§ THE MINISTER OF RECONSTRUCTION (LORD WOOLTON) moved to resolve, That this House welcomes the intention of His Majesty's Government, declared in the White Paper presented to Parliament, to establish a comprehensive National Health Service. The noble Lord said: My Lords, as a great number of noble Lords have indicated their desire to take part in this debate, it has been arranged, subject to the general consent of the House, that the debate shall be adjourned at a convenient hour to-day on the Motion of the noble Lord, Lord Horder, and be resumed as the first business on the first sitting day of the next series of sittings. I do not propose to take up a great deal of your Lordships' time to-day in commending the Resolution which stands in my name. My purpose in putting this Resolution on the Order Paper was to obtain the considered views of your Lordships' House, many members of which, through long and devoted service to the cause of public health, are peculiarly competent to give advice and to be heard on this subject. I am bound to confess that I have some anxiety about how properly to present this subject to-day, and to present it with reasonable brevity. The Government have already published two Papers on the subject, one the conventional White Paper and the other a shorter version, in order to bring out with clarity the principal points that we had in mind.
§ I may be a little over-anxious about this subject because it is one that is very near to my own heart, and one with which for some thirty-five years I have been 71 personally and intimately concerned. In my early days, when I was first trying to understand something about the economic problems of poverty, the thing that deeply impressed itself upon my mind was that so many of the people among whom I was then living, and who were very poor, seemed to be constantly suffering from ill health in one form or another. I remember very well—and I remember it, if I may say so, with some pride—taking part in the early movement to try to establish dental clinics in the schools of this country, so that we might begin by giving the child a reasonable chance of having a good digestion with which to face the world. In later years, when I was engaged in industry, time and again my mind was driven to the conclusion that there was some very close association between industrial incompetence in the individual and physical disability.
§ I am not for one moment going to suggest that all these evils are going to be cured by the Government's proposals. I hope your Lordships will forgive my personal approach to the matter, but I ventured to make it because I wanted to give the additional weight of personal experience and very deep conviction to my advocacy of the substance of these proposals. I hope your Lordships will think that it is a bold and adventurous proposal that the Government are putting before you as the outline of a plan, advocating as it does the greatest single advance that has ever been made either in this country or in any other in the service of public health. We are entitled as a nation to believe in our capacity to realize these proposals. For let us look at the basis of our hopes. In this country we have made great strides in the service of public health. It has passed through many generations from private philanthropy to public administration. Men of the greatest medical eminence in the country have been unstinting in their personal care of the sick, and they have placed their professional competence and their professional services at the disposal of the poorest of the people without any thought of payment or reward. The spirit of private philanthropy and the value of voluntary effort in the hospitals of this country make us to-day look at their record, and make us regard that record both with pride and with 72 gratitude, whilst the service of our teaching hospitals and the researches of the medical schools of the universities in this country have spread knowledge and practice beneficently over the whole world.
§ Now we look to the future. Twice in a generation this nation has been called upon to sacrifice its most virile people, and this factor arising from the war compels the Government of this country to concern themselves with repairing the breaches that have been made. The health of every individual making up a nation is at the very root of national vigour and of national enterprise. Therefore His Majesty's Government have tried to work out a scheme whereby, by the method of common insurance, we may secure for the people of this country freedom, in so far as it is humanly possible to get such freedom, from the misery, the worry and the economic consequences that come from the failure of health. This is not a scheme for relief. It concerns itself neither with poverty nor with wealth. It is a scheme that invites the whole of the community to join together in an effort to ensure for every individual the positive opportunity for good health in so far as that can be provided by the skill and the knowledge of the medical profession.
§ I observe with some regret that it has been called by people a free scheme. Well, I do not like that term. It suggests that there is going to be something given for nothing. I do not like these proposals for giving something for nothing. The true position is that the method of paying for the medical and health services will change in the future. All will pay for the services of all. We shall pay through taxation, we shall pay through local rates, we shall pay, all of us, through a comprehensive social insurance contribution. So this is not a free scheme. People are going to pay for the services and because they are paying for them they will have a consequential full right to demand that it shall be a good service when they get it. Having paid for it, and paid for it by their weekly contributions, then they will be able to rely on obtaining it without any further worry or concern if by mischance ill health comes their way.
§ I referred a few moments ago to the great strides that have already been taken in the public health services of this 73 country. But of course, in very characteristic British way, they have grown up—grown up without any particular plan or design. Local authorities have had the administration of various services put on them at various dates—services with a strictly limited object in view. Similarly the hospitals have grown up for dealing with all sorts of different aspects of ill health, mental as well as physical, clinics, and a whole host of services. The voluntary hospitals have combined the old tradition of philanthropy and private effort with, in some cases, all that is newest both in buildings and in research and equipment. There are hospitals that are publicly owned; some of them are relics of an old Poor Law system, and some of them are the most modern hospitals with the very latest equipment Well, here we have in the country a whole wealth of material, but we have never thought it necessary in the past to attempt to co-ordinate it into an organic whole. It is true, too, and we might as well face up to it, that sometimes the voluntary and the municipal hospitals have not in all places been working in the closest association; and whilst health insurance has done so much for the wage-earning section of the public, there has been no personal doctor for the wives and the dependents of insured persons, unless they were able to make private arrangements and to afford them. In our proposals we have tried to evolve out of all this material a new service, maintaining and extending the benefits of all that is good in current practice.
§ The proposals in the White Paper build up a new service round certain principles which the Government believe to be fundamental. Firstly, there is the principle that the scheme must be a comprehensive one. A full range of health care must be made available, starting with the family doctor and ranging through all kinds of clinical and domiciliary service to the hospital, the consultant and the specialist. The opportunity for the means of health must be complete for everyone. Secondly, there must be individual freedom; there must be no attempt to dragoon people into any part of the service or into any form of treatment, unless they want to use it. Neither must there be any regimentation of doctors or nurses or others whose job is to take care of personal health. That is a professional job, and it must be left as free as possible 74 for the professional people to practise it, and to practise it in their own way. Organization we must have in order to see that the services are in fact there when and where they are needed, but we do riot want to form an organization that involves a bureaucratic control of professional and personal services, because the truth is that these two things do not live together.
§ When legislation follows on this Report, if your Lordships are willing to commend it, then there will be a new public responsibility to see that the whole of this service exists in fact, and moreover to see that it is good. That responsibility must rest both centrally and locally upon the elected representatives of the people. It must rest with Parliament, it must rest with the Ministers directly responsible to Parliament, and in the country it must rest with local government in the general sense in which we know local government. Yet there must be, in addition to this, professional and vocational guidance of Government in this matter. The whole service must have the benefit of the very best professional and expert advice that is obtainable, and the plans we have outlined are designed to achieve this end.
§ There are a few special points to which I think it is important that I should direct your Lordships' attention. Outstanding among them is the fact that the scheme provides for the free choice of doctor. The personal and intimate relationship of doctor and patient is inherent in medical practice. People must be allowed to choose their own doctor, and, having chosen him, to change to another if they desire to do so. You cannot regiment people in medical matters, neither can you regiment service. So we have suggested medical provision of several kinds and with a rather wide range. Some doctors will be remunerated according to the number of individual patients they undertake; in some places groups of doctors will practise together. Where doctors practise as groups, in public health centres, a system of payment which does not involve their mutual competition within the group will be provided for.
§ In the Report we have laid great emphasis on these health centres. Noble Lords in this House have been considerably responsible for the advocacy of the principles behind these health centres, and I hope the Report will meet with their 75 acceptance. But let us be clear about this. When we talk of health centres we are talking about something that is new, something that is untried as yet, and we shall have to gain experience in the only way in which this country ever does gain experience—by methods of trial and error; and there is much to be said for that. It is a courageous way to dare to make mistakes and subsequently to put them right. Many people in the profession and outside of it believe that doctors can do their best work by collaborating in group practice in specially designed and adequately equipped premises, where they profit not only from the pooling of mutual experience but from up-to-date resources and, what has become a matter of very great importance, an adequate ancillary staff to help them to do the things that do riot call for medical skill.
§ Let me look at the patient's point of view. Even in these centres they will be able to choose their own doctors. The doctor will see the patient in his consulting room in the health centre, where the doctor will have his "hours" and then he will visit the patients in their homes. The profession's own planning commission speaks very highly of this idea, and it sounds eminently sensible and attractive. It will have this additional advantage that it will give the doctors grouped together in co-operative practice in this way an opportunity of getting away from their work and going to refresher courses to bring their knowledge up to date. Let us try it out. Let us leave it to the judgment of people as to whether they like it or riot. If they like it, the centres will grow. If the patients do not like it, then they will have full opportunity of going to doctors not in the health centres.
§ There is another aspect of this general question to which I ought to draw your Lordships' attention. We do not want to segregate private practice. Some practitioners, for their own reasons, may feel that they do not wish to join the public service. There is nothing to compel them to do so. More likely some will feel they would like to join the public service but do not wish to join for the whole of their time. They would like to retain a limited number of private patients. That is all right, but there must be no suspicion that private treatment is better than public treatment. A doctor taking both private 76 and public patients will only be allowed to take a smaller number of public patients than the doctor who remains free from outside commitments. This scheme is going to depend in the long run on the general practitioner. The White Paper calls him the "first line of defence". Other people have called him, in the fight against disease, "the man behind the gun". So much will, and must, depend upon him. The new scheme means a new opening and a new opportunity for the personal and family doctor. It gives him at last the chance to do so much that he has always wanted to do—to help his patients to avert and avoid ill health without the question arising in their minds whether they can afford to call in the doctor. It enables him also to link his activities more and more with things that have been too separate in the past—child welfare, maternity work, and all the different activities of the local clinic. We want to bring together all the different aspects of medical care.
