THE HOSPITAL SERVICES

LORD AMULREE

My Lords, I think your Lordships must agree that the noble Lord, Lord Nathan, has put us into great debt by bringing before us this Motion today. I think it is appropriate, when the National Health Service has been working for about ten years, that we should have an opportunity of discussing some of the facets which present themselves. I am extremely pleased to be following the noble Lord because whereas he has been the Chairman of one of the big London teaching hospitals for many years, I am a member of the medical staff of one of the big London teaching hospitals. I am bound to say that there is nothing which the noble Lord has said with which I do not entirely agree. I think he has put forward a good case and I entirely support every word he has said—which will mean that I shall not need to address your Lordships at any great length, as I might have done if I had not been in agreement.

What I would like to do is to go a little farther afield and say a few words about the hospital position in general. I think that all who have visited hospitals around the country must agree that there has been a considerable improvement in the hospital service during the ten years during which the National Health Service has been running. There are a great many hospitals that were rather poor, but which have now become very good. This refers largely to some of the old municipal hospitals which, really by no fault of the municipal authorities, had not been given opportunities to progress as they should have done, because of the depression of 1931 followed by the war in 1939. Nevertheless, a great amount of excellent work has been done in improving these municipal hospitals and also some of the other hospitals that were not so good. Another fact which I feel is interesting is that at the present time there has been no corresponding falling off in the work of the good hospitals. So that I think we can say that the balance is very much in favour of what the National Health Service has done for the hospital service in general.

There is one thing, however, about which I am a little frightened and worried for the future. Supposing that too rigid a ceiling (as it is called) is placed on the amount of money available for the hospital service, then I think that inevitably we are bound in time to get some 455 kind of falling off. It must be realised that medicine is a very expensive work to carry out properly and well. It is something on which one can economise, but one cannot avoid spending money. I am sure that it is most important now that every attempt should be made to run the hospitals as economically as they can possibly be run, so that there will be enough money available for improvements which will inevitably be needed in the future. If such improvements are not adopted or accepted by the hospitals, then it will mean that the service will in a short time become a second-rate one. At the present time one finds many drawbacks in hospitals. One great drawback, it seems to me, is a lack of facilities available for the surgeons who carry out the innumerable operations that are now performed. In the past operations were numerous, but not so numerous as they are now; and, of course, they were far less complicated. I am sure that to-day there are a large number of hospitals in which the surgeons have to do their surgery under conditions—I will not say of great difficulty, but certainly of some discomfort. One would like to see more progress made in that respect, if possible, by sensible economies in the running of other parts of the hospital.

One point that I have never regarded as of great importance is the fact that, as one sees stated in some quarters, the hospitals in this country are not very modern buildings. I have never thought it necessary to have a brand-new building to do first-class work: so long as there are good equipment and good staff, and the building is structurally sound, I am not at all worried by the fact that new hospitals have not been put up in place of some of those which have been there for a number of years but which are working quite well. The branch of the hospital of which I have had experience was built in 1874, I think, as part of an old poor law hospital. We have done a great deal of work internally, changing it round, but the actual structure, which, as I say, was built in 1874, is as strong as ever; and I think it would be a pity to say that, merely because the building is getting on for eighty years old, it is old-fashioned and not very satisfactory.

The same thing applies to the talk about building new hospitals. I am not 456 at all convinced that, except in one or two parts of the country, there is a great demand or need for more beds than exist at present. It is true that in some places the waiting lists are long, but the importance of that fact greatly depends on the amount of time a person has to spend on the waiting list. If there are a great many people on a waiting list, but they can be absorbed or got rid of in from ten to fourteen days, then that does not seem to me so serious as if the same number were on a waiting list which it would take six months to get rid of. The tendency now seems to be that the turnover in any one particular bed where good treatment is given is far more rapid than it was. I do not think one need be so worried about the large waiting lists, except in certain parts of the country, as some people seem to be. Another difficult point about waiting lists is that certain doctors on the staffs of hospitals are more popular than others. People tend to prefer to consult such a doctor and therefore the waiting list for patients who wish to come in under him will probably be longer than the waiting list for a doctor who is not quite so popular.

There is another rather curious facet of the service which I should like to mention, in passing. A large number of the big London hospitals have private patients' blocks and wings where people who are willing and able to pay the full cost of their treatment and service can be accommodated. This, so far as I can see, has become an important venture from an international point of view, because a large number of people are coming from abroad to make use of these private wings—not because they are free: the patients pay the full cost of anything from twenty-five to twenty-six guineas a week—but in order to get the benefits of the work done under the National Health Service. That, as I say, is an important factor from an international point of view.

The next point I want to mention is a subject which I have brought to your Lordships' attention several times before—namely, the shortage of accommodation for elderly persons in the country. Here again, I do not particularly want to put the blame on the National Health Service, because, broadly speaking, I think the number of hospital beds is roughly what we need. There are few people who would not say they could do 457 with a few more, but I do not think there is much ground for saying that more are required. What I think is required is more accommodation under Part III of the National Assistance Act—that is, accommodation provided by the local authority for the infirm and disabled persons who come into hospital, get what treatment is possible and are rehabilitated as well they can be, yet who are not quite well enough to go back to their homes, and, therefore, according to the law, become the responsibility of the local authority. The amount of accommodation for these people is not sufficient. If you go round any hospital ward where the care of the elderly is the prime object you will find a large number of people who should be the responsibility of the local authority but who are occupying beds which could be filled by sick persons.

To come back to my own instance (my wards are part of St. Pancras Hospital), that means that we are keeping perfectly fit people, though disabled, in hospital beds at a cost of twenty-five guineas a week, which one must agree is not a very economic proposition. Therefore I would suggest that local authorities should be encouraged to provide these beds and that there should be no administrative gap over the transfer home and rehabilitation of these elderly persons who are being treated in hospital to-day. One of the few advantages of the old poor law, which none of us wants to see come back, was that both the sick and the able-bodied, as they were called, were with the same authority, so that there was no difficulty in moving people from the hospital to the house when they were well, and vice versa; whereas now, with the best will in the world, there seems great difficulty in that way.

It is possible, I think for the Regional l3oards and local authorities to do a certain amount by making a joint appointment of the doctor to take care of the so-called elderly sick and of the sick or infirm people in the "Part III" accommodation. That idea appears to me to be sound. It was done years ago in one particular ease in one of the Home Counties, and. so far as I know, is working well. An attempt was made to do something similar in another part of London, but the responsible authorities made the mistake of not having their doctor on a 458 consultant basis, giving him no control of patients at all: he was merely a junior who could go round recommending people to do things, but his recommendations had no sanction. One cannot help wondering whether recommendations of that sort are of much value.

One thing that I am sure we need to do at the present time is to ensure that the hospitals are run with as much economy as possible—not with as much saving of money as possible, if your Lordships can see the difference. Attempts have been made to bring in studies of hospital work. Reports on the work of the hospital nurse have been published by the Nuffield Hospitals Provincial Trust, and one or two other bodies have taken up the same line and made detailed inquiries to ascertain whether people were doing the work for which they were paid, and whether that work was being done as economically as it could be done. One of the London hospitals is making an inquiry into the work of its X-ray department to see whether there is any preventable wastage and, if so, to try to put that right when the occasion arises. Provided that the Ministry, who have done such good work, continue to try to find every possible economy in running the hospitals, yet at the same time try not to stint them of the money they need (we are seeing signs of that to-day, although I hope it will not go too far) then I hope that if, in another ten years' time, the noble Lord, Lord Nathan, puts down another Motion, we shall be able to look back on a further ten years of progress.

LORD EVANS

My Lords, this is the first time that I have had the honour of addressing your Lordships. I hope, and, indeed, I feel sure, that I can count upon the indulgence invariably shown to the unfortunate members of my profession who find themselves in the position in which I find myself now. Perhaps I crave your Lordships' indulgence a little more than usual—I hope this is not out of order—because I should like to recall for a moment the recent loss we have all suffered in the death of Lord Webb-Johnson, my very dear friend, counsellor and colleague, who did so much, as your Lordships know, for medicine in general and in particular, of course, for the Middlesex Hospital and the Royal College of Surgeons. He was one of my 459 sponsors on my introduction into this House, which he always regarded as your Lordships' most friendly meeting place. He will be sadly missed by many.

