation of local government.

I turn to the question of the general practitioners. Here, again, none of the arguments put up yesterday seems to me to be at all new. We have been told, again and again, that such is the character of the service which doctors give, that they ought not to be directed to districts to which they do not wish to go. Doctors, like other workers, should be free to choose the form, place and type of work which they prefer, without governmental or other direction. Well, they are so free and so will they remain. What is the truth of the matter so far as this Bill is concerned? All doctors now in practice in any area before the appointed day are enabled, on making application, to be included in the list of medical practitioners undertaking to provide a general medical service in the area in which they are. There is nothing to prevent any of them from being so included in that list. If a change to a new area is desired, or a new application to share in the service is made, then that matter has to be referred to the local executive council.

What is the composition of the local executive council? Half of it consists of professional representatives, appointed by special practitioner committees, which are wholly professional bodies. They are to be appointed, not nominated, by these practitioner committees. The executive council is the employing authority, but it is not the selecting authority for the doctors in the area. Before the name of the applicant can be placed upon the local list in any area, and he can thus become employed by the local executive council, the matter has to be referred to the national medical practices committee to determine whether or not, in the view of the general profession there, there is need for extra medical practitioners to go to the area. If the medical practices committee say that, in relation to other areas, the one under consideration is well served, then no addition to the local list can be made. If the number of applications that are made exceeds the number of places that ought to be filled, then it is the medical practices committee which will select the applicants whose names are to be added to the list.

What is the composition of this medical practices committee, vested with all these powers? It is to consist of a chairman who must be a medical practitioner and eight members, six of whom must be medical practitioners. Of those six, five or a majority of the committee must be actually actively engaged in medical practice. That is called direction. What then, in the name of conscience, would be the definition of professional self-government? Where, may I ask, is there any other service paid out of local funds or out of national funds where anything approaching that amount of self-government exists?

That some control of the distribution of doctors must be established is, I think, obvious, because so far that distribution has been chancy and very uneven. The areas where the need is greatest have often been most badly served, yet the claim is made that no matter what the superfluity of doctors in any area may be, or the dearth in any other area, any individual doctor is to be empowered to decide for himself whether he is to be included in the National Health Service in that particular area. For, say the B.M.A., not only shall doctors like other workers be free to choose the form, place and type of work which they prefer—to which we all agree—but having decided their preference, whilst other workers may but seek and obtain it only if the need exists, the doctors shall be empowered to demand it, whether or not their services are required. Again, say the B.M.A., in addition to the claim already made: Every registered medical practitioner should be entitled as a right to participate in the public service

That is an impossible, impertinent claim. Who has a right to participate in a particular section of public service in a self-selected area? Neither town clerks, city engineers, school-teachers, postmen, dustmen, nor any class of public servants have that right.

Mr. Henry Strauss (Combined English Universities)

Is it not obvious that the claim of the B.M.A. is that doctors shall have the chance to find out whether the public does want a doctor? If the B.M.A. claim that capitation should be the basis is allowed, does it not follow that a doctor would be taking a certain risk in asking the public to decide whether he is needed?

Mr. Key

What the hon. and learned Gentleman must appreciate is this. We are here talking about setting up a public service for which the public pay, through public money. This is not some private arrangement between a private practitioner and a private individual. As I have said, none of the people who receive money now from national or local funds has the right claimed by the B.M.A. If a dustman cannot find a job with a particular local authority because no vacancy exists, he does not start to howl about being subject to bureaucratic direction because he has to go and seek work elsewhere. Why must doctors do it too? The interests of the community demand that the distribution of medical services shall be organised with the claims and needs of patients and not the whims and fancies of practitioners as the guiding factor. I wonder what would be said of teachers if as a body, they claimed that any individual teacher, having obtained the Ministry of Education certificate, should be empowered to decide what school he would serve in and as a right obtain a post in it, irrespective of the fact that the school he selected was already adequately staffed, whilst neighbouring schools were so devoid of teachers that classes were of such a size as to prevent the proper education of the children. Doctors would be among the first to say that that was all wrong, and that the best interests of education and of the pupils were being sacrificed thereby. That is equally true of the medical service and of patients if the doctors' claim is going to be allowed.

It is said that, if the Government limit the doctor's freedom of movement in this way, we limit the patient's freedom of choice thereby. None of us wishes to destroy the freedom to choose and the freedom to change. I want to say that for a very large number of people that freedom does not and never has existed. Firstly, there is within their means very often no choice at all. There is only one practitioner available in their area, at any rate to them, because they cannot afford to pay for the other fellow. Secondly, if they choose there can, of course, be no guarantee that the doctor of their choice will choose to take them. However, in so far as choice exists now it will go on and the doctor of our choice will go on looking after us as personal patients, visiting us at our homes, or we visiting him as need may be just as it is done now. He will prescribe the medicine we need and we shall get it made up just as we are doing now. We are not going to be told that we have to go to some new State doctor. We are not going to have our little secrets revealed to some State department without our consent. We are not going to be treated by a lot of civil servants acting under State orders. The fundamental relationship between doctor and patient will remain what it is now. The great difference will be that we shall not pay fees for attention. We shall pool our resources as a community and pay doctors for our general care, irrespective of our individual needs.

Another great difference will be this, that behind our individual doctor and through him we shall be able to get on the same conditions as to payment, all the specialist hospital, X-ray and other modern facilities that we need. In so far as choice can be exercised, this Bill facilitates it What we have to ensure is that what is largely pretence in actual experience, is not used as an excuse to frustrate the foundation of a real medical service and result in the superabundance of doctors in well-to-do areas and a dangerous scarcity in areas mainly inhabited by the less fortunate. "The Lancet" of 6th March puts this matter of doctor-patient relationship quite fairly. "The Lancet" said: The truth is that the doctor-patient relationship in modern form needs improvement rather than preservation; it can never be wholly satisfactory while the doctor (as someone has put it) is not only a friend in need, but also a friend in need of his patient's money; nor while there is competition rather than cooperation between him and his colleagues. The great fact about the service we desire as outlined in this Bill is that it will provide the opportunity for the development of real cooperation and thus help to do that which as "The Lancet" in the same article claims is one of the outstanding features of our new hospital scheme: remove from medical practice much of the mercenary element that has been growing more conspicuous for 50 years or more.

That leads, not unnaturally, to consideration of the questions of the sale of practices and the basis of remuneration of the general practitioner. What is it that doctors claim they should have the right to buy and sell? It is not now goodwill dependent on the ability of patients, as heretofore, to pay for attention, nor on the extent to which, no matter what that ability, they did or did not pay. What is claimed that doctors now shall have the right to sell is a definite guaranteed income dependent on payments from national funds. There are in this no uncertainties, no bad debts; indeed, it is, as the saying goes, "as safe as the Bank of England"—and that is safer now than it ever used to be. Is that privilege something which the medical practitioner should have the right to sell? If it is to be right for doctors why is it not also right for others whose incomes are guaranteed from national funds? If for doctors why not for medical officers of health, school teachers, health visitors and sanitary inspectors?

Sir Wavell Wakefield (St. Marylebone)

Would a sanitary inspector have a capitation fee?

Mr. Key

I do not think it necessarily follows that he ought to have a capitation fee, or that the doctor ought to have a capitation fee. All I am saying is that remuneration comes out of national funds, is guaranteed by national funds, and that the guarantee of this nation is not something which individuals should barter between themselves. If we are to have power to secure better distribution of doctors, which is essential to the future service, the sale of practices must cease. Whether its prohibition logically involves compensation I am not concerned to argue. Whether anyone should have the right to compensation because he is not to be allowed to sell the part he is to play in some new national service is highly questionable. But this is true: the establishment of that new service will destroy a considerable part, if not the whole, of the value of existing practices, upon which some have based provision for their old age, and in the purchase of which others have landed themselves into considerable debts. Difficulties of no mean dimensions will, therefore, be created for those whose participation, whose willing cooperative participation, is essential to the success of our service. We therefore think it wise, in the interests of that service, that they should be compensated for the loss they will suffer, and we are seeking powers under this Bill to do that. It has been agreed with the profession—and I want to emphasise that—what shall be the sum total of that capital value. We shall agree with the profession on the basis on which that capital value is to be distributed.

Mr. Scollan (Renfrew, Western)

Could my hon. Friend tell us the number of doctors involved?

Mr. Key

The number on which this was based was 17,900. Another point I ought to mention is this: Our scheme involved the setting up of superannuation arrangements, and if the sale of practices was abolished, and no compensation given, I think that in justice we should have been bound to take into consideration the past service, particularly under the National Health Insurance Scheme, of the practitioners concerned. if we did that the capital sum involved would have been £35 million, and that must be off-set against the £66 million which is being paid in compensation under this Bill.

What of remuneration? What about the slavery of the salaried service? I have been asked, why not make this into a salaried service and have done with it? Doctors in hospitals and medical officers of health receive salaries. Why not general practitioners? The education service is a salaried service, and has become more and more efficient. Why not the medical service? It is because the medical profession is not yet ripe for such a service and that some check of payment, in proportion to output, is still needed if we are to get from it the efficiency and the effectiveness which the community has a right to expect. That is not my statement. It is the statement of the Secretary of the British Medical Association, who said in a letter to "The Times," on 17th April, that a salaried medical service …might tend to replace competition for patients by competition to avoid them.

Second, and more important, a full salaried service is inconsistent with the free choice of doctor, to which we have agreed. A large salary cannot be paid irrespective of the work done, and the basis of fairness cannot be introduced into a wholly salaried service under existing conditions without compulsory allocation of the work, that is, distribution of patients among doctors. We regard the free choice by the patients as being the more important principle, and, therefore, we put forward a compromise. We propose that general practitioners' remuneration shall be partly basic salary and partly capitation fee. What the general range of remuneration shall be, what the proportion of salary to fee shall be, what the fee per head shall be are problems which remain to be determined. As has been said, we appointed the Spens Committee, consisting of half doctors and half others, to examine what the range of doctors' remuneration should be under the new conditions, and, just as we agreed the composition of that committee with the profession, so, when we have their full report, we feel we shall be able to settle with the profession the range of remuneration and the component parts of that remuneration. Opinions will differ as to what ought to be done. Some will claim that the salary part will be more important, particularly if we make the profession attractive and give young entrants a good chance in the early years of their practice, and we are able to develop the service as we ought. On the other hand, we shall, with a free choice of patient, need to look to adequate capitation fees to secure that each practitioner pulls his full weight in the new service therefore. With good will on both sides, I see no reason why we should not be able to settle that business.

Now, I turn to the question which was raised with regard to private patients and pay beds in hospitals. We felt that to prohibit altogether the private practice of doctors joining the service would only have the effect, at any rate in the early stages of its development, of keeping out of the service a great many good doctors who would otherwise have joined it. Doctors, of course, will not be allowed to charge fees to health service patients on their own lists, but if a patient who has seen his own doctor feels that he would like the opinion of another general practitioner—not, of course, a specialist, who is available within the service without charge—we felt that it was reasonable to say that that person should be asked to pay a special fee for so doing. There is also the related problem of pay beds in hospitals. We are making special provision, it is said, for privileged patients who can afford to pay for private accommodation, a practice which is really alien to a real public social service.

On that I would like to make two observations. The first is that within the public service which, by the proposals of this Bill, we shall set up, if there are any who on medical grounds need special privacy, single rooms, and so on, they will have them, whenever available, free of cost as part of the normal service. What we propose is that when private rooms are available and are not wanted for the time being on such priority medical grounds. it shall be open to people to pay for this extra amenity, if they so desire; but no one will be deprived thereby of services of which they are in need.

Secondly, I am convinced that, as our hospital specialist service builds itself up, the use made of existing private specialist services will decrease; but in the meantime we have a transitional problem of a serious character to face. At the present time, specialists are grouped in particular areas, and are not as readily available to the people generally as is needed. Their work, particularly in voluntary hospitals, is usually honorary, and naturally they group themselves in areas where paying private practice predominates. Apart from their private practice and advice, treatment from them can be obtained only at certain hospitals—all too limited in number—and it is practically impossible to get the specialists into the patient's home, however great the need may be. The dearth of specialists in given areas is not the fault of the specialists, but it is a difficulty that we are bound to try to overcome, and to meet the problem we feel it is wise that no ban should be placed on private specialist practice. We want the specialists to assist in our hospital services widely over the country, but we must prevent specialists who are giving part-time to the services from putting in a minimum routine attendance at the hospitals, and then rushing off to deal with their private cases in a private nursing home service. Therefore, we want to encourage the specialists to regard the hospitals more and more as their professional bases, and for that reason we are certain it will be best—on the distinct understanding that the needs of the ordinary service are fully met—to allow specialists to bring in some of their private work to pay-bed blocks within the hospitals. Two conditions will definitely be laid down with regard to that service. The specialist who is to have the privilege of doing it must be acting part-time in the national service, and secondly, his charges for his services must be subject to control to prevent the sheer abuse of the hospital facilities placed at his disposal.

May I now turn to the Amendment on the Order Paper? I listened very carefully to the Debate yesterday in the hope that I might find, not merely an explanation of the terms of the Amendment, but also some arguments in support of the statements it contains, statements which, to say the least, are surprising, for on the face of them there are three or four that are demonstrably false. Let me take, first, the statement about doctors. The Amendment says that the Bill "prejudices the patient's right to an independent family doctor." That is not true. The patient's right is not pre- judiced; it is safeguarded by this Bill. In fact, for a very large number of our people, such a right is created for the first time, for, despite inability to pay, the mere fact that any individual is a member of this British community will in future give him a right to the services of a general practitioner or specialist at a hospital or at home without payment of a fee. The statement, therefore, is pretty wide of the truth. It may be said that the governing word in that statement is the word "independent"; that the doctor whom the patient may choose is not independent. What does that mean? Independent in the sense of being free to take up the job as he pleases? He is so free. The Bill places no obligation on any medical practitioner. He may stay outside the service altogether if he wants to do so. He may come in with his present practice if he so desires, and with his present patients if they will come in with him. He is free to take any particular patient or not from among them if he wishes, for the Bill says that the consent of the practitioner has to be obtained. Not only does a patient choose his doctor, but the doctor chooses the patient, too.

I come next to the statement about hospitals, namely, that the Bill "retards the development of the hospital services by destroying local ownership." It does nothing of the kind. It promotes the development of the hospital services by ensuring that that development shall not be hampered by local poverty, by low rateable value, by the cheeseparing opposition of local Tory ratepayers' associations, or so-called Conservative Municipal Reform societies. By making hospital provision a national service, the Bill secures an adequate service for all, irrespective of local financial ability or local political opposition. Mere local ownership cannot ensure hospital development. That depends upon the ability to foot the bill, an ability which many of the most needy areas do not possess at the present time.

As far as purely local services are concerned, the Amendment says that the Bill "weakens the responsibility of the local authorities." Again, it does nothing of the kind. It increases their responsibilities. Optional powers are by this Bill made duties, and a direct responsibility is placed upon local authorities to provide services of a quality and standard in keeping with a real national service. It be- comes the duty, and not the option, of the local authority to make arrangements for the care of nursing and expectant mothers and children under the age of five. It becomes their duty, and not their option, to provide a free and full health-visitor service for all in their area who are sick, and a home nursing service for all who need nursing in their homes. It becomes their duty to provide an efficient ambulance service and health centre service for their own activities and for those of the general practitioners; and so, step by step, through the Bill, in these and many other directions, the responsibilities of local authorities are being strengthened, and not weakened.

I felt, while the Bill was being drafted, that we had in this Bill a really good Measure. Since seeing this Amendment on the Order Paper, and particularly since listening to what hon. Members opposite have had to say about the Bill, I am more convinced than ever that I was right, for if the reasons here stated for the rejection of the Bill are the strongest that its opponents can conjure up, it must be an excellent Measure indeed. Lastly, it has been claimed that the Bill is misnamed, that it is not a health service but a disease service that we are setting up. The health promotion and preservation services are, it is true, those which provide good housing, sound sanitation, proper conditions of work, economic security, adequate leisure and sufficient food. It is upon those that good health is to be built. It is those services that the great social programme of this Government will ensure to this country, but the service which this Bill will provide is not merely a curative service. It is, for many, a great preventive service as well. Much of the ill health of our people would have been prevented if they had been able to get proper professional advice in the early stages of their trouble. Much of it can be traced to the failure in these early stages, in the days of childhood, for example, to take those simple precautions and to adopt those simple practices upon which the preservation of health depends. This has not been done in many cases because of ignorance of their character, arising from inability, through poverty, to seek the expert advice necessary to their understanding. Because of experiences of that kind, I am sure no one will welcome this Measure more than the poorer housewives of this country, who, in many cases, have seen the health of members of their family sacrificed and their own health undermined by care and worry because of their inability, through poverty, to seek the early help and advice of doctor and of nurse.

This Bill will abolish that evil and by making assistance and advice available to all, irrespective of means, it will prevent much of that illness and disease which one finds among the poorer people today, and for them the day on which it becomes law will be a red letter day indeed. The Bill does not, of course, stand alone; it is part of that great social programme which the people of this country have so positively approved and which this Parliament, Session by Session, will resolutely fulfil. Nevertheless the Bill, of itself, will, I am convinced, do more than any other single Measure to lift from the minds of our people a load of care and worry that has added very much to the burden of their existence. May the knowledge of that certain resultant benefit serve to expedite its passage through this House and hasten the day of its administrative accomplishment.

4.53 P.m.

Mr. Willink (Croydon, North)

I beg to move, to leave out from "That", to the end of the Question, and to add instead thereof: this House, while wishing to establish a comprehensive health service, declines to give a Second Reading to a Bill which prejudices the patient's right to an independent family doctor; which retards the development of the hospital services by destroying local ownership, and gravely menaces all charitable foundations by diverting to purposes other than those intended by the donors the trust funds of the voluntary hospitals; and which weakens the responsibility of local authorities without planning the health services as a whole.

This Amendment stands on the Paper in the name of my right hon. Friend the Member for Woodford (Mr. Churchill) and of others of my hon. and right hon. Friends. The Parliamentary Secretary has just been making some uninstructed comments upon it, but when he has heard some exposition of the Amendment he will have to revise certain of his opinions. I could understand it being said that the Amendment was a poor thing, if its statements of fact were demonstrably false, but I cannot understand the contention that the grounds set out in it are bad grounds for moving the rejection of the Bill, if they are true. If it is true that this Bill does, in fact, prejudice the patient's right to an independent family doctor; if it is true that the scheme in this Bill retards instead of hastening the development of our hospital services, and if it is true that this Bill menaces all charitable foundations and weakens the responsibilities of local government without putting up a proper plan in their stead, then this Amendment states most serious grounds of objection to the Bill, and that is what I must seek to examine.

I was sorry that I unavoidably missed the first few minutes of the speech of the Parliamentary Secretary, and I was equally sorry when I came in to hear him gladly and voluntarily allocating to himself the position of school master in this House. Perhaps I may remind him that the last time that that position was taken up on those benches it was by his right hon. Friend the President of the Board of Trade when, I believe, the hon. Gentleman was sitting on this side of the House. I shall endeavour to avoid behaving in that way though I realised when I began to prepare these observations that, having studied this matter for so long when acting as Minister of Health before the right hon. Gentleman, I was in grave peril of myself being magisterial. I shall endeavour to avoid it, however much the Parliamentary Secretary likes talking of His Majesty's Opposition as his "class."

The House will understand and forgive me when I claim a very deep personal interest in and concern with the subject matter of this Bill. For 21 months there was no subject to which I gave more thought and attention than the comprehensive health service which was being planned, for the first three of those months, collaborating with Ministers of all Parties in the final formulation of the White Paper of 1944, and then for 12 months in the discussions which I was enjoined by the White Paper itself, and by my colleagues, to undertake with all those interested. The right hon. Gentleman the Minister yesterday made play with the word "negotiations." I have always understood that negotiations were transactions intended to lead to bargains. These were not negotiations, but discussions and true consultations. So little did I know of the result of these discussions and consultations, that it was only a short time ago that I saw the reports issued by the local authority associations with whom I had the discussions. The right hon. Gentleman has taken quite another course, and I venture to say that he would have come to this Debate better informed and better instructed, if he had had some such measure of humility as I had and had sought to learn the difficulties of those whom this legislation will affect.

Mr. Bevan

I had the benefit of the right hon. and learned Gentleman's experience and could improve upon it.

Mr. Willink

I never thought the right hon. Gentleman would use a Conservative Minister's experience without seeking to obtain his own information.

Mr. Bevan

Why not?

Mr. Willink

It is most important in matters of this kind where bodies so various, so ancient, and so honourable are concerned, that Ministers of the Crown, before they put forward proposals, should know how such proposals are going to affect those institutions and bodies. I feel certain that the very serious faults that I find is this Bill could have been avoided, and that they may yet be mitigated when the Minister has discussed them more fully with us on this side of the House.