§ Many of your Lordships will be particularly interested in the voluntary hospitals proposals in this scheme. You will see that we are suggesting an organization to bring both the voluntary hospitals and the hospital services of local government to work together as partners. I want to emphasize that it is the basis of partnership that we are advocating. The use of voluntary hospitals is essential to this scheme of complete medical service. In respect of the service that they render they will be paid, not like paupers, according to their need, but like partners, according to the help that they give. They will be paid by way of a standard payment from joint authorities, the central payment representing social insurance contributions. This will do something to restore some of the support that the voluntary hospitals have received from direct contributory funds, but they will still need the support of all those who want them to continue their work as autonomous institutions. Many people in this country believe in voluntary hospitals. They believe in their autonomy, and they believe in maintaining their identity, because they know and believe that there is something good and vital in the system. The voluntary hospitals receive their resources from such people, and at the same time they add to them their contributory schemes that, 77 in fact, offer an insurance against the costs of hospital treatment in the event of the contributor having need of it.
§ There will be no treatment charges to be insured against in the future, and it may be that the voluntary hospitals may lose income from contributory schemes, and of course, they will lose income that they have previously got from patients through the "Almoner" system. In the last pre-war financial year and from the available returns of about 80 per cent. of the hospitals, this would have meant that they received from this contributory source £5,300,000. Under the new Exchequer payment proposed in the White Paper, worked out on the same basis—that is, on the same number of beds involved as that on which the above figure was based—we would propose to give them £6,500,000 against the £5,300,000 they received from the source I have indicated.
§ In so far as contributory funds arose out of a desire for protection for the individual, that protection will be given under the national scheme, but I am quite certain—and I speak from some personal knowledge—that a great many of the contributions not only from the wealthy but from the workpeople came not only from a desire to get protection for themselves but from a belief in the voluntary principle of hospitals. They arose, too, from a certain pleasure and pride that these people got from a sort of personal association with the beneficent work of hospitals. Once it is clear, as it must be clear, that the voluntary hospitals are to continue to retain their traditional status as voluntary institutions, they will continue to require the support of the people who believe in them, and I am sure they will get it. Under this insurance scheme we shall not pay out of public funds the whole of the cost of the services that the voluntary hospitals render. Voluntary hospitals will come into the service on the basis of a free contract and I hope that these words of mine will serve the purpose for which they are intended; that is to assure those who are interested in voluntary hospitals of the importance of their maintenance and of the necessity for contributions still to be made to them,
§ I do not want to occupy your Lordships' time any longer. I have selected just a few of the points in the White Paper about which others have spoken to me since it was published, and which I 78 thought might be of sufficient interest to your Lordships to-day. No speech of mine on the subject could be comprehensive without being unduly long and unduly wearisome to your Lordships, but I hope that your Lordships will express your approval both of what we propose and of the method that we have adopted. Again, I submit that the plan is big and is full in its outline. There can be no suggestion that His Majesty's Government have not faced up to the issues that are involved, and that they have not quite boldly put forward proposals that are socially beneficent and, I submit, courageously conceived. On the other hand, if this outline of policy meets with the general approval of Parliament, then the responsible Ministers will enter into consultation with all the various parties—local authorities, voluntary hospitals and the several branches of the profession—in order to arrive at agreement and to hammer out the legislative details.
§ A Government is always in this difficulty. On the one hand it is in danger of being accused of being very slow if it waits until it has hammered out the full and final details of intricate propositions. On the other hand, if it presents its plans in broad outline then, as has happened in this case, people say "It may be all right in outline but we would rather see the detailed application before we come to a conclusion." This plan for a National Health Service is an innovation so great that I submit it was proper for His Majesty's Government to present their proposals in this form and to seek the general approval of Parliament for them, and then, having obtained that approval and being fortified by it, to enter into negotiations with the several interests to which I have referred. My right honourable friends the Secretary of State for Scotland and the Minister of Health will, without delay, embark on these discussions if the approval of Parliament is obtained to the Resolution which His Majesty's Government is moving in both Houses of Parliament to-day. Then they will come back to Parliament with a Bill which will give the opportunity to this House and those in another place to enter into detailed consideration of their proposals.
§ I must say that we have been very greatly encouraged by the general welcome that the public has given to the White 79 Paper, and I hope that the Motion which I submit to your Lordships to-day will be acceptable to you. As the mover of this Motion I shall occupy your Lordships' attention at the close of the debate on the next sitting day in an endeavour to reply to any specific points on which your Lordships feel it is proper that I should give you further enlightenment other than has already been given in the White Paper. I beg to move.
§ Moved to resolve, That this House welcomes the intention of His Majesty's Government declared in the White Paper presented to Parliament, to establish a comprehensive National Health Service.—(Lord Woolton).
§ LORD MORAN
My Lords, I beg to move an Amendment to the Motion of the noble Lord, to insert at the end of the Motion the words: "but regrets the absence of sufficient detail on many important matters, in particular on the consultant service, to enable the House to give a considered judgment." I think we can all of us commend the purpose of this White Paper. The aims are, indeed, unexceptionable. They have been advocated for many years by the profession itself, and I am quite sure that these aims are the explanation of the very friendly welcome which the noble Lord has just said has been given to the White Paper. But what really matters are not so much the aims of the Government as the means that are taken to achieve those aims, and I shall try and take a few points from the White Paper in considering the means. The noble Lord has spoken of a comprehensive medical service. I am a little puzzled, in spite of the arguments used on page 10 of the White Paper, why the term "comprehensive" is used. There is not one medical service, there are to be six, the Ministry of Health, the Ministry of Labour and National Service, the Ministry of Supply, the Board of Education, the Post Office and so on. Now what we had hoped for was that all these services would have been brought under one roof. It is true that that might possibly excite the opposition of the Ministers in charge of those Departments, and that perhaps would have created a difficulty. But the White Paper does not make mistakes of that kind.
However, I would like now to pass on to the central machinery of this scheme. 80 When I had the honour of addressing your Lordships a year ago for the first time, I spoke of the misgiving which was felt by members of my profession when asked to serve on these Advisory Committees of Government Departments. I was on one such Committee; it did not meet for two years. Another Committee connected with another Department had no meeting for three years. What is felt about these Committees was voiced by the Secretary of the British Medical Association recently, when he said that "many are chosen but few are called." When this Central Health Council was proposed the members representing the profession felt that they must ask for some reassurance about it, because it serves no useful purpose when a Committee is formed but does not meet for many months. Indeed it is misleading to the public, who are given the impression that the Minister is receiving advice from prominent members of the profession, when in fact he may have completely forgotten the very existence of the Committee. I was uneasy because I began to feel that these Committees might not be a means of giving advice to the Minister but rather a method of reassuring the public.
When therefore our discussions with the Minister of Health began by a proposal for just another Advisory Committee, the Central Health Services Council, the members representing the profession asked at once for some assurance that this Council would in fact exercise some influence over the course of events. They asked that it should be a statutory body, for at least it would be called together then, and that point has been conceded. They asked that it should not only be a statutory body, but that it should be able to elect its own chairman, and this was allowed. But they also asked for two further assurances, very much more important—that the Council should be allowed to publish its own proceedings, and that it should be elected by the profession or by the organizations representing the profession and not nominated by the Minister. We on the representative Committee were under the impression that these safeguards had been conceded in the discussions that had taken place, but I hasten to add that nothing that took place in those discussions had any binding value on either side. Still we were disappointed when the White Paper 81 appeared and we found that the Ministry had repented of its temerity.
At these meetings I was impressed by the general search on the part of all sections of the profession to find some alternative to the Ministry of Health to guide our destinies. It is not a healthy sign that the profession should have that attitude -towards the Ministry of Health which is responsible for its direction. Ministers of Health come and go—some rather rapidly—but a new Minister comes with a fresh mind and I welcome him. I would like to say how glad we are to be able to work with him, and I would like to make a personal appeal to him. He can do much to end this state of affairs and to infuse a different spirit into the relations between his Department and our profession. Let him trust the profession; he will never regret it. This Council will give him loyal service, he will get the disinterested advice of men actually practising medicine, and he will bring his Department at last into real touch will the leaders of the profession.
The other body which is part of the central machinery is called the Central Medical Board. This body is not an advisory board, as the Council is, but has executive functions. These functions are so unusual that I would ask your Lordships' leave to examine them for a moment. The White Paper proposes that the Central Medical Board, when it is satisfied that an area has sufficient doctors, should be able to refuse permission to any doctor in its service to go to that area. That is to say, the Board really has the power to direct doctors where they should go and work by a negative pressure process. That may be reasonable and may even be necessary so that people in scattered areas may get treatment, but it is a new proceeding altogether, and I hope at any rate there will be appeal machinery for cases which are likely to involve hardship.
