HL Deb 03 February 1965 vol 262 cc1183-236

4.16 p.m.

Debate resumed.


My Lords, the time has now come to continue our debate on the Hospital Service. Before I make a few remarks on it, I should like to say how pleased I am to be the first speaker after the noble Lord, Lord Sorensen, and to say how much I enjoyed what he said this afternoon. By virtue of the distinguished office he now holds, we shall have the pleasure of listening to him more often than as one of the Back Benchers. I am sure that what he says will be welcome and very interesting indeed.

It gives me great pleasure to take part in this debate, but I do not want to cover the rather wide field which the noble Lord who moved this Motion covered. I wish to confine myself to the affairs of some of the professions supplementary to medicine which the noble Lord mentions in his Motion. I am particularly interested in the fortunes of these professions for two reasons: first, because over the past twelve or fifteen years I have been involved in the governing bodies, as one might say, of the Institute of Almoners, the Association of Occupational Therapists, and the Society of Chiropodists. Therefore, I can speak from a certain amount of knowledge of the way in which those bodies run.

In the second place, I should like to talk as one who may call himself a consumer of what goods these people produce, because I worked for many years in close collaboration with their members at the hospital to whose staff I belong. I have found it would not be possible to do the work I do unless I had their enthusiastic and loyal collaboration and support. I am sure that is the general feeling of the medical profession about what are now called the professions supplementary to medicine. It is something I have said to your Lordships on more than one occasion before, and I am pleased to have this opportunity once more of mentioning the debt which my profession owes to the devoted work of those who practise in these professions.

The people I want to talk about first are occupational therapists, because I have not been concerned with the Institute of Almoners for a long time, so I am rather out of touch with their present work. One of the troubles is that even at the present time there is a grave shortage of occupational therapists in the country. The shortage is something in the neighbourhood of 24 per cent., which is quite large, and one of the points I should like to put to the noble Lord, Lord Taylor, who is to reply, is this: do the Government really know the total number of occupational therapists required at the present time to bring the places where they work fully up to establishment, particularly bearing in mind the big new development which has occurred with the passing of the Mental Health Act, 1959?

The numbers in the profession have gone up by what would appear to be quite a big figure—about 600—between 1956 and 1964, but I am told on all sides that, although that increase has been substantial, it is nowhere near enough to cover the posts where they are wanted. I could think of all sorts of reasons for this, and one which I should like to bring forward and which I know has been brought forward before is that the prospects and salaries which are offered to these girls—for the bulk of people who take up this work are girls—are poor compared with those offered to girls in other branches of the public service, not to mention the enormous advantages which can be offered to those in commerce and industry.

For example—and I hope your Lordships will not mind my quoting one example—the Civil Service have 50, 000 executive officers. They come into the Service when they leave school at the age of 18, which is just at the time the girl beginning occupational therapy has to start her training, and, instead of being paid, she has to pay out for the next three years. Although she may get a grant or a scholarship from somewhere, she does not get paid. Then one finds that when the executive officer reaches his or her highest grade, the salary is, I think I am right in saying. £1, 480 a year, whereas the highest grade in occupational therapy, provided the person does not get promotion to a supervisory post in a really big department, carries a salary of £829 a year. Even if he or she does get promoted to supervisor, the salary does not rise above £1, 300. That is not a very great encouragement to girls to take up a profession which is going to be hard work, because it is extremely hard, where the training takes quite a long time, and where they realise more and more that the work they are doing is something of great importance to people who are sick either mentally or physically.

My Lords, I will not say any more for the time being about occupational therapy, and I should like to turn to the chiropodist, where we find the same sort of story. There is a. considerable shortage of these valuable people. The number in training is in the neighbourhood of 300, and I am pleased to say that of that number 100 passed and qualified last year. One thing I was very pleased to see in The Times yesterday, I think, was that the L.C.C. propose to establish a new training school somewhere in London—I cannot remember exactly where. The only real, official recognition that the chiropodist has is that the local health authorities can (not "shall") set up schemes under which certain persons in priority classes may be provided with treatment. As far as I know, most of the 148 major local authorities in England and Wales provide these schemes. The total number, I think, is 146.

But what it comes down to, when we look at the number of vacancies for full-time chiropodists, is that whereas 188 people are occupying full-time posts, 90 posts are vacant in the establishment. If the service were to be complete, covering all the local authorities, there would be a necessity, I think, for a further 206, which seems really staggering, but I have gone into the figures very carefully and as far as I can see I have not made a mistake. So it means that here, too, more people are wanted than we have at the present time. When one comes to people working part-time, the position is not nearly as bad; the number of vacancies is quite small and the number of future requirements does not really cause trouble.

When the local health authorities are setting up their clinics they give priority, quite properly, to certain classes of persons: to the old, the physically handicapped, and the expectant mothers. Nobody would object to that. But it means that if you are not in one of those categories and you urgently require chiropody, you then have to go to a chiropodist in private practice and pay for the treatment yourself. Supposing one goes to a hospital, the treatment is restricted to the patients referred to the chiropodist by the consultant or doctor in charge.

Another rather serious matter in the chiropody world is that quite a number of old people's clubs employ chiropodists to treat their members. As far as I can make out, although a certain number of clubs employ properly qualified chiropodists, the chiropodists do not need to be properly qualified. By that, I mean that they do not come under the National Health Service (Medical Auxiliary) Regulations for 1954, nor are they qualified by virtue of State registration in 1962.


My, Lords, I think there is a practical point here. It is the absolute shortage in the number of chiropodists. If they did not employ these chiropodists who are qualified in the old way, there would be no chiropodists at all for the old people's clubs.


There I think the noble Lord has made a very good point, which I accept; but it is part of my plea that there should be encouragement to get more chiropodists, and that it should be possible for the better qualified chiropodists to go to some of these old people's clubs, istead of the less qualified going there. It is the shortage of chiropodists that is causing the trouble. I think it is particularly dangerous with these clubs, because although some of these chiropodists do their work extremely well, there may be some who do not. When you are old, your feet are particularly liable to damage if they are carelessly treated, and it seems rather bad luck that old people, whose feet are particularly susceptible to danger, should be exposed in this way.

Another thing I should like to ask the noble Lord is whether he can tell us the number of chiropodists employed in the school health service because it seems to me to be a point where what is wanted is, not a great number but quite a regular number of chiropodists. Because if chiropodial advice is not available for the young people it tends to lead to a lot of foot trouble which will probably cause more difficulty when the children grow up and will cost a great deal more to be put right than it does when they are young.


My Lords, with very great respect, the noble Lord is asking us to work out a lot of very complicated figures. He was complaining a little while ago about the number of officers employed in the Civil Service.


I was not complaining of the numbers; I was complaining about the amounts they were paid, compared with occupational therapists, which is quite a different story. I think that if you are going to get down to the sort of numbers needed, you must do a certain amount of sums. You cannot say: "Let there be occupational therapists and chiropodists", as in the first Book of Genesis; you have to know what numbers there are going to be. That is why I put these questions, not for answer now, but because I think the figures should be worked out rather more carefully.

What do I think should be done about the shortage of chiropodists? There is something which can be done, because a large number of chiropodists, rightly or wrongly, do go into private practice. That being so, would it not be possible for the local authorities, or the hospital authorities, to employ them, or to send people to them, under the control of the executive council, or to do something like that? I am sure there is some way by which some of these people could be brought in to work for the public good, even though they were in private practice. After all quite a number of doctors engage in some private practice and do quite a lot of work in the National Health Service.

There is one further point, dealing with the professions supplementary to medicine. I have never been entirely happy about the employment of the Whitley machinery for dealing with their pay claims and disputes in general. So far as I can make out, the Whitley Committee first met in 1916 or 1917, and one of their terms of reference was: To make and consider suggestions for securing a permanent improvement in relations between employer and employed. I know that the Whitley Councils did an enormous amount of good in the industrial field when they were set up, but I wonder whether that applies also to the relationship between, for example, occupational therapists, now that they are a professional body—and the other professional bodies, too—and the Ministry of Health.

Then again, I think the presence of the Treasury in the background rather vitiates the possibility of free negotiations between the Ministry and the occupational therapists, or whatever branch of the profession it may be: because one knows quite well that the Ministry cannot come to a conclusion without the agreement of the Treasury, whereas an employer in industry certainly could. One wonders whether something of that sort, some change in that machinery, might encourage more people to join these professions; and whether, at the same time, now that they have become professions, there could not be some body to review their terms of service and salaries, as is being done in the case of the medical profession at the present time. That, I think, might do a certain amount to bring more people in.

I should like to say one thing about the work of these professions. One must begin to think in terms of preventive rather than curative medicine. In the past, there has been far too much attention focused on the hospital, far too much attention on sickness and trying to cure, rather than to prevent. I believe that a lot of good could be done by bringing the various branches of these professions much closer together. I am pleased to see that it is occurring between the physiotherapists and the occupational therapists. They are finding that their work does dovetail together, and one may look forward to far more of this in the future.

Another thing I should like to see is more work done on bringing out goods, what might be called a production line, rather than making goods to be sold at the sale of work at the hospital involved. At the Royal Hospital and Home for Incurables, at Putney, we do a certain amount of work for various firms. They take the work of the patients, who are paid normal wages; for the work. There are quite a number of workshops for old people which do it, and I mention Finsbury as one which has expanded.

Finally, there is one point which might encourage people to join these professions. I remember that when the war ended, or was about to end, I was involved in the making of a film, to be shown to the girls in the various Services, showing what the work was like in these various professions. It was quite a good little film, although I say it who should not. So far as I know, it had some effect in drawing the attention of the girls in the Services to these jobs. One wonders whether something of that nature could be done in the schools, and other similar places, to give the people there some idea of the work to be done.

4.35 p.m.


My Lords, may I ask your indulgence for my first venture in intervening in your Lordships' debates? And, first, may I thank the noble Lord, Lord Auckland, for the kind words he spoke about those who are asking for your Lordships' indulgence and in particular for what he said about a Member of another place who is to-day sitting on the steps of the Throne and about myself.

