§ 3.47 p.m.
LORD STONHAM rose to draw attention to the problems of the Hospital Service; and to move for Papers. The noble Lord said: My Lords, I beg to move the Motion standing in my name on the Order Paper. It is somewhat difficult, in making what is virtually my third maiden essay in this Chamber, to ask your Lordships to turn your minds from a consideration of the always absorbing and controversial subject of weapons of offence to a subject on which I think we shall all be agreed in principle, however much we may disagree as to the details—namely, the healing of the sick. I think it is unquestionable that in the field of public welfare the Hospital Service stands highest in public esteem. The reason for this was, in my view, well expressed the other day when the London Star, referring to the death of a little Siamese twin, Jeremy, said:
The story of his sixteen months of life is packed with the greatest skill, service and love of which humans are capable.
§ However, this applies not only to miracle children, but to every patient in every hospital. Hospital staffs—doctors, nurses and technicians—are a special kind of people whose devotion and constant striving towards perfection in their work is a never-ending source of wonder and admiration to those of us who are privileged to have contact with them. The decision that Parliament took eleven years ago, that all in need of hospital care should be provided, without charge, with the best available medical and nursing care, seemed to provide a new incentive to hospital workers, and has thus, as it were, augmented the flood of skilled devotion. I think it is for this reason, despite grave handicaps, that there has been a tremendous improvement in the quality of the service provided in the ordinary Regional Board hospitals. I think, too, that what has virtually become the three-tier structure of the Regional Boards, hospital groups and the house committees, has been fully justified. Indeed, the system has led to a perhaps unexpected but certainly beneficial result.
§ Honest fears were expressed in 1948 that much voluntary work of great value would be lost. But the reverse has happened. The original spirit has not 784 merely been preserved by the thousands of voluntary committee workers, but become diffused throughout the Service. It flourishes equally in the former local authority hospitals, where formerly it was almost unknown. In addition to the official committees there are, of course, Leagues of Friends abounding everywhere, even in the mental hospitals where ten years ago there were none at all. We can all take immense satisfaction from this and, whilst rejecting any Party approach to the subject, make due acknowledgment to my right honourable friend Mr. Aneurin Bevan who, among all the hectic pressures of 1947 and 1948, and despite all the doubters, went steadfastly ahead and built so wisely and so well.
§ I feel it necessary to say these things first, because I must now express some strong criticisms about the present and some grave doubts about the future of the Service. It would, I feel, be improper for me to comment on the position of the consultants, except to acknowledge with gratitude the devoted voluntary service that they so freely give in addition to the work for which they are paid. I merely express the hope that the Royal Commission which is investigating the salary question will report soon, and that its recommendations will be implemented with all speed.
§ Nor do I intend to discuss the teaching hospitals, although I understand other noble Lords who will speak later in the debate will be saying something on that question. I confine my remarks to the main body of the Service, the ordinary regional hospitals which care for the overwhelming majority of sick people. It is on the quality of their medical and nursing care that the Hospital Service as a whole stands or falls. It is my considered opinion that the admittedly great achievements of these hospitals have been won by the people who work in them, in the face of relentless and blind opposition by Her Majesty's Treasury and the bureaucracy of the Ministry of Health. It is a disgraceful story of exploitation and parsimony, because despite a huge increase in the numbers of patients and the constantly increasing demands of modern medicine—both of them involving an enormous amount of extra work—we are in real terms spending less on health to-day than we did before the war, and our capital outlay 785 on hospitals, allowing for the difference in the prices, is only half the pre-war level when we had to have flag days to keep our hospitals going.
How is it possible to spend less and to do so much more work? I think the answer is in a rather remarkable letter by Dr. McCallum, published in The Times on September 2. He says:
The answer is shameful. It has been done by cheating. It has been done by relying on the traditions, the goodwill and devotion and indeed, the 'sweated labour', of those who work in the National Health Service. This country is therefore still enjoying a first-class service on second-class payment. The goodwill that enables it to do so is fast running out.
Doctor McCallum might have added that we are being asked to practise 20th century medicine in 18th and 19th century conditions. Because it is in capital
and maintenance that we find the worst situation of all. Your Lordships will be aware that the British Medical Association have given it as their considered opinion that we require to spend on capital account an average of some £75 million a year. The expenditure this year on capital account is £22 million, less than one-third of the requirement. Next year it will be £25½ million, and in 1961–62, provided the present plans are not varied, it will be £31 million. I do not know the extent, if any, to which that figure will be augmented as a result of the special major schemes which the right honourable gentleman the Minister of Health announced in another place this week, but we already know that out of that £31 million in two years' time £15 million is to go to centrally-financed major projects, and another £3 million to the replacement of obsolete equipment, such as boilers and things like that. That leaves only just over £11 million as the capital allocation for all the hospital boards in England and Wales. That £11 million also has to cover the cost of centrally-supplied equipment.
§ When you consider the tremendous pre-war backlog of work in our hospitals, half of them over seventy years old, one in every five over a hundred years old; when you consider the war damage, almost completely unrecompensed, and the virtual suspension of development in hospitals over the last twenty years, and when you consider the fact that this £11 million two years hence is to be divided among 2,500 hospitals with 400,000 786 staffed beds and nearly 3 million inpatients a year, you begin to realise its grotesque inadequacy.
§ What does it mean to each individual hospital?—and we all know of one or more. The region of which I have knowledge includes a considerable part of Metropolitan London and stretches upwards of fifty miles into the Home Counties. It comprises twenty-seven groups, and about 100 hospitals, with some 33,000 beds serving 6 to 8 million people. It is an average and representative region. Its capital allocation this year and next year is £660,000 for the whole region. In 1961–62 that £660,00G will be increased to £770,000, an increase of £110,000. That means an average increase of £1,000 per hospital. You have only to think of any single hospital in your knowledge—think of its needs, and think how far £1,000 is going to satisfy those needs—to realise the complete inadequacy of such a paltry increase. On such finances we cannot hope to maintain our hospitals, let alone see to the improvements which are so desperately needed. It is intolerable that we pay more in profits to the manufacturers and wholesalers of National Health Service drugs than we spend on capital account in our National Health Service hospitals.
§ Then consider the allowance for maintenance. The last available figure for maintenance shows that only 3.5 per cent. of the total sum spent on the Hospital Service was spent on maintenance—just 8d. in the £. It is a cruel figure and a stupid figure, when you think of the waste of so neglecting these buildings, whose replacement would require ten times their original cost. I think it is the case that if all our hospitals now had to be replaced, at current cost it would mean the staggering figure of £3,500 million. That is not my estimate and I do not know whether it is an accurate one or not; it is an estimate of experts. So I say how stupid it is to neglect maintenance. What does that mean to the condition of actual hospitals? For the five hospitals in my group in smoky, grimy central London, it means just one word—filth.
§ I do not believe that it is possible to have a good Hospital Service merely by pouring out money. Nor do I ignore the competing claims of other services or the country's financial position. But I do say that in hospitals some things 787 must be afforded, and they must come first. Other things can come when we can afford them. In other words, we must have what is so sadly lacking now, a plan and a system of priorities, and I want to suggest what I think some of those priorities should be.
§ The first is that our hospitals must be clean. We cannot go on as if Lister and Florence Nightingale had never existed. To give an actual example, some of my wards have not been painted for 20 years, and until fairly recently some wards still in use by patients had not been painted for 30 years. We cannot wash the walls down when they need it. We have had to stop despairing or enthusiastic members of the staff from wiping or washing as far as they can reach, because the black tide mark is so depressing and makes the dirt so much more apparent. And wiping down with long-handled mops is no substitute for washing, quite apart from the fact that we have not yet produced a mop which can be guaranteed not to spread infection. That is a matter on which in my group we are doing considerable work now, and when we are quite certain we hope to publish our results. But people who think they can smear over a hospital wall the same kind of mop that they use to smear over their car radiators had better start thinking again. We have had some magnificent cultures out of mops we have tried and some germs have been transferred from an unclean wall to one that was medically clean. The truth is—and if any noble Lord doubts it I should be pleased if he would some along and see for himself—that the conditions are such that if they existed in factories the inspector would serve notice under the Act, and non-compliance would mean prosecution. And this in a hospital where cleanliness should reign supreme
§ Two months ago I drew up a plan to paint wards and exteriors once every seven years—that is somewhat less frequently than some of us think it necessary to paint our houses—and to wash down the walls of the wards every six months. For the five hospitals and eight clinics the cost worked out at £38,000 a year. We have been able to spare from our allocation an average of only £10,000 a year, a quarter of what is needed—enough to paint four times in a century and wash down four times 788 in a decade. That is the money that we have been able to spare for that purpose over the last five years. The same situation exists in hospitals all over the country. The Regional Boards have not the funds to enable them to achieve in hospitals those minimum standards of cleanliness which can be enforced in factories.
§ This situation, my Lords, is not funny, and it becomes even less funny when the "gentlemen in Whitehall" send us circulars demanding action regarding the dangers of cross-infection, particularly staphylococcal infection. They demand the setting up of cross-infection subcommittees, and so, wearily, our consultants in their spare time, meet, consider and make the obvious recommendations. The committees consider and approve the recommendations, and the Regional Boards collate them and pass them on. That is endless labour by busy people, mostly unpaid. It would be a labour of love if it got us anywhere. But for eleven grim frustrating years it has been going on without result, except that more and more people are becoming seriously ill—and some dying—as a result of becoming infected in hospital. In one hospital in my region in the first nine months of this year there were 250 cases of staphylococcal infection; that is to say, one out of every 28 patients admitted to that hospital got a fresh infection or fresh disease after he went into the hospital. So I say that the first priority is to give us the money to get our hospitals clean, and the first economy is to stop Whitehall sending us a shower of printed instructions, at least until the Government are prepared to provide the money for their implementation.
§ Sterilisation is one such recent instruction of the highest importance which comes, of course, under the heading of cleanliness. We are asked to say what we need in modern sterilisation equipment to bring our service up to twentieth century clinical standards. At present in some wards and departments, we are still sterilising in fish kettles. That is a utensil you could cook potatoes in but in which I believe medical men would say you could not really sterilise if you boiled ten hours. We have made estimates of what it would cost to sterilise by dry heat, with vacuum drying, autoclaves, and so on, and the necessary clothing, rubber gloves and masks, for the staff. In our 789 one group that would cost £50,000. That means £1 million in the region, and possibly £15 to £20 million in the country as a whole—just for the sterilisation alone. I regard that as a high priority. People are entitled to know when they go to hospital that the maximum precautions are taken to ensure their safety from infection, and you cannot be sure without the proper equipment.
Nor can you arouse and maintain in the staff a sufficient awareness of the importance of this subject. The first principle laid down by Florence Nightingale in her Notes on Hospitals, published in 1859, exactly one hundred years ago, was this:
It may seem a strange principle to enunciate as the very first requirement in a hospital that it should do the sick no harm.
One hundred years later we are doing the sick great harm through cross-infection, simply because the Government have not yet provided the means of preventing it. What is more, they show no intention of doing so, because Regional Hospital Boards have been asked to start on this sterilisation programme but have been told not to expect any additional money for the purpose. That means they will have to scrape off a few thousand pounds a year from something else, and it will take perhaps 20 years before our hospitals are clean. I say that that is a national scandal.
§ I do not doubt that the new major projects that have been announced are all very urgent and necessary, but it is difficult to believe that they are more urgent than the achievement of safety and cleanliness in all hospitals. We have in all our hospitals first-class doctors, first-class nurses and first-class administrators; but we have third-class hospitals. In my group, in three out of four hospitals this year every nurse qualified; every nurse passed her examination. In one hospital last week, when I presented the certificates, there were girls from Finland, Germany, Iran, Ireland, Liberia, Nigeria and all parts of the West Indies. My Lords, you ought to see the conditions under which they are living, and read the minute from the nurses asking humbly if they could not have a fire in the rooms they pay £3 a week to live in, because at present they have to dry underclothes on hot water bottles. That is the kind of conditions we have in our hospitals now.790
§ The next item on my urgency list is a demand for a review of the effect of war damage on our Hospital Service. If they had been houses or factories, or if they had not been taken into the National Health Service, compensation would have been paid for hospitals totally destroyed, and partially damaged ones would have been rebuilt at public cost. But since 1948 the Treasury have not provided a penny on war damage account for hospitals. So that anything that has to be done must come out of the Regional Board's allocation, just like any ordinary capital payment. This makes the real value of present capital allocations hopelessly uneven as between different regions. In one region, for example, the war damage loss, at wartime values, was £6 million. Its replacement at present prices would be far more than double that, and more than 22 times that region's entire capital allocation—20 years of that region's capital allocation just for war damage alone Inevitably, that affects the quality of the service that can be provided. In my own hospitals at this very moment we have ruined buildings, potentially dangerous, which we cannot yet afford to pull down. We have emergency doors leading to non-existent fire escape bridges, which we cannot yet afford to brick up, 11 years after the Service started and some 14 years after the end of the war.
§ There are many more pitiful things of that kind, all because the Treasury seized the opportunity in 1948 to cheat the hospitals out of something that belonged to them. I ask the right honourable gentleman the Minister of Health—perhaps the noble Lord will convey this to him—in particular to have one more real battle on this issue. I do not think that the public are sufficiently aware of this point.
§ LORD STONHAM
Yes. But whether the Minister fights or not, and win or lose, I submit that he must make a special allocation of funds to remove the worst of the remaining war scars which are such a depressing, and sometimes dangerous, handicap to our hospitals; and capital monies for the restitution of 791 war damage must not be regarded as part of the region's normal capital allocation.
I should now like to say a word on a subject upon which I am sure there is general agreement—the inadequacy of hospital provision for old people and the chronic sick. Here, I believe that the trouble is that the Minister seriously underestimates both the present and future need. The Minister of Health estimates that over the country as a whole we need provide for geriatric and chronic cases only 1.2 beds per 1,000 of the population. That is manifestly absurd. We already have one bed per 1,000 of the population as a whole, and that is quite inadequate because we have as many people outside the hospitals waiting to come in as we have already in hospital beds at any given moment. So that is not enough. And since old people are in far greater need of hospital care than people of average age, we must have a far higher figure than that 1.2 per 1,000. In my experience the bed requirement for such cases is 2.5 per 1,000—at least double the Minister's estimate.
In our plans we must also take into account the fact that people are living longer. In 1956 we had 6½ million people of pensionable age—some 14 per cent. of the population. The Registrar General estimates that 15 years hence we shall have 8½ million people of pensionable age—that is, 18 per cent.—and there will be a preponderance of elderly women. In urging a considerable increase in the number of hospital beds for elderly people, I ask that special care should be taken over their geographical distribution. Proportionately higher numbers are needed in areas where, for social reasons, it is less likely that people can be cared for at home, and particularly in over-crowded urban areas from which many of the younger people have moved to new towns.
I hope also that the maximum possible facilities will be provided for remedial work This will be a sound economy, because it is both frustrating and depressing, as well as unnecessarily expensive, to have a hospital filled with chronic cases, many of whom, if we had room to manœuvre, could be back on their feet at home or in a hostel. I have a hospital of that kind, formerly of 792 600 beds but reduced by war damage to 300. In the grounds there is a complete hospital unit formerly of 100 beds. It is a sound building, with a good layout, a lift, ward kitchens, toilets and a bathroom. It needs some internal repairs and modernisation, and of course decoration and equipment; that is all. It has stood empty for twelve years. We want to install there pathology, physiotherapy and X-ray departments, and to put in 70 beds for remedial cases.
The cost of doing that would be about one-tenth the cost of a new hospital, and the need is not disputed. The scheme was approved and given what is called a job number 11 years ago. But nothing has been done. Consider what this delay has meant to the old people in the area, to say nothing of the frustrated feelings of the medical and nursing staff. I was told that even if a start was made at once it would be another three years before the unit would be in operation. The actual work could be done in six months—there is no dispute about that—but we must allow, I was told, two to two and a half years for all the sub-departments who would have to have a finger in it. That is a job that any one of us could get done ourselves in a matter of a few months. So that is another priority. We must find ways to reduce these fantastic delays in the carrying out of approved plans. You have a hospital with a lift shaft but no lift. You wait five years for the promised lift. You are then given the exciting news that authority has been given to proceed—to proceed as far as the preparation of sketch plans. You may have to wait another five years for the lift. We get that sort of thing over and over again.
While we are about it, let us put an end to the minor, pettifogging, bureaucratic restrictions which are an insult to the responsible people on our hospital committees. Even little things we are obliged, for example, to report to the Board—items of maintenance costing £1,000 or so—before monies already allocated to us can be spent for the specific purpose. That limit was fixed 11 years ago when prices were much lower, and the Ministry refuses to increase it. Of course, it is easy to dodge it by breaking up a job into its constituent parts and charging them separately. But what responsible committee 793 wants to do that sort of thing? Everybody knows that this is a perfectly silly regulation. You cannot even pay an experienced porter a little extra for cleaning and preserving expensive equipment. You must wait until you can get the money to employ an extra person on the staff. You cannot, without risking trouble with the auditors, pay for a taxi to bring a radiographer in for an evening emergency; or, if his salary exceeds £1,000 a year, you cannot provide a telephone in order to keep a technician "on call" out of hours. These restrictions do not save money; they actually give rise to demands for extra staff.
The manner in which, in real terms, the cost of the Hospital Service has been kept down, despite the enormous increase in the work, is evidence of the responsibility and efficiency of the committees. With their knowledge of local conditions they can surely be trusted to deal with these matters to the public advantage. My Lords, we are not even allowed to insure the lives of the people who collect wages from the bank, unless in defiance of the Minister, we do it out of our meagre free monies. Let us end some of these things which really are an insult to the intelligence and give rise to so much delay.
