§ 4.38 p.m.
§ LORD AMULREE rose to call the attention of Her Majesty's Government to the Review of Medical Services in Great Britain (Porritt Committee); and to move for Papers. The noble Lord said: My Lords, I have been thinking for a long time of putting down a Motion on the National Health Service for debate in your Lordships' House, but there appeared to be no particular reason for putting such a Motion down until the Report of the Porritt Review Committee was published, which was not so very long ago. That seemed to me to be an occasion upon which I could hang, as it were, a debate in which I could make some references to 553 my feelings about the National Health Service.
§ The first thing I should like to say is that the Porritt Committee is, I think, the first body of entirely medical opinion which has considered the National Health Service and has published a Report. The Committee was quite a large one. It consisted of 44 doctors and was representative of the various Royal Colleges both in England and in Scotland and of bodies like the British Medical Association. Most of these bodies, if not all, were represented upon the Committee by their President for the time being, so one can fairly say that it represents what a good deal of the informed medical opinion feels about the National Health Service at the present time. What they have issued in the form of this document is a general review of circumstances as they are now. They have come to some conclusions from their review and they have made recommendations for certain changes which might be made in the future. They have made a number of recommendations, with some of which I agree entirely and with some I do not agree; therefore it is not my purpose to try to support the complete Report but, as I said before, rather to take the Report as a basis for a general discussion about some matters concerning the Service.
§ The Porritt Review Committee say that the basic concept of a National Health Service is fundamentally sound and is acceptable to the vast majority of the medical profession. With that I would entirely agree, and I think I should be right in saying that such a concept is acceptable to the vast majority of your Lordships' House. When the National Health Service was first founded, however, it appeared that it was a Service superimposed upon others which already existed rather than an attempt to absorb all the services dealing with health into one big Service which would deal with every branch of medicine in the country.
§ For example, there are at the present time nine Government Departments who supply a health service of some sort. I refer to the Ministry of Education, the Ministry of Labour, the Ministry of Housing and Local Government, the Home Office, the Ministry of Pensions, the Ministry of Agriculture, Fisheries and Food and one or two more—I will not bother your Lordships with all the 554 details. There are various branches of health service which do not come under the National Health Service. I refer to the occupational health services, the industrial health services. The first is possibly a matter on which the noble Lord, Lord Taylor, may have something to say, because he has far more experience of occupational health than I have myself. But it seems to me that it might be an advantage if these services could in some way be combined. I am not going to say they should be carried out by the same people. I am not going to say they should all be run in exactly the same kind of way. But it seems to me that if you are going to have the Ministry of Health running the National Health Service, that should be the focal point for all the health services in the country. In that way one would probably economise in the use of manpower—and I mean both men and women doctors; one would probably economise financially, which is quite an important point; and one would certainly save a good deal of overlapping of work, which again is something well worth considering.
§ The National Health Service was really based upon two existing props and a third one which was made especially for it. The two existing props were the preventive and social medicine side, which were the province of the local authorities, and the general practitioner or family doctor side, based on the old National Health Insurance Scheme. The side which had no prop was the hospital service. That, I think, is what has led to the formation of the tripartite system, as it is called, with one body doing the preventive and social side, one body looking after general practitioners and one looking after the hospital service. That has led once again to a certain amount of disagreement and suspicion—I will not go so far as to say a certain amount of hostility, but a certain amount of difficulty between the various branches of the Service.
§ The Porritt Report recommends that these branches of the Service should all be brought together under a series of Area Hospital Boards which would be based upon the general hospital for certain areas. That sounds, on the face of it, a rather attractive, agreeable idea: but when one comes to think of it I am not sure it is really a practical idea, 555 certainly not from the point of view of the debate I am initiating now, because it would mean to a great extent a redrafting or re-writing of our present system of local government, which is more than I want to suggest should occur at the present time. That is one of the many difficulties. I do not want to pursue that line any further, but I do not think that at the present time it is a practical idea.
§ But there is one way in which I think a start might be made towards adopting a more rational method for dealing with the local authority side of the Service, and that is by combining the departments of health and welfare into one, which might, for the want of some better name, be called the social department. I merely suggest that as a name which occurs to me at the moment, but there might well be some better one. Porritt suggests that there should be a department of social health based upon the general hospital where these Area Boards are to be themselves based. But if it were to be combined with the hospital side, that, it seems to me, would be making too much of a hospital matter of the whole thing; whereas the idea is to try to make people think of the Health Service as based not entirely on people going to hospital but on their not going to hospital—on treating them before they get to the hospital stage. Therefore, I do not recommend making the hospital the central prop of the complete Service.
§ That advantage would be gained from combining the health and welfare departments can, I think, be drawn from the fact that under the Local Government Act, 1958, local authorities with more than 60,000 people were allowed to combine their two departments, in the sense that they could make the medical officer of health the chairman of both departments, of welfare and of health. That system has been adopted by most, if not all, local authorities of that size, and at the same time by quite a number of county boroughs and county councils. Many of the burghs in Scotland have done the same thing, although as they work under a different Act of Parliament, things are not quite comparable. I am sure that if that could be done, if the two departments could be joined together, 556 it would be more successful than at the present time; because it is practically impossible to make a real distinction between health and welfare. You probably have people on the far extremes of both services in regard to whom you can say that their work is either health or welfare; but you have an enormous number of people in the middle where it is very difficult to decide on which side of the fence they should come.
§ I think it was a pity that in both the National Health Service Act and the National Assistance Act that particular question was not recognised, and that those two very important Acts of Parliament tended to run in parallel rather than to come together from time to time; because, as we were all taught at school, the essence of parallel lines is that they never meet but go on to infinity. That, I think, has been a great mistake. Indeed, I once upon a time tried to get this matter elucidated in your Lordships' House. In 1959 I put down an Unstarred Question with this end in view. Unfortunately, we got nowhere in that discussion, which confirmed, I believe, that you really cannot separate health from welfare.
§ One of the points that the Porritt Committee make—they go a little further than I have gone now—is the great importance now of integrating social medicine, family doctoring and hospital practice. There, of course, nobody would agree more than I myself, and I am sure that the noble Lord who is to reply for the Government would agree too. I do not want to pursue that point any further, but I would say a word or two about the general practitioner side of the Service. What we are told when we are talking about the Health Service is that the general practitioner is far and away the most important person; that if it were not for him it would break down; that he is the kingpin, and such phrases as that. But when one comes to see what has been done for the poor fellow, one wonders whether that is merely a form of words and whether it has been put into force as strongly as it might be; because in many parts of the country general practitioners still feel cut off from the hospital and suspicious of the local authority. Both of these feelings go back a long way in history.557
§ I do not want to go into some of the unfortunate causes that have led to this feeling, but it is one which has certainly been in existence for a long time. The point about a good general practitioner is that he does not want to be merely a signpost to the hospital: you come to your doctor, you go to the hospital. That is not what the practice should be, and few really good general practitioners want that to be so. Unfortunately, more and more people are being transferred direct to hospital, with the effect that the hospitals are fuller than they have been before and are becoming rather overburdened with work.
§ One wonders what is the reason for all this. There are a number of reasons, some of which I think could be prevented, though some of them probably could not: because the science or art of medicine has greatly improved and expanded over the last ten, fifteen or twenty years, and there are to-day greater facilities than hitherto for diagnosis and for treatment, all of which puts a greater demand on the work of the hospital. At the same time, the number of doctors has become smaller and they are being given a good deal of work to do which is not necessarily strictly medical.
§ To move on from that point, do we really know what number of doctors we need, first, at the present time, and, secondly, in, say, 25 years' time? A Committee which was set up under the chairmanship of a former Minister of Health, Sir Henry Willink reported some years ago that the number of doctors needed might decrease rather than increase. As a result of that, a certain number of medical schools cut down the number of students they took in. I think that most of them have now realised that that was a mistake, that that Committee was mistaken in its views, and that the number of doctors we have now is too small. The shortage was not really apparent until about four or five years ago, but I think I am right in saying that as time goes along it is becoming more and more apparent. Therefore one wonders whether it would not be a sensible move to have a general practitioner advisory sub-committee of the Central Health Service Council, which would be able to report on the work and practice of the general practitioner and upon what should be the ideal size of such a practice.558
§ We have a certain idea about what should be the size of a practice, but I think that, of necessity, the right size will vary in different parts of the country. Probably in most parts of the country the practitioners' lists are still too large, although one must say straight away that the cutting down of lists to a more workable size does not necessarily mean in every case a better clinical practice—although in quite a number of cases that will be the result. One of the difficulties, of course, is that under the present capitation system if we reduce the particular number of patients on a doctor's list it means he will suffer a fairly substantial reduction in income. That, I think, is something to be deplored, not only because I am a doctor myself but because I think it is a bad thing that people's incomes should be reduced: they should be given a reasonable income for the work that they do. It has been suggested that there might be some other method of remuneration over the capitation fee. There has been a good deal of discussion about that proposal but, so far as I know, no system, apart from the capitation fee, has been worked out which it is thought would prove more successful than the capitation fee. So I think that the capitation fee has probably got to stay.
§ In the event of our needing more doctors where are they to come from? The present medical schools are, for the most part, working to capacity. They might be able to take a few more students, but not a great number, because there is a definite limit to the number of young men and women who can be taught in a class, especially on, the pre-clinical side. One wonders why none of the proposed new universities has a proposed medical faculty. One would have thought that some of the universities which are situated in fairly thickly populated parts of the country could well take a part and include among their faculties a small medical school. Possibly this is a matter for the University Grants Committee—and we know that at the present time that Committee is not feeling too kindly disposed towards distributing money. But I firmly suggest that one or two more medical schools are urgently required.
§ Another question also has arisen. It has not been talked about much lately, 559 but about two years ago there was a good deal of talk about the number of young doctors who emigrated. Finding that they could not get work in England, or because they did not like the work in England, they left the country. I believe that somebody once said that between one-quarter and one-fifth of the doctors emigrated. I know that it is a difficult figure to estimate, but I wonder whether the Minister has figures which would reveal the real number. Certainly from the experience of my own school, so far as we can work it out, the proportion is nowhere near as large as that; it is about 6 or 7 per cent. of those who qualified, not, as was said in other cases, 15 to 20 per cent.
§ We should also bear in mind that, in a number of cases, those who emigrated did so, perhaps, for only a year or two, and then came back again. I am sure that is a practice to be encouraged. It is one way we have of spreading British medical knowledge and skill among the under-developed countries. I personally should be extremely sorry if the number of doctors who emigrated for a short time were to drop, because I believe they are doing fine work in spreading their knowledge in other countries. At the same time, one hears people say that if it were not for the people who come here from the Commonwealth countries, the National Health Service could not run. That comment does not worry me at all, either, because it seems to me that we are doing our duty properly by these young people from other countries, in allowing or encouraging them to come here, so that they can work and be trained here, and then go back to their own countries and spread the good learning and knowledge which they have got from people over here.
§ There is another point about the practitioner to which I should like briefly to refer. Quite a number of general practitioners prefer to work in groups of four or five, rather than to be entirely single-handed. They find that if they work in groups they can afford to run a much more satisfactory practice; they can have reasonable premises to see patients; they can keep a certain number of secretarial assistants and receptionists, and others—like nurses, health visitors and midwives—to assist them in their 560 work. But I think that requires a practice of about 10,000 patients, which certainly means having four doctors.
§ I gather that one of the troubles in this connection is that it is extremely difficult for doctors to find suitable premises in which to practise. In the old days people practised from their own houses, with the dining room or the drawing room being used as a consulting room, and that sort of thing; but if one is going to have four doctors in a practice this is not practicable. Not only is it difficult to find suitable premises, but I am told that at the same time it is difficult to borrow money from the building societies for such premises. The premises are no good for any other purpose, and building societies prefer to lend money for ordinary houses rather than those which have been changed into consulting rooms and rooms for doctors to practise in.
§ Another point is this. If doctors are going to be encouraged to have working for them secretaries, receptionists, health visitors, nurses, and so forth, they will probably have to pay more for the staff they employ themselves as the salaries outside increase. A number of them find that they cannot afford to employ these people. Would it be possible to make some kind of extra-financial provision for the expenses of doctors in view of the increasing amounts of money needed to run a practice of this type? I am sure that if one could get more group practices one would cut down the referring of patients to hospital, with a consequent saving in the number of hospital beds needed. I am sure this would be a great advantage to the National Health Service in general. The hospitals could be of great assistance to the general practitioners in giving them more facilities than they do now in the way of X-ray photographs and pathological investigation, without the patients necessarily having to be referred to one of the consultants at the hospital. This would also have the advantage of not adding to the long queue of out-patients in the hospital.
§ There are several ways in which practitioners can be assisted. I will quote one or two examples which I have come across quite near London. There is a big centre in Peckham—it was the old Pioneer Health Centre before the war—which has now become the general 561 practitioner centre for South-East London, to which general practitioners can send patients for X-rays and pathological investigation. They can perform a certain amount of minor surgery there; they can send their patients to have their injuries dressed, and can get a certain amount of simple physiotherapy carried out. This takes a big burden off the hospital service. These are patients who do not really need to go to hospital, and this system encourages the general practitioner, with the aid of this centre, to treat his patients himself. There is a further service, though not on such a big scale, in the Borough of Ealing, where much good work is being done by the local authority in providing a centre to which doctors can send patients for physiotherapy and other forms of treatment. This, again, is a great advantage to the doctors themselves.
