NATIONAL HEALTH SERVICE CHARGES

§ LORD NEWTON

My Lords, at the beginning of his speech, the noble Lord, Lord Silkin, said that the Opposition do not often table Motions of censure upon Her Majesty's Government. Although I have many recollections of debates on Motions of censure in another place, I certainly have never been present when there has been one in your Lordships' House, let alone taken part in one. Ever since I knew that it would be my task to-day to speak on behalf of the Government, I have been wondering what it would be like. I suppose I shall know the answer by the end of the debate or, perhaps, before the end of my speech.

The noble Lord, Lord Silkin, made his case with firmness and clarity, and with his customary fairness. I hope he will think that what I am going to say is equally fair. The noble Lord, Lord Beveridge, I suppose, is more entitled to 619 speak on matters of this kind than anybody else in your Lordships' House. I was therefore grateful to listen to the qualified sympathy which he expressed for the Government's proposals which we are debating to-day. The noble Lord expressed in moving terms his fear that there may be people who, for one reason or another, are not getting, or will not get in the future, the treatment which they need. I hope that the noble Lord will feel reassured by what I am going to say, or, at any rate, if not, by what my noble friend the Leader of the House will say later on.

The heat of the public discussion of the Government's proposals for increasing the charges and contributions for the National Health Service has, I think, rather obscured what it is that the Government are actually doing. The details were, of course, announced in this House by my noble friend the Leader of the House on February 1, but in order that the nature and scale of the charges may be quite clear to your Lordships I should just like to repeat them briefly.

The charges for dentures will be increased by amounts ranging from five shillings to fifteen shillings, but children and expectant and nursing mothers will be relieved of charges which they now pay for dentures. The charges for spectacles will be increased by five shillings a pair, with a higher charge for bifocal and multifocal lenses, but children from the age of ten will no longer be charged for lenses in adult types of National Health Service frame. The maximum charge for amenity beds in England and Wales will be doubled. The prescription charge will be increased from one shilling to two shillings per item. Orange juice, cod liver oil and vitamin tablets will in future be sold at cost price. The National Health Service contribution will be increased by one shilling a week for the employed man, of which ten-pence will be paid by the employee and twopence by the employer. Those are the proposals, and I do not wish to belittle those increases, but I want to suggest to your Lordships that they should be viewed with a sense of proportion. They are not, I submit, of such a kind as to introduce any fundamental change in the conception of the Service or in the tremendous benefits which we all receive from it.

620 What, then, are the reasons for making these changes? If the National Health Service is to expand and develop with progress in medicine, and in conformity with changing needs, we must from time to time see what can be done to limit expenditure already being incurred so as to ensure that the money which can be made available for the Service is spent to the best advantage on the new developments, and we must not allow past commitments to mortgage future progress. The resources which can be devoted to this Service, as to any other, are not unlimited, and the Government have a duty to see that whatever sums can be made available are spent to the best effect. This cannot happen if all present arrangements must be regarded as unalterable no matter what the need may be to limit expenditure in some directions in order to provide resources for expansion in others.

We have reached a point where there are tremendous opportunities for further progress in three main directions: first, the expansion of the great programme for the better care of the mentally ill and mentally subnormal which is taking shape following the Mental Health Act, 1959. Over the next ten years there will be a special capital allowance for the modernisation of mental hospitals. Perhaps I may be allowed to say that this is a scheme which gives me great personal satisfaction. I suspect that the care of the mentally ill is, if not the biggest, at any rate very nearly the biggest, of all the problems confronting the National Health Service, and I very much doubt whether there is a single adult in this country to-day who does not know, either directly or indirectly, of at least one person who is or has been mentally ill. Such is the scope of the problem as I see it.

For more Than ten years I was a member of the management committee of a large mental hospital group, and I had necessarily to resign a few months ago when I was given the task of speaking in this House about health matters for Her Majesty's Government. But ten years was long enough for me to know the problem of old buildings, the difficulty of staffing mental hospitals and, above all, the exceptional degree of patience and compassion which are required from those who care for the mentally ill, and particularly the senile. 621 But, my Lords in those years we were able to improve our hospital all the time: we improved the wards, we improved the various amenities for the patients, we provided better opportunities for occupational therapy and many other things as well.

This is the point which I wish to make and why have indulged in this brief personal reminiscence—that we should not have been able to improve that hospital in the way I have outlined if Her Majesty's Government since 1951 had been actuated by that hatred of the National Health Service which some of its critics like to make out. If further progress along those lines is going to be made possible, as I am confident it will be, by the kind of arrangements which we are discussing to-day, then I have no hesitation in saying that in my opinion, for what if is worth, those arrangements are fully justified.

The second direction for further progress is to be seen in the far-sighted ten-year programme for rebuilding or improving our hospitals launched by my right honourable friend the Minister of Health last month. And the third is the expansion of community care needed as a supplement to the hospital building programme. These advances will depend partly on capital development, on the hospitals, hostels and homes provided by the hospital authorities and the local authorities; and partly on the number and quality of the staff, the doctors, nurses and all the many other workers who will be caring for the sick and others in need of help, both in hospitals, in other residential institutions and in their own homes.

The hospital authorities throughout the country are now drawing up their ten-year programme in response to the request of the Minister. The task is a heavy one but it can give a most helpful stimulus to the whole hospital organisation. The capital to be provided includes, as I have already said, a special allowance for the modernisation of mental hospitals. The Government cannot enter into commitments at this stage as to the rate of future expenditure, but the basis on which plans are requested shows that it is expected to be generous, and your Lordships may possibly recall that on February 8 my honourable friend 622 the Financial Secretary to the Treasury gave in another place the details of schemes which have been approved. It is a long list; I have it here.

The local authorities are already well embarked on the expansion of their mental health services. Training centres for both children and adults are being provided on an increasing scale. A start has been made on residential accommodation both for some of those attending training centres and also for other mentally disordered, such as those recently discharged from hospital who are not yet ready to live on their own in the community. Old people who are mentally confused are being received in suitable cases into old people's homes, which are also being provided at an increasing rate. The home visiting services are being expanded.

We are also on the threshold of great opportunities for making long-awaited improvements in the organisation and calibre of the staff of the Health Service, on whom progress depends even more than on the quality and quantity of the buildings. The Report of Sir Robert Platt's Working Party on the Medical Staffing of the Hospital Service, which has been so eagerly waited, should be published next month, and it will be immediately followed by consultations between the Health Ministers and the medical profession. On the local authority side we have the Report of Miss Eileen Younghusband's Working Party on Social Workers, which has been recognised as an epoch-making document in this field. The intention to introduce legislation to give effect to its recommendations has already been announced, and Sir John Wolfenden has agreed to act as Chairman of the National Training Council for Social Workers and of the associated training Council for Health Visitors. This is a fact which in itself should go a long way to ensure the success of the work of these Councils which will determine the future of the professions for years to come. Among the social workers will be the mental welfare officers who have so large a part to play in the community care of the mentally disordered and who attach great importance to a proper and officially recognised training.

I have been putting some emphasis on the training of all these officers, because anyone who is acquainted, as I am sure 623 many of your Lordships are, with the day-to-day operation of what is called community care—that is, the care of a patient in his own home—knows how essential they are to its success. Indeed, the whole pattern of successful community care turns on the proper training of those who will be responsible for it and the proper organisation of their work. I hope that what I have just said may strike the noble Lord, Lord Beveridge as being appropriate to what he said in his speech. I have gone at some length into the great opportunities for development and progress now facing us because what the Government have done is intended to ensure that resources will not be lacking to make the most of these opportunities and to keep the emphasis on progress and development, which is surely where in any lively and vigorous Health Service it ought to be.

I now turn again to the changes in charges and contributions which are the subject of this Motion of censure, because your Lordships will wish to know, and obviously it is my duty to explain, why these particular items have been selected for increase. Both Labour and Conservative Governments have recognised that dentures, spectacles and prescriptions constitute a field where the patient is in a position to exert a certain amount of pressure on the dentist, optician or doctor to go perhaps a little beyond his better judgment. Consequently, both Labour and Conservative Governments have thought it right to place on the patient a measure of financial responsibility.

§ LORD TAYLOR

My Lords, could the noble Lord explain how a dentist, in supplying dentures, goes beyond his natural responsibility as a result of patient-pressure?

§ LORD NEWTON

My Lords, I should have thought that it may be possible to bring pressure to bear on a dentist to do rather more than he thought was absolutely necessary.

§ LORD TAYLOR

My Lords, if the noble Lord would allow me once again to intervene, may I say that I do not think a dentist would really take out teeth and fit dentures unnecessarily because a patient brings pressure. I do not think there is any evidence of that.

§ LORD NEWTON

Well, my Lords, perhaps I could go on to say that when, on October 24, 1949, the Government announced that it was proposed to impose a charge of up to 1s. for a prescription, the Prime Minister, the noble Earl, Lord Attlee, said that the purpose was to reduce excessive and in some cases unnecessary resort to doctors and to chemists. The Labour Government did not, in fact, carry out its intention. But what I am concerned with at the moment is the argument in favour of a prescription charge used by the Government of the day in 1949.