Finally, my Lords (I hope that the noble Lord will be able to deal with this matter), I would appeal to the Government to give a fair deal to the ancillary non-medical staff: the pharmacists, radiographers, physiotherapists and the technicians; to the almoners and hospital secretaries. We cannot continue to trade so shamefully as we are now doing on their devotion. The present shortage is serious enough, but the small number of students in training is even worse. How can it be otherwise, when the salary scales are so low and the prospects are so poor? A radiographer must train for two years—three years if he wishes to qualify in radiotherapy. After all that, when he is 21 he gets £9 10s. a week. A great many unskilled teenage labourers are getting considerably more than that. Yet the radiographer is a man in whose hands we place our lives. The commencing salary of a top-grade superintendent radiographer at one of the largest hospitals is £14 10s. a week, which is a few shillings more than the average earnings of industrial workers—this in a service of 794 prime diagnostic importance which has assumed a new significance of recent years. Small wonder that the numbers coming forward for training are not keeping pace with the demands
Physiotherapists, who are important in the work of rehabilitation, have salaries which are even worse, whilst the position in respect of pharmacists is a tragicomedy. Your Lordships may have seen a report in the Press this week. I have here a cutting from the News Chronicle about a case where, unfortunately, a doctor had prescribed three grains of benzedrine when he meant three milligrammes. The woman died, and there was an inquest. At the inquest the coroner after questioning the pharmacist who made up the prescription said:I do not want to tread on the corns of any other court which may deal with the matter, but the chemist is in the background and acts as a protector-in-chief for the doctor who is careless.I do not wish to comment on whether or not pharmacists are "protectors-in-chief", but what do we pay these "protectors-in-chief"? The commencing salary of a qualified hospital pharmacist is less than £12 per week. That compares with £20 to £25 per week which the same man can get with retail firms or in manufacturing. So we are hopelessly under-staffed, with only some 1,300 pharmacists to man our hospitals. During sickness and holiday periods we must employ locums, but by Whitehall decree we are not allowed to pay them more than £16 16s. a week. The Pharmaceutical Journal, however, refused to accept advertisements at that figure, so we were permitted to advertise at £18 18s. a week. But we still did not get the locums: it did not make any difference. What happened was that hospital prescriptions had to go out to local chemists, and it cost the Treasury very much more. It is in this way that the little Canutes of Whitehall defy the tides of fact and finance.
Surely we are not going to permit a continuance of this humiliating and expensive farce. I ask the Minister to initiate at once, in consultation with the professional bodies concerned, a review of the salaries and conditions of employment of non-medical staffs, and at the same time—and this is vitally important—to improve the negotiating 795 machinery. Because only if career prospects are satisfactory and training facilities extended shall we get the staff we so badly need. I have mentioned only the matters which, from experience, I regard as of the greatest urgency. Your Lordships may have other views, but I trust we shall all agree that our resources should be spent first to satisfy the greatest need, not to win prestige; that the priorities must be settled; that a plan must be devised and implemented, and that the present financial provision is far below the need, and far less than the country can afford, while the one thing the country cannot afford is preventable ill-health.
I believe your Lordships will all agree that those who run our hospitals are frustrated by the delays arising from too much central control, too much paper work and too many meetings. It is my belief that this will not end until our hospitals are administered by a National Hospitals Board which should be given an adequate block grant and allowed to get on with the job. Until we can secure agreement on such a fundamental change we must strive together to persuade the Government to make the improvements which are so badly needed. There can be few of us who at some time have not worked in a hospital, and we all know that no service can be more worth while. I hope that those of your Lordships who at present hold power and influence will use it to ensure the provision of a new chapter in the story of human health and happiness. I beg to move for Papers.
§ 4.25 p.m.
THE LORD BISHOP OF CHICHESTER
My Lords, we are all grateful to the noble Lord, Lord Stonham, for bringing before us in so clear and cogent a way some of what he would press as the most important needs of our Hospital Service, expanding as it is, but not expanding fast enough. Some of those needs, and others which will be referred to by others of your Lordships, are familiar to us all. As one who has served on a Regional Hospital Board and a hospital management committee, I cannot recall a single meeting where the questions, "How much?" and "How soon?" were not a matter of acute discussion among us.
796 If I do not refer to most of these points which the noble Lord, Lord Stonham, has put before us, and if I refer to an aspect of the need of the Service which is to some of your Lordships perhaps less familiar, by some even overlooked, it is because I feel more qualified to stress that; and others will have more competence in other aspects. We all have in mind and feeling the wellbeing of the patients who are coming into our hospitals in increasing numbers. They come for their treatment, not as bodies or as cases but as persons; and their experience there will depend very much not only on the kind of treatment that is there allotted to them but how they are treated.
In my opinion, there is a vast improvement in the attitude of ordinary people to hospitals as such. I well remember before the war, in a poor, industrial part of a northern city, how there was still an intense dread of going into hospital. To many it was still the last resort, the lion's den, where nearly all the footsteps seemed to lead one way and so few the other. Of course it was wrong that they should think so, even then, but it was still a common attitude. Since then there has been a manifest change. There is an optimism about a hospital ward and a confidence about recovery which makes hospitalisation—that horrible word—no longer quite the ordeal that it was.
There are, of course, many advances brought about by medical skill and public service which have contributed to this end, for which, whatever else be said, we are all heartily thankful; and we are considering how these things can be extended further and more quickly. I believe that there is a danger, when we deal with priorities in buildings and facilities, that we may come to think of patients as rather less than real individuals. Even now, going into hospital is, to many, an intimidating experience. They are going away from their home, away from their family and familiar things. They are putting themselves in the hands of others over whom they have no control; and behind that there is the unknown that has to be faced; and the unknown is always apt to be magnified.
For this reason, because it is a crucial experience in the patients' lives, the personal element is very important, and the atmosphere of the hospital, and the 797 conditions of it, and, indeed, the relationship of others to them, the feeling that they count—all this matters for their cure. Now there are many factors involved in this; and I say this without deprecating the work of the ancillary staffs to which the noble Lord has referred. I want to stress again the work of the nursing staff. All of your Lordships, I believe, will have known patients who have left hospital not only healed in body but much chastened and refreshed by the patience and devotion of those who have attended them. It has been a discipline for good, and sometimes it is more than this. One young man known to me is at present training for Ordination into the Ministry of the Church after a process whose beginning he traces back to a remark made to him by a Christian nurse when he was a patient; and none of us would dispute the incalculable influence which nurses can exercise.
The quality, therefore, and the supply of nurses is bound up with the development of the whole Service. There are still, I believe, grievous shortages in some hospitals, much overworked staffs resulting from it and sometimes the closing of wards; and any further extension of our Service is bound to bring us to terms with this particular fact: how to ensure that hospitals not only will be built but will be manned. In part, this is not a matter of money. Medical work in all forms is obviously a vocation. Its demands, both physical and personal, upon the staff must be higher than in many better paid but less necessary jobs, and can be sustained only by a high sense of duty and humanity. I should hope that we could be assured that all possible steps are taken to make known the need for new volunteers in this field sufficient to what our anticipated need will be. I should hope, also, that the churches and schools of our country and all those who are in a position to influence the young will do what they can for this need by trying to inculcate a sense of vocation for this particular work in an increasing number of potential young servants of their community. It is interesting, my Lords, to note that Hospital Sunday, which was in the past devoted largely as a day on which funds might be appealed for and collected for hospital work, and was dropped when the Service first came in, has now been 798 renewed by many authorities on an entirely different basis, to sound this note of service and dedication which is involved.
Of course, the importance of the work in popular estimation, as well as in effect, will depend also upon how they are equipped and how they are housed and looked after. I ask whether we are satisfied that in extension plans a proper priority is given to the nurses' hostels and quarters and other conditions. Is it an improvement or it just a temporary expedient that they should in some cases have to live out? And if it is not good policy, can we persuade many that nursing is of such importance, if we do not place a very high priority in our spending upon those buildings and services which will make their work most congenial to discharge? I should hope that in every way possible we can demonstrate that it is the people who operate the hospitals, rather than the buildings themselves, which come first; that buildings must serve them.
This human factor comes up in another way which I feel is of particular concern. The implication of our Hospital Service is that anyone in this country, whoever he is and whatever his condition, is of sufficient worth as an individual to claim all the resources of medical skill in so far as they can be made available to him. It goes even further than this. The worst patients of our mental hospitals those who are most handicapped through no fault of their own in their response to normal life, are still claimed and treated as worthy of full medical attention, not from any utilitarian reasons, for they cannot indeed serve their communities, but because of some intrinsic value which we attach to them as human beings. That is the assumption.
If patients, then, are not bodies but real persons, then their treatment must deal not with the body only but with those intangibles which make up the individuals. All your Lordships would agree that any healing skill and treatment must be reinforced by the right attitude of mind in the patient; an element of faith and hope is a vital ingredient in recovery. For this reason, as for others, we must not underestimate the work of religion as an integral part of the Hospital Service. To some, no 799 doubt, religion is a counsel of despair. For them it is the cry of the mariners in The Tempest:All lost to prayers, to prayersBut I hope that most of us would not regard it in such an unconstructive way as that. Sickness is a disturbing, but sometimes very salutary, experience. Men awaken to a need for some strength and assurance which only faith in God can supply. And if there is someone to hand to help them towards this faith, then the doctors' work is made lighter.
I, myself, have seen instances where this has worked out in a quite triumphant—even in medical language, a miraculous—way. And we should wish that it might more often be possible. Sometimes this ministry of encouragement and belief will make all the difference between recovery and disaster. More than this, I would say that the time of sickness with the loneliness and the hopelessness that it begets, provokes questions about the issue of life, about its meaning and its hope, which in normal times men are very apt to gloss over. It is the patient's mind as well as his body that is then at stake. And if there is again someone here who can speak authoritatively to him in his awakened need, whether the patient's tenure of life is to be long or short, he will be helped thereby on to some new plane.
The Hospital Service has fully recognised in its intention the place of this religious element. It has made provision for chaplains to hospitals; and I should like to bear testimony to the way in which hospital authorities have cooperated with Church bodies in promoting conferences and training courses for clergy so that they may increase their own effectiveness as hospital chaplains. The Church of England has a Hospital Chaplaincy Council, representative of both the ecclesiastical and the medical sides, who are there to ensure a full liaison between the work of the chaplain and the hospital. But it still remains true that, for all the goodwill which the chaplain receives, his work is often handicapped by considerations of hospital finance and planning. The Ministry have made clear, in one of those regulations to which the noble Lord referred, that the provisions of a hospital chapel or room 800 is essential. Obviously, without it specific religious services cannot be provided for staff or patients with that regularity or reverence which they merit. And yet there are places—and I could cite them—where, under the pressure of space, buildings which had previously been erected as chapels, and even used as chapels, have been turned over to other hospital uses and have not been restored, or with very great difficulty have been restored, to their own proper original function.
In many hospitals, of course, makeshift arrangements are necessary; and while lip-service is paid to this place of religion in the work of healing, when it comes to the extension of hospitals or the building of new ones the impression grows that only when or if all other needs are met will the chapel come into its own; and that may be the Greek Kalends. The chaplain's work, of course, is not specifically confined to, or mostly residing in, a chapel, but there is often no room or office allotted and set apart for him in order that he may meet people and help them personally. I have known instances (not in small hospitals, either) where in a moment of crucial illness or of death, when it is anxiety and sorrow which have to be met by the Word and counsel, it has been left for the chaplain to try to bring comfort to the relations in the corner of a crowded waiting room or the thoroughfare of an entrance hall. Of course, that is not the whole story, and none would deny the immense pressure on space which management committees have to face. But a workman must be provided with the tools for his job, and our Hospital Council has pleaded that, in serious hospital planning and costing, the aim of this part of its service should have its proper place.
The work of the chaplain is a difficult work: sometimes it seems difficult to fit into the texture and programme of the hospital. It can best be discharged where there is a full-time chaplain, for then he can give himself, without any outside interruption, to the many opportunities of service which the hospital offers, both to the patients and among the medical and nursing staffs: and all these, your Lordships would agree, should surely come within his care and attention, since the hospital is a community in itself. It is not so easy when he is a part-time chaplain with parochial 801 and other duties outside, and this must often be the case. In one of its memoranda the Ministry has laid down that the figure of 750 patients should be maintained as justifying the appointment of a full-time hospital chaplain, unless there are exceptional circumstances which would justify a lower figure. Where possible, we would urge that it should be established as a principle that a full-time chaplain is desirable for the efficient work that he is called to do. It would be a small cost compared with some of the immense items which must come before the Ministry.
There are just two small points which I would add to that. In appointing a full-time chaplain, or when deciding whether he should be appointed, we would plead that there might be a more liberal interpretation of the circumstances that warrant these appointments. A teaching hospital for instance, where there are many students as well as staff and patients, provides an occasion where surely the work of a chaplain might have some exceptional importance, even if the number of patients falls below the standard figure. Some authorities say that they prefer a part-time man because he would have the stimulus and change of other work outside to enliven his hospital ministrations. There is something in that point, particularly in mental hospital work; but the logic of it, if they pursue it as we hope they would, is that there should be in such cases more than one part-time chaplain, such as could be warranted by the figures. Otherwise, at some rather miserable financial saving to the hospital they are asking him to do an impossible task which, in the nature of things, he will reduce to a minimum.
§ LORD STONHAM
My Lords, would the right reverend Prelate, before he sits down, allow me to ask him one question? Has the matter of war-damaged or ruined hospital chapels been investigated? I ask that because one of the buildings I cannot afford to pull down is a war-damaged chapel—though, of course, we have a makeshift chapel inside. But it may be that it can be dealt with separately, and I am wondering whether that point has been considered at all.
THE LORD BISHOP OF CHICHESTER
I could not give the noble Lord a direct answer to that question. It might depend 802 upon whether this was a consecrated chapel coming under the Private Buildings Act, or whether it was a dedicated chapel: but I will gladly refer that to my Council to see whether there is any answer. They would be only too glad of the loophole of war damage if it would ease their problem.
My Lords, we do not want the Hospital Service, with its great tradition, which is historically linking up the motives of charity and religious concern with scientific medical treatment, to become in any way de-personalised. I believe that the spiritual and the bodily elements of healing are closely interlocked, since patients are always persons; and this must be reflected even in the actual planning and spending of our Hospital Service. In the nature of things it is the invisible, intangible factors in life that are most easily overlooked, since their results are not easily calculated and their absence not immediately noticed: but I am convinced that the personal and spiritual element in healing is fundamental, if we are to send our patients home not only improved in physical health but strengthened and renewed in their whole being; and I should hope that in our hospital policies this factor would be given its proper place.
§ 4.46 p.m.
§ VISCOUNT WAVERLEY
My Lords, until I began to brood on to-day I had always thought my first solo performance in an aeroplane the most alarming possible experience. But I was quite wrong. Then there was, it is true, a slight chance of breaking my neck, but only a negligible risk of involving anyone else in the affair. Unfortunately, that is not the case today; so I can only hope for your Lordships' traditional kindness to people in my position.
I think it is generally conceded that one of the most important consequences of the National Health Service Act has been the progressive development of the non-teaching Regional Board Hospitals. These are mainly provincial. This is not in any way to suggest that before the appointed day these hospitals were not giving devoted and skilled attention and service to their local communities—they certainly were. But medical talents were unevenly deployed. Since the appointed day there has been a steady diffusion of 803 all types of specialist skill, particularly, but by no means exclusively, at consultant level. In consequence, these hospitals have been able worthily to uphold their previous high reputation against a background of ever-advancing medical knowledge and ever-increasing complexity of investigation and treatment.
Now, my Lords, this development must seem wholly excellent: and so it is, but it has brought with it considerable problems. I have the honour to be a consultant on the staff of one of these provincial hospitals, and it is about some of the difficulties which particularly affect provincial and Regional Board hospitals, rather than the teaching hospitals, that I should like to speak briefly this afternoon. As the skills available at the provincial hospitals have increased, so has the family doctors' confidence in them. The result has inevitably been that an ever greater proportion of patients are investigated and treated at their local hospitals and a smaller proportion are referred to the large teaching centres. At the same time, as we move steadily out of the era of medical empiricism and advance into the age of scientific investigation, family doctors, especially the younger ones, trained at first hand in the most modern methods of investigation, have come to rely more and more on the diagnostic facilities of their local hospitals. And while all this has been going on there have often been large increases in the size of the populations served. For example, in my own hospital group area there has been a 20 per cent. increase in the last eleven years—that is, since the appointed day; and the average increase continues at about 6,000 a year, and is expected to do so at least until 1973. It, is this ever-increasing demand on the provincial hospitals which is responsible for many of the problems of that part of the Hospital Service. It is an increase in demand which I feel confident has not been felt to the same degree by the teaching hospitals.
First, there is overcrowding: in the out-patient clinics, in the special departments, such as radiology and pathology, and in the wards. Appointment times for out-patients modify, but do not eliminate, chaos. Crowding in the wards is often serious. When the demands for urgent admission outstrip the number of 804 empty beds, the situation can be restored only by one of several means. Admission can be refused—a most distasteful and dangerous method. Patients barely convalescent can be summarily discharged, perhaps in the middle of the night. Needless to say, that does not recommend itself. Or extra beds can be put up—and this is the device commonly adopted. It leads inevitably to overcrowding. And overcrowding reduces privacy, accentuates nursing difficulties and, most important of all nowadays, greatly facilitates cross-infection with the modern hospital plague—the ubiquitous and often antibiotic-resistant staphylococcus.