I am not claiming in the least that my interest in this great Measure—the proposal for a comprehensive health service—is any deeper than anyone else's. I have merely tried to show that I was closely connected with it. It has, of course, been a most widespread interest, over the whole of the last four years in particular. During the darkest days of the war, in 1942 and the early months of 1943, the whole of this nation, so far as there was time to think about domestic matters, was considering educational reform, health reform, and social insurance reform. Just as with education, I am sure that the country as a whole felt that we were ready for a great Measure of comprehensive progress in the field of personal health. Hon. Gentlemen opposite know that those on this side of the House were with them in being resolute in favour of a 100 per cent. service. We resisted any criticism of that, and we were at one with them.

Why was this? We all realised that the progress of medical science, and also the immense increase in the cost of medical services, made it essential that there should be great development in governmental and Exchequer assistance of those services. Not only so—I remember making this obvious remark in the course of the Debate on the Beveridge Report—but all of us wanted to see the mothers and the children with medical attention available to them just as much as the insured population. That was the point which stuck out as being most necessary. In addition, it was most urgently desirable that consultant and specialist services should be available. Wherever we looked, in the field of maternity and child welfare, or in a field which has not so far been mentioned in the Debate, the care of the old, in which immensely more needs to be done than has been done in the past, there was room for development. I dissent from not one single syllable of the first few lines of the Bill. I think it is right that it should be, in future, the duty of the Minister of Health…to promote the establishment in England and Wales of a comprehensive health service designed to secure improvement in the physical and mental health of the people of England and Wales and the prevention. diagnosis and treatment of illness. I hoped and believed for a very long period, in fact until about December of last year—December, not July—that in this great field of personal health, we should proceed in the same spirit as we had proceeded in educational reform. I agree very much with what was said by the hon. Member for Abingdon (Sir R. Glyn) that this is a matter not for acute political controversy, if it can possibly be avoided. This is a matter for co-operation and an agreed basis for progress. It is a field of personal service in which scientific progress should be assured.

I knew that the Party opposite had declared their view—with which we are in total disagreement—on the medical profession in these words: In the Labour Party's opinion it is necessary that the medical profession should be organised as a national, full-time, salaried, pensionable service. I shall be asking before I sit down, in view of some observations made by the Parliamentary Secretary on the consequences of the application of that doctrine, in destruction of freedom of choice, whether it is still the policy of the Labour Party. I remember hearing— and then indeed the cat came out of the bag—from the hon. Lady who is now the Parliamentary Secretary to the Ministry of Food, that her idea of the general practitioner service was that it should be clinically supervised by the local authority. If anybody doubts that she said that, let me add that she said it on 26th April, 1945. I cannot begin to understand such a theory of general medical practice. I knew, too, the Labour Party's doctrinal preference for State as opposed to voluntary institutions, and for remote as against local control.

But in spite of these doctrinal differences, what was the position? The Socialist Ministers, my colleagues and seniors in the Coalition Government, had, in the words of the White Paper, declared their adherence to this principle: The sense of personal association which is at the heart of family doctoring must be preserved. I say that it is endangered by this Bill. They said, also in that White Paper, that it was not their wish to destroy or to diminish the voluntary hospital system. What has happened? What is this baleful influence of the Minister of Health which has overthrown the judgment of those so far more experienced? I recall a forthright statement by the Minister of Town and Country Planning, in these words: I agree with those who feel that the voluntary hospitals should be autonomous. I think they ought to have freedom in the general policy and the management of the hospitals. What has happened to the strength of will of the Minister of Town and Country Planning? He, too, has been beaten down.

As the discussions proceeded, the area of agreement became wider and wider. The Lord President of the Council, as he now is, got his way, and the idea of joint boards for local authorities was abandoned. Why the Parliamentary Secretary should knock on that door today I do not know. The Lord President got his way. He had resisted amalgamation of local authorities for hospital services. In the course of the discussions it became obvious that that proposal was going to be dropped. Then my colleague Mr. Tom Johnston joined me in representing to my colleagues that it was desirable—and the decision was announced in this House on behalf of himself and myself—that there should be no change in the early years after the war with regard to the practice of buying and selling goodwill, in view of the extreme difficulty, which is obvious in the Clauses of the Bill, in enforcing something so novel as prohibition.

I am bound to say that, until December last year, when one first heard rumours of the Government's intentions, I believed and hoped that we were going forward on this basis of cooperation. I had good ground for doing so. There was not a hint in the Labour Party's programme that they proposed to confiscate hospital endowments and destroy the voluntary hospitals. If that was their intention, it was most dishonestly concealed; as dishonestly as the hospital policy of the London County Council was put forward at a time when they knew they had agreed to give up their hospitals altogether.

As it has been brought forward, the Bill has very many good proposals, which I shall not detail because, in such time as one has, one can mention only major points of principle. Many of the good points emerged during the discussions of which the right hon. Gentleman has been so contemptuous. The local executive councils, which he has accepted wholly from the revised scheme which emerged in the course of last year, would never have been invented but for those discussions.

Mr. Bevan

May I interrupt the right hon. and learned Gentleman? I have never, in my Parliamentary experience, listened to a statement of the character we are now having. [Interruption.] Let me put my point. We had a White Paper, which was published and the contents of which are known to everybody. We have now had from the right hon. and learned Gentleman a series of statements purporting to describe departmental arrangements which were made by the last Government in modification of that White Paper and which have never been published; and which, if the right hon. and learned Gentleman proposes to go on with the statement, I imagine, ought to be published.

Mr. Willink

The right hon. Gentleman is entirely inaccurate. The most important matter which I have mentioned, the question of the sale of goodwill, was announced in this House.

Mr. Bevan


Mr. Willink

I had no idea that the right hon. Gentleman would challenge me on that point. I will let him have the reference tonight. The dropping of the proposal for joint boards has been referred to again and again in published documents, including those issued by local authority associations. So far as local executive councils are concerned, if the right hon. Gentleman says that it is improper for me to suggest what is undoubtedly the fact that the constitution of local executive councils, on which the Parliamentary Secretary, and I think the Minister himself, have prided themselves, has not been announced, it is so clear that the position is different from what it was in the White Paper that I should not have thought it was improper to disclose when the idea first arose.

Mr. Bevan

It is a point of considerable constitutional importance. I understand that the only announcement which was made of the proposals which were then in process of being formulated was the one relating to the sale and purchase of practices. All the other proposals were still under suspense and have not actually been approved in the form of a Bill.

Mr. Willink

The right hon. Gentleman has interrupted me again. It will be in the recollection of the House that I only referred to one announcement as having been made in the House. That is all I ever said. What I went on to say was that these other matters had been stated in public documents. However, I do not want the House to be delayed by a wrangle between the right hon. Gentleman and myself on such a trivial matter.

I was about to embark on what I consider the disastrous changes in these proposals from what appeared in the White Paper and what was emerging in the course of the discussions which I was asked by the House to undertake. The first and greatest of all these changes is the proposal to vest in the Minister and his successors every hospital in the country, and to violate or to abrogate—whatever word is preferred—every hospital trust, to administer every hospital through regional hospital boards appointed by himself, who in their turn appoint hospital management committees who, in their turn, appoint house committees. I am sorry to see that the right hon. Gentleman is unable to tolerate this speech because I wanted to ask him a specific question. Is it a fact, or it is not, that when he sent for the representatives of the voluntary hospitals, he immediately said to them. "I am not prepared to discuss the question of the extinction of the voluntary hospital system"? If so, and the statement was made by their representatives in a letter to him and not contradicted in his private secretary's answer, it seems to me a monstrous way of treating bodies which have been promised that they should continue to survive in undiminished vigour. The same attitude was adopted with the representatives of the profession and of the local authorities. We are all in agreement with hospital planning and with amalgamation of hospitals: we agree that where there is a large measure of Exchequer finance, public representation on Boards of Governors is necessary but it must, I should have thought, be significant to all, except possibly the Minister, that his over-simple solution of wholesale nationllisation was never suggested to me by a single soul, political or professional, during the whole of those 21 months—not even by Lord Moran who, during the last few weeks, has been so favourable to the Government's proposals.

I know that the Minister refers to everyone who disagrees with him as a clamorous, sectional interest, but why should he refer to the County Councils Association and the Association of Municipal Corporations as a sectional interest? They represent bodies of all political complexions. They cover between them the whole of the country. They are much less sectional than hon. and right hon. Gentlemen opposite. They have both said that they do not think this scheme of the Minister's as good as what was being proposed before, and I respect, and think that the House should take note of, their opinion. I can best sum up my observations under two heads by attempting to answer two questions. The first is this: it sounds technical, but the whole matter is very largely a question of administrative structure: Does this Bill provide that measure of integration and harmony which we all want to see running right through the personal health services? The second is this: Is the Bill going to preserve and develop what we rightly value in these services today? In my view, two disastrous changes have been made in this matter of harmonising the system as a whole. I was told by all concerned that the essence of this matter would be that the personal health services should be planned as a whole in all their varied forms over appropriate areas. The essential importance of this was always stressed by the late Lord Dawson of Penn who did a very great deal in the original thought with regard to the bringing together of all our personal health services. Indeed it is obvious, that in these developments it is essential that clinics, general practice, consultants and hospitals of all kinds should be considered as forming an interlocking organism. That is of first rate importance—an appropriate lay-out as between the hospitals and the local authority clinics, which have been sadly out of touch with the hospitals, as between the general practitioners and the clinics and the hospitals with their specialists, and perhaps most of all when the provision of the new and wholly untried health centre is under consideration. This harmony and integration seem to me to be of the greatest importance, and the whole of this essential idea has been abandoned in the Bill. It was in the White Paper and continued throughout the discussions but it has been abandoned because the Minister wants to nationalise hospitals and dares not nationalise the local authority clinics.

What do I mean by appropriate areas? I mean areas in which it is due to the people that they should find at their disposal all the services except the most highly specialised, such, perhaps, as neuro-surgery or deep-ray cancer treatment, because whatever regions are devised there will always be services which cannot fit into every region, services of which only one example may be wanted in the country or others of which only four may be wanted. But what one wants is an area which can have a life of its own and in which 90 to 95 per cent. of the services will find their place. Such areas could be far smaller than those regions of the Minister, apart altogether from my point that they are not regional boards but only regional hospital boards. There is no reason why these smaller areas could not have the full help and guidance of the universities.

Dr. Morgan

What about the B.M.A. and regions?

Mr. Willink

I am not appearing for the B.M.A. I am expressing my view.

Dr. Morgan

But the right hon. and learned Gentleman uses them to support his case.

Hon. Members

Why not?

Mr. Willink

I thought I heard the hon. Gentleman who has just sat down using "The Lancet" in support of his case. [HON. MEMBERS: "Why not?"] I agree, except that I thought that as one of his hon. Friends sitting behind him was so closely associated with "The Lancet" perhaps it is not entirely independent support. It is the hon. Member for one of the Islington Divisions. There is no reason why he should not be associated with it. Apart from this point, with regard to the planning of the service as a whole, may we look at the regional hospital boards and this form of regionalisation? I so fully agree with much that was said by the hon. Member for South Tottenham (Mr. Messer). They seem to me to be regionalism at its very worst. I can understand regionalisation of the mechanical and impersonal services, electricity, for example, which was referred to. There one would have a statutory authority with defined responsibility of its own, not subject to directions from the Minister, not acting under delegated powers, but with its own autonomous authority. Here not only is there the objection expressed by the hon. Gentleman that it is regionalising what is essentially personal, but it is a bad form of regionalising when it establishes a non-elective body subject to the directions of the Minister whenever he chooses to give them and covering an area so large that there will have to be two further sub-delegations from it—three bodies, each of which will be able to say, "This is not my responsibility. I have been told to do that by the hospital management committee," or when you go to the hospital management committee, "I am so sorry. I have been told to do that by the regional hospital board." How will these regional hospital boards work? I believe the theory put about by many experienced medical men that all that is necessary is to get the right men on the regional hospital boards is a hopeless and fatal delusion. The sort of men we want, and can get, to plan and guide a service will have neither the time nor the inclination to administer the huge organisation which there will be in one of these vast regions stretching, perhaps, from Bristol to Lands End.

The Minister will find himself forced to rely on, and the public will find themselves forced to submit to the administration of junior civil servants, unable to take the necessary decisions themselves and unable to get meettings of these very distinguished regional boards gathered from these huge areas. I do not believe the Minister has the slightest idea how he is going to staff these regions, any more than he knowsx2014;and this he has told the House—the principles on which the regions are to be defined. I have never heard anything more ridiculous than what he said yesterday, that this Bill would not create a single additional civil servant. The Ministry of Health has not got the civil servants to staff these regional hospital boards. Is it that all these eminent representatives of the universities will sit there day by day administering them? Each one of them will need a large staff of civil servants, and I do not believe they will be there for years to come.

Those are negative criticisms, but I venture to think they have some validity. Let me look at the other side. To give us this, what will the Minister destroy? In our view, this fancy of the Minister's, this idiosyncracy of the Minister's—because no one ever thought of it before him—will destroy so much in this country that we value. I will not continue to speak of the voluntary hospitals and what they have done. I was surprised and distressed that the Minister yesterday should be so arrogant—except that he is often arrogant—as to say that he was not concerned with the voluntary hospital authorities. I am referring to the countless people—and we all know that this is so—who feel today that under this Bill they are losing what they call "our hospitals." There is no doubt about that whatever. There will be a great loss to this community if the habit of giving to the local hospital disappears from our midst.

And how absurd it is to suggest that any harm whatever would be done by leaving the endowments—after all, only a little over £1 million a year in value in relation to a service which is to cost £152 million. It is ridiculous to suggest, as the Minister did yesterday, that the planning of this service would be prejudiced by leaving endowments where their donors meant them to be. I am not suggesting for one moment that if the purpose of the gift has now gone because the gift is unnecessary, or because the particular small hospital ought to be amalgamated with a larger hospital in the district, that that should be prevented and the endowment should remain with the individual cottage hospital, but I do press—and I think my hon. and right hon. Friends all think with me in this direction—and I urge the Minister to reconsider it, that gifts left or given, not all by Surtax payers, but by thousands and thousands of quite small people in memory of members of their families and so forth, should be left in the town and in the district which these folk meant should benefit. It could not do any harm, and it is very cruel indeed to do what the Minister proposes to do. With a developing service of this kind there will be a use everywhere for these endowments. It is ridiculous to suggest with this mounting cost that £1,000,000 a year spread over the country cannot be used in the districts where it was intended to be used, and how immensely valuable that there should be on top of the Government provision something which will enable a measure of freedom, and a measure of adventure, to exist in each of these units.

I urge the Government to consider the points made so cogently in a letter, not from a sectional interest, not from a doctor—who, to judge from some things said in this House, is a most suspect person; I cannot think why—but by Sir William Goodenough, the Chairman of the Nuffield Provincial Hospitals Trust. I urge the Minister to consider the points made in that letter which appeared in "The Times" of 6th April. Its salient features were that not the regional board but the hospital management committee should be the body, the real unit in the hospital service; that it should in every case, after proper constitution of the hospital, be called a "board of governors" and not a mere "managing committee"; that it should be endowed with legal personality, with its own staff, both medical and nursing, with its own income, and a right, which in the Bill as it stands no hospital is to have in future in the whole of this country, to attract gifts and legacies. Surely, even within their own scheme, the Government can save for us so much that the scheme as at present drawn up is destroying.

But I must add to what has been said about the municipal hospitals. I was really amazed by the Parliamentary Secretary. Every word he said about the unevenness of finance in different counties and county boroughs would defeat the whole of the Education Act, which is based upon counties and county boroughs with varied contributions from central funds. There is no reason in the world, if they are the right units, why the proper financial arrangements could not be made.

I may be unusually fortunate in the fact that the county borough with which I am most familiar is that which I have the honour of representing, namely, Croydon. In the report of the Royal College of Obstetricians and Gynaecologists, which has been referred to, Croydon has been picked out, with Guy's Hospital, as a conspicuous example of an integrated maternity service. The whole of that will be split in two by the Minister's scheme. Let me take another case, the matter of mental health. In Croydon we have a first rate and most progressive mental hospital, run in the closest conjunction with clinics in the town, to which people can go in exactly the way the Minister suggested, without any feeling that they are going to a mental hospital or anything of that kind. Now that mental hospital is to be entrusted to a region. Will it be the London region? We have heard nothing about the character of the London region. If the London region is to be one based on the University of London, and covering all the area for which the University of London is the natural university, it will contain about 14 million people. Is that the London region? If so, what is to happen to a place like Croydon which at present, both in the field of mental health and in the field of maternity services, has an integrated service which has won great admiration?

But do not let me rely on my own amateur observations. Let me first remind the House that none of these local authorities, who have been criticised rather unkindly by some who speak for the voluntary hospitals, have ever had a duty put upon them by Parliament to this day to provide general hospitals. All they have been given is a power, and they have only had that for less than 9½ years before the war. I fancy the Minister has as great respect as I have for Professor Henry Cohen. Let me read four lines of what Professor Cohen said in a recent speech: The more progressive local authorities availed themselves of their opportunity and made such strides in the 10 years preceding the war, since when building has ceased, that there were, in many areas, public hospital services which equalled, if indeed they did not occasionally surpass the voluntary hospitals of the area. It is all nonsense for the Parliamentary Secretary to suggest that if you made a plan, let us say for the County of Nottingham with its county borough, or the county of Derby with its county borough, you could not adjust and arrange entry into the hospital which might be geographically in the county or might be in the county borough.

Indeed the county councils and county borough councils have come to an agreement about that very point and as to how they should deal with it. That is taken as an argument in favour of taking away from the major authorities one of the functions they have valued greatly, where they have developed it, and it would be scientifically of the greatest advantage for this integration to which I have referred in the borough I represent, to continue.

Let me quote Lord Moran. Lord Moran says: It is perfectly true that doctors are working perfectly happily under municipal administration under the Middlesex and Surrey County Councils, and I think that proves that there is nothing inherent in the municipal system which would make doctors discontented. There is nothing exceptional, so far as I know, about the citizens of Middlesex or Surrey, and what is done there could be emulated elsewhere. It is only that many of the counties and county boroughs have had insufficient means. They have been burdened with unsatisfactory buildings which they could not alter in the four years before the war. The London County Council are a typical example. They are saddled with old buildings, although I think they could have got on with the matter very much more quickly. I do resent the jeering tone in which the Parliamentary Secretary referred to those who think they should be careful about the expenditure of public funds, ratepayers associations and the like. Let the House note that the two counties which have made outstanding achievements in this field are two counties which had Conservative administration throughout the period.

Mr. Kenneth Lindsay (Combined English University)

May I ask a question? The right hon. and learned Member for North Croydon (Mr. Willink) says there is no difference between citizens of Middlesex and Surrey and elsewhere. Will he not also admit that, irrespective of political complexion, they are two of the richest counties, and also that the Education Act is likely to break down because they have not sufficient finances in the local authorities to implement it without more from the centre?

Mr. Willink

I would be very reluctant to embark in this speech on the question whether the Education Act is likely to break down. My point is that where there was sufficient money available, local authorities could do the job and now that we are undertaking the provision of services of a comprehensive kind this House can see that they have enough for the purpose. The question is, are the local authorities the correct instrument? What I have said in regard to Middlesex and Surrey is that they are good counties and that other counties are equally as good. It is for this House to see that the possibilities of running a good service are not frustrated, just as it is for this House to see that the Education Act does not break down for the same reason.

How childish it was, if the Minister will forgive me for saying so, for him to refer to the smallest county and county borough, Rutland and Canterbury, in considering this case. These major authorities are just as capable of running a hospital once they are told what sort of hospital it is necessary for them to run as the regional hospital boards the Ministry is setting up.

I turn to the proposals in Part IV of the Bill. Do these proposals give us any feeling that there will be an improvement, an enrichment, in the field of general practice? We on this side of the House are bound to remember at all times the view of the Party opposite, not yet called back or revoked, that general practice should be a full time, salaried, pensionable, national service. The Parliamentary Secretary has today admitted that that is inconsistent with free choice of doctor, because it will be necessary in such a service to see that the same amount of work is done by doctors whether patients want to see them or not. We are bound to note that this Bill is one under which regulations could be made under which full time salaried service could be introduced and free choice of doctor destroyed, as the Parliamentary Secretary admits.

There are all sorts of things we want to see developing in general practice. We want to see the development of group practice and partnership with men of varied qualifications. But we believe a man should choose his own partner. For this Bill and the White Paper to talk about developing partnership and at the same time to set up this fantastic medical practices committee—on which I shall have something to say—means that when four people wish to go to a place where there is a vacancy, the medical practices committee in London is going to decide which of the four is going to be the doctor there. We do not want medical practice to be what the hon. Member for Edge Hill (Dr. Clitherow) said this Bill offered to the medical profession—a life like that described by King Henry VI: So many hours must I tend my flock. That is our fear. Not one good doctor I have ever met took that view of his work, yet it was expressed from the Benches opposite yesterday.