Charges for dentures and spectacles were first introduced by the National Health Service Act, 1951, and it seems clear to me that those items were selected largely because charges upon them would not generally have to be paid by people who were sick. I would remind your Lordships of the speech made by the late Lord Haden-Guest when moving the Second Reading of the Bill in this House on May 9, 1951. He said—and I quote from Columns 813 and 814: It has, regrettably, been found that the only way to enable expansion to continue in other directions is by shifting some of the expense to the patients. All other alternatives were explored and reviewed … In selecting the services for which charges are to be made, the Government tried to choose the field where charges would obviously do least harm, and they chose the field of spectacles and dentures, because to a large extent they affect people who are well in health and able to make their own way…Charges for appliances under the National Health Service are not new: I wish to emphasise that point. It is suggested that these charges are a departure from the principle of the National Health Service Act, and that no charges should be made. But charges have been made for appliances, some since the inception of the Service. The Government already have power to charge for medicines. I submit that these are substantially the same arguments that I am using this afternoon, and I would particularly ask your Lordships to note two points made by Lord Haden-Guest: first, that all other alternatives to the charges were explored and reviewed, which must mean that the alternative of raising more money for the National Health Service by direct taxation was considered and rejected—in other words, the Government decided that there was a point beyond which rises in the cost of the 625 Service should not be borne by general taxation. The second point to which I beg to invite your Lordships' attention is that, in the view of the Labour Government, to impose charges was not to change the principle of the National Health Service.

There will be a fuller opportunity to discuss these higher charges which the Government now propose when the Bill already introduced in another place comes before your Lordships' House. I should, however, like to say that the new charges for both dentures and spectacles do no more than reflect the increase in their cost. The power to impose and vary prescription charges by regulation is provided by Section 16 of the National Health Service (Amendment) Act, 1949. When one contemplates that date one is immediately struck by the fact that it was very soon after the beginning of the Health Service that the Labour Government of the day decided that it was necessary to take power to impose a charge.

I have already mentioned the Government statement about the proposal to impose a charge of up to 1s. and the reason given by the Prime Minister. The increased prescription charge now proposed is still a modest proportion of the cost of the average prescription, and I would suggest to your Lordships that it is not an unjust imposition when one remembers that since 1949. when the 1s. charge was first proposed, benefits and wages have more than doubled, and that since 1952 when the charge of 1s. per prescription form was imposed they have nearly doubled.

I should like to speak a little later about the arrangements for the relief of hardship, but I will now turn to the welfare foods. The position of these foods must be seen against their history. They were first introduced as an insurance against the inevitable restrictions on diet in time of war; they have become progressively less necessary as the variety of the diet available and the financial resources of the average family have improved. The stage has now been reached when it seems clear to Her Majesty's Government that the great bulk of the population are in a position to provide their children with a proper diet, and to pay for any necessary vitamin supplements. At this point the 626 continuance of an indiscriminate subsidy is surely no longer required.

The charge for amenity beds is in a wholly different category because it is not a compulsory charge. Ordinary beds are available free of charge on medical needs. No one, therefore, need pay this charge and it will not, in any circumstances, exceed the same proportion of the cost of the accommodation as was envisaged when the present charges were fixed. The change is simply an adjustment to take account of rising costs.

I should now like to say something about the proposal to increase the National Health Service contribution by 1s. to 3s. 4d. per week. This is the new rate for the man in employment. There are to be other, lower, rates for women and boys and girls, and for the self-employed. The benefits of the Service are, of course, open to everyone, and that is the most important fact about them. They are not conditional on any qualification such as having had to pay a certain number of insurance contributions. But, from the beginning, there has been a sense in which the people as a whole have been insuring themselves against the costs of medical treatment of all sorts by agreeing that a part of the weekly contribution which they make should be used for the Health Service.

The major part of the cost has always been met from general taxation and will continue to be so met. I will not risk boring your Lordships or confusing you on a subject on which I find it very easy myself to run into mathematical confusion, by talking about the percentages of the cost of the Service which have been met in the past in this way or the other, but I wish to emphasise that we have to think in terms of the 1960s. This country, in the 1960s, is a very different place from what we had any right to expect, or to hope for, at the time, during the war, when the noble Lord, Lord Beveridge, was preparing his famous Plan. There is no high unemployment to-day—thank God! Average earnings have risen and so has the standard of living of the people of the country.

In this situation it is not unreasonable to ask people to pay a little more when they are well for the benefits of the Service which will take care of them when 627 they are sick. But having said that, and having claimed that it is reasonable to ask people in the present circumstances to pay a little more than the Government asked them to pay immediately after the war, I agree that the obligation remains strong on the Government to ensure that in absolute terms this is not too heavy a burden on the people. I think it is not unreasonable to suggest that the burden is still just about all right in the sense that although the percentage which the total weekly contribution bears to total earnings has fluctuated a bit, it does not show any serious increase.

I think the truest guide to your Lordships in this matter comes from a consideration of the relationship of the total weekly contribution to the earnings of a group who are, on the whole, among the lower-paid sections of the community. I am thinking of agricultural workers. The wage rates for these workers were increased recently and we have not yet got any figure for the average earnings in the industry later than April of last year, but even taking that figure and making the quite unrealistic assumption that earnings will not rise between then and next July—when the new rates of contribution are to be introduced, if Parliament approves —the ratio has risen by only 1 per cent. comparing October, 1948, with the situation after next July—from 4.7 per cent. to about 5½ per cent.

In the light of what I have said this afternoon I believe that the changes which Her Majesty's Government propose are generally fair and reasonable; and I believe, too, that they will be accepted as reasonable by the public which has, after all, accepted for some years now a system of charges and contributions. All the necessary arrangements for meeting hardship will be continued and applied to the new charges. War pensioners will continue to be entitled without charge to all medicines needed for their accepted disabilities. All those in receipt of National Assistance are entitled to refunds on charges for medicines, dentures and spectacles. The National Assistance Board also make refunds to people who are above the Board's normal standards of need, including those who are actually working. The Board's scheme for pro- 628 viding welfare foods free of charge relieves, and will continue to relieve, those in need. In cases where medicines are regularly required by the chronically sick, doctors are able and encouraged to prescribe for periods up to three months.

I believe these arrangements will ensure that the proposed changes will not result in hardship. Moreover, my right honourable friend the Minister has pledged himself to examine any case of potential hardship due to prescription charges which may be brought to his notice. The Government proposals which we are debating to-day form part of their plans for promoting the continued progress and development of the National Health Service. I ask your Lordships to decide that they call not for condemnation but for approval.

§ BARONESS SUMMERSKILL

My Lords, I rise to-day to speak on a subject in which I have a profound interest, and therefore I find that the conventional handicaps attaching to a maiden speech are weighing rather heavily upon me today. I propose to exercise great self-restraint, but if I do err I cannot be justly charged with introducing a partisan note, because the British Medical Association, which cannot claim to be an ally of my Party, have themselves opposed these health charges. In the first place, I should like to stress the point made by the noble Lord. Lord Beveridge, in his poignant speech, and to emphasise the iniquity of taxing a section of society which demands the maximum degree of indulgence from us—the aged, the chronic sick and the children. And have your Lordships realised that this same measure will leave completely untouched the well-to-do hypochondriac who cares to press his doctor to prescribe expensive proprietary drugs?

I believe that everyone on both sides of this House will agree that, to the aged, easy access to the doctor should be regarded as a necessity and not a luxury. No financial barrier, not even what the noble Lord has just described as a small one, this increase of 100 per cent. on the charge for medicines, should come between the aged and medical help. And let us think of the details. May I remind the noble Lord who has just spoken that these figures which he dismisses in such an easy way mean, in 629 fact, that in the winter months an old person will be called to pay for a bottle of cough mixture and a bottle of liniment—not luxuries, surely—the sum of 4s. The noble Lord has told us to-day that it is proposed to refund this sum. Has he thought of the mechanics of that? Has he realised what it means to an old person, sick and lonely, as described by the noble Lord, Lord Beveridge, to be told he has to fill in the appropriate document and deliver it, or arrange for it to be delivered, and that he will then be able to have a refund of his money? My Lords, to put aged people who are on a small pension to the positive task of retrieving their money when they are already ill is to place an extra burden upon them just when they are in extra need of our help.

We have heard to-day about hospital building. We have been told what it is proposed to do in the future in respect of mental hospitals and general hospitals. But I would remind noble Lords that it has been argued time after time in another place that, while the revenue accruing from these sums is to be used for the hospital programmes, nevertheless the only way to reduce the pressure upon the hospitals is to improve the domiciliary service. To put any barrier between the patient and the general practitioner is to diminish the therapeutic and preventive value of service of the domiciliary service and will undoubtedly increase the demand for hospital treatment. Indeed, I foresee that all these new beds we have heard about this afternoon will already be mortgaged as soon as they are provided if it is intended to diminish the value of the domiciliary treatment in this way.