§ Before I move from the general practitioners, I should like to put in a good word for trying to retain some of the general practitioner hospitals which it is intended to get rid of under the ten or fifteen year Plan. The reasons for retaining these hospitals have been given on numerous occasions; I do not want to elaborate them too much now. There are really two important reasons. One is that it is very good indeed for general practitioners to have a hospital of their own, where they can take care of their patients, and where they can meet their colleagues so that they do not feel they are working in complete isolation from the other practitioners in their part of the world. At the same time it would make more use of part-time nursing staff than if the hospitals were merely to be concentrated in one big district hospital. Furthermore, it would be appreciated by the patients and their relatives, who would not need to travel such long distances to reach hospital. Supposing there were some real objection to retaining these hospitals under the Regional Hospital system, would it not be possible for them to be transferred to the Executive Council so that they could be general practitioner hospitals in the true sense of the word and not part of the whole Regional Board system? I feel this is a point which is really well worth considering. I should like to ask the Minister to what extent the various branches of the profession were consulted 562 on the ten-year Hospital Plan, apart from the Central Health Services Advisory Council, which was obviously consulted.
§ Then a question in parenthesis. Would it not be possible for hospitals to be given some sort of transport of their own? At the moment the ambulance service is run entirely by local authorities. The local authorities, broadly speaking, do their job very well, but I work in the London County Council area and we experience great trouble in dealing with elderly patients who come up, say, for physiotherapy once or twice a week in the afternoon, most of whom have got to be brought by ambulance. This work usually finishes at 4 or 5 o'clock, but frequently patients have to wait until 7.30, 8 o'clock, in some cases even 9 o'clock before the ambulance can pick them up and take them home again. This means that the staff of the department must also stay there, and it means that the patients are kept waiting there, which is discouraging for them. Could not some change be made in the rule that transport must be entirely under local authorities? Could not the hospitals in future be allowed a limited amount of their own transport?
§ I should like to see the general practitioners as directors, as it were, of what one might call the public health services, with the local authorities—or whatever would be the appropriate body—seconding to, or deploying in, their service a large number of the nurses, health visitors, and social workers who at present work entirely for the local authority. I know that this has been done in a number of areas, and where it has been done well it has worked with great success. If that were done it might be possible to reduce the number of workers who go round visiting people in their homes. One problem in the past has been that there have been large numbers of people, some employed by the local authority and some by other bodies, who have visited people in their homes, and this has been rather confusing to some of the homes. The more unscrupulous families have played one visitor against another.
§ I wonder whether something could not be done about combining some of these services into one. I put forward 563 these ideas rather tentatively, but, for example, could not the health visitors and the social workers be combined? I know we have just passed a Bill dealing with the training of more social workers, but perhaps we should think again, and make some other arrangement of that service. Would it be possible to co-ordinate more with the nursing service? Should the social workers be given some nursing training, not to the extent of being State registered nurses, but rather more than the ordinary Red Cross training for nurses, or something like that? If that were done, they could become of great assistance to the general practitioners, to whom they could be attached. That, I think, would be one way whereby the local authority side and the general practitioner side could be brought very much closer together, and work could be done for the mutual benefit of the two. At the same time, I think that a certain amount of staff could be saved, with a saving in money, too.
§ My Lords, before I sit down (I am afraid that I am keeping your Lordships a very long time) I should like to refer to my own particular subject; that is, the care of the elderly people. I agree that the crying need for these people is to keep them at home as long as one possibly can, with as many services to assist them as is humanly possible. But I wonder whether the time is coming when we shall be able to get many more people to assist them in their homes. The other day I was looking at the Report of the London County Council and I was rather shocked at the figures which I saw for home-helps—and these people are really fundamental in keeping a single, old, frail person in his or her home.
§ What I found, rather to my surprise, was that between 1957 and 1961 the number of home-helps had gone up by only about 500. It occurred to me that maybe the supply is tending to dry up, and that we shall not get enough suitable women to take on that job. It may, therefore, be necessary—much as I deplore the idea—to think more of arranging suitable accommodation in communal homes for some elderly people, or of some other means of preventing them from becoming sick and becoming a charge (I do not mean 564 a financial charge, but a moral charge) upon members of the community. That leads me to another question that I should like to ask the Minister: whether he has any idea of the total number of beds required for old people in the country. I do not mean the total number of hospital beds, but the total number of beds required for those in need of some kind of care, whether it is mental care, physical care or medical care. I wonder whether there are figures for that, too.
§ Then I think that something might be done to provide some sort of clinics for old people, rather on the lines of the old maternity and child welfare clinics, possibly staffed by a general practitioner, where old people, or not so old people—young-old people, if you like to put it in that way—who would not want to call in their general practitioner, could go and consult about various problems. I merely put that forward as an idea, but I think it might be worth looking into.
§ I would also ask the Minister whether it would be possible to transfer back to the hospital service the accommodation which is available for infirm and elderly people under Part III of the National Assistance Act, because at present it is very difficult, to get a normal though frail old person transferred from hospital to accommodation under Part III. I wonder whether it would be an improvement if that could be encouraged and brought about. I know that the subject has not been thought about very much until now, but it seems to me that that might be one way of solving the difficulty.
§ Another thing which might help would be to make the housing lists of local authorities a trifle more flexible. On several occasions I have heard about people who live by themselves on the top floor of a two or three-storey building and who could cope with life quite well if they lived on the ground floor. But because of the housing list and their place on that list it is almost impossible to get them moved quickly up the list. I do not want for a moment to suggest that people should be "jumping the queue", right, left and centre. But it seems to me that an exception might well be made in the case of a fairly frail person living on the top floor, who cannot manage but 565 who could live an independent life on the ground floor. It does seem to me rather silly if that person cannot move to the ground floor, because she is No. 452 on the housing list instead of being No. 2. Perhaps the attention of local authorities could be drawn to that point, so that some change might be made there.
§ My Lords, I have been speaking far too long, but there are just two other points to which I should like to refer before I sit down. There is the body which was rather well described in the Lancet as the "greater medical profession," which consists of all those people who are of such enormous assistance to the doctors at the present time—physiotherapists, occupational therapists, almoners, and many others. Their numbers are nowhere near enough to go round, and their pay is not all that it should be. I know that we have discussed this matter in your Lordships' House on many occasions, but I should like to mention it once more, because I think it is something of great importance with which we shall have to come to grips fairly soon, or the supply will just dry up.
§ Before I sit down I would make two suggestions to Her Majesty's Government. One is that the Health Service should be far more decentralised than it is at the present time. At the present time, we have the hierarchy, on the hospital side, of the hospital management committee, Regional Hospital Board and Ministry of Health. That journey up there and back again takes quite a long time, wastes a great deal of energy, and frays a good many tempers. When the Health Service was being debated we were told, if I remember aright, that though centralisation was essential at the start, the time would come when a cerain amount of decentralisation would occur. I wonder whether that time has now come, and whether, if decentralisation cannot yet occur, we really need this further tripartite system of the management committee, Regional Hospital Board and Ministry of Health.
§ The other point I wish to suggest, which may seem a minor one after what I have said, concerns the composition of the Central Health Services Council. I wonder whether that could not be a body elected by the profession, or containing 566 a number of elected members, rather than a body nominated by the Minister. If such a change were made, I think it might give great encouragement to the profession; and it would not, I think, lead to any diminution in the quality of the work the Council did. My Lords, I have taken up far more of your Lordships' time than I usually do when I address you. I beg to move for Papers.
§ 5.20 p.m.
§ BARONESS SUMMERSKILL
My Lords, I am quite sure that we should all like to thank the noble Lord, Lord Amulree, for putting this Motion on the Paper and so enabling us to debate a very interesting Report. I agree with him that one cannot approve of all its proposals, or disapprove of them all; but this review—and it is a very long review—nevertheless stimulates thought among those of us who are very anxious about this subject, and who have only one objective, which is to improve the National Health Service. I must confess that, by the time I had read this document (as I say, it is a very long one), I was very sorry for the chairman, because he apparently sought and received so much advice from so many quarters that, in endeavouring to please everybody, he arrived at some conclusions which tend to cancel each other out.
I always believe that, in a Report of this kind, one should never try to compromise on matters of principle. That is absolutely fatal, because by the time people who are interested in it and who read it arrive at the end they are not quite sure precisely what kind of service the authors intend to establish. I must confess that, to me, the Report seemed finally to be speaking with two voices—the voice of Jekyll and the voice of Hyde. Dr. Jekyll pronounces with wisdom, experience, humanity and knowledge; and then, suddenly, Mr. Hyde pops in his little ugly head with some mean little suggestion. For instance, Dr. Jekyll announces that the Gallop Poll reveals that people believe that the concept of the National Health Service is sound. Mr. Hyde—a hireling, I suspect, of the Fellowship for Freedom in Medicine, which is a very small, reactionary body (I am glad the noble Lord smiles) representative of only a small number of doctors—in this guise, whispers, 567 "The doctors should, when possible, be in direct financial relationship with the patient rather than with the State, thus strenghening the bond beween doctor and patient while weakening the power of the Government over the medical profession." Can it be in the interests of the patient—let us say, one suffering from some mental disability—to feel that the strong bond between himself and the doctor is a financial one?
Then, again, it is suggested that the drug bill of nearly £100 million should be increased by providing drugs for private patients on the same terms as those for National Health Service patients. Of course, if this were done it would inevitably undermine the whole structure of the National Health Service, because it would thereby establish two categories of patients within the service. I do hope that noble Lords realise that this is entirely different from approving of private patients who go to the doctor as a private patient, take their prescriptions and go to the chemist. The suggestion here is that the prescription, E.C.10, which is provided under the National Health Service, should be given to one patient free, but that a charge should be made by the doctor if he gives it to somebody else. Now this would introduce such discrimination that it would, I believe—I do not think this is an overstatement—undermine the whole principle of the National Health Service.
Now these various suggestions to increase the financial interest of the doctor hardly accord with the evidence before us that both the doctor and the patient are, under the National Health Service, faring well. The Committee tell us in the Report that the doctor has retained his clinical freedom and that the very small number of formal complaints by the public against the doctors is one indication of the public's general satisfaction with the service. I have said that this Committee is speaking with two voices. On the one hand they say that, and then, in paragraph 116, it is suggestedthat the possible advantages of a direct contribution by the patient should be the subject of continuing study.It is to be regretted that the 44 people responsible for this Report, mostly doctors—if the noble Lord looks through the 44 names I think he will find that 568 they are not all qualified doctors of medicine, but that most of them are doctors—seem to have forgotten that one reason, as I recall it, almost the primary reason, for the introduction of the National Health Service was to include the mothers, the children and the aged. If a financial contribution is now demanded from these particular categories, they would inevitably tend to avoid obtaining medical advice in the early stages. That is what happened in the poorest parts when we had children dying from bronchial pneumonia following measles. It was because the mothers could not afford, out of the housekeeping allowance, even a small contribution to the doctor. They said, "This is only measles", and they waited for the rash to go, but the cough continued and the child developed bronchial pneumonia. Look at the statistics to-day. These women can now obtain medical treatment for their children at an early stage of their illness, and the result is that the change in our morbidity statistics in this field is absolutely spectacular. I do ask the noble Lord, when he comes to reply, to give us the assurance that we shall not go back to the stage when these particular categories were asked to make a financial contribution.
I welcome the suggestion that the family doctor's maximum list of patients should be reduced from 3,500 to 2,500. Although the noble Lord said that, if this were done, he did not think it would mean that the patient would necessarily have more attention and that the doctor would perhaps take more trouble in the clinical field, I confess that I welcome this proposal, particularly in the interests of the doctor. For the same reason, I am pleased that it is quoted again that the "properly organised emergency deputising services" in large cities are not frowned upon.
There are so few family doctors to-day. There are not enough family doctors for the whole nation. Their occupation hazard is coronory thrombosis, and their expectation of life is one of the shortest in the community. I believe that the longest is for a minister in the Church of England, and I believe the shortest is to be found for some people in the breweries. The doctor of medicine, one would think, with his knowledge, would have a long expectation of life. But not 569 at all, my Lords. The pressure upon him—physical, mental and intellectual—is such that his expectation of life is not very long. I would ask the House to consider whether the time has not come when the doctor should cease to be the only worker in the country expected to do day and night shifts. That is why I welcome the paragraph on the emergency deputising services. I think that certainly his conditions of service must be reviewed more carefully if we are to receive good recruits for medicine. That is why I should give more consideration to the establishment of health centres.
The noble Lord spoke just now about the corner house, with its drawing room and dining room—the kind of place in which I was brought up—which was converted into the home and the surgery and the waiting room. These big, old Victorian houses were absolutely ideal in which to conduct a general practice for the neighbourhood, but they are no more. He was of course quite right in what he said about the building associations and the banks, which are not prepared to make big advances for colossal museums, as they think they are, which are converted by the doctor and afterwards, of course, are of no use for family residence. I think the answer to this is health centres, and I am very sorry that health centres have been dismissed as they have. Again, the noble Lord spoke about the payment of the general practitioner. He thought that the capitation method was not the right one. Again, I really think that perhaps the whole question of a salaried service should be reviewed. It functions very well in many other countries which have a health service equal to ours.
Now we come to the shortage of doctors and medical students. This has been emphasised, but in view of the demand by able girls for places in medical schools the statement in this document thatFew of any walks of life have so much to offer the able young man as medicinewill astonish many of us. I suppose that this Freudian lapse should not surprise many of us who will already have observed that this survey was conducted by a Committee of 44 individuals, of whom only one was a woman, to examine a service in which about 75 per cent. of 570 those employed are women. The noble Lord reminded us just now of the "greater medical profession", of these wonderful women, the psychiatric social service workers, the workers in what we have called "the professions supplementary to medicine" (this is a clumsy term and I should have preferred "the larger medical service"), and we find that all are women. Yet this document has been compiled about a great women's service by 43 men and one woman. No doubt this attitude accounts for the failure to direct attention to the diehard attitude of the London medical schools, which still attach more importance to sex than to ability.
I would remind noble Lords that we are discussing the shortage of doctors. In the North of England, North of the Wash, the hospitals cannot be conducted without immigrants to this country. In many wards the men and women, not necessarily doctors but helpers, find it difficult to speak English. Yet of the London medical schools to-day only one admits more than 15 per cent. of women. We are told that there is a shortage. We all know this. There is a deplorable shortage. The Willink Committee was entirely wrong. I hope that now the medical schools, when able young women go to them, will recognise that they can be first-class doctors irrespective of their sex. No noble Lord who looked at television last night would have minded having an anæsthetic given him by the women anæsthetists who were then shown. But the diehard medical schools say 15 per cent. and no more.