While Minister of Health, I examined most closely this proposal to control and regulate the distribution of doctors. I was not impressed by the examples the Minister gave yesterday and the towns he spoke of as so-called "over doctored" places; Bath, where the number of invalids is notorious, Hastings, where the number of elderly retired people, including doctors, is notorious, and Bromley, where doctors live but practice in various parts of London.

Mr. Sparks (Acton)

What about Kensington?

Mr. Willink

The same thing could be said of Kensington. The hon. Member for Acton (Mr. Sparks) probably knows that practices are not localised in London as they are in other places. I was very much more impressed by the comparisons which were drawn, and which have not been challenged, by the British Medical Association. Surely, it is more significant that Barrow-in-Furness, Darlington and Macclesfield had more doctors before the war than such salubrious places as Rich mond and Winchester? The truth is that the instrument has not been invented which could measure with any reasonable accuracy the extent of over doctoring or under doctoring. I remember Mr. Tom Johnston saying that he had been told that Bridge of Allan was terribly over doctored. It was thought that that was true because it was said so many times, but it was found, when he investigated it, that there were a large number of elderly doctors there who had gone there for a little part-time work and to spend the last years of their life there. And, of course, it was a place like Bath, full of invalids.

We are told that it may be something like two years before the Bill comes into operation. One of the great objections is that the changes it makes have delayed the coming into operation of the comprehensive health service. I am convinced that with the prospect of 100 per cent. service the doctors will in fact be most evenly distributed over the country. In any event I am quite sure that the risk of their not being evenly distributed is not sufficiently great to justify setting up this most unsatisfactory machinery with a large and most unsatisfactory addition to the criminal law and an expenditure of £66 million.

Why do I say the machine is unsatisfactory? I am really surprised that the Ministers can put forward the idea of a central practices committee with a serious face. Here is one committee sitting in London, consisting, it is said, of so many doctors, five of whom are to be in active general practice. They are to decide the succession to every single practice in England and Wales. Do the Ministers really think that the five doctors will remain in active general practice for long if they are doing that? It is mere camouflage for bureaucracy, as in the case of the regional hospitals' board. It is clear that there can be no effective professional majority on this central committee doing the work of an effective majority. It is certain that the decision between four applicants such as I have mentioned will be made simply on paper material by junior civil servants, with no knowledge of the particular problems of the place—

Dr. Haden Guest (Islington, North)

Does the right hon. and learned Gentleman think that the decisions of the Central Medical War Committee are made in that way?

Mr. Willink

No, Sir. The Central Medical War Committee was in this far superior position: in the first place, everyone knows it is easier to get busy people to undertake that kind of work in wartime. The comparison is that the Central Medical War Committee has done its work with 145 local committees. This one committee is to do the work for the whole country. I believe it will need a staff of 40 or 50 civil servants.

Mr. Bevan

I am sure that the right hon. and learned Gentleman does not wish to misrepresent the situation. After the scheme has been started the number of doctors required to be appointed will be under 1,000 a year. In fact, the executive councils will appoint them, and they will be referred to the medical practices committee solely on the question whether that particular area is under-doctored or over-doctored. I should not have thought that that would be an oppressive job.

Mr. Willink

We were told by the Parliamentary Secretary that it would be one of their jobs to decide between applicants—only when there are a number of applicants, an hon. Member says.

Mr. Bevan

The right hon. and learned Gentleman's hearing is as bad as his understanding of the Bill. I said no such thing. I said that there would only be 1,000 changes a year in practices.

Mr. Willink

Would the Minister answer the specific question: If there are four applications and one vacancy, who will decide between them?

Mr. Bevan

The executive. All that the central practices board will be called upon to decide is whether a particular appointment is to be made in the light of whether the area is over- or under-doctored.

Mr. Willink

I am grateful to the Minister for that explanation. I shall look to see whether the White Paper and the Bill are in contrary terms. That seems to establish, in my submission to the House, that if it is done in the way the Minister has now defined, it will never be done by five practising general medical men. I see no advantage in it.

Mr. Key

Did not the right hon. and learned Gentleman propose to set up a central medical board under his scheme? May I be excused for asking him whether he did or did not say in this House in March, 1944, giving an illustration of the operations of the Board, that that central board would say to a young doctor: …before we authorise you to take up public work in Wakefield we wish to tell you there is a great shortage of public service practitioners, and we feel that for five years you should give your whole time to that service and should not have any private patients.'—[OFFICIAL REPORT, 16th March, 1944; Vol. 398, c. 434–5.] Did he say that?

Mr. Willink

I thought I had made that position perfectly clear. I told the House, and if I did not make it clear, I intended to, that the examination which I certainly told the House I had given to the question, was subsequent to the publication of the White Paper. I took the responsibility in February, 1944, of suggesting something very similar to this—in fact, identical. It was in the examination of it I discovered how difficult and unsatisfactory it would be. [Laughter.] Hon. Members opposite seem to laugh when someone looks at something and finds it unsatisfactory. The Minister has gone back to my original proposal, which I discovered, I believe correctly, was most unsatisfactory.

May I now see whether the Minister was right about his own Bill and the central medical board? Clause 34 (3) says that the medical practices committee may refuse any such application on certain grounds… and, if in the opinion of the Committee additional practitioners are required for any area or part but the number of persons who have made applications exceeds the number required, the Committee shall select the persons whose applications are to be granted.… I do not know whether the right hon. Gentleman will have the grace to withdraw.

Mr. Bevan

That would not be inconsistent with what I said. In the event of it being decided that one of four persons should be permitted in a particular area, there is nothing inconsistent in that with the actual individual doctor being appointed by the executive. At any rate it is a point that does not confirm the right hon. and learned Gentleman's statement, because I said, and I still adhere to it, that only about 1,000 new practices will change hands in any given year, and that is not an oppressive task for the central committee.

Mr. Willink

I do not know whether the House will agree with me that the right hon. Gentleman is a little evasive on this matter. He was quite specific in stating that where there are several applicants and only one vacancy, the decision between the applicants will be made by the local executive council. Thinking that he knew his Bill I was a little modest about my own knowledge of it. Is the Minister now saying that he is right?

Mr. Bevan

I am now saying that the medical practices committee would be in the position of determining who would be appointed. I will at once admit that I see no fundamental objection to the local executive appointing the doctors so long as the central committee decides the number.

Mr. Willink

The right hon. Gentleman has conceded my point.

Mr. Bevan


Mr. Willink

It is said that there is no interference in the freedom of choice of doctor. I am convinced that, the medical profession being rightly independent in spirit, there will be quite a substantial number of doctors who, in the early stages of the scheme, while they are watching what the Minister's regulations are to be, will say "I will practice on my own; I will not go into this service until I see what it is." I believe that some of those who are refused admission to an area will go and practice there none the less They may be the best doctors in the area. but the Minister will not let any patients go to them under the public service. The system under which they will have to work will be a definite limitation on the freedom of the choice of doctor. If an independent doctor goes to a place without permission, no one will be able to go to him however good he is without paying a fee.

To me the fundamental objection to the whole of this general practitioner set-up lies in the matter of salaries. I have never heard three more flimsy reasons given for something which the Minister knows is obnoxious to the profession as a whole than the three he gave for this basic part-time salary. He said that in the first place, when this service starts, a lot of men will be coming back from the Forces unable to earn any money. The difficulty in getting a young man of small means into the medical profession has nothing whatever to do with his making a living once he is qualified. Every qualified medical practitioner of good repute will be able to earn a good income for a long time to come. The difficulty is to enter the profession. The second reason the Minister gave was that there must be a salary so that the Minister can have something to add to in the case of unattractive areas. Why is something needed to be added to in the case of unattractive areas? Is it a metaphysical idea? I do not begin to understand it. His third reason is that it would be something to add to in the case of special qualifications. Why not give a man £100 a year extra if he has taken some particular qualification? He can be given an extra £100 a year although he has not already got £100 a year.

The Minister has introduced a Bill in which he can turn the general practitioners of this country into what his party still wish them to be—a full whole time salaried pensionable service. There is no reason why the profession should become part-salaried at the moment except as a concession to Socialist doctrine. The doctors do not want it. It destroys pro tanto, and the Bill allows to be destroyed altogether the feeling that what the doctor is getting in respect of his medical work is in respect of his patients and not in respect of a salaried service to somebody else. I feel that these matters taken together—I have not mentioned the health centres—threaten, as we say in this Amendment, the right of the patient to an independent family doctor. He is in peril under this Bill of having a doctor who is not his but the local executive council's or the Minister's. Until this Bill safeguards that position, I could never vote for it or indeed abstain from voting against it, whatever its merits or demerits. Before I sit down, may I as a matter of personal explanation, apologise to the Minister of Health for attributing to him a remark which was in fact made by the hon. Member for South Tottenham (Mr. Messer)

5.52 p.m.

Mrs. Ganley (Battersea, South)

This is an extremely important Bill. I regard it as the third of a series of legislative proposals which will give security and much more protection at a time when people need security and protection most. We have had the National Insurance (Industrial Injuries) Bill and the National Insurance Bill. Now we have this Bill which is a positive Measure—the National Health Services Bill. Those three will coordinate activities which have been voluntary in origin, but patchy in development. The Debate of the last two days has shown that in all areas there has been a patchy development of the services which are essential to poor people. These Measures, however, will bring the largest amount of security to all. As a past member of a local authority, I am disturbed at the prejudice that is being expressed at the present moment. Many people are saying that they are going to be deprived of the services of the doctor they have known. I am glad that the Parliamentary Secretary has assured us that that certainly is not contemplated under the Bill. In the Bill, as far as I have been able to see, there is a safeguard against that.

Older people feel about this very keenly. Apart from the loss of the doctor to whom they have been accustomed, some of them feel the change of service in hospitals. The amazing thing about it is that people are not so concerned about the fact that the voluntary hospitals are now to become a State service for the nation, as about the suggestion that they are not going to be able to get the service in the hospital which they have had previously. It seems to me amazing that people should express prejudice of that kind. The Debate has shown that doctors are still to be the people who will serve and that nurses will still be trained for nursing, either in hospitals or in homes wherever they are needed. There is nothing in the Bill to interfere with the training either of the doctor or the nurse. There is nothing to prevent the most extensive and particular training that can be given and which has been given in the past. What happens under this Bill is an extension of the opportunities for research and closer working over the whole nation, so that services which hitherto have been extremely good in parts, can now be available for the whole.

Local authority experience has provided an excellent service in maternity and child welfare work. I recall the early days when the local authorities had power to being into being maternity and child welfare services after the 1918 Act. They had the power to initiate maternity homes, to encourage midwives, and to make the service comprehensive. When those services first came into being there was, very unfortunately, an enormous amount of prejudice. It was said at that time that the public authority must not be allowed to do work which, in the past, the private practitioner had in his own hands. We know perfectly well that the result since those days has been an enormous improvement in the health of the people of the country. Mothers and children have greatly benefited from the service given by progressive authorities. We entirely agree with the right hon. and learned Member for North Croydon (Mr. Willink) in his remarks about progressive authorities, whatever their opinions may be. The progressive authorities took the opportunities given to them and brought into being a comprehensive service in their own neighbourhoods, which has been most beneficial to the whole people.

Again, we have the general hospital services organised through the county council. Would anyone say that the standard of the hospital services under the county councils was any lower than the standard of service in voluntary hospitals? We all know of services in local authority hospitals which have been of the highest standard and which have been intensely appreciated by all who had the opportunity, or necessity, of taking advantage of them. We appreciate, of course, the difficulties in the rural areas where it is not always possible, because of the scattered population, to put within reach of the ordinary person the services of the hospital, the nurse and the clinic. We therefore hope that under an organisation of this kind, the rural areas will be considered.

I particularly welcome the proposed health centres visualised in the Bill. Their main value will be the prevention of the development of disease by earlier diagnosis and treatment. It is only in health centres of this kind, where it is possible for all people to go, that we can follow up the work done by the maternity and child welfare organisations, with the advantage of the knowledge that has been gained. If we can persuade the people fully to use the health centres, we shall have information which has never been avail- able before and we can use it in such a way as to bring increased benefit to the persons concerned as they are growing up.

I have a very strong belief in the development of preventive organisation. One of the most useful books ever written was an outline of preventive medicine by Sir George Newman, published immediately after the last war. I am sure that it induced a large number of workers under local authorities to get on with the job which was there outlined and to adopt the various suggestions which were there made, with very real benefit. When we come to consider the work to be done by the local authorities, if all imaginative local authorities establish health centres, we might very well see carried out the suggestion of making available all the documents that can be gathered together at the centre, dealing with the health, growth and development of each person. If this were done, in conjunction with nutritional considerations, the examination of which has been going on for some time, all these activities affecting the welfare of the people could be coordinated in the health centre. Is it a very big hope that this will prove to be a really constructive health Measure, which will use preventive organisation and preventive medicine in promoting the better health of the nation, and combine it with the study of such questions as housing, education and sanitation?

The growth of maternity homes, antenatal and post-natal clinics, led to an enormous drop in infant mortality and in maternal mortality, and that was the result of the work undertaken in these local centres. There was a very strong prejudice against these institutions in the early days, and it was quite a long time before it was broken down. It was a long time before people stopped saying, "We do not want to go to these places and mix with all sorts of people." When the war came, and it was a question of saving the health of the nation, the antenatal and post-natal clinics were used to a greater extent to the great credit and benefit of the country. The maternity service was never better than it was during war time, and it was very much extended, not only in regard to local authorities, but in other directions as well, to the benefit of the nation. It is suggested that these voluntary organisations, which have rendered yeoman service in recent years, will not be fitted successfully into the new scheme. I was grateful to hear the Parliamentary Secretary say that representatives of the voluntary hospitals will have a part in the constitution of hospital management committees or whatever term is used for those who will be responsible for the organisation. There certainly ought to be on such bodies some representatives of the voluntary hospitals. The Minister has not disregarded the value of voluntary hospitals at all. He has everywhere recognised that here is a valuable service, conducted in the interests of the people. It has been the conception of service to the nation which has altered, and I wonder sometimes, when we are talking about the glory that comes to a man who has left his kindred and gone into the Forces of the Crown, whether we have any measure at all of the praise that ought to be given to the people who have conducted these services in the past.

We are seeing today the creation of a new national health service. There is no question of compulsion about it; it is only a question of the encouragement and coordination of various different activities which hitherto have grown up piecemeal. Yet, when we think of the wonderful service which has been given to the nation in the past by these men and women, who have spent long hours in close research in the service of the people, using their natural gifts and the opportunities afforded to them to bring those gifts to the service of the nation, we recall that, when these people brought their new ideas into being, those ideas were as hotly contested as this new national health service is being contested today. Surely, the changing circumstances demand that the wider vision which recognises the greatest good for the greatest number, shall be the determining factor, and that we shall recognise and welcome the opportunity of using all that is available for the service of the whole country.

Reference has been made to the rights of patients. There are some of us who realise that there has been a strong determination that the hospitals should be made ready for the doctors. I was glad to hear the Minister say that the patient was the person who mattered, and, in future, we hope that the patient will be the person who will have all the rights in the hospital. When we think of the position facing us we must appreciate very much indeed that the difference of outlook between this side of the House and the other, is bound to cause a clash occasionally. Opinions are obviously different. I cannot accept the idea of this Bill as a Juggernaut car which is to crush every atom of initiative and every independent thought in the minds of doctors and those who run our hospitals. It seems to me that the present position is an opportunity to encourage our young people to take part in, and derive great benefit from, a national health service. Such a service will give doctors and nurses the opportunity of satisfying their ideals. It will give them chances for research work which will result in achievements even greater than the wonderful progress made in the past. More glorious service to humanity will be the result of this coordination of the activities of our health services and hospitals and those who are trained in them will gain a very much wider understanding of service to the country, so that there will no longer be any question of fear of the future for many people but on the contrary a certainty of the benefits that the future is going to bring.

6.10 p.m.

Mr. Clement Davies (Montgomery)

It falls to my lot to be in the fortunate position of congratulating the hon. Lady the Member for South Battersea (Mrs. Ganley) upon a speech made with knowledge, understanding and, if I may say so, with great charm. I think it is only right that Lady Members should take more part in our discussions with regard to health than we of the other sex, for from the time of the creation of man or, at any rate, from the time that our two ancestors left Eden compulsorily, in times of distress the cares have fallen upon the women rather than upon the men. I most sincerely congratulate the hon. Lady on her speech.

Health is no longer a question merely for the individual or even for the family. It has now become a question which concerns us all. But this is a new conception for, until recently, it was a matter which concerned merely the individual and those who were nearest and related to him. Except for such charity as they might receive, those who were incapable of paying for medical attention and advice had to go without. It is almost within our own memory that the new conception that the health of each individual con- cerns us all has come about. We now realise that the wealth of a nation depends upon the health of the individual, but we also understand that we have a responsibility towards anyone suffering from ill-health and that we have to share with him the benefit of our production until such time as he can be restored to health. Therefore, it has become a matter of concern for the nation as a whole. In time of war we realised that more than at any other time because wherever men or women happened to be, we in this House said that we had complete control over them for the service of the country. From an economic, a safety and certainly from a human point of view we realise that we are responsible for one another and must come to each other's assistance.

Therefore, the first question I put to myself is whether the present service given to the people is satisfactory, and its seems to me that the answer given by everyone is that it is far from satisfactory. The next question I have to put to myself is, Will the service be better under the Bill that is now being introduced by the Government than it is at the present time? Quite obviously, again the answer is in the affirmative. Now, for the first time, it does not matter where the individual may be. Hitherto that has been a tremendous handicap. Whether or not there are any means of paying for the medical service does not matter. All the medical science of this country will be available to rehabilitate the individual at the earliest possible date. That is one of the greatest steps forward that we have taken.

It is a matter of deep regret to me that we have had to wait until 1946 before tackling this question of a national medical service. I have listened to nearly every speech which has been delivered during this two days' Debate and I, like the Parliamentary Secretary, was at a loss to understand what is the position of hon. Members above the Gangway. They say that they are in favour of a national health service and that they wish to establish a comprehensive service. If that is their wish, why do they put down an Amendment, the only object of which is to wreck this Bill? Every one of the reasons given by the right hon. and learned Member for North Croydon (Mr. Willink) were not questions of principle against a comprehensive medical and health service; at best they were Committee points which could be raised during the Committee stage. But the Opposition have seen fit to put down this Amendment and I take it that they are going to carry it to a Division. If they succeed, the country will have to go for a further time without a comprehensive national health service. Let us make no mistake about that. This is a wrecking Amendment, but the extraordinary thing is that somehow or other, they can never get out of a habit, however bad it is. The right hon. and learned Gentleman kept on referring to statements made previously by the Parliamentary Secretary and by the hon. Lady the Parliamentary Secretary to the Ministry of Food, and various others. Let me remind him and some of his hon. Friends that this Amendment is almost exactly in the same terms as those which were moved against the Third Reading of the National Insurance Bill of 1911, which was the predecessor of this Bill.

It seems rather unfortunate that the right hon. Gentleman the Member for South Kensington (Mr. Law) should have had to open for his party yesterday because I am sure he will recollect the part played by his revered father who led the Opposition to the 1911 Bill. Exactly as this Amendment is today, so it was then. They could not say "Yes" and they did not dare to say "No," so they invented a sort of new, middle Conservative way of trying to get the best of both worlds. Obviously, the intention was to wreck the then Bill while paying lip service to the necessity of creating a new medical service available to the poor of this country. I have listened again to the words that have been uttered here and they have certainly been rather mild in their criticism.

Fortunately, a constituent of mine has retained the kind of document which they were issuing in 1911. It was well worth preservation because the language that is now being used by the national Press which supports the Opposition bears a great similarity to the language in the document which was issued from St. Stephen's House, Westminster, in 1911. I will quote one or two phrases: The State Insurance Bill must be killed— Why? because we cannot afford it. The reason why we could not afford it was that under that "iniquitous" Liberal Government that started all social reform, the annual expenditure in the Budget had gone up from the amazing sum of £150 million to £172 million. The next slogan was: The State Insurance Bill must be killed— remember their anxiety for the people— because it will ruin the British workers. Another one was: State insurance must be killed because it will severely tax the British manufacturer and subsidise the foreign manufacturer. I would like to give two other quotations, because history will repeat itself. We have heard so much today about the breaking of the relationship between the family doctor and the patient and about the freedom of choice of doctor, to which matter I will come in a moment. Listen to this, which is rather similar: The ill-feeling that is going to be created in every British home by this Act cannot be over-estimated— and then, horror of horrors: Servants and mistresses will become deadly enemies. That is the sort of language which we find, in another form, used against this Bill by which it is proposed to bring in a comprehensive health service.