My own interest and occupation is really with bedside medicine rather than with administrative medical affairs, and it may be that this will be reflected in my remarks which will be somewhat different from those made by my noble predecessors. But the one has now become so intimately associated with the other that I am immensely grateful for this opportunity to draw attention to a few aspects of this big and important hospital problem. I speak, of course, especially on behalf of the teaching hospitals. It has been well said, I think, that a very important part of education—academic, technical and professional—is the personal influence of the teacher upon the taught. Be the building, the laboratory, the equipment, and so on, ever so perfect, there yet must be this essential personal contact between teacher and pupil which creates an atmosphere, the atmosphere that develops and makes the teaching hospitals. One can say that this aspect goes very well in medicine in this country to-day. But there is a sad trend for these functional advances to have outgrown the structural. That great doctor and philosopher William Osier said: It is, I think_ safe to say that in a hospital with students in the wards the patients are more carefully looked after their diseases are more carefully studied, and fewer mistakes are made. I am quite certain that this is so, and no one can surely doubt that the quality and standard of medicine in any country must depend upon the quality of its teaching hospitals. If this is ensured first, I think the standards of the non-teaching hospitals will surely follow. But I doubt if the converse is true.

I must remind your Lordships that the teaching hospitals train, not quite all, but certainly most of the teachers, not only in medicine but in all the ancillary services such as nursing, midwifery, physiotherapy and radiography, as well as almoners, dietitians, occupational therapists and domestic science students—all this in addition to undertaking their primary duty in the care of patients, teaching of medical students, and research. Now since the introduction of 460 the National Health Service, almost exactly ten years ago, little has been done for the teaching hospitals except the provision of funds to keep the machinery going. There has been really little structural advance in building except those previously planned, and, indeed, very little of that. We have outmoded, inadequate accommodation for patients, teaching and research, as we have heard; indeed, one has sometimes felt slightly ashamed to show visitors from abroad these features of some of our great teaching hospitals in London. Remember, too, that out of the twelve teaching hospitals in London only two—the Middlesex Hospital and Lord Nathan's hospital, the Westminster Hospital—have been rebuilt. Many of the others, your Lordships will recall, were badly blitzed during the last war. There must surely be some limit to the enjoyment of such austerities.

In the past a great deal of the success of these hospitals was due to the complete freedom of management, lay and medical; and although the teaching hospital still has some freedom it is very curtailed in many ways. Now one hears, for instance, that a lay administrator cannot employ an extra kitchen maid without permission from the Ministry of Health. I agree, of course, that doctors are notoriously bad administrators, and I should consider that good lay administration is absolutely essential to the success of any hospital service. How this can be maintained with the present scale of salaries I just do not know. A catering officer, for example, who may be responsible for spending more than £160,000 in a year, is not paid as much as £1,100 per annum salary. There cannot be more than a handful of senior hospital lay administrators who earn more than £2,000 a year. Surely this seems to be a grave fault in the structure.

The very much higher costs of teaching hospitals have been referred to, and the comparative cost of the care of patients in teaching and non-teaching hospitals has been recently reviewed, as your Lordships will know. This shows, to quote one example, that in a London teaching hospital the in-patient cost per week is now about £27, compared with the in-patient cost per week in a non-teaching hospital of £18. The average cost per patient of a teaching hospital 461 is £67, compared with £41 for a non-teaching hospital. To me the difference in these figures is surprisingly small when one considers all that is entailed, and I personally find it difficult to agree with the Report of the Select Committee on Estimates. Surely it must be absurd for the teaching hospitals virtually to mark time until every other hospital catches up with them. Of course, there must be no hard and fast rules for particular hospitals, teaching or non-teaching; but it is essential, in my view, to maintain the teaching hospital at the highest possible level, whatever the cost, if British medicine is to maintain its high standard.

The immediate past President of the Royal College of Surgeons of England has suggested that for their special requirements in the future the hospitals must not only be set free but must be encouraged to seek additional sources of finance outside the Government budgets of the National Health Service. For the teaching hospitals this, to the minds of many, would be a welcome return to old practices and in keeping with their long heritage. He goes on to say that in appealing to the community, to industry and to philanthropic individuals they would thus behave as do the universities at the present time. Such efforts might even enable us to see in the space of a few years several new teaching hospitals in this country.

My Lords, I believe this is the freedom we need and must: have if we are to maintain leadership in our profession. If we can achieve this and at the same time restore the general practitioner to his rightful place as the family doctor, all will go well with medicine in Britain.

LORD MORAN

My Lords, may I, firstly, associate myself with what the noble Lord who has just spoken said about Lord Webb-Johnson, with whom I worked in close association for very many years. I am sure I am speaking for your Lordships when I say how pleased we are to have the noble Lord, Lord Evans, in this House. The ability of his speech reminds us that he has lived all his life in the critical atmosphere of a teaching hospital and also that his opinion carries great weight in the profession to-day. We are always in need in medicine of sane and able counsellors, 462 and the noble Lord has those qualities to a remarkable degree. I only fear that in his busy life he may find it difficult to take as great a part in our deliberations as we should all wish.

A learned member of your Lordships' House, comparing the professions of medicine and the law, said of the law, "It is not a progressive science; it is much the same as it was fifty years ago". Coming to the revolutionary changes in medicine, he quoted the Dean of Harvard who said, "In ten years' time half of what we know will prove be wrong, and alas! we do not know which half." I am sure your Lordships will realise that if we attempt to measure the progress of a science bounding forward all the time, it is dangerous to use the foot-rule of the administrator. Nevertheless, I think in fairness we ought to congratulate the Ministry of Health on a remarkable administrative achievement. In the first place they have decentralised or redistributed the consultants in this country. Before the National Health Service they were all congregated in great centres of population. It was difficult and sometimes impossible to get a second opinion unless you were in one of those centres. In Barrow-in-Furness, to give a single example, you had to go two or three hours by train to Manchester, or, if you were too ill to do that, to pay a very large fee to a Manchester consultant to come north. This decentralisation has ended that. It was necessary for these men to live in the great centres in the past because in smaller places they could not make a livelihood. By paying men for their hospital work, that was obviated, and now there are available in almost every part of the country first-rate specialists in every branch of medicine.

It is not only that they have been redistributed; they have been greatly increased in number. In the Newcastle region in 1949 there were 164 consultants; there are now 409. Moreover, the patient can not only see a first-rate consultant at any hospital in the country but if he is too ill to go there then, without financial anxieties. he can call him to his house. In the year 1956 there were 265,000 domiciliary consultations. This decentralisation has been made possible without discontent, because wherever the consultant went, whether it was to 463 Truro or Carlisle or some distant peripheral part, he knew he had the same chance of a merit award as if he stayed in London.

This decentralisation has made possible a second great reform, which is the upgrading of hospitals throughout the country. Before the Service there were, of course, first-rate hospitals, some of the best in the world, but there were other institutions which Dickens would have delighted to describe in one of his reforming moods. That has really ended. The difference between the first-rate hospital and the second-rate hospital is the quality of the staff—it is as simple as that; and by redistributing those consultants it has been possible to upgrade hospitals because it has been possible to provide all of them with first-rate staffs. Examples will occur to all your Lordships: St. Anne's, Tottenham; St. Mary's, Colchester; The General Hospital, Barnet—are all examples of first-rate hospitals which had very humble beginnings. If the Service had done nothing else than to decentralise the consultants and upgrade hospitals, that would have fully justified its existence. It has transformed things.

I agree with the noble Lord, Lord Amulree, that buildings are important, to the extent that they make it easier to get staff, and so on; but they are only of relative importance. Much has been said about the rebuilding of the mental hospitals. I would point out that in recent years the conditions in the mental hospitals have been absolutely transformed. Doors have been unlocked. The padded room is virtually a thing of the past. Eighty per cent. of the inmates are voluntary boarders and can walk out when they like, and out-patient departments have been opened. People come from America and the Commonwealth countries, from all over the world, to see how these institutions should be run, and it has been done without rebuilding. What we need more than anything else in the mental health service is not so much new buildings as more men of first-rate ability, who will add to our knowledge of the mind in health and in disease.