To try to compensate for the bed shortage, the rapidity of patient-bed turnover has been speeded up until no more is possible in that respect without the risk of a breakdown in the service through staff fatigue and inadequate investigation and treatment. The tempo is already so great that it jeopardises nursing recruitment and is responsible for serious waste by resignation. A comparison of the average number of nurses to 100 patients in acute wards in four categories of hospital is illuminating. In London undergraduate teaching hospitals there are 99; in London postgraduate teaching hospitals, 89; in provincial teaching hospitals, 81, and in the rest, 60. Then there is a serious shortage of physiotherapists. This is particularly unfortunate, because it gravely retards the rehabilitation of just that category of patients who, if inadequately treated, tend to occupy hospital beds immoderately long and at great expense. It also includes the huge number of unfortunate patients of all ages with the various rheumatic diseases.
Shortages of technicians in the radiology departments cause frustrating and often dangerous delays in completing essential examinations. This is particularly the case in those hospitals which operate the invaluable "open department" system, to which family doctors have direct access. In my own hospital, the waiting list for a barium meal examination in the open department is one month, though rather shorter for patients referred from the hospital out-patients' department. It is true, of course, that if a growth is suspected, for example, the patient is given the highest priority and is done 805 almost immediately; unfortunately, growths are often unsuspected. There are grave shortages of technicians in radiotherapy departments. The department in my hospital was obliged to close its doors for five weeks in the summer of 1958 because two radiographers had left and could not be replaced. Patients in need of treatment—and treatment in these cases cannot wait—had to be transferred to other hospitals, remote from their homes, at great personal inconvenience and at considerable cost to the community. The same pattern of shortage is apparent whichever provincial hospital department is examined.
My Lords, not only the welfare of patients but our reputation in world medicine increasingly depends on the way our provincial hospitals can acquit themselves. The bulk of all the clinical material is investigated and treated in the provinces. From there should come a steady and increasing stream of valuable original work. But this work is not well fostered by present conditions of lack of accommodation, crowding, rushing about and constant preoccupation with staff shortages of all kinds. These hospitals deserve much greater support, and I am sure that the interest of the country also requires it. The only possible way out of these difficulties is the immediate launching of the most massive programme of new hospital construction. In that respect, the Minister's statement on Monday in another place was very disappointing to me.
Even the most massive programme of construction and reconstruction, however, will not suffice by itself. It must be combined with an imaginative review, not only of conditions of service in all nursing and ancillary departments but also of rewards for that service. It is no good building hospitals and then finding that there are insufficient nurses, or X-ray departments without radiographers, or physiotherapy departments without therapists. The Hospital Service must be able to compete with industry or it will starve. It is not good enough to hope to rely indefinitely on selfless devotion. It is just that which is keeping so many departments in our provincial hospitals going to-day. This re-thinking and increased support must not be at the expense of the teaching hospitals, which so amply justify our pride in them, and which must never be stinted. It 806 must come as recognition that, while the teaching hospitals must have no less, the provincial and other Regional Board hospitals require much more if we hope to develop in this country a balanced and creditable Hospital Service.
§ 4.58 p.m.
§ LORD COHEN OF BIRKENHEAD
My Lords, my first duty, and it is as pleasant as it is acceptable, is to congratulate the noble Viscount, Lord Waverley, who has so delighted us and informed us in his maiden speech. One of the noblest of ancient philosophers held that when we pass on, we look down from the Elysian Fields on those on this earth whom we love, and rejoice in their success. If Aristotle be right, then to-day one of the greatest ornaments of this House, one of the greatest servants of this nation, is looking down on us and sees that the torch which he lit is being so brightly carried by his son. I know that your Lordships would wish me to express our warmest congratulations to the noble Viscount on his memorable maiden speech. We look forward with the most pleasurable anticipation to his further illumination of the debates in your Lordships' House.
No one can have listened to the debate this afternoon without sensing an earnest desire on the part of all noble Lords who have spoken to criticise constructively the Hospital Service. Yet it is inevitable, in a debate of this kind, that the shortcomings should be accentuated. I merely say this in passing: that it is important to avoid a distorted and unproportioned view of our Hospital Service. I share most of the misgivings and the criticisms which have been expressed, yet it is well to recognize—and I stress this from no narrow, parochial patriotism—that despite the fact that some countries have newer hospitals, we still have the best hospital and consultant and specialist service in the world; and I think we should be proud of it. There has been an immense improvement in the hospitals since 1948; the noble Viscount, Lord Waverley, has referred to the improvement in the regional hospitals, many of them local authority, old municipal hospitals. Upgrading, renovation, addition and occasional rebuilding have all made an indelible mark for the better on these old hospitals. We now, at any rate, have a distribution of hospitals which is not dependent upon charitable 807 effort, and a distribution of consultants and specialists which is not dependent upon the ability to pay, but is patterned by the needs of the community for which they are providing.
I should like to endorse what has been said by the right reverend Prelate the Lord Bishop of Chichester. I recall being invited some years ago to contribute to the Sunday Times a section on medicine on the advances which have occurred in the 170 years since the Sunday Times was first published. I laid stress on the fact—and I believe this to be true—that we should be remembered not so much for the brilliant discoveries of antisepsis and penicillin, and all those magnificent instruments which help us to analyse the physico-chemical mechanism of man, but rather for the fact that we in this country still regarded our patients as ill people and not as cases. It was, indeed, as your Lordships will remember, Plato who decried the fact that there were physicians for the soul and physicians for the body. We in this country have tried to avoid that dichotomy. I have said what I have said about our Service in no spirit of complacency, but simply because we need to look at this problem in perspective.
There are a large number of problems which I should like to raise, but I propose to confine myself to three only. They are primarily medical and not administrative or financial; and they are concerned with improving the service to the patient. The first is that the concept of regionalisation of hospitals which was put forward in 1948 has not been realised. The points of the regionalisation of hospital services were, first, that we should be able to provide for any patient any day the service which the patient needed. Secondly—and this perhaps is the one to which I would draw greatest attention—it was supposed that the influence of the teaching hospitals, at which it might be expected would be found the more recent developments and the higher standards of practice, would permeate throughout the whole of the hospital region. To that end, we at that time delineated 14 regional hospitals (there has since been added a fifteenth, which I hope concedes that these hospital boundaries are not inviolable), and we put at their centre—not the geographical 808 but the functional centre—a teaching hospital.
What has happened? What has happened, in fact, is that in many, if not most, regions there is no contact whatsoever between the regional hospitals and the teaching hospitals. The old antagonisms which existed in the old days between the teaching and voluntary hospitals and the municipal hospitals have been perpetuated, although the regionalisation of hospitals sought to erase the barriers between them. It seems to me that that is an ill thing both for the regional hospitals and for the teaching hospitals. There is still in many areas a feeling of regional inferiority, and that allows the regional hospitals to remain divorced from the teaching hospitals, because, quite rightly, they do not want to be looked upon "with a patronising air." This is of great importance because—and let us be frank about this—the standards of service in regional hospitals, as a whole, are not those of the teaching hospitals, though there are many quite outstanding exceptions.
But if we take Morris's paper (this was a paper published a year or two ago, and Morris works with the Social Medicine Research Unit of the Medical Research Council), he showed that in 1953 there was twice the chance of dying from an operation for acute appendicitis with peritonitis in a regional hospital as in a teaching hospital, even after correction of age and other standardisation; and twice the chance of dying from an operation for enlargement of the prostate; and if you were unfortunate enough to be a diabetic—and, after all, there are a quarter of a million in this country—and you developed diabetic coma, your chances of survival in a teaching hospital were even more than twice as great as in a regional hospital. I am not suggesting for a moment that there is any difference in the skill of those physicians and surgeons and the nursing staff attached to regional hospitals. I am myself fairly certain that it lies in other factors. It lies in the factors which have been mentioned by the noble Viscount, Lord Waverley; differences in staffing, differences in facilities, differences in accommodation and the like; and it is clearly important that we should carry out appropriate clinical and epidemiological studies in 809 this field to elucidate the present situation.
I do not propose to offer a detailed solution of this problem of the failure of the concept of regionalisation which was so prominent a part of our hospital programme when the Service began, but I would suggest that our regions are, on the whole, far too big and sprawling. After all, one cannot expect the University of Manchester to influence Barrow—and that is indeed what is expected. We know from studies which have been made at Barrow (the Nuffield Provincial Hospitals Trust has carried out studies there) that there is virtually no association between Barrow, which works in isolation, and the Manchester teaching hospitals. I am suggesting that there is a need for rather smaller regions, possibly with sub-regions, in which there will be a central hospital, which itself is under the influence of the teaching hospitals, and also that there shall be a regular interchange of staffs between teaching and regional hospitals.
If I may—and here I must declare an interest, as a member of the Liverpool Regional Hospital Board and the Board of Governors of the United Liverpool Teaching Hospitals—I would ask your Lordships to look at Liverpool as the appropriate prototype for those investigations. Here you have not a region which spreads a hundred miles north. Here you have a region in which the teaching hospital is no more than 17 miles from any other hospital in the region, and members of the teaching hospital are on the staffs of almost all the regional hospitals. So there is that appropriate interchange. Now we have only 2 million population, unlike the region of the noble Lord, Lord Stonham, which is vast. But I doubt, from what he said, if it is as efficient as the Liverpool region. I will not press that.
§ LORD STRATHCLYDE
My Lords, before the noble Lord leaves that interesting point which he has been developing. I think he has been speaking chiefly of the system which exists in England and Wales. Is he advocating that that system should be changed to the system that has been operated in Scotland since 1948?
§ LORD COHEN OF BIRKENHEAD
I hoped the noble Lord would not raise the question of Scotland at this point, 810 because I am well aware that Scotland is regionalised under the different concept of a single Regional Board governing both teaching and regional hospitals. But, of course, it is necessary to recall that in Scotland there were hardly any regional hospitals, and there would have been no particular hospital community for a separate Regional Board to preside over. In any event, I do not want, as it were, to draw an Aberdeen herring over this particular path. I should prefer at the moment to keep to the subject which I have myself experience of-regionalisation in this country.
The second point to which I wish to draw your Lordships' attention is the association of general practitioners with hospitals. There was, in the pre-National Health Service days, much closer association, and no one concedes more readily than myself that some general practitioners in some of the local hospitals undertook work for which they were not fully competent. I think it is right that there should be in charge of all departments in these hospitals men who have been specially trained for the particular problems which are likely to arise. But I think this has perpetuated the isolation of the general practitioner from the hospital which is wholly unhealthy for both—the general practitioner and the hospital. We refer not infrequently, in varying similes, to the general practitioners as the backbone of the Service or the linchpin of the Service and so forth. If he is the backbone, you cannot have merely a vertebral column walking about in isolation. You must have the body, and the body includes a hospital and, as I shall mention in a moment, the local authority services.
I would suggest that it is not enough simply to give general practitioners access to the X-ray departments and to the clinical pathological services, but that in some way they must be integrated within the Hospital Service. Many suggestions have been made. My own Committee on General Practice in 1952—of which the noble Lord, Lord Taylor, was a member—advocated many ways, which I need not here reiterate, such as working as clinical assistants in hospitals and taking part in the hospital service, where there is a demand for so many additional consultants and specialists. In many cases this virtually means simply 811 a pair of skilled hands. I cannot believe that the general practitioners cannot provide some of those pairs of hands. It might, of course, be said that general practitioners are not necessarily available at the appropriate time. But with increasing group practice there is no reason at all why they should not be available. It is interesting that at the Birmingham General Hospital recently they advertised for a general practitioner assistant in one of their departments, and they had fifty-eight applications for the post. Although it would take me far too long to expand this view, I believe that there is a need for a reconsideration of the place of the general practitioner in the hospital, because in hospital and in consultations lies the best post-graduate education which a general practitioner can have.
The third point I want to mention is: are we using our hospitals to the best advantage? I would agree wholly with what has been said, that we must try to jockey the Government into spending as much money as possible on hospitals. I am not unaware that there are other claims, such as housing, education and the like, and, indeed, that there are difficulties in labour and material and in finding the appropriate sites. But we must try to get for the Hospital Service as much money as we possibly can. As has been pointed out time and time again this afternoon, we have worked in outmoded premises sometimes unfitted for the particular work which we have to do. But it would be misleading if it went out from this House that we had simply to clean the wards of our hospitals to get rid of staphy-lococcal infection in hospitals. It is an immense problem to which I agree cleaning hospitals would make a certain contribution. But there are a large number of factors responsible for infection with which a committee of infection can deal to-day and can still limit the rate and incidence of staphy-lococcal infection.
§ LORD STONHAM
My Lords, if the noble Lord will allow me, may I say that I quite support what he said, but one of my own cross-infections committees made fourteen recommendations, all wholly good and comprehensive, but there were only five of them that could 812 not be done without the expenditure of money.
§ LORD COHEN OF BIRKENHEAD
I agree that they were wholly good, because they were taken from a Report of a Committee over which I had the honour to preside on Staphylococcal Infections in Hospitals. So we shall not differ on that. But there are also certain essential comforts which have already been mentioned and which are lacking for patients and for staff. On the other hand, I think we ought also to stress what the right reverend Prelate the Lord Bishop of Chichester mentioned, that, after all, it is men and not machines and premises which necessarily make for good medicine and make patients well. I have recently spent a little time in some chromium-plated institutions across the Atlantic, but I should still prefer to be treated by the human beings in our own hospitals.
I was going to stress this point. If we are pressing the Government that they should spend more money on hospitals, we must assure the Government that we are using the beds to the best advantage, and that these beds are needed. We really need to look at this question of numbers again. When the National Health Service came into being it was suggested by the Ministry of Health that for acute general hospitals five beds per thousand of the population was the number needed. But recent investigations—case load studies, as they are called—have shown that in many areas where they have been undertaken that number is too high. In Northampton and Norwich the number is nearer two, and in an industrial area recently investigated by Dr. Logan and Dr. Forsyth under the Nuffield Provincial Hospitals Trust's ægis it was shown that 2.5, at the outside, was the number required. This is a disquieting state.
§ LORD COHEN OF BIRKENHEAD
Yes, simply the acute general beds; I have excluded the chronic, the geriatric, the mental and so forth. In those hospitals it was found at the particular time of investigation that one-third of the men and one-half of the women were not in hospital at that time for medical reasons but largely for family, social and 813 economic reasons, and therefore the responsibility for them should lie upon other authorities. It is the local authorities who ought to make available housing, who ought to make available home helps, domestic nurses and the like, to make good the deficiency of hospital beds that may be there.
I think it is also true that we cannot decide from the number of beds present before the Act the number of beds which is now appropriate. If you had analysed the beds in this country before 1948 you would have found that there were some areas that had ten beds per thousand of population and other areas that had four. That was not due to medical needs. But there is an interesting inference to be drawn. All those beds are full, wherever they are, and the fact really is that there is a Parkinson's law in relation to hospital beds; if you provide them they will be filled, and they will be filled for much longer periods than they should be filled. I think that we have to look at this question with much greater care than we have done in the past.
Here I should like to pay a tribute to the Ministry of Health. They have recently introduced their Organisation and Methods Research Department, and already they have produced two documents of immense value, one referring to out-patients and the other to medical records, and I hope that with methods of work-study and operational research we shall hear from them what is the answer to this question of bed needs. But let me emphasise finally that you cannot consider the problem of hospital organisation in this country in isolation; you must consider it in relation to general practitioner services, in relation to local authority services—indeed, in relation to the whole social welfare structure of the country.
I have, as have other speakers in this debate, been mainly critical, but that was the purpose of the debate. I should like to end on a note of gratitude and optimism. No one who views objectively the National Health Service can dissent from the recent pronouncement from an unlikely source, the President of the British Medical Association, who on August 8, 1959, stated:It is doubtful (in spite of its shortcomings) whether any political measure has ever brought 814 so much relief and hope to those who needed it as the Act which came into operation in July, 1948.
§ 5.25 p.m.
My Lords, may I first of all join with the noble Lord, Lord Cohen of Birkenhead, in congratulations to the noble Viscount, Lord Waverley, on his maiden speech. It is a great tradition of this House that one can always find noble Lords to speak with great authority on any subject. We can certainly say that the noble Viscount, Lord Waverley, has joined with his colleague, the noble Lord, Lord Cohen of Birkenhead, in not only speaking with authority but also speaking in language which we laymen can understand.
I wish to speak for a few moments to you to-night on one special hospital. That hospital is the Fountain Hospital in Tooting for mentally deficient and mentally handicapped children. I was asked a short time ago to see this hospital and I went down and spent a day there. I fully realise that there is a scheme in hand for this hospital, but to-night I just want to bring before my right honourable friend the Minister the urgency of this scheme and try to get a little more information about it.
With your Lordships' permission, I should like to give you a short history of this hospital. It was built in 1893 in eight weeks as an emergency hospital for infectious diseases, with 384 beds. It remains to-day structurally almost as set up, but now houses 600 mentally deficient children and mentally handicapped children. The waiting list in August when I saw it was in the region of 140. I was informed the day before yesterday that the waiting list to-day is 170. May I deal first with the structural side of the hospital. It is, in the main, corrugated iron huts. The wards are of the barrack-room type and the floors are wooden floorboards, which cannot possibly be described as hygienic for this type of children. There are no indoor recreation rooms; hence, during inclement weather the beds are moved up to the end of the ward so that the children who can get out of bed can have space to play there. Owing to the numbers of patients the wards are terribly overcrowded, and in many cases it is hard to move about between the beds. In many cases, and may be the majority, the children have no idea of anything 815 which is going on. Maybe that word "Bedlam", used in the old days, might have suited this hospital. Here may I pay a very humble tribute to the staff, from the superintendent right down to the nurses and those who scrub out the wards.
The nursing comes under two categories. The first is for those children who will never understand or know what is going on around them, and that is chiefly a job of keeping them clean and as comfortable as possible—and a very arduous task it is. The second type is for those who can be assisted and who must be forced to do things for themselves, for their own good. In both cases that needs patience and understanding, and in most cases one will realise that the normal thanks one would get from an ordinary patient cannot be forthcoming in these cases.