The subject being debated this afternoon is one that I have had cause to think about, for since 1954 I have had the honour of serving on the North-West Metropolitan Regional Hospital Board, a Board of which two noble Lords, Lord Cottesloe and Lord Moynihan, have been, or are, chairmen. In 1960 I was appointed chairman of one of its hospital management committees. That appointment was the subject of some exchanges in another place. Indeed, a noble Lady opposite, who I am sorry to see is not at the moment in her place, was perceptive enough to remark, when she was in that other place, that it was a case of creating "jobs for the girls". How right she was I have had reason to discover. Being chairman of a hospital management committee is some job. That is why I am so glad the Minister of Health to-day is someone with whom I have worked on a Regional Hospital Board, someone who has learned about hospitals the practical way and can appreciate the feelings and frustrations of those in the field.

The Motion before us is: To call attention to the Hospital and Medical Services, with particular reference to the shortage of physiotherapists and other ancillary grades. If debated exhaustively, this Motion could keep your Lordships here for days, because there are so many of these grades. Thirty are listed on the statistical return, SH 5, which is used to collect data about the numbers of professional and technical staffs supplementary to medicine in post in each hospital. It may be of some relief to your Lordships to know that I am not proposing to talk about all thirty. After glancing at the picture as a whole, I should like to turn to three or four of the professions supplementary to medicine which are causing most anxiety to those of us who are trying to administer the Hospital Service satisfactorily.

In November, 1962, the Welsh Hospital Board appointed Miss Anne Crichton, a senior lecturer at the University of Cardiff, to conduct research into the effect of the Hospital Plan on hospital staff in Wales. In 1963 the first of a series of reports by Miss Crichton and her research assistant, Miss Marion Crawford, appeared under the interrogative title Disappointed Expectations? It deals with professional and technical staff in the Hospital Service in Wales. The title which I assumed upon introduction to your Lordships' House may have created in some a feeling of despair over its potential pronunciation. But I think your Lordships will agree that that and my Welsh parentage do give me some claim to speak of Wales and Welsh affairs, though that is not my sole reason for referring to this Welsh report this afternoon. The report is revealing and interesting. It deserves attention outside, as well as inside, the Principality. Although some of the features discussed are peculiar to Wales, many are likely to be similar elsewhere.

The report poses a number of questions, to many of which the answers are as yet unknown. Is the demand for laboratory staff likely to grow steadily? Will the demand for radiography remain stationary? With the growing emphasis on home care, might not some of the therapists be better employed in the community than in hospitals? Could some of the simpler routine be done by less highly trained staff? To my mind, these and many other questions should be pursued, and some of the answers found, before all the new district hospitals are built and the problem of staffing them has become a burning issue.

There are also the questions implicit in the task of recruitment. With the acknowledged wastage of women from the National Health Service to the fuller and even more testing life of matrimony, has enough thought been given to the relative numbers of each sex who should be recruited and trained? Would more men come forward if higher salaries were offered? And, speaking of salaries, are the present ones, and the existing conditions of work, attractive enough to prevent a large loss to industry of trained staff in some of the services? These are some of the questions that spring to mind.

In their contacts and interviews, and as a result of the answers they obtained to questionnaires which they circulated, the authors of this report became aware of what they described as a sad state of low morale and a waste of efficiency which the new district hospitals must endeavour to avoid". We hear a great deal to-day about team work in the Hospital and Medical Services. The conception is grand but in far too many cases only an undersized baby is delivered. Many of the ancillary staff feel that their function is not properly understood by the medical and nursing and administrative staff with whom they should be working. They sometimes feel that these others expect them to play a part for which they were not trained and from which they can see no distinctive benefit to the patient.

Dietitians, for example, have to produce five "O" levels, in which English, chemistry and mathematics are essential, before training can start; and they have to train for four years or more. But many of them feel that when they take up a hospital post the special knowledge and qualifications they have obtained are not always used as effectively as they might be. In the recruitment and retention of dietitians salary plays an important part, and it is not enough to com- pare their salaries with those of other medical ancillaries: they should be compared with what dieticians can command elsewhere. At present there is, in fact, an overall shortage of them. Dietitians in hospital are not as well paid as dietitians who teach in colleges or take jobs in the catering industry; so the Hospital Service tends to lose them.

Two other fields of acute shortage are radiographers and physiotherapists. Why do relatively few girls take up radiography as a career? The main factor seems to be the lack of publicity at school. This branch of medical service appears to be ignored by many of the careers mistresses. Where the profession has been given direct publicity at school, recruitment has increased.

Then, the educational requirements for a radiographer, particularly the high standard they must attain at school in physics and mathematics, mean that many of the girls who are good enough to attain these standards opt to go to a university, rather than train at a radiography centre. So the radiography profession is always liable to be short of trainees. In my own group of hospitals the staffing position fluctuates seasonally. We have a full complement when radiographers leave their training schools and colleges in mid-summer. Then, as the year progresses, there is the natural wastage due to marriage, having children, or moving away from the district. The lowest level of establishment is normally between Easter and August. Yet the work of the hospitals must go on.

Another difficulty is that there is an almost complete lack of accommodation for radiography students in most hospitals, and the students' allowance of £265 a year makes it difficult for a girl to pay for food, accommodation, fares, books and uniform unless she can live at home. These are the difficulties in recruitment. What about the circumstances which lead to a girl's giving up radiography after qualifying?

As in so many other professions marriage causes the greatest wastage. There is also the fear of the effects of radiation during early pregnancy—and this despite the precautions that are taken and the authoritative reassurance that is given. Some hospitals, too, make use of a shift system; and such hours as from one o'clock to eight o'clock make for difficulty in running a home. Other reasons for wastage may be that a radiographer "on call" may be alone with great responsibility; but the pay for "on call" duty is the same for senior as for junior radiographers. There is no doubt that pay is a great cause of discontent, and I cannot help thinking that some of this discontent has been justified. Although the basic salary for a junior radiographer seems to be satisfactory—it is £623 at the age of 21—the maximum salary for that grade, the basic grade, is only £829. These pay scales also apply to men. The prospect of raising a family on this kind of pay makes the profession unattractive for male radiographers. Those who do qualify usually transfer fairly rapidly into industry.

Then, to turn to physiotherapists, in common with other professions supplementary to medicine—I am trying to give the correct term to the ancillary services described in the Motion this afternoon—their numbers have not expanded as they should to meet the rapidly increasing demands which modern treatments in surgery and medicine make on their services. Physiotherapy can play a vital part in speeding up rehabilitation after serious illness or operation, as well as in the saving of life in the current developments in such fields as neurosurgery. To meet this need a steadily expanding profession is required, but in fact the profession has for years practically stagnated so far as its numerical strength is concerned.

I believe that has been due primarily to the low rates of pay and to the inadequate career structure offered. Five "O" level passes is the minimum educational standard demanded, and the training then lasts for three years. But the maximum salary that a basic grade physiotherapist can attain is only £829 a year. Compare that with the maximum salary of £960 for a clerical officer in the Civil Service who entered at 16 with no post-school training at all. Even the higher grade of senior physiotherapist has a maximum salary of only £979—hardly more than a clerical officer. One is inclined to ask: way train? Yet everybody says that our country needs more trained men and women. The Hospital Service most certainly does.

If we accept that there is difficulty in recruitment to these professions, and that it is unlikely to come right in the short term, we must ask ourselves whether those we have are deployed to the best advantage, and whether their trained skills are used to the maximum. The first point is in part dependent on the personal preferences of the people concerned. But there may be a need for financial inducements to make good particular shortages, in much the same way as special inducements are offered in under-doctored areas. Whether their trained skills are used to the maximum is hard to assess. The work they do is determined by the demands and requirements of the leader of their team, the consultant. I wonder whether he always sufficiently treats their skill as a scarce commodity.

I know of no published measurement of the numbers of trained staff in each of these many ancillary services who are reasonably required per hundred beds, so that a hospital could be helped in determining whether it ought to give preference to a radiographer, a physiotherapist or a laboratory technician when there is sufficient money for only one of these grades. The conditions in which they work, the equipment they have, the subordinate help available to them are all determined by the funds the hospitals have, and there is no rational and objective assessment. The only figures published are limited costing, which are subject to so much qualification, approximation and "guess estimation" as to be virtually valueless for this purpose.

The capital needs of hospitals are well known. Great enthusiasm all over the country is devoted to the planning of new hospitals and new departments. It is the deferment of plans because of shortage of funds and rising costs that tends to engender disillusionment and a feeling that one's work is no more than "paper planning". Along with progress in hospital building and reconstruction, it is, in my view, absolutely essential that funds for maintenance, minor works, and current expenditure are increased so as to keep older hospitals up to date and viable. Hospital management committees have found that when financial pressure is greatest the only practicable way of restricting expenditure is to cut back on maintenance and the purchase of equipment. This has happened so constantly that deterioration of buildings has become marked.

My own particular nightmares are outbreaks of dry rot—the reason for which, I am always informed, is that there have been insufficient moneys made available for adequate maintenance. We all acknowledge the common sense of planned maintenance, but the other needs of the Service are so great that the maintenance done is not so much planned as forced upon us, when something has broken down or is threatening to do so. There is a story, apocryphal no doubt, of a matron of an old hospital, one of whose ward sisters reported to her an outbreak of fire in the ward and asked her what she should do. The matron, desperate for a new building, replied "Fan it, Sister, fan it!" This slanderous story serves to mirror the feelings of a great many people who are striving to do modern hospital work in ancient surroundings. I grant at once that the problems of the Hospital Service cannot be solved overnight—nor are more staffs the only requisites. I believe, for instance, that we need also to deploy our existing trained staffs better throughout the Hospital Service, and in at any rate some hospitals to make better planned use of their scarce skills. And, incidentally, that last applies, in my view, to nurses, too.