Everybody knows that the aged patient who fails to obtain advice immediately may well need hospital treatment when finally a doctor is called. Again I refer to the speech of the noble Lord, Lord Beveridge, who said, quite rightly, "Unfortunately, the aged, when sick, cannot be bothered to call in a doctor". Precisely! There is the picture, the picture from which perhaps we are a little remote in this House at times. And when, finally, a relation calls a doctor the doctor says, "This patient must go into hospital". I have therefore tried to emphasise to your Lordships that the hospital schemes of which 630 we have heard, which have been described by the Minister of Health in another place, can be satisfactory only if at the same time we improve the domiciliary service.

Now I come to the chronic sufferers —that is, those suffering from diabetes; the bronchitics, or those suffering from tuberculosis and nervous disorders—who need a continual supply of drugs. I would remind your Lordships that these are not people who are enjoying an average wage of £14 a week. These are people who are trying to live on the National Insurance benefit; and these are people who will feel this imposition very keenly. We have just heard that it is proposed to tell the doctors—indeed, the doctors have been advised before—to prescribe for these people for a long period. I am surprised to learn from the noble Lord that he suggests two or three months. But does he not know that similar advice has been given to the doctors on other occasions, and it has been learnt that reducing the total number of prescriptions does not solve the problem? May I recall to him the Civil Report of the Comptroller and Auditor General? What did he say on this subject? He said: Although the total number of prescriptions dispensed fell from 228 million in 1957 to 227 million in 1958, their total cost rose from £68 million to £73 and the average cost per prescription rose by some 10 per cent. from 5s. 11½d. to 6s. 6½d. Within this total the cost to the Health Service of proprietary preparations had risen by 1958–59 to some £34½ million and represented over 70 per cent. of the cost of ingredients of all prescriptions. I might remind noble Lords, too, that this figure for the average cost of prescriptions is completely out of date. To-day, a prescription in this country costs over 7s.

I come next to the children. I do not think that anybody here is unaware that there has been a spectacular improvement in the physical condition of the children in the last twenty years. Nutritional disease, particularly rickets, is almost non-existent; and the infantile mortality rate and morbidity rate of children's diseases have dropped in a dramatic manner. All this has taken time, and has involved the education of the mother in the necessity to use medical facilities and welfare foods. And I say that to reverse this policy now, to make a visit to the doctor an added 631 expense and the welfare foods a luxury, is bound slowly to undermine the fine achievements in the field of preventive medicine. We cannot possibly see the results immediately. It will be an insidious process, and only the social historians will be able to point to the folly of this action.

People who have the greatest knowledge of the subject, who have lived with it, not just surveyed it briefly for a few weeks, namely, the medical profession, as organised in the British Medical Association, recognise the profound un-wisdom of this step. I realise that the new Minister of Health has not, and cannot have after a few months of office, an intimate awareness of the problems involved. I am afraid that I have to say—I say this very gently—that he has not viewed it as a compassionate Minister of Health but as a fugitive from the Treasury. Indeed, he views his primary function solely as a close ally of the Chancellor of the Exchequer. Indeed, he is virtually undertaking the same task of which he found himself baulked at the Treasury a few years ago.

On the question of drugs, I feel that I have not to appeal to the noble Lords opposite me in vain. There have been repeated appeals (I have made them myself time after time, to successive Ministers of Health) to curtail the huge profits of certain drug houses. Nothing effective has been done, then or now. The Minister (I think it has been repeated from the opposite Bench) said that he proposed to take action. I can only quote to the noble Lord what was said in theBritish Medical Journal of December 24, 1960, under "The Minister and the Drug Firms".They said: The recent rumours in the press that the Minister of Health was taking a much tougher line with the pharmaceutical industry than his predecessors when negotiating renewal of the voluntary scheme for the regulation of drug prices seem to have been exaggerated. The modifications which he announced in Parliament last week, though important, are not likely to reduce the drug bill substantially. My Lords, in the interests of the country, I would esteem it of great importance if you would concern yourselves with the drug traffic ("drug" is a generic term) in this country. An outrageous exploitation of the sick by the drug firms has been exposed by a Senate Committee of the United States of 632 America, under the chairmanship of Senator Kefauver. The special significance to us and to this country is that most of the drug companies which Senator Kefauver castigated for extracting colossal profits in the United States from the sick have now established subsidiaries in this country and are conducting their business in precisely the same way, with high-powered salesmen, in order to take the maximum profit from the National Health Service. Because of this, I believe that this action which is proposed to-day will fail to have the desired effect, in view of the powerful interests which encourage the "bottle of medicine" habit.

Finally, my Lords, I should like to make a few constructive suggestions. I think we need a bold and imaginative campaign designed to re-educate the people. There should be more research, in order that doctors should be given only authoritative information about the most effective drugs; and successful clinical trials of drugs should be the sole criterion of their worth. There are still those—knowledgeable people—who think that the new, expensive antibiotics are infallible. People should be told that already, in consequence of using these antibiotics for trivial complaints, we are left with resistant organisms which to-day defy antibiotics. Furthermore—and I agree with the noble Lord when he talks about the importance of mental disease in this country—statistics reveal that one-third of the drugs prescribed are for some form of nervous disorder, including, of course, the psycho-sematic complaints. Here is a challenge, not only to the Ministry of Health but to the Ministry of Education and to the Home Office. I believe that action along these lines is long overdue. Meanwhile, we fiddle with a measure which is calculated only to penalise the poor. Surely, my Lords, the criterion of a civilised society is that the strong should succour the weak, and I therefore ask you to oppose these proposals, on moral and practical grounds.

§ VISCOUNT AMORY

My Lords, it has fallen very agreeably to me to congratulate the noble Baroness, Lady Summer-skill, on her first intervention in our debates in this House. My regret is that this task has devolved on such a junior Member of your Lordships' 633 House. The noble Baroness has experience of high office in two Departments of Government; and, furthermore, she is a member of a profession for which I personally have always had a very high regard indeed. She has therefore been speaking from first-hand knowledge of her subject. I remember, too, that when I was Minister of Food, the noble Baroness and I, at Question Time, almost bi-weekly, indulged in verbal sparring, if the noble Lady will forgive that expression borrowed from what I know she regards as an ignoble art. But, whatever may he her views on pugilism, she is known as a stern critic and an exacting taskmaster, or taskmistress, and certainly in her instruction she does not spare the rod. She is always practical; she speaks often from first-hand knowledge, and I am sure that noble Lords will feel that our characters are likely to benefit and be strengthened by advice from the noble Baroness on many future occasions.

My Lords, the broad subject which we are discussing to-day—the treatment of ill-health—is not one that we should consider purely in the dry terms of finance because it clearly has to deal with suffering misfortune, hardship and sacrifice, and it is excusable that each of us, in his or her own way, should feel a little emotionally about these subjects. I am not going to take on the noble Lady on her technical ground, because I also, of course, am a fugitive from the Treasury, and I know that there are those who feel that my heart, if I ever had one, was atrophied by two and a half years' service in that Department. But because of that temptation or incentive that I have mentioned, to think emotionally, I am sure that we must be on our guard and must try to keep a sense of perspective and remember just what are these proposals that have caused this Vote of Censure.

There are, first of all, no new principles compared with the practice of the past ten years. The principles which have been followed, and which are to continue to be followed, as I understand it, for allocating the cost of the Service, are principles that were officially approved by the Government of the Party opposite. As the proportion of the gross national product or national income, the National Health Service has about kept, I believe, its percentage, though we must remember that no one service has any prescriptive 634 right to do so. In fact, if room is to be found for educational progress, for instance, it is perfectly clear that some other services will have to contract in the proportionate demands they make. To date, I think there can be little doubt that people, as recipients of social service benefits and as against their position as taxpayers, have actually improved their position over the past ten years. They have improved their position and their claims, not merely in real terms but relatively to other demands. Nor again, as I understand it is, there any intention that there should be a substantially different ratio between the direct contribution from the individual, whether in stamp or in stamp and charges combined, and the contribution from the general Exchequer revenue. Therefore, one wonders at first sight what all the indignation is about.

I think that the main trouble is that many members of the Labour Party have never really accepted the decisions of their Government, or the strong insistencies of two of their Chancellors of the Exchequer, that a strict upper limit must be set to the cost of the Service falling on general public funds. Speaking from memory I believe that in the days of the Labour Government that limit was fixed at £400 million. Many members of the Opposition seem to feel that, because treatment of ill-health is a good thing, it must be morally wrong to question the amount spent on it, quite regardless of other commitments, and that it must be right that the whole of that expenditure, whatever it is, must fall on general public funds. Incidentally, I noticed during my time at the Treasury a fairly widespread inclination to feel that, if only one could shift something from a specific heading of account to the general account that was almost as good as saving the expenditure concerned. I think that some of us, in our private transactions, perhaps do the same. Payment seems to cause much more heart-burning when it is a question of producing cash from one's wallet than it does when it is a matter of meeting it by banker's order and having it added to one's overdraft.