May I turn now to the waiting list, which numbers 170 to-day. These children are in many cases in the home, and application would not be made to go into hospital unless it was highly desirable from the point of view either of the children or of the parents. I need hardly stress the strain on those families, and for that reason alone the urgency of the matter is paramount. The Superintendent tells me that he has tried to move children to other hospitals in other Regional Board areas, but there again it seems impossible to find vacancies; and the fact of that waiting list going up in the last few months shows this to be so.
I come now to the scheme as I understand it. Since 1920, very often a new hospital has been put into a scheme, but there has never been enough money to erect it. A new scheme was made about three years ago and plans were drawn up, but unfortunately this again was turned down. I think the scheme now is that 300 of these children will eventually—may I mark that word "eventually"—be transferred to Queen Mary's Hospital, Carshalton. The Fountain will be cut down, as I understand it, to 100 beds. Now one can see that with the waiting list as it is, 770 beds are needed now. So 370 children are not catered for, and it is hard to tell what would happen to the remainder that are in that hospital to-day or on the waiting list.
816 I should like to ask the noble Lord who is going to answer if he can tell us whether that scheme, as I have outlined it to your Lordships, is correct. If so, can he or the Minister give any indication as to when it can be put into operation, and tell us whether there is any idea in the Minister's mind as to what happens to the children who are not catered for? As I have said, it is a matter of grave urgency, and I know that my right honourable friend the Minister realises this. Money must be forthcoming. We have all called for money. But let us remember again that these children are human beings like ourselves; and we are thinking not only of them but also of the nurses, the doctors, the superintendents and the parents. I hope that I shall be able to get some answer tonight.
§ 5.32 p.m.
My Lords, in all that is related to mental deficiency and mental handicap I am always well content to follow the noble Lord, Lord Grenfell. I hope that his earnest plea will receive a good response from the Minister. I should like to join in the tributes that have already been paid to the noble Viscount, Lord Waverley, so deservedly and so delightfully, by the noble Lord, Lord Cohen of Birkenhead, who, I gather, has unfortunately been called away. We on this side certainly hope to hear the noble Viscount, Lord Waverley, very often, to some extent for his father's sake (he will not mind my saying that), but also very much for his own.
The noble Lord, Lord Cohen of Birkenhead, is, of course, always very interesting on these subjects of which he is such a master. This time he asks us to consider what Plato and Aristotle would have thought about this matter. I was glad to find that the alleged gulf between humanists and scientists seems to be disappearing. Of course, we have often seen pictures of Plato pointing to Heaven and Aristotle pointing to earth. I gather that the noble Lord, Lord Cohen of Birkenhead, supposes that if they came back to-day they would point to Liverpool, and particularly to the institution over which he has himself been presiding. Unfortunately, he is not here to reply.
This is a debate which is memorable for many reasons. Everyone, I think, including the right reverend Prelate, is 817 an expert in this field. I have some claims to speak, being Chairman of the National Society for Mentally Handicapped Children, expressing therefore the feelings of perhaps 15,000 parents of afflicted children; and I am most proud, of course, to think that the noble Lord, Lord Grenfell, is our treasurer. But I am not personally an expert like those who have spoken—we have listened to most expert speeches.
The debate is memorable in another way in that I think two of the main speeches from this side are to be made by those who are sitting on the Front Bench for the first time, and the noble Lord, Lord St. Oswald, will be speaking as a Minister for the first time from the other Front Bench. So I think it may fairly he said that the three chief speeches on this matter will be made by maiden speakers on the Front Benches. As an old hand who was forced to speak from the Front Bench (without any particular reluctance, but still forced) on the first day I was in the House, I would say that they will find it far easier to speak from there than anywhere else, although they may find themselves tempted to make too many speeches from there; and I would say that one finds it hard to speak half as well from anywhere else. However, I am sure that they will overcome that difficulty, and we wish the Minister and the noble Lord, Lord Taylor, well
I would say how deeply I was impressed, as was everybody here—I have had the opportunity of finding out from outside this House, as well as inside—by the speech of the noble Lord, Lord Stonham. I have already found several doctors outside the House, and no doubt there are others inside, who have said about Lord Stonham's speech that it showed he knows what he is talking about. When you get doctors saying that of a layman talking on medicine you can see what an exceptional effort his has been, and it will certainly give the noble Lord, Lord St. Oswald, a great deal to reply to. I am sorry that a moment ago I was commenting on the speech of the noble Lord, Lord Cohen of Birkenhead, in his absence, but it was nothing at all offensive—it was almost obsequious. I do not think my remarks are likely to give any offence, and no doubt when he reads them to-morrow the noble Lord will suffer no distress of any kind—at least, nothing that a 818 psychiatrist like Lord Taylor could not cure very quickly.
My Lords, I believe that this is a very serious occasion, and I feel a considerable responsibility, speaking as I do for the National Society for Mentally Handicapped Children. But I think Lord Stonham would agree—as probably would Lord Cohen of Birkenhead and others—that we should have a special day devoted to those who are mentally afflicted, perhaps a particular day for the mentally handicapped. After all, something over 40 per cent. of those in our hospitals are in mental hospitals, and they have their own very wide and difficult problems. Whereas Lord Stonham, rightly, as I think, described our hospital position to-day as grossly inadequate—excluding, of course, the high standard which is maintained by those who minister to the needs of the afflicted—I think the inadequacy is most blatant in the mental deficiency hospitals.
In dealing with mental deficiency we enter a sphere where, in theory, ultimate ideals and more urgent steps could be discussed separately. But it is a little hard to keep them apart. I think we all accept the aspiration expressed by the Royal Commission and implied in the new Act that, so far as possible, the mentally handicapped should be transferred away from hospitals into hostels. In that way, a great number would eventually—and the sooner the better—leave hospital, so that only those in need of continuous medical care would remain. But that is all obviously some way ahead. But from this side of the House—and not from this side alone—we all call once again for a determined effort to accelerate this process which, of course, means that in the last resort, if they prove tardy, the Minister must compel local authorities to provide hostels as envisaged in the Mental Health Act.
I would call the attention of the House, if I may, to one particular project with which my own Society is concerned—it is the joint effort of the Buckinghamshire County Council and our own National Society to erect a mental hostel of this type by the end of 1960. I cannot help wondering whether the noble Lord who is to reply would agree to speak to his right honourable friend and ask whether the example of this project 819 could be drawn to the attention of all local authorities, because I feel that it would have a most salutary effect upon them. To-day we are discussing hospitals, not hostels, but obviously it is a little difficult, in dealing with the mentally handicapped, to keep the two concepts apart. For the next few years a high proportion of mentally handicapped will obviously remain in hospital, however actively the Minister and local authorities move; and in what I have to say this afternoon—and my remarks will not be very prolonged—I should like to concentrate mainly on the physical conditions in mental deficiency hospitals and on the need for improving them.
I believe that we all agree—talking now of hospitals and passing away from hostels—that for these life-long patients we must try to get hospitals approximating to a home. We should like to bring to an end these huge institutions-with up to 2,000 patients, and to have smaller units where patients could live in residential groups. I know that the noble Lord, Lord Grenfell, will support and endorse that aim, and I believe that my noble friend Lord Taylor and others will agree that the staffing of such smaller units would be much less difficult and the work of the staff less arduous. And on all those grounds we support the new pattern for hospitals. Perhaps we could come—and certainly if we have a special day for the mentally handicapped we must come—to the very large question of how far those of the mentally handicapped who remain in hospital should be in separate hospitals, and how far they should be mixed up, so to speak, with general patients. I am the last person to have the credentials for dogmatising on that matter, but it is a subject which we need to discuss carefully. I believe that we should all be ready to say that there ought to be much more mixing up than there is at present, though whether a residue of the extremely difficult cases should always be treated on their own is something on which I would rather hear medical opinion than hold forth myself.
May I come to the immediate proposals of the Minister? I was interested to find that some of those who have spoken to-day, with very expert knowledge, found them inadequate. I do not want to be ungenerous to a Minister 820 who has certainly shown his earnestness in this field, but at the moment, speaking for myself and, I suppose I should say, for my Society, we have not been able to form an opinion on how far we can congratulate the Minister on his building programme in relation to the mentally handicapped. Everybody is glad that something considerable is to be done, but we must reserve judgment as to how far the years eaten by the locusts are to be atoned for.
May I put one point, however, in connection with the proposals to the noble Lord the Minister who is to reply? Do we assume that the building programme of Her Majesty's Government will reach a figure of £50 million a year about five years from now? I am not asking for an immediate reply. Perhaps the noble Lord will tell us when he winds up. I believe that in their Election programme the Conservative Party mentioned the figure of £50 million a year. Do we assume that this programme will be organised so as to keep that promise? Whether that is so or not, can the Minister tell us what proportion of this sum—and what is the total sum in money—is to be allocated to mental deficiency hospitals, or otherwise allocated so as to facilitate the treatment of the mentally handicapped? I have given the noble Lord some small notice of this point, though I do not know whether it was sufficient. But perhaps he will tell us when he speaks at the end.
When I criticize—as I must, like other speakers—the terrible shortcomings of the hospital arrangements from the point of view of the mentally handicapped, I am very anxious to do justice to what I would call the generosity of feeling of the parents of these children. I do not want to create the impression that parents of mentally handicapped children are bitter, or are people who are niggardly of gratitude for what is done; for that would be to give a very false impression. I know they would want me to say very clearly that they appreciate the very fine things which are done for their helpless children in these hospitals, and I would rather make that clear and sit down at once than give the opposite impression. They are fast losing their fear and distaste for these mental deficiency hospitals, and they recognise that in those hospitals the patients are treated with 821 kindness and love, and that they are safe and secure.
These are things which I know would be endorsed by the noble Lord, Lord Grenfell, and should be clearly said by anyone speaking for the National Society. Nevertheless, parents of mentally handicapped children are beginning to feel that, perhaps out of genuine gratitude for what is being done by those who look after their children, they have been almost too indulgent towards these conditions and have not, perhaps, spoken out loudly enough of the conditions with which they are familiar. Therefore I shall not, I hope, seem to be detracting from the appreciation of the actual treatment if I join in the general comments that have been made about conditions in hospitals—and, indeed, add to them quite severely.
May I take a few figures? If they are not correct perhaps the noble Lord will tell me, because I believe he knows where they come from. I put them up to him only so that he can tell us whether they are about right and, if so, whether in his view there is some reasonable explanation which sensible people ought to accept. Or, if he cannot give that kind of answer, perhaps he will tell us how he proposes to rectify these anomalies. According to my figures the allotments made to mental deficiency hospitals throughout the country amount to £6 2s. 1d. per patient per week. This figure compares with £9 6s. 1d. for long-stay hospitals and £21 15s. 6d. for acute hospitals.
In saying that, I do not want to give the impression which might occur to some noble Lords who do not know this side of things that mentally handicapped people in these hospitals are not receiving any medical treatment. Quite a number of them suffer a variety of physical ailments, and some from multiple ailments; and therefore one must realise that there is some quite high element of sickness—or what the layman would call sickness—contained among these people. But, according to my information, the figures—they may be slightly out of date, and if so perhaps the noble Lord will give later ones—-are just over £6 a week per patient in mental deficiency hospitals, and over £9 for patients in long-stay hospitals. It is perhaps just worth noticing that the 822 average cost at an ordinary local authority home per person is £7 4s. 1d. per week; and at homes administered by the London County Council the figure is £8 4s. 6d. a week. So, on any ordinary standard of comparison, the figure of just over £6 per week for the mentally handicapped hospitals seems very low.
I have also been given some figures from a selective hospital, which I hope is a fair case—perhaps it is better that I should not give its name publicly, though I can give it to the noble Lord or anyone who is interested. I have nothing to say against this hospital, which I trust is typical. It houses about 1,600 patients, and the medical salaries work out at 3s. 6d. per patient per week, as compared with 4s. 1d. for long-stay hospitals and £2 10s. 4d. for acute hospitals. Taking this large and, I hope, typical hospital, this means that in a hospital of 1,600 patients the medical staff amounts to 5 or 6 to 1 compared with those on administrative duties; so that, in practice, it means that one medical officer has perhaps 400 patients. I will not go on to describe further details for I do not want to detain the House, but I give those figures as a rough illustration of what is going on. In regard to the nursing services the salaries, according to my information, average £1 16s. 2d. per patient per week, as compared with £2 4s. 10d. for long-stay hospitals and £10 4s. for acute hospitals, where, I agree, the problems are very different. We had some reference to the number of patients per nurse, and I am informed that typical figures for us would be a ward of 60 patients, with one male nurse or sister in charge and one nurse or student nurse to help. I could dwell at length (and will on another occasion) on the implications of that.
I must say one word about food. According to my information, the cost of food in our mental deficiency hospitals is considerably lower than the cost of food in hospitals generally. I do not know whether the noble Lord will be able to give complete figures. I have no complete figures on this matter, but I gather that the figure in our hospitals is 19s. 11d. per patient per week, and the comparable figure I have been given for other hospitals is £1 7s. If that is wrong perhaps the noble Lord will give 823 me the figures which draw the comparison between the cost of food in mental deficiency hospitals and the cost elsewhere. I should be surprised if the food in our hospitals, according to the figures, is as good as is provided elsewhere. Finally, a word on clothing. I have not any comparisons on this aspect but the clothing is generally agreed to be very depressing. The allotment is extraordinarily stingy. There is a clothes allowance of 3s. 1d. per week; that is, £8 a year. I am not, as noble Lords may have noticed, a dressy man, but I should hesitate to try to dress on a figure resembling that; and I am bound to ask the noble Lord whether he seriously believes that 3s. 3d. per patient per year for underwear, which is the figure I have, is anything but a disgrace to a country which we are told has "never had it so good".
My Lords, I throw out those figures. I know they may not be the latest figures, and the noble Lord may have more recent ones. But if we are to talk about Cinderellas—we must sometimes try to find another lady for these comparisons, because we all overwork Cinderella rather hard—and if the Hospital Service is the Cinderella, the mental deficiency hospitals are the Cinderella of Cinderellas. And I should like to place it firmly before the noble Lord that I am solidly behind—as are all noble Lords on this side of the House and most noble Lords in other parts of the House—my noble friend Lord Stonham in calling for a completely new approach to the Hospital Service. Speaking, as I do, for many thousands of people whose children are in the care of the community, in these mental deficiency hospitals, I do not want to leave an impression of ingratitude. Far from it; I think everyone would be deeply moved by the response and kindness shown to these children. But the fact is that I, at any rate, and many other noble Lords in the House also, feel we cannot tolerate much longer the conditions in these mental deficiency hospitals. And I must ask the noble Lord, whose heart and goodness are not in dispute, to say something before the debate closes to give us some encouragement.
§ 5.53 p.m.
§ LORD AUCKLAND
My Lords, speaking as one who has been in your Lordships' House for less than two years, I 824 should like to associate myself with the tributes that have already been paid to the noble Viscount, Lord Waverley, on his speech, which was outstanding in stimulation. I should also like to pay tribute to the noble Lord, Lord Stonham, for the forthright and zealous way in which he moved this Motion to-day. I am not connected with the medical profession myself; I am an insurance underwriter; but my qualifications for taking part in this debate are that I am on the committee of a quite well-known children's hospital in Chelsea, the Victoria Hospital for Children, of which my father was chairman for several years, and I have toured this hospital on a number of occasions. I have seen the difficulties under which the staff frequently have to work and I can say that the staff, from the matron to the most junior student nurse, carry out their duties with exemplary efficiency.
I think none of us can have failed to be moved by the speech of my noble friend Lord Grenfell, but I cannot say that I was very pleased to read the remarks which the Minister in another place made about the improvements which are to be made at the Fountain Hospital, Tooting. I quote [OFFICIAL REPORT, Commons, Vol. 613, col. 91]:Some adaptations of wards and other improvements for the accommodation of severely subnormal children are to be carried out at Queen Mary's Hospital for Children, Carshalton, and a new reception unit, out-patient department and research and teaching unit provided at the Fountain Hospital, Tooting.My Lords, there seems to be no reference whatever there to more beds, which is surely the crying need for that particular place. I have not been to it myself, but I live not many miles from it and I have heard a fair amount about it and the extremely difficult conditions under which the staff work.
The noble Lord who is to wind up this debate did me the courtesy of ringing me up on Sunday night, and I intimated to him then that I should be talking primarily on children's hospitals. I see from the future hospital projects, which were mentioned in another place on Monday, that there seem to be no references to the building of or to constructional improvements to existing children's hospitals. There are a number of cases in which children are housed in adult wards. I am not denying that they get very good attention, but I think it 825 is fair comment to say that children do like to be with other children, and at present the shortage of accommodation, at least in some children's hospitals, gives rise to concern.
Another aspect which has not been mentioned to my knowledge to-day is the provision of maternity hospitals. The birth rate increased by some 0.6 per cent., I believe, between 1957 and 1958. The infant mortality rate has decreased in like proportion, which is an excellent thing. But the provision for maternity hospitals is extremely seriously lacking, and the period covered by waiting lists for mothers to go into maternity hospitals or into nursing homes is, I believe, something to the tune of about seven months. So as soon as a woman has any indication whatever that she is expecting a child she has to book to have any chance—I repeat, any chance—of accommodation in a maternity unit. Speaking for my own area, I may say that Epsom Hospital has a small maternity unit, but it is by no means adequate. The Cranbrook Report mentioned the need for ante-natal care, which is an extremely good thing; but, my Lords, this project is being grossly handicapped by the shortage of beds, and I hope that perhaps the noble Lord who is to wind up may have something to say, either now or later, about this problem.