The third great reform in the Service is concerned with the remuneration of consultants. Before the Service came in, the consultant, broadly speaking, obtained his remuneration from private practice. Now I think it is true to say that the vast 464 majority get their remuneration for hospital work. This is a very great change. The man about 40 years old will get £3,255 per annum as a maximum basic salary, and he will get no more for the rest of his working life—twenty-five years, perhaps, before he retires—unless he is given a merit award for professional efficiency. That is to say, his material prosperity now depends upon his professional efficiency. It would not be too much to say that before the Service it was dependent to a great extent on his personality—and they are very different things. That is perhaps one of the great changes that have taken place in the consultant service.

I have spoken of merit awards. Merit awards are given to one-third of the 6,902 consultants in England, Wales and Scotland. One-third of that number get awards added to their income ranging from A, B and C in sums of £2,500, £1,500 and £500. That is a substantial contribution. But we must remember that they do not really get these sums unless they do the full number of sessions; otherwise they get only a proportionate figure. Why were these awards introduced? They were introduced because the Spens Committee felt that when the incentive of private practice was removed it would be difficult to keep the consultants on their toes. The merit awards were to provide that incentive. Have they been a success? You will no doubt have seen in the Press many arguments for and against. I would remind your Lordships that when the Treasury, which is not at all in love with the principle behind these awards, gave evidence in the person of Sir Thomas Padmore before the Royal Commission, he said: "This is an odd system; it is a curious system. There is nothing like it in the public service. But it works, and we hope it may go on ". Of all the various bodies that have given evidence before the Royal Commission, with one insignificant exception, every one has spoken in favour.

Why has this system worked? I am revealing no secrets when I say that when it began practically the whole profession thought it could not work. To give one-third of the consultants remuneration denied to the other two-thirds could only, they felt, lead to ill-feeling. It has worked, first of all, because it was thought out. It was seen at once that 465 the selection of the recipients of these awards must be decentralised and that it must be done by the consultants themselves all over the country. Further, instead of explaining this in one White Paper, every year for seven years thirty or forty meetings have taken place all over the country to answer criticisms, to make it clear that the scheme is fairly administered, and I think that the profession are now convinced that, difficult as the system is to administer, a great attempt is made to make it fair and to distribute the awards all over the country.

Leaving the question of merit awards, I should like to say a few words about finance. Perhaps the most anxious matter is what is going to happen to the amount expended on this Service. A short time ago it was £400 million; to-clay it is £661 million per annum. One new antibiotic may add £2 million a year. We know that in a progressive science essential expenditure must always be mounting. How are we going to check it? Certainly we cannot check it by denying the population real advances. Nor can you economise on doctors' salaries. Years ago Adam Smith in The Wealth of Nations said: The doctor has great power. Nobody knows whether he is abusing that power or not. We have got to trust him. Therefore he must be a man of character and substance, and therefore he must be paid accordingly by the community. That was said by Adam Smith. It is still true to-day. These are not the fields, therefore, in which we can economise. On the other hand, I think the time may come when we may have to give a sum of money to the regions and tell them to get on with it, to restore the spirit of economy which was so prevalent in voluntary hospital circles in their clay and which is not quite so evident to-day.

Again, when committees, some of which have been mentioned to-day, begin to investigate and suggest economies, it seems to me that they go the wrong way about it. For example, take the drug bill of £74 million per annum. Recently a committee went into that matter. What did they do? They set out to find whether there was irresponsible prescribing—whether the doctor prescribes drugs in which he has no faith. Most of us know that the average doctor believes in the drugs he 466 is giving. That is not the point. The point is, has he any scientific reason for his belief?

The Regius Professor of Medicine at Oxford, Sir George Pickering, said recently that in his time, as in mine, tons of iron were given to anemic patients without the slightest effect. It was proved experimentally later that we were giving much too small a dose, and that many cases of anæmia do not respond to iron. He said that this is no isolated instance in the Pharmacopoeia. Many of the drugs, he said, with a touch of levity, are given for no better reason than the reasons that govern the changes in ladies' fashions. What is quite certain is that Pickering is right when he said that every drug in the Pharmacopoeia should be experimentally investigated to see when it is necessary, and then, and only then, shall we get an economy in this drug bill, for much money is completely wasted. As we have been told before in this House, drugs in two of the countries of the world are separated into three groups. There is the first group of life savers, about a dozen in number, paid for by the State; and then the second class, where some good is done by them, paid for partly by the State and partly by the patient. Then there is the third class which includes the great number of tonics, for which the patient pays the whole amount. We may come to that here.

The second point in economy which I think is worth touching on is this. I hope that the Ministry will take its courage in both hands and bid in the open market—by which I mean the universities—for the men of promise, to compete with other professions. Has that been done? No. In 1954, £3 million was awarded to the consultants as a partial equivalent to the Danckwerts award given to general practitioners of £40 million. When that £3 million came to be distributed by the Ministry of Health it was given to the junior grades those who had A and B awards, the flower of the consultants, did not get a penny. That, of course, is a prudent political move to avert the wrath of an Opposition which does not believe in giving to him that bath. But if we really wish to compete with the other professions we must take longer views.

It is important not only that we should get the right quality of men into I medicine, but that when the man is in 467 we must give him some reward if he submits to the discipline of years and years of training to become a consultant. To become a consultant he will probably have spent ten, fifteen or more years on a very small salary as a registrar, and if he gets no reward for this, if his family are no better off than if he had become a general practitioner at 26, he will not do it, and recruiting will suffer. Yet when I said this to the Royal Commission, and said in answer to a question that of course the man at the end of all these years was a better man than the man who had not taken this course, I received a spate of abuse in correspondence in the Press which must have discouraged other consultants from giving evidence in that way. It surely is all wrong.

At the risk of boring your Lordships, may I say this further about it? If we do not maintain a proper balance between the pay of the consultant and that of the general practitioner, recruiting to the consultant service will die away and wither. Confusion has arisen because when the 1954 award was given for the consultants they felt it was a very poor substitute for the Danckwerts award to general practitioners, and there was a good deal of discontent. Those then in authority naturally made the best of it and said, "This is the best we could do." Now, to be consistent, one or two felt they must say the same thing, but their position was absolutely riddled by members of the Royal Commission itself. One member of the Royal Commission said: "Do you think it is equitable that consultants should get a 30 per cent. or 40 per cent. increase and the general practitioner 100 per cent.? "He said, further," It is a mystery to me how you can think that the Spens Report in the case of consultants has been implemented." Finally the Chairman of the Commission said: "I think you would like to go away and think this over." Could there be a more definite proof that the present relationship of the remuneration between the general practitioner and the consultant is not yet finally settled?

I have been taking up a great deal of your Lordships' time on the scaffolding" erected in the last ten years. We want to know what is happening to the people who work and live within this 468 scaffolding. Are they productive? Are they adding to knowledge? Is research starved in this service? When I was President of the Royal College of Physicians for some years I was chairman of their Science Committee on which was the President of the Royal Society at the time and the Secretary of the Medical Research Council; and I learned then that there is nearly always the money for research but that the difficulty is to find the man capable of it. I quite agree with what has been said about the danger of the able man going abroad, but that comes under a different heading. If what I have said is true, I believe we might say this about research: we must provide, in the Service, posts which are as attractive financially as any that can be found in other professions outside it. If we do not do so I do not know where we are going. I feel that that is essential.

That brings me to something on which in the last resort the efficiency of the Service really depends—not administration but the quality of the entry and the training of the students in the medical schools. I am not happy about the quality of the entry. I want your Lordships to realise that that is only an impression. It has no roots in statistical facts, but I have that impression. Not very long ago middle-class parents paid for the fees of all medical students. Now exactly two-thirds of the students are maintained by the State and are selected by examination without any test or regard to character. I believe that that is absolutely fallacious and can end only in disaster. There are already signs of the effects. One cannot possibly select people solely on examinations for a profession like medicine which requires the human touch more than almost any other. Money which is spent on bricks and mortar wants watching very carefully. It is, after all, a question of priorities.