I was very glad that the noble Lord spoke about preventive medicine. Of course the Porritt Committee are quite right, and there should be a reorientation of service from curative to preventive medicine. Nobody would dissent from that. But I find it difficult to reconcile this proposition with the establishment of Area Health Boards. I agree entirely with the noble Lord, Lord Amulree, who reminded us of the variety of Government Departments concerned with preventive medicine, with housing, welfare and the children's service. As I read it, if these Area Health Boards were set up they would be entirely divorced from these welfare departments which it is so necessary to amalgamate with the strictly health service.
571 I also agree with the noble Lord, Lord Amulree, when he was talking about social workers and the health workers—he did not call it a team—who are sometimes attached to certain general practitioners. It is the well-organised team of domiciliary health workers which should be in the van of preventive medicine. They know what is happening in the family; they know who is sick; they know who needs help, and they know where to send some individual for that help. If successive Ministers of Health had taken more action in this field, we should not be told in this review that the facilities for the chronic sick and elderly are inadequate in every respect. I thought the noble Lord, Lord Amulree (as we all know, he devotes his life to the geriatric service), was very kind in not emphasising those parts of this review which related to his particular field of work, though he reminded noble Lords that the service for the chronic sick and elderly is inadequate in every respect.
Might I remind noble Lords who were at the unemployment debate only a fortnight ago that I said then that in the North-East of England where the noble Viscount, Lord Hailsham, spent some of his time, are large numbers of able young men who have the aptitude to serve in our welfare service if only we could recruit them. They could be given work immediately. The need is great and, as the noble Lord has said, we could bring them into some of these teams to care for elderly men neglected in their homes. In the North-East in a short time we could establish a first-class geriatric service. This was my suggestion in the unemployment debate a fortnight ago. The noble Earl, Lord Dundee, who answered regarded it as so stupid that he did not devote one sentence or one word to it.
A fortnight later we come to this House to debate another Report which reveals the desperate need for able young men and women—not necessarily with high educational ability, but able in other respects, willing, kindly, cheerful, and prepared to help in a team where there is a desperate need for them. Yet the Government Departments work on the subject in such a watertight manner that while unemployment is rife in one area and is dealt with in one Department, yet another Department introduces a Report 572 —or at least gave its blessing to its being debated—which shows there is a great demand for labour.
Now I come to another aspect of the work. The Report states thatthe closer association between general medicine and psychiatry will we confidently expect, lead to a raising of psychiatric standards.Well, my Lords, we all agree with that. We welcome it. Nevertheless, out of 44 members of the Committee—mostly doctors—there were very few psychiatrists.
§ BARONESS SUMMERSKILL
There were only three psychiatrists out of 44 doctors. Does this omission indicate, strikingly, the fundamental attitude of general medicine towards sickness of the mind? I believe that while we permit the people of this country to become pill addicts in the interests of the pharmaceutical industry we tend to ignore the crucial problems of psychogenic disorders. Therefore much more attention must be paid to the teaching of psychotherapy in our medical schools.
Now I come to the tripartite administration of the Health Service. I agree with the noble Lord, Lord Amulree, entirely on that aspect. Of course, one cannot really complain, and I do not complain, in so far as it is our attitude—the British way—to deal with matters in a piecemeal fashion. We are completely pragmatic in our approach to many of our services. We find out if something works and if it works we set up a committee to administer it. After a time we find it has been a little haphazard, but nevertheless the rest of the world admires us for this pragmatic approach and for being not so doctrinaire as some other countries. But the time has come when the whole thing must be revised.
The criticism of the tripartite administration is well justified, particularly with regard to the maternity services; and the Porritt Committee mention the maternity services as illustrating their point. We are reminded that some maternity hospitals are so overcrowded and understaffed that they are compelled to discharge mothers within a few days of delivery. I read somewhere a little while ago that in some hospitals mothers were 573 being discharged after 48 hours. We must remember that when a poor mother is discharged, she does not go to a home where there is somebody to wait on her, but often it is necessary for her to sit in bed and conduct the housekeeping from there. Although, from a medical point of view, a stay in hospital may not be necessary, a mother may not be ready mentally to grapple with household problems, and she deserves and needs a rest mentally, if not physically.
In support of the Porritt Committee's adverse comments on the maternity service, I would remind your Lordships of the findings of the perinatal mortality survey conducted under the auspices of the National Birthday Trust. Every year there are 25,000 babies born in Britain who are either stillborn or die in the first week of their lives. It is significant that the death rate of babies in the professional classes is half that of the rate in the class of unskilled labour. When the noble Lord comes to reply I hope he will deal with perinatal mortality and not with the infantile death rate, which is a different thing. I am glad to learn that a conference is being held in Friends' House on this subject, in which eminent obstetricians, of whom Professor Nixon is one, will speak.
The Cranbrook Report on Maternity Services recommended that all women having their first babies should be delivered in hospital. Yet one-third of the women having their first babies are booked for their confinements outside hospital. In the year ended March, 1962, over 4,000 women were admitted to London hospitals as obstetrical emergencies—that is, after labour had started—an increase of 20 per cent. over the previous year. This reveals that in London more and more women have to go into labour before proper arrangements are made for their delivery.
I say deliberately that to-day the women of this country have only a second-class maternity service. The figures I have given and the conditions I have described are evidence of this. The pressure on the available accommodation in hospitals is so great that the limited number of overworked and underpaid midwives are subjected to an intolerable pressure. It has been said over and over again—by the Porritt Committee, by the Cranbrook 574 Committee, in this House and in another place in one debate after another (though perhaps in years past your Lordships did not talk so much about maternity as we do now)—that midwives are overworked and underpaid. At the moment, the question is sub judice, I understand, because the midwives are before the industrial court. It is grossly unfair for people who have no pressure groups to be called upon to do this invaluable work and still be exploited by the community.
While I am speaking on the maternity service, I would remind the House that while other countries have taken action since the thalidomide tragedy to protect their mothers and children against the consumption of inadequately tested drugs, the Minister of Health has done nothing but set up a Committee. Last week in another place, he was again asked what was being done to protect people against these inadequately tested drugs and he said that he was still waiting for a report from a Committee. The United States took action, the Scandinavian countries took action and the German Government took action, but in this country tranquil-lising drugs are still sold and advertised as the proper thing to give women in the early months of pregnancy. Yet eminent physicians have said that women would be safer without any drugs in the early months of their pregnancy.
I can in this debate deal with only a few aspects of this Report which must be limited. I welcome the unequivocal statement in paragraph 607 that… basically the concept of a comprehensive health service is soundand that in general it… has proved of great benefit to the community".On the other hand, it is a little naïve for the authors to plead that the Service should be kept out of politics, having regard to the fact that when the Labour Government introduced the National Health Service it was voted against on Second and Third Readings. In the course of the last eleven years, it has been necessary again and again for the Opposition to draw the attention of both Houses to the condition of hospitals, the shortage of staff of all kinds, the long waiting lists, and the low pay of nurses and midwives and in the larger profession of medicine. This review highlights these 575 things and calls for improvement. I can only say to the authors that while we thank all 44 of them—43 men and one woman—who have given their time and energy to produce this survey, the improvements they would like to see introduced can be expedited only by an active and ever-vigilant Opposition.
§ 5.48 p.m.
§ LORD BRAIN
My Lords, the Report of the Porritt Committee covers such a wide field that it is impossible to deal with more than a small part of it, and I propose to concentrate on the question of medical research. But, first, I should like to make one general comment. I echo what the noble Lord, Lord Amulree, said about how striking and satisfactory it is that this Committee—I was going to call it broadly representative, but perhaps, after what the noble Lady said, I should not—has reached the conclusion that basically the conception of a comprehensive National Health Service is sound.
The Committee did not have a great deal to say about research, because, as it pointed out, its remit did not extend to the scientific aspect of medicine. Nevertheless, it emphasised, and rightly, that… research is so vital to the development of the nation's medical services, …and added this:From our study of the existing arrangements for the co-ordination of research, we have concluded that basically they are now working well within the financial limits imposed. However, it is impossible to judge how much research potential has been lost through lack of adequate funds.These are the points which I wish to discuss.
There is a good deal of dissatisfaction with the state of medical research in this country, and it is those with the greatest authority and experience in this field who are the most vocal. Our organisation of medical research illustrates in the highest degree our national genius for interdepartmental complexity and divided responsibility. To discover how it works is a work of research in itself, and it is this which makes a diagnosis of the cause difficult and makes it possible for those who are responsible to point to individual parts of the system, which admittedly are working very well, without paying due regard to the picture 576 as a whole. Everyone, I think, will agree that we may well be proud of the Medical Research Council. It can point with satisfaction to its expanding budget, to the excellent work done in its units, and, as the noble Viscount the Minister for Science said in this House last Wednesday, to the Nobel Prizewinners, fostered by the Council. This is a justifiable pride. But, as every gardener's wife knows, it is possible to win prizes for lilies and yet to be short of potatoes. It is the shortage to which I want to draw attention.
The present organisation of medical research as a whole is such that an élite is fostered, but there is too little encouragement for promising young doctors to go into it; and if they do go in, so many obstacles are put in their way that many give up, and those who persevere have to battle with unnecessary frustrations. It has always been the policy of the Medical Research Council to use the greater part of its resources to pay for the management of its own units and to be highly selective in its award of grants to other applicants. I do not criticise this policy which, it may be claimed, continues to yield excellent results. But I want to look at its consequences. In the year 1960–61 the current expenditure of the Medical Research Council amounted to £4,600,000. Out of this sum, the amount which it spent on temporary grants and training awards—that is, to workers outside its own units—was £424,000, or 9.2 per cent. of its total budget. There are two kinds of research workers who may receive temporary grants from the Medical Research Council: there are groups working in a university department, to whom the grant is made in the first instance for five years, and there are individual workers, whose grant is usually made for three years. So the £424,000 which was spent on temporary grants in that year was not all available for new research projects, because some of it went in continuance of existing grants. Hence, if we leave out of account what the Medical Research Council spends on its own units, the amount it spends on groups or individuals wishing to start new research in a single year is about £100,000, out of an annual budget which is now over £5 million.
577 But, having been selected, what has this type of research worker to look forward to? If he is an individual with a three-year grant he has no security beyond the three years, and at the end of that time he must show that what he has done justifies the continuance of his grant. With groups working in the university the position is somewhat different. At the end of five years, by an arrangement made between the University Grants Committee and the Medical Research Council, the university concerned will be asked whether it is prepared to take over the responsibility for the group and to assess the priority of the takeover in terms of its other commitments. Here, then, two elements of uncertainty enter into the picture: the research group has to prove its worth to the university, and the university has to have enough money to take it over. The Clinical Research Board can point to a gratifying increase in the amount of money which it is devoting to clinical research, but here again, outside its own units, the policy with regard to the individual research worker is the same as that of the Medical Research Council. He has no security for more than a few years ahead.
There are many young doctors who start their medical careers imbued with a sense of scientific inquiry. While holding junior posts they have opportunities for research, but they do not want to devote their whole career to nothing but research. They may perhaps want to become consultants, but to go on doing research at the same time. Very often the quality of the research they have already done is an important factor in securing for them a consultant post. But what encouragement or opportunity does the young consultant receive to go on doing the research of which he has shown himself capable? There are a small number of medical schools which have adopted the far-seeing policy of providing additional sessions for research as an integral part of their new consultant appointments. But these are still a minority, and this policy, if generally implemented, would mean more money from the universities. Elsewhere, all the young consultant can do is to apply for a grant from the Medical Research Council or the Clinical Research Board, which neither will guarantee for more than a few years. 578 And even if he could get such a grant, only too often the hospital has not the laboratory accommodation or the technical assistance which he would need. What happens? Instead of doing research, he can get another consultant appointment at another hospital, and he will then have a contract which will last until he is 65, and will not only give him security but, like his original appointment, render him eligible for a distinction award. Is it surprising that in such circumstances research gets left behind?
I know that there is held to be a good reason for the cautious policy which requires grants to be frequently reviewed and which makes hospital boards reluctant to give sessions for research as well as for clinical work. Superficially this caution looks prudent. Who can tell, it is said, that a man who is doing good research at 30 will still be doing it at 40, or even 50? Is there not a danger that we shall waste a lot of money if we encourage peple to take up research who may not continue to deliver the goods? The noble Viscount the Minister for Science, in the debate in this House last Wednesday said [OFFICIAL REPORT, Vol. 247 (No. 46) col. 95]:It is easier to waste public money on science than on almost any other subject.But in scientific research, as every scientist knows, you cannot always predict results, and you must be prepared to risk wasting money, if that is what you call it. For only by encouraging and supporting considerable numbers of scientific workers, by an act of faith if you like, will you create the conditions in which, not only by scientific judgment, but sometimes also by good fortune, great discoveries are made.
On December 4 the Parliamentary Secretary to the Minister for Science, in reply to a Question in another place made this statement [OFFICIAL REPORT, Commons, Vol. 668 (No. 26) col. 1121]:It is untrue to suggest that greater progress in finding the causes of cancer would necessarily be made by the mere expenditure of money. If money in research is not to be wasted, there must be first-class men with first-class ideas"—
§ LORD BRAIN
I am still quoting—who must then be supported. I do not believe that there are any such projects in this field which are not being supported either by the Medical Research Council or by the voluntary bodies.My Lords, I believe this to be a dangerous fallacy, and I would ask: how does the Parliamentary Secretary know? By choosing first-class men with first-class ideas you may run a department with the maximum economy. But in research, as elsewhere, the spirit bloweth where it listeth, and it sometimes happens that a man turns out to be first-class only ex post facto. Fleming discovered penicillin as a result of a happy accident. He could not have put down on paper in advance any ground for thinking that he was going to discover it. Besides, much valuable work is done by research workers who would not claim to be individually distinguished. It is not wasteful to support them. And if a clinician wants to continue to do research work part-time, it should not be impossible to arrange for him at a later date, if he finds that he can do no more, to give it up in exchange for a further clinical appointment.