It may be, of course, that some time in the future changes in our social economy may cause the whole concept of the financial principles on which the 635 National Health Service has been based to be called into question; I do not know. But the point I want to make is that that is not being done here in the proposals that are being put before us. The Government's proposals, as I understand them, are in fact of an extremely limited nature. They are designed to ensure that the Service will continue to develop, with the cost shared in approximately the same proportions as hitherto between the individual's direct contributions and general funds respectively. The Minister of Health, in what I thought was a very able speech in another place, made it clear beyond doubt, I thought to anyone, that there could be no question whatever of the Service being either attacked or undermined. The figures he quoted of the record of the past decade, both as regards expenditure and achievement, I think spoke for themselves. So far from the Service having been undermined in these ten years, in real terms it has been substantially developed; and for the future, the Government plans we have heard of provide for further development on a broad front. So there is really no proposal before us that could amount to any cut in the Service in any way.

The noble Lord, Lord Silkin, made, as is his habit, a reasoned and temperate criticism, but it seems, from proceedings in another place, that once again the Opposition have planned to destroy the Government by an explosion of moral indignation of nuclear proportions. I doubt whether that will be successful, because, really, the facts are against them. Noble Lords opposite are no doubt doing their best, with the strong sense of duty which characterises them to work themselves up to desirable temperatures and pressures, but their fuel supply is lacking. It might be said of them, as I think was said of one great statesman of the present century, that if the facts were against him, so much the worse for the facts.

It seems to me that there is really only one point that is directly relevant to our discussions to-day, and that is whether the proposed proportions between the sources of financial contributions are reasonable ones or whether there should be no direct contribution from the individual at all. If I may, 636 at this stage I should like, in parenthesis, to mention my own attitude to the National Health Service. It is this. I favour the scheme because I believe the financing of the treatment of ill-health is something which it is sensible and advantageous to us, as individuals, to tackle on a comprehensive pooling basis—the insurance principle—even though this scheme itself is not strictly and literally an insurance scheme.

I did not vote for the particular National Health Service Bill at the time it was started, because, as I think I made clear in a speech at that time, I thought the scheme as brought forward then was too big a one to digest in one bite without serious loss of quality. But I was all in favour of a National Health Service scheme of a fairly comprehensive kind. Secondly, I personally most strongly favour the principle of meeting the main part of the cost of treatment while people are in sound health—the insurance principle. Thirdly, and because this is a direct service to the individual, it seems right that each beneficiary should, during his working life, while in good health make some direct contribution as an insurance premium to the cost of the scheme.

Now, what precisely the figure should be is of course, an arbitrary decision. When both costs and incomes are changing from year to year it would obviously be wrong to think permanently of just a monetary figure. The relevant considerations, surely, are: what relation should the direct contribution bear to the total cost of the Service, on the one hand—or, to the cost of specific items of the Service, if that is what it is dealing with; and, on the other hand, its relation to the level of personal incomes.

I think the Minister told us in another place that the direct contributions—the stamp and the charges together—have recently been substantially lower than the proportion at the inception of the scheme. I understood that, allowing for these new increases, they would not be much higher. In terms of cash per week, the stamp will be, I think, 2s. 8½d. for the employed man; and in relation to current levels of incomes and the fact that it is not paid by the old, the young, or certain other categories, I cannot myself think that that is an excessive Percentage, or other than a very 637 moderate insurance premium for such very comprehensive cover. I believe that a failure to adjust this direct contribution in any way in the light of the rapidly rising cost of the Service, and so to allow the present decreased percentage which is now substantially less than it was originally, to be further eroded away, would be a cause for which no case, I think, has been made out.

The Party opposite are strong, even fanatical, believers in the principle of progressive taxation; and, indeed, it is a principle that is firmly established in our taxation system and which, to a greater or less extent, all of us accept. But even a sound principle of taxation, like an improved method of medical treatment or an educational idea, must not be pushed without any regard or consideration for the need of a sound balance. If it is, then the beneficial effects of it will be destroyed.

My Lords, I have heard it said that there are three things not worth running after—a woman, a bus, or a taxation principle, because if you wait a little while, another will come along. I think there is a good deal of evidence that, in the light of experience, the present levels of direct personal taxation linked to earnings are still too high and must be further reduced if the incentive to earning is going to be safeguarded. It is true that a still greater part of the cost of the National Health Service scheme could be met by further increases in indirect general taxation; but I believe, there again, that the present percentage of the gross national product taken, in the aggregate, by the central Government through general taxation, though substantially less than ten years ago, is quite high enough. Indeed, every effort must be continued to be made to reduce it further. So, in all the circumstances, I believe the maintenance of a proportion of round about a fifth or a quarter of the cost of the scheme, to be covered by direct contributions of stamp and charges together from the individual, cannot be regarded as anything but moderate and reasonable. So I entirely support the proposal to increase the weekly stamp.

The proposals to put up the charges merit, I think, a still closer look, because here there is an expense falling directly 638 on those who need treatment. If that were carried too far, then it would conflict with the principle I have referred to earlier, that the main cost should be paid by those in sound health. The real justification, to my mind, for imposing a charge on the individual to cover part of the cost of prescriptions is if it discourages waste and abuse. One would expect a charge to have some effect, on balance, in that direction; how much I do not prefess to know. But clearly the charges must not be so heavy as to conflict with the principle I have mentioned.

I know that when I was at the Treasury the aspect of National Health Service expenditure which afforded me the most concern was the rapid and continuous rise in the drugs bill, from £31 million to start with to something over £80 million foreshadowed for next year. This was also the item over which there was least control. I know the medical arguments for the uninhibited use of the latest drugs, which are also often the most expensive. Looking back, I am hound to say that I do not think that the Ministries concerned have been very successful to date in tackling this matter. I am not sure whether the independent Committee appointed helped them very much. But, having said;that, I agree that it;is an immensely difficult field of action for the Government to limit or interfere with the clinical judgment of the doctors. But the evidence of waste is, I think, pretty compelling. I am glad to hear that the Ministers concerned are going to make still greater efforts to see whether they can find ways to ensure greater efficiency and economy in the use of drugs and in getting best value for money.

If the object of increasing the prescription charges were simply to find some revenue as a means of helping meet this greatly increasing bill, then personally I should have preferred a still bigger increase, if necessary, in the stamp: but if it is considered—and I understand that it is, and personally I think that there are good grounds for this—that the maintenance of a charge representing a proper proportion of the cost (not too big) does help to reduce waste and abuse without involving hardships to those of small means, then I think that the course is justified. I understand that the Minister 639 in another place has said that though the charge of 2s. a prescription would be double, the cost per prescription has more than doubled in the time that has intervened.

§ LORD SILKIN

My Lords, may I ask the noble Viscount whether he has read the justification for these increases made by the Minister in another place? It was exactly the one which the noble Viscount has just said he would oppose, if that were the reason—namely, in order to meet the extra cost of the Service. The Minister did not say that the justification was to deal with waste and abuse.

§ VISCOUNT AMORY

My Lords, the noble Lord, Lord Silkin, will know that I am expressing my personal view and saying where my own preferences would lie, because I believe so strongly in this principle of paying while your are in sound health. I think that the proposed increases in charges, on balance, at the moderate level to which they are being raised, should help to effect economy without damage and prevent abuse. But I am expressing purely my personal view.

I was about to refer to the speech of the noble Lord, Lord Beveridge, to which I am sure we all listened with respectful interest, because he is speaking on a subject on which he knows so much, He mentioned inflation as being a deadly enemy which must be combated with all possible resolution. I could not agree with him more. The noble Lord spoke of the difficulties that confront the elderly, who are always the first victims of inflation. That is why I am sure that the finance of a Service like this must be looked at very carefully. After all, the prevention of inflation is the first and best service of all that we can render to the elderly who have to live on small incomes.

This is one of the occasions, of which there have been a number in the past few years, where some members of the Opposition a living a little in a world of fantasy unrelated to what is going on in the real world around them. My noble friend Lord Newton mentioned this. All the time they seek to find wicked dragons for slaughter. Tory Ministers who confront them seldom measure up quite to the dragon-like specifications (if I may put it like that), so they invent a 640 caricature of Tory political attitude, then shut their eyes, raise the battle-cry and charge. The charge is exhilarating but less than decisive, because the enemy are not there.

I remember once teaching a young chap to shoot and having to reprimand him for inaccurate marksmanship. He said, "I am not inaccurate. I shoot absolutely straight, but when I fire, the rabbit is no longer there". Substitute "the Tory dragon" for a rabbit and I think that there is some truth in this.

§ VISCOUNT ALEXANDER OF HILLSBOROUGH

My Lords, has it not been said constantly of the Tories over the last fifty years that they have always been condemned for stealing other people's clothes while they were bathing?