The Minister of Health, when he was not in office, made his view very clear that more money ought to be provided for the ordinary running expenditure of the hospitals. This is obviously very relevant to the development of these ancillary services which we are debating today. The Hospital Service has grown and developed out of all recognition over the last sixteen years. Those of us who were working in it just after 1945 can remember how we struggled with a myriad of inadequacies. The Service as we know it to-day is exciting and inspiring. I would pay my tribute, with the noble Lord, Lord Auckland, to those doctors, nurses and other ancillary services who are helping to make it the Service it is; but much more has still to be done and it is sometimes difficult to remain patient.

In my maiden contribution to your Lordships' debates, I have been so anxious not to be controversial or provocative or to sin against the Standing Order relating to asperity of speech. I do not think it can be controversial if I conclude by saying how much we look forward to the realisation of many of the improvements in the Hospital Service which the present Minister also, when he was not in his present responsible position, said he hoped to see.

4.54 p.m.


My Lords, it is my privilege this afternoon, on behalf of all your Lordships, to congratulate the noble Lady, Baroness Brooke of Ystradfellte, on her maiden speech. I hope she will not be offended by my pronunciation, but as a Lowland Scot I could hardly be expected to do justice to her title. We have all enjoyed a speech of great lucidity and of great, solid content. We hope that we shall hear from the noble Baroness on many occasions in the future.

One thing which has been common to most of the speeches this afternoon has been a probing of the deficiencies of our Medical and Hospital Services. Another factor is that the common solution has been, generally speaking, more money. However, I was glad to find that at the end of her speech the noble Baroness paid tribute to the success of the Medical and Hospital Services and their improvement over the period since 1948. Although I, too, am going to draw attention to what I regard as a deficiency, I would preface my remarks by saying that we should all pay a tribute to the great work done by the Medical and Hospital Services. In drawing attention to deficiencies, we are doing so, I hope, in a helpful rather than a destructive manner.

I will not detain your Lordships for very long because I want to draw attention to only one point with regard to the mental health services—and even that point is only within a rather specific and narrow aspect of the very wide field of the mental health services. I believe that in raising this point I may be pushing at an open door: at least, at a door soon to be opened. I believe that for two reasons. One is that we have a Minister of Health who has in the past shown deep and profound interest in the development of the mental health services. Another reason is that Her Majesty's Government have, in the Queen's speech, pledged themselves to the modernisation of the Hospital, Health and Welfare Services. I am also encouraged by the fact that my noble friend Lord Taylor, who is to reply, is himself particularly interested in the psychiatric services.

The matter to which I wish to draw attention is, again, one of shortage in a particular category—namely, the shortage of psychiatric social workers, and particularly that which exists in the psychiatric hospitals. It is true that over the last two or three years the number of psychiatric social workers in all services has increased from 1962 to 1964 by a total of 123; but this increase has mainly been in child guidance and associated children's services, local authority mental health services, teaching posts and other social-work posts. Naturally, one does not begrudge these services the increased staff, insufficient though they be, which they have had. But one has to look at the other side, and that is the extent to which the psychiatric hospitals have fared in this connection. In fact, they have fared very badly indeed. The number of psychiatric workers in the psychiatric hospitals increased by only two from 1962 to 1963, and by only six in 1964. The significance of these minute figures will be appreciated when I say that 133 hospital posts for psychiatric social workers were advertised in 1964, and only six appointments were made—only six out of 133 vacancies were filled.

The reasons for this shortfall would appear to be twofold. One is the very familiar one to which I have already referred, and it has been referred to in connection with every other deficiency of staff: an inadequate salary scale. I am not going into that in detail, but it is interesting in passing to notice—I do not know why it should be—that the local authority salary scale is higher than the hospital scale in this particular regard. I recognise that the Ministry of Health Inquiry into the salary structure of the medical and psychiatric social workers has recently been set up. I hope that its Report may be helpful in this field, and I also hope that its Report will not be too long withheld.

But there is another reason for the shortfall. That, in my opinion, is the problem of training, which raises the question of the grants to the universities for the training of psychiatric social workers. I understand—I find it difficult to know what lies behind it—that the Minister of Health is not empowered to make grants towards university costs for the training of psychiatric social workers. On the other hand, the Home Office is able to contribute to university costs in training child-care and probation officers. Industry and commerce, as we all know, offer financial help to the universities for the training of people from whom industry and commerce believe they will get some advantage when that training has been completed.

I do not know why the Ministry of Health should not have similar powers to those of the Home Office, to make grants to universities to get the training in the fields where they require trained recruits. I suggest that the Ministry should be put in the same position as the Home Office, and should be able to make such grants to the universities as are needed to provide training for the requisite number of psychiatric social workers. One university, I am told, has available places for field work training and is unable to get the students because of the lack of financial support. We certainly need an increase in the number of university training places for medical and psychiatric social workers, and I hope that a sympathetic Ministry will make that possible in the not too distant future.

5.3 p.m.


My Lords, in addressing your Lordships' House for the first time, I have to confess that I find myself pack in somewhat familiar surroundings, on recalling the years after the war when it was occupied by the other place. In those days the Bar stood at the opposite end and my first impression was that this House was sitting the wrong way round—an impression doubtless shared by many noble Lords opposite. However, I am now beginning to feel that this House is indeed sitting the right way round, and that a wider acceptance of this view may gradually develop with the passage of time.

I am sure that many of us are deeply grateful to the noble Lord, Lord Auckland, for having raised the subject of the Hospital and Medical Services at the present time. I have to thank him also for the felicitous remarks he made with reference to colleagues who are speaking for the first time; in my own case, if I may say so, somewhat over-felicitous remarks. I hope the noble Lord will forgive me if I confine my remarks to what I consider by far the most crucial issue facing the National Health Service—namely, the profound malaise now prevailing over the whole field of general practice to-day. The term "malaise" is a gross understatement, because at no time since the inception of the National Health Service Act in 1948 has the feeling of frustration, bitterness and disillusionment been so widespread among general practitioners as it is to-day.

I am quite convinced that no amount of increased remuneration, of better conditions of service, of further recruitment of doctors, of provision of locums and after-hours services, of postgraduate courses, of merit awards and bonuses, of rotas and abolition of pools, can wholly eradicate this feeling of bitterness and frustration, for its actual causes go much deeper than all these. They have arisen, in my opinion, from the totally false relationship that has developed between doctors in the National Health Service and a very small minority of their patients.

In the olden days before the Act of 1948, the patient would come to consult her doctor armed with a list of symptoms, the classical femme à petits papiers. Today that list has been replaced by a list of drugs, now offered, and rightly so in the case of a person who is genuinely ill, without any charge or payment whatever. But the essence of a list of symptoms was this: the experienced doctor could assess them in their order of importance, and, by concentrating his treatment on one or two of the major symptoms, could hope to eliminate most, if not all of the rest.

But woe betide the general practitioner who refuses to prescribe more than one or two of the list of drugs demanded! For him another list is directly involved; his own Capitation List on which he depends for his livelihood. No doctor can work at his best under such a relationship. It is almost as bad as the instance of the general practitioner setting out on his round of visits, who was stopped by a patient with the request: "Doctor, can you give me a certificate of incapacity for work, to enable me to go down to Cardiff to watch the Welsh Rugby International? If you do not, then Dr. B. round the corner will, and I and the whole of my family will transfer to his list." This doctor, to his credit, refused and the threatened transfer duly took place. This is admittedly a very rare and extreme case, but a single experience like this can rankle in a doctor's mind for days and months afterwards. It makes him wonder what on earth he is doing in general practice at all, and why all his years of scientific study and high endeavour should have reduced him to this low level.

That such a state of affairs can be allowed to exist is, to my mind, an indictment of the whole present-day relationship between a doctor and his patients. But now that all charges on prescriptions have been removed, there may well be some reduction in the actual quantities of drugs prescribed. The number of items may, indeed, show an increase, but the decision reached two days ago enabling the Ministry to purchase drugs abroad should effect a substantial economy. Some watch should, nevertheless, be exercised, so that the overall drug bill does not show too steep a rise. But so long as the existing capitation system of payment prevails, doctors may have difficulty in resisting the demands of a small minority of their patients.

I believe that, given time and restraint, the situation will adjust itself. But the whole position will need to be assessed in the light of experience, and it is hoped that interim statistics will be presented periodically to this House. Certainly, an increase in the issue of drugs can hardly be justified in the absence of an increase in illness, and the whole question of the repeated issue of household remedies, such as those issued in the absence of illness or in self-medication, may have to be reviewed.

The principle of free medicine to those who are genuinely ill is so right and just that it would indeed be a pity if it were jeopardised by the demands of a small, importunate minority. The highly-experienced prescribing section of the Ministry of Health will now be faced with a new situation, which I am sure they will be able to resolve with success and distinction. Time and again doctors have pleaded for the abolition of the pool; yet it survives to-day, more complicated, more illogical, more inimical to the best interests of medical practice than ever before. No profound grasp of the intricacies of higher mathematics is required to convince anyone that, whoever else may have won on the pools, the really good doctor and the really sick patient have been definitely the losers.

Those of us who are able to rejoice in our own family/doctor relationship (and a perfect example of this has been brought home to us during these last agonising days) can realise how futile it is to assess such a profoundly human relationship in terms comparable with the output of machine tools or a 4 per cent. rise in productivity. I have never been able to understand why the present system of capitation fees must be regarded as sacrosanct. If any such suggestion were made for the remuneration of specialists, it would at once be laughed out of court. So would the same suggestion if made to dentists, or to medical officers of the Armed Forces, of the Ministry of Health, or of the Public Health Service or the School Medical Service. Why, then, have general practitioners alone been singled out for this shabby treatment? It is all very well now to fling it back in their faces, and say that this method was chosen, in all good faith, some sixteen years ago by the vast majority of the doctors themselves. But the fact is that it has since been falsified in the light of experience. So that to-day a good doctor, who desires to maintain his highest standards of medical practice, fines himself compelled to limit the size of his capitation list; and in this aim he has consistently received the benediction of the Ministry of Health.