I should like to say a word about the discontentment in the profession. That may seem irrelevant when we are speaking of the hospital service, for such discontent as there is is to be found among the general practitioners. I have not the slightest doubt, although we cannot measure it, that there is considerable discontent among general practitioners and I do not believe that that is based upon their remuneration. Although it is, of course, always unsatisfactory for a general 469 practitioner to know that he can increase his income only by taking on a bigger list of patients, whom he feels he cannot adequately look after, the discontent has deeper roots. I believe the cause is to be found in the general decline in the status of the general practitioner, which began when people generally felt when they were seriously ill that they were well advised to go into hospital. That was extremely mortifying to the doctor. He found that the patient, in this particular crisis in his life, preferred to put himself in the hands of a complete stranger. It is hardly surprising that, as a result, the general practitioner was inclined to lose heart.

Moreover, the Service has exacerbated this because, with consultants in every branch of medicine on their very doorstep, the general practitioners are not able any longer to make those modest excursions into the consultant field which previously lent flavour and interest to their life. For these reasons I believe that there is a great deal of unhappiness in the general practioners' camp and if that is true it is most serious. What is the remedy? I have no doubt that what I am saying is highly controversial and probably many consultants will differ completely, but I believe that in time the very pick of the general practitioners must follow their patients into hospital and will become part of the staff of those hospitals. I know it will be said that the standard of those hospitals will go down, but I do not think that that should happen if we see that the general practitioners are properly integrated with the consultants already on the staff of the hospitals. It is the bond between these two which will decide the success of this experiment. I shall not myself live to see it carried out, but I believe that it is the most important administrative move in the next decade. If that is not done, with a discontented profession, efficiency must wither, whatever the remuneration.

I am sure your Lordships will agree with me that our fundamental problems in this Service are not to be settled by any committee or by any multiplication of committees. The great administrator, no matter what are the calls upon his time, will always find the opportunity to think for himself, and he already sees that in medicine, as in every other field of human, endeavour, if we are to compete in world markets we need a more sym- 470 pathetic attitude on the part of high authority towards the gifted minority, who in the past have been responsible for all progress, upon whom we now depend for every advance and to whom we must look for the fulfilment of our hopes in all the time to come.

VISCOUNT ADDISON

My Lords, this is the first time that I have had the privilege of addressing your Lordships and I am conscious of my limitations. I am encouraged, however, in the knowledge of your Lordships' accustomed kindly tolerance towards new speakers. Perhaps I should declare some interest in the matter before your Lordships, though it is not a financial interest. I am a member of the board of governors of one London teaching hospital and chairman of a group of hospitals in the country administered by one of the regional hospital boards. In the circumstances it would be appropriate for me to speak in general terms only, and I do not propose to stress any matter of particular concern to either of the two organisations with which I am associated.

I believe that the rising curve of expenditure over the first ten years' experience of the new service was to be expected. I feel that that is largely the natural result of great uses to meet the needs of people hitherto probably not fully provided for. In the light of advances in medical science the curve of expenditure may not even yet have reached the limit, though I believe that in the course of time the advances and developments which have taken place will themselves bring about economies.

Like the noble Lord, Lord Nathan, I wish to draw your Lordships' attention to the comparatively small amount of expenditure on capital development as compared with the large and increasing bill for maintenance. I feel that perhaps we should aim at a somewhat more unified and streamlined service; and I feel that economies in maintenance may be achieved (I hope that the noble Lord, Lord Amulree, who is not at the moment in his place, will not mind if I disagree with him here) by the scrapping of some unsatisfactory buildings and, in some cases, their replacement by modern units, though I think they will be fewer. I believe that an imaginative and bold programme of capital development is 471 needed and that modernisation, particularly of buildings, must itself result in economy in maintenance.

I think it has become clear that advances in medical science have brought about some changes of emphasis, and I should like to illustrate this by mentioning particularly the great advance in the treatment of tuberculosis, which seems to me to indicate, for instance, that the large number of sanitoria, as a permanent feature of the organisation, may well be somewhat out-dated. The treatment and cure of various infectious diseases by modern methods have also taken some load off the shoulders of the organisation generally, and I hope we may hear that the Government will consider taking steps as a result of these changes in emphasis. Surely there must be, as a result, savings, either now or in the future, in premises, medical staff, services and so on. We may be sure that there will be other advances which will result in like savings. I should like to make the point that I think we should always endeavour to have an adaptable organisation, so that when these changes of emphasis come about they do not upset the balance of our plans.

Although the problem of the recruitment of nurses may not perhaps affect the teaching hospital groups so greatly, there have been great difficulties in some parts of the country in attracting young women into the profession. There are obvious reasons for that, and the most important is probably financial. But I am not sure that there are not a good many young people who have been frightened off by the ever-increasing academic standards seemingly required and insisted upon by such organisations as the General Nursing Council. I feel that we should aim, in the training of these young women, to get a high standard of nursing and not give the impression that we are out to produce a number of pocket-sized, female professors of medicine. Wards are largely manned by student nurses, and in my view steps should be taken to try to make life a bit easier for them. I wonder whether the Ministry would be willing to discuss the matter with the General Nursing Council and other bodies to see whether something cannot be done to attract the increasing number of women who, I understand, will be available within the next few years.

472 I think that some of the burden could be removed from our hospitals by increasing facilities for home nursing; and I should like to stress what I believe to be the desirability of encouraging young doctors to enter general practice. I think that more money might well be provided for the development of district nursing. I get the impression, from my own experience, that in some cases general practitioners may be making use of hospitals unnecessarily. One of the reasons for this tendency may be a fear of litigation, which seems to have crept increasingly into the Service recently. General practitioners, it appears to me, are sometimes inclined for their own protection to send patients to hospital for X-ray and similar examinations, which they would not have thought of doing until recent years. I should like to know whether the Minister has any views on this aspect of the problem, though I admit to finding it difficult to suggest a remedy. I believe that people would always prefer to be nursed at home, under their own doctor, rather than enter hospital, and I wonder whether perhaps the Minister would devote some consideration to this point.

Medical research, as the noble Lord, Lord Nathan, has mentioned, is being financed, at any rate so far as teaching hospitals are concerned, largely from their own endowment funds and from somewhat small grants from one source or another. It is often difficult, in view of the continual economy drive on the part of the Exchequer, to hand over to the Exchequer Vote methods produced as a result of research activities, after they have taken their place as a part of normal clinical procedure. As a result of this difficulty, it is possible that a brake may be placed upon research generally within the teaching hospital groups, and I feel the Minister might well consider whether there should not be some more frequent method of assessing the stages to which various researches have developed. There is also a tendency (I think that the noble Lord, Lord Nathan made this point, with which I entirely agree) to utilise endowment and private funds for purposes which are in fact the responsibility of the Exchequer. In my view, this situation, where it exists, can be regarded only as unsatisfactory and undesirable.

I hope that noble Lords will not feel that I have had only points of criticism to offer. I feel that we have a hospital 473 service which is probably the envy of the whole world, and we have reason to be very proud of the first ten years of its growth. Teething troubles have to some extent already been overcome, but I would stress the need for adaptability and for an open-minded approach to future developments. We have, as usual, been pioneers, and it is satisfying to see the interest in the service taken by other countries, which will not be slow, I think, to try to follow our example.

LORD UVEDALE OF NORTH END

My Lords, to-day we have had maiden speeches from the noble Lord, Lord Evans, and the noble Viscount, Lord Addison: their speeches have been very helpful and they have been expressed in the most felicitous language. We are pleased that they have spoken on a subject in which they are greatly interested, and we hope that in this House we shall hear them on frequent occasions in the future. I am very grateful to the noble Lord, Lord Nathan, who introduced this Motion for the tribute that he has paid to doctors and nurses, because he recognises that the success or failure of a hospital depends not so much on the matter of administration as on the quality of the doctors and nurses who are working in that hospital.