I now come to the part played by the universities in medical research. I began by drawing attention to the complexity of our arrangements for the promotion of research in this country, and I should like to say at this point that, in spite of its drawbacks, I think it is a very good thing that medical research is not the responsibility of any single body. The universities may have the opportunity of doing things which the Medical Research Council, by its nature and organisation, cannot do; and the independent private research organisations also play a vital part. Incidentally, may I at this point put in a good word for the pharmaceutical firms? In some ways they are not very popular just now, but they do make a most important contribution to medical research, particularly in a field and of a kind which no other body would be likely to undertake.
Of course, it is only to a limited extent that one can generalise about the part played by the universities in medical research at the present time. But I think it is a safe generalisation to say that for a long time they have had far too little money to devote to it. Forty years ago, after the First World War, when the 580 medical professorial units were first founded, there was a considerable amount of accommodation, and the problem was to find and train up the right people. Now, with all the growth of the technological side of medicine, and the enormous development of medical research, the problem of accommodation is an important limiting factor. One university department, for example, with an international reputation, which started 40 years ago with ten research workers and about the same number of technicians, now has 60 research workers and over 100 technicians in the same space. There can be few, if any, medical schools which are not seriously hampered by the lack of space for research facilities, and particularly space for clinical research which needs to be done in the immediate neighbourhood of the wards. If some schools are not even asking for the space they need, I suspect that it is because they have become completely disheartened by the financial stringency adopted in respect of university expansion in recent years; and the recent rejection by the Treasury of the University Grants Committee's recommendations in this respect was a blow from which the universities have not yet recovered.
I could quote many instances of our research deficiencies in the university field, but I will mention only one. As Professor McMichael pointed out in The Times the other day, we have only one professorial Chair in Virology in this country. Virology is concerned with the vast range of diseases caused by viruses, including poliomyelitis, influenza and the common cold. But, more than that, the study of viruses is throwing light on heredity, cancer and the nature of life itself. I know that good work is being done in this field elsewhere, including M.R.C. units, but it is not being adequately fertilised at the university level. We ought to be leading the world in virology; instead, as Professor McMichael pointed out, we depend on the United States of America for our Salk and Sabin vaccine for poliomyelitis, products of their inadequate high school education.
There is another reason why it is important that the universities should be encouraged to play a much larger part in promoting medical research. Medical research has a vital part to play in medical education. If universities ever came to 581 be regarded merely as teaching institutions they would lose half their educational value. It is essential to the education of both the undergraduate and the post-graduate student that they should be brought up in an atmosphere in which positive contributions are being made to knowledge and there is a spirit of critical inquiry alive. This can happen only if active research is going on in the medical schools. There will be some research workers who devote their whole time to research, and others who will combine with teaching. What matters is that the student should have the opportunity of seeing research at first hand, and that research workers and teachers should meet over lunch or a cup of coffee.
As the Porritt Committee Report says:We cannot escape the conclusion that the medical faculties of British universities are now lagging considerably behind those of many comparable countries in respect of research facilities, accommodation and available teachers … Unless the Government provides the funds to facilitate research and expand accommodation in our medical schools, universities will be unable to recruit all the staff they need, and in a time of world shortage we must expect to see many of our most able doctors absorbed into other countries"—which, of course, is happening. Not only that, but we shall cease to attract to our shores the cream of the post-graduate students from all over the world who in the past have come not only because of our reputation as teachers, but also because of our outstanding contributions to research. Only the universities can implement the educational value of research. Apart from its units which happen to be housed in universities, the Medical Research Council can make no contribution to this. Indeed, its influence operates in the opposite direction because, by isolating leading research workers in its own institutions, it withdraws them from the teaching life of the universities.
My Lords, it is inescapable that we cannot develop medical research properly, especially in the universities, without more money. I have said how much we owe to the big charitable funds and generous individual donors, but it cannot be right that heads of departments should have to spend so much of their time begging for money from private sources in order that research may be begun, or even continued. One London post-graduate hospital, in addition to recurrent grants from the 582 U.G.C. and the M.R.C., receives money from no fewer than 30 private charities and individuals. What I have said about medicine is true of dental surgery, too. Excellent work is being done in the field of research, but while we spend £50 million a year on dental surgery, in the form of treatment, we spend a comparatively meagre amount on research. Dental colleagues need better facilities and more encouragement to take up research as a career.
So far I have said nothing about the Ministers. The Minister of Health at present has little direct responsibility for research but, just as he must provide facilities for medical teaching, he is concerned, with the U.G.C, with questions of accommodation for research in teaching hospitals. I suspect that his negotiations are directed mainly to making sure that the U.G.C. pay for it. In the Regional Hospital Board hospitals a little research goes on, and it is said that there is little application for the funds which the Board can allot for this purpose. That is not surprising, because, on the whole, effective research does not spring up sporadically: it grows in an atmosphere where it is cultivated; and that atmosphere does not exist in most Regional Hospital Board hospitals; nor have they the accommodation for it; nor have most Regional Hospital Board consultants the time.
I hope that special attention will be paid to the need for both education and research in Regional Hospital Board hospitals and especially in the new district hospitals. I know the Minister is very sympathetic to developments in post-graduate education in this field, but I would emphasise that research is as important for education there as elsewhere. At present, Regional Hospital Board hospitals in general have no link with the universities, though Birmingham's new plans are setting an excellent example of this. The material for research in Regional Hospital Board hospitals is very large, and I hope that future plans will provide for space, equipment and salaries. To sum up, I know that, given the opportunities, the accommodation and the equipment, we can hold our own in the field of medical research, and education, with any other country in the world. But we are not now getting the opportunities we deserve. We all know the reasons for this, but I hope that we may be honest about it and not pretend that we do not really need more money for 583 medical research because we have not the workers to spend it on.
The Times Review of Industry and Technology, published this month, contains a survey by Mr. Brian Abel Smith of the health expenditure in seven countries, including England and Wales and the United States. I will not go into details, but a comparison which comes out of it is that, according to his estimate, we in this country spend on education and research £33 million a year, and the United States £207 million a year. Taking into account the difference in the population, this means that the United States is spending about twice as much per head of the population on medical research and teaching as we are. As the noble Lord, Lord Todd, said in this House in the debate last Wednesday [OFFICIAL REPORT, Vol. 247 (No. 46) col. 129]:… if we want to spend money on anything like the American scale the first thing we have to do is to increase our gross national product.I do not question the desirability of that, but it does not exclude another possibility. We might have a different sense of priorities and spend more on medical and scientific research and, indeed, on our universities in general, even if we have to spend less on some other things.
§ 6.10 p.m.
The LORD BISHOP OF LICHFIELD
My Lords, I should like to begin by expressing my gratitude to the noble Lord, Lord Amulree, for bringing this subject to our attention to-day, because it seems to me that at this particular juncture of the National Health Service it was an excellent thing that this distinguished body of people should have taken this long, critical look at the medical services of Great Britain; and I am very thankful that it is being debated in this House. I feel, as one who is not an expert in these matters, that I ought in a sense to apologise for taking part in this debate, but it is a fact that, apart from the trained workers in this field, I suppose there is no one who is more closely in touch with the sick people of the land than a minister of religion. One of his primary pastoral duties is to visit the sick and, therefore, we do get a pretty good idea of the sort of opinion that people have about the way in which they are treated.
584 I therefore ask myself what it is that the ordinary person wants and needs in regard to possible illness. He needs, first, to feel that if he or any member of his family is overtaken by illness he will be able to get skilled attention. Second, he needs to feel that he can get this without being ruined financially; and, thirdly, in a free country such as ours he desires to go to a doctor of his own choice. Under the National Health Service these needs are basically met. As has already been pointed out by the noble Baroness, Lady Summer-skill, no one to-day need fear that they cannot get medical treatment on the ground of expense; everyone can get it. All of us have our own doctor, on whose list we are; and the Executive Council has a duty to see that everybody is fixed up with a doctor. So, when the Porritt Committee state that in its view the National Health Service is approved by the people of this land, there is no doubt in my mind whatever that they are 100 per cent. right. I think it has conferred great benefits on our people. I know that there are certain aspects of the National Health Service which can be misused, but, after all, that is part of the moral issue which faces the nation and I think it has to be viewed on that ground.
What is also needed in the National Health Service is that the people who work in it should be content. They must be able to do their job in reasonable freedom and decent conditions and must feel that they have been given a fair deal in regard to both their status and remuneration. The noble Lord, Lord Amulree, made some amusing remarks in regard to the lip service that may be paid to the phrase that the general practitioner is the lynch-pin of the whole Service; but, as he himself pointed out, in actual fact that remains true, because it is the general practitioner more than anybody else who is in touch with the general public at the first moment of the development of illness, and it is he who has to decide what illness is serious and what is not. I therefore welcome this opportunity of saying that, in my view, having talked it over as I have done with many people, the vast majority of these people in this land are very grateful to their general practitioner for what he does for them.
585 I notice that in conclusion No. 50 the Committee find little ground for the allegation that the G.P. is conscious of a loss of status. I have often discussed this with a number of my medical friends and I would, with all respect, beg leave to ask if there is not possibly a sense in which the general practitioner is feeling that he has lost a certain status. I think there is some evidence that not all the general practitioners are particularly happy at the present time, and it may be that some are feeling that their position vis-à-vis the consultant is not quite what they wish it to be. If so, are there not means by which real partnership in every sense of the word between the consultant and the general practitioner can still be further strengthened?
May I say how much I welcome the stress in the Report that the general practitioners should have full opportunities of playing a part in hospital work? This is already done to a much greater extent than is sometimes realised. In the Birmingham region, the one with which I am personally most acquainted, one-third of our general practitioners have some kind of hospital post, which is a very large number. But, again, in talking with some of my medical friends, I have heard it suggested that it would be desirable and helpful if there could be more traffic the other way. Just as it is encouraged that general practitioners should go into hospitals and work there, can consultants come out more and discuss with the general practitioners their problems, and work with them? Here I speak as a layman. I cannot venture an opinion on a professional matter such as this. But for the Service to work absolutely satisfactorily obviously the fullest fellowship between consultants; and general practitioners is vital.
It seemed to me, therefore, that presumably this was one of the reasons which led the Porritt Committee to suggest the idea of the area health board. As the noble Lord, Lord Amulree, said, at first sight this must be a very attractive idea. In the whole National Health Service the fewer watertight compartments there are the better, but I hope I may be permitted to make one or two observations on the proposal and, in so doing, I want to turn to the question of hospitals. In conjunction with the Ministry of Health one of the chief 586 duties of the Regional Hospital Board is to plan the set-up of the future hospitals. I would suggest that to do this adequately it must be in charge of an extensive area if it is really to get a broad sweep into its planning.
But if the area health board is to be responsible, as it is, for practically all the aspects of the Health Service, if it is to be in charge of such a wide area, what would follow? Just think of the enormous amount of detailed running of services that would come its way. From the point of view of detailed administration, surely the area health board should not cover too big an area; but if its area is reduced for that reason, what of the planning of the hospitals? I would further suggest that to scrap almost the entire present administrative set-up would be a very drastic step to take. The present bodies—the hospital services, executive councils, and the health authorities of the local authorities—might be prepared to give up some of their functions or even to die if there was a great benefit thereby caused. But will the benefits conferred by centralised control really justify the upheaval? Only comparatively recently have the existing bodies been able to plan ahead. Until then they had been adjusting themselves to carry their heavy loads. Forward plans are now being made which are broad in scope and these will improve and rationalise the services which are being given. I would suggest that a major administrative upheaval now might well delay those plans.
Further, I think we ought to consider the relationship of the teaching hospital with the rest. The Committee propose that if area health boards are set up the teaching hospitals should be left outside them. What would be the effect of that? One of the greatest benefits, I think, conferred by the National Health Service has been the upgrading of many of our hospitals. I know that we have a long way to go, but there is no longer now the two-tier system of the voluntary hospital and the rest; and in saying that I am not criticising the old voluntary hospital at all, but I am saying that one of the most encouraging things is to go into some of these hospitals which in the past were rather shocking, and see the way in which they have been improved and the way in which their morale has gone up as a result. This has had an agreeable effect 587 on the recruitment of staff in these hospitals.
I would agree that the teaching hospitals must occupy a special position. Their functions demand this, and that is why, very properly, they have their own boards of governors. But I would suggest that if you are not to get an unpleasant kind of dichotomy in the hospital system of the land, while the teaching hospitals must have their special position they should not have an extra special position; and I cannot help feeling that if you have this proposal of an area health board with everything else there and the teaching hospitals outside it, you might get that rather unfortunate division.
I would also suggest to your Lordships that this proposal for the setting up of area health boards might lead to such an upheaval that it would cause a great deal of uncertainty in the working of these services at the present time. It is my privilege to see a good deal of the way in which our official administrators, the salaried men in our staffs, carry out their duties, and I must say how impressed I am with the sense of devotion and vocation with which they do it. I would ask, therefore, is this the moment when they should be disturbed? Further, we ought to consider the effect of this sweeping proposal on those who work voluntarily in this system. I do not think it is generally realised that there are more people who are working voluntarily to-day in our hospital system than ever before. That, I think, gives the lie to the nonsense that is occasionally talked about the whole system being one of bureaucracy.
At this moment I am thinking of the people who are serving on Regional Hospital Boards, hospital management committees, and the like. The composition of these bodies changes gradually from year to year as one-third go out of office each March, and they may return or they may not. But I would feel that normally gradual change in the composition of these bodies is all that is required, for sweeping change can lead to a breakdown in the sense of continuity of the work. Occasionally I would not deny there must be sweeping change. That took place in 1948 on the Appointed Day, when the new committees and 588 Boards took over from the old ones. But I would beg leave to doubt whether a similar sweeping change is needed at the present time, and I think that there are many who would agree with me when I say that the relations between the various branches of the National Health Service at the present time are good and they are improving.