There are so many alternative methods of remuneration to be considered, which could go far to relieve the present malaise in medicine, and to raise the status of the general practitioner: not only payment by salary, but also payment by sessions, or by items of service, or by a combination of these. Could not some small pilot schemes be tried out in different parts of the country, where they are approved by a majority of the local doctors, and where local conditions of practice may lend themselves easily to such tests? Or could not even an individual doctor be allowed to opt for some alternative method of remuneration, say for a period of two or three years, in order to test its effect on his own doctor/patient relationship? Such practical tests, to my mind, would be worth more than a cartload of questionnaires.

Many of us are instinctively averse to any form of amending legislation. But where the National Health Service may have gone wrong—and no service is perfect—as, for example, in the captitation system or the pool; or in the many difficulties that still beset a young doctor, despite the initial practice allowance; or in the plight of an ageing practitioner; or in the relative immobility of an established doctor, who has long become stale in his surroundings, then it is wise to go back to first principles, and to consider some alternative to existing legislation. Especially just now, when the present Government are trying to lead the country into a radical re-thinking of the whole of our defence problems, and into a re-thinking of the whole basis of our industrial relationships, has not the time also come for a re-thinking of the whole present relationship of the general practitioner towards his patients?

My noble friend Lord Taylor has often taken a distinguished part in previous medical debates in this House, and no one is better fitted than he to reply on behalf of the Government. The fact that we now have an entirely new team to speak in both Houses for the Ministry of Health is the one gleam of hope in an otherwise sombre outlook. They are also served by as loyal and conscientious a body of civil servants as any Minister would wish for. But there is a real danger that the Bruce-Fraser Working Party may resolve itself into a reporting party, and fail to give our general practitioners the lead that has now become so desperately urgent.

I would also venture to remind my noble friend that the medical profession, probably the second oldest profession in the world (it has, I may say, nothing in common with the oldest), does not take kindly to legislation: it is too steeped in tradition, and rightly glories in its individualism. It knows that the impact of a doctor's personality is often worth more than a shelf-load of medical text-books, as many a patient, saturated with antibiotics, has found out, to his cost. It knows, too, that a doctor's personality can often impress itself far more effectively in the privacy of his own surgery, or in his own home, than it can in a hospital or a health centre, or even in a group surgery. For too many doctors, on the other hand, the lock-up surgery is partly a form of escapism.

Small wonder that general practitioners to-day are apt to mourn with the poet: The capitation system is too much with us, late and soon, Gaining or losing, we lay waste our powers, Little we see in the National Health Service that is ours, We have eaten our hearts away for a sordid pool". So I would plead with my noble friend who is to reply to avoid the grafting of new legislation upon existing legislation, to try to ease the burden of blue prints and blue books and blue prospects, and to give the general practitioner a little more freedom to call his soul his own.

My Lords, I know only too well that my noble friend cannot reply to this debate as fully as he himself would wish, and I would not press him for an immediate answer. We can only hope that his remarks, in replying to this debate, will be followed by speedy and effective action, so that the high hopes of so many anxious sections of the community now, at long last, centred on our new Ministers, may be a little further on the road towards fulfilment.

5.20 p.m.


I am privileged to congratulate the noble Lord, Lord Segal, on his excellent maiden speech. His great experience of medical administration will be of the utmost value in your Lordships' future deliberations and we look forward eagerly to further wise contributions from him. We must be most grateful to the noble Lord, Lord Auckland, for ventilating this subject, about which I, as a member of the Hospital Service, feel perhaps more Wrongly than some of your Lordships who may not be so conscious of the accumulating difficulties. It is a disappointing commentary on the evolution of the Hospital Service that each time, except once, that I have addressed your Lordships the theme has been the same. I do not wholly exaggerate when I say that my thesaurus is liable to fall open at a now rather grubby page and at paragraph 53. This paragraph is headed "Incompleteness" but it encompasses also other similar abstractions. It is the one that I have consulted time and again in search of synonyms for "shortage".

The theme of to-day's debate is regrettably familiar. There is no doubt at all at the present time that the Hospital Service is living on borrowed time, and that the increasing shortage of members of professions supplementary to medicine will, if not remedied, bring the Service down. As your Lordships have heard, the remedy lies almost solely in improving pay, conditions and prospects in these professions. There is a ghastly snowball of difficulties. For example, the establishment of physiotherapists in my hospital area is 30; the average number in post during last year was 21, and the lowest number, during school holidays when a number of part-time physiotherapists had unpaid leave, was 16. The overwork required of those in post is such that a physiotherapist must be particularly dedicated otherwise she will feel it more sensible to take herself and her skills elsewhere. The other day a girl trained in our physiotherapy department in Reading, and having only three years' experience, was eagerly snapped up by Nuffield Motors. She was to be paid slightly more than the superintendent physiotherapist who had largely trained her—and this without emergency duty, with better holidays and a better pension scheme. The Hospital Service cannot compete with this sort of thing.

When considering the shortage of radiographers we find that the factor that most influences this is, again, salary in comparison with salaries in commerce. A senior radiographer can double his pay by becoming a representative of a firm selling X-ray material. The shortage of radiographers, as much as increasing the work demands on X-ray Departments, is responsible for the often deplorable delays in arranging examinations which might provide diagnoses: life-saving if correct; tragic if correct but too late. It must be a prime consideration of the Hospital Service that needless death and suffering must not be laid at its doors. The shortage of radiographers must, therefore, be remedied. Countless women die every year from cancer of the uterine cervix. None need do so if sufficient facilities are provided for the necessary screening techniques. The shortage of laboratory technicians, which is in the main responsible for this squandering of lives, must be remedied.

I will not weary your Lordships with a great list of similar deprivations which the public, in their ignorance, accept; but examples are the difficulties in the fields of open heart surgery and artificial kidney work. We have the requisite skills; we have, indeed, pioneered large fields. But in many areas lack of trained technicians has gravely curtailed this work.

Now, my Lords, I wish to speak quite briefly about a ludicrous situation which now exists in the Hospital Service—I refer to the shortage of pharmacists. I say "ludicrous", because, whereas other staff shortages to which I have referred disastrously prejudice patient care, this shortage not only does that but also levies a considerable charge on the Hospital Service for the privilege of doing so. I will explain. Because of this shortage (I shall refer to some of the reasons, but they will be only too familiar against the background of the Hospital Service) it has followed that all over the country many hospital pharmacists have been compelled to discontinue prescribing to outpatients. We, the staff, have, therefore, been obliged to prescribe on the same form as the family doctor, the so-called E.C.10. The patient then, often at personal inconvenience, repairs to a retail chemist where the drugs are dispensed. It has been estimated that the Ministry of Health pays some £450, 000 a year more for prescriptions dispensed on E.C.10 than if they were dispensed by a hospital pharmacy. The absurdity is that the cost of meeting the last Whitley Council salary claim (which was unsuccessful in the Industrial Court) would not have exceeded £400, 000. If that claim had been met, there is every reason to suppose that, at least for a time, the shortage of hospital pharmacists would have been relieved.

It is, to me, and doubtless will be to your Lordships, a daunting thought that one chest clinic in the Oxford Region has reported that drugs which would have cost £2, 200 if supplied from the hospital had been re-costed, having come from a retail chemist, at £9, 750. I think that even the most philanthropic commercial concern would justly be regarded by their accountants as spendthrift if they went on in this way. There are a number of reasons for this inflated cost, but part is clearly due to the fact that the retail chemist is unable to take advantage of the Ministry of Health's central contracts for the supply of cheaper but equally effective drugs. Monday's Judicial decision in your Lordships' House in the matter of these drugs simply enhances the importance of these contracts. There are also the factors of bulk buying and Regional Hospital Board contracts which keep prices down for the Hospital Service.

But, my Lords, aside altogether from this frightful and, I believe, needless waste of money there is a more important element—danger—involved in this situation. I shall attempt to explain this in a moment or two. All pharmacists, hospital, retail or industrial, are members of an honourable and learned profession in its own right and, as such, are not included on the Register of Professions Supplementary to Medicine. G.C.E. "A" levels in physics, chemistry and biology or mathematics are minimum requirements. The minimum period of training is three years at a university, or at an approved school of pharmacy, with a further pre-registration year getting practical experience. But within the profession we can clearly discern exactly the same competing factors that have been described in your Lordships' House to-day in regard to physiotherapists, laboratory technicians, radiographers and others.

The issue facing a qualified pharmacist is materially straightforward. He can enter retail pharmacy, where his minimum pay on entry will be £1, 200, or he can enter the hospital pharmacy service, where his maximum on entry will be just over £1, 000. If our young retail pharmacist succeeds, and in due course becomes a departmental manager, he will Probably earn £1, 700 a year and will be Provided with free accommodation. A hospital chief pharmacist will earn no more than £1, 600, without accommodation, and may, as in our case in Reading, be responsible for an annual budget exceeding £100, 000.

It is true, of course, that money is not the only motivator, nor free accommodation a decisive factor. Hospital pharmacists regard themselves, as it were, as consultants in pharmacy. They devote themselves entirely to the sciences of pharmacy and to the application of pharmacy to medical advance, and they work as part of the hospital team. This no doubt is satisfying. A pharmacist in private practice or in commerce, however, should not be regarded as an inferior being, but his development is in the business world and he is obliged to devote a great deal of his time and energy to this world, as distinct from his profession.