§ VISCOUNT AMORY

My Lords, so long as the clothes are the right clothes their source does not matter so much. There was a General in ancient history whose prepared attacks were models of military art and whose aggressive spirit was superb, but he never won his battles because, when the time came, the enemy were never there.

If I may respectfully say so, the Opposition have once again invented an issue out of their imagination, an issue of the alleged destruction of the Health Service, which simply bears no relation whatever to the actual proposals which are before us. I suggest that we ought to confine our attention, though it may be less exciting to do so, to the actual proposals being made to us by the Government. I am convinced that if we do so, then we shall find them reasonable and justified and likely to contribute to the further development of the Service, to the benefit of the nation at large

§ LORD TAYLOR

My Lords, it is a great pleasure to follow the noble Viscount, Lord Amory, in congratulating my noble friend Lady Summerskill on her delightful maiden speech—her non-controversial maiden speech, because those noble Lords who have seen her and heard her in controversy will know that to-day was but a small taste of things to come and of things past. She is a redoubtable and formidable fighter. When I was a new Member of another place, I viewed her with the 641 greatest respect and a little alarm and apprehension; but she was so helpful to those of us who were new that our fears soon disappeared.

I remember that on one early occasion I was supporting the Government on a measure. My noble friend was sitting on the Front Bench, obviously not agreeing with the Government at all, and she was indicating her disagreement in no uncertain way. Finally, she turned round co me and said. "Don't try to teach your grandmother to suck eggs." I was sure that I was right and I am sure that she was equally sure that she was right. My noble friend is an expert not only on medicine but also on that kind of feminine logic which we all know in the home and know the effect of—that: is: how to save money by buying a new hat. I am delighted by the addition not only to our medical strength but also to our strength on the ladies' side in future and we look forward to many interesting speeches from her.

I was delighted to listen to the very reasonable speech of the noble Viscount. Lord Amory. At least half of it could have been delivered from these Benches and the other half was the most reasoned arid reasonable presentation of the case that I have heard. It really is the only substantial statement that has been made in attempted justification of the increases in charges. It was notable at once that the noble Viscount had great doubts about the increase in charges on prescriptions, even though he was quite ready to defend the increase in charges on contributions. And if one is going to defend anything, he was correct in his choice of strategy, because the increase in the charge on prescriptions is the difficult, dangerous, unpleasant and thoroughly bad one. The noble Viscount said, very honestly, that when the National Health Service was debated he voted against it, because he said it was too big a thing to tackle at one bite. Of course, he was wrong, and I am sure he will be the first to admit it; just as, if I may say so, the Labour Party were wrong when, eleven or twelve years ago, they introduced a charge for health services. I have no doubt that we were wrong to do that and I see no virtue in continuing to pretend that one must support what one has done eleven or twelve years ago even when it is obviously erroneous.

642 A few days ago the Lord President of the Council announced what the British Medical Journal described as "Hailsham's Law" (I do not know if he saw it), which is that a Party is absolved from its proposals by defeat at a General Election. The noble Viscount may recollect that he was replying to a question by the noble Lord, Lord Airedale, about doctors' free prescriptions for private patients. He quite rightly said that a Government are not bound by their proposals made at an Election when they are defeated. Of course, what is sauce for the goose is sauce for the gander, and I have no doubt that we were wrong to put these charges on. They have been tested and re-tested for ten years and have been found wanting, even by the Government's own Hinchliffe Committee. Therefore, say the Government, they must be increased.

The Government's argument, as I see it, is that the increase in cost in the National Health Service is such that either the Service must be cut or the charges and flat-rate contributions must be increased. This is a wholly false dilemma, and it is an argument which could have been applied every year since the National Health Service has been in existence, because every year the cost of the National Health Service has gone up. In a society where national economy and national wealth are increasing, it is right that the amount devoted to the health of the people should also increase, so, that health gets at least the same share. Indeed, the attempt by Sir Stafford Cripps to put a ceiling on the cost of the National Health Service was not only mistaken but quite impossible. He tried to do it, but could not do so, for the simple reason that where wages and prices are increasing, inevitably the costs of the wages and prices of those inside the Health Service must also increase. In fact, it was never done. Over the years ahead it is certain that the cost of the National Health Service will continue to increase, as it has done every year under the present Government. So each year there has been, and each year there will be, an excuse, if one is wanted, for increasing the charges to the patients. It has happened every year.

Why then have the Government picked on this year? We know that the real reason is the particular philosophy of 643 the present Minister of Health. But he has a little better case this year than he might have had last year, or will have next year, because, for technical reasons, the increase will not be the same each year: some years it will be a little bigger than other years. This year we have had to absorb not only the effect of the Royal Commission on Doctors' Pay—and doctors' pay has not gone up steadily, but in a series of jerks at three or four yearly intervals, because of the machinery for adjusting their pay—but we have also to face their back-pay award, all pushed into the one year. That is the main reason for the increase in the Health Service Estimates. It has nothing to do with hospitals, and although it may have a little to do with drugs it has little to do with anything else: the real reason is the absorption of this increase in doctors' pay, which we should consider as a continuous curve as part of the cost of the National Health Service over the years.

If we look at the increase in hospital costs, we find that it is microscopic. It is only £5 million over previous Estimates, as compared with the £75 million which these increased charges in contributions are going to yield. The hospital building programme is very desirable, but in this context is quite a political red herring. Incidentally, we finance our hospital building in a peculiar way. We pay the total capital cost (the noble Viscount, Lord Amory, will correct me if I am wrong) out of current revenue; we do not fund it and spread it over the life of the hospital, as we do with, say, a factory, a house or any other building. This is a peculiarity of the National Health Service and I should have thought that a financially-minded Minister of Health would be much better looking at the way hospital building is financed than doing this particular kind of squeezing that has been going on.

The third item to which the noble Viscount. Lord Amory, quite rightly referred is the increase in the cost of drugs. This is not due to public profligacy. Admittedly there has been, and there always will be, some small wastage of medicine; you cannot avoid that. The increase is partly due to bad prescribing. But the main reason for the increase in the cost of drugs is the enormous volume 644 of rubbish which descends every morning on every general practitioner in this country. I took the chair at a conference of general practitioners a couple of months ago, and one of them asked when we were discussing the drug industry, if he could bring in exhibit A. It turned out to be two boxes, each four times the size of the Dispatch Boxes in this Chamber, crammed full with circulars, booklets and what-not. They represented fourteen months' deliveries by the drug firms at that doctor's house. Imagine the chaotic state of mind if the doctor tries to read but one-tenth of this!

I am not on their mailing list, but I get three or four every morning; and once or twice a week, I usually get a parcel of drugs, beautifully packaged and some of them looking like "hundreds and thousands". But the effect on the doctor's prescribing habits must be substantial, or the firms would not go on doing it. We beg them not to do it, but they take no notice and go on pushing out this stuff. It is partly due to the pharmaceutical industry, its highly competitive methods and its non-coordinated research activities, and partly to the real improvements in medicines. Drugs are better and are still getting better. It is true. as my noble friend Lady Summerskill said, that we must have better information services for doctors, and that we must also, somehow, get the pharmaceutical industry to serve the public interest. One does not say more than that it should do that. One does not say that it should be nationalised or socialised. If only it will serve the public interest, we shall have it working as a part of this great public service.

The pharmaceutical industry is a most interesting one. It is highly competitive, and that should make it highly efficient. But it does not. It is highly profitable, and also highly secretive. As those of your Lordships who served on the Public Accounts Committee in 1937–38 will know, the Ministry of Health find it difficult to drag information out of the pharmaceutical industry. There are two divisions of the pharmaceutical industry. There are the genuine manufacturing firms, and there are the packaging firms, who simply buy from other people, wrap the stuff up and advertise it—and 645 occasionally they compound it a little. They are purely parasitic. They need very little capital to get going, and they contribute nothing beyond the wrapping and the, advertising. I think we could do, without these parasitic pharmaceutical firms. The genuine manufacturers have done much good work and produced many excellent things. However, they still waste an immense amount of public money, first, on competitive research, and secondly, on competitive advertising.

In research, there is the most extraordinary overlapping. If we have, say, ten firms, each having a small research team looking for either an antibiotic or a tranquilliser, then each team is treading exactly the same ground. In medicine, we combine and pool the knowledge, but here it is impossible because these firms are in acute financial competition and must not give away their secrets to each other. There was, in fact, one attempt to make such a combination, and four of the big firms got together to build a thing called the Therapeutic Research Corporation. I am not absolutely certain but I think they were B.D.H., Boot's, Burroughs and Well-come, and I.C.I. There I stand open to correction. It was a complete failure; they could not do it. It has disappeared, and any attempts at combined pharmaceutical research have, so far as I know, met with complete failure.

So what happens? A firm expends, say, £50,000 to £100,000 in looking for a new antibiotic. They find one which looks promising. Tests are started, and the results are a little equivocal. In medicine, at this point we write off that line of research and return to our laboratory benches. Not so in industry. The investment in research must be made to yield a return, so the product is marketed and boosted, hoping that it will recover its costs in a short run of popularity—for they only get a short run of a couple of years and then they disappear; that is the usual sequence. There are a few which go on, but most die a pretty early death before they have got properly costed and any control starts to operate.