Finally, I would just mention one or two things about which I am extremely grateful to this Report for what it has said, because undoubtedly there are certain aspects of the National Health Service which could be improved and which should be improved. The noble Baroness, Lady Summerskill, spoke in a very moving fashion about the maternity services of the land and the need there is for improvement in this direction. May I suggest that one of our chief difficulties is the shortage of practising midwives—not trained midwives, there are a number of those, but practising midwives? I therefore think that if there could be greater co-ordination whereby the local authorities and the hospitals could pool their resources of practising midwives that might considerably help. I think that possibly—here the noble Lord. Lord Amulree, is an authority—that pooling of resources between hospital and local authorities might also help in the matter of geriatrics.
I would also say how grateful I was to the Porritt Committee for what it said in kindly fashion about the value of small hospitals. We know the great district hospital of the future has to come and I suggest it will do great things. It will be the parent hospital for the area and set the tone for the rest and encourage them in their work. But as one who has recently emerged from being a patient in a small hospital, mainly manned by general practitioners but with consultants coming in, I cannot forbear this opportunity to say how grateful I was for the treatment I received and the kindly, friendly atmosphere in such places. I know these small hospitals cannot exist everywhere and they obviously have their limitations, but I believe that they have definite assets and I hope we shall not lose them.
I have had the privilege over the years since the Appointed Day of working very closely with various aspects of the National Health Service. I think the 589 Service is something of which our country can be justly proud. I believe it confers social benefits which are of immense value to our people. I am therefore grateful to this distinguished Committee for this careful look they have taken at it, and for the debate to which it has given rise in this House to-day, and I feel that many of us will go back to the work we try in all humility to do, with renewed enthusiasm.
§ 6.25 p.m.
§ LORD TAYLOR
My Lords, it is always a pleasure to listen to the right reverend Prelate giving us his personal experience of the working of the Health Services in his area: one gets a breath of fresh air and a feeling straight away that he knows exactly what he is talking about from personal experience. He did it as usual to-day, and I agreed with almost everything he said. I am not quite sure that I always enjoy being in a small hospital. If I were due to have my gall-bladder out, I think I should rather go to a bigger one and pick my surgeon rather carefully. But if one is to have something less serious, there is immense advantage in the pleasures and comforts of the small hospital. The practical difficulties which arise are those which come from having so many doctors coming into the small hospital, particularly if it serves a large area and a large number of general practitioners. The nurses have great difficulty in keeping track of the differing instructions which different doctors give; and not all small hospitals are of the standard we should wish them to be.
The other point where I take leave to depart a little from the right reverend Prelate is with regard to what he said about teaching hospitals. Not that I do not agree with his criticism of the possible effects of the area health boards, but I think his criticism is equally valid now: the separation of the teaching hospitals from the Regional Board hospitals is a very real thing, even to-day. It might be a little worse with area health boards, but it is certainly something which already causes some difficulty.
It seems to me that the noble Lord, Lord Newton, is going to have a difficult job, when he comes to reply to this debate, because it has already ranged so widely. We cannot blame the noble Lord, 590 Lord Amulree, for that, for the Porritt Report ranges so very widely. I felt that the noble Lord, Lord Amulree, rather cheated a little, because he took the Report as his text and preached a series of sermons which did not bear any great relation to the text. He made us read the Report, but then, so far as he was concerned, all our work was in vain. The Report is an interesting document, but it is rather odd and peculiar. It was born in the anger and discontent of the Annual Meetings of the British Medical Association in 1956 and 1957. That is what started it off, when there was talk of strikes among doctors. They were all so fed up and furious—mainly on money matters, let it be said—that they decided they would do something about it. Their attitude was that anybody could think up a better National Health Service than the one we had at that time. So they took some steps, and it was a very sensible thing to do.
First of all, they decided to select a distinguished Chairman, and get the Secretary of the B.M.A. to be the Secretary. Then they invited all the professional bodies to nominate possible members, which these bodies did; and then the Chairman and Secretary themselves selected from these nominees the people they would like to serve on the Committee. That is how this Committee came to be appointed. It was a most odd proceeding, and although the Report says at the beginning that it is sponsored by the Royal College of Physicians, the Royal College of Surgeons and so on, it is not really sponsored by them, and I do not think it would claim now to be sponsored by them.
In fact, my Lords, the Report is produced by this group, as my noble friend Baroness Summerskill said, of 43 men and one woman, of whom half are under the age of 50, as a sort of intellectual exercise. That is really what it is, and I am told by my friends who know a lot about this Committee that at first there was a terrific amount of scrapping; they were all at each other's throats; they thought the National Health Service was Terrible and all the rest of it. But as they started to study it, they began to get more and more sensible—which was a healthy thing; they performed a job of self-education. They set out a number of the recommendations in 591 the Report—perfectly sensible and reasonable recommendations, though some of them are not properly thought out.
The great majority of these people were practising clinicians. They were weak on administrative experience; they did not know anything about it. They knew little about public health. They had, I think, one representative of industrial medicine, yet they have a most important section on industrial medicine. There was nobody who had run a Regional Hospital Board. There was certainly nobody except doctors—it was a wholly medical Committee. As my noble friend Lady Summerskill said, they were a little weak on psychiatrics. I think they were a little cheeky about psychiatrists; they said that if only psychiatrists were as good as general physicians, how much better everything would be! My experience is rather the reverse: if only practising physicians were as good as some psychiatrists, how much better things would be! But that depends on the kind of people you have on the Committee.
They started off in a state of criticism and they ended up in a state of praise of the National Health Service. My noble friend Lady Summerskill quoted their view, and I do not want to repeat it, but I draw your Lordships' attention to the Gallup Poll survey at the end. It is not a bad piece of work. It contains some most interesting statistical work, including some interesting questions about whether women would prefer to have their babies at home or in hospital. Table 24 shows this interesting fact: that about 30 per cent. of women would prefer to have their baby at home, and about 54 per cent. would prefer it in hospital. This depends on all sorts of factors, as your Lordships know from other sources, but it is worth remembering that a great many women want to have home midwifery for good reasons—perhaps because there is nobody else to look after the home if they are not there, and they can at least keep an eye on things upstairs, where they are, if they have younger children; and perhaps for other reasons.
The Committee started this inquiry in criticism and ended up in praise. But there were two themes running through it. They were concerned, if they possibly could, to concentrate all the health 592 services under the Ministry of Health, although they were not absolutely consistent about this. They suggested pulling out the services in industry at present run by the Ministry of Labour and putting them under the Ministry of Health; and they also wanted to pull away all services run by the local authorities, put them under the area health boards and then place them under the Ministry of Health. So really they wanted to get a monopoly of services under the Ministry of Health.
The second theme was the creation of the area health boards. I think they had the germ of a good idea here, and that was that it would be a good thing to bring the general practitioners, the local health authority services, the hospital services and the consultants all together, so that they were all of equal parity and esteem and were all working as one group. But they have not thought it out at all. They have not told us how big an area health board should be; they do not give a clue about this, whether it is to cover 100,000 or 1 million, or 2 million or 3 million population. There is no clue in it as to whether it is to have one major hospital in it, two or four major hospitals—there is nothing here about it. The composition of the boards they never thought out. They did not say whether they are to be appointed by the Minister of Health or elected by various bodies. They have not thought the thing out at all. They have not proposed the size, or the number of people who should comprise the board, and they have not looked at the question of the position of the general practitioner.
Whatever the defects, out tripartite system has the nice advantage that, so far as the general practitioner is concerned, he is a self-governing person. The general practitioners run their own service through their local executive councils, along with the chemists and the dentists and the opticians. Those in the general practitioner service are more self-governing than in any other part of the Service. But, so far as I can see, under these area health boards the general practioner would quickly be subordinated to the medical officers of health and the consultants and hospital services. The Committee have not examined that at all. They have not examined the statutory results of converting the 593 medical officer of health into a sort of social medicine physician working for the area health board. If they had done, they would have found that they were faced with a mountainous task in trying to straighten things out.
The difficulty about the work of the medical officer of health is that a lot of it is often dull, but most of it is important. Preventive work is often not exciting because you do not see much happening; it is only when things go wrong that you get a dramatic picture. Yet a lot of the work of the M.O.H. is of that kind. I am not at all sure, just as the noble Lord, Lord Amulree, said, whether it really is right to put him in with the Hospital Service. But I suspect that one of the attractions was that in the Hospital Service he would be graded as a consultant and would get a better salary. So I think this is ill-thought out and not really practical.
The noble Lord, Lord Brain, spoke about research, and I must say that his was a most interesting speech. I only wish it had been delivered a week ago, when we were debating scientific research, because I tried to say almost exactly the same thing as he did, except that I was speaking about psychiatric research. Every problem I spoke of, every difficulty we had, was reflected in what he said about general medical research. The position is exactly the same vis-à-vis the Medical Research Council. There is the difficulty over getting the universities to create research posts; for junior and more advanced people—they are identical. The time that is wasted over getting money from private charities in order to keep the good work going is deplorable and sad. I agreed with everything he said, and I only hope that his having repeated the argument will have driven it home. The only thing is that, unfortunately, it is not the job of the noble Lord, Lord Newton, to answer on research, unless he is holding a watching brief for the Medical Research Council as well as everything else.
I am going to say only one word more, and that about the proposals in connection with industrial health services made in this Porritt Report. They suggest that the industrial health services have been neglected in the past; and they are quite right. They suggest that that might well be one of the functions of 594 the area health boards. They want to see the appointed factory doctors and the medical factory inspectorate transferred to the Ministry of Health. They have not thought at all about the nursing side of industrial medical services which are, from the cost point of view, far the most important. They have not thought about how they should be paid for at all. They make some vague reference to money coming from the area health boards to pay for them, and that the area health boards should play some part in their administration. That is really not good enough because, in my experience, these services are extremely difficult to run. But they are well run where paid for by industry, and I think there is a great deal to be said about making industry pay for them, though it might be nice in some ways if we could have contributions from the Health Service. Nevertheless, there is a lot to be said for them because they are an integral part of industry, and ought to be. Again, the Committee have not thought it through.
Therefore, the impression which this Report has left on me is one of satisfaction that the medical profession should have come so far in its own personal growth and development, but I also have the feeling that perhaps there is not a great deal that is very novel or very important in the Report. It is encouraging that they should have found things far better than they expected to find them, but in so far as they have made constructive suggestions they have not, as I say, thought through their full implications.
§ 6.40 p.m.
§ VISCOUNT WAVERLEY
My Lords, I should like to thank my noble friend Lord Amulree for giving us this opportunity of debating the Report. I do not propose to take up much of your Lordships' time to-night. There is, however, one aspect of the Report which I should like briefly to mention. I refer to Chapter 16 and the comments on medical education. Here the Report records the members' conviction that the standard of medical care in any country can be fairly directly equated with the standard and the efficiency of medical education. It expresses anxiety—an anxiety echoed by my noble friend Lord Brain—that this country's medical schools in teaching 595 hospitals and universities may be lagging behind those in other comparable countries. The Report urges the Government to provide the necessary money to overcome shortcomings in respect of research, accommodation, and teacher availability. That Her Majesty's Government should indeed strive to undertake greater responsibility in these fields is, I think, right.
There is an aspect of the problem which has not received emphasis, indeed it has not really been mentioned; and it will, I am sure, in the years to come assume an ever-increasing importance. Traditionally in this country a considerable part of medical education has taken place around the bedside. Here are learnt the art of interrogation, the techniques of full and efficient physical examination, and the correct evaluation of such abnormal signs as may be found. All these, despite the enormous expansion of scientific methods of investigation, are still an indispensable part of the full evaluation of the patient.
One of the products of the National Health Act, as I am sure your Lordships will agree, has been the progressive upgrading of the standard of service provided by the Regional Board hospitals. A consequence of this has been that increasing numbers of patients, who in former times would have been referred by their family doctors to teaching centres for investigation and treatment, are admitted to their local district hospitals for this purpose. As one who has the honour to be on the staff of such a hospital, I have over the past decade become increasingly disturbed that so much excellent, indeed one might say indispensable and essential, teaching material is being denied to our medical undergraduates.
I think it likely that, as I am on the staff of a non-teaching hospital, diffidence would have prevented my presuming to mention the question of medical education at all, were it not that one of the most experienced of medical educationists, my noble friend Lord Cohen of Birkenhead, raised just this point when your Lordships debated the Hospital Plan approximately a year ago. My noble friend said on that occasion [OFFICIAL REPORT, Vol. 237, col. 531]: 596… teaching hospitals are now feeling the draught. They no longer have a sufficiency, either in number or variety, of patients for clinical teaching.He described how shortly before a board of clinical students of a university hospital had written to him, saying:it is generally agreed that there is an increasing insufficiency of teaching material in teaching hospitals because first-class hospitals now supply the needs of patients in their own neighbourhood …It was my noble friend's belief, as he put it, that teaching and district general hospitals should walk the path of progress together, and that into district general hospitals students should be admitted, believing, as he did, that district hospitals had a major and indispensable part to play in medical teaching, education and research.
With the views of so distinguished a colleague I most emphatically agree. If patients are no longer arriving at the teaching schools in sufficient variety and number, then inevitably undergraduates must go to the patients. This implies periods of secondment to selected district I general hospitals. The present staff of these hospitals are already too hard-pressed to undertake the additional responsibility and burden of fully supervising their studies and teaching. It would be necessary for clinical tutors, probably of senior registrar grade, to rotate from the teaching centre. They, too, would benefit from the added experience. It would also be necessary, in the planning of the new district hospitals, to provide library, lecture room, laboratory facilities, and so on, for these many young men and women, and, of course, residential accommodation. I hope Her Majesty's Government will give due consideration to the perspective of the whole question of medical education.