Let me deal with this matter under three heads. First, the patient. Undoubtedly, there are not only in industrial areas but certainly in the rural areas, in the smaller villages and in the remote districts, people who have not been able to obtain proper medical service. They have been so remote that very often they could not consult even a doctor but had to rely upon their own home services such as they are. Think of the suffering and the loss that that must have caused. An hon. Member referred yesterday to the fact that the cost of medical service in this country, the amount that we are spending upon the maintenance of health, on doctors, nurses, hospitals and so on, totals the enormous sum of £300 million. I do not know whether that figure is correct, but I am certain that the loss which the country has suffered in the past through our inability to give proper medical service, bearing in mind the number of people who have died or who have become chronics, can never be estimated. In the arguments objecting to this Bill to which I have listened, little attention seems to have been paid to the patient. Most of the arguments have been directed to the position of the doctor and those estimable people, the governors of the voluntary hospitals. Surely, the one consideration should be: What is likely to give the best and fullest service to the people, wherever they may be?

I would like to turn for a moment to the question of the doctors. A great deal of nonsense has been talked about the freedom of choice of doctor. In country districts we do not have to take the doctor of our choice, but the one who happens to settle within that rural area. If I may give my own personal experience, the old doctor who saw to my advent into this world sold his practice to A. A sold it to B, B sold it to C, C to D and D to E, and I think it is now F to whom I go when I am in the country. I did not choose him. He was chosen by his predecessor who sold his practice to him. This applies to the whole of the countryside. If I go to an industrial area, even to London, what choice have I of a doctor? What we often see is the plate on a corner house—doctors usually choose a corner house because it is the best site and the most likely to attract—which happens to be nearest to us, and we go there without any knowledge at all of the doctor. Let us be real in this matter. Much is talked about direction. What amazes me is the fact that the right hon. Gentleman has given so much freedom to the doctors. They have never had as much freedom as they have now, neither have the patients in the past. I am not talking about well-circumstanced people but about the ordinary, everyday people. Never have they had so wide a choice as they will get when this Bill is functioning fully and properly, and when there is a better distribution of the medical services.

May I now turn to the hospitals? Undoubtedly, they have been badly sited and badly equipped. What advantage is there to be obtained in a voluntary hospital which is not to be found in any other hospital? I do not understand it. Are the doctors better because the money which is used in the hospital has been begged on the streets and not paid by the Government? Are the nurses better? Is there more humanity in such a hospital because of the source from which the money has come? Are we going to slander the medical men and the nurses in that way? I was glad to hear the right hon. Gentleman refer to the way in which this money has been collected in the past. It made me blush with shame, as it made the right hon. Gentleman blush, to think that our nurses and young medical students should have to dress up and go about the streets of London begging in order to give the necessary medical service and keep the research going which is needed by the millions in this greatest city in the world. One has to get a complete picture of what is wanted in this country. If health is a national matter there must be a national system and a complete system. It is suggested that that could be undertaken by the local authorities. The germ knows no boundary. I defy anybody to say where one county boundary begins and another ends, and certainly the germ knows no boundary.

What we have to do is to get the hospitals, equipment, medical men, nurses and necessary staff so placed as to be able to deal with all the diseases and accidents which will arise, wherever they may be, instead of, as at the present moment, having a hospital put up not so much for the benefit of the people as for the glorification and happiness of some particular person who has been able to give money for that purpose—I see an hon. Member shake his head. I do not know why—I can speak of that in my own county. I can assure hon. Members they would be treated very differently should they need hospital treatment in either of two places, one in the North West of the county and the other in the South West of the county, where two charitably minded families set up two small hospitals. For the generality of the people we have to do with what we have, which is very little.

We have to have a broad general scheme. It has to be planned from the centre. As the Minister has said, it cannot be worked from the centre; we have to decentralise. Decentralise in what way? I cannot see any way other than the way in which he has done it, namely, by regional boards. If it is done by regional boards it is suggested that charity will dry up. I am surprised that so far nobody has referred to the fact that in Wales we are fortunate enough to have had experience of a regional board. [An HON. MEMBER: "Oh?"] Does it surprise the hon. Member that we are fortunate in having had charitably minded persons who have put down £1 million to support the voluntary hospitals, to deal with the most dreaded disease of tuberculosis? It was due to my predecessor as Member for Montgomery and his two sisters that that was started.

Soon afterwards the National Health Insurance Bill was introduced into this House, and Wales was turned into one complete unit; the 13 counties and four county boroughs were made into one region. It was fortunate that they were made into one region, because the incidence of tuberculosis is higher in Wales, unfortunately, than in any other part of the United Kingdom. We were much more fortunate than England, because in England the duty of caring for those suffering from tuberculosis, and providing the sanatoria, medical staffs and nurses fell upon the county authorities, as if the county boundary was something sacred. The National Memorial of Wales, which is now a Government institution and will be incorporated into this Bill, is the envy of all the English counties, and the envy of Scotland. What is more, it is the place to which continental countries and America apply for information with regard to the latest treatment of tuberculosis. More has been done in research under that regional board than has been done anywhere else. What, therefore, can be the objection to a regional board carrying on in this way?

Hon. Members have referred to the drying up of charity. Do they really think that will happen? That regional board in Wales is financed partly by the Government and partly by the county councils. But that has not prevented people from making contributions towards the local sanatoria, not for the absolute necessities but for those little items of attention that make all the difference to the patients in the hospitals. There are cases where those little gifts and little attentions, mean far more than the general matters which are dealt with in ordinary hospitals. I would ask my hon. and right hon. Friends above the Gangway to study again and think over the words uttered by the hon. Gentleman the Member for Abingdon (Sir R. Glyn). He, with his great experience of hospital work, began his speech by saying he would find it very difficult to vote against this Bill. He very rightly commented upon the attitude of the Minister and the delightful way in which he introduced this Bill, and asked for cooperation in order to make it a success, so that we might being benefit to those who have hitherto had to go without, and so that we may have a complete medical service available for all, from the greatest specialist to the ordinary general practitioner. This is a great thing. I am sure the Minister himself regards this as only one instalment. In the Bill unfortunately the phrase "comprehensive health service" is used. It is a comprehensive health service from the curative point of view, but the right hon. Gentleman is also the head of the Ministry which will be responsible for the local authorities carrying out the preventative side, which is so important.

When we can abolish slums, when we can make pure water available to all houses, when we can abolish cesspools and bad sewerage systems, when we can have better feeding of the people, when we can have better feeding and better schools for the children—it is appalling that at a time like this, even now after the war, less than 40 per cent. of the school children are being properly fed—and when all that can be coordinated with the three great services, prevention, cure and maintenance of health in a new charter of health which I hope the Minister will introduce, then, indeed, we can look forward to a happier, healthier country. There are many other questions which we will have to discuss in the Committee stage, and it is not worth while dealing with them now. Let us now deal with the general principles. I am proud indeed that a fellow countryman of mine has introduced this Bill, planned it and brought it forward. In many ways he reminds me of our fellow countryman who introduced the first Bill dealing with health. Just as the right hon. Gentleman and I would have wished him well in those days, introducing a new hope to the people wherever they may be, so do I, from the bottom of my heart, wish the Minister well in carrying out this Bill.

6.38 p.m.

Mr. Ungoed-Thomas (Llandaff and Barry)

May I carry on where my fellow countryman, the Leader of the Liberal Party, left off and add my congratulations to my other fellow countryman, the Minister, on this Bill? It is a matter of great pride to us in Wales that the great social services of national insurance and national health should both have been introduced by our fellow countrymen. Whatever trepidations the Minister may have had before the Bill was introduced, he can have little doubt now of the strength of his position, or that the Bill is acceptable to the House and to the country. I hope that in due course, taking heart from this, when the Bill goes through the Committee stage, he will take every possible opportunity, not of yielding to pressure from the other side, which I am sure he will not do, but of strengthening the Bill in precisely those ways which he himself would most welcome. If this Bill had nothing else in it at all apart from the structure which has been attacked by the right hon. and learned Gentleman the Member for North Croydon (Mr. Willink), namely, the structure of the regional boards, it would be a great Bill deserving of the support of this House. There are, of course, various points of detail in the Bill which one would like to see adjusted here and there; the general structure however, of the regional boards, executive councils and so on is excellent. Here and there perhaps the line of demarcation could be drawn a little differently; there have been references to the maternity service and clinics, and it may be a matter for consideration whether it would not be better to bring the professional personnel of those services directly under the regional boards instead of leaving them with the local authorities. Still, that is a matter of detail which can be worked out.

Another matter in the Bill is the constitution of the regions. I do not know exactly how these regions are to be constituted. I hope that the right hon. Gentleman will not follow the precedent which—so rumour has it—his predecessor had in mind when he was considering some larger regions than those we favour in the House today. I should have liked to see it laid down in this Bill that Scotland and Wales should be two of those regions. My own view is that these 16 or 20 regions throughout the country will provide the pattern for the future development of local government, and that local government—regional government—will approximate more and more towards the regions which will be established under this Bill. When that time comes, of course, we shall have a democratisation of the regions in the way which my hon. Friend the Member for South Tottenham (Mr. Messer) envisaged last night. If my view is correct, then quite apart from this Health Bill altogether, the constitution of the regions will be a matter of vital concern, and I hope that we shall have an opportunity of discussing it in this House. If My view is correct, it is not merely a matter of health administration, it is a matter which affects the life, in all its aspects, of the people living in the regions, and as far as Scotland and Wales are concerned at any rate it is obviously a matter of tremendous importance.

I now come to one aspect of the Bill which has given me very considerable concern and which really accounts for my seeking to intervene in the Debate today. It is a matter that has been referred to by more than one hon. Member on this side of the House, namely, the arrangement whereby medical practitioners not only practice under the service provided by the Bill, but can also take paying patients. This is a matter which affects administration and medical practice throughout the country. It affects it in the hospitals and amongst the general practitioners. The Minister in his opening speech said that he had taken the welfare of the patient as his one criterion in drawing up this Bill, and it is indeed most welcome to know that it is only by having that criterion constantly in mind that he could have drawn up the structure presented in the Bill. He has shown the greatest courage in dealing with local authorities, voluntary hospitals and other vested interests, and I hope he will continue to strengthen his position as far as he can in relation to all vested interests affected by this particular Bill.

If, however, the patient is the sole criterion, why then are we having a paid service as well as the national service? Why are we having the private fee system as well as the State system? A considerable number of doctors themselves are opposed to this dual system, and obviously, a doctor who is interested in his practice and his profession, who wants to be free from financial considerations and concentrate upon his work and his patients, does not want to have in his practice a dual system whereby some will be fee-paying patients and others will come in under the general system. He does not want to serve one patient because he is interested in him and another because there is a financial consideration involved. It is the old story of serving God and mammon. It is undesirable to preserve this system under the present National Health Scheme. It is a flaw which runs through the whole system; it is not merely a matter of detail. There is scriptural authority for winking at minor transgressions, but this is not winking at minor transgressions, it is not compromising, it is capitulating; it is not winking, it is "Willinking."

I appreciate the practical difficulty which the Minister is up against, and I will not here, today, press the case in regard to hospitals; the same consideration does not apply in the case of general practitioners. The right hon. Gentleman himself, in introducing the Bill, put it very apologetically. He did not attempt to defend the dual system in principle. He apologised for it, and said that unless we had it, we should be faced with the cry that there is no freedom of choice, and there would be a black market. These arguments do not really bear examination. The Minister himself forbids a patient to pay fees to a doctor on whose panel he is, but if black marketing is to take place, it is most likely to take place between a patient and the doctor on whose panel he is. Yet the Minister himself forbids black marketing in that particular instance. The freedom of choice of doctor, as my hon. and learned Friend the Member for Montgomery (Mr. C. Davies) and other hon. Members have emphasised, is almost entirely an illusion, an illusion which has been fostered by the B.M.A. bureaucracy, which so largely misrepresents the interests and the views of doctors. I agree that although it is an illusion, and as far as it can be done without jeopardising other matters, we can afford to pander to it, but not to the extent of bringing into this Bill the dual system which we had before and which has been proved to be pernicious.

It can be limited in various ways. It could, for instance, be provided that patients should go to, and pay for, a doctor outside a certain area, so as to prevent the scheme existing within, say, a small town. If a patient wants to go from a small town to a larger town to see a general medical practitioner, as happens in various parts of the country, it could be limited in that way. There would not be the same evil involved. The question of a free choice of doctor could be solved by providing that a person on a panel should be free to go to another doctor. That can be solved either by transferring from one to another or, in special circumstances, by an ad hoc arrangement. The payment of a fee should be regulated; it should be paid by the State out of insurance funds, or paid by the patient himself but not left to be settled between the doctor and the patient It should be settled on the same principle as are medicines under the panel scheme, by an ad hoc payment.

The disadvantages of the dual system for those on the panel, for the working classes, are obvious and well known to everybody. What are not equally obvious and real are the disadvantages of this scheme to the middle classes in whose name the argument that this dual system is needed is put forward. The relationship between doctor and patient is not jeopardised in any way by not having payments by contract. The middle classes, the professional classes, whose susceptibilities are considered in some quarters as an argument why the dual system should be put forward, go to their public schools and go into the Army. In the public schools they have a doctor to whom they are sent, to whom they go willy-nilly, and they are well drilled in the system of no free choice of doctor.

Consider the danger that will follow from a regular system of payment of doctors by private patients. I do not mean an exceptional instance or occurrence here or there, but the development of a whole regular system such as there is at the present time. Look at what has happened in education. We have, unfortunately, in this country a system of education by private schools where fees are paid and by other schools, and we find that the middle classes, considering that the private schools provide advantages—I do not say a better education, but advantages of one kind or another which the other schools do not provide—strain themselves in order to send their children to those schools. That is a perfectly proper human urge—to give their children the best education they can provide for them. But these very people would be the happiest at having the advantage of being deprived of this urge to send their children to private schools. This is one of the big factors, undoubtedly, limiting the population in this country. I certainly consider that the development of a dual system in medicine, comparable with a dual system in education, would be something that would be inimical to the interests of the middle classes themselves, and would be resented by them.

I myself represent what is largely a middle class constituency, and I should be far happier going down to that constituency to defend a Bill providing one all-in system, without doctors having patients who pay private fees, and, at the same time, patients on the panel.

Mr. Bevan

May I point out that the argument that the hon. Gentleman is advancing is of great cogency, but that it is impossible to legislate for snobbishness? As doctors can claim to remain outside the public service entirely, those middle class people to whom he refers can pay them fees.

Mr. Ungoed-Thomas


Sir Arthur Salter (Oxford University)

May I put this question to the hon. Member? Supposing that patients—and we know many such instances—are not quite satisfied with their doctor, and feel themselves getting worse and worse, if they feel they can get alternative advice, and, whether wisely or not, can change their doctor, surely it is an alleviation for them?

Mr. Ungoed-Thomas

I entirely agree. That is one strong point which, I appreciate, is in the Minister's case. But that can be made good, as I endeavoured to illustrate, not necessarily by private contract paying arrangements between the patients and doctors directly, but by a system analogous to the system of payments for medicines—by a fee for a particular service. That can be done by fixing the fee, perhaps, through the National Health Service committees.

Sir A. Salter

Any such system as the hon. Gentleman suggests would render practically impossible the practice of private consultation which, when the patient is growing doubtful of his doctor, is essential.

Mr. Ungoed-Thomas

It would not break down private consultation in that case any more than it would break down private consultation between the patient and the doctor on whose panel he was. As regards the Minister's point about the system, I entirely agree. It is perfectly possible to go to such doctors as remain outside the service, but that does not bring them into the service. It is a very pernicious system—he will fully appreciate this, I am sure—having two standards of service provided by the same doctor.

Mr. Bevan

It would be, if I unfortunately adopted that principle. It would encourage a large number of doctors to remain outside the public service entirely on the assumption that they would get a great deal of practice.

Mr. Ungoed-Thomas

Now, I think, we are getting down to the root of the matter. I suggest that the Minister has underestmated his own position. If, in fact, a very large number of doctors remain outside the service, or if there is really a danger of that, I would at once agree with him. I do not think he appreciates the strength of his own position, either with the middle classes or with the profession itself. I know perfectly well that he is of exactly the same mind as I am in this case. I am not criticising the Minister adversely, but I am hoping that he will take the opportunity, as this Bill goes through its various stages, to strengthen it in precisely the way in which I know he would like to see it strengthened. The Minister's courage is at least equal to his pugnacity, and I am sure that he will not miss any opportunity to strengthen the Bill wherever he sees the chance of doing so.

The alternative proposal put up by the Opposition in their Amendment, is really based upon sectional interests of one kind or another. The right hon. and learned Member for North Croydon made an astonishing statement when he said that because county councils and borough councils cover the whole country, they are therefore not sectional. That really is an astonishing statement. Of course they are sectional interests, not within their own areas, but in relation to the country as a whole. When we consider the chaotic conglomeration of voluntary hospitals and local government hospitals, and compare that with the scheme proposed in this Bill, one realises how very fortunate one is to have the present Minister and the present Government.

7.2 p.m.

Mr. Sidney Marshall (Sutton and Cheam)

I looked forward with deep interest to the time when I could hear the Minister make his introduction of this Bill. I expected that he would be rather frightening but I was encouraged by the very smooth manner in which he proposed what is obviously a very carefully prepared measure of highway robbery. I am very glad indeed that even the Minister has not such predatory instincts as the hon. Member for Llandaff and Barry (Mr. Ungoed-Thomas). At least the Minister has left a little of something which is worth having, although unfortunately, in the particular aspects in which I am most interested, namely the hospitals, there are two great blemishes in the Bill.

I do not know why it has become the custom, during these last two days, suddenly to discover that the voluntary hospital system is entirely bad. Very few appear to have anything to say in praise of the voluntary hospitals, in spite of the fact that hon. Members opposite have for years applauded and praised them. Now we find that the voluntary hospital system is too bad for words, and there is not a good word to be said for it on the other side of the House. I cannot believe that Members who deride the generosity and philanthropy of our forefathers are really speaking from their hearts. I cannot believe that the great efforts which our forefathers made to alleviate sickness throughout the years in a voluntary manner, have now become so unfashionable and obsolete as to call for the strongest condemnation possible. I hope that we shall see in this Bill some of the voluntary hospitals receiving consideration which at present, unfortunately, it is not proposed to give them.

I imagine that the Minister was confronted with a great problem when he had to decide the exact position of voluntary hospitals. His position is somewhat similar to that of the promoters of the Education Act who had to deal with voluntary schools, independent schools, and the dual system of the Church schools and the State schools. I think it was gratifying to the country that such a fine Education Act was produced, providing means by which independent schools could continue, and also the old grammar schools with grants in aid. It was a matter of gratification that they could still maintain their independence and carry on. If the Minister had considered the system which was adopted in the Education Act, in deciding the position of voluntary hospitals, he might have shown a little more mercy than at present appears to be the case. I agree that the small hospital is outdated and outmoded. It is obvious that for many years they have not had sufficient wealth to enable them to provide the adequate equipment required in the modern medical interest. I should have thought that the Minister could have preserved some of the larger voluntary hospitals in the same way as the schools have been preserved, allowing them to carry on in the same way as at present. They could have had their boards strengthened by Government representatives in the same way as the schools, and they could have been aided each year by deficiency grants from the State. In that way some famous voluntary hospitals could have been allowed to continue their great traditions, and all that they have stood for during many centuries in regard to the health of the people. I am hopeful that when the Bill reaches the Committee stage the Minister will be accommodating in many ways towards suggestions that larger voluntary hospitals should be allowed to carry on.

Dr. Guest

Would the hon. Member state the names of the voluntary hospitals he is referring to?

Mr. Marshall

I could not quote the names at the moment, because I have not brought my papers with me. I know the numbers of hospitals and beds in the country. There are 924 voluntary hospitals, which include a few sanatoria—probably one similar to that mentioned by the hon. and learned Member for Montgomery (Mr. C. Davies). The total number of hospitals with over 150 beds is only 185, and these are probably fairly efficient hospitals, otherwise they would not have been able to continue, nor would they have had beds of that number. I am afraid that the smaller hospitals cannot expect to receive consideration under a comprehensive health system such as we are aiming at today, because their equipment and efficiency will certainly be below par. I consider that the larger voluntary hospitals might have been allowed to carry on with State assistance by means of deficiency grants. I think it will come as a great shock to the people of this country, that some voluntary hospitals will not be allowed to continue under the proposals in this Bill. The proposals would, in some measure, be alleviated if the larger hospitals could be maintained and kept in their present form.