It may be possible that some of your Lordships regard a pharmacist working in a hospital or in a shop as substantially the same creature, each faithfully, but pedestrianly, dispensing the drugs prescribed by the doctors. Nothing could be more incorrect. With the progressive complexity of drug therapy, the hospital pharmacist is increasingly required to act as an adviser to the medical staff on drug doses, drug incompatibilities, and the problems, unhappily more frequent recently, of dangerous drug side effects. The whole field of drug therapy is his—not in most cases as an initiator, but as a monitor of knowledge. He is an absolutely indispensable part of the Hospital Service. We must see to it that his special skills are not dispersed by dissatisfaction. The Hospital Service will founder unless it is appreciated how essential all these diversely skilled people who have been discussed to-day are to that Service and unless a more enlightened attitude to their Service conditions prevails.

5.35 p.m.


My Lords, I am young in the service of your Lordships' House and therefore I plead for the consideration which your Lordships always are willing to accord to the novice. May I say how deeply grateful I am to the noble Lord, Lord Auckland, for the gracious personal reference which he made in the preface to his speech?

I wish to introduce into this debate a word which we try to avoid using in our personal conversations with our families and friends. We coin all kinds of euphemisms to describe it. We skate around it as often as we can, as delicately as we can. That word is "cancer". I spent 40 years of my working life engaged in the production of newspapers. Please do not think too harshly of me for that. One of the things I always used to advise, as the news editor of one of the great morning national newspapers and then as assistant editor of that paper, was that writers and reporters should always get the main point of their story into the first paragraph. I shall try to get as near to that as I can this afternoon.

I have it in mind to try to make two points. The first is that although grants are made by the Medical Research Council in aid of cancer research and development, a very great deal of that work relies upon the generous-hearted donations of philanthropic citizens. Therefore it might well be that this work is not so co-ordinated and so comprehensive as it might be. It might well be that only too often the researchers have to cut their coats according to their cloth.

The second point I wish to make, arising from that, is this. Can we not, through the National Health Service or through some similar official channel, provide systematic and substantial aid to enable us to go forward progressively in expanding this research? Personally, I should like to see £10 million set aside for this purpose. That money, I feel, should be used both for research and for treatment. In connection with research, by expanding and co-ordinating all the work of the surgeons, physicians, hospitals, radiographers, bio-chemists, and even nuclear physicists. And also in assisting with the money they urgently need many of those worthy voluntary organisations that exist to assist with cancer research activities. I would particularly urge that money should be devoted to the training of still more researchers, still more postgraduate students, because not only is there a shortage of these people at the moment but there will be an even greater shortage in the generation to come unless we tackle this problem now.

In the field of treatment I would suggest that we should supply more widely to the hospitals the newest ultra-revolutionary electrically-based machines which have been proved to be adequate for the treatment of certain kinds of cancer. They are now very sparsely distributed among the hospitals of this land, and then very often because of the result of private charitable effort. I should like to see a national "blitz" on cancer with no cost spared.

I am not going to concern myself especially with that particular kind of cancer which has received an enormous amount of publicity recently—that is to say, cancer of the lung. This is a very special problem, but I do not want the consideration of it to overshadow the general problem, nor do I wish to enter into the controversy as to whether lung cancer is contributed to in any respect by smoking, particularly by cigarette smoking. I would say, incidentally, that it is quite easy to give up smoking if only the effort is made. When I was 25 I said to myself one afternoon, when I was going to work: "Give up smoking for the next 25 years." The anti-litter laws were not then so stringent as they are to-day, and I threw my cigarette packet in the gutter: and that was that! It is true that when I became 50 I kept the other part of the bargain and started to smoke again. This time it was a pipe. But after a few years I gave that up as well. As I say, if the effort is made, it is not impossible to give up smoking.

There is no doubt whatever that cancet is on the increase. I am not going to weary your Lordships with statistics: they mount up to a terrifying total of 100, 000 deaths a year and incalculable human suffering. I am going to say that when we look at the statistical picture of this disease it may not be quite fair to compare today's statistics with those of a decade or so ago. It may be that in our more cancer-conscious days our registration and our diagnosis is more accurate than it used to be. It may well be that cases which were diagnosed as being due to bronchitis and other diseases ten, twenty or thirty years ago were probably due to cancer. But when all these modifications and qualifications in the statistical picture have been made, it is undoubtedly a fact that cancer is becoming more and more of a murderer in our modern society.

We can all recall many friends whom we have "known long since and lost awhile". I myself can count up a dozen of my intimate friends who have been killed by this disease during the last few years. There was a jovial old farmer in the Essex village where I lived who went into hospital. The surgeon made an exploratory incision. The old gentleman, when he came out of hospital, thought that everything had been removed. But there was practically nothing that could be done. There was another farmer—and I mention farmers because they live an open air life and engage in healthy exercise every day—a member of the county council over which I had the honour to preside, who went in the same way. There was another member of the county council, one of the most conscientious in the performance of his duties, who suddenly began to miss our meetings. Within a few weeks he had gone as well.

The chairman of the urban district council to which I used to belong also disappeared after three or four weeks in hospital. In the newspaper office where I used to work, four of my former colleagues have died from this disease in the last few years. Then there was one of my neighbours, a non-smoker for the whole of his life and an enthusiastic walker in the open air, whom I used to meet striding through Epping Forest whenever I went there, who died not long ago from lung cancer. Then there was the beloved old rector of my Essex village. He, with great fortitude, kept the secret from us all, but he, too, was taken from us.

There was one more case which hit my heart the hardest of all, a worthy artisan, a member of my county council and a close comrade in political work. He told us that he had to go into hospital for a gallstone operation. He went in and had the operation. His wife, incidentally, had told some of us it was cancer. He came out and he thought he was cured. We gave him sympathetically some electoral work to do to keep his mind active; but within three months we had to say goodbye to him. I do not want to weary your Lordships with any more of these personal recollections, and I have given these few examples to show that this is a very personal and not merely an abstract problem.

While I do not want to say anything more about that, I must praise all those surgeons, physicians, radiologists, biochemists and others who are in the front line of this great fight, and along with them the many voluntary organisations, whom I do not in any way wish to displace and whose work I trust will expand rather than contract. But the magnitude of this menace is such that we cannot leave it partly to voluntary organisations and partly to donations and grants on occasion from the Medical Research Council. I think we have to mobilise the whole resources of this very wealthy State to take a more active part in the direction of this fight. The money required would be merely a drop in the ocean compared with the amount we spend each year, and rightly spend each year, on national defence. I want to repeat that I do not belittle in any way all the voluntary effort that goes into this very worthy work; but it simply is not enough.

I want to take a look at the position of some of these voluntary societies, and I would crave your Lordships' permission to quote from their recent annual reports. There is the Institute of Cancer Research. They complain that the completion of the Royal Marsden Hospital, Surrey Branch was being postponed until 1972. They called this "a great disappointment", first because of its effect on the treatment of patients by radiotherapy, and secondly, because of its effect on research. I do not know whether that postponement has been reconsidered; but even if it has, the making of one decision and then its reversal by another decision does not provide a very good foundation on which to build an ordered, progressive programme of research. The Institute had a deficit of £23, 000 on the year, but they said that the financial position would worsen yearly until 1967, and that unless the Medical Research Council could give help they would have to draw on a fund that they were keeping in reserve for major capital expenditure and for the financing of postgraduate scholarships. This is a very shaky kind of foundation upon which to construct any kind of systematic programme.

Then there is the British Empire Cancer Campaign for Research. During the year their expenditure exceeded their income by £78, 000. They made what appeared to me to be a very sensible point. They said that any unhappy influence, economic or otherwise—and we can all visualise such possibilities—might affect the inflow of funds and thus possibly jeopardise the research programme. I suggest that this again is not a satisfactory basis on which this work should be founded.

Then there is the Imperial Cancer Research Fund. Their complaint was quite a different one. They said: Until we have additional and more regularised clinical co-operation the progress of several of our projects will be seriously retarded. We will not be making full use of the unrivalled laboratory facilities which we have. That, again, is not exactly a happy kind of situation.

I want to say a word or two about one form of cancer treatment, and it is the form which is based upon electrical energy. We read a few days ago that the Churchill Hospital in Oxford had installed what was said to be the most modern cancer treating machine that had ever been devised—a 35 million volt linear accelerator. The announcement said that this had been installed by the Minister of Health. In my political youth I never dreamed that I should stand up in any public place and pronounce a benediction on any Minister of any Party, but I certainly do in respect of that. The distinction between this particular type of machine and the ordinary X-ray apparatus is one that has been explained to me as a layman and which I think I can comprehend. It is that the rays are shot on to the malignant cells which are the target and do not proceed past that target and damage the tissue beyond. That sounds to me to be a development well worthy of encouragement. If that is the case, if the potentialities of this machine are of the nature which I have indicated, then why can we not supply it to more and more central hospitals here and there throughout the land out of this £10 million which I have suggested might be devoted for this kind of purpose?

A week or so ago the editor of the People newspaper announced the distribution of the charitable fund which he raised in response to a Christmas appeal. He said he was giving £4, 000 to the Guildford Ray Therapy Centre towards the cost of a betatron which they had purchased. This betatron is a somewhat similar machine to the one I mentioned in the case of the Churchill Hospital. The Churchill Hospital machine is a British machine. The editor went on to say that this was costing the Guildford Centre £150, 000, the whole of which had to be raised by public appeal. Again, I repeat what I said in the other case. If these machines are effective, if they are capable of bringing relief to suffering people, can we not use some public funds—that £10 million which I have mentioned—to see that this kind of machine is located at convenient spots throughout the length and breadth of the country?

There is one thing more that I must mention and that is the question of early diagnosis. The noble Viscount, Lord Waverley, who preceded me, touched on this matter. The fear and dread of cancer of the cervix is something which hangs over the head of every woman. There is at this moment a campaign on foot for the provision of routine testing facilities. It will be known to your Lordships that a simple smear testing system has been devised, and that the Minister has given this system his blessing. But last year the Minister explained that there would be considerable delay in training the laboratory staff who would be necessary if this smear system was to be adopted generally. And he also said: There would be considerable delay in the establishment of any routine form of testing. The Ministry have said that they will provide the money to train the laboratory assistants. I plead with my noble friend to try to persuade the Ministry to expedite this work, because so much depends upon it.