Another aspect of the Hospital Service is the provision of casualty departments. I happen to know Eastbourne well because it is my wife's home, and last August we toured the Princess Alice Memorial Hospital at Eastbourne. That is a very fine hospital, but the casualty department gives reason for the greatest concern. I would ask your Lordships' indulgence if I quote a few figures. The overall area of the casualty department of the Princess Alice Hospital, Eastbourne, is 376 square feet. During the past three years the yearly average of casualties which have had to be dealt with at this hospital is 8,438, and I think that about 70 per cent. of these have been in the summer.
Now as your Lordships know, Eastbourne is a seaside town, but its activities as a town extend well beyond the holiday season. It is now scheduled for a certain amount of development; and the hospital facilities in that town leave quite a lot to be desired. I am conscious that there are many towns other than 826 Eastbourne which need these facilities, but these figures are, I think, important. There is also the very disturbing factor that casualties often have to be brought in through the out-patients' department, which means that children often see brought in people who are victims of a road smash. As your Lordships will recall, a few years ago there was a serious rail accident at Eastbourne, when six people were killed and a number injured. The two main hospitals in Eastbourne, St. Mary's and the Princess Alice, dealt extremely well with these cases, but they were labouring under tremendous difficulties. Another problem is that of laboratory space. Turning again to Epsom, I would mention that one of the largest mental hospitals in Epsom has a laboratory in which there is, colloquially speaking, hardly room to swing a cat. This is a hospital of 8,000 beds, and I submit that something is gravely lacking here.
My Lords, the time is getting late, and I do not want to detain your Lordships with a lot of figures, but I should like to say this: the nurses and the doctors in this country are second to none. If there is a major accident, they will work and work and work. There is no question of overtime. In an office, if there is an epidemic of illness work can be shelved. In a hospital, it cannot be shelved. If thirty nurses go sick, patients still have to be looked after; and in our hospitals the staffs buckle to in a remarkably fine manner. In the past few months I have visited several hospitals and have seen for myself just how hard these young nurses work. To give an example of the type of nurse that we are getting now, I quote from the Weekly Scotsman of a few weeks ago, which says:The young student nurses of Arbroath Infirmary believe in doing things the tough way. They have been out on lifeboat practice exercises.We need have no fear as to the calibre of those who run our hospitals to-day, certainly in the medical sense. As for the Regional Hospital Boards, no chairman or secretary of a Regional Hospital Board can necessarily expect to be popular. I know of a mental hospital in Birmingham which I have visited twice. The chairman is not exactly a popular man in the literal sense of the word, but he is an assiduous worker—and so is the 827 hospital secretary. On a very limited budget, and often by using direct labour, wonderful transformations have been carried out at this hospital, which proves what can be done.
In conclusion, my Lords, I would say that the call has been made for more money. Working in the City, I do handle money—indirectly, at any rate: and the question is as to how the money is to be raised. As the noble Lord, Lord Cohen of Birkenhead, said, if I quote him aright, "It is often a question as to how the existing money is raised, rather than trying to get fresh supplies," although I would be the last to say that fresh supplies are not needed. I would quote the words of a very great Englishman who was our Prime Minister for a number of years and who said during the dark days of the last war,Give us the tools, and we will finish the job.My Lords, the tools—the matrons, the doctors, the nurses—are there, and they are wonderful people: but it is open to question whether sufficient facilities are being granted to them for carrying out the job to the standards which they themselves represent. I hope, my Lords, that this debate will go a long way towards seeing something done about this very pressing problem.
§ 6.8 p.m.
§ LORD CHORLEY
My Lords, as a complete outsider I find this debate fascinating and enthralling. It is debates like this which lend authority to the discussions of this House. We have had contributions from men who speak from real knowledge about the matters which are under discussion; we have had the advantage of one of the most interesting and well-informed maiden speeches that we have heard for many months; and we have had a searching and critical analysis by one of the leading medical authorities of the day. I only wish we could have him dealing with National Health for a few years: I think we should then see some things happen.
Now I, who know nothing whatever about these things, ask your Lordships to bear with me for a few minutes while I refer to a matter which does not come into the light of day very much and which has not, I think, been mentioned 828 this afternoon, but which does seem to me to be a matter of really substantial importance. I might perhaps refer to it as a question of amenities in hospital, and yet that is not the right word because what one might call the general amenities of hospitals are on the whole, I think, as far as I can make out, pretty well looked after. What I am concerned with to-day is one single point, and it is the point as to the provision—or, rather, the lack of provision—which is made in our hospitals for patients to be by themselves. My Lords, every civilised man and woman needs from time to time to be lonely and to have seclusion—to be by himself. It should be the right of everybody. It is interesting that one of the greatest modern English philosophers described religion as what we do with our loneliness. The general ward of a great hospital is not a place where one can be lonely. It is not a place where it is possible to obtain seclusion. And I feel that more provision should be made for patients to be able to be by themselves from time to time.
This matter has been brought home to me by the experience of several friends who during the last few years unfortunately have had to spend considerable amounts of time in hospital, and I know that, as a result of their not being able to afford private wards, they have felt this matter keenly. I know them well and they are not misogynists. All rejoice in the society of their fellow human beings. But they are also people who feel the need, which I am sure almost all your Lordships must feel from lime to time, to be by themselves. I discussed this matter with a friend, a man of culture, who has had to spend more than a year in the general wards of hospitals. This man's admiration for the medical attention and nursing he received is boundless, but as time went on he felt more and more that he could not be by himself, and by the time he had left the last hospital—I am glad to say he seems to have been cured—the matter had become a sort of obsession with him. I am sure that there is none of your Lordships who cannot understand and sympathise with the feelings of a man who has had to spend something like eighteen months in the general wards of hospitals.
829 The obvious solution would be to have private wards available, but I appreciate that to provide private wards for all patients would be so expensive that it would be quite impracticable, at any rate within the foreseeable future. Yet I am sure that something more ought to be done than is being done at the present time. No doubt many patients would not like to have private wards, especially the less educated and less sensitive types, who probably prefer to be with their fellow patients in the general ward. Yet, clearly, people who can afford it go to the private wards. It seems to me altogether wrong that in our present democratic age there should still be this distinction, this duality, between people who are well endowed with this world's goods and those who are not and who, as a result, are (I do not like to use the word, but I must) condemned to live in this way for substantial periods of time.
I should like to ask that this matter be dealt with. In a modern egalitarian and democratic community, it is intolerable that this situation should be allowed to go on indefinitely. We do not have to wait until it can be handled 100 per cent. A start can be made now, and it is important that a start should be made at the present time, because new hospitals are being built, and if they are built in such a way that provision for private wards cannot be made, the situation will become static and it will be impossible to handle it effectively. I would express the hope that in drawing up plans and in building new hospitals the situation should be kept so far fluid that private wards can be added in substantial numbers or small wards in proximity to the general ward. I should be grateful if the noble Lord who is to reply would indicate what the proposals of the Government are. I wrote to the Minister who I was informed was going to answer this debate, but I am afraid that the noble Lord who is actually going to reply may not have received the letter in time to get this information, and I shall be grateful for anything he has to say.
I have read that there is to be a provision of about 20 per cent. private wards. That does not seem to me to be adequate. I hope that it is not a rigid figure. It may be that that is as much as we can afford at the moment, but I trust that the possibility of expansion will be borne in mind. Meanwhile, it has occurred to me 830 that it should be possible to have in close proximity to general wards a number of private wards to which a patient who feels the need of being by himself can go to spend a week or even twenty-four hours. That would make a great deal of difference to him. Hospital beds are now easily moveable and it should be administratively possible to make some provision of this kind. Of course, it actually may be that something of this kind is being done, and if it is, I apologise for trying to teach my grandmother to suck eggs. I am very much out of my depth in debates of this kind. I only wanted to make this particular point because it has been brought home to me by the experience of my friends.
There is one other aspect on which I should like to touch before I sit down. It is one of considerable psychological importance. It is the problem of the visits of relations to patients in hospitals. From my own experience, I know that visits of relations are looked forward to with astonishing eagerness. Hardly anything counts so much with many patients in hospitals as the visits of close relations. The short amount of time which is available in general wards is a considerable contrast to the arrangements which are made in the private wards, and the absence of seclusion weighs heavily—and there can be no question of this—on husbands visiting wives or people visiting sweethearts in general wards. I am certain that the provision is not satisfactory. It is possible that in general wards as they now exist it cannot be made much better, but with a larger number of private wards or even small rooms available, to which the walking patients, at any rate, could go and see their close relations, not under the scrutiny of the entire ward, we may be well on the way towards a solution of this problem. Perhaps these matters are a little apart from the general run of this debate, but I am sure that they are matters of considerable importance and I do not apologise for having brought them to your Lordships' attention.
§ 6.20 p.m.
§ LORD TAYLOR
My Lords, some years ago I was a patient in hospital and I certainly had occasion to endorse the observations of my honourable friend Lord Chorley about the need for privacy and for small wards for some 831 patients. It must also be said in fairness that there are many people who enjoy being together in small groups and not just on their own. They get depressed and miserable by themselves—I rather work the other way. In modern hospital design, the aim is to provide something like four or five groups of four beds and five or six single rooms as a ward unit. That makes a very good working unit, plus some day space, and it meets the point which the noble Lord, Lord Chorley, has made.
When I was a patient, there was one other matter which I must say made a deep impression on me, and it has been referred to in this debate. I was greatly helped by the hospital chaplain. The value of a hospital chaplain who really does his job and goes and helps people at a time when sickness, as the right reverend Prelate the Lord Bishop of Chichester said, makes you think about things that perhaps you have not thought about for a long time, is really very great indeed. I was immensely aided by the hospital chaplain and he certainly helped to restore me to health again. I hope that all that can be done to assist the hospital chaplaincy service will be done. Incidentally if it is of any assistance to the right reverend Prelate in his arguments, I may say that Holloway Prison has one full-time chaplain for 350 women, which is rather more than one for 750 patients permitted by the National Health Service.
When fresh eyes look at old problems they notice things with which most of us are so familiar that we take them for granted. To-day my noble friend Lord Stonham has brought fresh eyes to bear on the old and forbidding hospitals of our great cities, and he sees dirt, dilapidation and decay. As he said, these are enemies which medicine has been fighting since the time of Florence Nightingale, Spencer Wells and Lord Lister. The fact is that two-thirds of our hospitals are in fact Victorian workhouses or public assistance institutions. Two hundred of our hospitals occupy buildings which were completed before 1820, and as long as these buildings remain in use we are bound to have a tough and costly struggle to keep them even reasonably efficient and reasonably safe. If this debate has done nothing else but open the eyes of the people of 832 this country to the physical conditions under which patients have got to be treated and cared for in these old hospitals, then it will have been worth while, and we are all in the debt of my noble friend Lord Stonham.
But the debate has done a good deal more than this. Your Lordships have surveyed the picture of hospitals as a whole. In England and Wales there are in fact about 2,600 hospitals, and even your Lordships could not do full justice to every aspect of all their problems in the course of a single debate. But you have gone a long way towards this, for the hospitals naturally group them selves into certain types. First, there are the great teaching hospitals in London and the Provinces. My noble friend Lord Cohen of Birkenhead speaks here with the greatest authority. He spoke particularly of Liverpool, but I think he knows all the teaching hospitals well, and he knows a great deal about the non-teaching hospitals through his association with the Liverpool Regional Hospital Board and through being one of the trustees of the Nuffield Provincial Hospitals Trust. I could not find anything in his speech with which I did not agree. One is only sorry that my noble friends Lord Nathan and Lord Moran were prevented by their Health Service duties from adding to the debate their special knowledge of the London teaching hospitals.
Important though teaching hospitals are in providing the leadership and the standards which they set, the great bulk of hospital medical care in this country is in Regional Board hospitals. Many of these are of the type so vividly described by my noble friend Lord Stonham, but in the smaller Provincial cities another type of hospital is often found, well exemplified by the Royal Berkshire Hospital at Reading. On the staff of that hospital is my noble friend Lord Waverley, who serves there as a physician. I am particularly privileged to add my congratulations to the noble Viscount on his maiden speech, because he and I were students together at St. Thomas's and also for a short while in Frankfurt-am-Main. I must say that I do not think either of us dreamt, when we were perhaps behaving in a rather less decorous way, as medical students sometimes do, that one day we should 833 be speaking in the same debate in your Lordships' House. We hope that we shall hear from the noble Viscount again. He has spoken to us—and again I can endorse from personal experience everything he has said—about the difficulties, problems and tensions under which the staff of Regional Board hospitals have to work.
Of the 470,000 beds in the National Health Service, 200,000 are psychiatric beds, and of these 61,000 are beds for mental defectives. Their problems have been high-lighted in the speeches of my noble friends Lord Grenfell and Lord Pakenham. I must say that I share Lord Pakenham's hope that it will not be long before we have a full debate on this subject, because it cannot be dealt with as the tag-end as a part of the hospital problem. They are a specialised problem, and for this reason: that in the mental defective hospital the hospital and the school meet. They are residential places where people have got to be taught, live and have their being, in a way which now happily is getting rarer in the mental hospitals. It is much more like the situation which arises in, say, the physically defective school. So one hopes that this subject may be properly treated in the not too distant future.
The reply for Her Majesty's Government is to be given this evening by my noble friend Lord St. Oswald—and I hope he will not mind my calling him that. It is something of a special day for both of us, because, in a sense, we are both "cracking our ducks" in speaking from the Front Bench for the first time. If he had been a little older, or I had been a little younger, we should have been at school together at Stowe, where we both served under a remarkable headmaster, the late Mr. J. F. Roxburgh, who was very much given to what are called sesquipedalian sentences, and if either of us ever gets sesquipedalian your Lordships will know why. I hope that my noble friend Lord St. Oswald will feel that both the temper and the tenor of this debate have been directed to an object which we can all embrace and support—namely, the improvement of the Hospital Services in this country. I hope he will speak for the Health Services for many years, but not too many years, and to help him in the years ahead I hope he will accept 834 this little pamphlet. It is called Members One of Another, and it was the Labour Party's policy for the Health Services, published just before the General Election. Lest he should think it is part of a deep-laid Socialist plot, let me read to him what The Times said on October 1 last:Nine-tenths of the improvements in the Hospital Service which it suggests will not provoke Conservative dissentWe will not worry about the one-tenth, provided the Government accept and carry out the rest.
In attempting to draw together the threads of this debate I propose to touch on three subjects only—namely, the overall cost of the Hospital Services, capital and maintenance expenditure, and the administration, and for this reason: that if we get the right answers in these three spheres of activity, all the rest will follow and drop into line. First of all, then, the cost. Our Hospital Service costs about £400 million a year, which is 57 per cent. of the total cost of the National Health Service. For this we get 470,000 beds, and in these beds 4 million patients are treated every year, and at the same time 55 million people attend the hospitals as out-patients. To see these enormous figures in perspective one would just remind your Lordships that in an average year, at the same time as the hospitals are doing all this work, the general practitioners are rendering about 200 million acts of service for their patients, at a cost of only 10 per cent. of the total National Health Service bill, though to this has to be added another 10½ per cent. for the cost of the drugs and appliances that they prescribe.
The question to which I think we must address ourselves is this. Is this total cost of £400 million per annum too much, too little, or about right? The figures are so big that there is a risk that we may not see them in their proper proportion. In a recent editorial on March 24 the Lancet said this:There is a risk of the National Health Service being skimped for cash, while the rest of Britain prospers.The only way we can intelligently assess our Hospital and Health Service spending is to examine the proportion of our national wealth which goes to these Services. Fortunately, there was a recent report from the International Labour Office, published this year, which showed 835 that the cost of medical care in most developed countries is between 3.7 per cent. and 4.5 per cent of the national income. Top of the league was New Zealand, which spends 4.6 per cent. of her national income on her Health Services. Next come the United States and Norway, which spend 4.5 per cent. Then come Canada and France, which spend 4.4 per cent. Then come Belgium and ourselves, spending 4.0 per cent., and after that come a number of other countries. If we were to spend the same share of our national resources as France and Canada, it would mean an extra £67 million a year.
Are we prosperous enough to spend on our Health Services the same as France and Canada? I would suggest that we are, and that if we spent that money we should have enough to do all that we have in mind. It can be fairly said, I think, that at present we are getting our Health Services, and particularly our hospital services, on the cheap. Moreover, we are the only country of the ones mentioned where the proportion of national income devoted to Health Services for the past years has actually fallen. I think the trouble has been—and this is not just something to do with Her Majesty's present Government; it was the trouble and a difficulty with the Labour Government of 1945 to 1950—that they were hypnotised by the gross figures. Consequently, there was a continuous search for economy. I think we ought instead to think of the cost in relation to our national resources, so that the Health Services may share in any general prosperity, and we should make our search one for true efficiency, which will automatically bring with it true economy.
Now a word on capital and maintenance expenditure. For ten years the hospitals have been starved of both. In this period one-third of our schools have been rebuilt, but only one new hospital has been completed. Now, at last, we can look forward to substantial Government spending on the hospitals. The figure suggested by the British Medical Association of £75 million per annum as the proper capital expenditure on hospitals has been mentioned. I think we shall be well content if the figure reaches £50 million in a reasonable time. But whatever the figure, the 836 important thing is that we should get good value for money. In new hospital construction it is certain that there are going to be mistakes, but we must profit from them. The reason why there are bound to be mistakes and difficulties is this. First of all, the lack of experience of architects. They have not designed any hospitals in this country, or virtually none, for 20 years, and there is all that leeway to be made up. The second difficulty arises because all of us, when we get into committees and start planning new buildings, tend to get rather grandiose and to think about building magnificent marble entrance halls and memorials to ourselves. And doctors are certainly not immune from this. We all want the optimum maximum for our own departments, and no one wants to compromise. At the same time, we have the feeling that if we push hard enough the public purse is bottomless.