The noble Lord, Lord Moran, has spoken very eloquently on certain aspects of the profession, and with your Lordships' permission I will take up the line that his speech has suggested. I will start with the Insurance Act of 1911. This Act was passed against the violent opposition of the profession. This opposition was overborne only by the threat of a full-time salaried medical service. The National Health Service Act of 1946 was not enthusiastically received by the profession, and did not especially commend itself to the profession; but it was accepted by the profession in that all political Parties supported it. We have to remember that both these Acts improved the financial position of the medical profession.

If your Lordships are interested in the financial position of the medical profession before 1911, I would refer you to the September numbers of the British Medical Journal about that time. Year after year, able and ambitious young men were warned not to enter the profession. 474 It was pointed out that the profession at that time was semi-philanthropic; that no doctor could expect adequate remuneration for his services; that the work was exacting and exhausting, and that a doctor's prospects were particularly gloomy, unless he had private means or was backed by personal influence. The average income of general practitioners before 1911 is not known, but it was notorious that many practitioners at that time were in financial difficulties, doing their rounds on foot or on bicycles. By 1931 the average income of the general practitioner had risen to £850 per year; by 1938 to £1,111 a year; by 1948 to £2,055 a year; and by 1950 to £2,220. And by 1957 it stood at the figure of £2,333 a year.

In view of the consistent increase in the income of the general practitioner, it may be asked: what then are the objections of doctors to these Acts of Parliament? In my view they can be summarised as follows. First of all, there is loss of independence. In our legal system it is necessary to defend the patient against the doctor and also to defend the doctor against the patient, but the introduction of a State medical service has meant more supervision, more attention to records, and more reliance on methods of treatment recommended by the Ministry of Health. The general practitioner is afraid of a loss of that personal relationship which used to exist between physician and patient—the "family doctor" idea—when the family doctor was the friend and confidant of the patient. To-day, the family doctor is being replaced by the State practitioner.

Another cause of dissatisfaction among general practitioners, of course, is the overcrowded surgeries that have resulted from the passing of these Acts and also the increase in cases of imaginary illnesses that come to those surgeries. Then under the State system the general practitioner feels that he is in a groove: that X-ray examinations, laboratory methods and physiotherapy are outside his scope, and that he has no opportunity of specialising in any department of medicine.

Whatever be the disadvantages of the new system, however, the medical register shows a great increase in the number of doctors. In the last twenty years the numbers of men on the medical register have risen from 60,000 to 90,000. This increase in England is from 29,000 to 475 43,000, so that there is now one doctor to each 900 of the population. If, at the present time, there is a desirable post vacant in general practice, there will be anything from 40 to 50 applications from qualified men for that post. I hold it that one of the objects of nationalisation is to see that no man works to the detriment of his health or to the disturbance of his peace of mind, and in this connection your Lordships may note that the mortality figures for doctors have diminished in recent years, so that they are now nearer to the mortality figures for solicitors and clergymen.

Now a few words with regard to the specialists. There has been a great increase in the number of specialists in the last twenty years. In 1938 there were 2,480 Fellows of the Royal College of Surgeons of England; in 1957 the number was 4,370. In 1938 there were 1,690 doctors who were members of the Royal College of Physicians of London. In 1957 there were 3,749. The specialists are happier than the general practitioners under the present system. Basic salaries, as the noble Lord, Lord Moran, has explained to us, are from £2,205 per annum rising to £3,255 per annum. In addition, they receive pay for domiciliary visits up to a limit of 800 guineas a year. Then there are the distinction awards, and these, in my view, should engage the attention of your Lordships.

There are three distinction awards: £500 per annum for 20 per cent. of the specialists; £1,500 per annum for 10 per cent. of the specialists, and £2,500 per annum for 4 per cent. of the specialists. In 1957 2,343 specialists in England and Wales were receiving these awards at a cost of £2 million to the State. It is astonishing to recall that these are secret awards, a principle that is contrary to what has always been the conception of public policy. Doctors receiving these awards are not allowed to mention them even to other members of the same medical staff. No one can find out why certain doctors are favoured and others are not. The system of these awards has been referred to in the medical profession as one of "diabolical secrecy".

A NOBLE LORD

Shame!

LORD UVEDALE OF NORTH END

Your Lordships may feel that where public money is spent the public should 476 know how and why the liability is incurred.

The maximum salary under the Health Service is in the region of £6,000 per annum. General practitioners and specialists have pension rights where the contribution of the State exceeds the contribution of the individual. Before I leave this aspect of the Health Service, I must mention the plight of certain of the senior registrars in the Service. These are men who are qualified to be specialists but who are not appointed as specialists because there are no vacancies. The number of registrars is in excess of the number of vacancies available. These highly qualified men who are denied promotion to specialist rank have difficulty in getting into general practice, and many cases of hardship have occurred.

May I say a word with regard to the nursing staffs in hospitals? It is notorious that it has been difficult to obtain adequate numbers of nurses for many of our hospitals. The position is that before 1939 the salary of a ward sister was about £90 a year. By 1948, this salary had risen to £180 a year, with residential emoluments, income tax being paid on the net salary only. By 1958, salaries for ward sisters were ranged from £514 to £646 per annum. This seems a great rise of salary, but from the total amount 1173 is deducted for residential emoluments, and income tax is paid on the gross figure. The actual rise in salary, therefore, from 1948 to 1958 is about 80 per cent. The only suggestion I can make to increase the supply of nurses would be that nurses should be paid overtime. They are frequently called upon to spend extra hours in the wards, and I understand that for this overtime work there is no remuneration. I would suggest that they should be paid overtime at the rate of five shillings an hour.

Just a word about the costs of the medical services. It was stated recently in another place that hospital costs over the last ten years have risen from £110 million to £320 million per annum. In the same period the total cost of the Health Service has risen from £400 million to about £600 million. The contributions of the insured population have risen, in the case of a man, from 4s. 11d, a week to 9s, 5d, a week. When the contribution of the employer is added, the total is 17s, a week. The benefits obtained by this contribution are not only 477 health benefits, of course, but also injury benefits and national insurance. In dealing with these large sums the constitution of the responsible spending committees is obviously of the greatest importance, yet when we look into this matter we find that democratic control has been abandoned and that committees are selected by nomination.

The Regional Hospital Boards are appointed by the Ministry from the universities, the medical profession, local health authorities and other organisations. The management committees are appointed by the Regional Boards from local health authorities, any executive council, hospitals and other authorities. The hoards of management of teaching hospitals are appointed by the Minister from the universities, the Regional Boards, hospital staffs (up to 20 per cent. of the committee of management), former members of the governing body and other suitable persons. The field of choice is a very wide one, and many applicants for positions on these boards are totally unsuitable. For example, I heard of one gentleman who applied for a position on the managing board of a hospital on the ground that he wished to avoid washing up at home. A lady who made a similar application said that she wished to serve on the board because she liked to visit the sick on visiting days. The composition of these boards is of the greatest importance.

The general conclusion from these facts and figures is that, by comparison with other professions, the medical and nursing professions have had generous treatment from the State. But in dealing with these figures we must remember that the man who had £700 a year in 1938 now requires £2,500 a year to maintain the same standard of life; and a man who in 1938 had 1,200 a year now requires £5,200 a year to maintain his standard. We may also note that medical salaries have not kept pace with rising costs, so that members of the medical and nursing professions are sharing in the hardships of our times, though, I venture to say, not to the same extent as other members of the community. Any further improvement in standards for doctors or nurses is bound up with the problems of inflation and high taxation.

I should say, as a final word, my Lords, that the conditions of the Service at the present time are such as to attract men of 478 the right type into the professions. I should say that if it is a matter of research and discovery, there is no connection between remuneration and the results of research. The advances come in most unexpected ways. I am all in favour, however, of facilities being provided for research, and of a man being encouraged to take up research, even though there are many lines of research that in the end prove to be unfruitful. I can only say that the conditions of the Service at the present time are good; there seem to be plenty of able and energetic people entering the Service, and the outlook for the future should be excellent.