What I am more concerned about are the proposals in regard to local authority hospitals. I think that it is the desire of everyone in this House that we should provide the most comprehensive medical service possible. We have gone a long way towards that in some counties. As the right hon. and learned Member for North Croydon (Mr. Willink) said, there are at least two counties which have provided an example of that by setting up efficient hospital services and coordinating them and also the domiciliary services. An hon. Member opposite said that the two counties of Surrey and Middlesex were very wealthy counties, and were, therefore, able to do this. I accept that; but I am sure that the Minister could have provided a scheme whereby the county authorities could have given an equally efficient service to the people of their areas by some means of special grants as distinct from the ordinary Exchequer grants. I am sorry to think that the joint authorities appear to have "gone west." I had hoped that we should not see these regional hospital boards set up. An hon. Member opposite said that he could foresee in the principle of joint regional hospitals boards an indication of what was to come with regard to local government in the future. I hope that this does not mean that the Minister of Health, in considering the future of local government, will follow these lines. They seem to me to be the direct opposite of the democratic principles which the Government are supposed to follow.

Mr. Ungoed-Thomas

If the hon. Gentleman is referring to me, I said that in my personal view local government would tend towards the bigger regions, and, if that development took place, it would, of course, be democratised at the same time.

Mr. Marshall

That is not my experience. About three years ago, there arose the question of the reform of local government and many conferences were held.

Mr. Speaker

We had better not get into a discussion on the reform of local government, but confine ourselves to this Bill.

Mr. Marshall

I was referring to regional authorities. The Minister proposes to set up regional hospital boards. I think that regional authorities would be equally democratic. The members of these boards are not to be elected by the ratepayers or taxpayers, but selected and appointed by the Minister. I realise that he suggests that these regional hospital boards shall contain a certain number of people selected from the local authorities, but these people, I take it, will not be answerable to the local authorities, but to the Minister, because the regional hospital boards will come directly under the Minister or his Advisory Council. I cannot see that it is an advance in government to appoint these selective boards directly under the control of the Minister, and not under the control of the elected representatives of the people. That is a very serious blemish.

In my own county of Surrey we had, in anticipation of the desires of the Minister of Health, worked out very clearly a comprehensive health service, called the Surrey plan, in which the county borough of Croydon was ready and anxious to take part. This comprehensive scheme for Surrey received very high commendation, and my view is that a scheme such as that would meet all the needs which the Minister is providing under this Bill. It would make our public health services one coordinated unit. Under the Bill, the public health services, in regard to the general hospitals and the mental hospitals, will now be taken away from the local authorities. They will not administer these services but only the domiciliary services and the health centres, which will be under the direction of the public health authorities and, apparently, of the Executive Council.

The Parliamentary Secretary made great play with the statement that, under this Bill, the local authorities, instead of having duties and powers taken from them, would have additional duties and powers. I cannot see in what way the duties and powers of the local authorities are being added to. I certainly agree that, under the Bill, what are now the powers of local authorities will become no doubt duties, but I cannot see that there is anything new in the Bill which gives the local authorities more powers than they have today. Therefore, it is wrong to say that their borders of government are enlarged or that their duties are increased under this Bill. The truth is that we lose a large part of our powers of governing our own districts. These powers are passed, not to someone elected by the popular vote of the people, but to a board which is appointed by the Minister. Therefore, I cannot see how the Minister can say that this is a democratic Bill. To my mind it is the very reverse, and, from that point of view, I think that there is much to be said against it.

I had hoped that a system of joint authorities would be set up. I see nothing against that, where the districts are large enough. The county of Surrey and the county borough of Croydon have a total population approaching 1½ million, and are, perhaps, big enough to be almost a region. If there are to be 16 to 20 regions, some of them will be very scattered in order to embrace the population of a region. The system could have been worked equally well by joint authorities. We know that there are county districts which could not maintain and support a comprehensive health service as we would wish it to be, but, in cooperation with other counties and districts, they could provide all that was necessary and still retain their identity as local government authorities. This was done under the Education Act of 1944, where, in the case of two county districts in which there was not a sufficient number of educatonal institutions within the ambit of each, they could combine to form a joint education authority. I do not see why the same principle cannot be applied to the hospital system, and I cannot understand why the Minister now desires to introduce these regional hospital boards. I view this with very great alarm from the point of view of the local authorities. It is a distinct weakening of the local government position. It was not so long ago that members of the Government were all in favour of joint authorities. They certainly were not in favour of regional councils, and I cannot imagine those who belong to local authorities being in favour of giving up their municipal hospitals to the State. I do not know from where this gymnastic turnabout comes, but their opinion now seems to have turned right round, and they appear very anxious to hand over their hospitals to the State. I do not understand why the great County of London so readily wishes to hand over the whole of its wonderful hospital system—and I think that it must be conceded that it is a very fine and wonderful system—lock, stock and barrel to the Ministry of Health. The Minister is smiling with the gratifying smile of one who has got something from somebody else for nothing. I hope he will be accommodating enough when the Bill gets to Committee to deal with some of these points regarding the hospitals. I know he is adamant, or appears to be adamant, on some of the facts on the hospital side of the Bill, and some of his supporters have requested him to be more adamant still. However, I hope that when we come to the matters of major detail we shall find the Minister more soft hearted than he appears to be, not only in regard to the voluntary hospitals, but in regard to the hospitals now managed by the local authorities whose efforts in some cases are praiseworthy. Certainly they are rendering the very highest public service in public health. I know that there are other aspects of the Bill such as that concerning the medical practitioners, but I do not propose to deal with them. I am content if what I have said about the hospitals receives some consideration. I shall be very happy if I have achieved something towards making this Bill a better Bill and the service more comprehensive, in order that the health of the people may be properly safeguarded and carefully nurtured.

7.31 p.m.

Mrs. Corbet (Camberwell, North-West)

Some of the remarks that I propose to make on this Amendment may seem irrelevant but were it not for the fact that I have the opportunity now, at last, to make my maiden speech, were it not for the fact that I realise that in such circumstances Members are particularly kind, and were it also not for the fact—and this I say particularly to the Minister—that I believe the point I am going to raise is a very important one I should not have stood up this evening. Before I proceed might I congratulate the Minister on his excellent Bill and speech and also the Parliamentary Secretary on his equally excellent effort this afternoon? I would venture to say one controversial word—although I should not do so—in reply to the last speaker. I happen to be a member of the London County Council and it may be that some of my colleagues on that body are anxious to participate in the Debate this evening but will not manage to do so. Therefore, I want to say that it was not with any pleasure that the London County Council gave up their great system of hospital ser- vice. We have a great pride in that service, but we have an enormous desire for a comprehensive health system throughout this country. We feel that the sacrifice that we have made is in the interest of the nation, and we are proud and indeed glad to do its We only say to the regional boards following us, that we hope they will have as much interest and pride in that service as we ourselves have always felt.

The aspect of this Bill to which I wish to refer this evening is the provision of a comprehensive dental service. The Minister himself said that the state of the teeth of the nation was disgraceful. If those were not his actual words they were to that effect. The Minister is correct. The hon. Member for Abingdon (Sir R. Glyn) referred to the enormous difficulties which people in country districts had in securing dentures. He also talked about the necessity of providing openings for ex-Service men in new trades, and mentioned the possibility of such men becoming dental mechanics. I hope that point will be borne in mind by the Minister of Labour. I would also say a word about the inspection of teeth. To begin with, in my view it is essential that everybody's mouth should be inspected at least every six months. Schoolchildren in particular, nay, children before school age, should have the same inspection. It ought to be possible to conserve the teeth of young children so completely that they do not lose any until the time comes for them to get their new set. I have some figures here. In Cambridgeshire, in 1938, it was found possible in the case of schoolchildren to conserve 13.6 teeth, to each one that was extracted. At the Eastman dental clinic in London, which children from 16 schools attend, they conserved 19.7 teeth to every one extracted. However the overall figure for the country is three teeth preserved for one extracted. We have details which show us that when children just under school-leaving age are examined for entry into school, they have an average of 4.8 teeth decayed.

With regard to the rest of the population I have not any figures here. I can only say I reached the age of 16 before anybody ever looked at my teeth. Then they looked at them before the Dentists Act of 1921 was passed and they lugged out any that had little bits of black on them, so that I lost a number of teeth which should never have gone. My re- maining teeth were subsequently preserved and have lasted me until this day. What is the possibility of satisfying the demand that is going to be infinitely multiplied as soon as people find that they have a right to dental treatment and dentures without having to pay for them? The demand will be increased many times. I hope that not only will the demand increase naturally, but that every step will be taken to encourage that demand, in the interests of the health of the people of this country. If I know my people, and I think I do, I tell this House quite frankly that nothing but the best that they can get will satisfy them in the years to come. We can see it only too plainly in the demand for the standard of housing. I assure the House that dental treatment will be no exception.

What are the chances of meeting the demand? The Minister himself has said—and this is what is agitating me—that during the coming years priorities will have to be given to school children, and expectant mothers and so on. These are very important categories, and must be seen to first, but the rest of the population is entitled to treatment, too, and it is going to be a serious thing, which I hope this Government will not tolerate, if the people in this country have to go without proper attention to their teeth and the comfort and health which ensue from that attention. The Teviot Committee in its report said that the number of recruits to the dental profession was somewhere under 300, and that it would have to be raised to 900 if, in 20 years' time, we were to get the 20,000 dentists needed for the comprehensive dental service. We know what building is, and we know the difficulty of the training of teachers in any subject at all. We realise the difficulty there will be in increasing the number of dendists. I cannot say that I know the remedy, but I can say that we ought to pay very careful attention indeed to the reservation to the report of the Teviot Committee by Major-General Helliwell, a distinguished dental surgeon and officer of the London County Council. He said: Perhaps one of the most surprising customs pertaining to the dental profession is the combination and practise, by the same person, of dental surgery and preventive dentistry with the supply of artificial teeth. On the one hand, we have that side of dentistry in which the one great aim of the dental surgeon should be the preservation of the natural teeth and their associated tissues, to prevent, so far as possible, the need for artificial dentures, but, on the other hand, it is in the provision of artificial dentures that he makes his greatest profit. In no other branch of medicine does such a practice exist, and in my view, unless there is a radical change, the progress to the best type of dentistry will continue to be severely hampered.

Members will remember that the Dentists Act of 1921—although a very necessary reform—gave dentists the monopoly not only of the care of the mouth, which required medical qualifications, but also gave them a monopoly in the making of the impressions necessary before dentures are fitted. The dentist not only gives advice on the care of the teeth and conserves them; he also pulls them out, and he has the greatest incentive to pull them out because, if he can fit dentures, he makes more profit by doing so than by keeping the teeth in the patient's mouth. That is the position, and it must cause us seriously to think. A dentist's training is long and expensive, and it is not right that his skill and knowledge should be wasted in this time of national stress. If he can have help in his work—and Major-General Helliwell and I contend that he ought—then his skill and knowledge might be made to go much further. I ask the Minister to take the necessary steps to see that that help is given to the dentist, with proper safeguards of course, and that the best possible use is made of the dentist's skill and knowledge.

There are ancillary workers, who can clean and polish teeth and teach oral hygiene, often described as dental hygienists. The Teviot Committee advocates the training of such workers to assist dentists, and I hope we shall push ahead with this. A training period of two years is suggested, but they were used in the Royal Air Force after a very short period of training—a few months—and were quite satisfactory. They are used in the United States. In New Zealand they go much further—school medical services are run by dental nurses. Each nurse has the care of about 450 children. She stops teeth, gives instruction in oral hygiene, and, in addition, extracts teeth. I am not saying that we should go as far as that. I think that probably the filling of teeth should be the dentist's work, although I do not quite know where his work begins and stops. Then there are dental mechanics who are capable of taking better impressions than some of the dentists themselves, because of their long years of practice. The dental mechanic needs to see the patient in order to fix his smiling or lugubrious countenance, but under the present law, he cannot do it himself, unless the patient goes to the dentist, so wasting the time of both men. What I am suggesting today is the possibility of making the dentist's skill go as far as possible. I also want to call attention again to the minority Report of the Teviot Committee, and ask the Minister to see whether he cannot do more than we have been led to expect from what has been said in the past.

7.35 p.m.

Sir Harold Webbe (Westminster, Abbey)

It gives me peculiar pleasure to congratulate the hon. Member for North West Camberwell (Mrs. Corbet) on her first contribution to our Debates. I have had the privilege of knowing her and working with her for many years on a great local authority, and I can assure the House that if she brings to the House—and I am sure she will—the same solid work and keen attention to her job as she has shown there, we shall have gained a very valuable recruit. I noticed that many Members were a little alarmed by her exposé of the state of mind of the dentist. In my own particular case, that left me cold because I know that the field for his future operations is now strictly limited. None the less, I am sure that the House, in spite of the alarming character of some of the hon. Lady's remarks, listened to her with pleasure, and will look forward to hearing her again.

Having passed that rather pleasant stage, I feel I must now accept a criticism made by the hon. Member for South Tottenham (Mr. Messer) towards the end of yesterday's Debate. The hon. Member made a speech with more than 90 per cent. of which I found myself in agreement, as I usually do, and made a complaint, or a comment, that up to that point, at least, there had been little real opposition to the Bill. I am encouraged to endeavour to fill any deficiency there may be in that particular regard. Earlier today, we listened to an informative and vigorous lecture from the Parliamentary Secretary, delivered to the class then assembled, with the exception of yourself, Mr. Speaker, and that has encouraged me also to be a little vigorous in what I have to say about the Bill. I say, quite bluntly, that I find it difficult to imagine that there has ever been a Bill presented to this House, the purpose of which was so generally accepted by the House, which contained in its provisions so many deplorable, reactionary, and destructive proposals as the one which is now before us. When one is faced with a Bill, a large percentage of which one regards as utterly pernicious, it is not easy to make a choice of the matters with which one wishes to deal, and I therefore feel obliged to restrict myself to one aspect, to which reference has been made, and which, I think, cannot be too strongly stressed. I refer to the inevitable effect of the provisions of this Bill on the structure of local government. The transfer of the hospitals, which is the major effect to which I refer, has been described in these terms: The transfer represents an encroachment of the first magnitude on local government, and is the most serious loss it has been called upon to sustain. Those are not my words; they are not the words of a Tory local authority; they are the words of the great Socialist London County Council, appearing over the signature of the Noble Lord who, under the Minister, is now responsible for the affairs of London. It is true that, having given that opinion, the Socialist County Council promptly declared their complete, ready and cheerful acceptance of the proposals, and I have no doubt the Minister could give us an imposing list of Socialist local authorities which also accept them in the same full openhearted spirit. That is not in the least surprising. It is exactly what would happen in any dictatorship country. The local gauleiters have had their orders, and in fact the leader of the London County Council was in such a hurry to carry out his orders that he actually announced in the public Press the decision of his party to support unanimously the Minister's proposals before it was conceivably possible that any one of its members could have had even the White Paper in his possession. That was a fine example of intelligent foresight.

But the phrases used by the London County Council are an under-statement. For the last 50 or 60 years, the local authorities in this country have built up, on the humalistic side of their work, a great health service, a health service which, as we have been reminded more than once in this Debate, goes a long way beyond those purely medical services which are referred to in the Bill. It includes housing, drainage, the supply of water, the control of the quality of food, sanitation—the whole group of services which form virtually the whole of the local authorities' occupation and purpose, with the exception of education, and even education is involved through the school medical services. When, in 1929, the Local Government Act gave to the counties and county boroughs the power to take over the poor law hospitals and they became hospital authorities, the major local authorities were able to complete the picture of their health services, and they found in the hospitals a natural focus for the whole of the health services which they provided for their citizens.

What does this Bill do? It tears the very heart out of the whole of the local authorities' health services, it takes away from them the administration of their hospitals, and it leaves them emasculated, truncated, deformed and completely open to the future attacks on the autonomy of local authorities of which we have already heard the rumblings in recent statements by Ministers and others. This Measure marks the beginning of the end, even of the major authorities. But what of the minor authorities, to whom during recent years have been confided all the domiciliary health services, the maternity services, and so on? The minor authorities are to lose them altogether. They are to be transferred to the counties and county boroughs. The counties, as some consolation for losing a job which they did admirably, are to be entrusted with a job which a very large number of people believe they cannot perform, simply because those domiciliary services are so close to the individuals who need them.

I am well aware that an exactly similar proposal was included in the White Paper issued by the Coalition Government. If my right hon. and learned Friend the Member for North Croydon (Mr. Willink) were here, he would be able to confirm that my opposition to those proposals is not of recent growth, but that I opposed them when they were made in the Coalition Government's White Paper. Although the Socialist County Council at County Hall were most anxious to take the chance of grabbing anything they could get, I fought them and I beat them, but I did not have to fight alone. I had behind me every borough in London. I had behind me the unanimous support of the Standing Joint Committee of the London boroughs, and I had as my most doughty, able, competent and vigorous colleague the hon. Gentleman who is now the Parliamentary Secretary to the Ministry of Health. I shall not insult my hon. Friend—I call him that because I have known him so long—by asking whether he has changed his mind. I have known him long enough to know that he is always sincere, that he believed what he said then, and I am convinced he believes it today. I shall not ask him whether he has troubled to put these views before the Minister. He is an old hand, and he knows how hopeless it is to argue with a man who does not know what you are talking about and who has already made up his mind; but if any hon. Member has any doubt as to the wisdom of this particular transfer, I commend him to have a private talk with the Parliamentary Secretary to the Ministry of Health, and he will get the complete and convincing case against the transfer which is proposed in the Bill.

Those are the things that are going to happen to local authorities. What is being put in the place of this highly organised, highly specialised and highly efficient local authority health service which the country has enjoyed for years past? The hospitals, the whole control of medical services within the local authorities, are to be transferred to regional boards, consisting of men nominated by the Minister, his creatures, serving on sufferance and subject at any moment to direction and regulation by him. It is to me an amazing piece of irony that it should be left to a Socialist Minister in a Socialist Government to kick over the local authority ballot box and deprive the people of this country of any voice in the management of services of such vital importance and of such intimate concern to them. It would be fantastic if it were not true. Why is this being done? I have been asked by many people why the Lord President of the Council, that great apostle of local government, who made such heart-tearing speeches, at the time the Local Government White Paper was under discussion, about the dignity of the local authorities, about the way they could do things that no central government could do—including, of course, the whole of the services which the Minister of Health now takes away from them—I have been asked why he does not protest against this crippling of local government. I have known the right hon. Gentleman the Lord President of the Council for many years. It may well be that local government, which has served him not too badly and has carried him quite a long way, has now served its purpose, and may go. What is the real reason, what is the positive reason, why we have these proposals before us? It is that, by the accident of our electoral system, less than half of the voters have put into power a Socialist Government with a very large majority.

Mr. Messer (Tottenham, South)

It was not an accident.

Sir H. Webbe

I said it was an accident of the system. The right hon. Gentleman now finds himself, I dare say as much to his surprise as to that of anyone else, the Minister of Health. He finds himself faced with serious problems in a field in which he has had virtually no experience and the result is this hotchpotch of political prejudice, political idealism, and a very large measure of intuition. My right hon. Friend the Member for South Kensington (Mr. Law) stressed that more than once. I do not want to remind the Minister that the last leader of men who relied on his intuition is dead and his country in ruins. I do not wish that fate for the Minister of Health, but I do hope that his Bill will be thrown out.

I have spoken strongly because I feel strongly; I believe in local government, I believe our Constitution is based on local government, and I believe it is in the practice of local government that our people have learned how to govern themselves in the way no other people in the world have done. I beg the House to consider the implications of this Bill on that local government structure. If the Bill in its present form reaches the Statute Book, at that very moment the Minister will have signed the death warrant of local government as we know it and will have made a laughing stock of our claim to be a democratic country.

7.51 p.m.

Mr. Somerville Hastings (Barking)

I hope the hon. Member for the Abbey Division (Sir H. Webbe) will excuse me if I do not follow him in his attack on the London County Council. At another time and place I should be delighted to do so, but tonight I would rather talk about the Bill. I should like to explain to the hon. Member in a few words why, in my opinion, the Minister has found it necessary to take over the hospitals as he is proposing. This Bill cannot be looked at in isolation; it is part of a broad scheme for ironing out some of the inequalities and uncertainties of life. It is made necessary, I think, by the National Insurance Bill which is before Parliament, because, according to the terms of this Bill, all will have to pay and therefore it is the interest of all that there should be as few demands as possible on the National Insurance Fund. One of the main claims will be probably for sickness, so that it is up to the Minister to do all he can for the prevention and cure of sickness. Further, contributions will be the same in all parts so that the Minister must provide not only a good service but one which will be equally good everywhere. I think these facts must have been in the Minister's mind when he framed the Bill because to get equally good service everywhere he must have a good deal to do with the appointment of committees governing the service and take over the hospitals which will provide the hospital part of that service.