Then there is the fact—one hardly likes to mention it; nevertheless it is a factor—that both architects and quantity surveyors, when they design buildings, are paid on a percentage basis on the cost of the building, so that the more expensive the building, the bigger the architect's and quantity surveyor's fees. It is fair enough in one way, because the amount of work they have to do goes up; but at the same time it presents a continuous temptation, perhaps quite unconsciously, tending to inflate the costs of hospital and other public buildings.
Fortunately, the barren years have not been entirely wasted, because there was set up a body called the Advanced Architecture Division at the Nuffield Provincial Hospitals Trust and the Nuffield Foundation, run by that excellent young architect Mr. Richard Llewellyn Davies. They have done some first-class studies on hospital design, precisely meeting the type of point my noble friend Lord Chorley was talking about; and now, when the time comes to build, a great deal is known. The Nuffield Trust has also financed a good deal of small Health Service building, which again has given us information which we need in order to do the job economically and efficiently. Indeed, it has been possible to cut the cost, for example, of building a health centre, from £200,000 to £30,000, without any loss of efficiency and, indeed, in some ways with a gain.
837 Another encouraging thing that is happening is the appointment of Mr. Tatton-Brown as the Chief Architect to the Ministry of Health. He has had exceptional experience in Hertfordshire, building schools. There are, however, some excellent hospitals now beginning to go up. I should like to draw your Lordships' attention to two of these, and I am sorry that the noble Lord, Lord Cottesloe, could not be here this evening, because they are both in his region and are a tribute to the work which the region has done. The first is the Hatfield. Welwyn hospital, designed by the Regional Board's own architects, Mr Maunder and Mr. Andrews; and this is a very interesting hospital. It is a vertical hospital, and what looks like a fairly expensive type. One wishes some, times that we had a projector here, so that we could show illustrations of our talks, but that might present problems with Hansard. But I have here a picture of this hospital. It has 340 general beds, and the important thing about it is that its cost, including the fees, is just under £6,000 a bed. There have been a number of hospitals projected and under construction which will cost sonic thousands of pounds more than that. It is going to have a psychiatric wing of 100 beds, and the cost there, including fees, is just under £3,000 a bed. I think that is a very good achievement, and it sets a target at which to aim.
One cannot emphasise enough that, given a certain allocation by Her Majesty's Government for hospital spending, if we can do the job efficiently and build as many beds as we can for that money by avoiding extravagant and unnecessary expenditure, we are serving the patients well. The other hospital is a very interesting one which is being built at Wexham Park, near Slough. It is a 300-bed hospital, and has been designed by two young architects, Powell and Moya, in association with Mr. Richard Llewellyn Davies. It is a single-storey building. Up to now single-storey hospital building has been thought of as a very sprawly affair, with vast long corridors and spread-out communications. Here they have done something quite different. They have made it compact, much more like an Oxford or Cambridge College. The result is that communications are 838 exceedingly convenient. It is well ventilated, and the whole building is capable of being added to very simply if excess needs arise. There are great advantages from having single-storey buildings, constructed for Health Service purposes.
I would mention here two or three other things about architectural design, and the importance of flexibility in hospital design. Function is continually changing, because diseases are changing. There is just one personal foible or feeling with which I hope your Lordships will sympathise: that architects tend to use far too much glass in hospital design. There was a Dr. Rollier, who was very famous in Switzerland in the inter-war years, who introduced heliotherapy for tuberculosis, and there was a lot of talk about "Dr. Sun". This, I think, has just reached the architects, and they now tend to build everything out of glass because it is healthy. But glass is not necessarily healthy; it may be very hot in summer and very cold in winter. And while it is nice to look out of the window when you are ill, it is not so nice to be continually exposed to public gaze. Architects forget that patients have to undress and do not want to do it in an aquarium. They put up the glass and then put up Venetian blinds to cut off the glass. Such blinds are terrible dust traps. They are very fashionable with architects at the moment; they have found out how to make them from aluminium. They were given up when they were made of cane in Victorian times.
Planning a hospital is like planning a campaign. The big mistakes are made long before the architect puts pencil to paper. Preliminary planning is all important. As the noble Lord, Lord Cohen of Birkenhead, said, you have to begin by setting the population the hospital is to serve; and not merely its size, but its age composition and the incidence of the different types of disease, so that you can really work out what the hospital has got to do. Up to now the architect has been told to go ahead and build a 200-bed general hospital. That is quite unrealistic. The whole thing has to be planned very carefully: careful study of the work to be done, the rooms and room sizes required to do it, and then preparation of a complete and detailed brief for the architect. 839 Above all, one man, and not a committee—or worse, several committees—has got to act as co-ordinator and client to the architect. I think he should be a senior experienced officer, either a doctor or hospital administrator (it does not matter which), and in the case of a Regional Board he should be in a position to devote pretty nearly all his time to doing this job of hospital planning and design. He will save his salary, which one assumes would be £2,000 or £3,000 a year, many hundreds of times over in unnecessary and wasteful hospital construction.
At the present time there are two great defects of hospital building. The first is control of cost, and the second the interminable delays while papers go up and down and back and forth from the Ministry to Regional Hospital Boards, hospital management committee and the medical committee. Control of cost is perfectly simple. Its basis ought to be a block allocation of money to cover the site, the site works, the fees for the architects and quantity surveyors, the fittings and the furniture. I would suggest that the figure we have had for the Hatfield-Welwyn Hospital of £6,000 a bed is perfectly all right. If you tell the architect this, he will say at once that it cannot be done. Then you say, "All right, it cannot be done. Off you go, chum". Then he will start and he will go ahead and do it for that money, and you will get your hospital for that given sum. To get rid of the delays there must be a clear allocation of responsibility and power of action. I think the Ministry must delegate the whole job to the Regional Hospital Boards without the need to refer plans back time and again for each little alteration. Of course, the Ministry experts must co-operate with the Regional Hospital Board by sitting in when the planning process is actually going on, but they must not have to approve and control. They should do it by advice and not by orders. If we do this, and if the Government will trust those it appoints as its agents, we shall achieve efficiency, speed and economy in hospital building.
I should like to say one word on maintenance expenditure—and my noble friend Lord Stonham was absolutely right in what he said. But, despite 840 the difficulties, much has been done. There are vigorous hospital management committees, and vigorous administrators, who have been able to do wonders by pinching and scraping out of current budgets. That is the way it has been done. Nevertheless, it is a constant struggle, and surely we ought to set aside a proper percentage of running costs and earmark it for maintenance, because we have got to put up with the buildings; there is no possible alternative. We have gat to continue using the 1800 ancient hospitals we have, and we must maintain them properly or we shall be in a completely hopeless situation. One would ask that the percentage set aside for maintenance should be comparable with that set aside in industry, and here is a problem I think for the new Advisory Council on the management and efficiency of the National Health Service which the Minister has just set up, under Sir Ewart Smith. I must say that I am very glad about the appointment of this Committee. Sir Ewart Smith is not only a scientist but has been Vice-Chairman of I.C.I., and we hope that he will bring methods of business efficiency into some of these problems and give high priority to this business of hospital maintenance. We would ask: is the Sir Ewart Smith Committee a permanent committee, which will report periodically to the Minister, or will it just make an investigation and issue a single Report? Will it take evidence? Will its members go out into the field, and will its findings be published?
I have spoken of delay in decisions over capital expenditure. It is just the same over day-to-day administration. My noble friend Lord Stonham spoke of the three-tier system: the house committee, the hospital management committee and the Regional Hospital Board. It is, in fact, a five-tier system: the house committee, the hospital management committee, the Regional Hospital Board, the Ministry of Health and the Treasury; and it is the existence of those five levels that produces the trouble. I do not feel like blaming the officials of the Ministry of Health for the slowness and frustration experienced. I think the real cause lies in the design of the Service and in the method of finance and control. Some of these difficulties are precisely similar to those which one sees in all large organisations. This is the sort of 841 problem one sees in I.C.I., Unilever, I.C. and T., and all the rest of it.
The great problem is the degree of autonomy to be given to the peripheral unit. They are all finding that the more autonomy given to the periphery, the better the job is done. In the case of the Hospital Service there is the added awful complication of detailed Parliamentary accountability, which results in grossly excessive recording and reference to higher levels. It is rule by circular and policy-making by making of returns. I think that Sir Ewart Smith will find that administrative costs have increased startlingly over the last ten years to no purpose whatsoever—or very little purpose—except to make it possible for Parliament to ask any sort of question whatever about any patient in any hospital in the country. And that, I suggest, is an absolute farce.
There is the further difficulty in administration, the multiplicity and size of committees. I read only to-day that the Manchester Regional Hospital Board was proud to say that it had no hospital management committee with more than eight sub-committees. I have served on a number of public bodies and investigated others, and I find that efficiency varies inversely with size. The smaller the committee, the better it is. The two best I have personally struck have been the B.B.C., which is a wonderfully efficient organisation, and the New Town Development Corporations; and if I may say so, there are dozens and hundreds of examples in private enterprise. If any ordinary private enterprise concern had a management committee of 28 members and 8 sub-committees, each of 17 members, I should think many times before I invested my money in it, if I had any to invest. But the two examples I have quoted both have governing bodies of eight members, with no sub-committees. All their decisions are definitive. As it is, in the Hospital Service the hospital administrators spend most of their time servicing committees, when they ought to be doing real work; decisions go back and forth from the finance committee to the catering committee, the works committee, the medical committee, the nursing committee; and decisions do not get taken for months and months. My noble friend Lord Stonham and I discussed this question when he started, and I am 842 pleased to say that he has stopped that sort of thing.
The trouble has arisen because there is confusion over representative and executive functions. Regional Boards and hospital management committees were designed to be representative, to meet all the interests: the local authorities, the voluntary hospital people, the trade unions, doctors, women's institutes and all the rest were all to be represented on these bodies. But in fact they are executive bodies. The answer is to reduce the size of hospital management committees and Regional Hospital Boards to a maximum of eight members; to forbid the formation of sub-committees. And I myself would pay members of Regional Boards as we pay members of other public corporations. Much of this, although not that last suggestion, could be done without legislation—indeed, it has been done in the case of the Oxford Regional Hospital Board where Sir George Schuster has carried out this sort of function and has produced an exceptionally efficient piece of machinery.
To perform the representative functions one needs something quite different, and I would think that the answer here is to have large advisory councils, elected by the local authorities and other bodies, alongside the Regional Hospital Boards and hospital management committees. They might meet in plenary session, in public, for a couple of days, once or twice a year, for a grand inquest on the work of the committee or the Board. Given such advisory councils, I would see little justification for day-to-day inquests on individual cases in Parliament.
My noble friend Lord Stonham made a plea for a National Hospital Corporation as an escape from the disadvantages of day-to-day Parliamentary and Treasury control. In fact, the Regional Hospital Boards are bodies corporate. The need is for them to be allowed to behave as bodies corporate. They need not only responsibility but power as well. We have often heard orators speak of the evils of power without responsibility. In these days it is a much greater evil, and a much more common thing, for people to be given responsibility with no power, and it is something we ought to put right if we are to make democracy 843 work. The Boards need to be free from day-to-day, or even year-to-year, of Treasury and Ministry control, save as to their overall budgetry allocations and as to national negotiated agreements.
My Lords, I have spent far too long on this detailed consideration of the administration, because these are the limiting factors. Our hospital services are good—they are better than ever before. But the Service itself is just not quite as good as it should be. The calibre of the staff, medical, nursing, ancillary and administrative, is very high, and wonderful work in the latter group has been done by the King's Fund College for administrators. But their enthusiasm needs to be rekindled. They need quick decisions; they need the freedom to decide, and enough money to do the essential jobs. It has been our purpose in this debate to help Her Majesty's Government by showing what needs to be done, and how it can be done. We do not expect complete or comprehensive answers to all the points we have raised to-night. We believe that the time has come for a new deal for our hospitals, and for the sick and disabled whom they exist to serve. In every positive step towards this end the Government can count on our full support.
§ 6.54 p.m.
LORD ST. OSWALD
My Lords, my first thought and my first desire on rising to-night is to follow other noble Lords in congratulating the noble Viscount, Lord Waverley, on his most remarkable maiden speech. I do not know whether he was present in this House on January 28 of last year when some of its greatest figures paid tribute upon tribute to his father—a series of tributes which were described by my noble and learned friend Lord Hailsham as being seldom heard before in this House. I know he had not taken his seat by that time, but if he was within the hearing of the House it may account, I think, for the very high standard that he has set himself in his maiden speech to-day—a high standard which was so notably achieved. Indeed, it is humbling and salutary to realise that my own debut is bound to be a good deal less distinguished than his, and a good deal less distinguished than any of the other three "maiden" speeches which have preceded mine.
844 I hope that the noble Lord, Lord Stonham, is aware of the warmth as well as the respect of my feeling towards him. He has presented his argument to-day—for it was an argument—with a force and a candour that I was expecting. He has been critical, and in his criticism he has used figures which I certainly cannot fault. But he will forgive me, I know, if I draw some different conclusions from those facts and figures and from others which, through sheer shortage of time, he omitted. One would hardly have guessed from the selective spotlight of the noble Lord's review that we are living in an epoch of quite dramatic expansion in the Hospital Services; but there are facts and figures which I hope he will find equally faultless and which stand to demonstrate this expansion in very striking terms.
Until 1955–56 a maximum of £10 million had been spent in any one year in hospital building in England and Wales, but in that year a series of major building schemes was announced covering new hospitals and replacement of plant. These programmes are now being carried out and provided for a good deal more generously than the noble Lord's speech suggested. Last year the figure was £20 million; this year it is £22 million, rising to £25½ million next year, and in 1961 it will be £31 million. These figures were in fact given by the noble Lord, but in rather a disdainful way, and he quoted as the proper figure, I believe, £75 million, which was given by the British Medical Association. If the day ever comes when the noble Lord's Party is in power, I wonder whether he will regard the findings and the advice of the British Medical Association as entirely binding upon the then Minister of Health.
§ LORD STONHAM
My Lords, if the noble Lord will allow me, I would say that if my Party had been in power we should have been looking forward now to an expenditure rising to £100 million a year on hospitals.
LORD ST. OSWALD
My Lords, that I think was a question that arose during the Election campaign, and there was a certain amount of disbelief as to the potentialities of the noble Lord's Party to find such a sum. These increases are mainly devoted to programmes announced in 1955 and subsequent years 845 to be centrally financed. This rising expenditure is reflected in an ambitious programme which now includes over 150 major projects in course of construction or planning—the definition of "major" being a minimum outlay of a quarter of a million pounds per project.
Use has been made by the noble Lord, Lord Stonham and others of the apparently depressing fact that no hospital has been built in the last twenty years, although Lord Taylor admitted to one new hospital. It is a fact that no new general hospital, and in fact only one new hospital of any kind, has been built during that time, but it is, I would suggest, a slightly pedantic insistence on fact if one knows, as I am sure most noble Lords do know, that six new hospitals are already in extensive use, although further building remains to be completed. Nevertheless, they are working to-day as self-contained hospitals, and if, as projects, they had in the first place been less ambitious, they could be referred to now as new completed hospitals. The six are the Balderton Hospital at Newark, about which I shall have a little more to say later; the Good Hope Hospital at Sutton Coldfield; the Greaves Hall Hospital at Southport; Oakwood Park at Conway; the West Wales Hospital at Glangwili in Carmarthen and the Princess Margaret Hospital at Swindon. Three out of these six are mental deficiency hospitals. Work on another nine new hospitals is already in progress; building will start on four more in the next financial year: and yet another eleven are being planned.
I think it would be of interest to noble Lords to know that out of those thirty new hospitals, eight are teaching hospitals and five are mental deficiency hospitals. This does not include major extensions to existing hospitals, which in terms of beds and services are in some cases as large as new hospitals themselves.
I cannot help feeling, for instance, that had the noble Lord, Lord Nathan, intervened in this debate, as was his wish, he would have spoken with, if possible, even more than his normal benevolence, and this would be partly owed to the approval announced three days ago by my right honourable and learned friend in another place, of the Westminster Hospital plan to develop the Page Street 846 site. The cost of this is estimated at £990,000, the first stage costing £523,000. The whole scheme will include a six-storey building, with a number of special departments and services. The site is now owned by the Westminster Hospital and has been made available free by the Governors for development; and once it is under way noble Lords will not have to voyage far to see with their own eyes the flowering of some of the rather dry figures that I have felt obliged to give. The noble Lord, Lord Nathan, regretted very much his inability to be here to-day, though hardly as deeply as I regret it myself. No doubt he will be easily persuaded to show Members of the House over the building, which will have owed so much to his own determination.
Before leaving the whole question of finance, with its unavoidable strings of figures, upon which the noble Lord, Lord Stonham, also dwelt at some length, I must refer to the level of revenue expenditure itself, which he regards as being on the grudging side. The amount provided for the Hospital Services in England and Wales for the current year is £381 million compared with £363 million for the previous year.
I should emphasise here that these figures refer to England and Wales alone, but there has been no sign during the debate of any noble Lord from Scotland rising to complain of unfairness to his notoriously hardy race. Had he done so, I was prepared for him. Such noble Lords will no doubt have read, I hope with pleasure, the Answer given in another place on Monday announcing further expenditure on hospital building in Scotland. This will be of the order of £3.2 million in 1960 to 1961 and £3.9 million in 1961 to 1962. Although the level of capital expenditure for subsequent years in Scotland cannot yet be fixed, my right honourable friend the Secretary of State has asked Regional Hospital Boards in Scotland to prepare plans for these major projects: at the Royal Infirmary of Edinburgh, a new out-patient department and casualty accommodation, as a first stage of the reconstruction of the hospital; at the Western General Hospital, Edinburgh, a new out-patient and casualty department, also a first stage in reconstruction; at the Western Infirmary, Glasgow, a new out-patient and casualty department, another first stage; at the Glasgow 847 Royal Infirmary new specialised facilities for treatment and research, new accommodation for some of the professorial departments and a new ophthalmological department; and a new unit at Foresterhill, Aberdeen, beside the existing hospitals there, to provide mainly additional surgical beds and operating theatres. Detailed planning of those projects should be ready in time for building to start by 1962 or 1963. Plans for a new teaching hospital at Dundee are also being prepared, and all these projects are intended to provide a radical improvement and extension of the facilities available in the main Scottish teaching hospitals.