§ 6.48 p.m.
§ LORD AUCKLAND
My Lords, I would first apologise to the House for not being present, due to a private engagement, when the noble Lord, Lord Amulree, opened this debate. From these Benches I would welcome this debate on a most complex but highly interesting Report—a Report which can hardly be debated in full in one sitting. I hope that when the time comes for the next debate on hospital services or the ten-year 597 Hospital Plan the contents of this Report will be carefully studied and the relevant parts incorporated in the Government's proposals. This seems to me to be the best way of implementing the more desirable aspects of this distinguished Report.
Most noble Lords who have taken part in this debate are themselves distinguished persons in the field of medicine, but I take part as a layman whose only claim to do so is serving on a house committee of a children's hospital. May I at this juncture make one criticism of the Report? There seems to me to be no mention of children's hospitals, which play a vital part in the hospital life of this country. I think it is a pity that nothing has been said about the care of children other than the care of subnormal children—though I recognise that that is a very important aspect of our hospital routine. But bearing in mind the recent Ministry of Health recommendation to allow unrestricted visiting in children's wards and in children's hospitals, I am rather surprised that the Report did not have something to say on this score.
The noble Baroness, Lady Summerskill, and others, have dwelt on the maternity services. I should like to say just a word about them, because I have toured quite extensively the maternity department of my own local hospital at Epsom. I would bear out much of what the noble Baroness says, because no mother is fit to leave hospital and run a home after only 48 hours' confinement after the birth of a child. I think that at least ten days are needed. Being a father of three young children myself, I have naturally been given views on this, and I think it is fair comment.
This argument is reinforced by the fact that there is an acute shortage of home-helps—certainty in the Surrey area. This means in many cases that a mother who has no relations or close friends living near has to go home and cope not only with the new-born baby and the cooking and other household duties, but probably with other young children as well. This frequently means that the mother develops further complications, leading to a return to hospital and imposing an added burden on the already overworked hospital staffs. So I feel that the Government should pay particular attention to improving maternity services. This is especially true, I believe, in the 598 New Towns. I have mentioned this point before, but there are two or three New Towns planned to commence construction shortly, and in these New Towns there will be a preponderance of young people, many of whom will, in time, marry and have families. So it is essential that there should be proper facilities for hospitals, especially new hospitals to be built under the ten-year plan, for this improvement to take place.
May I now say a word about the problem of the smaller hospitals, which is mentioned in paragraph 398 of the Report? I agree that old, small and uneconomic hospitals should be scrapped, but there are many small hospitals, cottage hospitals, especially in rural areas, which do an exceptionally good job. There are also small general hospitals—and may I instance just one, that at Teignmouth in Devon? This is a new hospital, built in 1954; indeed, it is the first completely new National Health hospital to be constructed, because the old building was completely destroyed during the last war by a direct hit from a bomb. So far as I know, this hospital is not scheduled for closure, but I would paint out that it has equipment and amenities of which many London teaching hospitals might well be jealous. If one is going to be ill, or even have a major operation, this is an ideal hospital to enter. It has lovely views of Teignmouth harbour, the most modern operating and X-ray theatres, and it serves a large area. It also precludes the need for many elderly people to travel fifteen miles to Exeter, where there is already, I believe, quite a large waiting list in the city's two rather old, although very well-run, hospitals.
May I now say a word about accident services? It is very necessary, with the increased amount of traffic on the roads, and the ever-increasing number of accidents in the home, to have properly equipped casualty services in our hospitals. Many of the modern ones have these, but a number do not. In one of the daily newspapers recently there was a disturbing story of how in the Grimsby General Hospital a number of drunken people, some of a violent nature, had been admitted for casualty treatment during the evenings, and young girl nurses were frequently asked to look after them. It seems essential that there should be a component of male 599 nurses for such work. That case also shows how the casualty departments of these hospitals, particularly at night, are often understaffed. I would ask the Minister to bear this point in mind, and, if necessary, bring it to the attention of the Regional Hospital Boards.
Another small section of this Report deals with the ancillary services—radiographers and physiotherapists. As I understand it, a recent pay award has been granted and is in the process of being implemented. But, even so, salaries are still not adequate. I would say particularly of physiotherapy that recent advances in medicine have made it even more necessary to have fully qualified and sufficient numbers of physiotherapists and especially, I would say, of male physiotherapists, who often have families to support, and frequently very inadequate salaries on which to do it. My Lords, I would conclude as I started, by commending this Report. It is not perfect. To be quite frank, I have not had a chance of reading every single section of it, and I do not suppose many others of your Lordships have, either. But I hope that the Government will study it very seriously, and that when their own ten-year hospital plan comes up for further discussion this Report will be largely taken in conjunction with it.
§ 7.0 p.m.
§ BARONESS HORSBRUGH
My Lords, I have listened with great interest to this debate. I, like others, am most grateful to the noble Lord, Lord Amulree, for putting down this Motion to-day. Many noble Lords have spoken about the amount of reading, and certainly, with a Report of this size, our homework has been quite considerable; but I made a list of the various points, and I thought that, as the debate went on, I should know how many I need not refer to because they had already been referred to by other noble Lords. Some noble Lords, I know, realise the particular interest to me of this Report, because in the days when I was Parliamentary Secretary at the Ministry of Health we were doing all the basic work for the Health Service; and I think that never enough praise was given to the late Mr. Ernest Brown for the difficult years he went through then. We began before the Beveridge Committee had reported in 600 1942, and we worked on until we produced the White Paper of 1944.
My interest in coming back to the White Paper again was because this idea of an area board is very much in line with some of the proposals in that White Paper of 1944. At that time, as noble Lords know, there was a Coalition Government, and the debate on the White Paper in February, 1944—there was no Division—was an extremely interesting debate. I took the precaution of looking up and re-reading the speech I made then, when I was in another place but geographically in this place, and the points that were brought up then on the subject of a National Health Service. We all agreed from the start, I think, on a National Health Service (inside here it is called a "comprehensive service for all") but the question was: how was it to be organised?
When I read this Report, and particularly that part about the area boards, I came to the conclusion that this Report is a very disappointing one, and it is disappointing for two reasons. The first reason is that, on going through the whole thing, one feels it shows a certain dissatisfaction of the scheme by the authors, but very little suggestion as to how to improve it. In fact, they take one bit after another, put up a suggestion and then say that they do not agree with it. I was interested because I think we have really had something pretty genuine from these people. So often a Report comes out and it is thought that everybody on the Committee believed in every mortal thing, and people do not realise that the members of the Committee had any difficulty in their minds at all. As I say, there was no difference between us, and there is none between them, on a comprehensive Health Service: it is on what sort of a Service that is going to be. That was my first disappointment with this Report.
My second was this. I had always hoped that we might get a less complex method of administration. We have an organisation from the Minister down to the hospitals; we have the general practitioners; we have this council, we have the other; we have committees; we have all the rest of it. It is tremendously complex; what I would call very bulky. I hoped that on this occasion we were going to find that a Committee of people had 601 been able to find a simpler method of organisation, a simpler framework for the administration. But as I went on, I jotted down on a piece of paper the various committes and the various boards recommended. You have the area board, and you also have the Regional Board. On we went, through the divisional councils, the department of social health, and so on. I came to the conclusion that, if possible, this was worse, and it was worse for another reason—and I hope that this will not be misunderstood in any way whatever. It seemed to me that more and more of the doctors' time was going to be taken up sitting on committees, councils and boards, when after all, they ought to be using their skill to heal the sick.
It is a very difficult problem, I know. The Committee say that the internal administration of any hospital should be tripartite—medical, nursing and lay—to concentrate on making it harmonious. We all know these things; I knew them very well in the Emergency Hospital Service during the war. Then we find that the chairman is to be the honorary secretary of the medical committee, or one of the consultants. In each case more and more skilled doctors are being taken and used on more and more committees. I am not satisfied that our present set-up is completely right: I was not satisfied, as we said in the debate in 1944, that the White Paper was completely right. That put forward a scheme for a wider, joint board; and a scheme, too, suggesting that the hospitals should not be separated from the other services. It set out that the new joint authority should be charged with preparing an area plan for the Health Service as a whole, not only the hospital service.
Then it set out that it was to be the duty of the joint authorities themselves to secure a complete hospital and consultant service for that area, including sanataria, isolation, mental health services, ambulance and ancillary services. We also kept the maternity hospitals inside the plan of this joint board. I do not believe the idea of different personnel would have been entirely satisfactory, but I do not think we have necessarily found the most satisfactory way yet. This is not surprising: we are dealing with an enormous problem. We are dealing with something which is costing an enormous 602 amount of money. It is spread over the entire country, and yet its success depends on the individual doctor looking after the individual patient. There is the big problem we have to face.
Now, my Lords, if we are to deal with this Report, and not, perhaps. with our ideas on a new Health Service (though it would be interesting if every noble Lord would make his suggestions), I must cut out a good many things with which other noble Lords have dealt and with the majority of which I agree, but I should like to say something about rehabilitation, because nobody has yet mentioned that. It is dealt with in paragraph 510. As to rehabilitation or convalescence—call it what you will—I believe that at present there is a big gap. The Report says:Rehabilitation is concerned with the recovery phase of illness.Further down, it says,… yet in this phase of illness the patient is left to fend for himself more than in any other".I am myself absolutely convinced that there is a great deal of truth in that. People naturally come out of hospital very soon these days. Beds are required, and not only in maternity cases. Often it is very difficult for people coming out of hospital; they get depressed and worried. The trouble is psychological as well as physical. Only last week I was inquiring of somebody about a friend of hers, an elderly person who had come out of hospital about six months ago. I asked her how she was, and my friend said, "The operation was entirely successful, but she has never really recovered her health". There is too much of leaving the thing at that stage, to see what help can be given afterwards. That help might be given by the family doctor, in which case there might be more room for the smaller hospitals, so that the family doctor could help the patient when the acute stage was over.
So far as I remember, no noble Lord has yet referred to two parts in the Report, one dealing with private practice and one dealing with private beds in hospitals. I have been trying to get some figures (but I do not think it is really possible to get them) to show how many people are using private practice only, how many are on a doctor's list 603 but mostly go to private practice, and how many go between the two. I have figures, but the figures I have are for 1952, and I believe there has been an increase in the number who are going to private practice. As the noble Lord, Lord Amulree, has already said, there is a great deal of praise for the work of the general practitioner; and this is right. There is also the feeling that perhaps the standard will not stay as high as it ought to stay. I am sure that in any profession there are the good, the very good and the not so good. I hope that the standard is being sufficiently kept up so that we do not have many of the not so good. Some patients are not finding it so, and are therefore going to private practitioners. They do not take their names off their doctors' lists; they simply go somewhere else.
But I would say that I have nothing but praise for the medical attention I have had under the National Health scheme. Nothing could have been better; there was kindness, skill, attention, and patience, endless patience—and I am one of those people who ask a lot of questions. The standard could not have been better. I have been treated both under the National Health scheme and as a private patient, and I have been struck by the care, attention and patience both of the general practitioner and of the consultants. I believe that they could not have given me better attention. I would say that that happened in Edinburgh, where we find one of the highest standards of medical attention in the world. But perhaps I had better be careful because I might be thought to have some prejudice in favour of the surgeons in Edinburgh. As I had the great honour of being made a Fellow of the Royal College of Surgeons, Edinburgh. I wish that the noble Baroness, Lady Summerskill, were here. I could tell her that I was the first woman to receive that honour.
§ LORD TAYLOR
My Lords, is the noble Lady aware that in Edinburgh and in Scotland there are only two ladies who are practising surgeons? In that way Scotland is very far behind us. They are a Miss Kate Branson and one other.
§ BARONESS HORSBRUGH
My Lords, if I had been asked the number, I would have said that it was higher; but probably 604 the noble Lord knows best. Perhaps they thought it better to help out in England and to bring their extra skill here. But the number of patients who are using private doctors is going up. I cannot get the exact figures.
I should now like to say something on the subject of private beds in hospitals. There is nothing against having them. We find this Report says that the rise in the price of private beds is astronomical. There is a great demand for medium-price beds, but I would ask: what about amenity beds? Are they being fully used? We know there are now various provident associations and that people are insuring so that if they have to have an operation or go into hospital they have their expenses paid. I believe the number in these schemes is over one million. It is moving in that direction. More and more people are wanting that cover. Reading the debate of 1948 on the Second Reading of the National Health Bill, as it then was, I noticed that the late Mr. Aneurin Bevan pointed out that there was no reason at all why people who wanted to pay for extra amenities, such as privacy, should not be allowed to do so. He went on to say that if we had a State theatre one would not charge the same price for all the seats.
I do think that we ought now to do something further for people who want privacy but have not a great deal of money. I would say that this applies particularly now that we have—and I am not against the plan—so many times more visitors coming into the hospitals. It is very tiring for some patients, who perhaps are in pain, if you have this crowd of people in the wards. There are many who, if they could get amenity beds—and I was told that they ought to cost about eight guineas a week—would be glad to pay for that privacy. I should like to ask the Minister: is it the case that there are amenity beds at that price? Is it the case that the amenity beds are not being used? And is it the case that patients are told in the hospitals that if they wish to have amenity beds, or to be in private rooms for the sake of privacy, then they have a chance of obtaining them? I do not believe they are told. I should like to know whether I am right in thinking that.
There are one or two other things I should like to mention but it is too late.
605 It has been an extremely interesting debate. We have agreed on a comprehensive Health Service. The first time we had the proposal actually in print was in 1944. We had the Act in 1948. None of us would say it was perfect, but I would say that if people will get together and study the position—even if, as noble Lords have said, this study is not very realistic—then we shall get some improvements, although they may be minor ones. Although I would not say it was perfect, I do not think the time has come, as the right reverend Prelate said, to reorganise the whole Service.
§ 7.18 p.m.