THE EARL OF LUCAN

My Lords, I should explain that my noble friend Lord Crook, who had intended to speak now in the debate, has been unable to get back to London in time; but he hopes to come in before the end of the debate and I have taken his place. This debate has attracted the usual galaxy of experience and talent. In particular, we are glad that the noble Lord, Lord Evans, was able to make his maiden speech on this occasion. If he at times verged rather near the controversial (I am sorry he is not now in his place) he did not actually overstep the boundary. My noble friend Lord Addison, whom we have at last persuaded to make a contribution in this house has come here with great experience of the hospital world. We have heard a most thoughtful speech from him, and we hope that we shall often hear him again. And although it was not a maiden speech, I think I should mention my noble friend Lord Uvedale of North End, who all too rarely comes to give us the benefit of his experience. I could have wished that while he was speaking the noble Lord, Lord Moran, had still been in the Chamber, because it seemed to me that there was some conflict between the evidence given by those two noble Lords, both speaking from such long experience in the profession.

I speak as a comparatively new recruit to the hospital world, in that I have been connected with a board of governors since the appointed day and on a hospital management committee in more recent years. My noble friend Lord Nathan and the majority of noble Lords who have spoken up to now have dealt mainly with the problem of the teaching hospitals. I 479 should like to say a few words dealing mainly with the non-teaching hospitals, those under the regional boards. The first thing I would say is that one of the criticisms made of the whole Service is that between the teaching and the non-teaching hospitals there is a great gulf fixed; indeed, more than that: there is competition and rivalry and, some say, even jealousy.

In my short experience I have seen the working of a system on a small scale which, to my mind, ought to be greatly extended; that is, the use of non-teaching hospitals as well as the teaching hospitals for clinical teaching of students. Certain teaching hospitals have for some years been working on these lines and have established excellent relations with non-teaching hospitals. The way the system works is that those members of the consultant staffs who are employed both by the teaching hospital and the non-teaching hospital take their students for teaching in the wards of the non-teaching hospital; other teaching is done by the consultant staff of the non-teaching hospital. So you get a merging of the teaching in the two spheres, a softening of the boundaries that have too often become hard and fast, and an improvement in relations. It is, I believe, to the benefit of the students that they should see the work in a general hospital, and it is of advantage to the general hospital to have this link. Naturally such teaching is merely complementary to that which is carried on in the teaching hospital.

In what has been said and written about the Health Service, particularly in recent days owing to the anniversary, some attention has been attracted to another gulf—namely, that between the hospitals and the general practitioners. This was referred to by the noble Lord, Lord Moran, and other noble Lords, and undoubtedly there is a good deal of truth in what has been said about the lower status (in his own eyes or in the eyes of the profession) of the general practitioner as compared with the practitioner in the hospital and specialist services. There again, I have seen the beginnings of a breaking down of this gulf and a bringing in of the general practitioner into the hospital service and its work. In a big London general hospital that I know there are monthly meetings 480 of general practitioners living in the neighbourhood. The occasion is not quite clinical teaching, but a kind of clinical seminar or discussion day. The doctors come in and see the patients in the wards, and discuss the cases, many of which they have themselves sent in to the hospital, with the consultant staff in the hospital. There you get complete cooperation and the beginnings of complete confidence between those in the hospital and those outside.

It seems to me that an extension of a system such as that would go a long way to remove many of the disadvantages from which we hear the general practitioners are suffering. Moreover, in this same hospital the local general practitioners can get the full facilities of the ancillary services of the hospital; they can, as a right, call on all the diagnostic facilities. This local arrangement in West London seems to me to be the key to the mitigation of the disadvantages from which we hear the Service is suffering.

There are only two other small matters that I should like to mention, because to deal comprehensively with the hospital services would need far more time and far more ability than I have. I think that a few points are worth mentioning, and I have already dealt with two. The question of administrative staff has not been touched upon much so far. We have heard about the medical staffing of the service, and on that subject I certainly should not attempt to dogmatise. So far as the administrative service is concerned we have just had the valuable report of Sir Noel Hall on the grading and structure of the service. We hope that that report will produce a satisfactory reorganisation of the service.

The point that Sir Noel Hall's investigation brought out was that the service is not offering a sufficiently attractive career to get the best type of administrator. When we are talking in terms of several hundred million pounds of public money, those who have responsibility for it must be of the highest quality obtainable. We take enormous trouble to select the best people for the other branches of the public service, but so far, I am told, there is no sign of the hospital service becoming popular as a career among young people just leaving school. That matter seems to me to need urgent attention. We have to offer conditions sufficiently good to attract them 481 from the more glittering paths of private industry, and there must be proper prospects of promotion and training. After all, the public service competes against industry only by the conditions of promotion that it offers. It cannot compete in terms of cash—none of the public services ever has done—but by offering a career that anybody might be proud to take up, that of administering the Health Service, and reasonable prospects of promotion (which in itself is a big subject) the Service should, to my mind, be able to attract a number of the best type of young men.

On the training side, there seems to be a serious gap. There is a national scheme for training which started a year or two ago, but on a ridiculously small scale. I believe that the number of students is something like twenty-four, and that the course is of three years duration. If it is to staff a Service with over 400 boards of governors, hospital management committees, and Regional Boards, that scheme represents an infinitesimal contribution to the training problem. The result is that all the training these young men receive is by being attached for periods to different departments in their hospital, or other hospitals, and by learning as they go. It seems to me that something much more systematic and positive is needed on the training side.

Finally, there is the question of economies. We are agreed that the Health Service must not be allowed to deteriorate. We know that costs everywhere are rising. Economies, therefore, can be found only by a greater efficiency both of methods and of buildings. I notice from the report of the Ministry of Health for 1956 that quite a promising beginning has been made with the use of work study. The "O. and M." Service—the Hospital Organisation and Methods Service—has been brought in in a number of cases. I think that they had eighty cases under investigation during the year 1956, and it seems to me there must be a great deal of scope for investigation, because traditional methods die hard, and it needs a scientific investigation to point out where effort is wasted, where staff and labour can be saved, and how hospitals can be made more efficient. I hope that the Minister may put in a word about the prospects of that—as to whether that tendency is developing, as I think it should. There 482 is another direction in which economies can be looked for, and that is by replacing out-of-date buildings and equipment by modern ones. There is no end to the field in which a moderate capital expenditure could produce really important economies.

So we come back to the old question of capital investment. My noble friend Lord Nathan spoke about that, as have other noble Lords, but the deplorably low level of investment in our hospitals is something which I am surprised Her Majesty's Government can tolerate. I believe that not a single new hospital has been built since the war. The number of beds has hardly increased and century-old buildings are almost, I should say, in the majority, causing great inefficiency. The Chancellor of the Exchequer tells us, of course, that there is no money for hospital building. But when we walk round the West End of London or the City, and see the millions of pounds that are being spent on office buildings, put up, so far as I can see, mainly for prestige purposes or to produce profits, I feel that we have much to be ashamed of. I think that historians in 100 years time will look back, unable to believe that we could get our priorities so wrong.

LORD DOUGLAS OF BARLOCH

My Lords, I certainly would not disagree with my noble friend, Lord Lucan, that there is a field for investigation with regard to administration in the hospitals. I am told that a great many wasteful and bureaucratic methods have crept into some of them. For example, when a doctor has a cup of tea in a hospital, apparently it is impossible for him to pay cash for it upon the spot; he is sent an invoice at the end of the month for a few pence, or somebody waylays him upon the stairs and collects it. If the cost of that procedure were analysed, it would be found to be a great deal more than the amount of the debt which is collected. That is one small illustration of the necessity for hospital administration to be examined in a businesslike and scientific manner.

However, I do not wish to pursue that side of the discussion. We have had a debate which has ranged over a very wide field, as it inevitably must do, because the hospital service is only a part of the National Health Service and is, of necessity, very closely linked with the rest of it, or perhaps should be very closely 483 linked with the rest of it. Unfortunately, the aim and purpose of the National Health Service has from the beginning been in the direction simply of treating disease, with little or no attempt towards preventing it. I made that criticism some twelve years or more ago in another place and I think it is still justified to-day. The lessons which were learned by the Peckham Health Centre, for example, have not been put into practice, with the result that instead of preventing disease or detecting it at its earliest onset the Service waits until the symptoms become obvious or acute, with the result that the expense of the Health Service, both on the general practitioners' side and on the hospital side, is increased beyond what it need be. If there is going to be a search for justified economies in the National Hearth Service, I think it ought to go in that direction of trying to establish a genuine preventive service which will prevent people from getting into those bad habits and conditions which result either in acute or, in many cases, in chronic diseases which become quite incapable of cure and can be the subject only of mitigation.