The Report of the Central Health Services Council for 1963 rather tends to dilute the pleasure which I find in that announcement that the smear campaign could be carried on, because that Report says: The adoption of general population screening would have significant effects upon the hospital services. Finance might have to be allocated to this work at: the expense of other developments. I am a financial realist—Goodness knows! I have to be—but I do not see why it should necessarily be that, if finance is devoted to this worthy work, which is blessed by the Minister of Health, it calls for financial cuts in other branches of the Hospital Service.

Then there is a second example from that same Report of the Central Health Services Council. It says: Beds and theatre time would need to be allocated to accommodate patients admitted as a result of the tests. In other words, we know there is something wrong with them; we know they want treatment, but we cannot give it to them yet. So they may get worse, and ultimately they might have to stop in hospital for months instead of merely for weeks. I hope my noble friend will pay some attention to this matter as well. I know there is a shortage of hospitals. I know that hospitals and staffs cannot be produced merely by the waving of a wand, but in this matter of testing for cancer of the cervix could not clinics be established in a centralised hospital in each area, so that the facilities for the time being might match the needs? I am quite sure that that should not be beyond the possibility of execution, and I hope that some consideration will be given to it.

There were two more passages in Central Health Services Council Reports which seemed to me to be rather disappointing. The first was in the 1962 Report, and it was this: Standing Advisory Committee on Cancer and Radiotherapy. This Committee was not called upon to meet in 1962. The corresponding Report for 1963 said: The Committee was not called upon to meet during 1963. I know that committees do not mean everything. I am not so naive as to think that even if a committee does meet it necessarily does some work. But when we view this as part of the general picture, may it not indicate that perhaps some overall co-ordination is needed by some kind of Cancer General Staff?

One more point concerns industrial cancer. I know that my noble friend Lord Taylor has perhaps devoted more attention to the industrial health service than almost anybody else in this country. Many preventive measures have been taken during recent years which have curbed the spread of many industrial cancers—mule spinners cancer; cancer associated with the tar and pitch industries; cancer associated with some branches of the rubber industry. But all the time new industries are growing up, and new industrial processes are being devised, and many of these are extremely dangerous. Only last week we had the case of a cable factory in the East End of London where four men are said to have died from cancer, said to have been induced by the use of some chemical at that factory. I will say no more about that, because obviously some detailed examination of the evidence in that case is needed. I shall regard it as being sub judice for the moment Although we can register progress in the realm of industrial cancer, at the same time we must not allow that progress to breed complacency.

This is not a national problem; it is a world problem. The best brains of every civilised country in the world are engaged upon it, and they arrange for interchanges of their discoveries and their information. We do not know where the breakthrough is going to come. We have to search for the fundamental cause and, at the same time, have to expand the use of such ameliorative treatments as are already available to us now. It may come through improvements in surgery, by earlier diagnosis, by the use of these electrical instruments, by the study of hormones, and perhaps even through developments in connection with drugs which may provide a cure, or may provide immunisation, but in respect of which enormous research in many pans of the world has not yet really led to any substantial results.

Perhaps the breakthrough will come accidentally—such scientific discoveries often have. We all remember Newton's apple and James Watt's kettle. But do not let us have to cut our coats according to the cloth that happens to be available. The prize is enormous and I think we should spare no effort, withhold no money, that might take us a step along the road. I think we should invest our money and our effort on a grander and more imaginative scale than we have ever done before. And if, through applying our minds to this subject, we can convince ourselves that this is the right thing to do, and then if we do it, I think that in the coming years millions of men and women will bless this House.

6.01 p.m.


My Lords, I have the pleasure of following two of my noble friends who have made their maiden speeches this afternoon, and I should like to congratulate them both. First there is my noble friend Lord Segal, who was a colleague of mine in the other place and who, of course is very near and dear to me because we are both members of the same profession. I want to congratulate him, as I have congratulated him years before this, on an excellent exposition of a medical subject. Indeed, in the way in which I propose to follow him one would have thought that we had consulted together before this debate; but, as my noble friend knows, we have not discussed the matter at all. Nevertheless, if I may, I shall dot his "i's" and cross his "t's".

I also follow my noble friend Lord Leatherland, whom I had the honour of sponsoring. Many of us have for years watched his wonderful work on the Essex County Council, and as we sat and listened to him to-day we were reminded of his humanity, of his application of science to the needs of the ordinary human being I hope very much that on other occasions when we have health debates we shall have equally good contributions from both my noble friends.

I am very sorry that on the other side of the House the noble Baroness, Lady Brooke of Ystradfellte, is not in the Chamber at the moment. I just missed the beginning of her speech, but I understand that she reminded the House that I muttered to somebody when she came here that this was a "job for the girls" at last. In a House of this kind it is rather refreshing to see another woman's face, and any noble Lord who heard her this afternoon will realise that we have added to the House a woman of experience, knowledge, and, if I may say so to my noble friend in front of me, one obviously coming from the Principality—because that is why she had such facility of language. I hope, therefore, that we shall hear her again.

Many of us here have taken part in similar debates before, and we must thank the noble Lord, Lord Auckland, for putting this Motion on the Order Paper in order to give us another opportunity to speak on the various aspects of the National Health Service. He said, I think quite wisely, in his opening remarks that he had No 1ntention of adopting a political attitude. I will say quite gently to him that it would be a little difficult to charge the new Government with not having remedied all the omissions in the Health Service which we inherited. If evidence of this is wanted, one has only to read almost any newspaper any day to find articles and letters from doctors stating their long-standing grievances, which have culminated in a sense of frustration.

Now, of course, the situation has reached a climax: with 400 general practitioners emigrating every year. We are, in fact, as I have said before, in the most curious position of finding doctors who qualify here emigrating to other countries, while we are introducing into our hospitals and general practice doctors from Commonwealth countries, some of whom, of course, take a little time to grasp our language in order to be able to communicate quite freely with the patient. Indeed, the position is so bad that one of the doctors' organisations is contemplating strike action; and even the ultra temperate British Medical Association, which has dragged its feet for far too long, is writing letters of protest to The Times. This is indeed revolutionary in the field of medicine.

It takes years of neglect and incompetence in high places to create this situation. A recent cartoon well illustrated the position, with a sketch of a bent, over-burdened general practitioner and a youth entering a medical school. The youth was calling out: "Don't give up, Doc; I'll be out in eight years". The fact is, my Lords, that owing to the failure to meet the demand of potential medical students we cannot hope for any improvement in the doctor—population ratio before the 1970s. We have had Committees on the subject. The doctors have waited patiently. The latest Committees, the Porritt Committee and the Gillie Committee, have examined the grievances of the family doctors—grievances other than those concerning remuneration—and have made it clear to the Government of the day that these grievances were well founded. However, it was deemed necessary to set up a Working Party, under Sir Bruce Fraser; and again the exasperated doctors have been asked, collectively and individually, to submit their complaints. Nothing new has emerged, and my noble friend Lord Taylor, who is to reply to this debate, will know what I have in mind when I put to him certain things which I think might be done immediately. There was no need for me to warn him about them: he knows all about them, because he has read about all these various Committees year after year.

The fact is that the general practitioner has a responsibility for his patients for 24 hours a day throughout the year. Furthermore, he must provide a deputy for holidays, sickness and time off. In a community where the tendency is towards a shorter working week, these men and women, whose work involves physical and mental strain, are denied adequate leisure, and their sense of vocation is exploited. I emphasise that point, because there was a letter from a member of the Church in The Times the other day which charged the medical profession with being a little greedy. He said that they had a sense of vocation, and that they should remember that. We have heard about these girls in the various professions supplementary to medicine, to whom the same applies: their sense of vocation is being exploited, and it is for us here in Parliament to come forward and protect them. The general practitioners formed a rota system which was devised by doctors, on their own initiative, to give them some relief. But even this is now becoming more and more difficult to work, since the individual is so over-worked during his own day that he feels unable to offer his neighbour, when he is away, his time and his energies because it means double work.

May I put this point to my noble friend? In the hospital field, the Service provides adequate relief for its medical staff. Why cannot the same attitude be adopted for the general medical service? I suggest that the Executive Council, in close collaboration with the local medical committee, could operate a scheme whereby the family doctor is equally well cared for. Furthermore—and perhaps noble Lords are not aware of this point—the personal responsibility which a doctor carries for the acts and omissions of his deputy is undoubtedly a great hardship. When the doctor is away, even on his holiday, if by chance he has a locum who drinks, and he finds, on his return, that the locum has not fulfilled his duty properly, it is not the drinking locum who is held responsible, but the doctor who owns the practice and who has been away on his holiday. It has been strongly represented by the doctors that a qualified doctor in charge of another's practice should be required to accept full responsibility for his own actions.

The latest burden, I feel, that has been placed on the back of the doctor is to act as a tester, let me call it for pharmaceutical firms who are more concerned with making quick profits than with the safety of the public. Each week up to a hundred reports of adverse reactions to drugs are being received from doctors by the Ministry of Health Committee on the Safety of Drugs. The overworked general practitioner has been asked to report on the side effects of drugs which should surely have been adequately tested before their release to the public. The pharmaceutical firms who are using the public as guinea-pigs are ensuring that they are afforded some protection if there is another thalidomide scandal, by blaming the doctors for not reporting side effects. It seems that there is no control being exercised over this very powerful industry.

The profession are aware, of course, of the pressure tactics of the pharmaceutical commercial travellers who pester them endlessly, and they are advised by the Ministry of Health to use the equivalent of the national formulary for proprietary drugs. I know, and my noble friend knows, that in order to try to keep down the cost of the Health Service—and the average prescription now costs 9s.—we have regional medical officers who examine doctors' prescriptions, and if they find they have been over-prescribing the doctors concerned are warned. I should like to suggest to my noble friend that, as well as this warning, letters should be sent to doctors who consistently ignore the national formulary in favour of expensive proprietary drugs.

