THE PORRITT REPORT ON MEDICAL SERVICES

§ 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 suggested that 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 that Few of any walks of life have so much to offer the able young man as medicine will 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 that the 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.

§ A NOBLE LORD

My Lords, I think there were three.

§ 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 sound and 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.

§ 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"—

§ BARONESS SUMMERSKILL

And women.

§ 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.

§ 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.

§ 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.

§ 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.

§ 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 dest