I entirely agree with those who have said that splendid work is being done in the hospitals under the National Health Service, and it is being done, in certain cases at any rate, under conditions which seem to me to be unfair to the medical practitioners who are concerned in providing that service. The noble Lord, Lord Moran, said that general medical practitioners were dissatisfied, but the hospital staffs are also, in many cases, extremely dissatisfied. When the National Health Service was established they were promised by the Government that the conditions of employment would be based upon the Report of the Spans Committee, but in fact the salaries which are being paid to medical staffs in hospitals are far below that level. There are the junior registrars, the senior registrars, the junior hospital medical officers and the senior hospital medical officers. There is not a single one of those whose salary in any way compares with that which was proposed by the Spens Committee, and in many cases the salaries are such as the Spans Committee considered to be appropriate to the conditions as they existed before the war, without taking any account of the lower 484 purchasing power of money, or paying very little attention to it.

It can be said, I suppose, in the case of the junior registrars and the junior hospital medical officers, that they have some hope of being promoted into the senior grades, and that may be some consolation for the salaries which they are paid and some encouragement to them to continue. But when it comes to the senior registrars, and still more to the senior hospital medical officers, the position is very different. It has been said to-day that there are not sufficient consultant posts available to provide openings for the senior registrars, and emphasis has been laid upon that fact here and elsewhere but still more is that the case with regard to the senior hospital medical officers, who in fact are doing specialists' work and have specialists' qualifications equal to those held by specialists or by senior hospital registrars, and their grade has virtually become impassable, so that they do not get any promotion at all.

It was in fact intended originally, when it was created, to serve a totally different purpose: to be the means of absorbing a number of general practitioners who, had been doing a limited amount of consultant work, and therefore was a grade which was intended to die out. Instead, it has become a grade of recruitment, and it has become a blind alley because the prospect of promotion from it to be consultant has become increasingly remote—that, apart from the fact that the salary does not conform to that of consultant, as it ought to conform to what is now approved for a consultant, let alone conform to the principles of the Spens Report which were accepted by the Government. That is extremely unfair, and the position has become doubly unfair because the appointment of consultants in practice is made by committees upon which the teaching hospitals are strongly represented. I impute no unfair motives, but it is quite a natural result. The result is that the appointments of consultants are given to senior registrars who come to the teaching hospitals, instead of being distributed among the senior hospital medical officers who have equal qualifications and a great deal more experience in the work which requires to be done. That, I think, is something which ought to be remedied.

485 I dare say that the noble Lord who is going to reply on behalf of the Gov-eminent will say that this is one of the matters which is before the Royal Corn-mission. If the Royal Commission is fully seized of it and is empowered to deal with it in all its aspects, I shall certainly be delighted; but I am not quite certain that that is so, either from the terms of reference or from the kind of evidence which has been given. I think that a great injustice has been created here, and a breach of faith which the Government ought to remedy.

LORD CLITHEROE

My Lords, I am sure that the House is very grateful to the noble Lord, Lord Nathan, for giving us the opportunity of this discussion to-day. I was glad that he postponed the debate on the previous occasion when it was set clown, because it would certainly have been most unsatisfactory to start so late in the day. We all know how devoted the noble Lord is to the service of the hospitals, and I propose to take the opportunity of reverting to the topic which he raised in the speech with which he opened this debate to-day. I have only one theme, and I shall not be too long about it—that is, to emphasise that it is not possible to overestimate the importance of the teaching hospitals and the need to make sure that they are properly equipped for their work and always in the forefront.

These teaching hospitals are responsible for the training of the doctors who will work in the National Health Service. The standard of British medicine and, if I may say so, the efficiency of the Service depend largely upon what these students learn there and upon the influences under which they come when they are in the teaching hospitals, and the atmosphere they absorb there. To a large extent, this also applies to the nurses; because, although we know that nurses are trained in hospitals which are not associated with medical schools, it is often rather difficult to got recruits for those hospitals, whereas there is no lack of applicants for nursing in teaching hospitals. So it is vital to maintain, and to improve, the standards and facilities of the teaching hospitals. They should be improved in line with the great advances which are, and have been, taking place during the last ten years. There are many new 486 techniques of investigation and treatment Which have been evolved in recent years and which add to the accuracy of diagnosis and provide treatment for diseases that have hitherto proved incurable. One could give many examples of these specialist activities. Let us take, for example, the artificial kidney. All these specialist activities, which save young lives, need for their application, I am told, an experienced and skilled team of medical workers. So, for reasons both of economy and of medical skill, these facilities should be available in special centres such as the teaching hospitals.

I do not for one moment deny that the standards in non-teaching hospitals must be raised, but medical standards and treatment throughout the country will inevitably deteriorate unless the standards in teaching hospitals are allowed to rise too. As the noble Lord, Lord Evans, whom we were so delighted to hear make his maiden speech to-day, said, it is absurd for teaching hospitals to mark time whilst others are brought up. I entirely agree with that. Not only must the staffing at a teaching hospital be on a generous scale, but there is need for the housing of special apparatus; and this requires space so that it can be kept in readiness for immediate use. I have been told that lack of space often hampers scientific development just as much as lack of money, if not more so. Many advances which would benefit the whole community, and not merely the patients of the teaching hospital, are being made too slowly through lack of facilities for them.

At the present moment our doctors are equal to any in the world; and that applies equally to our nurses. But, unless we are to lose this great heritage, we must maintain and improve the standards in our teaching hospitals. It seems to me that it is so important that, the standards in those centres should be something above the average; that they should have also something above the average in quality to offer. A wide area from which to draw case material is a very important asset, and patients will not be sent by their local practitioners, nor will they themselves want to go a long way from home, unless this is so. I think that similar arguments could easily be made to apply to the care of the more difficult and rare cases.

487 Then again, in order to attract the best minds to compete for the posts there must be above-average doctors and above-average equipment for research. I am sure that research is inseparable from first-class treatment, and all of us who are in business know that unless money is continually and constantly spent in research, you are not going to get ahead. So may I conclude by saying that the teaching hospitals do not seek preferential treatment because they consider themselves superior to the excellent hospitals that exist in the periphery; they seek it because their responsibilities are so much greater, and because we want to continue to lead the world in reputation, in service and, above all, in quality.

LORD HADEN-GUEST

My Lords, we are debating to-day an important Motion on the subject of hospital organisation and nursing. I think it is necessary that we should get our heads clear on the subject. I doubt very much whether everyone who is in this audience really has his head quite clear on what the subject is. The real point is: are we able to get the right kind of nurses to do the work in our hospitals, and are we pursuing the right course with regard to their training and the programme of work which is laid before them? It is absolutely essential to have well-trained nurses, not only in time of war and in time of political disturbance, but for the everyday work of the community as it stands now. I say this because I have had a great deal of experience myself, both abroad, in a world war—a most extensive experience indeed—and afterwards at home in time of peace. I have had experience on the Continent of Europe also in time of peace, and have investigated and written upon the subject of what kind of organisation we require—to an extent which, I am afraid has bored some of those to whom my words were addressed.

The plain fact is that, beginning at an early date in the First World War and going on to the Second World War, we have gone on without making any fundamental organisation and without using the powers of organisation which we have, and with which I have to a large extent been concerned in organising medical services. I am thinking espe- 488 cially of the nursing service, for unless we have more nurses in our hospitals, civil and military, we shall not get a good nursing service. I hope that the noble Lord who is to reply to this debate will be able to give us a clear explanation of what is to be the future of the medical service.