§ THE PARLIAMENTARY SECRETARY, MINISTRY OF HEALTH (LORD NEWTON)
My Lords, like everyone else taking part in this debate, I am grateful to the noble Lord, Lord Amulree, for giving us the opportunity of a "free-for-all" on the Health Services of this country—an opportunity afforded, as he must recognise, by the all-embracing comprehension of the Porritt Report. We have had a "free-for-all", but I will not say that the various bits of advice which your Lordships have given me cancel each other out, to use Lady Summerskill's description of some parts of the Porritt Report. I was a little daunted when it became borne in on me that no subject would be out of order in this debate, and I am glad to hear I have the sympathy of the noble Lord, Lord Taylor. I am obliged to those of your Lordships who were good enough to warn me of matters that might be raised. But, even so, I fear I shall not be able to deal with all the points if I am not to speak at quite inordinate length, so I may have to reply to some of your Lordships by letter. We have roamed at will over the whole field and I hope the House will not think it unreasonable if I, in my turn, make some observations on my own account.
The Report has been referred by Sir Arthur Porritt to the nine bodies which sponsored the Committee for their views. It would obviously be right to wait for those views, and the House will understand that this limits the extent to which I can comment on the Report's recommendations. However, I can say that we welcome the results of the Gallup Poll organised for the Committee by the Daily Telegraph, which shows that 89 606 per cent. of those approached were satisfied with the services they received under the National Health Service. This is something in which we can all take pride, particularly the doctors and nurses and other professions in direct contact with the patient. We welcome, as did the noble Lord, Lord Amulree, the noble Lord, Lord Brain, the right reverend Prelate and all who have spoken, the Committee's concept that a comprehensive National Health Service is sound, and that they have no evidence that patients receive better service under different systems. We welcome the emphasis throughout the Report on a doctor's obligations to his patient and on the importance of clinical freedom. We welcome the emphasis on the importance of adequate services for old people, based on the belief that, wherever possible, they should continue their lives in good health in their own homes.
A number of the Committee's recommendations are already accepted policy—for instance, the encouragement of group practice, which the noble Lord, Lord Amulree, supported, the attachment of health visitors to particular group practices, the conception of the domiciliary team, with the family doctor as its clinical leader, and the emphasis throughout the Report on the importance of expanding community care.
The central recommendation is the, creation of area health boards responsible for planning and development. This recommendation was discussed particularly by the noble Lord, Lord Amulree, by the right reverend Prelate and by the noble Lord, Lord Taylor. This proposal is not worked out in detail, but certain questions will have to be answered. For instance, will co-ordination between the separate branches of the Service be improved by a system under which the day-to-day administration, as seen by the patient, will be split between four separate subsidiary councils, as well as the local health and welfare authority? Is it an advantage to split the local health service, which it is proposed to put under the area health board, from the welfare services, which would remain under the local welfare authority? Will the consultants in the proposed departments of social health, who are to be recruited from existing medical officers of health, happily 607 serve two masters—the local health authority and the area health board? Is it in the national interest to deprive county councils and county borough councils of so large a part of the functions which they now exercise? I feel that the noble Lord, Lord Amulree, would probably answer, "No", to that question. I have taken note of those observations of your Lordships which have a bearing on these questions and the Government will await with interest the views upon them of the sponsors of the Committee.
The proposal of area health boards follows from the Porritt Committee's conclusion on what they call the "artificial tripartite division of the present National Health Service organisation." This was discussed by the noble Lord, Lord Amulree, and the noble Baroness, Lady Summerskill. I must say that I was a little surprised that the noble Lady thought it an unsatisfactory arrangement. I think she must have forgotten who was responsible for the National Health Service Act. Unless my recollection is wrong, she herself was a Minister in the Government at the time.
§ BARONESS SUMMERSKILL
My Lords, the noble Lord has forgotten that that was 1948, and the noble Lord's Party has been in power for eleven years. Times change.
§ LORD NEWTON
Certainly, my Lords, but we are talking about something very fundamental—the organisation of the National Health Service. Again, I think that I ought to refrain from comment on what is said in the Report about this in advance of the views of the sponsoring bodies, but I should like to assure your Lordships that we believe that there should be the fullest co-operation between the three branches of the Service.
A recent circular on admission to hospital shows in a practical way how we seek to promote such co-operation. The principles which the circular sets out are generally accepted as good practice, but they need to be known and widely applied. Many patients, especially the elderly and those with some kind of chronic illness or mental disorder, do not need to be admitted to hospital if the domiciliary services of the local authority are effectively mobilised. I am referring 608 to the services of the home nurse, the health visitor, the social worker or welfare officer, or the home help. This is why the general practitioner, before he approaches a hospital for the admission of a patient, considers whether the patient, with the help of these services, could be properly cared for outside the hospital, and, if so, he informs the local authority officer concerned.
Again, if the patient is put on the waiting list for admission, the hospital authority will give the general practitioner some indication of the probable date of admission and the general practitioner will often approach the local authority to see what supporting services they can provide meanwhile, if necessary, by an intensive mobilisation of help for a short time. A similarly close interaction between general practitioner, hospital and local authority is called for at the time of a patient's discharge, and a complementary circular on discharge procedures will be going out shortly.
Association between general practice and the local health authority services is quite rapidly becoming closer in a number of ways. For instance, current experiments, which are extending to more and more areas, are basing health visitors on the practices of general practitioners instead of on geographical areas, and we regard this as an important future development. At the same time, there is a growing use by general practitioners of the services of social workers, especially mental welfare officers, to collaborate with them in looking after the patients in their practices. The development of a local health authority service of trained social workers is at present in its earliest stages, as your Lordships will realise, and it would be premature to decide now the most effective way of organising this service, but close collaboration with general practitioners will certainly be a feature.
The home nursing service is, of course, closely linked with general practice and it is always available where treatment requiring nursing skill is prescribed by the general practitioner. I am not at all sure that there is a real need for the formal attachment of a local authority home nurse to an individual or group practice, since close collaboration of the home nurse and the general practitioner 609 in respect of individual patients has always existed.
Moreover, I could not agree with any suggestion that, because there may be dangers in having too many people advising a patient, the home nursing service should be expanded at the expense of health visiting. The functions of home nurse and health visitor are quite distinct. The health visitor advises on the health problems of people of all ages in the family setting. She is called in when such advice is needed. Much of her work is in the field of maternity and child welfare, and lies not with sick people but with mothers who need guidance in mothercraft, nutrition, behaviour difficulties and things like that.
The home nurse's work is not advisory but clinical. When treatment requiring nursing skill is prescribed by a doctor, the home nurse, under the doctor's supervision, provides the nursing. At times the health visitor and the home nurse will both be concerned with the same family. But even here their work does not really overlap. Each is essential in her particular sphere, and there is no difficulty in establishing a satisfactory partnership.
The noble Lord, Lord Amulree, called for the combination of the health and welfare departments of local authorities into what he thought might be called a social department. In recent years, the trend of much development has been to bring local authority health and welfare services so closely together that they can be administered as one for the benefit of the patient. I agree with the noble Lord that there are innumerable cases, particularly among the old, where it is difficult to say where health ends and welfare begins. Our policy is to emphasise in the strongest terms the need for close cooperation between local health and welfare services but to leave it to local authorities themselves to decide how this can best be achieved. Some have chosen to refer their welfare work to the health committee, but the majority still prefer to administer the services under separate health and welfare committees, each with its own chief officer. Whatever machinery they choose to adopt, however, it remains the responsibility of committees, and particularly of officers, to ensure that the health and welfare services work as one. I do not think I can do better than quote 610 some remarks of my right honourable friend at the Welfare Conference of Local Authority Associations in March, 1961. He said:There is in fact no intelligible boundary line between the services provided under the National Health Service Act and under the National Assistance Act: indeed, the division between the two is probably partly of historical, and partly of accidental, origin; it has little or no contemporary or logical significance. Whatever the illogicalities of the statutory framework, the plain fact is that the health-and-welfare services ought to be in a single entity from the point of view of those whom they serve. What matters is not the Act under which the powers are exercised (so long as the powers are sufficient), nor even the way in which the exercise of the powers is organised by the local authority (so long as The organisation is efficient), but the way in which the powers are applied to the individual or the family in need of help. They should be unaware of any distinctions created by Acts of Parliament or forms of organisation: the whole combination of services should come smoothly into play according to their needs".Those are the views of my right honourable friend in his own words, and the local authorities are constantly being reminded of them.
The noble Lord, Lord Amulree, asked me whether hospitals could not have some ambulances of their own. Since the National Health Service Act came into operation in 1948 the ambulance service, as he knows, has been a local health authority's responsibility. The Guillebaud Committee, which reported in 1956, reviewed the organisation of the service in England and Wales and considered the suggestion that administrative responsibility for its provision should be transferred from the local health authorities to the hospital authorities, and they concluded that the arguments against the transfer of the whole of the ambulance service were decisive. This, too, is our current view.
I now come to the care of the elderly. The services for the elderly fall into four main groups: provision of suitable housing—that is to say, single bedroom dwellings and special flatlets with resident wardens; help in the home; residential care; and hospital care. The aim is to provide and keep all these services in balance so that the needs of the elderly are met in the right way at the right time—and I take this opportunity of reminding the House that the gracious Speech from the Throne forecast the publication 611 this Session of the long-term plans of local authorities for the further development of their health and welfare services. I cannot this evening offer any anticipatory comment either in general terms or on the plans of individual authorities. I have, however, noted what the noble Lord, Lord Amulree, said about the desirability of making statistical studies.
As for progress up to date, the House, and particularly my noble friend Lord Auckland, might like to know that between December 31, 1959, and December 31, 1961, the number of home helps (in whole-time equivalents) employed by local authorities in England and Wales rose by 2,000, and the number of households assisted annually by home helps rose from 290,000 to 328,000. As regards residential care, the number of elderly people provided for has been rising steadily in recent years. The total reached 76,000 at the end of 1961. In 1962 some 4,000 new places were provided, which works out at between 75 and 80 every week. The ratio of purpose-built to adapted homes has increased continuously for many years, and it has accelerated quite rapidly in recent years. In 1951, 250 homes were opened, but only 5 were purpose-built; in 1957, 68 homes were opened, of which 26 were purpose-built; in 1961 no fewer than 55 of the 75 homes opened were purpose-built. This, my Lords, is an indication of the increased amount of capital made available for welfare services in the last few years. The current rate of opening of new purpose-built homes is about three a fortnight.
The result of all this development in terms of quality has been impressive. In 1948 almost all the available residential accommodation—some 42,000 places—was in ex-Public Assistance institutions. By the end of 1961 the number of such places had fallen to 34,000, even though the number of elderly people accommodated under Part III of the Act had risen to 76,000. The ratio of new to old will improve with every month that passes, and, indeed, my right honourable friend declared last September:We shall not be content unles we can see the end of all the workhouses in a decade, reprieving only such as can be made to give service fully on a level with modern standards and ideas. The rest are a blot and an in-adequacy. They must go.612 While on the subject of local authority provision generally, I should like to tell your Lordships that during recent years training centres for the mentally subnormal have been opened at the rate of about one a week, roughly half of these being additional provision and the other half being replacements of unsatisfactory premises. The number of places in training centres for the mentally subnormal has been increased by some 2,000 or more a year, roughly 1,000 each for children and adults.
Local authorities generally take a sympathetic attitude towards applications for housing made to them by elderly people. They are advised to take into account ill-health as a factor of housing need when it is caused or aggravated by conditions which might be improved by a transfer to other housing. Inability to manage stairs is obviously a material factor. Nobody would claim that elderly people can always obtain a council flat or bungalow as soon as they ask for one. However, public authorities have completed about 250,000 one-bedroom flats and bungalows since the war, and the priority that is being given to the needs of the elderly can be recognised from the fact that one-bedroom dwellings account for about three out of every ten dwellings currently being completed by public authorities in England and Wales.
If any local authority tenant, of whatever age, lives high up in a block of flats he is more likely than not to have the use of a lift. But dwellings provided specifically for elderly people are generally built low. There have been one or two high blocks of old people's flats—which have proved popular—but the general arrangement is that old people's housing is provided as bungalows or in blocks of flats of not more than two storeys, or on the ground and first floors of higher blocks. This is not to say that elderly people can never be found living in the higher flats in local authority blocks. Some may have moved into such flats when they were younger, and may still be there, because they like it. A year or two ago, the Building Research Station undertook a sample survey of old people's dwellings, and, according to a report made last May, four-fifths of the old people they found living on or above the sixth floor preferred to do so. But 613 local authorities, practically without exception, are prepared to allow their tenants to transfer from one dwelling to another when the need is proved. Indeed, it is often in the local authority's interest to allow such a transfer, since the flat released may be suitable for a family.
I now move on to medical manpower, about which a number of your Lordships have expressed opinions. The Porritt Report alleges shortage of medical manpower in various fields. Its conclusions are, however, tentative, and it simply makes the point, with which we agree, that the various factors which might lead to shortage should be investigated and analysed. The Report continues with a note of warning, thatany unjustified increase in the number of doctors could … lead to serious consequences.Its main recommendation is for the establishment of a mechanism to record the facts of medical manpower to which future studies of need could be related. We have already started on arrangements, in co-operation with the British Medical Association, for improving the collection and recording of factual information. The full benefit of the improved system will not, of course, be seen at once, but the information derived will be of cumulative value as time goes on.
My noble friend Lady Horsbrugh asked me about emigration. An inquiry last year of deans of medical schools indicated that, in the case, of those who have kept in touch with former students, some 4 to 12 per cent. (varying according to the school) of their British graduates in the preceding ten years or so are now established abroad. A study on emigration and other aspects of losses from the pool of medical manpower is being undertaken under the auspices of the Nuffield Trust. More reliable information derived from this study, coupled with the improved method of keeping long-term records, should be available in the fairly new future. It has, of course, always been part of the tradition of this country that a proportion of our doctors should go overseas. I was glad to hear the noble Lord, Lord Amulree, endorse this point also.