There are other functions of this Board which are far more startling. The Government now exercise the power of civil direction over men and women of military age. They can direct that anybody of that age shall be sent wherever their work is needed. It is proposed in the White Paper that the Central Medical Board should have this power of civil direction in time of peace, and not only in time of peace but over every single 82 entrant to the profession. This power of direction is to be exercised over every single entrant to the profession, and they are to have the power to say to a man in the early years of his career that he shall work full time for that service whether he intends to stay in it or not. These are very unusual powers, and I think it would be relevant to ask the Government whether they intend to apply similar powers to other sections of the community. Certainly if a body is to exercise powers of this kind it will have to have the confidence of the whole profession, and that means that a portion at any rate of its members should be elected by the profession. Before leaving this question I would say that these functions of the Central Medical Board are more controversial than all the rest of the White Paper put together. This is a new power that is being asked for, and it is looked upon with the very greatest suspicion in the profession. The first part may be necessary. There has always been great difficulty in getting men to go to parts of the country which are scattered and thinly populated, but I should have thought it possible to get men to work there not by compulsion but by the same means that have made the medical services of the Highlands and Islands of Scotland renowned for their proficiency.
Leaving that question I come to the local provisions. The county and county borough councils, as your Lordships know, have been combined into a joint board. This Joint Board is to look after the hospitals, using that term in its very widest sense. What is left? There is left to the county and county borough councils only what may be called the small change of the medical services, sanitation and things of that kind. The life of the medical officer of health serving the county and county borough councils will be dried up. Interest will be taken out of it. I ask the Government if they have considered what will be the effect on this very important branch of the medical profession of desiccating it in this way of real interest. I think the difficulty could be got over if these men were used for part time service for the Joint Board. Then I would ask how is the voice of the profession to be heard locally. It is true there is to be a local health services council, but I think it will have no great power. If half a dozen members of that 83 council were allowed to serve on the Joint Board—not necessarily with voting powers, that is immaterial—they would bring the technical advice of the members of the profession to the Board and would greatly reinforce the medical officer of health. I regard that provision as the most important in the whole of the local arrangements which are designed to give the profession an opportunity of expressing its opinion.
Now I come to the conditions under which the general practitioner will work. He will work in one of two ways. He will either work in what is called a separate general practice, in which case he will be paid a capitation fee, just as the panel doctor is paid at the present time, and the conditions of his life will be very similar to those that now exist, or he will go to work in a health centre, where six or ten doctors work in one building, in which case he will be paid a salary. I think there is very great reason to believe that the doctors who qualify after the war will prefer to go and work at health centres, because there they will not have to buy a practice, and very few men qualifying after the war will have the money with which to buy practices. Moreover, the Central Medical Board will be able to add momentum to this drift towards health centres. So I anticipate—I know that prophecy can be very dangerous—that in no distant time the great majority of the younger men in the profession will be working in these health centres, working on salary because that is the means of remuneration proposed for the health centres.
You will then have this happening; a whole mass of the profession, the great majority of its members perhaps, removed from a life where their rewards were very strictly conditioned by their success in practice—their professional success that is—and transferred into a service where their rewards will bear very little relation to their success in their profession. I think we must at once say this. Many men will find themselves in a service in which there is no promotion as there is in the Civil Service, so that the one great incentive left is that of doing well a job which is worth doing. That undoubtedly will have great influence on many men, but I think it would be advisable to have some material stimulant to keep men on 84 their toes. Once this practice of remuneration by salary becomes fairly general such an incentive could easily take the form of letting the men have, in addition to their basic salary, a capitation fee; or, alternatively, they might be given extra remuneration for taking up some special branch of work in the health centre, such as child welfare or maternity work or things of that kind, for which they have fitted themselves and in which they have made themselves specially competent. But whatever is done, I feel that we must be very careful to sec that the profession in which in the past the general practitioner has been one of the hardest worked members does not become a service in which he does not work so hard.
I would like to say this also about health centres. There are many forms of such centres. You will, as I say, get in them from six to ten doctors working together in one building, but I think that the form of health centre which is put forward in the White Paper is most unattractive. There is little, so far as I can see, except secretarial work and rooms that will be shared. I would like to see health centres set up where there is provision for forms of practice most appropriate to the general practitioner, such as child welfare and maternity work, where there would be a health visitor attached to the practitioner and lectures would be given on health. As I see it, in the future these centres will have three functions. First, there will be places where doctors work; secondly, there will be places where' healthy people are periodically examined so that the first signs of disease may be detected at the earliest possible moment; and thirdly, there will be community centres, like the Peckham Centre, where the people in the neighbourhood will find rest and recreation. I would only say this before I leave the subject of health centres. I believe that neither the profession as a whole, nor the public are yet prepared to welcome these centres, but I believe that they will provide opportunities for work for the practitioner which have never existed in the past, and that they will make for greater efficiency. It is because I believe that, that I think I ought to say so. I congratulate the Ministry of Health on the manner in which it has dealt with this issue, for resisting criticism and for going on with 85 this experiment out of which, I think, there is so much to be hoped for in the future.
I come now to the consultant service, or rather to what is said about it in the White Maher. It is flat very Much. A page and a quarter out of fifty. It is, in my view, the most incomplete section of the Report. The contents of the one and a quarter pages are largely pious aspirations with hardly any detail at all. To bring out a plan for a comprehensive medical service, and to leave out of it any details about the consultant service is, it seems to me, very much like asking your Lordships to pronounce judgment on an aeroplane without being told what kind of engine is being put into it. I find it very hard to understand this lack of interest on the part of the Ministry in the consultant service. The hospital service is obviously the keystone of any medical service, and the efficiency of the hospital depends upon the consultants and specialists who staff it. It is common ground that there are not nearly enough consultants and specialists in England at the present time. And what are we doing to remedy this state of affairs? The Ministry seems to forget that it takes years to train a consultant. If we are to have any kind of service ten years hence it is necessary that the medical schools should begin training more consultants now. But how can you ask them to begin doing so when they do not know how many to train? We want to know how many there are at the present time, and where they work, so that we can realize how many there should be and where they are needed. In other words, what we need is a list of the consultants in England.
But when at last the Ministry was persuaded to ask the Royal Colleges to prepare such a list, and when they had been making these preparations for many months, suddenly the Ministry began arguing with another organization which was the proper body to draw up that list. It is, perhaps, not unnatural that the Vice-Chancellors of the Universities throughout England who are Chairmen of the Committees drawing up these lists suspended their efforts for several months while the argument went on, in order to hear what the Ministry had finally decided. Even now when it is vital that the Deans of the medical schools should have in their hands the information provided by these lists at the very earliest 86 possible opportunity, we are told by the Minister in another place that these lists are only for his private eye—rather as if they might give information to the enemy. Now surely we must take this consultant service seriously, for it is the key to the whole thing. It and the general practitioner are the two arches on which the whole thing is built.
I have said there are no details about this consultant service. That is not quite true. There is one clear and it is a disquieting one. It is that this whole service is to be put under the hospitals. If there are arguments that the general practitioner should be under a central body for remuneration and contract and things of that kind, surely the arguments are twice as strong for putting the consultants under a central body? Further, it is disastrous to have the profession split in this fashion, with the consultants tinder one body and the general practitioners under another. I should like to see the Central Medical Board in two sections, one for the general practitioner and the other for the consultant and specialist.
Leaving the question of the consultant and coming, by a natural transition, to the hospitals, I look at the White Paper and I see that it is very friendly to the voluntary hospitals. Obituary notices generally are friendly. In spite of this, those who are in a position to advise me are very anxious about the future of the voluntary hospitals. They will lose at once half their income, which comes from patients' contributions. What will replace it? I think that that is the task on which friends of the voluntary hospitals have to concentrate. If it is not done, I see no future for the voluntary hospitals. I think that the danger to their immediate existence can very well be exaggerated, but I should be sorry to insure their future unless further safeguards are given to them.
On these financial matters there are many of your Lordships who are far more competent than I am to express an opinion, but I should like, with your permission, to ask what will happen if these voluntary hospitals go under at the present time. There is a spirit of service which brings the very best out of men of our race when they are attached to great institutions, and it has been a very precious thing in the lives of the voluntary 'hospitals, sweetening many a long day's 87 work. But it is not of that that I wish to speak. The glory of the voluntary hospitals is that for many years the best brains of the profession have worked within their walls, adding to knowledge, and they have done so in an atmosphere of complete intellectual freedom, though that atmosphere has been sharpened by criticism, for no diagnosis is accepted in a great hospital until it has been mauled by half a dozen departments. Now turn for the moment to the municipal hospitals. In many of them, I believe, it is still necessary to ask for permission before you can send a medical contribution to a medical journal. There you have the two different ways of life, and I cannot but wonder whether the type of man who has made the good name of the voluntary hospitals will continue to come into the profession if our very professional thoughts are to be censored.
There is something more that I should like to say about the hospitals. I think it is a practical point. Twenty-five years ago, I was appointed to the staff of a Poor Law institution in Paddington. I have seen that taken over by the London County Council and converted into a great municipal hospital. I have been happy in working there with medical superintendents of very exceptional ability, and I think we may say at once that the London County Council has done very good work in these institutions. But they cannot work miracles. To bring these institutions up to the standard of the great voluntary hospitals will be a matter of many years. We have a saying in medicine that if you cannot do good you should not do harm. I hope that you will not allow the voluntary hospitals to die through want until there is something equally efficient to take their place.