Although the Guillebaud Report was published in January, 1956, I feel it is likely to be quoted for many years to come and I am not shy of quoting it now. In Paragraph 100 of the Report it was considered thatThe total amount of the country's resources to be allocated annually to the National Health Service is and must remain the responsibility of the Government which must relate the needs of the National Health Service to other competing demands.I am sure the noble Lord did not ignore, and I doubt if he would disagree with, this view. But the Report also pointed out that to make the Service fully "adequate" in the extreme interpretation, a greatly increased share of the nation's human and material resources would have to be diverted to it from other uses, and the noble Lord will not ignore that either, I am sure. It made the further point that even if the Service were to become "adequate" by such a criterion, it was far from certain that it would remain so without continually increasing expenditure. The growth of medical knowledge adds continually to the number and expense of treatments and by prolonging life also increases the incidence of slow-killing diseases and the ailments as yet inseparable from old age.
I have made statistical reference to expenditure and I devoutly hope that I can now leave statistics behind me. The Government consider that the increased expenditure I have already mentioned is all that should be diverted at present from other uses. There remains the factor of improvements and of greater efficiency, and in this context I should like to emphasise the contrast between the old approach and the new.
My Lords, before the noble Lord leaves figures, may I ask whether he is going to reply at all to the figures I raised and the one or two statistical points I made?
LORD ST. OSWALD
Yes. I was trying to get away from the general figures. A great deal of active thought has been given to the development of out-patient work. The emphasis is now on keeping the patient if possible out of a hospital bed altogether, and, if he has to be in one, on getting him home as soon as that can be safely managed. The outpatient clinics contribute to these aims by undertaking diagnosis and treatment that would, until lately, have entailed admission as an in-patient. This is complemented by follow-up care and supervision, which allows the patient to go home after a fairly short stay in hospital, where hospital treatment has been necessay. Over £7 million has gone into new out-patient and casualty departments and improvements, in more than one hundred hospitals, with this end in view.
There is also a great deal of new thinking in the matter of design. A small design unit, set up in the Ministry five years ago, consisting of architects, engineers and doctors, has already prepared and published one study on the design of operating theatres and a further study is nearing completion on the design of nurses' homes. Work proceeds on a number of other studies, principally out-patient departments and kitchens. In Scotland a similar small design unit consisting of experts has been set up in the Department of Health for Scotland which will undertake studies complementary to those of the other unit and not overlapping.
The Ministry's design unit is now being greatly expanded and with it the production of bulletins will be speeded up, but, in addition to writing bulletins, the unit will design certain hospital departments to be built in various parts of the country. The first of these will be an out-patient department at Walton Hospital in Liverpool. Another department which may also benefit from this work is the hospital kitchen. The aim of such building will be to demonstrate the fruits of this highly professional study and to illustrate to hospital authorities the Ministry's ideas with regard to design. A further aim will be 849 to demonstrate the cost at which various hospital departments can be provided, and, as part of this, detailed costing will take place and the lessons learned will be passed on to the hospital authorities. It is hoped that this will lead to significant economies and also give hospital boards the chance of comparing various plans and finding one suited to their particular needs.
Other noble Lords will know far more than I of the great variety as between hospitals and of the obvious limits to standardisation which could be achieved or would be desirable. The object of this work is to demonstrate how value for money could best be obtained, to the advantage, in good and economical design, not only of the hospital authorities, but of the architect whom they engage.
This is related to the dissatisfaction of the noble Lord, Lord Stonham, with the present building procedures, and his views on this are bound to command respect. My right honourable and learned friend is at least equally concerned, and I doubt whether there is much separating their views. It is his decision that the Ministry will now take increased initiative by getting a great deal more information to boards about hospital design which they can then use in preparing their plans, instead of waiting for them to submit their own ideas without any prior knowledge of the Ministry's views. Clearly, I should have thought, valuable time can be saved and will be saved in this manner, to the delight of the noble Lord, Lord Taylor, who has been preaching that very doctrine tonight.
The noble Lord, Lord Stonham, has pronounced himself also in favour of another form of streamlining. He would like to see a central control of the Service, to see it placed under a National Hospital Board or Corporation. This has been discussed before on more than one occasion. The views of the noble Lord expressed to-day will certainly be given careful study; so also will those of his noble friend, Lord Taylor, who joined issue with him. The arguments against the form of streamlining suggested by the noble Lord, Lord Stonham, have also been stated before, and I hope that, in his turn, he will give them careful study. One great objection has still to be met, and was not in my own view met in the 850 speech of the noble Lord. That is the stern difficulty of entrusting the spending of hundreds of millions of pounds raised out of taxation to a body outside the control of Parliament. Such a Board could not be classified with the public corporations or the nationalised industries because those industries, even when run at a loss, are revenue earning. In money terms the Hospital Service is revenue-spending, and, as so far visualised, it cannot be self-supporting and must be mainly financed by the taxpayer. Money terms are not the only terms involved, and I will refer to this aspect a little later.
The fact remains that the Guillebaud Committee saw no way round this barrier, and even expressed doubt as to the value of the sort of change the noble Lord, Lord Stonham, urges. In paragraph 144 he will find it stated:We do not believe, however, that its advantage would justify the appointment of a new Board or Corporation whose constitution alone would pose a host of difficult problems. Nor do we believe that the appointment of a national Board would improve the integration of the Health Service.In naming some of the advantages he sees in such a system, could it be achieved, I wonder if Lord Stonham has bent his mind to seeing whether those same advantages could not be obtained within a Government Department. I am certain that any suggestion he cared to make in that direction would receive the closest and most careful attention.
The principal advantage of such a system, if I understood him aright, would be the easier interchange of staff between the different levels of administration But even this, as a purpose, conflicts with what I think is widely regarded as one of the great virtues of the Service, as established by the Labour Government in the 1940's—that is, the local bodies formed of voluntary members devoting a great part of their time and energies to this work. There are to-day 20 Regional Hospital Boards, 36 boards of governors of teaching hospitals, and 471 hospital management committees, or in Scotland boards of management: the chairmen and members of all these Boards and committees giving their services entirely free. No Government has seriously suggested changes that might interfere with or destroy this most precious element in the Service and possibly tip the balance towards over-centralisation and bureaucracy.
851 The noble Lord, Lord Taylor, has proposed a change, but not so much a change in principle as a change which in his view would make the present system more efficient and durable. I have no doubt whatever that this proposal, in common with all the other invariably constructive suggestions that come from the noble Lord, will be given constructive attention by my right honourable and learned friend and his advisers. But this is not the first time he has put forward his viewpoint on the matter and the reaction of my right honourable and learned friend's advisers appears to be that the noble Lord has formed that viewpoint from his great knowledge and experience of a New Town Corporation, and against that background. It is an idea that was examined by the Guillebaud Committee and was rejected on the grounds that the gain in administrative efficiency appeared dubious and that the loss of representation of the community would be too high a price to pay.
§ LORD TAYLOR
My Lords, will the noble Lord arrange for the Ewart Smith Committee, which is not headed by a don but by an industrialist, to have a look at this matter and find out whether perhaps there may not be something to be said for the small committee of management?
LORD ST. OSWALD
My Lords, I have said already that no doubt the noble Lord's words this evening will be given careful consideration, and I should have thought that that was one of the places where they would be considered. His suggestion of a larger advisory committee meeting once a year would hardly meet the need for representation which so characterises our national life and the institutions growing from it. That is still the feeling of the Government. Whether his eloquent words today will, on examination, alter the position remains to be seen, but without any doubt they will be read and digested.
His insistence, if I understood him aright—I may be mistaken—that the present proportion of the national product should never be allowed to drop below its present figure is somewhat harder to swallow. I agree with him that our prosperity is likely to increase for at least the next four or five years, 852 but to fix a proportion to be claimed as a right by any one Service would, I think, be a perilous procedure. I have already quoted the Guillebaud Report in its reference to "other competing demands"; and the essence of competition is surely that all those engaged should compete, if we are using that word, on equal terms. What the noble Lord seems to suggest is a kind of handicap system by which the Health Service would for ever have a start on the rest.
§ LORD TAYLOR
My Lords, no. We do not want any start; we merely want a fair share. If the national income goes down, then the Health Service should bear its burden along with the rest, and handle the cuts as best it can. But if the national wealth goes up, and when we know what the conditions are—my noble friend Lord Stonham has described them—it really is not good enough that we should not get the share of our prosperity to clean up—just wash the walls—of our hospitals.
LORD ST. OSWALD
My Lords, no. The point is that if we fix a proportion (I may be wrong in attributing this to the noble Lord), and make it permanent, then we make no allowance for increased demands from other services in a given year. The noble Lord means that everybody else has to be limited.
LORD ST. OSWALD
I beg your Lordships' pardon. I am not making myself plain to the noble Lord, and I think we had better discuss this matter privately. I am not speaking about the national income going up or down; I am speaking of particular circumstances in a given year which might build up a requirement or increase the requirement of other services, which would have to be cut down to fit this proportion promised to the National Health Service. Perhaps I was taking the noble Lord's words too literally. In that case I apologise.
However, I hope I have indicated already the priority and importance which the Government give to the Service during the present period of expansion; but I should like to point out that from the years 1949 to 1955 the gross cost of the whole of the National Health Service for Great Britain, as a 853 percentage of the gross national product, dropped yearly from 3.84 in 1949–50 to 3.24 in 1954–55. Since then it has risen steadily and is still rising steadily, largely due to the many improvements I have named during the course of my words. For 1958–59 it is estimated at 3.49 per cent.
LORD ST. OSWALD
The gross cost of the whole Health Service in Great Britain, as a percentage of the gross national product, dropped yearly from 3.84 in 1949–50 to 3.24 in 1954–55. Since that time it has risen steadily.
§ LORD LATHAM
My Lords, could the noble Lord say whether that drop was due to a fall in the cost of the Service or to an increase in the national product?
LORD ST. OSWALD
My Lords, I confess that that had not occurred to me. I think an increase in the gross national product.
More than one noble Lord has drawn attention to the pay of professional staffs, with special reference to pharmacists, radiographers, physiotherapists and almoners. These matters, as noble Lords know, are the concern of the Whitley Councils, and occasionally of the Industrial Court. An award of the latter last June improved the salaries of radiographers, and claims on behalf of pharmacists, physiotherapists and almoners are now under negotiation in the Whitley Councils. The machinery for such negotiation is agreed by the management and staff. Should there be a failure to reach agreement on the Councils they can be taken to the Industrial Court.
During the last two years the salaries of hospital staff have improved, in some cases substantially, as in the cases of higher salaries for administrative, clerical and nursing staff of hospitals. I would not attempt to deny the charge made by my noble friend Lord Waverley, and supported with figures, that some doctors and nurses are over-worked and 854 are too few for the demanding tasks required. This, of course, overflows the confines of the Hospital Service, but it might be worth mentioning that the number of whole-time and part-time consultants employed in the National Health Service in England and Wales has increased between 1949 and 1958 by 1,800; that is, from 5,189 to 6,988. One hundred and seventy-six new appointments have so far been approved this year. The expansion has not been entirely level. In general medicine it has been on the low side. Training difficulties are partly responsible for this shortage. In radiology, for example, only about half of the required training and experience can be obtained in the course of normal hospital work, and a university course is necessary. This limits training largely to teaching hospitals, and that was my reason for emphasising earlier in my speech the fact that, out of the thirty new hospitals which will be functioning in the next few years, eight will be teaching hospitals.
It is quite true that a number of these thirty hospitals have not advanced very far beyond the proverbial twinkle in my right honourable and learned friend's eye, and further criticisms have been made in the debate on the time taken to get going with such building. I hope I did something earlier in my speech, not to reject these criticisms but to give some reassurance that they are being met. The belief is that by giving more information at the earlier stages of planning, time can be saved in the later stages such as the scrutiny of working drawings. This would mean that the full weight of criticism would be delivered before, and not after, planning had reached an advanced stage—and that, I think, was precisely the point made by the noble Lord, Lord Taylor.
The noble Lord, Lord Stonham, introduced the subject of war damage, and here I think one should say that the needs and problems of different localities will be, and are, always respected. However, national considerations have also to be borne in mind. There was one aspect of war destruction which the noble Lord omitted in suggesting, as he seemed to, that such destruction should always be replaced to provide at least the same hospital capacity as before the bombing. 855 At first sight this appears to be undoubtedly so; but, in point of fact, as he knows better than I, there are cases where one result of the bombing has been a permanently reduced population due to industries and householders, once evacuated from an area, remaining, so far as one can see, for ever outside that area.
Where the population is reduced, it is reasonable to think that the hospital requirements are also reduced. For instance, the population of the County of London is not far less than one million under what it was in 1938. One must therefore think, before making good the hospitals to what they were before the war merely because they were there, and study the new population figures. Before the noble Lord rises in indignation, let me say that I do not suggest that there is a neat rule-of-thumb ratio to follow in this matter, it is quite possible that the hospital capacity of a district was inadequate before its partial destruction and is now only slightly less inadequate as a result of the movement of inhabitants. I am not saying that the former capacity of war-damaged hospitals should be ignored: I am saying that it should not be the only consideration or the minimum yardstick—and I do not suppose that the noble Lord will disagree with me there.
§ LORD STONHAM
My Lords, if the noble Lord will allow me to say so, I agree with him that if the population has fallen there is no justification for rebuilding hospitals for which there is no longer any need; but there is a proper need in these circumstances. The case to which I referred has had no capital expended on it at all in the last eleven years except for £14,000, which was for the repair of war damage to the roof of the hospital, which they are not allowed to use—a most extraordinary state of affairs.
LORD ST. OSWALD
Yes. I was very struck by the noble Lord's argument in particular, but I was speaking in general. I had hoped I had made it clear that I was speaking in general and not in particular, and was not contradicting him on his own example.
He also referred specifically to the need, widely recognised, for hospitals to be clean; and he focused upon the danger of cross-infection. Last year my right honourable and learned friend 856 sought the advice of his Standing Medical Advisory Committee on this subject. They appointed a sub-committee under the chairmanship of Lord Cohen of Birkenhead, who is also chairman of the main Committee, to make a complete investigation, and the Report of this sub-committee was published this year. It brought together a great number of detailed suggestions as to precautionary and preventive measures. The Report was commended by the Minister to all hospital authorities, who are undoubtedly taking full action. It deals in detail with measures to keep hospital premises and equipment free from contamination, and hospital authorities are bound to give high priority to these measures and to these proposals. When these take effect, the noble Lord, Lord Cohen of Birkenhead, will have played his part in yet another advance in medical practice.
This connects fairly directly with the accident services, which were also mentioned by my noble friend Lord Auckland. My right honourable friend is well aware of the importance of this problem, which has come into particular prominence in recent years. Very large numbers of accident cases are brought to the casualty departments of hospitals. The number of attendances has risen by 1½ million between 1949 and 1958—that is to say, from 10,108,000 to 11,759,000. Measures have been taken. In 1953, a new grade of senior casualty officer was introduced in larger centres, and there are now seventy-one such posts. In the last ten years the number of consultant orthopædic surgeons has risen from 227 to 365. The number of traumatic and orthopædic surgical beds has increased from 12,000 in 1950 to 18,000, in round figures. In the same period, the number of in-patients treated rose from 133,000 to 244,000, which noble Lords will quickly appreciate is not in the same proportion. However, orthopædic services have been set up in many centres, and are still being set up; and there are special arrangements for the treatment of fractures in a great majority of hospital centres now.
In the matter of major accidents, my right honourable and learned friend issued guidance to hospital boards in 1954 advising on the medical arrangements that should be made. These 857 arrangements, once adopted, stood the test of such major accidents as the Lewisham railway disaster. They became the subject of careful study by the hospital board concerned in that disaster, and all boards have been asked to review their own arrangements in the light of the lessons learned there. All this has not prevented a strongly critical report by the British Orthopædic Association in recent weeks, with which some noble Lords are no doubt familiar. The report is being studied by my right honourable and learned friend, and has been brought to the attention of the Regional Boards. The detailed survey of casualty departments is also being carried out under the auspices of the Nuffield Provincial Hospitals Trust. My right honourable and learned friend is anything but complacent about the situation, and will seek further advice on these problems from his standing medical advisory committee.
Geriatrics and the chronic sick have also been touched upon in the debate, and the noble Lord, Lord Stonham, considers that provision on a ratio of 1.2 beds per 1,000 for this type of patient is not enough. But the chronic sick survey of 1954–55 considered it adequate, and this guidance has been followed until to-day. There are now about 58,000 staffed chronic sick and geriatric beds in England and Wales—that is, for nearly 1.3 per 1,000 of population—which implies that there is no overall shortage on the standards of the survey. There are undoubtedly serious local shortages of beds in areas with an exceptionally high proportion of old people, or where the domiciliary and welfare services are not fully developed. In these areas, local authorities are doing their best to improve their services and to persuade families to accept a responsibility in this matter. Hospitals do this not only through additional beds but by setting up geriatric departments where elderly patients can be assessed and given active treatment and rehabilitation. Nearly 100 such departments have now been set up in England and Wales. It may be, as the noble Lord, Lord Stonham, has said, that, as time goes on, a greater proportion of hospital resources will have to be devoted to old people. At the moment, there is no evidence that the demand is growing faster than it is being met. In fact, the 858 total waiting list for admission to chronic sick and geriatric beds dropped last year by more than 10 per cent.