He referred to the need for more medical students and more medical schools. In 1961, the Government, made a check of the calculations of the Willink Committee 614 for student intake, using information which became available subsequent to the Committee's Report. We did not think that the revised figures were based firmly enough to justify precise new estimates, but we felt satisfied that the prospective demand for medical services would justify a rise in the university intake of pre-clinical students to 10 per cent. above the level recommended by the Willink Committee. We invited the University Grants Committee to consider, with the universities, the effect of such an increase. The universities indicated that this increase could be absorbed in existing schools without loss of standard. In the event, the intake increased in the autumn of 1962 by more than 16 per cent. over the Willink figure, and by more than 14 per cent. over the intake for the year ending July, 1961. Hospital boards have recently been asked to undertake a review of their medical staffing to cover the next five years, and the results of this will be available later this year.
§ LORD TAYLOR
My Lords, the noble Lord is of course aware that the Willink Committee figure was a cut of 10 per cent. on the previously existing figure, so that the 10 per cent. was merely a restoration of the cut which had been made by the Willink Committee. Apparently there has been some extra 4 or 6 per cent. over and above that.
§ LORD NEWTON
The noble Lord, Lord Taylor, can put what interpretation he likes on what I have said. I am sorry he is not pleased by the explanation I have been able to give your Lordships.
§ LORD NEWTON
If the noble Lord will be good enough to read in Hansard what I have said he will find it clear enough.
In view of the observations of the noble Baroness, Lady Summerskill, and of the right reverend Prelate, about the maternity services, I should like to mention that in September of last year the figures of nursing and midwifery staff in National Health Service hospitals in England and Wales showed a continued increase over the previous year in all types of staff, whole-time or part-time. Whole-time staff increased by 5,282, or 615 3.2 per cent. This rate of increase was larger than in the two previous years and well above the average for the last six. Part-time staff increased by 7,955, or 16 per cent., which was the highest rate of increase ever recorded.
As regards figures for midwives alone, in the same period September, 1961, to September, 1962, the increases were: whole-time 127; part-time 245, and pupil midwives 185. In view of what the noble Baroness, Lady Summerskill, said about maternity services I think I ought to say that the number of births has increased and is continuing to increase very rapidly. Hospital authorities are reviewing their building plans in the light of the latest statistics and forecasts and some maternity units will have to be brought forward and given priority over other projects in the building programme. In London, where the pressure is especially heavy, special steps have been taken to make available upwards of 100 extra maternity beds. I was glad that the noble Lord, Lord Taylor, drew attention to the findings of the Gallup Poll about the number of women who preferred to have their confinements at home, because it has saved me the necessity of drawing attention to them myself.
Now a word about general practitioners. The average list of general practitioners in England and Wales has fewer than 2,300 patients. The total number of general practitioners has increased every year since the Health Service began. Apart from 1959–60, when a number of doctors retired on qualifying for a National Health Service pension, this increase has always been greater than the corresponding increase in the population. The real problem exists in "designated" areas—that is, places where there is a sufficient excess of patients over an average of 2,500 per doctor to make it likely that another doctor could develop a practice in that area. The percentage of the population living in such areas has steadily fallen. It was over 50 per cent. in 1952, and in October, 1961, the latest date for which figures are available, it was 17.1 per cent. It has been calculated that the number of extra doctors required to remove the designation in these areas is less than 250; that is, not much over 1 per cent. of the present number of general practitioners.
616 The Porritt Report suggests that if doctors could be sure that later in life they would be successful in applying for another practice in an attractive area, they would be more willing to start their careers in an unattractive one. In fact, if a practitioner who had managed successfully a large practice in an industrial town were to apply, say, in his late forties for a rural practice in the South, his experience would make him a very strong candidate, and he might well be successful. But I am not convinced that such considerations as these really deter doctors from starting work in industrial areas. Mobility among general practitioners has probably never been very great, and I think that most doctors would view a practice as being their work throughout their career.
Both noble Baronesses who have addressed your Lordships to-day spoke about private practice, and my noble friend Lady Horsbrugh said she thought the private practice had been growing. I am afraid that we have no information on which to form conclusions about recent changes, if any, in the extent of private practice. On the other hand, there is no evidence to suggest that it is diminishing. The Government certainly attach importance to its continuance. In this connection, I was interested to see that the Gallup Poll showed that, although 41 per cent. of those approached knew that their doctor had private patients, only 9 per cent. thought that his arrangements for his private patients were different from those for his National Health Service patients.
My noble friend Lady Horsbrugh asked me three questions about amenity beds. One of them was: "Are they fully used"? The answer to that is, "No". The second question was: "Are patients told whether amenity beds are available"? The answer to that is, "Yes". Hospital authorities have been advised that if a patient's primary desire is for privacy and quiet beyond what is medically necessary, he should be told of the existence, nature and availability of any amenity beds. The third question was about charges. The charges are prescribed by regulation. They are 24s. a day for accommodation with a single room, and 12s. a day for accommodation in a small ward. If the average daily cost per inpatient is less than 48s. a day then the 617 charges are half the daily cost for a single room and a quarter for accomodation in small wards.
The noble Lord, Lord Amulree, discussed the future of general practitioner hospitals. I am aware that fears have been expressed that the transfer of work from some of the smaller hospitals to the new district general hospitals might mean a lessening of the contribution that general practitioners can give, and wish to give, to the hospital service, but this is not so. As the Hospital Plan says:Decisions on the number and location of beds set out in the Plan do not prejudice the question which of these beds or of the hospitals comprising them should be general practitioner beds or general practitioner hospitals.The Plan, however, specifically envisages general practitioner beds in new maternity units; and, indeed, the new maternity hospital at Birmingham, for which my right honourable friend announced last week an earlier starting date, is planned to include 25 general practitioner beds. Over the next few years developments arising out of the recommendations of the Platt Report on the Medical Staffing Structure in the Hospital Service will deeply affect, and should greatly strengthen, the relationship between general practice and the hospital service. Decisions on the future control of beds, both in the new hospitals which are planned and in the existing hospitals which remain, can best he taken in the light both of these developments and of the outcome of the study being made by the Standing Medical Advisory Committee on the future field of work of general practitioners. Perhaps I should just add here that it has long been our policy that general practitioners should have access to X-ray and pathological departments in hospitals, and, in fact, there are few areas where this is not the case.
The noble Lord, Lord Amulree, asked me whether small general practitioner hospitals could be placed under the executive councils. I am very doubtful whether such a transfer—which, incidentally, would require legislation—would be beneficial. Indeed, separation from the main hospital service might be damaging because it would lead to isolation from the main and constantly developing stream of medicine. The point is that the principles governing 618 hospital development derive from the staffing, accommodation and equipment needs of hospitals, and not from the nature of the authority administering them.
The noble Lord, Lord Taylor, gave us the benefit of his great knowledge and experience on industrial medicine—or "occupational medicine", as I think the Porritt Report calls it. He expressed views on the Committee's ideas on the subject, and quite apart from anything else, that lets me out of doing the same thing. I had thought of telling the noble Lord what the Government's policy on this matter is, but I am quite certain he knows it; and, as the hour is getting on, perhaps he would prefer me not to tell him again or at any rate, not to tell him what he knows already.
Although the noble Lord, Lord Taylor, told me—and this was very strong—that he did not think it was my busiess to talk about medical research, I feel that I ought to say something about it, because the noble Lord, Lord Brain, gave us the benefit of his views, and the noble Viscount, Lord Waverley, talked about education. Like the noble Lord, Lord Taylor, I think it is a pity, from Lord Brain's point of view, that he did not make his authoritative contribution in last Wednesday's debate, for he would then have had the benefit of a reply from my noble friend the Minister for Science, instead of from me. Like the noble Lord, Lord Taylor, Lord Brain recognised that my right honourable friend the Minister of Health has but little responsibility.
The Porritt Report, in paragraph 156, criticises the Clinical Research Board for failing to make a sufficient impact or to fulfil its high expectations. The facts are that in the nine years since the Board became responsible for advising the Council the number of clinical research units has risen from 22 to 43, and the total annual expenditure by the Council on clinical research from £400,000 to an estimated figure of over £1,800,000. The noble Lord, Lord Brain, called that a gratifying increase, and I was glad that he did. In addition, the Clinical Research Board has played an important part in the evolution and planning of the Clinical Research Centre, which is a very forward-looking project. This will comprise a comprehensive 619 concentration of relevant clinical and para-clinical disciplines and thus facilitate the type of planned collaborative work which is becoming increasingly required to-day. The Centre will be linked with the new district hospital to be built by the North-West Metropolitan Regional Hospital Board at Northwick Park, Harrow.
With regard to Lord Brain's observations about the Medical Research Council, I feel that I must point out that the Council's budget has increased steadily over the past ten years, rising from £2 million to nearly £6 million a year. The Council operate with a high degree of independence and allocate their funds in accordance with their own expert scientific judgment. Their standards for the award of research grants are high, but on the average about 85 per cent. of the applicants have been given an award. In addition to support from the Medical Research Council, medical research is financed through the normal university funds available through the University Grants Committee. There is also an increasing allocation within the National Health Service to Hospital Boards for clinical research closely bound up with the treatment of patients.
Financial support comes not only from the State but also from outside sources, from the benefactions of individuals and from foundations like the Nuffield Trust, as well as from organisations in the United States. There are sometimes complaints that the diversity of these sources causes confusion and waste of time among the scientists seeking support, but I believe that no single body is a repository of all wisdom in these matters, and the diversity of support is an assurance against any worthwhile project being overlooked and provides, I believe, the best hope for the outsider, if I may so describe the potential researcher whose qualities have not yet been recognised or developed.
The noble Lord, Lord Brain, also made reference to post-graduate medical education. I think he knows that the various bodies interested were in agreement that there is a need for the development of schemes of post-graduate medical education of a non-academic kind in the non-teaching hospitals. A sum of £250,000 has been made available by the Nuffield 620 Provincial Hospitals Trust to promote developments of this kind, and Regional Hospital Boards have been encouraged to seek support for experimental schemes in their areas so that the most fruitful and economic lines of future advance can be determined. A number of Boards are developing schemes, and reports in the autumn of 1962 indicated that good progress was being made. Eight Boards had been granted, or offered, assistance by the Nuffield Trust for specific projects. They include organising lectures, demonstrations and clinical conferences, library facilities and so on. The arrangements being worked out provide for post-graduate education of general practitioners, as well as hospital doctors, and for fellowships for overseas graduates. We are fully in sympathy with the view that the arrangements should include suitable training for young doctors from overseas who are occupying junior posts in the hospital service, and we hope that many such doctors will continue to come here for this kind of training and experience. Further progress reports by Boards are now being called for, and we shall study them with great pleasure.
Both the noble Lord, Lord Brain, and the noble Viscount, Lord Waverley, talked about accommodation for research in hospitals. We fully accept the need for improved research facilities and we recognise it in the guidance given to hospital authorities on the design of new and redeveloped hospital buildings. In the district general hospitals of the future, clinical research on patients actually under treatment or investigation may well not call for a great deal of accommodation, since much of the research will be undertaken on patients in the wards. But some extra facilities will be required—for example, in the pathology laboratories; and the necessary provision is being made in current building projects. The Ministry's hospital building note on the pathology department of a district general hospital recommends minimum standards which are very considerably higher than those of the past. Not only does each main section of the department—that is to say, morbid anatomy, hæmatology, chemical pathology and microbiology—have its own laboratories, but provision is also made, where local circumstances demand it, for laboratories required specifically for research. In teaching hospitals, of course, fundamental research is 621 undertaken as well as clinical research on patients under treatment or examination. The needs of both types of research have been given full weight in the designs of the new hospitals at Cardiff and Sheffield, and at the Royal Free Hospital, Charing Cross Hospital and St. Thomas's, Bristol.
The last thing I want to do is very briefly to answer the question which the noble Lord, Lord Amulree, put to me about what consultation there was with the medical profession about the Hospital Plan. In discussing the Hospital Plan the Porritt Committee say in paragraph 364:We understand that there was no consultation with the profession before these plans were announced.This statement arises from a misunderstanding. The Hospital Plan is in a very real sense the plan of the hospital service as a whole. The plans and proposals of the hospital authorities which it embodied incorporated the thought, the work and the aims of the medical staffs who at every level are integrated into the administration and planning of the Service. Thus the medical view was built into the plan at every stage.
Although I have a great deal more I could say, I think the time has come when your Lordships would wish that I should not do so. I should like again to say haw grateful I am to the noble Lord, Lord Amulree, for giving us all the opportunity to discuss pretty well anything we liked. I certainly have enjoyed the debate. I hope your Lordships have, and I hope that, like me, you have found it valuable.
§ 8.4 p.m.
§ LORD AMULREE
My Lords, before asking your Lordships' leave to withdraw my Motion, I should like to thank the 622 noble Lord, Lord Newton, for his full reply. I am afraid we must, between us, have given him a great deal of trouble in preparing this reply, because the debate has ranged over an extremely wide field. I am more than grateful for the remarks he has made to me. Some, at the moment, have not been very satisfactory, or have not given me the satisfaction I thought they might, but there are one or two things at which I am very pleased.
I was very interested in what the noble Lord said about the Ministry's views about the health and welfare departments of the local authorities. I was impressed with the figures he gave about accommodation for old people. My only comment on that is that although the increase is large, it is nowhere near large enough. I was pleased at what he said about the consultation that took place before the ten-year plan. I shall certainly bear in mind what he said about re-housing elderly people when the question comes up again in my experience. I shall possibly be able to quote from his speech, which may have some effect on the local authorities with whom I am dealing. Finally, I would thank noble Lords, from all parts of the House, for the help they have given me in this debate, for the contributions they have made to it and for the fact that none of us have said the same thing twice, which shows. I think, what a satisfactory debate it has been. I beg leave to withdraw the Motion.
§ Motion for Papers, by leave, withdrawn.
§ House adjourned at six minutes past eight o'clock.