All this has happened in the case of a drug which claims to be the first antibiotic to act against the viruses. A factory was opened by this firm in the North of England, in an area of substantial unem- 646 ployment, thus giving the Government a reasonable and real interest in its success. As a matter of fact, it was opened by my noble friend Lord Boothby. I told him that I was going to mention him to-day, so I am not taking an unfair advantage of the fact that he is not here. He opened it with a very merry speech, in which he said that he was a confirmed taker of pills. This firm is marketing this so-called antibiotic. I am not going to name it, but it is marketing it with tough publicity. I was invited, with the local doctors in my area, to see a film strip show and to partake of an excellent buffet lunch. The film strip was shown, arid then our local doctors, who are very intelligent, cross-questioned the representatives. First, they learnt that it was no good against any big viruses; then they learnt it was no good against any small viruses, and then they learnt it was no good against any fatal or severe viruses. It was claimed to be any good only against those from which one recovers spontaneously, mainly influenza and upper respiratory infections. It was claimed to be good not only therapeutically but prophylactically. What a wonderful opening for this drug!—everybody needing it, and everybody able to take it with a clear conscience to prevent these things.

To prove this requires very careful control therapeutic trials. We were offered therapeutic trials with about 70 persons, conducted by some Swedish gentleman, which were completely and utterly inadequate to show that this stuff did anything. Unless I am thought to be exaggerating. I will quote to your Lordships what the British Medical Journal had to say about this drug in its columns: Thus it is quite impossible, on the basis of work published on this drug so far, to form a clear estimate of its therapeutic value, if indeed it has any. The basic National Health Service price is 48 tablets for 15s. Up and down the country these sales representatives are pushing this drug as hard as they can, no doubt with the aid of other good buffet lunches, and certainly with the aid of the film strip. I reckon that of least £1 million of National Health Service money will be wasted on this product, in the absence of any evidence that it does any good at all, before it goes out of fashion. I have not named the firm or the drug, but I would say that this is a fairly typical story, and I am certain 647 that the only proper answer is not to rely upon internal departmental investigation but to have a proper Royal Commission on the pharmaceutical industry as soon as we possibly can.

§ THE LORD PRESIDENT OF THE COUNCIL AND MINISTER FOR SCIENCE (VISCOUNT HAILSHAM)

My Lords, I quite agree with the noble Lord in not naming either the firm or the product; I think it would be most unsuitable to do so. But as he has said this about it, I hope he will give it to me in confidence at a later stage.

§ LORD TAYLOR

With the greatest pleasure. I shall be delighted to furnish the noble Viscount with full particulars. Indeed, I am sure his own Department will be only too familiar with these extraordinary claims.

§ LORD FERRIER

My Lords, might I inquire whether the drug in question is in fact on the list of those prescribed under the National Health Service?

§ LORD TAYLOR

I understand that that is so.

§ VISCOUNT HAILSHAM

We will soon find out.

§ LORD TAYLOR

When we take the overall picture of the cost of the National Health Service, the real measure of whether we can afford it is, as has been said, the proportion of the national product devoted to it. Here the figures are quite simple: 3.8 per cent. of the national product in 1949–50; 3.7 per cent. in 1950–51; 3.2 per cent. in 1954–55—notice that it is going down—3.4 per cent. in 1956–57 and 3.6 per cent. in 1959–60. Compare that with the proportion of the national product which we spend on defence, which I understand is about 8 per cent. I understand that it is the custom for honourable and right honourable gentlemen in another place habitually to defend the Defence Estimates on the grounds that they amount to about 8 per cent. of the national product. That is a fair defence, but, surely, it is equally a fair defence to say that we should have our National Health Services financed in the same way as Defence. We do not finance that by contribution charges or charges for Home Guard uniform 648 or what you will on the users at the time of service.

Moreover, if we are to have defence forces, surely we must have something worth defending, and one of those things is the National Health Service. Manifestly, we can, and are, affording the National Health Service quite well. The present charges are a matter of budgetary convenience only. I think we could, and should, afford up to about 4 per cent. of the national product, and I am not claiming any completely extensible ceiling. The noble Viscount said that we must have a ceiling on essential services. That is fair enough; but let us express it as a percentage of the national product, as that is the only fair ceiling to take.

I should have thought that if we take it at 4 per cent. of the national product it would be about right, bearing in mind that we have to finance an increased capital expenditure in the years ahead, because we have let the thing run down. We have had virtually no capital expenditure in the last ten years except on maintenance of existing buildings, and that pretty poor. Secondly, we have defeated the easy diseases. We are now running into a very difficult situation, because more and more people are living on into old age. They are not dying of quick pneumonias, but from chronic illnesses which take prolonged treatment over weeks, months or years and very often end in death. But they are going to provide us with an increasing volume of work; and that volume will increase.

Behind the National Health Service, as my noble friend Lord Silkin said, there are two great conceptions. The first is that we should relieve those who are sick of the unnecessary financial burdens of ill-health. The second is that we should all pay for our National Health Service when we are well, according to our capacity to pay. The effect of the new charges is to shift the method of payment: an increase in the poll tax —the flat per capita tax—to avoid putting the cost on the graded tax; that is, income tax according to capacity to pay. Increased contributions hit everybody equally, regardless of income, and they hit the poorest hardest and the richest least. Increase in the payments at the time of illness are much more serious. These hit at the time when the payments are hardest to make.

649 We have heard from the noble Lord, Lord Beveridge, about old people and poverty. He is going to inquire into their position in an affluent society he were to look at poverty in an affluent society he would find that most of the sick are poor, and the reason they are poor is perfectly simple; it is because most of the sick do not get their wages continued when they are sick; they go on to sickness benefit. They are the people we are now penalising by these increased cash contributions on medicines. It is not so bad, perhaps, if you are a wife—though it may be bad in other ways—if you are sick and in bed. But if you are a wage-earner, and you are sick and in bed, you are not only ill, not only losing wages, but now you will pay two, four, six or eight shillings a week for your medicines as well. I think it is a shame. It is a negation of what the National Health Service stood for.

Here we have the extraordinary discrimination between hospital medicines and extra hospital medicines. If you are sick in hospital, as the noble Lord, Lord Beveridge, was in St. Thomas', and as I was later on, you get your drugs free. But if you are sick outside you have to pay 2s. a bottle or packet. If the Government charge for drugs outside hospitals and not for in-patients, the logic is that one is more necessary than the other. And this, my Lords, at a time when the Government are urging doctors to treat patients at home and save money on hospital beds!

Many people have the idea that general practitioners do not look after the seriously ill: that what goes on in doctors' surgeries is a lot of nonsense. But it is not so. I have sat in many doctors' surgeries and we have produced statistics of the amount of serious illness the general practitioner sees. One in five of the visitors to the surgery are suffering from serious illness, illness so serious as to carry the danger of risk of death or so severe that the person has got to alter his manner of life very substantially. One in five of the people in doctors' surgeries are in that category. Among those the doctor visits at home the proportion is one in two—except, of course, in time of epidemic, when the minor complaint group shoots up. Most of the people the doctor visits at home are seriously sick. They are the people who will have 650 to pay two, four, six or eight shillings for every prescription they have taken to the chemist.

Doctors have always opposed the charges for medicines, because it puts back the cash barrier between the doctor and patient. It is particularly hard on the chronic sick. About 20 per cent. of all patients in this country suffer from bronchitis and other respiratory infections. Chronic bronchitis is a terrible thing, particularly in the North and Midlands. People get bronchitis and then slowly develop heart failure. As a result, they are kept going by drugs, digitalis for the heart, the anti-cough medicines, sedative cough medicines, and usually sleeping medicine as well, because they cannot sleep. This goes on not for six months but five or ten years. It is the basis of their life. They cannot get by without it. Those are the people we are taxing six or eight shillings a week for their medicines. Of course they cannot take them en bloc, because if you keep cough medicine it gets a mould on it after a week or two.

We have heard about the mentally sick. The noble Lord, Lord Newton, referred very seriously and graphically to it. But we are being urged under the Mental Health Acts to treat more and more at home, and this is possible only if we can prescribe quite elaborate sedatives— largactil and the other tranquillisers, as well as sleeping tablets. Those people are not fit to work. We are being asked to keep them out of hospital beds; yet we are being asked to prescribe costly drugs at home for which the patient has to pay. Time and again the doctor will find himself in the extraordinary dilemma that the 2s. charge will be more than the cost of the drug he is prescribing. The only thing lie can do is to write another prescription on an ordinary piece of paper and say "Take that along and pay 1s. 6d. for that one", which is fantastic. As the noble Baroness, Lady Summerskill, was saying, it is quite unrealistic to expect the chronic sick, or their relatives, to go traipsing along to the National Assistance Board. They cannot do it. There is nobody available. It is hard enough to get anybody to cook a meal, let alone to go for long bus journeys to gel this money back. It is all nonsense. My only conclusion is that those who framed this legislation 651 have no idea whatever how poor people live or how sick people live. They just do not know.