My noble friends Lord Grenfell and Lord Auckland are perturbed about the Fountain Hospital. There is undoubtedly to-day a problem of overcrowding. It will be relieved in the near future, as my noble friend Lord Grenfell has described, by transferring 120 children to Queen Mary's Hospital at Carshalton. In addition, there is included in the present list of major hospital building announced by my right honourable and learned friend on the 16th of this month a new reception unit at Fountain Hospital of up to 100 beds, an out-patient department and a research and teaching unit. The immediate relief of congestion will enable the Regional Board to carry out further work of improvement, while the unit at Carshalton will be expanded to greater size depending on the need.
The noble Lord, Lord Taylor, referred in heartening terms to the National Health Service Advisory Council on Management and Efficiency. He referred to it more simply as the Ewart Smith Committee. In answer to the noble Lord's more detailed question on the Ewart Smith Committee, I may say that it is a permanent standing Committee, but that its methods of reporting and acquiring information must be decided by the Committee itself, which has been in practical existence now for only three months and has not yet chosen the methods under which it will work.
Both the noble Lord, Lord Taylor, and the noble Lord, Lord Pakenham, dwelt on the problems of mental health. It may well be imagined how hard it is for anyone to attempt to discuss with them on level terms a subject on which, whatever they may say, they are recognised authorities. I hope that it will not sound unduly evasive if I say that the Mental Health Act received the Royal Assent only at the end of last July, less than four months ago, and all concerned are still engaged in the preparatory work to implement it. My right honourable and learned friend, while promising to avoid delay in completing this work, has also said that there will be no scrimping either of administrative or consultant work which he regards as essential. The only part so far implemented is that which enables patients to be received in mental hospitals without any formality 859 at all; and I think that this in itself can be regarded as a long, useful and practical step forward.
At the end of last year, out of some 480,000 staffed beds in the Hospital Service, 156,329 were allocated to mental illness and 57,670 to mental deficiency. That will give some idea of the scale of the problem. Many of the 360 or so psychiatric hospitals are old buildings which date back to a time when close custody and segregation from the community were looked upon as the proper régime for mental patients. That is no longer so, as I hope to convince your Lordships within a minute or two. Great advances in the treatment of mental disorder have been developed in the present century. The function of mental hospitals is now seen as curative rather than custodial. New methods have meant an alteration of the balance between in-patient treatment and out-patient treatment, the emphasis now being upon the latter. This reflects the new tendency to stimulate the sense of responsibility of the community, and to regard the psychiatric hospitals as only one of the means available for the treatment of the mentally ill. No one, I think, has been more lucid, persuasive, or dedicated in expounding this humane doctrine than the noble Lord, Lord Pakenham, himself, but he made it clear today that his anxieties on this score are by no means at rest.
It is, in a small way, a measure of his persuasiveness that I myself went last week to the new hospital at Balderton, near Newark, to be shown round. I have once before mentioned this as a new hospital; so it is, in the sense that it has been opened for only two and a half years. It now has 250 patients, but its eventual capacity will be 560. There is much more that is new in this hospital than the buildings. There is the absolute refusal to regard the patients as incurable—in fact a determination to show that some, at least, are curable. The hospital is proud of its discharge rate. A number of patients are regularly placed in jobs and continue to come to out-patient clinics. Most of the older people are regarded as permanent inmates and given work where possible until they die. But the younger ones, when sufficiently recovered, are encouraged to find work outside. It is an interesting fact that there are some jobs for which they are 860 particularly suited—for instance, jobs involving monotony, which they do not mind.
Those include such jobs as domestic service, and some former patients have become cooks, and even housekeepers, and have given perfect satisfaction to their employers. It is necessary for the employer to understand that there may be moments of unhappiness, impatience and unreasonableness, for which they have to be prepared, but which must be weighed against devoted and uncomplaining service so long as this degree of understanding is present. I was given one example of a young man of 24 who was recently discharged to a job in a sawmill where he is now earning £14 a week.
I could dwell with some enthusiasm on the conditions in which the patients live. I am not contradicting the noble Lord, Lord Pakenham, when I say that in this particular hospital the patients live in infinitely greater comfort than I enjoyed at my public school; and that in turn was considerably more comfortable than his—or that is my impression from the visits I have paid to that distinguished place. If challenged on this. I shall invite the noble Lord, Lord Taylor, to support me.
My Lords, I cannot believe that what the noble Lord said is true; but apart from that I am only too happy to agree with him.
LORD ST. OSWALD
The kitchen block at Balderton is the most modern and impressive that I have ever seen in a hospital or any other public institution, and I cannot believe that the noble Lord himself would be anything but impressed, if he went there, as I hope he will. It cost a quarter of a million pounds by itself. The kitchen is even fitted with smell-extracting equipment. The food seemed to me of excellent quality. I was assured that the patients are very quick to notice any change in quality, and only recently have requested boiled eggs instead of fried eggs. The food is cooked centrally and taken in electrically-heated trolleys to the one-storey blocks, where the trolley is plugged in and kept warm before serving. This, I think, does not indicate a negligent attitude towards the patient.
From the technical point of view I have already passed on the noble Lord 861 the dietary which was given to me. It will probably mean more to him than it does to me. I was told by the doctor in charge that it was good compared with other hospitals, whether mental or general. In answer to another question, I may say that the cost of food, including the wages of catering staff, is £1 14s. 8d. a week per patient. Deducting the wages of staff, it is £1 5s. That is only in one hospital.
But of greater importance to me than any physical comforts is the attitude of the staff and the ingenuity with which patients are employed and saved from idleness. Wherever possible, they are given useful and productive work, sometimes domestic, wherever possible outside rather than indoors. Every effort is made to escape the old attitude that mental cases must be shut in at all costs. Some are employed looking after the poultry and pigs. There is a workshop where, apart from the characteristic rugs, mat-making and rush-weaving, such unexpected activities as the making and painting; of polythene models are provided as occupation. Even the time of those who are incapable of doing directly productive work is employed to good advantage. Those who are engaged in tearing up newspaper all day are providing material for others. Torn into tiny pieces, the paper is soaked for 48 hours and the papier maché is given to high-grade patients to make such objects as bird baths and other garden ornaments.
I have dwelt perhaps for an unreasonable length of time on this one hospital. I hope that it does not appear that I am presenting it as a rebuttal to Lord Pakenham's case. To do that would be to forfeit far more in his opinion than I would ever voluntarily do. It has been made very plain to me that Balderton is an exception, but a significant exception. It has not been established in order to distract attention from earlier and out-of-date hospitals. It exists to point the way which those older hospitals may now follow. One swallow does not make a summer, and one Balderton does not win this particular battle. But I submit to the noble Lord that by its existence it indicates that the whole policy of mental deficiency hospitals is on a new and more promising beam.
In a general way, I feel bound to assert that the other older hospitals have not 862 been so wide of this beam as the noble Lord, Lord Pakenham, suggests; and, while corroborating everything that noble Lords have said about the humanity and dedication of the staffs, it is misleading to suggest that their achievements have been won in spite of a stingy and unappreciative Government. In general figures, there are 145 hospitals for the reception of patients under the Mental Deficiency Acts. Many of these have ancillary units, bringing the total of places where mental defectives are cared for to about 190. The number of beds is 51.015 and there is an average over-crowding of about 9.5 per cent.
Building in recent years has been at a somewhat slower pace than for other hospitals, because of some uncertainty about the way in which the Service would develop. The great colonies of the past were seen to belong to the past, but it was not so clear what the future pattern should be. Although the new Mental Health Act points the way, there is still need to wait until the local authorities have worked out their plans for increased community care of this sort of patient, and until the requirements of the Mental Deficiency Services are clearer, before the final specialised shape emerges. Despite this prudent deliberation, great advances have been made not only in new building but in extending and renovating the buildings we have.
Available beds have increased from 44,000 in 1952 to 51,000 last year, and the over-crowding of 9.5 per cent. represents a fall from 12.7 per cent. in 1952. The present building programme, coupled with hostel accommodation to be provided by local authorities, promises greater improvements. In the matter of expenditure since 1948, I may say that, of the £22 million spent on capital work in mental deficiency hospitals, more than £10.5 million has gone to mental deficiency. That is another figure for which the noble Lord, Lord Pakenham, asked.
LORD ST. OSWALD
Yes. Four major schemes have been partly completed and brought into action. Three other major developments are in progress and eight other projects being planned. On 863 November 16 my right honourable friend announced the latest list of major schemes which he has authorised, and this included six new mental deficiency projects, including one completely new hospital.
The new methods and new approach that I have referred to at Balderton are found in other hospitals as well. The Board of Control Commissioners and Inspectors have lately commented on the improvement of clothing and the efforts to establish a sense of pride in appearance among the patients. In the matter of catering, welcome improvements have been noted in the past six years. There are more catering officers, about 50 per cent. of all mental deficiency units now being covered by a catering officer. The cost of food per patient per week now averages between 18s. and £1. Balderton, as I have mentioned, is better than that. The average cost of maintaining a patient in a mental deficiency hospital has risen in the past three years by 21 per cent., to £6 2s. 1d. weekly, which was the figure mentioned by the noble Lord; and even taking into account the rise in the cost of living it still represents a betterment in real terms. I hope that, with these few words, I have done something to relieve the anxiety of noble Lords who have the situation of the mental deficient so much at heart.
The noble Lord, Lord Pakenham, asked whether the £50 million expenditure would be reached within the next five years. There has been no announcement beyond the announcement of £31 million for 1961–62, but it is reasonable to hope that the upward trend can be maintained, and that £50 million per annum will be reached. He then asked what proportion of this capital expenditure will be on mental deficiency hospitals. That, I am afraid, it is not possible to forecast precisely, since the rate of progress of each individual scheme cannot be known at present. But it is probable—and I only say "probable"—that it will be in the region of 10 per cent.
I think I have already answered the question on food. The figure I have for mental deficiency hospitals is 19s. 10d. for long-stay hospitals £1 2s. 1d. (I think that was also the figure given by the noble Lord), and for acute general hospitals £1 8s. The noble Lord's 864 figures are accurate; but the above are national averages of expenditure on food, and I have already given one example where they are exceeded. Expenditure in acute general hospitals is necessarily much higher, because of special diets. The standard in mental deficiency hospitals, which has admittedly been low, is now steadily rising. It is true that the total weekly costs of hospitals are much higher than those of mental deficiency hospitals—and necessarily so, because of the much greater variety and complexity of the services they provide. But during the past three years expenditure at mental deficiency hospitals has risen substantially by 21 per cent. It is not denied that mental deficiency patients may suffer from other things as well as mental deficiency, but in fact the variety of the ailments from which they suffer is generally uncertain, smaller and less diverse than those of patients in general hospitals.
The noble Lord, Lord Chorley, asked for more privacy for hospital patients—and he has apparently sought more privacy for himself, for which he cannot be blamed. There are various ways of obtaining privacy in a hospital. The noble Lord mentioned the method of private pay-beds, for which patients pay the full cost. Of these there are about 6,000 in England and Wales. Then there are the so-called "amenity" beds for which a low weekly charge is made; and this may suit those who want a bed for 24 hours only, which was the type of patient the noble Lord mentioned.
May I interrupt the noble Lord? I think I can perhaps undertake to convey to the noble Lord, Lord Chorley, the gist of any further thoughts the noble Lord has.
LORD ST. OSWALD
I should be grateful. There are 5,500 of these "amenity" beds. Thirdly, an effort is being made to divide up the large general ward by permanent screens and by curtains which can be drawn round each bed. This kind of sub-division is taking place on a large scale in hospitals all over the country, as the noble Lord, Lord Taylor, mentioned, and if it is appreciated it will no doubt be hurried on.
I come last of all to the speech of the right reverend Prelate the Lord Bishop of Chichester. I speak briefly, and at 865 the end, but I know he will not think this is due to any casualness towards his views, because until lately I was one of the most admiring members of his flock before he moved to Chichester. The point about nurses' hostels is that nurses are not particularly unlike other young women in the country, and "freedom" is very often the cry. The result of this is that certain nurses' hostels which have been built and which do exist are, regrettably, about half empty. I am sure the last thing the right reverend Prelate would wish is to incarcerate these young ladies in hostels simply because they have been built.
He also mentioned the matter of chapels. It is, and always has been, the policy of successive Ministers of Health to do everything possible to promote the spirtual welfare of hospital patients and staff, as is shown by the great increase in hospital chaplaincies since 1948. In the same way it is the policy of the Government to provide hospital chapels within the building programme, subject to the needs of other even more urgent building schemes. Chapels are already included in the early stages of building of many new hospitals.
I referred earlier to the fact that the National Health Service could not be regarded only as a wealth-consuming service; that wealth-producing was not confined to money terms. The Guillebaud Committee made it clear that they appreciated this fact, and so indeed do Her Majesty's Government. In describing the Service and its purpose, the words of the Report read:In so far as it improves the health and efficiency of the working population, money spent on the National Health Service may be properly regarded as 'productive', even in the narrowly economic sense of the term.If I may harness a phrase which has been sometimes used in a more controversial context, a healthy nationworks more, produces more, buys more, eats more and spends morethan an unhealthy nation. It also certainly enjoys itself and fulfils itself to a greater degree. My Lords, it is that nation which Her Majesty's Government are leading to-day, with continuing and increasing pride.
§ 7.50 p.m.
§ LORD STONHAM
My Lords, I have not been a Member of your Lordships' House long enough to be able to refer 866 to 7.50 as "this late hour" without some feelings of embarrassment. But I have been a Member of this House long enough to know that at the end of a debate of this kind it would be unfair, unwise and ungracious for me to make another speech. I assure your Lordships at once that I do not intend to do so. But I hope I may be allowed to refer to some noble Lords who have taken part, and in particular to the noble Viscount, Lord Waverley, for what, by general agreement, has been a memorable maiden speech. I am sure the noble Viscount will now be aware that I was speaking the truth when I said that nothing I could say would prevent him prior to his speech from being nervous, or ceasing to feel nervous as soon as he was on his feet, and that after it was over he would not understand what he was nervous about at all. I am sure that that has been justified.
I thank, too, the noble Lord, Lord Cohen of Birkenhead, for what I can describe as an inimitable speech. Perhaps he alone of your Lordships could have made such a speech on this subject which was not merely enjoyable but immensely informative, in a way that even I could understand. I do not think, however, that even the noble Lord quite appreciates how true his statement was that hospitals are men and women and not bricks and mortar. That is paraphrase of what he said. How much better do I know that, with a hospital group which consists of two former workhouses 95 years and 90 years old respectively, a former local authority hospital 72 years old, and two other hospitals, both in their eighties, all partially war damaged, and having to contend with an allocation of capital and other funds which are all on a per bed or per patient basis, so that we get the same kind of allocation as a hospital whose conditions are, by comparison, like Elysium. That was the kind of thing I was trying to say. No one could be more conscious of the tremendous debt which we owe to the doctors and nurses and all other members of the staff working in those hospitals than I am for the tremendous courage and devotion they have shown in building them up to a level where the service they give is incomparably higher than it was formerly, and approaching the level of the best. That was entirely the reason 867 why I was prompted to table the Motion that we have debated to-day.
I most fully support my noble friend Lord Pakenham and my noble friend Lord Grenfell in what they had to say about mental hospitals and mental deficiency hospitals. I was for four years Chairman of a Mental Health Committee of 100 of these hospitals, with 17,000 beds, and I know some of the conditions. I am immensely grateful to my noble friend Lord Taylor for his masterly summing up. It seems extraordinary that my noble friend should have made his first maiden speech in this very Chamber some fourteen years ago, and it has taken him all that time through, shall I say, the misunderstanding or misinformation both of his seniors in the Party and the electorate before he has made his maiden speech at this Bench. I am sure everyone will be agreed that it was a lot too long in the waiting. He even managed to introduce an innovation by handing over a remarkable pamphlet to the noble Lord, Lord St. Oswald, and I only regret that the noble Lord did not incorporate that in his speech as well. I am sure we should have greatly enjoyed it.
I am exceedingly grateful to the noble Lord, Lord St. Oswald, for the tremendous care he has taken in replying in such great detail to all the points that have been put. I myself cannot recall having listened to a closing speech by a Minister when so much valuable information has been given. It has been quite impossible, of course, as he will realise, to absorb all that he has said, but I shall certainly read it again, probably many times, with tremendous interest. One thing perhaps did stick in my mind, which shows the completely different way in which we can look at a particular item of information. The noble Lord regarded the fact that the Government are going to permit the 868 expenditure of £990,000 on a new wing or a new unit for Westminster Hospital as a matter for congratulation. That may well be true, and I would be the last to deny that expenditure. I imagine it will provide about 120 beds. But the immediate thought that comes to my mind—and I hope the noble Lord will forgive this—is that I am a tiny part of a region in which there are not 120 beds and one hospital, but 33,000 beds and 100 hospitals. Their entire capital allocation for a whole year is not even £990,000—it is £660,000. It seems to me, having regard to the conditions which I truly described, that there is something crazy about that kind of economics.
I will not pursue the point, but would only say this now. What we think of each other, and what we say to each other in your Lordships' House, is, of course, of some importance, but its importance lies in the fact that it has an effect on those outside who will read it far more important than its effect upon us. I believe that when they read what we have said here—as read it they will, and study it with the greatest care—two things at least will arise in the minds of everyone in the Hospital Service who has cognisance of this debate. The first is that there are in your Lordships' House Members who have the keenest possible interest in, and some with the greatest knowledge of, the Hospital Service. The second is that there exists in this House as a whole the keenest appreciation of all who work in hospitals, and the strongest desire to be of assistance to them. It is in that belief, and in the hope that this debate has done something to help those whom we desire to serve, that I ask your Lordships' leave to withdraw my Motion.
§ Motion for Papers, by leave, withdrawn.
§ House adjourned at two minutes before eight o'clock.