Apart from financial worries, what have these hospitals to fear? They will be asked to accept certain conditions, such as the Rushcliffe rates for nurses and conditions of that kind. They all make for efficiency. They may press hardly on institutions which are in dire financial straits, but they should be accepted. There is one disquieting feature, however, to which I should like to call your Lordships' attention. Let me illustrate it by a purely fictitious position. Paddington has two hospitals—Paddington 88 Hospital, a great municipal hospital, and St. Mary's, a teaching hospital. Power is given to the Joint Board to say where any man or woman gets his or her hospital service of a particular kind, whether at St. Mary's or at Paddington. There will probably be only one thoracic centre, one head centre, and one department for venereal diseases in Paddington. Will the London County Council, which is the Joint Board in question, decide that these departments shall be in its own hospital, or, by a great act of altruism, station them at St. Mary's? I can only answer that the Minister will have a busy time in keeping the scales of justice even. It is an anxiety which must press on any one who has anything to do with hospital management.
There is hardly an important statement in this White Paper which is not qualified by a "might" or a "may." Throughout the White Paper you will find that attitude. I am not at all certain whether that is not very adroit, but I am equally uncertain whether that is the quality which is most needed in setting forth the charter of a great profession. Aristotle believed that a physician had opportunities of studying human nature which are given to no one else. A philosopher, he said, should begin life as a physician, and a physician should end his life as a philosopher. Thinking men in my profession, reading the White Paper, are asking a question to which there is no immediate answer. They have seen in recent years much of the interest taken out of the life of the general practitioner. His patients, when they are very ill, are taken out of his hands and bundled into hospital. Responsibility is shifted from his shoulders to those of the consultant. Men who are worth their salt do not like parting with responsibility in this way.
I am well aware of the many cogent reasons which have led to this state of affairs, but I believe that unless we find some way of bringing the ablest and the keenest general practitioners into our hospitals to work, the type of man entering medicine will deteriorate. The changes which are foreshadowed in the White Paper will add momentum to the tendency of which I have spoken. They seem to strike at the general practitioner as an individual; and, in John Stuart Mill's phrase, "The initiation of all wise and noble 89 things comes and must come from individuals; generally at first from some one individual." I keep asking myself—I cannot gel: it out of my head in reading the White Paper—what is the type of man who is going to enter medicine under this service in future? Because the medical student of to-day will make or mar the medical service of to-morrow. I beg to move.
At the end of the Motion insert: ("but regrets the absence at sufficient detail on many important matters, in particular on the consultant service, to enable the House to give a considered judgment":.—(Lord Moran)
§ LORD NATHAN
My Lords, the personal distinction and the professional eminence of the noble Lord, Lord Moran, who has moved this Amendment, made it clear that it would be supported in a speech and by arguments of great impressiveness, and your Lordships have not been disappointed in that expectation. It was natural that the noble Lord should address himself to this subject largely from the standpoint of the profession which he adorns. I have no such qualification. I approach this subject from the standpoint of a layman whose experience of the problems which this White Paper confronts is limited to that of one who for a good many years past has been actively concerned in the management, as a member of the lay committee, of one of the great teaching hospitals—what is sometimes called Parliament's own hospital, the Westminster—and as chairman of one of the special hospitals. I therefore in no wise claim to be able to speak with that technical knowledge which the noble Lord possesses in so remarkable a degree. But I hope, as a layman basing myself on the experience of many years and standing in this place, to be able to reflect the views of those who sit upon these Benches, the views, as I believe, of the great mass of the public. And let me say at once that I do not think that there will be much in what I shall say in which there will be fundamental differences of opinion with the noble Lord who has just sat down or the noble Lord, Lord Woolton, who moved this Resolution.
It is clear that the subject of this White Paper is one of quite unrivalled importance. Our health 'is our wealth. Without it there can be no social security, without 90 it there can be no full employment, without it there can be no national well-being; I think it was Francis Bacon who said that being without well-being would be a curse. It is because those who sit upon these Benches believe that the proposals contained in this White Paper will make a substantial contribution towards national well-being that we give it in general a warm approval. It must have been a matter of great satisfaction to the noble Lord, Lord Woolton, to be able to come before your Lordships with the proposals contained in this White Paper as the first fruits, so to speak, of the relatively short time that he has occupied the key position of Minister of Reconstruction. It must be a matter of equal satisfaction to your Lordships' House to have from the noble Lord an exposition so lucid and so sympathetic, and touching so many of the principal points which emerge from the consideration of this White Paper. I congratulate the noble Lord on being able to bring this White Paper before the House, and I think he would not disagree with me if I were to say that there were others too who spent much work during the months that are past over this White Paper whose names might not inaptly be mentioned—I am thinking of Sir William Jowitt, Mr. Ernest Brown and the present distinguished Minister of Health.
The contents of this White Paper are in general outline, if not in detail, a compromise, but in the view that I submit to your Lordships' House they are the best possible compromise in the circumstances in which we find ourselves. They are not an ideal solution, they do not give even a wholly logical solution; they are clearly a compromise, political, professional and practical, but they are a good compromise. And I wish to say at this point that should, contrary to my anticipation, the noble Lord, Lord Moran, take this Amendment to a Division, then my noble friends would be found in the Lobby with the Government in support of this White Paper. I do not know if it has occurred to the noble Lord, Lord Woolton, or to other noble Lords, as it has to me, that the impact of these proposals on the public outside purely professional circles has been very small compared with the excitement of thirty years ago, when Mr. Lloyd George and the Government of which the noble and learned Viscount on the Woolsack and the noble Viscount, 91 Lord Samuel, were members—the only members I think in your Lordships' House to-day—
§ LORD NATHAN
Of course Lord Crewe, whose absence we regret. I should be very sorry to omit the name of any still surviving member of that gallant band whose name should to-day be remembered. There was a tremendous surge of public feeling at that time. Something momentous and revolutionary almost was thought to be happening, and indeed was happening.
§ LORD NATHAN
There is no such excitement and enthusiasm to-day, and I ask myself what is the reason for it. I think to some extent the reason is that these proposals are themselves not new. The goal of a comprehensive medical service was set in those proposals of upwards of thirty years ago to which I have referred. But the lack of excitement to-day is really a tribute to the merit of those proposals, and it is a great and deserved tribute to one whose name has not been mentioned in this debate—to that great man, now a venerable figure, Mr. Lloyd George, to whom in my view the proposals of 1911 are the enduring and conspicuous monument. This excellent White Paper of 1944 is built upon tae foundations of the proposals of 1911. Even the panel system is to be found within the four corners of this White Paper, a modified panel system it is true, but still the panel system. This whole scheme is an extension, within the framework of a comprehensive social security, of the existing social insurance scheme. It is none the worse for that.
It is of course, as I think Lord Moran pointed out, and certainly as Lord Woolton did, only a skeleton. The people are unable to tell exactly how this scheme is going to work out in practice. They ask themselves what facilities will in fact be available, what will the position be after this scheme has reached fruition compared with what it is now. They ask themselves, and justly, when will they be available. What difference, they say, is it going to make? I shall not refer to the position of the medical profession, for 92 Lord Moran has already dealt with that at length, but the question is being asked, not only by those in the profession but by the layman as well, "What will be the pay and position of doctors?" There is no very clear or precise statement in the White Paper on that. They ask themselves, "What is the future of the voluntary hospitals?" Lord Moran has dealt with that at some length too, and he has put some questions to Lord Wootton who also referred to this matter.
What is the future of the voluntary hospitals? I speak as a Londoner. When the man in the street thinks or speaks of going to hospital, what does he think of? He is not thinking of a municipal hospital, he is thinking of Bart's, St. Mary's, St. Thomas's, or Westminster, hospitals of great repute and long history. Many of them are great teaching hospitals with a world reputation and a long tradition of professional freedom. Some of them, of course, are obviously too small, badly housed, poorly equipped. They ought either to go out of existence or he stepped-up, but that is because of their position and is independent of these proposals. The remarkable thing seems to me this, not that the municipal hospitals are not better than they are, but that they are as good as they are. After all, these municipal hospitals not only have no tradition but no history that extends beyond fifteen years, and they have scarcely had an opportunity in that short period to bring themselves into line with modern practice and tradition to the same extent as the great voluntary hospitals. It is true that London and certain other municipalities have established or stepped-up municipal hospitals of a first-class character in many important respects, but it is inevitable, for a long time to come at least, that the voluntary hospitals must play a vital part in the whole conception of hospital service.
After all, these hospitals provide between one-third and one-half of all the available hospital accommodation. They comprise upwards of 75,000 beds. There is a strong case in logic for making them public; there is a strong case in practice for keeping them voluntary and, within limits, free; but there is no case at all on any grounds for keeping them voluntary and free, as the White Paper postulates, without securing that they will be able to continue to have the means of getting 93 the voluntary contributions that alone can enable them to be free. I do not quite understand the figure that Lord Woolton gave as regards the contribution from central funds. He said, as I understood him, that this would be a figure of £6,500,000 or so, compared with £5,300,000. The White Paper itself, on page 83, mentions a figure of £10,000,000, and that is the figure which has been contemplated in the discussions that have taken place among the hospitals in which, to some extent, I have myself been a participant. I feel that they are comparable figures. I think we are referring to the same matter. Perhaps when the noble Lord has an opportunity of referring to this matter again he will clear up what appears to be at first sight a discrepancy between the statement in the White Paper and the statement he made to your Lordships' House to-day.