If any noble Lord here thinks that the picture which noble Lords are giving of the doctor's life is over-stated and the doctor is not suffering from overwork and inadequate leisure, he should examine the Registrar General's figures, which disclose that the highest rate of coronary thrombosis is found among doctors. We all know that the profession is now awaiting with impatience the report of the review body, and meanwhile, as my noble friend has said, it seems that there is no support for the pool system of assessing remuneration. May I put this question to my noble friend? If it is decided to continue the capitation system, why is no attempt made to estimate what would be the fair capitation fee for looking after one patient for one year? Under the pool system it works out at something like 18s. a year, but I am hoping, of course, that the pool system will end when we hear the announcement from the Minister. The capitation system was introduced in 1911 and one wonders whether the time has not arrived seriously to consider whether it has served its purpose.

While the older people in the profession, I know, do not favour a salaried service, nevertheless most young doctors regard it favourably. And again I was so pleased to hear what my noble friend said on the subject. Under a salaried service the doctor would be free to express his candid opinion of a malingerer or a compulsive drug taker and withhold unnecessary prescriptions. However, under the capitation system if the most honest man pursues this policy in his consulting room he may well jeopardise his whole livelihood. How can you expect an honest, idealistic young doctor with three children to bring up to say, "Now I will be so honest with my patients that they will walk out of the room and take their cards to another doctor", or indeed charge the doctor in the consulting room, which is not at all uncommon, and say, "If you are not going to give me this drug I will go elsewhere"? This surely is too much to expect from a young doctor. I think that a combination of the capitation system and a salaried service could be introduced immediately by paying a salary to part-time doctors practising from a health centre. This could well serve as a trial run for a salaried service, and of course if it proved unsatisfactory it could be dropped.

We have to-day heard so much about physiotherapists; we heard from the noble Viscount, Lord Waverley, with his great knowledge. All of us here applaud what he said and absolutely accept his attitude towards the question. Doctors, not only those in hospitals, but general practitioners all over the country, who deal with the problem of the aged persons living at the top of a building and wanting some help other than that of the doctor feel that if a physiotherapist could visit them it would help tremendously, and they are pressing for a domiciliary physiotherapy service. What hope is there of meeting their needs? There were 3, 907 physiotherapists practising in 1955, and 3,912 in 1962. This means an increase of five in seven years. What an appalling picture of stagnation! And yet these are auxiliary workers who would of course help the overpressed general practitioner. I am told that this situation is true by and large of each of the professions supplementary to medicine, and the shortage is primarily due to low rates of pay.

I feel we should be constructive. It seems to me that a Review Body similar to that of the medical profession should be set up and charged with responsibility to determine fairly the relation of one profession to another, and salaries which will attract both men and women. I see no reason why these other professional groups should not be treated in the same way as the medical profession when it comes to a question of assessing their remuneration.

Another constant source of irritation could be removed if the admission procedure at hospitals were improved. Unfortunately, hospital doctors always seem to be far removed from the general practitioner and they do not realise how precious the time of the general practitioner is, and if the admission procedure could be improved this would save the precious time of the general practitioner over emergency admissions.

I now come to the maternity services. I listened to my noble friend Lord Sorensen and I rather gathered from him that we should not have a sufficient number of beds until 1975. I may be wrong; I will read his speech again. Every noble Lord must know that the need for beds is very pressing. I have said this before and I must say it again: it seems to me as if we are living in an underdeveloped country when I read of women being discharged from hospital 24 hours after their confinement, as they are: in England to-day. Therefore the need for more maternity beds is one of the greatest urgency.

There is also a strong feeling that those doctors who elected to practise obstetrics should be provided with refresher courses at intervals of at least five years. Doctors complain of the shortage of midwives. Yet what can we expect when we consider the miserable conditions of service of these fine women? As I drive to the House every day I pass a woman in blue with her equipment, riding on a bicycle in the heart of London's traffic. She is one of our midwives, going to do work of paramount importance. I feel that this symbolises the attitude of authority towards the auxiliary workers in the National Health Service.

I want now to say something about certification. I have already said that the general practitioner's time is precious. I think the whole question of certification needs examining. If it is clear that a patient will be at home for more than a week, why cannot a doctor exercise his discretion and give a first certificate for a longer period? Why should he, or she, in this weather, being grossly overworked, be required to attend a patient weekly at home merely to issue a certificate, when no medical treatment is necessary? I have sought to make it clear that there are widespread grievances which need not wait upon the Report of the Review Body. I ask my noble friend, who has again escaped me—


He is not far away.


His ears are with me; that is the most important thing. I ask my noble friend to make a gesture of sympathy, because he has it in his power and he understands these things. If you understand these things you can take much more action than if you have to sit back and are told about them. I ask him to make a gesture of sympathy to the long-suffering family doctor, by expediting the means whereby these legitimate complaints can be dealt with.

6.23 p.m.


My Lords, I should like first of all to associate myself with the most sincere and well-deserved tributes that have been paid to our four maiden speakers to-day. My noble friend Lord Auckland listed them all at the beginning of the debate, and I think I can fairly say that the expectations that he raised then were well realised in the event. Speaking for these Benches, I hope that we shall have the pleasure of hearing all four of them again many times in your Lordships' House. I cannot remember an occasion in your Lordships' House when, in one debate, we have had four maiden speakers; so it may be that one record has been broken this afternoon.

I should also like to add my thanks to my noble friend Lord Auckland for initiating this debate to-day. I think it has been a valuable debate, and it has covered, as I felt it would, a wide field. Your Lordships may remember that the last full-scale debate in your Lordships' House in the previous Parliament was concerned with the Hospital and Medical Services. That was at the end of July, and many noble Lords who are now sitting on the Government Benches were at that time not slow in offering criticism of many aspects of the National Health Service and in urging prompt action in the implementation of their solution to the problems that they raised. I hope that I successfully defended my own Party's record on that occasion.

The priority to-day remains the same as it was then—namely, how best to serve the public for whom, in terms of human happiness and security, the National Health Service is perhaps the most important of all the public services. I think your Lordships will wish to hear this afternoon how the Government, after nearly four months in office, are approaching this part of their responsibilities. I quite agree that four months is not a long time, but I may say that so far I have not seen any great sign of action. The 100 days seems almost to have passed by the Ministry of Health; but, judging by its effect in some directions, perhaps that is just as well.

We have had one measure, the abolition of prescription charges, for which the Government can rightly claim to have a small mandate. It will certainly, as I said on the occasion of the announcement, and rightly so, benefit a number of people—the chronically sick, those on National Assistance, and war disablement pensioners. But I still feel that it would have been better to deal with these categories more selectively, and possibly to save the greater part of the £20 million-odd that total abolition will cost, for perhaps some of the more urgent needs of the Health Service which many noble Lords have raised this afternoon, for there are indeed—I think this is recognised on all sides of the House—many problems within the Health Service which are troubling your Lordships.

I should like briefly this evening again to refer to a few of them, in the hope of eliciting some information which I am quite certain that the noble Lord, Lord Taylor, with his usual kindness and courtesy, will do his best to provide. First—and this is something which has been raised many times—there is the really urgent problem of the remuneration of general practitioners and the general shortage of doctors. The noble Lord, Lord Segal, in his most interesting speech, I thought, gave the House a valuable analysis of the feeling among the profession. He suggested different types and systems of remuneration which might be adopted. I think we shall all be most interested to hear what the noble Lord, Lord Taylor, has to say about that.

I understand that the Report of the Review Body is now before the Prime Minister. I should like to know when a decision on it can be expected; and I would, along with other noble Lords, urge most strongly that it should not be too much delayed, for, like the noble Lord, Lord Segal, 1, as a layman, have been increasingly disturbed lately by the number of sensible, level-headed and dedicated doctors up and down the country who are obviously becoming increasingly alarmed and restive over this matter.

I do not myself think that at the moment the National Health Service, as I have seen suggested, is in any real danger. It would be a terrible tragedy, worth doing anything to prevent, if this were true. There is no doubt that morale among general practitioners is low and is getting lower, and a situation is obviously developing where every effort must be made to improve it, in the interests not only of the doctors but of the patients as well. I know full well what a complex, technical and difficult problem this is, and I hope that the noble Lord can assure us that it is being faced urgently.

I should like also to try to find out from the noble Lord how Her Majesty's Government are approaching the problem of the general shortage of doctors. Are they, for instance, going forward with the late Government's plan to increase the number of places in medical schools, and to build a new medical school at Nottingham? Or are they going to follow the proposal—made by the noble Lord, Lord Taylor, among others—for four new medical schools? And, if so, has it yet been possible to ascertain what the cost might be? Those are two points connected with the medical profession which I wanted to raise. In view of the time, I will not detain the House any longer on those points. There are, however, two other matters which I believe are causing increasing concern in the country.

The first—and I must apologise that this is some way away from the mainstream of the debate—is the question of ill-health among immigrants. I believe that there is a statistical Question on this point on the Order Paper for to-morrow, and I do not wish to go into that side of it. But we ought to be careful to make it clear that this is not basically a racial or even a colour problem. The British have always had a tradition of tolerance and neighbourliness towards immigrants. Yet we do like to be certain that they are healthy, and also that they can live in conditions where good hygiene; is possible. I think that somebody in Newcastle remarked, and very rightly, that it was less a problem of colour than of plumbing. But I was amazed to read that, according to one estimate, it costs the City of Birmingham authorities something in the region of £60, 000 a year to deal with T.B. among immigrants. Nationally, the figure must be very much higher, and it would be interesting to have an idea of exactly what it is. To my mind, it is an incredible sum. If it could be saved, it would certainly make the Minister's life very much easier, and would also save a great deal of time in relation to the doctors themselves.

I am very glad to welcome the action that has already been taken. I understand that a new X-ray unit for the investigation of suspect immigrants has been, or is about to be, opened at London Airport. Doctors are being increasingly exhorted to be on the alert for infection, and immigrants are now being encouraged, as soon as they arrive in the country, to join the National Health Service and register with a doctor.