What other possibilities were open to the Minister? The Minister and the Parliamentary Secretary have shown very clearly today that it would have been quite impossible to leave the new hospital service in the hands of either the voluntary or municipal hospital authorities. The only other alternative to taking them over was to try to control them by monetary grants. I think all who have considered the matter realise how important it is that there should be a unified and integrated service and how each of our hospitals must be given its proper place in that service according to the sort of work for which it is most suitable. Would the Minister, by means of monetary grants, get what might be considered a prosperous but small hospital to take a minor place and become a convalescent home or a hospital merely for the chronic cases? Supposing that hospital belonged to a large and powerful local authority, would they toe the line merely because of the withdrawal of a monetary grant? The hon. Member for the Abbey Division knows very well the history of Waterloo Bridge, and how when the local authority wished to rebuild it the Government then in power said, "No, we will not give you the necessary grant," to which the L.C.C. replied, "Very well, we will do it without that grant." Exactly the same would be the reply of the voluntary hospitals. Some of the smallest of the voluntary hospitals are exceedingly well endowed, and what they would say is, "Very well, we can manage quite well without the monetary grant."

I should like, if I may, to deal with this necessity for a unified and integrated hospital service. I have had the very good fortune to be a member for the last 16 years of a committee that has had in its charge some 70-odd hospitals. The L.C.C. took these over in 1930, when many of them were working as isolated units. In the intervening 16 years the committee has been endeavouring to weld these hospitals into a unified system. I do not suggest that the work is entirely complete even yet, but we have had sufficient experience to show us the extraordinary advantages of such a system. May I mention just a few? First there is the bulk purchase of supplies; not only can we get supplies cheaply but we get better quality because by sampling we can make sure that they are up to standard and it is quite clear that no dealer would willingly offend one of his largest customers. Then there is the standardisation of equipment—beds, bed tables, and so on—which can be secured in a unified system. But much more important than that is the easy transference of both patients and staff when this is found to be necessary. I will give one example from the experience of London. Early in 1937 there was a very bad epidemic of influenza. The municipal hospitals were filled and the voluntary hospitals refused to take influenza cases. What could the L.C.C. do in the face of the many hundreds of cases needing admission to hospital? Just then, fortunately, many of our wards in the fever hospitals were empty. They were rapidly disinfected, and within a few days 500 patients were admitted into the fever hospitals. Although there were cases of influenza which are not generally token into such hospitals, there were fortunately, no cases of cross-infection. A greater advantage than that and one which would be secured from an integrated and unified hospital system in each region, such as is contemplated by the Bill, is the possibility of specialisation and of the segregation of patients in hospital wards where they would be under the care of doctors and nurses and other workers with special experience in the treatment of their particular diseases. I say advisedly "other workers" because, for example, in Queen Mary's Hospital, Carshalton, there is a lay worker, who is neither doctor nor nurse, but who is obtaining in cerebral diplegia, as it is called, extraordinary results. By this system in London, we are able to segregate cases where they can be best looked after. We put cancer cases, who need X-Ray and radium treatment, in two hospitals. In another hospital we put plastic cases, who need operation on the face. While in still another hospital we put cases needing surgical treatment of the chest, and so on. Not only do patients get great benefit from this segregation, but research is facilitated also. Before the war, the London County Council had some 900 cases of rheumatism in children in three hospitals. That gave extraordinary opportunity for research on this disease, the etiology of which is little known.

I would like to refer to the hospital management committees proposed in the Bill. The right hon. and learned Member for North Croydon (Mr. Willink) pointed out that letters have appeared in "The Times" and elsewhere putting up a very strong case for granting more power to the hospital management committees, powers almost, but not quite, equal to those of the committees which will be in charge of the teaching hospitals. I look upon that as a very dangerous proposal. Anything that would limit the far sighted planning of the regional hospital committees, or would limit the influence of the universities and teaching schools, one of which it is proposed should be, as far as possible, situated in each region, would be a real disaster. I am well aware that to secure the right sort of people to take their places on these hospital management committees, we must give them a good deal of power. They must have power to spend a certain amount of money, to make rapid decisions and to experiment, but their power must be strictly limited. If we give these committees power to appoint doctors and senior staff, as is proposed, they are very liable to follow the voluntary hospitals into that inbreeding which has been the curse of the system. Most of us prefer the devil we do know to the devil we do not know and most hospital committees dealing with a single hospital are all too ready to promote one of their own staff rather than to appoint a better man or woman from outside. The suggestion is also made that these hospital management committees should be permitted to receive legacies. I also look upon that as dangerous within the national system, and sectional interests in the hospital system must be restrained

Nevertheless, there is very much in local interest, local patriotism and local pride in a hospital, and I do not see why they should not be developed and continued under a municipal or national system as much as under the present voluntary system. However good the public provision may be, there will always be opportunity for voluntary effort and for experiment in social service. Not only will it be necessary to have hospital management committees, but in all hospitals there should be Samaritan committees, aftercare committees, library committees, and amusement committees for hospital and staff. These can to a large extent be voluntary committees. I would like to show that voluntary effort is just as necessary and as important and just as easy in a municipal hospital as in a voluntary. In the East End of London, in Mile End, there is a hospital owned by the London County Council. It was much damaged in the blitz, but it is much beloved by the local people. Only a couple of weeks ago, in order to show appreciation of the services of the nurses of that hospital, a local concert was arranged, and £300 was raised for a fund for the welfare of these nurses.

I come to the question of paybeds in hospitals and payment for the services of doctors in these paybeds. I hope that as our hospitals are rebuilt and brought up to date, there will be provided between every pair of beds a curtain, which can be pulled as the patients desire. I hope that there will be a sufficiency of single bedded wards, so that anyone can have a single ward not only if he needs it on medical grounds but even if he desires it. People vary very much. Some people like solitude when they are ill and some desire just the reverse. Meanwhile I consider that a very strong case can be made for permitting those who wish to buy privacy to pay for a single bedded ward, provided, of course, and the Bill is explicit in this, that it is not needed for a case that requires it for medical reasons. If the Minister or the Parliamentary Secretary, which God forbid, should need hospital treatment, they will be quite justified in making use of one of these paywards because in them they could discuss matters with their officers without the B.M.A. learning of everything that was said.

But when we come to consider payment for treatment in these wards, an entirely different question arises, and here I can speak from direct and personal experience, as for many more years than I care to say I have been on the staff of one of our teaching hospitals which some 10 or 12 years ago provided a block of paybeds. I am quite sure that I and my colleagues do as good an operation for our public patients as for our private, but I am equally sure that we pay more visits to our private patients and leave the care of our hospital patients much more to our registrars and house surgeons. And in so far as the senior staff are more experienced than the junior, I suppose that the patients in the private wards are getting better treatment. However that may be, I am perfectly sure that those patients believe they are getting better treatment, and it will be exactly the same in the national hospitals. The patients who pay for their treatment will believe they are getting something better, and it will be in the interests of the surgeons and physicians concerned to keep up that delusion, if indeed it is one. I feel that this is most undesirable. All of us want the best possible treatment given under our new national hospital system, and we want the patients to realise that they are getting the best treatment also. But is that likely when the patients in the wards know that there are two sorts of wards and two sorts of treatment in the same hospital? It is a convenience to the doctors to have all their patients, private and public, under the same roof or in the same curtilage but I appeal to the Minister that important as doctors are—I would be the last to deny that—the patients in the hospital are even more important.

8.14 p.m.

Lieut.-Colonel Gage (Belfast, South)

I feel that I shall command a large measure of agreement in this House when I say that the only point of view from which this Bill should be approached is the point of view of what is the best for the patient. It does not matter—and it is not the case here—what best suits the medical profession or what suits any particular party, and it is with that in mind that I shall try to make three criticisms, which I hope I shall be able to make quite briefly. I could make them in three minutes, but I shall be a little longer—certainly not very long. My first criticism is with regard to the method, or the principle underlying the method, of remuneration of the general practitioner. I cannot help feeling there is something wrong here because, as I understand it, the general practitioner is to be remunerated by means of a part-salary and by capitation fees which will diminish as his patients increase. That is not the right method. It is bound to produce a general levelling in the standard of remuneration paid to the general practitioner, and it is not really suitable to any profession, and least of all to the medical profession. Let us assume that in a small community there are two doctors practising: one of them is an idle and not very competent fellow, while the other is a vigorous and zealous young man. They will start by getting a small salary that will not vary, however good the one may be or however bad the other may be. The zealous young man will attract many patients to himself but he will find that with every additional patient, the remuneration gets less. He will find that while he is practising alongside a man whom he knows to be his inferior, that man will be getting practically as much remuneration. There will be a difference in the remuneration but it will not be a very large one, and the principle seems to me to be quite wrong. I do not say that good work should be disproportionately rewarded or that idleness should be harshly punished, but with the capitation fee alone we have a fair method of rewarding the practitioner, and, as the Minister of Health said yesterday, by keeping the capitation fee lower we are getting a proper reward for zeal and a proper punishment or penalty for idleness.

Let us consider the two main arguments put in favour of the part-time salary. First of all, it is said that there are places in these islands where the population is so scattered and so small in numbers that a doctor could not make a livelihood out of it on a capitation basis. Surely, that could be put right simply by increasing the capitation fee in that sort of place. Secondly, it was said, I think more cogently, by the Minister yesterday, that we want to give some security to young men starting out in the profession. Security is all very well for people who deserve it—the old, the infirm and the children—but surely a young, vigorous man starting out on the profession of his choice is the last person who would ask for security. Indeed, I have always felt that it is the very insecurity of all professions, and particularly the medical profession, that attracts the young, adventurous, vigorous and fit people with incentive. When I started in my own profession I was told that three qualities were required for success. The first was that one must be very poor; the second, that one must be very industrious; the third, that one must be very much in love. I think that that also applies to the medical profession. The feeling of insecurity, and being very poor and keen, helps one along and tides one over the worst part.

That brings me to the second point of criticism, which is with regard to the buying and selling of practices. There again, as I understand it, the keynote is security for the young man starting in his profession. I should have thought that the same argument would apply to that, but I would not have thought that the burden of borrowed money which is hung like a millstone round the neck of the young man starting in practice, as the right hon. Gentleman said, was really so very great. I do not know the figures, but after all, many young men with no more capital than their brains, and with no other asset than their industry, have started and made a success on borrowed money. I would have preferred to have seen the global sum of £66 million, which is to be spent in the compensation of elderly practitioners, used for providing security for the young man at a time when he needs it, which as my right hon. and learned Friend the Member for North Croydon (Mr. Willink) said, is before he is qualified. It is not after he is qualified. If some of that money could have been devoted to the provision of scholarships and other aids for getting the young man through those two or three years of study, then indeed a great deal would have been achieved. Finally, I would like to deal shortly with the question of health centres. I have never understood why they should not have been equipped and started by the local hospitals. That may be due to my ignorance of the subject, but I have always understood that one of the objections to connecting the hospital scheme with the local authorities was that doctors, as a rule, do not get along well with local authorities. I entirely agree with the right hon. Gentleman the Minister that the health centre should be a place where there is equipment which the general practitioner cannot get normally. I should have thought that hospitals could have supplied such equipment, with the dual result of connecting general practice more closely with the hospitals. There may be a difficulty about that of which I do not know, but I should have thought it was a better method of dealing with the health centre.

Yesterday the right hon. Gentleman the Minister spoke very feelingly and eloquently about the shudder of revulsion which he felt when he saw nurses and medical students collecting money on the streets for their hospitals. I feel also a shudder of revulsion whenever I go into a surgery or into the outpatients' department of a big hospital and see queues of people waiting patiently for their turn. It is a dreadful thing to see these unfortunate people, obviously suffering, having to wait in a very patient row for their turn to go in to see the doctor. I hope that these health centres will not have the effect of removing the queues from the surgeries to the health centres, and making them longer queues, because more people will be attending. I hope that doctors will be encouraged to go into the homes of the people and see them there. It has been said that one of the reasons why people pay fees to doctors is to obtain privacy. Of course, that is true. It would be mere hypocrisy for myself or for any other person to say that they did not like privacy with their medical man. Of course they do and, if they can afford it, they will pay for it. The tragedy is not that there are a few people who can afford it, but that there are so many who cannot afford it. I hope, therefore, that under this scheme the doctors will be en- couraged to go into the homes of the people and will not simply use the health centres as glorified surgeries where they expect everyone to go and wait in rows. If the health centres accomplish what I have suggested, they really will have gone a long way towards the goal which, after all, every hon. Member of this House is striving towards, which is to try and raise the standard of our health services throughout the country.

8.26 p.m.

Mr. Boardman (Leigh)

I want to make one or two observations on the Bill and on the Amendment. First a word about hospitals and their charities. I think it ought to be underlined, for it does not seem very clear from the discussion I have heard in this Chamber, that we on this side do not regard charity as being an end in itself. It ought to be understood throughout the country, and certainly by the Opposition, that the one increasing purpose of the present Government is not to perpetuate charity but to eliminate the need for it, or at least to minimise it.

A picture has been presented of how the hospitals are financed. I do not think sufficient stress has been laid on the fact that a very substantial part of the hospital incomes is derived from the weekly contributions of the working man and working woman. But that is not all, and that is not the only way in which the worker pays. There is a case known to me of an industrialist, a large employer of labour, in whose factories trade union organisation was taboo, and trade union wages and conditions also were taboo. As a direct consequence of this embargo on the free association of his people, his wages bill was little more than two-thirds of what it would have been had he observed trade union agreements. However, he was a big-hearted fellow and he had built and equipped at his expense an operating theatre. He had built at his expense a hospital ward, and he equipped that. That man will not be remembered in local history because he was a bad employer; he will be remembered as a philanthropist.

These fillibustering philanthropists are pretty common just now. We are not concerned about them, because I am satisfied, if I know anything at all about working men and working women, that they do not want charity whether the source is good or bad. Charity at its best humiliates. What an absurdity it would have been in September, 1939, had someone suggested then that we should limit our expenditure on the war to the charity of patriotic people. If that had been the position, we would not have been meeting here tonight in the British House of Commons. It was proper that we should use the financial resources of the State, it was proper that we should accept a certain measure of State control, and it seems to me to be just horse sense that if you harness the resources of the State for the purpose of destroying life, it is more in keeping with 20th century civilisation that we should harness those same resources for the purpose of saving life. That is precisely the purpose of this Bill.

If existing facilities were adequate probably there would have been a different story to tell. It may be that in some places they are adequate; I can only speak of those places which I know. I have the honour to represent Leigh in Lancashire a mining community which comprises a non-county borough and two urban districts. The whole of the area is a coalfield. The population is about 85,000, of which approximately 13,000 people get their living in the dirtiest and most dangerous occupation we have—in the pits.

There is one hospital catering for the whole constituency, the Leigh Infirmary, a small hospital completely inadequate to the needs of the district. In the outpatients department it is cruelly inadequate. The hon. and gallant Member for South Belfast (Lieut.-Colonel Gage) spoke of being moved when he saw queues of people waiting inside hospitals. At Leigh he would find at this hospital, catering for 85,000 people, a waiting room for the outpatients which will not hold more than 40 people. The people waiting for treatment go into the corridors, overspill outside, and wait there whatever the weather. It is so easy, too easy, to pat hospital staffs and boards of management on the back and say, "Well done, a magnificent job done under difficult circumstances." It is humbug, cant and hypocrisy, unless we are going to do something to alter those circumstances. It has been in the power of Parliament for a very long time to do something, but nothing has been done. I welcome this Bill as strongly as I deprecate the Amendment. I am, however, very unhappy about one section of the Bill, that concerning the family doctor service. I have every reason to believe, from what I heard the Minister say yesterday, that he is no more happy about it than I am. It so happens that before I came into the House I was for 10 years a trade union official, and throughout that time I was taking part in negotiations. I know how heartbreaking it is when one is asking for something to which one thinks one is justly entitled, to realise the price that must be paid for it. I have the greatest respect for the Minister, for his ability and sincerity, but I am bound to be frank about this—I think he has paid too high a price.

He has paid too high a price by allowing the concession that a doctor who participates in the service can also take fees for his doctoring. I have spoken of the ability of the Minister, but I think it would require someone far more able than the Minister—if such a person can be found—to convince a miner in my constituency that he will get the same treatment as the mineowner who can pay for it. It is said that the relationship between doctor and patient is a psychological one. That is where psychology will come into the problem. There will be people who by reason of social snobbery or plain ignorance will go to the doctor who prefers to remain outside the service. These people are going to create the impression among those who remain in the service that in this Bill we have simply an enlargement of the panel system. I notice that the Minister said that it will probably help to clamp down the black market in the medical service. I am interested in this matter. I am also interested in the retail trade. I do not know of any such concession being made to retailers. Yet if some of these people are caught engaging in the black market they are clamped down pretty heavily.

Another point which disturbs me is in regard to the major authorities, the county councils and county borough councils and the powers they are given under some Clauses of this Bill. When Bills sponsored by the Lancashire, Cheshire and Nottinghamshire county councils were presented to the House recently, Members in all parts of the House took strong objection and the Minister said that if those Bills were withdrawn he would insert a Clause in another Bill coming before the House. It seems to me that here is the fundamental principle again in this Bill and I see no reason why non-county boroughs should be left out. I know a great deal is said about the size of the non-county boroughs but it is a fact that many non-county boroughs are bigger numerically than county boroughs. It seems that the only fault of the non-county boroughs is that they have refused to grow up into oversized, ugly, sprawling townships. It ought to be said, in fairness to non-county boroughs, that many of them have shown initiative, enterprise, and, what is more important, have demonstrated efficiency which would do credit to many major authorities.

One final comment on the Amendment. I am one of those who believe that whichever party sits on this side of the House, it is necessary, in the interests of healthy Parliamentary government, that we should have sitting on the other side a virile Opposition. Therefore, I welcome an active interest, even to the point of seeing the Opposition put down Amendments. But so far as I can see the only purpose of this Amendment is that it cries "stinking fish" on behalf of its sponsors.

8.36 p.m.

Lord Willoughby de Eresby (Rutland and Stamford)

It falls to my lot to be the first to have the honour and privilege of congratulating the hon. Member for Leigh (Mr. Boardman) on his maiden speech. It is rather an odd coincidence, that this is the third time running I have congratulated someone on a maiden speech, although I do not think I have myself spoken more than three times during the 12 years I have been a Member of this House. If my remarks are somewhat drab and commonplace, I hope the hon. Member will believe me when I say that they are none the less sincere. We one and all congratulate him on an interesting, informative and eloquent speech. Now that he has come through the ordeal with flying colours, I hope that it will not be long before we again have the value of his contributions to our Debates.

I realise that I speak in this Debate on sufferance, on sufferance from you, Sir, and the strict understanding that I do not speak for more than five minutes: on sufferance, possibly, from the House be- cause I am afraid I speak with no great authority or knowledge from a medical point of view. The only excuse, which I can offer to the House for taking part in this Debate, is that I am, possibly, one of the few people in this House who have spent many months in one of the right hon. Gentleman's own hospitals. I even remember an occasion when I was in a Ministry of Health hospital when I had to button up my pyjama top, because the hon. Member for North Islington (Dr. Guest) was coming to inspect us.

Dr. Guest

I hope the Noble Lord did it properly.

Lord Willoughby de Eresby

Unfortunately the hon. Member did not do me the honour of inspecting my ward, though I remained with my pyjama top buttoned on a very hot summer afternoon.

My first point, before I make any more general observations, is a special point to the Minister in regard to voluntary hospitals. We in Rutland happen to be in a unique position, as our small voluntary hospital is also our county war memorial. I am certain that it is not the intention of the Minister, that it is not the policy of the present Government, and is not even covered by that all-embracing electoral mandate of which we hear, that war memorials in this country should be nationalised. We in Rutland recognise the difficulties of the Minister's position. We wish to play our part. We recognise that it is impossible today for the small voluntary hospitals to carry on in their completely independent position when they are in future to receive the larger portion of their funds and equipment from the State. The future plan for the hospital services for the county of Rutland, in spite of what the hon. Member for South Tottenham (Mr. Messer) said last night, is obviously a question which one of the regional boards will have to decide. I think the Minister quoted the figure of 1,000 beds as being the ideal unit. That is obviously rather exceptional for Rutland——

Mr. Bevan

Not in one building, of course.

Lord Willoughby de Eresby

The future of the hospital will have to be decided. In regard to whether our particular hospital is to be enlarged to embrace a larger district or whether Rutland is to go in with Leicester, or some other area, I would not press the Minister for any direct answer now. I am quite sure he understands the point I am trying to make. Money has been subscribed for this hospital which consists of only 24 beds and one operating theatre. It will not make or mar the whole scheme if it can be kept as a memorial of the dead of the county of Rutland who gave their lives in the last war.