Be that as it may, whatever the precise figure may be, if the voluntary hospitals remain outside this scheme they must retain their characteristics and they must retain their monetary resources. It seems to me it must be one thing or the other. They must either he abolished or they must be retained It is almost wholly a financial question. They are to advise and help according to the White Paper; because of their standing, qualities, and, traditions which other hospitals lack, their co-operation in the scheme is absolutely essential. Indeed, the White Paper makes the voluntary hospitals what in fact they are—the keystone of the whole arch of this scheme of national medical service so far as hospitalisation is concerned. How are the voluntary hospitals to carry on, having regard to what the noble Lord has told us to-day? How are they to maintain their voluntary contributions when people who make no such extra contributions are entitled under the scheme to all hospital facilities just the same?
It is a question whether hospitals free and paying can exist side by side unless arrangements are made under which contributors to the voluntary hospitals are given special facilities at these hospitals or at least allowed to choose a hospital. Voluntary hospitals cannot do without voluntary contributions, and these contributions will not be forthcoming unless contributors get something for their money. It would not be sufficient to fill the gap in my estimation if voluntary 94 hospitals have to depend solely on the good will and charity of the benevolent-minded who have so largely supported them in the past. Contributory schemes have become over a period a vital element in the maintenance of these hospitals.
What I have referred to is one special instance of the gaps, the unanswered questions, if you like, the flesh that is not on the skeleton. They are rather important, and it is necessary, if public scepticism is to be allayed, that these doubts should be cleared up quickly. I have a feeling that in this matter the Government have not altogether clone themselves justice. They have never attempted to catch or reflect the new enthusiasm for reform even to the extent of the reforms which they are willing to accept. Instead of putting a good face on it, they are rather apt to put a bad face on it. People are therefore inclined to be a little sceptical. I am glad Lord Woolton had the courage to clear away one cause of scepticism to-day. It was a mistake, I am sure, that in speeches and in the White Paper, with perhaps some qualification, and in the small pamphlet without qualification, it should have been stated that the new health service in all branches will be free. That that should have gone forth to the public in an official statement made by the Government was not only inaccurate, but it was a statement that profoundly disquieted the public mind because people have not believed it. As the noble Lord has made clear to-day, the public are right. The service will not be free. It is an insurance scheme. People will have to make their own contributions to insurance as well as in their capacity as taxpayers and ratepayers. We must not talk about a free service. This is really a service under which all you need for yourself and your dependants you can get without paying any extra doctor's fees. It means a cheaper service, a fuller service, and that is a tremendous advance.
Can it really be said at this point of time that this is yet a comprehensive service? Here again I think it is wise on the part of the Government and of all of us to be candid, for, after all, it is not a matter of intention, it is a matter of supply. Are the doctors, nurses, specialists, consultants, administrators, hospital beds, buildings, clinics, equipment, available or are they within sight? What methods are going to be adopted to 95 make them available and within what period of time is it calculated that that will be done? The White Paper, it is true, is frank in the two instances of teeth and eyes. I make the guess—I hope I shall be proved to be wrong—that before this service really gets under way as a comprehensive medical service along the lines adumbrated in this White Paper, at least ten years will have passed, and before the dental services are fully available perhaps twenty-five or thirty years. This is really a pretty long-distance programme. It is no worse for that, but let us recognize it for what it is. I should be sorry if the public should think that the services promised are going to be almost immediately available because I think that would be a mistake.
Of course there are some who say this is not a good scheme because it is not 100 per cent. a State scheme, and others say it is not good because it is not zoo per cent. a private scheme. It is, as I say, a compromise, as it must be, and it is a good scheme because it is a compromise. I think it is rather a pity that the old distinction between fee patients and panel patients, and between the treatment of them, should continue. It will be for many people merely a fiction to say they have a choice of doctor and a guarantee of the best treatment. Logically there is a case for a complete public service with no distinction, but I agree that is neither politically nor practically possible. The proposals in the White Paper are to be formulated in the form of a Bill. It has to be passed by Parliament, it has to be worked by doctors, and so we have this mixed service, a public service for all who want it, patients and doctors, and a private service, outside and over and above the scheme, for those, patients and doctors, who want that. I am willing to accept this mixed service as a compromise on one important overriding condition—provided that the existence of the private service does not reduce the quality or restrict the facilities of the public service. If it is a fee-patients scheme the scheme will turn out to be a sham. We must not allow that to happen. The people at large are entitled to the best possible scheme. Indeed in the White Paper they have been promised it and we must see that they get it. The I.O.U. must be honoured.
96 This means public control to see that it is honoured, to see that the very large sums of public money involved are properly spent in the public interest. There must be sufficient public control to see that with expert aid and advice all the facilities promised are made available at the first possible practicable moment, to prevent the compromise between private and public doctoring from being a brake on the wheel; to prevent private practice from skimming the cream and leaving the public service under-nourished in personnel, equipment and facilities. And this is, first of all, a question of supply. The number and kind of doctors needed have to be recruited, trained, paid for and properly treated. Probably to prevent one treatment for fee patients and another for panel patients, doctors should not do both. They should choose between public and private practice. Mixed practice should not be permissible. It should be made worth while for the best of the doctors to enter a public service. But I will make a proviso to that suggestion, and it is that as regards those at present in the profession mixed service might be permitted, but a choice should be made compulsory by new entrants into the profession. We must have, as I have said, efficient and effective public control, but at the same time side by side with it we must have professional independence. To some extent no doubt the doctors' demand for independence is a political demand. It should not be listened to as such. But we must recognize that only doctors can decide about doctoring.
It is also a question of administration. Is the administrative compromise efficient? There will be three authorities in each area: the general practitioners under Whitehall; Joint Regional Boards looking after hospitals and consultants; the local authority with responsibility for clinics and preventive services. It is obvious that there is a danger in divided control, but I think that the compromise which starts necessarily from the status quo and not from scratch, will work, but it will only work if certain conditions are fulfilled. First, there must be firm control from the centre. The Minister must have effective powers to enforce minimum standards of performance on all agencies. Then the doctors, while free professionally, must, administratively, be under orders, and powers should only be given to the large local authorities and joint 97 boards who can administer a uniform service over the widest possible area consonant with democratic control.
I have great sympathy with what Lord Moran said in regard to this, question of the organs of control. Democratic control, although it is essential, should not be misconstrued to mean that the joint bodies and other agencies must be wholly representative in a political sense. There must, of course, be a representative majority but there must also be a strong, expert minority, a minority of members who know professionally about health. The views of doctors must be fully stated inside the Board's Committees. So must the needs of voluntary hospitals. I see no reason why representatives of the profession and of the hospitals should not be co-opted on to the joint Boards without in any way derogating from the principle of representative government. After all, on local authorities there are co-opted members. There are the aldermen and I should like to see co-opted members of the joint Board. I should also like to see voluntary hospitals co-opt members of the point Board as members of their lay committees in order that there might be a common knowledge and that they might get to know each other and their problems very much better.
There is one other matter to which I must refer and it is the question of finance. Too much is being put on the local authorities. The Education Bill will add one-fifth to the over-all burden of rates and this White Paper will add one-fifth to the health costs which fall on rates. Other Bills will add more. The central Government are rather adopting the position that they leave a foundling on the door-step of the local authority and say to the local authority: "We refuse a great part of the responsibility. The rest of the responsibility of paying for this foundling is to be yours." This cannot go on. I am not asking that there should be reorganization of local government now. Though I think we cannot long postpone the reorganization of local government areas and functions, that will probably have to remain until after the war.
But the reorganization of local government finance, of course, cannot be postponed indefinitely—cannot be postponed very long—without the whole structure of reconstruction collapsing. Unless ways 98 and means are found of enabling local authorities to bear their old and new burdens it will suddenly become necessary, to avoid breakdown, to transfer whole services bodily from local to national administration. After public assistance, health would be the next to go. Is this what the noble Lord, Lord Woolton, wants? Would it not be wrong that our administrative policy should be determined willy-nilly by failure to find the right financial reforms and find them in time? This is not a subject for this debate, though I think it might well be for another. The Government must consider all the alternatives—equalization of rates, revision of the rating system, modification of derating, uniform valuation, regional Income Taxes, higher rates of grants, and so on. It must, if it is to increase local burdens, find ways to increase local capacity to bear them. Whether it does or not vitally affects the future of this White Paper, of this sketch plan for a real national health service.
I end as I began on a note of welcome and of caution. This is only a sketch plan; the details have to be filled in. Then the scheme has to be worked; it has to be administered; it has to be financed. It is a compromise, but the service must be provided—there can be no compromise about that. We have got to be frank. It is not a free scheme. It cannot be done in the twinkling of an eye. For purely physical reasons it will take years. But it will take the fewer years if we realize this and devote our energies to making the proposals into a scheme that will work. Perhaps if these proposals are seen and solved realistically, if the promises are performed as promptly as may be, perhaps then, just as for the past thirty years and even to-day people have talked of "drawing their Lloyd George," they will speak in the future of "drawing their Woolton," or perhaps it will be "drawing their Willink." This is a good scheme, a sound, workmanlike compromise on the right lines. It is a definite approach to the fulfilment of Sir William Beveridge's, Assumption B. It is a milestone on the way to making what was his assumption into a fact. It is a milestone, therefore, on the road to social security.