The increases in charges for welfare food are in a different category. This is quite a small item, because most of these welfare foods are being taken up only by a small group. Only a few people are using these welfare foods free, but they are the people who need them most. They are the feckless, rather stupid, mothers, who cannot be got to do what they ought to do. They are the people who are getting these free welfare foods from the clinics, and it is a jolly good thing, because this is preventive. They are the people who will develop rheumatic carditis when they get older, and will be a burden on the community for twenty years because they have not had prophylactic foods. It seems to me absolutely dotty". I sincerely hope that, whatever else the Government do, they will drop that particular bit of nonsense.

The right answer is, surely, a graded National Health Service and National Insurance tax, a graded one as a proportion of income tax. How simple it would be! You would get over this business of industries all over the country having to do the whole job twice, first with P.A.Y.E. and then with stamps. Really the stamps are not fair; they are a poll tax. As national income rises so would contributions to such a scheme rise.

The Government have, up to now, enjoyed, I think, a remarkable measure of electoral success, and the reason is mainly, as the noble Viscount, Lord Alexander of Hillsborough, said, that they have been up to the old game of "dishing the Whigs by pinching their policies." If the Government's Commonwealth and Colonial policies had come from Labour Ministers, the roars which would have come from the other side of the House would have made one sick. I am all for their "pinching" our policies; I think it is the most sensible thing they can do. I am interested in this new programme of hospital expenditure of £50 million a year. It is identical with what we had in our pre-Election booklet, Members One of Another, setting out our Health Service policy. It is very intelligent of them; they have it exactly right. This is the first misjudgment of 652 the people they have made. They have gone absolutely off-beam here, and they base it on pure ignorance. They do not know how ordinary people live or get ill or die, and because of this I hope that those of your Lordships who do care about the sick and the needy will join us in the Division Lobby, or at least will abstain and show what you feel about this wrong.

§ LORD FERRIER

My Lords, in thanking the noble Lord who introduced this Motion for bringing about this debate I have one personal regret, and that is the shortness of the notice which came our way—though I appreciate that it was not entirely his fault. It also is a pleasure to join in the congratulations to the noble Lady opposite on her first contribution in this House. I only wish that her stern self-control in regard to controversial matters had been exercised with more thoroughness, shall we say; and I shall use all my firmness to control my temptation to be controversial on the matter in return. Let us hope that it will not be long before we shall have an opportunity of again crossing swords on this or some other subject.

I am concerned on this matter of National Health Service charges not only as a member of the public, but also (and this noble Lords may not know) as chairman of a group of pharmaceutical companies who manufacture distribute, wholesale and export, pharmaceutical chemicals and supplies. I am not a chemist; I am not a pharmacist. In fact, any skill I possess, if I possess any at all, is that of an industrial administrator and a student of man management.

My connection with the pharmaceutical industry is entirely fortuitous. It happens that this is an important industry in my native city, to which I returned after a number of years in the Tropics, where I had been at the receiving end of many thousands of grains of quinine. But, further than that, I have a childhood background of connection with the medical profession. I was brought up by an uncle who was an eminent professor of physiology, and all my life I have been connected with the talk or the jargon of medicine and the knowledge of frequent contact with laboratory work and research. It is therefore fasci- 653 nating to me to find myself concerned, as I am to-day, with the (intricacies of this highly competitive business—highly competitive, remember, in an international sense.

It is an extremely complex industry. Would it were as simple as the noble Lord, Lord Taylor, seemed to indicate in some of his remarks! It is a highly speculative and a highly rewarding industry. I say that deliberately, because I do not mean "rewarding" in a remunerative sense, but in the sense of ethical reward for services rendered. I am a member of an industry which, in spite of what all the noble Lords opposite have said, has made, and is making, a real contribution to the welfare of the nation. In passing, I would remind your Lordships of the important part played in the community by the pharmacist, the ordinary chemist, and sometimes by his wife as well. They are qualified and skilled people. They are respected. They render a 24-hour service. They have considerable responsibilities, not only to the customer and to the public, but to the doctor and also to the law. In the village the chemist's shop is the first-aid post. Not only is the chemist a professional man, but he has the added burden of making a business pay. Often, indeed generally, it is his own business. At the research and manufacturing end his colleagues are deeply engrossed at the highest level of scientific expertise, striving to improve the service which renders what it does to medicine, and which contributes what it does to the exports on which we live. It is a matter of pride to me to be associated with this business.

With that disclaimer, I would turn to the charges which are the subject of the Motion, and accept what my right honourable friend the Minister in another place, and the noble Lord, Lord Newton, here, have said in regard to the necessity for more finance in order to pay for the necessary development in the hospital services. When I have the task of moving the Motion in regard to road construction later this week, I shall be referring (and I hope that I shall get support from him) to Lord Taylor's point about the need for financing capital work from capital. But more money is needed. I do not think that anybody in any part of the House will doubt that, whatever may be his ideas as to where it should come from.

654 On the subject of the hospitals I have but little to say, except to join in the remarks which have been made in all parts of the House about the wonderful attention obtainable in British hospitals from the staff —from the doctors, the nurses, and everybody. There is one point here which I have come across and which I would mention that in dealing with the cost of the hospital service I feel that my right honourable friend will sooner or later have to face some increased differentiation between the wages and salaries paid to trained and senior nursing staff as compared with the wages of junior nurses and domestic staff. Though much has been done and is being done, more has still to be done, about the conditions under which nurses live. I had occasion to talk the other day with a colleague whose daughter has within the last couple of years nursed in both the United States of America and this country: and whereas she was in no doubt as to the comparison and standard of nursing qua nursing, it meant a great deal to her that the conditions under which nurses live on the other side of the Atlantic were infinitely more conducive to their fitness for their duties.

I will not go further in reference to the charges until I come to this problem of the prescription charge. Other noble Lords are better able than I am to develop the hospital side of it. But on this problem of the prescription charge I find myself, a little to my surprise perhaps, but no more than to the surprise of the noble Lord, Lord Taylor, in entire agreement with him. Some have maintained that the application of the increased charge will reduce the off-take of drugs and their consumption. I personally doubt it. The effect was slight when the 1s. charge was first put on, but it soon swung back again. I do not think their consumption will be reduced more than temporarily; nor do I believe that the increase will reduce waste. Nor do I believe that it will have the effect of improving prescribing: it will only encourage over-prescribing.

Another side-effect will be the encouragement of self-medication. Perhaps the noble Lord will have found the reference in the Hinchliffe Report that we were discussing just now. That Committee were not only against the 1s. charge, but were against an increase and in favour of complete abolition of a prescription charge. As the noble 655 Lord has pointed out, the problem as it now arises is that with 2s. per item you get a prescription charge on a number of items which exceeds the cost of the item itself. From the pharmacist's point of view, that is going to lead to a strain in chemist-customer relations. It will lead to the customer not putting in a prescription and going in for self-medication; or even, perhaps (and this is particularly so in the case of those in need), going in for no medication at all. This point has been made before. Although the noble Viscount, Lord Amory, made it in a gentle sort of way, I should like to reinforce what he said with almost the same force as the noble Lord. Lord Taylor. Doctors are opposed to it, and I therefore hope that the Government will agree to have another look at it.

In the debate in another place one honourable Member indicated figures with which I have no reason to quarrel showing that this charge will go unnoticed by 80 per cent. of the people; that 10 per cent. will be borne by National Assistance anyway but that for the other 10 per cent. it will represent real hardship. If finance has got to be found for this, surely it should and must be found somewhere else. In the light of what has been said, I was going to read only a portion of a letter I have here from a colleague, who is a doctor of medicine; but I will read more because it sets out very clearly the position of people in need who would now be subjected to this increased prescription charge. The letter says: Anyone who is on National Assistance, but not employed, can get a receipt for the prescription charges from their chemist and have the money refunded at a post office on displaying the National Assistance book. An unemployed person receiving a disability pension can proceed in the same way, using his disability pension book as proof. An unemployed person receiving unemployment benefit can obtain a refund at the employment exchange. Old age pensioners do not automatically qualify for a refund; if they are not on National Assistance they have to make a special claim to their local National Assistance office. Anyone who feels that the prescription charge causes him undue hardship can make a claim on the National Assistance Board for a refund, and this is likely to be allowed if his income is at, or only slightly above, the level at which National Assistance would normally be granted. 656 Your Lordships will appreciate the trouble this will bring to some poor, ill, tired old person. My colleague, who is a doctor of medicine, goes on in his letter to say: These rules do nothing to help the proud old age pensioner who normally just manages, but whose economy may be completely upset by the necessity of paying perhaps four to six shillings a week in prescription charges. I can remember patients for whom even the old charge was too much, but who were too proud, or unable, to go to the Assistance office, and one often had to produce the odd shilling oneself. I am sure that this must be the experience of most general practitioners. I cannot suggest a solution, for manifestly the old age pensioner who is paying surtax should not be let off his subscription charges! Equally, it seems rather an imposition to ask the G.P. to decide which of his patients should have to pay and which should not. If I do not refer further to the question of charges it is not because I have no views, but because they are views which have already been stated or are points which are to be made by other speakers. But I do press that Her Majesty's Government should think again on this matter, and either alter their proposal or take steps, very urgent and earnest steps, to see that the means for making recoveries for poor people should be facilitated, and, indeed, that it should be possible for them to get the cost of prescription charges in advance.