I would now refer to the Minister's own hospital, a hospital run by the Ministry of Health. I happen during the past year to have spent most of my time in a Ministry of Health or a State hospital, in a voluntary hospital and also in a Canadian Red Cross hospital. Comparisons are odious especially when one has received nothing but kindness in all three types of hospital and when one's treatment has been free; but it is a matter of such importance that I feel I can say, without any prejudice and in all honesty, that if I were given a free choice of which type of hospital I would select for further treatment, the Ministry of Health hospital would be the last choice I would make. I say that, not because the surgeon the doctors, the sister, or the nurses were any less skilful, obliging, helpful, or considerate in the Ministry of Health hospital than many of the other types of hospital in which I have been. I myself am eternally grateful to them. I probably owe my life, I certainly owe the fact that I can walk at all today, to the service which was given me in the Minister's own hospital. I wrote to his predecessor and thanked him for all that was done for me there, for which I shall be eternally grateful.

To my mind, it is the system that is wrong. The system, unfortunately, does not enable the surgeons, the doctors, and the various members of the staff to give of their best or to give—this is most important—just that extra bit of treatment, that extra bit of comfort, those one or two things extra which are so important when one is lying on one's back for months on end. It may seem unreasonable but anyone who has been ill for a long period of time, I am sure, will agree with me, that it makes all the difference. We all know that the right hon. Gentleman the Minister is himself of an extremely volatile and effervescent disposition, with an active and energetic brain. I happen to be of a rather placid and extremely lazy disposition. He may need much more dope to keep him quiet than I would possibly need myself. The trouble is that in these hospitals they do try to prescribe for the general rather than the particular case. If the bills are particularly heavy in one week, for, shall we say, some modern dope, questions are asked. Not only are questions asked by the Minister of Health, as the right hon. Gentleman well knows, but possibly by the Treasury, and so on. That may be rather an exaggerated example. The point I wish to make is that in a voluntary hospital, one can pay, as a private patient, for those little extras which make all the difference. If one is in there as a non-paying patient, someone just goes a few doors away and asks whether permission can be given and it usually is given, but, unfortunately, in a State hospital, there may be questions which are ultimately asked right back to Whitehall, and possibly in the Treasury, about the extra expense.

I have also been in a Canadian Red Cross hospital, which, as I saw from a picture in "The Times" the other day, was recently handed over to the right hon. Gentleman himself by the Canadian Red Cross. In that hospital, it certainly was not a question of what extras you wanted. One was given everything; their only concern was whether anything more could be given. I am certain that if the right hon. Gentleman keeps his State hospitals up to the standard prevailing in that hospital at the time when I was there, he will do a great thing for the people of this country, and I am also certain that that is his aim and object. All I would say to the right hon. Gentleman is that he has a very long way to go to get all the hospitals up to that standard. But I know that is what he wishes to do, and I am certain that he will work to that end.

8.47 p.m.

Dr. Haden Guest (Islington, North)

I should like to say at once to the Noble Lord who has just sat down that I apologise for not having visited the ward in which he was at the hospital to which he referred. Had I known he was there, I should, of course, have done so, but I confess I am still in the dark as to where it was.

Lord Willoughby de Eresby


Dr. Guest

I have visited a great many hospitals to acquaint myself with what was going on, and I rather gather that the Noble Lord was in an Emergency Medical Service hospital during the war. It may have been in any type of building which had been taken over; it might even have been, originally, a lunatic asylum.

Lord Willoughby de Eresby

A Ministry of Pensions hospital.

Dr. Guest

Well, that is a particularly good one, in my opinion. The hon. Member compared it with what one might call a super-equipped Canadian hospital with the whole resources of the Canadian Army and the Canadian nation behind it. That is not quite fair. It is rather like comparing the Dorchester with a small hotel in a back street off the Strand, so far as equipment goes.

Lord Willoughby de Eresby

No. The point I was trying to make was that we are going to be contented with standardised mediocrity. Surely, we must aim at the very best, and, if we go in for a lower standard, we are going to fail?

Dr. Guest

I agree, and I am sure that is what, in fact, we are going in for, but, in the war we had to take certain standards and had to do the job, and, in fact, did it most effectively and on a very large scale. I do not want to extend this personal interchange of pleasantries with the hon. Member opposite, but I want to say that I hope the Minister is going to adhere very closely to the Bill in its present form. I believe that there is a very strong case for the Bill, and I hope that it is not going to be modified out of recognition. Its two main provisions are those of a complete hospital service and a personal medical service for all persons of all ages, insured or uninsured, without exception. That is the foundation of all future building, which can extend and grow as our resources and our knowledge extend and grow, and if the national health service, in fact, did nothing more than provide this complete hospital service and complete personal medical service at home for all persons, it would be of the very greatest benefit to the health of this country.

I take the personal medical service first, although I will not go into details. The extension to all means that a large number of people, self-employed, uninsured people very often, and poor people who are not in the scope of the panel service will now come into the service and get treatment. It also means that the service extends at once to women and children. I know from personal experience that in the old days of the panel system there was a very large number of women who were not insured and who were afraid to consult the doctor for some woman's illness because, at the end, they might have a bill which their husbands could not face. This health service will extend treatment to them and will prevent a very large proportion of women's chronic internal complaints, which is going to be of immense advantage in improving the health of the nation. With regard to the so-called minor infectious diseases of children, like measles and whooping cough, in the past—and, indeed, at the present time—some mothers did not take their children to the doctor for these complaints. The result is that among the members of the manual working classes, the death rate from the complications of measles and whooping cough is very considerable, whereas among those in better circumstances it is practically negligible. Proper treatment will make an immense difference in that respect, and save many children's lives.

I welcome this Bill for another reason. I remember, years ago, seeing the coming into existence of the Act for the medical inspection of school children. I said at the time that it would shine a light into all kinds of dark places where there was ill health and bad conditions, which had not previously been seen, and would make a great change in the condition of children because it would direct attention to troubles which up to that time had been overlooked and had not had adequate attention. As all hon. Members of this House know, the statistics show that in the last generation—this has gone on for about a generation—the health of children has improved enormously. Nowadays, children are very much better in health, in height, in growth, in development and in activity than they were a generation ago, which is the result of the application of medical knowledge to the life of children. When this Bill comes into operation and attention is directed into all the holes and corners of our social system, so that there will no longer be unilluminated places in which disease can hide, there will at once be an immense change for the better in the health of the nation, even though this is only called a "curative" service.

I believe that the hospital service will have an immense effect and one which will be very far reaching. But before the hospital system can be effective it must, of course, be brought into existence. That can and will be done, but I suggest to some hon. and right hon. Members opposite—I do not include the right hon. and learned Gentleman the Member for North Croydon (Mr. Willink) in this—that they do not understand what an extraordinarily complicated matter this is. It is not only a question of the voluntary hospital versus the municipal hospital, or one kind of hospital against another; it is a matter which varies from area to area in the country. Even in a particular area like the London survey area, to which I will refer in a moment, there is much variation.

When the right hon. Gentleman the Member for South Kensington (Mr. Law) was speaking yesterday, he said that the object of this scheme was to sweep away the voluntary hospitals … Nothing could be more absurdly untrue than that. The idea of sweeping away hospitals is not in this scheme; the idea is to coordinate the hospitals and to make them work together in a scheme for providing a hospital service for the nation as a whole. Then the right hon. Gentleman went on to ask: Why is the Minister determined to take over the ownership of the hospitals?—[OFFICIAL REPORT, 30th April. 1946; Vol. 422, c. 68, 69.] He implied that it was a fad of nationalisation for nationalisation's sake. Of course, it is nothing of the sort. The coordinated hospital plan arises from the logic of the facts. The national control of all hospitals in the hands of the Minister is the way of efficiency and gives the best human service to the community. I would mention in passing that no less conservative an authority than "The Times," in a leading article, said that of all the schemes produced on this matter my right hon. Friend's scheme is the best one up to date. I cannot quote what goes on in another place, but I would draw the attention of the House to the fact that so far from the voluntary system being abolished, a Member in another place, who happens also to be the President of the College of Physicians, uttered words to the effect that by preserving the teaching hospitals, this new scheme preserves the essence of the voluntary system. He also said an interesting thing which the right hon. Gentleman the Member for North Croydon might like to know. He said that this scheme presented the medical profession and the country with a regional scheme which they had demanded without success from the right hon. Gentleman and that they wanted a regional scheme. The right hon. Gentleman can find that statement if he looks up the reference.

I said that the necessity for a hospital scheme on a national basis arises not from any desire for nationalisation for its own sake, but from the facts of the case. The facts to which I refer are to be found in the reports in a series of hospital surveys, one of which I have in my hand, which have been instituted following a statement made by Mr. Ernest Brown when he was Minister of Health in 1941, when he said that in order to provide for a proper portwar hospital service, the Government of that time were instituting a series of surveys to be made by medical experts all over the country. Those surveys have been made. It is also a fact that those surveys—the one which I have deals with London and the surrounding area—were only published in 1945. I suggest to hon. Members opposite, including the right hon. and learned Gentleman the Member for North Croydon, that one of the reasons why opinions on this side as well as on the other side of the House may have changed in this matter, is because we now have a very large and important body of facts drawn practically from all over the country, on which to base our conclusions, instead of just general opinions which may not be quite so useful. When we get a factual view of the hospital system we get a very different view from that which has been presented by some hon. Members during the course of the Debate yesterday and today.

The London Survey area covers a very large expanse of country. It covers London, Middlesex, Kent, Surrey, Sussex, the Isle of Wight, part of Berkshire, Hampshire, Dorset, Essex, Hertford, Bedford and part of Bucks. That is the area, I think, to which the right hon. Gentleman the Member for North Croydon referred when he spoke of a population of 14,000,000. It is about that size. In this area there are voluntary hospitals, municipal hospitals, and hospitals of every kind, but they are by no means all of equal importance and of equal value to the country. Inside the London area itself, we have the great teaching hospitals.

Perhaps I ought to remind some hon. Gentlemen opposite that voluntary teaching hospitals will retain their independence and their leading position in the medical world and in the world of healing. They will, in fact, be in an improved position to that in which they are at present, because they will be freer from any financial anxiety. The voluntary system in regard to them is being maintained, entirely and completely unimpaired. They will, of course, be correlated into the general system and will, in effect, take an important part in developing it.

Mr. Willink

Has the hon. Gentleman taken account of the fact that the teaching hospitals will be subject to any direction the Minister may give, the limit to this direction being in no way defined in the Bill?

Dr. Guest

I have taken that fully into account. I know my own profession. I know the anxiety in regard to the working of the emergency medical service, having participated in it during the early part of the war when I was on the Staff in Eastern Command. I think I know the anxiety, and I have not the least fear in the world of any domination by the right hon. Gentleman the Minister of Health. I do not think he is in the least degree likely to do that Things done by agreement among equals are not the subject of unnecessary fears, and I do not think the Minister is to be feared as a tyrant. I believe he is to be cooperated with as a friend. In regard to the hospital area, I wanted to draw attention to the outline of the conclusions drawn by the very distinguished gentlemen, whose names I need not mention, who drew up this Report, which is entirely non-political and professional. They were asked to report on the area with a view to ascertaining what was the best means of organising cooperation between the voluntary and the municipal hospitals. What did they find as a general picture? Not at all a rosy coloured picture. They found that there is in the area a deficiency of beds for acute medical and acute surgical cases; a deficiency of beds for tuberculosis; a deficiency of beds for maternity; very bad provision indeed for the clinic sick, and only a very small amount of provision for the clinic sick from voluntary sources. I would emphasise that the amount of provision for the chronic sick from voluntary sources is always very small indeed, if it exists. I quite understand that that does not follow. The distribution of hospitals over this area is very haphazard. I will give one or two facts with regard to this Speaking of the voluntary hospitals the writers of this Report say, under the heading "Uncoordinated effort": The majority of the voluntary hospitals are distinguished (in the London area) by their independent spirit, initiative and power of inspiring local loyalty, [HON. MEMBERS: "Hear, hear."] but their fruits— I hope hon. Members will cheer this too— are not always conducive to fully efficient and satisfactory hospital services. They give the example of the tendency to enhance the importance of the individual hospital rather than arrange the best facilities for the patients. They give the instance of hospitals competing with each other in the same field of work, regardless of the needs of the patients. The voluntary hospitals are very human bodies, not coordinated, and very badly in need of coordination among themselves, as well as with the municipal hospital services The municipal hospital services in this area are a very recent growth. A good general municipal hospital is a comparatively new creation, even in the London area. London, Surrey and Middlesex are very advanced, but in some areas, such as Dorset and Hampshire, the survey reports that little or nothing has been done to develop municipal hospital services. We have, therefore, in one part of London, Middlesex and Surrey, good municipal services and good voluntary services, but in two other counties very little is done. In fact, there is a terrible patchwork all over this very large area. The general conclusion of the gentlemen making this report is that in quantity and quality there are deficiencies of all types of accommodation all over this area.

The problem is not one of buildings at all. As they say, a good hospital consists not of buildings, but primarily of an expert medical and nursing staff. In the London area we are fortunate in having a large number of consultants, because under the existing system consultants having unpaid appointments at voluntary hospitals have to support themselves by private fees. There is, therefore, a concentration of specialists in an area such as London, where there is an opportunity for specialised practice from which specialists can earn a substantial living. But in the surrounding areas, even in the London district, there is a very small and inadequate number of specialists, for the simple reason that no specialist can at the same time discharge his duty as a volunteer and unpaid adviser in a voluntary hospital and live in an area where he cannot have a specialist practice.

It is much worse than that in certain other parts of the country, and in some cases it is extremely bad. For instance, in the South-West of England, which contains Devon and Cornwall, there are very few hospitals and a very bad service. Sometimes there is even definite competition between adjoining municipal authorities. There may be a boundary down the middle of a street which divides them geographically, and because they are different authorities it is difficult for them to combine. The question of combining voluntary and municipal hospitals is so complicated when considered from the standpoint of the country as a whole that, unless it is done on a national scale, I am convinced it cannot be done at all. We simply cannot get hold of the problem except on this big national scale. In these conditions, nothing but bold national planning, and the coordination of municipal systems on a national scale, will solve the problem.

The difficulties are enormous, but it can be done, and we shall do it. The need for increased accommodation is very great, not only for tuberculosis but for acute medical and surgical cases and for maternity, and the number of specialists is not adequate for a large service. I was discussing this matter the other day with one or two of the leaders of the medical schools in our universities, and we came to the conclusion that under this scheme we should need at least double the number of specialists we now have. That is because in some places, at the present time, there is practically no specialist attention at all. In the Devon and Cornwall survey area—that includes the Bristol area—there is only one hospital, in Bristol, which has a full staff of specialists. In three or four others there are some specialists, but the remainder have no specialists at all. They are general practitioner hospitals carrying out major surgery for which general practitioners are not fitted, as they themselves know, but they have to do it because it is not organised. It needs organising; the hospital system is not only disorganised but it is, in some sense, almost chaotic. I want to make a suggestion about this, how to tackle it.

Mr. Willink

Will the hon. Gentleman allow me? Do I understand him to say there were substantially no specialists, for example, at Exeter?

Dr. Guest

I was endeavouring to make myself clear. [An HON. MEMBER: "Look it up."] I will. Let me take this area, the South-Western area, Gloucester, Somerset, Wiltshire, Devon and Cornwall, with a population of 2,600,000. There are about 300 hospitals, voluntary. Only the British Royal Hospital has a complete staff of specialists. The Gloucester Royal Infirmary, the Cheltenham General Hospital, the Royal United Hospital. Bath, the Royal Devon and Exeter Hospital, the Prince of Wales Hospital, Plymouth, and the Torbay Hospital, Plymouth, have specialist staffs, but all the rest have not. This is an extract from the South-Western area survey which, no doubt, the right hon. and learned Gentleman has seen. There is not the slightest doubt that these hospitals are without specialists. But it is much worse than that. The right hon. and learned Gentleman has drawn my attention again to this issue. I thought I was wearying the House, and I did not want to go on with it, but now I may say some of the things I had thought of saying. I will now mention them to encourage hon. and right hon. Gentlemen opposite.

One of the evils of the voluntary hospitals in this area—and it is reported in very great detail, and any hon. Member can get the report in the Library, if he does not wish to purchase it—is that in these small hospitals there is failure to keep adequate case notes. Also, the midwifery accommodation is very unsuitable; and that for the chronically sick, in a good many of these areas, is seriously overcrowded in the institutions with un- trained nurses; and the majority of the public institutions have so many defects as to be unsuitable for the aged and chronically sick persons. I did not want to bring all this out, but I give that as an example of the conditions which are found in different areas all over the country. The conditions are very much worse than the right hon. and learned Gentleman has given the House to understand. They are much worse than a great many people in this House do understand, and they cannot be tackled adequately except on a national line.

I want us to take a lesson from our war experience with the Emergency Medical Service, not because the right hon. Gentleman and the noble Lord with whom I had a pleasant interchange just now, reminded me of the Emergency Medical Service, but because I want to refer back to it, and to remind the House that with our inadequate number of specialists, and with our inadequate number of doctors—the number is certainly inadequate—we did manage during the war period, by coordinating the work of the voluntary and municipal hospitals, to create an Emergency Medical Service which did most valuable work for the Armed Forces. It acted as the medical base for the whole of our expeditions overseas. It saved us thousands of lives. It saved us many hundreds of doctors.

If we can do that in war we can do the same kind of thing in peacetime. There is not the slightest reason why we should not. We have the Central Medical War Committee doing valuable work, mostly members of the B.M.A.—we must say a good word for the B.M.A sometimes—with another committee, the Medical Personnel Priority Committee, of which I am now chairman, undertaking the general work of the principal allocations of medical priorities. There is no reason why those two Committees should not go on with their work in peacetime. I appeal not only to this House but to the medical profession to help in this peacetime reorganisation, and to coordinate the hospitals on the lines carried out in the war, not this time for war casualties, but for T.B. cases and chronically sick people. Members of the House will remember that in the war, when we thought we should have thousands of casualties, from bombing—which fortunately, we did not have—we made provision for those casualties. I should like to see the House make provision for thousands and thousands of casualties from tuberculosis which, unfortunately, we already know exist. I think that we could do it. I believe that by putting our backs into this matter we could make provision for some of the more serious things which we have not got at the present time. I believe that a central medical peace committee might do very valuable work in the same way as the Central Medical War Committee have done very valuable work during the war.

It has been said by various Members opposite that the prospect offered to medical officers under the new scheme would not appeal to them, that this was not the kind of thing which would appeal to men of vigour and of adventure. I do not for one moment believe that. I have a suggestion to make, which, perhaps, will make the attractions of the service greater. I want to make our National Medical Service a service as wide as the British Commonwealth of Nations. I want to make medical officers within the Colonial Medical Service, which is at present one service interchangeable from Colony to Colony and interchangeable with medical officers within the national service of this country. I want doctors in this country to have the opportunity to go out to the Colonies, and come back enriched by their new experiences. I should like to see this done not only with our Colonies, but with the Dominions. I should like to see men go out to Australia, New Zealand, Canada and Newfoundland and come back enriched by their experience. I believe that we are now organising in this country a service for all without distinction of income or occupation, age or sex. We should provide those who are to give this service with the widest possible experience of the world, which our British Commonwealth, extending over one quarter of the world's surface can give, and which is large enough in which to gain this experience. We are organising something more than a National Medical Service. It is nothing less than the turning of the knowledge and wisdom and practice of the medical profession, and of all the sciences on which it rests, to the service of our common humanity. Nothing less than that is the objective of this Bill. I believe that this medical service should be given to our common humanity, without restriction and without barrier, save only the claims of human needs. It is an objective within the grasp of the Bill. It can be done; it should be done, and I believe that when this House votes tomorrow night, it will be done.

9.17 p.m.