§ VISCOUNT SAMUEL
My Lords, I shall ask the attention of your Lordships for only a very brief time. We all wish to hear the views of those who are able to 99 speak on the subject with personal knowledge of this question. I shall not attempt to engage in a comprehensive survey of the whole of the proposals in this most important White Paper, but it would be an omission if no one from these Benches were to rise and to give to these proposals a most cordial welcome. Like the noble Lord who has just spoken, my thoughts go back thirty years to the National Insurance Bill of 1911, which as he said owed so much to the initiative, to the resource and also to the combative capacity of Mr. Lloyd George. For what controversies he had to face. The whole medical profession was in arms against the Bill. It became a Party issue. We lost a number of by-elections because of the compulsory clauses of the National Insurance Bill When it came up for Third Reading in the House of Commons Mr. Bonar Law, then Leader of the Opposition, declared that if he came into power before the Bill was in full operation he would most certainly repeal it. Thirty years have gone by, and what a channe! Now there is no controversy with regard to this measure, which really in effect extends and completes the principles of the National Insurance Act of 1912. After too long a delay that pioneer measure is now succeeded by one which complements and completes it.
This White Paper presents proposals which, as Sir William Beveridge has de-dared, are essential to hid own plan. We are glad to know that Sir William Beveridge has publicly expressed his concurrence, and his endorsement of the main principles of this White Paper. This proposal and the Education Bill are both of them to my mind large and important measures of constructive legislation and administration which reflect very great credit on the present Ministry, if I may respectfully say so. But I am obliged to add they are in very happy contrast to the procrastination and uncertainties in another province with which the noble Lord, Lord Woolton, perhaps to his regret, is now closely associated—namely, town and country planning, with special reference to land acquisition and land use, a matter not less important than these questions of health and education and perhaps even more urgent at this moment.
This White Paper deals with one large part of what is the great political problem of our time. The nineteenth century 100 mainly had to deal with questions of constitutional reform and the establishment of lull self-government. Its attention was directed mainly to those matters and the great controversies were on those issues. This century is mainly considering the right province of the State, how far State action should extend in industry, commerce, environment, education, health. After much debate I think the country has come to the clear conclusion that they cannot be dealt with by any one formula, whether the formula of individualism or the formula of socialism, but must be dealt with by a combination of both. The conclusion is that a line is not to be set on any theoretical principle; it is not a straight line, but a wavy line. Nor is it to be a fixed line but one that shifts with the changing conditions of our society. One hundred years ago no public health system existed. Today we have one of great elaboration and this Bill will elaborate it much further. The principle is not either State or private enterprise, but in these various matters a combination of the two.
Here we find, in the matters with which this White Paper deals, some difference of opinion and some doubt as to where the line precisely can be drawn between the State and the individual at two levels. One is the level of the local authority on the one hand, representing the State, and the voluntary hospitals and other voluntary organizations. As the noble Lord, Lord Nathan, has said, it is possible to have three methods of dealing with this question of voluntary hospitals. They can be superseded by the State and an entirely different system established; or they can be left in full vigour and efficiency; or, thirdly, they may be allowed to survive but maimed. They may be offered a choice between either being efficient or being free, but if they wish to be efficient they cannot be free and if they wish to be free they will not be allowed to be efficient. Nothing, of course, could be worse than the third alternative. As to whether the last is really the position in which hospitals will be is a matter on which experts must debate and we will listen and exercise our judgment afterwards. Various representations have been made to me on behalf of the hospitals to the effect that the financial proposals are quite inadequate, and the speech of the noble Lord, Lord Moran, to-day seemed rather to indicate that they have not been treated, I 101 will not say as generously, but as justly as they could demand.
The other level at which this question of the State or the individual comes in is at the level of the individual patient and his own doctor. The White Paper states with the utmost clarity and emphasis that the principle of free choice of doctor by the patient must be maintained, and die noose Lord, Lord Woolton, has reasserted that to-day. And that principle surely is right, for doctoring is not only a mater of physiology, it is also a matter of psychology. You may have two doctors who have equal academic qualifications and equal technical skill, yet ore at them, because he is able to command the confidence of his patients, will be a successful doctor, while the other will be a less successful doctor. Of course, the principle ought, obviously, not to be carried too far as in the case of the character in the old play who said that he has so much confidence in his doctor that he would rather under his care than be cured by someone else. Even that degree of confidence might be justified, however, for a patient would be less likely to die if he had every confidence in the treatment which he was receiving. This right of free choice is assured by the White Paper, but is it ensured? Will it actually he open to the patient to have that free choice? There seems to be considerable doubt upon the point.
We must listen to the course of this debate and await expressions of the views and the expert knowledge of those who are qualified to speak, and we must also await the result of the consultations that are to take place between representatives of the profession and the Ministry. I think we may all feel confident that such difficulties as may now be emphasized will, in due course, be overcome, that this excellent at White Paper, after, we hope, not too long an interval, will be translated into a Bill, and that the Bill will become an Act and greatly conduce to the health and, therefore, to the welfare of the people.
§ VISCOUNT DAWSON OF PENN
My Lords, I interpret the Motion that the noble Lord, the Minister of Reconstruction, has invited the House to pass as being one of approval by your Lordships of the notion of a comprehensive medical service. A vote for it would not commit your Lordships to approval of the terms of the 102 White Paper, many of which are, undoubtedly, put forward for discussion and constructive criticism, and many of which are admittedly indeterminate and vague. Broadly speaking, I take it that the aim of the proposal is to ensure that the best measures for furthering health and curing disease will be at the disposal of every citizen. That, briefly, seems to me to summarize the purpose of the proposed comprehensive health service. I think it may be said that thus far this proposition is supported by a wide consensus of opinion both in the profession and amongst the public. Indeed, as my noble friend Lord Moran has said, such a comprehensive service has been advocated by the profession from the year 1920 onwards.
I think it is fair to say that the White Paper is in itself a bold effort, reasonable in its unfolding, and, because of its good English, attractive reading. Some of the measures which it outlines, some of its proposals, give me pleasure. Others give me real concern and for this reason. When one reads what appears in the early pages of the Paper, where the principles are laid clown, those principles carry your approval, but you are shocked to find later on that in many instances the implementations of the proposals which are made do not conform to the principles contained in the early pages. In my judgment the, scheme tries to go too far; it cries to embrace too much. Lord Nathan said that in any case the ultimate scheme must have a long vista; that for many reasons which are well known it could not be completed for many years. Surely, then, the sensible plan is to take the foundations first. Begin with those as early as you like, and leave the superstructure to a later period to be erected in the light of accrued experience then, and not in the light of speculation now.
I will give your Lordships one example to illustrate the divergency between the principles laid down and the implementation proposed. I will take the question of health centres. Having wisely said that health centres should be a matter of experiment, of cautious trial and error, the White Paper later on breaks out into a flamboyant passage, elaborating and extolling the particular application of the health centre of which we have less experience than any other—namely, utilizing it for the purposes of group practice. There is nothing new in group practice. It exists now. Whether it goes 103 to a health centre or not is not essential to its efficiency. I ask myself, therefore, why this enthusiasm, why this desire to push the health centre for the purposes of group practice? If you read the Paper you very soon realize that it is a way of insidiously introducing the principle of whole-time salaried service. I am not going to say that whole-time salaried service is not perfectly right for certain offices, certain departments of medicine. I think it is likely in the future, in any case, that doctors as a whole will probably draw a larger proportion of their earnings from salary than from fees. That, however, is a very different thing from saying that this new medical service has to bend the knee to a political ideology and be forced into a particular mould of thought, and that sooner or later it must be universally whole-time. Looking as far as possible into the future, I can see nothing but disaster for the best type of medicine if any service were universally whole-time.
I now come to the mechanism of the administration. We quite see that when once a service becomes world-wide it is necessary for it to be under general Government control; no other arrangement is possible. We are met with the difficulty, however, that the medical profession is particularly difficult to regiment, not on account of the men but from the nature of their work. The White Paper faces this truth with admirable fairness, and I will quote to your Lordships what it says:There is a certain danger in making personal health the subject of national service at all. It is the danger of over-organization, of letting the machine designed to ensure a better service itself stifle the chances of getting one.The difficulties there set forth are particularly illustrated in that part of practice which is concerned with the individual man, with what may be briefly called the doctor-patient relationship. Of all parts of the service none requires greater flexibility of administration if the planning of the service is to be satisfactory. The reason is a fundamental one. To whatever brand of politics a man belongs, it is a fact that man sick is individualistic, and will remain so to the end of time. The result is that the doctor who looks after him gets fashioned in the same mould; and individualism is resistent to restraint.
104 That has to be borne in mind when considering the administrative authority. If we take the administrative authority at the centre, under the Minister, we find that there are two bodies under the Minister, which have already been referred to. One is the Central Health Services Council, and the other is the Central Medical Board. The Health Services Council represents the vocational element. There is only one way in which it is possible to administer a large profession with all its technicalities, and that is to put at the right hand of every administrative body a vocational body with power to advise and guide its policy. We have to watch carefully to see that at every level, wherever there is an administrative body, such a vocational body at its right hand is a reality—not shorn of power, not just used for convenience to shelter Government Departments, but with real power.
I apply that test in the case of the Central Health Services Council, and I find that at the very outset that principle is violated. The Health Services Council, which is to advise the Minister, should at least to the extent of half its members he freely elected by the profession, whereas at present, as the White Paper sets forth, it is to be nominated entirely by the Minister. That is a breach of the vocational principle at an important level of the administrative structure. The Consultative Council is consultative, but not executive. The Central Medical Board, on the other hand, is executive, and its dangers are peculiar to itself. There is no part of the structure which is more likely to suffer from the disease of bureaucratic control, which my noble friend opposite said that the Government wished to avoid. There is no body more in danger of becoming bureaucratic than that Central Medical Board. The fact that it has medical men upon it gives no guarantee that they will not ultimately become bureaucratic too, because it is a most insidious and progressive disease.