My Lords, I now turn again to the pharmaceutical industry. This has been described in another place as a "dragon". I have a feeling that my noble friend Lord Taylor and the noble Lady who has just made her maiden speech feel rather the same way as their friends in the other place. I believe that they have made a mistake. They have mistaken for a dragon what is, in fact, a serpent; and a very prudent serpent. I refer to the serpent of Aesculapius which, if memory serves me right, was very cunning in finding healing herbs. I have already said I am associated with this "serpent", but I would say that I am not in any way a mouthpiece of the industry. I have no place in their hierarchy. It is just that I come into day-to-day contact with the problems of the industry; therefore I feel that I have a contribution to make to your Lordships' deliberations.

I gather that several noble Lords opposite, and their friends in the other place, feel that there is something wrong with the industry. Or is that putting it 657 too mildly? Be that as it may, I propose to show that there is something right with it. Admittedly the National Health Service is the industry's largest customer; of course it is, in a country with such a Service. But, broadly speaking, only one-third of the product of the industry goes to the State. One-third is sold over the counter and the remaining one-third goes for export. That is a very important point, and I feel that it is important to have those proportions clear in our minds in turning to the accusation of over-extravagant advertising.

Noble Lords will, of course, know that the advertising to the public, and on television, if you like, do not affect drugs which are prescribable under the National Health Service. Those are over-the-counter drugs, and that form of advertising, therefore, does not come into our calculations. The "glossy" type of material, to which the noble Lord. Lord Taylor referred, which is posted and distributed to doctors, may be, and in some cases is, extravagant. I think that can be definitely accepted. The industry as a whole does not like that kind of feeling and I know that they are keeping an eye on it.

Nevertheless, my Lords—and this is why I mention this matter immediately following my reference to the fact that one-third of the drugs produced are exported—it is not that other places are so different from this country but that we in this country are rather different from other places; and this particular type of sales promotion applies elsewhere throuhgout the world. Actually, the industry has a difficult task in promoting sales abroad, and on that I feel I should read a cutting from the City Press of October 28 last, in which the reporter says: From daily contact with customers all over the world, the industry is painfully aware of the harm which has been and is being done in overseas markets by the campaign carried on at home against proprietary preparations. By the constant battering of uninformed critics, the term proprietary preparations' has come to have almost a derogatory connotation. This attitude does not pass unnoticed abroad, and it is perhaps not altogether coincidence that a fall in the average rate of increase in exports of pharmaceutical products in the early 1950s coincided with the adoption of this short-sighted policy. 658 I should like to make that point and to press home the fact that, where we have to live by exports—and as the noble Earl the Foreign Secretary made so plain to us last week, exports are our very life-blood—it is a pity that any member of the nation should be injudicious in attacking an industry which provides a great deal, and will provide more, to the export trade of the country.

§ LORD TAYLOR

My Lords, will the noble Lord permit me to intervene for one moment? Surely it is equally important that the quality of what we export as pharmaceutical products should be maintained.

§ LORD FERRIER

Does the noble Lord suggest that the quality of our pharmaceutical exports is inferior?

§ LORD TAYLOR

I suggest that on some occasions they are the type of remedy of which I was speaking; that as a result of this multiplicity, by very slight modifications in drug structure, alleged new drugs are produced which are not, in fact, new drugs at all; and that there is, on occasion, an accidental as it were, misleading of the receiving public at the exporting end.

§ LORD FERRIER

My Lords, I think that "on occasion is the operative phrase there. Knowing the largest single exporter in our industrial community in this country, I cannot believe that the largest exporter could have such an imputation made on any of his products. I do not want to weary your Lordships, but I could turn to an American paper which says that there are wails in America at the low costs of drugs which are obtainable from this country.

While on this subject, I would say that there has been criticism of the industry's force of representatives, of travellers really bitter criticism and. in my view. quite unfair criticism. This staff of excellent men are employed calling upon doctors. The noble Lord, Lord Taylor, himself made the point—and do we not all in business know it, as in every other walk of life?—that you cannot read everything you get nowadays. The fact is this—and correct me if I am wrong. In my view, the fact is that the great majority of doctors rely on a visit from the representatives of reputable firms to keep them in touch or to draw their attention to developments as they come 659 along. I have personal knowledge of a large number of occasions in which this has happened. In my own locality I was pleased the other day to be talking to a doctor who indicated the same thing.

The traffic is two-way traffic, because not only does the doctor keep in contact with the industry through the representative, but the industry keeps in contact with the doctor through the representative. At the teaching hospitals and the like they have the main medicaments, and problems in regard to packaging, storing and the like are always accessible to the manufacturer through this force of representatives. They are, as I said. an important link in the chain of service that strives to relieve sickness; and the traffic is two-way traffic.

I made some notes while the noble Lord, Lord Taylor, was speaking, and I feel it would be only fair if I referred to one or two of them. I have dealt with the problem of the suggestion that the industry does not operate in the public interest. I would refute that with every ounce of my energy. That is just not so. If there are black sheep in the family, well, that occurs in every walk of life. But to brand the whole industry in that way is quite out of reason.

§ LORD TAYLOR

My Lords, I was very careful not to brand the industry in that way.

§ LORD FERRIER

Good!

§ LORD TAYLOR

I certainly did not intend so to do. I said that there are many firms doing excellent work, and then I went on to explain why they were not doing better work.

§ LORD FERRIER

I thank the noble Lord. I am glad I made that point. Frankly, that was not the impression I got when the noble Lord was speaking. There was another point he made regarding competitive research. Again, I said in my opening remarks how I wish it were as easy as the noble Lord thought it could be. On pooled research he mentioned The Therapeutic Research Corporations which, he admitted, broke down. The problem is one which, to my simple mind, is this. The only way to pool research is to nationalise the whole industry, and if you do that you 660 get a muddle and your research becomes a whole lot of—

§ LORD TAYLOR

My Lords, that is precisely what we have done with medical research as a whole, nationalised it, and we have had the Medical Research Council. It has not proved a muddle but an absolute example to the world.

§ LORD FERRIER

I said, first a nationalised industry. That is where we come up against it. The problem is this. If we centre or concentrate research in one place, then who is to make the product that is invented? That does not apply to the problem of medical research. It is a question of trading which, as I pointed out, applies only as to one-third of the requirements of the country. One other point I should like to make is that the noble Lord referred to a drug which he criticised very adversely. I should like to know whether it is in fact on the list. I rather doubt it myself. If it is, he would not be criticising the drug industry; he would be criticising the medical authority which permitted a drug which is apparently of no practical use to appear on the Government list.

§ LORD TAYLOR

My Lords, surely many drugs appear on the official recognised list of prescribable substances which are of very doubtful therapeutic value, with a note that they are of doubtful drug therapeutic value.

§ LORD FERRIER

My Lords, judging by the activities of the noble Viscount who is to reply, I feel certain that we shall get something from him on the subject, and we need not go on with it at the moment. They are classified clearly by the medical profession. This rapid development in new drugs is one of the imponderables of this very complex trade. These new drugs are almost invariably more costly than the old. I am sorry that the noble Baroness, Lady Summerskill, is not in her seat, because I think it is fair to say that it is "pie in the sky" to believe that the more complex drugs become the cheaper they are going, to get. It is going to be the other way. It seems to me inevitable that that should be so. For instance, it is possible to put down a plant for the manufacture of a new drug—I know that this occurred in one instance—where not one thing is produced by the plant 661 because by the time the drug is ready a new drug has been invented which supersedes the original one.

There is another point to be made while we are talking of the cost of drugs. I feel that it is fair to consider—it is often not considered—the credit entry opposite the debit entry for the cost of drugs. It is quite incalculable. I think noble Lords will agree that, with improved drugs, the pattern of hospital admissions has changed altogether as the years have gone by. The duration of stay in hospital has varied and fallen and fallen. Of course, that can be calculated in terms of pounds, shillings and pence, but it is not possible to calculate the savings to the nation which result from prevention or early cure by modern therapy before patients are hospitalised.

§ VISCOUNT ALEXANDER OF HILLSBOROUGH

My Lords, on the question of these costs—I am very interested in the argument—could the noble Lord, during the course of his speech, give sore indication how it is that the costs of drugs have gone up so enormously, by giving us the basic cost of units of drugs leaving the fact