Mr. Wilson Harris (Cambridge University)

This Debate has by this time covered a wide field. That is not surprising when we are dealing with a Measure which extends to over 70 pages. But when all is said that has been said I believe that whatever anxiety still exists—and I think it does exist—centres around two main questions, the future of the family doctor and the treatment of the voluntary hospitals. I subscribe, as I am certain every Member subscribes, to everything which has been said by way of tribute to the family doctor, the general practitioner. There is no more devoted or more disinterested body of men in this country than the general practitioners. If I thought that these men who ease our entry into the world and our departure from it, who mitigate our pains and cure our diseases and would prevent many of them if we gave them the opportunity, would suffer any serious detriment as a result of the passage of this Measure, nothing would induce me to cast my vote in favour of it. But I believe, in spite of all that has been said, that if this Measure is passed, the lot of the ordinary general practitioner in many respects will be easier, and in only a few respects more difficult, than it is today. That opinion, I recognise, is not the view of all the medical profession. It will not have entirely escaped the notice of the right hon. Gentleman opposite that some of the members of the medical profession entertain slight reservations in regard to the proposals which he has brought forward. He will not be unduly depressed by that if he remembers, as I do, the events of 35 years ago, already referred to by my hon. and learned Friend the Member for Montgomery (Mr. C. Davies), when the Queen's Hall was packed by vociferous medical practitioners, denouncing the Bill which was introduced by my right hon. Friend's illustrious compatriot and vowing they would not work it. Well, that storm blew itself out in about a month, and, as was said earlier in another connection, history does sometimes repeat itself. As I have studied the criticisms of this Bill, and the hostility manifested towards it in certain quarters, I have come to the conclusion that it springs largely from two sources. There are psychological reasons, and there are misunderstandings and misapprehensions. In accordance with the tradition of Parliamentary draftsmanship, the executive authority in this Bill is invariably referred to as "the Minister." That means, in effect, "the Ministry," and how much less disturbing it would be if "Ministry" were used instead of "Minister." For it is a hard but painful fact that the forceful and occasionally provocative personality of the present incumbent of that office has not evoked from the medical profession precisely that wholehearted and enthusiastic admiration which he, no doubt, desires and, no doubt, deserves. Therefore, it can be well understood that an agitated medical practitioner, conscientiously working through this Bill, and finding on every page a reference to "the Minister"—the Minister may do this, prescribe that, may provide this regulation, may change that regulation—should be found exclaiming with some frequency and some vigour, "That man again!"

But even there, I think that the medical profession may take some comfort. We are legislating tonight not on the short term but on the long term. In the course of nature, the right hon. Gentle man will give place to a successor, and, in the course of politics, that may be sooner rather than later. In any case, I cannot help thinking that even the most hostile members of the medical profession, if they had read the speech which the right hon. Gentleman delivered yesterday, may feel that like one of his habitual associates, he is not so entirely black as he is sometimes painted. There have been many misapprehensions in regard to this Measure—misapprehensions which will be hardly entertained by any one who has read the Measure carefully. Many of them have been dissipated in the course of this Debate. There is the perfectly untenable charge that, under this Bill, a doctor may be directed to go to a certain place and practise there, and nowhere else. That idea was dispelled by the Minister in his speech yesterday, and by the Parliamentary Secretary in the essay which he read so fluently this afternoon.

There is further a great deal of misapprehension, as it seems to me, on the subject of health centres. That was illustrated by the speech of the Noble Lady the Member for Hemel Hempstead (Viscountess Davidson) yesterday, when she gave a picture on the working of the health centres which I will not pursue here, since it seemed rather more imaginative than realistic. This has to be remembered about the health centres. In the first place no health centre exists as yet, and unless the right hon. Gentleman's health centre building programme wins by a very long head over his house building programme, it may be some time before any health centre appears. Secondly, when there are health centres there will be nothing to require any member of the medical profession to go near one. He can still see patients in his own surgery if he prefers to exactly as he does today. Thirdly, if he is wise enough to use the centre and take advantage of the equipment which will be there supplied, he will have his own hours for consultation, his surgery hours just as is the case today, and patients will naturally go and see him at those hours, not dropping in at any odd time expecting him to attend them, because it is a place at which he occasionally functions.

One comment frequently made about this Bill is that it will destroy the relationship between the doctor and patient. All I have to say about that is that as I understand it the relationship between doctor and patient is made by two people—the doctor and the patient. I do not flatter the Minister of Health sufficiently to suggest that he is capable of coming between a doctor who cares for his patient, and a patient who has respect for his doctor. If the relationship between doctor and patient does break down it is the fault of those two, and not the result of any Measure introduced into this House. I must confess I am a little more concerned with the observations made on both sides of the House today and yesterday in regard to the free choice of doctor. The suggestion was made in one case that no real freedom of choice existed, and in another case that no freedom of choice, in fact, is desirable. The right hon. and learned Member for North Croydon (Mr. Willink), if I may say so with great respect, seemed to me to be a little less than ingenuous in his observations when he said that because certain doctors would not come in under this service, preferring private practice, it could not be said that there was free choice of doctor. But, after all, words must be read in their natural context. What I take them to mean and what I think most hon. Members take them to mean is that free choice of doctor is a free choice of doctor within the National Health Service, and that will certainly exist when the national health service is established.

What I was more concerned with was the remark made by the hon. Member for Silvertown (Dr. Comyns), when he suggested that because the average patient did not know enough about medicine to decide which doctor was skilful and which was not he did not see why there was any reason for that freedom of choice at all. From that thesis I must vigorously dissent. Skill is not the only quality required in a medical man. There is no profession in which personality is rated higher and plays a greater part. Let me illustrate. There are some seven or eight medical practitioners sitting on the opposite side of the House. What degree of medical skill, if any, they possess I have no idea, but as I sit here and scrutinise them at leisure I have reached very definite conclusions on whose ministrations I would and whose I would not welcome, if I were seized with sudden indisposition in the House, and they came hurrying to my assistance as I have no doubt they would. As a matter of fact if the hon. Lady the Parliamentary Secretary to the Ministry of Food were in the vicinity, I trust I should have sufficient strength left to beckon appealingly to her.

Now I come to the question of voluntary hospitals. I must frankly confess that this is the part of the Bill about which I have entertained the greatest misgivings. They have to a great extent been dispelled by the Minister yesterday, because the conclusion does seem inescapable that in the necessary redistribution, coordination and reorganisation of hospitals, the hospital buildings at least must pass into the possession of the State. After all, we do not perhaps always realise the relation to this question of the revolution in transport in the last 40 or 50 years. When I was a boy and went occasionally to the Methodist chapel—they were Wesleyan chapels then—in a Devonshire village it was common to hear the local preacher, who was a little weak in his aspirates but none the worse for that, announce that the collection that day was for the "'orse' ire" fund. The horse of course was hired to bring the preacher from the nearest town to the village. I quote that because the hospitals which have to be dealt with now are survivors of the horse-hire age. Patients could not then be transported any distance, and so there had to be hospitals for every small community built by the pounds of the rich and the pennies of the poor and often offering services for which they were not really competent. Those hospitals must have a new place, or sometimes no place at all, in the reorganisation of the hospital world which is necessary today. But one point on which I still feel unhappy is with regard to voluntary hospital endowments. The right hon. Gentleman said yesterday that they amounted to £32 million——

Mr. Bevan

That would be the figure after setting aside the endowments of the teaching hospitals. The global figure is about £45 million.

Mr. Harris

I am much obliged, but the actual figure is immaterial. Whatever the sum is, it will, I understand, remain in the possession of the hospitals, their basic normal needs being supplied by the Exchequer. It would not remain in the possession of the individual hospitals, but would go into the general fund and be redistributed. Now I ask the right hon. Gentleman whether that process is really necessary; whether the hospitals could not be allowed to keep their endowments, particularly as he is paying the basic necessary costs of management and operation. On the grounds of justice and humanity, and as the line of least resistance, it would, I suggest, be the wise and statesmanlike course if the right hon. Gentleman left the endowments to the individual hospitals, and merely took their buildings and fitted them into the general scheme. If the right hon. Gentleman will give some thought to that matter before the Bill goes to Committee I think he would be doing a great service to the community.

With regard to the suggestion about the annexation, as it has been called, of the voluntary hospitals, and the statement that this will destroy the local patriotism, local spirit, and local support on which we all set so much store, that will only be the case if the people who should be sup- porting the hospitals decide not to support them. Why should not that support continue in future, just as it has in the past? I agree that there would not be the same need for financial support, but it has never seemed to me that the warmest and the most humane form of charity consists merely of signing a name at the bottom of a cheque which someone else has drawn. Surely, visits to patients and the gifts of flowers, gifts of books, gifts of games, gifts of wireless sets, with all the little thoughtfulnesses which go with them, introduce warmth and humanity into this sometimes sad and sombre atmosphere. Therefore, I dismiss entirely from my mind suggestions that because voluntary hospitals are being taken over these qualities, on which we set so much store, will disappear in the future.

Finally, speaking as one who is attached to no party, I confess to great disappointment that this great Measure will not have, on its Second Reading, the support of a united House. It is impossible not to draw a contrast between the wise, generous and statesmanlike speech which we heard last night from the hon. Member for Abingdon (Sir R. Glyn), and the general tone of the criticisms which have come from the Opposition Front Bench. Of course the Opposition are perfectly justified in opposing this Measure, and in putting down an Amendment, but I wish they could have found it possible to support the Second Reading without reservation, while holding themselves free to make whatever proposals they desired on the Committee stage.

The Amendment will be defeated, the Measure will get its Second Reading, and we shall pass to the Committee stage; and that will be a period of immense importance, because there are obviously changes which could be made in this Bill to the general advantage, and I hope they will be made. But there is something a little more than that. If the right hon. Gentleman the Minister of Health shows himself, as I believe he will, ready in Committee to accept reasonable suggestions and to listen to constructive criticism from his opponents, I think two most desirable objects will be achieved. Not only will the Measure be substantially improved, but what is even more important, confidence will be created that, under the right hon. Gentleman's administration of the Bill when it becomes an Act, the doctors, the public, the patients, can count on just and generous treatment at his hands.

9.36 p.m.

Captain Baird (Wolverhampton, East)

As a fairly new Member of the House, I feel rather reluctant to follow the hon. Member for Cambridge University (Mr. Wilson Harris) and the hon. Member for North Islington (Dr. Guest), who have made excellent speeches, but I should like to deal further with the question of the hospital system, which was raised by the hon. Member for North Islington. I should like also to associate myself with the tribute which the Minister paid yesterday to the great work which the voluntary hospitals have done in the past. In my opinion, the reason this reorganisation of the voluntary hospitals is necessary is simply that they no longer fulfil their function in a modern society. In estimating this matter, we must look into the history of the growth of voluntary hospitals as we know them at present.

The voluntary hospitals first became a power for good in the land at the time of the industrial revolution. At that time industrialists and capitalists had the foresight to recognise and utilise the new forms of power which had recently been discovered. Rural workers were then flocking to the towns in tens of thousands. Housing conditions were abominable. Sanitation was non-existent. Women and children were forced to work in the factories and pits for long hours and in bad conditions. Ill health was rampant. Therefore, it is not to be wondered at that the new industrialists, who were mostly deeply religious men, should have had some qualms of conscience. Conscience money flowed into the now hospitals, and we can only hope that it bought the necessary marble halls on high. However, with the development of modern industry and modern capitalism, surplus profits have dwindled, and the subscriptions to the voluntary hospitals from wealthy sources have also dwindled. Today, contributions from wealthy philanthropists make up only a small proportion of the income of these institutions. Some 60 years ago, in an attempt to find new sources of income, the hospital contributory associations and the hospital Saturday funds were founded to organise new sources of income from the working classes. It is rather interesting to note the history of the Birmingham Hospital Saturday Fund, published recently, in which we read: In 1873, the inspiring suggestion was made by a Mr. Gamgee, a well known surgeon of that time, that everyone should be asked to work overtime for the hospitals on a particular Saturday afternoon, that day to be called 'Hospital Saturday,' a fine idea, and though found eventually to be somewhat impracticable from the point of view of systematic organisation, it was decided to go for ward with the scheme. From that day to this, the great majority of the income of the voluntary hospitals has come out of the pockets of the working classes.

The point I want to make before going any further is that even with the contribution of the Hospital Saturday Fund the voluntary hospitals in many parts of the country are facing bankruptcy at the present time. Take the case of one typical provincial town, Birmingham, in which I happen to have lived for some considerable time, and of whose hospitals I have some knowledge. What is the position there? In 1939 the voluntary hospitals in Birmingham, which are organised in what is called the United Hospital Board, were faced with a loss of £56,600. In 1940, the next year, the loss was only £32,600, but upon going into the question further one finds that in 1940, during a year of war, the voluntary hospitals in Birmingham received a donation of £63,000 from the State, through the emergency hospital service. Therefore, in 1940, if it had not been for the war, the Birmingham voluntary hospitals would have been faced with a loss of almost £100,000.

I will take the question of this same town still further. Some years ago the voluntary hospitals decided to complete a new hospital because of the lack of hospital beds in the town, and they built one of the most modern hospitals in the country, the Queen Elizabeth Hospital. It was only after the hospital was complete that the organisers of the voluntary hospitals realised that they would have to finance it and that they had not the wherewithal to do so. They therefore set up a committee to find out where the money was to come from. The committee reported that in this new 600-bedded hospital, one of the most modern in the country, they could only afford to open 200 beds, after which other beds would be opened only as beds were closed in the older hospitals, in this a city where there was a great shortage of hospital beds. I want to submit to the House tonight that the reason why it is necessary to bring the voluntary hospitals into this scheme is because they are facing bankruptcy, and because we cannot get efficiency except under a new system.

May I give one other example from my own constituency, Wolverhampton? In the Royal Hospital there it was recently found necessary to cut down the expenditure in the radiological department. The way this was done was by saying that no medical practitioner should have direct access to the radiological department; he could only use it at the whim of one of the consultants employed by the hospital. That is entirely against modern medical practice and theory; today we want to keep the practitioner in the closest touch with the hospitals. There are many other examples, but my time is limited.

My main reason for intervening tonight was to deal with some of the dental aspects of the Bill as one of the few dental surgeons in the House. On the subject of dentistry I want to say—and this is a point we must bear in mind—that in the past, before the war, the dental services of this country were entirely adequate for the restricted number of people who could buy conservative dental treatment. Indeed, many dentists were under-employed before the war. The reason was, first of all, as was said by an hon. Lady opposite last night, that dental education was very lacking in the past in this country, but the chief reason why the dental services were not more used was lack of financial means of the working classes to buy dental treatment. In the past the working classes as a whole knew nothing about conservative dental treatment, by which I mean fillings and so on. They thought of dentistry as what we dentists call "blood and vulcanite"—waiting until it was necessary to have their teeth pulled out and then having dentures. That was dentistry for the working classes in the past. I am very pleased to think that that era is passing.

Today there is a great need of dental surgeons. First of all we must pay a compliment to the work of the dental surgeons in the Forces. That work has laid the foundations of dental education for the masses of this country. Young men and young women are coming out of the Forces today convinced of the necessity of conservative dental work. Also with the changes now proposed, there will be free dental treatment for everybody in the near future. Those two factors have created a shortage of dentists. There are not enough dental surgeons to go round. The dental profession have criticised the Bill to some extent. The reasons for the weakness of the dental side of the Bill is the shortage of dental surgeons. Our problem in future will he to discover how we can get more young men and young women to enter the dental profession. Dentists themselves could do something about this matter because, in the past, they have been disunited. This is a very young profession, only about 25 years old. If only dentists would get together and unite themselves into one organisation they would be able to do a lot to raise the status of the profession.

The medical profession and the public do not always realise the good job which this branch of the medical profession are performing. Dental surgeons play a very important part in modern medicine. Much of the surgical treatment which they carry out is very responsible. Taking four, five or six teeth out is a major surgical operation. [Laughter.] Some hon. Members may laugh, but it really is the case. Further, most dental surgeons carry out many more general anaesthetics than do doctors. Speaking generally, the dental surgeon is the partner of the doctor in the medical services of this country. That fact must always be recognised.

I believe that the Minister can do much to raise the status of the dental profession. He has not so far done it. In the First Schedule to the Bill, in the constitution of the Central Council, the Minister makes provision for the chairmen and secretaries of various medical organisations, but I suggest that there should be a place upon that Council for the chairman of the British Dental Board. I do not think that that would alter the constitution of the Board, but it would help to raise the standard of the profession and get it recognised by the public and profession as a whole. Further, in the past, dental surgeons employed by local authorities have been given a very lowly place in the medical system. Hon. Members interested in local work will know that a dental officer employed by a local authority cannot, in most cases, approach his medical committee direct but must do so through the senior medical officer. That should be finished with. The senior dental officer should be able to approach his committee direct.

An even more important question is the appointment of public dental officers. In a copy of "The British Dental Journal" which I have here, there are some advertisements. One is for a senior senior dental officer, a man of great responsibility. The salary offered is £650, rising, subject to satisfactory service, by £25, to a maximum of £800. Another is for an assistant dental officer at a salary of £450 rising to £650. I believe that hon. Gentlemen opposite and the country as a whole have not recognised in the past the good work which the doctors and dentists of this country have done. The general practitioner, both in dentistry and medicine, has been under-paid. I am confident that we will not be stingy when it comes to the question of discussing salaries for medical or dental officers, and as far as dentists are concerned, for increasing the salaries of our public dental officers.

I attended a meeting organised by the British Dental Association recently, and I heard various criticisms of the Minister in regard to the Bill. We were told that if the Bill went through dentists would not work as they have done in the past. There is much talk in the House and in the country about the need for dilution of the dental profession. If the dentists talk about not working so hard under a State scheme, they are asking for dilution, whether it is right or wrong. Some remarks were made earlier this evening by the hon. Member for North West Camberwell (Mrs. Corbet). I do not like to criticise a maiden speech, but her remarks should not go unchallenged. She referred to the minority report of the Teviot Committee on Dentistry, signed by Major-General Helliwell, for whom I have a high regard. Let me say here that, with regard to the question of the dilution of the dental profession, I think he has oversimplified the problem. It was suggested by the hon. Lady that there was a great incentive at the present time for dentists to make dentures, but the present panel scale of pay is much better for conservative work, than for dentures.

The hon. Lady also referred to the question of dental hygienists and said what a great contribution they could make to dentistry. The idea of dental hygienists, smartly dressed young ladies ushering you into the surgery and carrying out work there is all very well. The hon. Lady also suggested that in New Zealand or Australia these hygienists pull and fill teeth and do all sorts of treatment. She also suggested that dental mechanics could make dentures. I began to wonder what job would be left for the dentist to do. As a dental surgeon, I would say that dental hygienists cannot make any great contribution to the problem of the lack of dentists in the country. The amount they can do is of a very restricted nature, and it does not include fillings or extractions. With regard to the question of dental mechanics entering the profession, this is very important. The argument is used that dental mechanics can carry out the mechanical side of this profession and supply dentures. That may be necessary in time, but I will not go into that argument tonight. The dental mechanics have only been organised in a trade union during the last three or four years, and at the present time there is no way of judging who is a dental mechanic and who is not. The trade union movement is pressing for a course at various technical schools for dental mechanics, and in three or four years' time we may get registered dental mechanics who may do some of that work. However, in relation to the problem of the shortage of dentists at the present time, that is not very satisfactory. The only solution is the solution recommended in the majority report of the Teviot Committee, that we should open the profession to the working boys and girls of this country.

I come from a working-class household. I managed to get to the university chiefly as a result of sacrifices by my parents. With me went other working-class boys and girls, and I remember that during the years of the depression when we went to the university together without large financial means, I saw many boys and girls as able as or abler than I drop by the wayside because their fathers became unemployed and they were forced to go down the pit or into the factory. After a few years all ambition was knocked out of them. Others, because of bad housing, were forced to give up owing to ill-health. I believe that if we can provide the financial incentive to the working-class boys and girls of this country, we shall get the dentists we require, and, therefore, I hope the Minister will implement the Teviot Committee's Report.

There are, however, one or two weaknesses in the Bill. I think there was one very apparent weakness in the Minister's argument when he attempted to justify the pay beds in our new hospitals, and also the right of consultants to have private patients. The argument he used was that if we did not allow consultants to have private patients, and if we did not allow pay beds in our hospitals, we would have a black market in nursing homes. Surely, with the great Government we have, we can register—[HON. MEMBERS: "Hear, hear."] I am not worrying about what hon. Members opposite say; I am thinking about what the people of the country say. Surely, with the great support the Government have from this side of the House, we can control the nursing homes by registering them, and we can easily control the black market. I think that when the Committee stage comes along we shall have to take such steps.

This Bill is only the beginning. By itself it can do little. It is like a skeleton which has yet to be clothed with flesh. The whole gamut of industrial medicine, prevention and research and medical education, has yet to be tackled. We on this side of the House are awake to the demands for legislation to deal with all these ancillary problems. We have been waging this fight for a generation. It is a fight to take the profit out of ill health and to give to the whole community that access to the best medical and surgical treatment which has in the past been so often denied them. Under our present day system of medical private enterprise, there are two standards of treatment, one for the rich and one for the poor. While the wealthy patient can, if he requires it, be carried direct to a private bed in a voluntary hospital, the working class patient has to put his name on the waiting list or queue up in the out-patients' department. In country districts it is quite common for a local medical man to have a special side entrance where his panel patients can call and consult him at a given time, but for the private patients there is a front door and consultation by appointment. The Labour Government are determined that this two standard system of medical treatment shall be abolished and, therefore, we shall support this Bill. I repeat that this is not the end, but the beginning of our fight for better health for the people of this country.

Motion made, and Question, "That the Debate be now adjourned"—[Mr. R. J. Taylor]—put, and agreed to.

Debate to be resumed Tomorrow.

  1. ESTIMATES 20 words
  2. c313
  3. GAS (SPECIAL ORDERS) 94 words
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