I come now to another point. It is said in the White Paper that it is the desire and intention of the Government that the administration of the comprehensive service shall be kept free of the Civil Service structure. I applaud that, for anybody who has been connected with Government Departments knows only too well the insidious and potent influence of that extremely able body, 105 the Civil Service. Over and over again you see something which began by being independent being slowly drawn, year by year, within the spider's web. I think that one of the dangers and one of the criticisms of the administrative structure of this service is that it is put too near that dangerous area. It will be easy enough to start with an independent service, but I am not sure that it will be able to remain independent; and once you get medicine and its science and art under the control of the Civil Service, good-bye to the best that medicine can do! It may be very suitable for many other callings, but for medicine it will be fatal to efficiency.
I turn next to the larger area of the hospital and allied services. The real foundation of all this scheme is the hospital and allied services. That is something which can be got on with quickly, and which should be got on with first, before we start speculations about whether we are going to have grouped practice in health centres. The only way in which the hospital and allied services can be got on with is by bringing the two sets of hospitals together, as has been advocated for years by my profession. So make your Organization that its members habitually sit around the same table and learn to know each other; and if they do I have very little doubt that they will evolve the course of the years a new ideal, a new type of hospital, which will be as good for that new era as the voluntary hospitals have been for the present age. It is by that kind of feeling that this new service will be built up, not by the dragooning which I will refer to at a later period, and to which my noble friend has already referred. That is the reason why we should not only begin promptly but should go gently and guardedly. It is really by getting people together in the hospital services that you will make the foundation of the whole movement. And if you do so my belief is that all the other things will be added unto you in time.
These larger areas are not, I think, big enough. I know the Minister's difficulty. What is in the White Paper is surely a compromise which has had to be effected with the major local authorities. But the areas are not large enough. You must have an area large enough to embrace every type of hospital and clinic, interconnected one with another, working one 106 with the other—a regular scale upwards to a key hospital, wherever possible, at the top. The areas indicated in the White Paper, as I understand, would amount to nearly forty in number. That is too many. You could not get in every one of the forty areas a complete service. I hope by the time the Bill arrives we shall have got them down to a smaller number, and that they will have key hospitals at the top. Wherever possible those key hospitals should be teaching hospitals—the highest court of appeal. Each of these areas is to be governed by a joint authority, but your Lordships' attention has already been drawn to the fact that that joint authority has an exclusively local authority make-up. It is quite proper that the local authorities should have the main control of the joint authority. At the same time I entirely agree as to the inadequacy and foolishness of that arrangement. How can these laymen determine questions of policy confronting a learned profession which gets more technical every year? Assuredly they should have associated with them by the process of co-option a certain number of professional men at their meetings—not necessarily with a vote, but in order that the professional view may always be before the joint authority. There is ample precedent for that in other departments of government. As your Lordships have already heard, each of these joint authorities will have at its right hand a local health services council. That council will not merely consist of doctors, representatives of voluntary hospitals, and other ancillary services, but it will be necessary to make it quite clear that it is an obligation on the joint authority to listen to, and even ask for, advice before any major question is settled. And I have little doubt that that will be conceded.
I pass next to voluntary hospitals. Voluntary hospitals do not need to stand upon sentiment. There is ample reason for surrounding them with sentiment, and they have the admiration and affection of a large part of the population of this country. But we do not place our claim for the voluntary hospitals merely upon sentiment. For many years to come the country could not do without them. They are the dominant part of the hospital service, and so they ought to be. Many of them have had centuries of existence, have gained a vast experience of administration, and have had under their roofs 107 the master minds of medicine in the past, who have left their mark upon them. It would be just crass folly to attempt this new comprehensive service without those hospitals. That is not in any way to derogate from the excellent work that some of the local authority hospitals have done in their fifteen years of existence. I think in the time they have done extremely well—not in all parts of the country; in some parts of the country they have done nothing at all. But that does not alter the fact that the voluntary hospitals are a necessity.
Now if they are for the public interest I put it to your Lordships that they should be placed as free from financial anxiety as the local authority hospitals. We have to face up to this. From the moment this service starts you take all the ground from underneath the contributory scheme. I forget for the moment the figure that Sir William Beveridge gives but I think it is something like £10,000,000 a year which is obtained under the contributory scheme. The moment the new service is founded is it to be supposed under the conditions of the post-war world that the voluntary hospitals will receive the same amount of charity as they did before? I think it is almost inconceivable. I cannot see why there should be any hesitation in making them secure. And here we have an interesting parallel in the way in which the present Education Bill is proposing to treat the aided denominational schools. That Bill proposes to treat the aided denominational schools in the following way. It guarantees them payment of their whole running expenses and half their capital costs, which, added together, will actually provide them with 97 per cent. of the cost of running the schools, leaving them only 3 per cent. to find. And the reason for that is avowedly that the aided schools have performed great services in the past. They have great traditions, and they wish to preserve them, altogether apart from the fact that, very properly, they have to consider the particular religious convictions of those for whom they are run. The Education Bill thinks it worth while and right to secure the aided schools to the extent 1 have just stated, and if schools, if education, why not health, why not the voluntary hospitals?
108 Now I pass to the health centre. This idea had its origin in the year 1920 in a body of which I had the honour to be chairman. I may therefore say we do know what the health centre was meant to meet. It was looked upon as an outpost of the hospital system, a means whereby general practitioners could, where they had inadequate accommodation, go and have all the facilities of an institution on a small scale. Amongst other things there were to be, as my noble friend opposite said, means whereby preventive and curative medicine could be brought together in actual fact, where the communal clinics could meet, where the practitioners who went there could actually learn and see what the communal services were doing. In addition to that, it was supposed that there would be a certain number of beds. This is a place where the White Paper has forgotten something, and that is the provision of beds for general, practitioners. If you put general practice without beds that service assuredly deteriorate. The position is met at present by cottage hospitals, many of which have been modernized and where there is consultant advice available should the general practitioner need it; but there are parts of the country where there is a lack of beds, and the health centre was meant to fill that gap. As between separate practice and partnership—it may be of two or three or more—or again group practice, which represents a still larger grouping, all these three forms of practice should have equal rights of access to a health centre. It causes me disquiet when I read that part of the White Paper which goes out of its way to extol the health centre for group practice without thought of the single practice or the simple partnerships that exist now.
Here and there, far too often, in my judgment, there peep up in the White Paper signs of what was described some years ago by the late Lord Hewart as "the new despotism." In reading the White Paper we have conceded to us that every administrative body will have at its right hand a vocational body to guide it, and then you come upon here and there sentences which practically give the Minister power to override the whole of them. One sees that with the health centres. I shall quote one ominous sentence. Having said that the health centre will be subject to the joint authority and its advisory committee, there follows this: 109… but will depend in the last resort upon the decision of the Minister in the light of his central policy on the general practitioner service and the new health centre experiment in the country as a whole.We know quite well that in that sentence lies a power for a Minister to override anything. If he happens to be a partisan for any particular form of health service—it may be for a whole-time salaried service for everybody—he has opportunities of stepping forward along the road before many people know what he is after.
It may be that in the future the health service will extend in the direction of a whole-time State service and doctors may be paid like schoolmasters. That may be; but do not let us anticipate those days. One thing is quite clear: it would not do now. Any attempt to impose it would produce an unheaval inside the medical profession, and that is one of the things we want to avoid, for the success of this service depends without any doubt whatever on the good feeling, contentment, and satisfaction of the medical profession, and particularly the general practitioners. It is my belief that if a full-time State service were introduced at this moment your general practitioners would be a set of mediocrities without a spirit of adventure, without initiative, just a drab uniformity; and in no profession would that be more desperate than in medicine.
I am coming nearer to the end. With regard to the freedom to pursue private practice, my fear is rather different from that of the noble Lord, Lord Nathan. The White Paper says it is in the power of any doctor to serve partly in private practice and partly in Government practice. I think I may say to the noble Lord that we have proved by our conduct in the past that we can do both and do them well, giving of our best to everybody in the community. I am not so sure when I read the White Paper—I should like to be put right—that private practice will not have a penalty attached to it. For instance, a patient will, on occasion, want to choose his own private doctor, may even want to go further and choose his own consultant. Supposing after that he wants to have hospital treatment. He should be able at any stage and at any level to join in the comprehensive medical service. After the passing of the 1870 Act, when everybody paid for elementary education, those who chose went on sending their sons to Eton or Winchester. Those 110 schools still existed, whereas once we set up this service there will only be one pattern of hospitals, and with only one pattern of hospitals there must be equal access to any patient, whether private patient or public patient. There is every advantage in the same doctors looking after all grades of patients. After all the world is their parish and they learn to give of their best no matter to what class their patients belong. I am very apprehensive that under this scheme private work will be much discouraged, as indeed Sir William Beveridge in his Report does discourage it. I think the danger is that those who feel they would get the best from a private doctor, and want to have a private doctor, may find that there will be not enough opportuntities for private practice to go on with anything like adequate success.