I should like to know particularly what is to be the future of the nursing services, as well as the purely medical services. I have seen failure come on the battlefield as well as in civilian life, and I believe that unless we have a clear-cut statement on what is to be the function of the medical services, in war and in peace, we are going to fail when a big strain comes. Everybody who studies politics at the present time and takes an interest in public affairs knows that the world at present is not a safe one. It is far from being a safe world and it seems very unfortunate that we have no clear-cut ideas on the future of the nursing service and other medical services. I very much hope that the noble Lord who is to reply will let us know how far we are able to proceed in making a really adequate medical service sufficiently well organised, sufficiently strong and well-staffed and with sufficient well-trained people, in the circumstances as we now know them.

VISCOUNT ASTOR

My Lords, I wish to say only a few words as a humble member of a hospital committee for the last ten years and to plead that the time has come for another inquiry into the administrative systems of our hospitals. an inquiry more searching, deeper and going down more to the grass roots than that of the Guillebaud Committee which, I felt at the time, was rather a defensive Committee which had the feeling that they had to protect the hospital service against the potential "Geddes Axe" of a wicked Conservative Government. That Committee never really got down to the fundamentals of administration.

First, I feel that most hospital committees are far too big and that the work could be done by half the number of people in half the time. We go into far too great detail on many minor matters which in ordinary administration should be done by a staff; and at the same time the ordinary house committee has practically no responsibility for the hospital 489 which it is supposed to know intimately. Then we move up to the hospital management committee, and again there is the trouble of excessive size and a proliferation of sub-committees to such an extent that it is extraordinarily difficult for any busy man engaged on active administration to be a conscientious member of a hospital management committee; yet those are the kind of people whom we most want. I believe we need small committees, meeting perhaps half as often, with chairmen and officials having (greater responsibility for many minor decisions. We should try to recruit our hospital officials from a rather wider circle and be prepared to bring in some of those of great administrative ability who are being "axed" from the Services but yet have leadership and knowledge of organisation of people.

Another point is that we get almost complete separation of the medical and the lay side. We have some doctors on the management committee but no layman knows anything of what goes on at the doctors' committees. So we have these two parallel chains of committee both looking after the same hospital; but if one suggests that even the chairman of the hospital committee should go to the doctors' committee—well, my word! I was invited once but I was shown out very quickly as soon as a particular item on the agenda was finished. I believe we should have far greater confidence and mutual knowledge than exists at present in what each side is trying to do.

I believe that Parkinson's Law is in full operation regarding secretarial staff as compared with pre-war numbers, and yet there is less liaison between general practitioners and the hospital. Often when a discharged patient goes back to the general practitioner the general practitioner has literally to wait for weeks before he can learn what the hospital has found out, because of the clog of sheer paper work in administration. I feel that the Organisation and Methods Branch is a promising development, but far too small; and at the moment when they arrive they are resented as if it were the appearance of the Spanish Inquisition, If we are to have the disadvantages of nationalisation, let us have the advantages, too, and proper administration and inspectorate going down.

490 We all want to help at local level and to get the advantages of other people's improvements and administrative methods; and we want a more responsible feeling about finance. Once at a committee the chairman said, "Ladies and gentlemen I have desperate bad news to tell you." We all blanched, and he added." I have underspent by £16,000." That is the spirit in which finance is sometimes tackled. We also want a careful and searching appraisal as to how much money is being spent in patching up old hospitals as opposed to making a clean break and starting on a new one. The noble Earl, Lord Lucan, made a very good point. Those of us on committees of old hospitals have a desperate time, and it would be much better if we had a programme for the future building of modern hospitals of most simple construction.

Those are some of the minor points I would make. I hope that I shall not be considered as criticising my colleagues or anybody else, for everybody tries to do his best; but I believe the time has come for a practical, down-to-earth inquiry again into our hospital system.

THE EARL OF CRANBROOK

My Lords, all of us who have spoken or are to speak this afternoon speak with experience of the hospital services—as indeed I do, having been chairman of a hospital board since the appointed day. The majority of the previous speakers have said (and I would agree) that during that ten years we have vastly improved the hospital service. I think most of us would be ashamed to come here to-day and speak at all if we had spent ten fruitless years and could not say that. I do not think it is really to be wondered at, for we had a good administrative machine, although I agree with the noble Viscount, Lord Astor, that we want to have another look at it. During that ten years we have also seen the most remarkable advances in the art and science of medicine; so it is small wonder that we have an improved service.

On the other hand, I do not think that we should be complacent. Several noble Lords have drawn attention to the fact that some of our hospital buildings have been starved of capital development—and I suppose that I know as much about 491 that aspect as anybody, having as hospitals in my own region a quite considerable number of Gilbert Act workhouses adapted as hospitals, one of which will celebrate its bicentenary in a couple of years' time. The noble Lord, Lord Nathan, drew attention to the fact that to-day we are getting about one-third of the capital spent that was spent before the war. It is a ridiculous position that the State cannot provide to-day even an equal amount to that provided by private individuals before the war for a voluntary service.

One of the results of that starvation—which I look upon as the most disastrous; it is one of the respects in which I think the hospital services fail—is to be seen on some sides of the mental health service. We still have up and down the country to-day low-grade, mentally-defective children ruining the lives of the rest of the children in their family, and ruining their parents' lives, merely because we have not accommodation in which to put them, entirely due to the fact that we have been starved of capital in the past ten years. In passing, I may say that one of the nicest things of the hospital service has been that it has always been run on entirely non-political lines: we have always, within my recollection, all been at one in being absolutely certain that the Government of the day were not providing nearly enough money for the service for which we thought they were responsible.

There has been a great advance in the treatment of mental disease. More people have been coming into hospital and going out sooner. The increase in out-patient clinics has done a great deal, and we are finding more and more that we are able to treat mental patients at home without their ever coming into hospital at all. I speak with some diffidence in front of the noble Lords here who are doctors and surgeons, but with that sort of idea in my mind I would venture to look, not back at the past ten years, which are dead and gone, but on to the years that are ahead. I am inclined to think that in the future, with the improvements in housing and living conditions which are taking place, affecting both mental and physical health, actual residence in hospital may become an increasingly smaller part of the treatment. After all, to-day 90 per cent. of 492 patients are, I suppose, treated by a general practitioner, with the assistance of the home nurse, the home help, the psychiatric social worker, and the other help which he can get.

The noble Lord, Lord Moran, referred to the general practitioner coming into the hospital. That is a thing we are all trying to arrange, whether by clinical assistantships or otherwise, and one hopes that in the future the general practitioner will be brought more and more into the hospital. But my own feeling is that the hospital needs to be brought more and more outside itself and into contact with the general practitioner and those who are serving the public in the homes. I have referred to how this is happening in the sphere of mental health; it is happening also in every other branch of medicine. I remember how, when I was a young man, the old arthritic patient was put to bed in a hospital, nursed with care and with kindness, and how he rapidly stiffened up and stayed there for the rest of his natural life. To-day, with the new services that we are being enabled to provide, such patients are going into hospital for a short time and then going out again under the care of their general practitioner, the home nurse, the home help and the like. Of course, they may be returned to hospital again, but we are, so far as we can, bringing the home and the hospital together, and people go from one to the other with much greater facility than they did in the past.

The noble Viscount, Lord Astor, referred to the Guillebaud Report, and in particular to the fact that he felt there should be another investigation into the administrative side of the hospital services. I should like to see another investigation into the whole of the administrative side of the National Health Service Act. The Guillebaud Committee were appointed, if I recollect aright, entirely to investigate the cost of the National Health Service; that was the yardstick by which they had to measure the work. They were concerned not with whether the administrative side was good or bad, but only with whether they thought any alterations would lead to a saving in cost. At the moment, whether we are in hospital or out of hospital, we are still patients of a doctor, whether he happens to be the consultant under whom we are in hospital 493 or our general practitioner at home. But for administrative reasons, we pass from the hospital service to the local authority service, or we pass to the service administered by the executive councils; and I do not think there is One of us concerned with the administration of any one side of the National Health Service who would say that there are not patients, and I think many patients, who fall between two of the three stools which are meant to support it.

The noble Lord, Lord Amulree, suggested as a