Is this new service to be free and flexible? If so it must avoid the Civil Service pattern and we must be constantly watchful of that potent influence to prevent the medical profession being gradually brought under its sway. That is one of my greatest anxieties In another sense I have anxiety about the Central Medical Board. In the powers given to that Central Board there are some which are distasteful to me. I think in times of peace to direct a doctor where and how he is to practise is nothing but authoritarianism. It will never succeed. It you want to get a doctor to go to a part of the country where the conditions are difficult you will have to grant subsidies. I think we should be on our guard against the regimentation of the profession by the Civil Service. The Civil Service is there and we have to be careful that it does not convert us into a stereotyped uniformity. We have also to be on our guard against a universal whole-time service either now or by means of insidious instalments. We are agreed that we do need a comprehensive national service. We have already advocated it, but it must be free minded, it must be flexible and it must be professionally guided, because we want to preserve our great profession and to hand down its freedom and its great traditions to the generations which follow us.
§ LORD LUKE
My Lords, I must apologize to the noble Lord, Lord Woolton, as I was not here when he began his speech but I do not think that I missed 111 very much of it. I should like, in the first place, to give a general welcome to the contents of the White Paper for it seems to me that the health service that is envisaged is an attempt to embrace all the branches connected with the treatment of sickness and to provide that treatment for the whole community. It is in that sense that I may allude once more to the appointment of the noble Lord, Lord Woolton, as an appointment to help reconstruction and, as he put it himself, the co-ordination of all the health services as they exist to-day. I am afraid that I must weary your Lordships for a short space of time once again on the aspect of the voluntary hospitals, but I promise that that is the only aspect of this question that I propose to speak about to-day. We have in the White Paper the Government's word for it that they welcome help and suggestions in settling the details of how the voluntary hospitals are to participate in the scheme and yet retain their independence. I think, if I may say so with all due respect to the noble Lord, Lord Moran, who moved the Amendment, it is the Minister's hope that the result of this debate will provide those very details for which Lord Moran has asked.
I think that the Minister is not at all clear himself how this participation of the voluntary hospitals is to be effected. There is, without any doubt, a dilemma. As the noble Viscount, Lord Dawson, has already said, there can be no comprehensive scheme without the voluntary hospitals. On the other hand, the Government are anxious to give the voluntary hospitals the choice. They are voluntary in another sense of the word. They have the power to choose under the White Paper, and I am sure I speak for most voluntary hospitals when I say that they will welcome that choice of what they shall do. I am sure the voluntary hospitals have a general wish to assist the Government in framing their scheme, but on a closer study of the position I am not so sure that it does not mean Hobson's choice for the voluntary hospitals. They cannot stay outside without being accused of wrecking the Government scheme.
If they participate, or even if they do not, their means of raising income is taken from them. The White Paper proposes that the health service is to be paid for partly by insurance contribution (but not, be it noted, by the hospitals' own 112 existing contribution scheme apparently), and also partly from central and local taxation. I agree very much with what Lord Nathan said that it is a very great disservice to the voluntary hospitals that it should have been said that this comprehensive treatment would be free. It is in no sense a free service, but that is the impression the public has gained. I realize quite well that if the voluntary hospitals remain voluntary it is not the concern of the Government where they receive the rest of their money. They will, of course, receive certain payments for their participation and they have to find their balance elsewhere. Some of them are lucky enough to have endowments, others again receive donations and payments by patients and contributory schemes make up the balance of their income. I think therefore it is rather difficult to reconcile the situation that faces the voluntary hospitals with the wish of the Government—and I quote their own words—"not to destroy or to diminish a system so well rooted in the good will of its supporters." I think that is the very thing they have done even though they have paid lip service to not doing it.
Unless I am very much mistaken the results of the appeals of voluntary hospitals and other bodies that go to the public do not justify the contention that people are any less charitably minded than they were. I think the reverse is the case. It is very remarkable what has been collected. I am thinking particularly perhaps of flag days, from which there has been a very considerable increase of money for the hospitals and other objects, in spite of the fact that taxation has increased. But I think the effect of these proposals may begin to show fairly quickly. Contributory schemes have undoubtedly grown in size and in popularity, and the contributors feel that they are doing their own hospitals and themselves a good turn at one and the same time. If I may make a comparison, it is rather similar to the National Savings Movement. Much of the success of the Savings Movement has been due to the fact that people feel they are contributing to the cost of the war while the money is still theirs and may benefit them at some future date. These contributors have taken a very special pride in their own hospitals and I think they have a genuine anxiety I about the continuance of these schemes. 113 One question I should like to ask is, what is to happen to past contributions and the future treatment that contributors hope to receive? I hope it may be possible to continue such schemes within the framework of the insurance contribution that is referred to as one of the means of paying for the health service. I would suggest that it might be a sort of earmarked insurance, as it were.
So much for finance, and perhaps the majority of the public hear more about the financial side of voluntary hospitals than anything else. I was very glad to hear the tribute paid by the noble Lord, Lord Moran, to the services rendered by the voluntary hospitals, for, that really has been their main object throughout their long history. They have a great tradition of service to patients, and they have acquired a very great fund of knowledge and of experience in the treatment of the sick. In the training of doctors and nurses they have accumulated a tradition of service, and we should not forget the great amount of voluntary work that has been put into these great institutions. The effect on the health of the nation must be incalculable and since it is incalculable is apt largely to be forgotten. The White Paper obviously has its doubts about the future of the voluntary hospitals. It is, as it were, written between the lines that if need be we shall go on. I regret that the voluntary hospitals, with all the experience they can offer to the national health service, are to have no representation on the bodies who will order the new scheme. They will act as advisory bodies on the local and central councils, no doubt, but on the Joint Board, which will possess the power, the hospitals will have no representation. I regret that very much. These Joint Beards will be a combination of local authorities, and they will consider first and foremost the local authority hospitals. I think it is only human nature that they should do that. The voluntary hospitals expected a full partnership, but they have not got it.
In the health services of the country the voluntary hospitals are now the senior partners and they have been the senior partners for a very long time. They are to become the junior partners in the future. Their position will be reversed. Therefore I want to urge that there should be a central hospitals board analogous to the Central Medical Board, and that there 114 should be local hospital boards, so that both voluntary hospitals and local authority hospitals will be represented on the joint boards, because I think that is the only form of partnership that would be a success. If both types of hospital are made equal in status and in representation and are given equal powers, I believe the voluntary hospitals will most willingly give their great experience and make their contribution to the scheme.
My Lords, at this late hour I propose to be extremely brief. In the admirable speech to which we have just listened the noble Lord, Lord Luke, referred to voluntary hospitals. I am pleased to know that he is following in the footsteps of his father and taking an interest in the voluntary hospitals. May I be allowed to say a few words as a layman who for some thirty years has been chairman of one of the London teaching hospitals? We welcome this scheme and are anxious to make it a success, but do not think anybody who has studied the medical side of this question can feel satisfied at present. Both the Minister of Health and the noble Lord, Lord Wool-ton, have laid great stress on the word "partnership." I have studied the White Paper as well as my poor brain will allow me but the more I read it the less I see of partnership. The voluntary hospitals which as I think anybody who knows anything about it must acknowledge have led medical science for hundreds of years, are now going to take a secondary place. I am not sure that we are not going to be put in a position of being made use of for just as long as it pleases the authorities and then they will say: "Thank you, we have learnt all we want to learn, good-bye." The noble Lord, Lord Woolton, seems to dissent but I am not at all sure.
What I would specially ask is that this matter of partnership should be thoroughly discussed between the Ministry of Health and the voluntary hospitals, with the object of removing some of the apprehensions which we feel about the future of the voluntary hospitals. If we could be assured that this question is going to be thrashed out we should feel a great deal happier, because no voluntary hospital wishes to come under complete bureaucratic or political control. I see great danger there. We have learnt during the war how bureaucratic methods 115 can creep into voluntary hospitals. The number of forms we have to fill up, the returns we have to make, the mass of correspondence which Government Departments have thrown upon us, make us feel that if we get tangled in red tape we shall never get out of it.
As regards financial proposals, as far as I can make out all voluntary sources of income such as the Hospital Savings Association will be completely swept away. We are told that we are going to be given lump sums—£10,000,000 has been mentioned—but we do not know how the money is going to be distributed. We do not know what is going to be given us for working expenses, for capital expenses and so on, but we do know that we shall lose very large sums of money. We do not know to what extent hospitals will be called on to pay for medical services. At the present moment we have a wonderful free service given by practising doctors and by consultants. If other hospitals run by local authorities are going to pay for their services, undeniably we shall be asked—certainly by junior members of the profession—to conform and pay. We should like to be assured that we shall receive help. Already our expenses have increased considerably. The 116 scheme put forward by Mr. Bevin on the domestic side is costing my own hospital £2,000 a year. We are paying for exactly the same service as we used to receive, a great deal more than we think it is worth. The financial side is really a very important one, and I entirely agree with what my noble friend Lord Dawson of Penn has said about it. I do not see why we should be called upon to render services that we shall not be paid for. That is a matter which I hope the Minister of Health will discuss with the Voluntary Hospitals Association and other bodies.
I do not wish to detain your Lordships any longer at this late hour, but these are two things that are certainly troubling the lay side—one the question of partnership, and the other the finances of voluntary hospitals. It would be so easy for any body, for any local authority, that is not friendly to the voluntary system quietly to cut their throats in a financial way.
§ Moved, That the debate be now adjourned.—(Lord Horder.)
§ On Question, Motion agreed to, and debate adjourned accordingly.
§ House adjourned.