I am certain that all these steps will help, but I do not think they will solve the problem entirely. The technical and financial difficulties of screening every immigrant, at every port of entry, are very great. I am not personally convinced that this is the answer. I feel—and this has been suggested elsewhere—that the long-term answer would be for would-be immigrants to be screened at their country of origin and issued with a medical certificate which they could present here on arrival. If there were then any doubt about any particular person, he could no doubt be re-examined in this country. I should like to know whether the Government are considering, as a long-term measure, trying to set up a system of this sort by international agreement. Is this not something in which the World Health Organisation might play a useful part? Even if the noble Lord cannot answer these questions to-day, I should be very grateful if he could at some time give me some indication as to the Government's views on this subject.


I have not quite followed the point. Is it the question of medical investigation in the country of origin?


Yes, as opposed to carrying it out in this country.

I should like now to say a word about the Hospital Service, which, in essence, I suppose, affects more personally and directly every man, woman and child in the country then any other part of the National Health Service. The noble Baroness, Lady Brooke of Ystradfellte, in a most interesting and stimulating speech, said practically everything there was to be said on the subject, although at one point she told us that she could have gone on for a great deal longer.

The Ten-Year Hospital Plan, which was drawn up by the late Government and revised every year, laid the basis (for the first time, I think) for a sound progression towards an up-to-date and efficient Hospital Service for the whole country. The Plan has certainly been criticised, by noble Lords opposite and by people outside this House, who have been impatient to get more done than was physically and financially possible. But we do not at this moment know what the position is. It is of the greatest importance for the morale of everyone connected with the hospital services to know what the Government intend to do about the plans. There have been rumours in the Press of cuts. I should like to know whether Her Majesty's Government are going ahead, and, if not, are they considering alternatives? When can we expect an announcement about this? I believe that the Minister has the subject under review.

There is another point in relation to the Ten-Year Plan which I wish to mention. Here I take a slightly different view from that of my noble friend Lord Auckland, who was pleading for more new hospitals at the expense of upgrading many of the older hospitals. I believe that the Government should resist this temptation. It is tempting to spend your resources on building new, nice-looking hospitals; it is a sign of achievement and they are marvellous places. But it is important to strike the right balance in this regard and to proceed at the same time with a steady programme of upgrading. The late Government did this with success, and I hope that the present Government will continue such a policy in the future.

I have kept your Lordships perhaps too long already and have asked a great many questions, but I have attempted to concentrate on what I believe are some of the more urgent priorities. As this is our first opportunity to find out from the Government how they propose to translate their words into deeds, I feel that the noble Lord will have expected an interrogation, and I hope he will not mind it. I hope even more that he will be able to give us some positive news and not merely tell us that all these matters are still under review.

Of course, anyone who has had the privilege of having something to do with the National Health Service knows that its many achievements are the fruits of years of patient and loyal devotion by all those connected with it in Whitehall and throughout the country. Just as the development of the health services is something for which no political Party can take all the credit, it does, to a great extent, depend on the support and encouragement of the Government in power. That is why I am still a little apprehensive that in the overall pattern of the Government's calculations the National Health Service, and the nation's health in general, possibly does not stand quite so high as I think it should.

The noble Lord, Lord Taylor, in our debate last July, a little unfairly, I thought, accused my Party of treating the Ministry of Health as a second-class Ministry. I must say I would not have thought that the present Prime Minister's action in demoting the Minister of Health from the Cabinet and scrapping one of his Parliamentary Secretaries savoured very much of what I might call "the V.I.P. treatment", but I hope that this is not indicative of the Government's attitude to the development of the National Health Service as a whole. I shall be only too glad to be told by the noble Lord that my fear about this is unjustified; and I am sure that all your Lordships look forward to hearing what he has to say with great, and indeed critical, interest.

6.40 p.m.


My Lords, I am setting myself the task of answering this debate in under 30 minutes, and it has taken nearly 4½ hours to deliver, so if I leave a number of questions unanswered I must apologise at once. I cannot do otherwise, because every speech that we have listened to has been cogent, well argued and full of facts. There has not been a single one which was what might be loosely described as "waffle". Everybody had serious points to raise. It is physically impossible, therefore, to answer all the points raised, so I must try to draw a general picture.

I am, however, a little disappointed in one respect. The noble Lord, Lord Auckland, who moved this Motion and to whom we owe a debt, as we always do when he introduces these Motions on health services, gave us a specific subject to consider—namely, ancillary workers. If we just look at his Motion it says: To call attention to the Hospital and Medical Services, with particular reference to the shortage of physiotherapists and other ancillary grades; and to move for Papers. That is fair enough. In this House one can stretch any Motion just as one likes. But I think the debate has been less valuable than it would have been if we had concentrated on one or other aspect, or had not diffused our energies over the whole sphere of the National Health Service. I have to try to answer on the whole sphere of the National Health Service.

Let me begin by saying how grateful I am to have a colleague in the shape of my noble friend Lord Sorensen. It gives me immense pleasure and real support to have him sitting beside me, and to have him deal with most of the points—and I think he dealt very well with most of the points—which the noble Lord, Lord Auckland, raised. Lord Sorensen is an old friend, a valued colleague, and I am sure we are all welcoming him very much. I am welcoming him, not because I did not value my noble friend Lord Stonham as a colleague on this subject—I did—but because Lord Sorensen is also going to be my colleague or Commonwealth Relations and Colonial matters. To have somebody to whom I can turn when the burden gets a bit heavy, and somebody who knows these subjects even better than he knows health, if I may say so, is a real relief; and we will try to give your Lordships better service than we have in the past.

The next point is to say a word about the maiden speeches, and there has been a series of very fine maiden speeches. I am sorry that the noble Baroness, Lady Brooke of Ystradfellte, has had to go. She gave us a grand and vigorous speech of the kind we should expect, and I was very pleased, also, to see her husband on the steps of the Throne. It is a real pleasure to see my noble friend Lord Segal back; though, my goodness me, he was critical! There was an air of gloom. I came to this debate feeling rather gloomy myself, and as time went on it got gloomier and gloomier. But I became rather mere cheerful, which is a shocking thing to say, but this in fact is what happened. My noble friend Lord Segal pointed out the dire possibilities which could follow all the possible methods of paying doctors, and I am going to come back to that in a minute. But it was a very good analysis.

Then I come to my old friend and former boss Lord Leatherland. I used to work for him when he was news editor of the Daily Herald, and I was the "dog's-body" who did the medical stuff. I always remember that his people used to ring up and make such remarks as, "What do you do if a duck swallows a domino? Is this unusual?" I had to think of five lines to dictate back over the 'phone. Lord Leatherland is, I know, a very devoted public servant. As a matter of fact, due to him as much as to any other single human being, we have growing in Essex a very fine university. So I am delighted to see him here and it is a real pleasure to welcome him.

Now I come back to the subject matters raised in the debate, and let us start with the Hospital Plan. The Hospital Plan, as the noble Marquess, Lord Lothian, thought, is being very carefully examined. I do not think the fundamental principles have been changed, and I agreed with him rather than with his noble friend Lord Auckland, that the right thing to do is not to lay all the stress on new buildings but to improve existing buildings.


My Lords, may I just make one point quite clear here? I was not advocating the pulling down of all old, existing hospitals, but there are some which seem to me to be too old to improve on economically. It is those hospitals—and I have pictures here of some of them—to which I was specifically referring.


My Lords, of course there are hospitals which could with benefit be pulled down. But, again, one is back to this awful problem of priorities and getting one's priorities right all the time. Time and again the right thing to do is to "make do and mend"; to do the best one can with what exists and have a plan for steady progress and gradual upgrading. Where a new area is developed, there build a new hospital: build as wisely and as well as one can. Here I would say that the general principle of the district hospital, the highly specialised hospital, seems to me to be the right one. It is also right that we should not spend too much money on each hospital that we build Sometimes in the early days of hospital building we did spend too much money, but I think, since the Ministry of Health followed the example, if I may say so, of the Ministry of Education and started to work out functional guidance notes for the building of hospitals, the cost of hospitals is now getting more reasonable.

The noble Lord mentioned the hospital at Hatfield and Welwyn for which he has great affection and for which I must say I have affection, too. I think that is a reasonable and a good department. Yet, once again, he mentioned that it was too small for physiotherapists; there was not enough space for physiotherapists. Whatever we do, there will always be not enough for all we ought to do, and that is one of the facts of life. My noble friends were talking about tests for cervical cancer, a very important subject indeed. Yet it is one of the most difficult subjects to decide how to tackle properly, because it requires a great technical skill to read these smears. Nobody knows the right intervals at which to take the smears, and it is even questioned as to whether some of the things that are detected are in fact pre-malignant. It is not easy. These are frightfully difficult technical problems.

My noble friend Lord Leatherland, in a very interesting speech, spoke of the various aspects of cancer research, of various types of electrical devices. I could give your Lordships—and I will see that he is sent—a full statement of the position about all these different devices: about the linear accelerators, about the betatron, about the machine that is being purchased at Guildford, about the work of the Hospital Friends in raising this money, which I for one think is a very fine job—indeed, as he indicated, they raised a great deal of money for this machine—and about the long-term planning for radiotherapy. I think it is not bad planning; I believe it is good planning. I think that the experts who have advised the Ministry of Health have, on balance, done their work as well as human beings can. They have made mistakes; we all make mistakes. But it is a pretty good plan that they have got, and it will provide for a remarkable diffusion of these new devices. But each one has to be decided on and proven. The one at the Churchill Hospital at Oxford is by no means proven. We think it is better than the Swiss machine, the betatron. We are not sure, but it looks as though it is.

Then the noble Lord asked, "What about £10 million?" My Lords, it is a good thing to put a figure on the amount of money that Governments ought to give to particular projects. I remember the stimulation the "mental million" had, and the noble Lord will remember it very well. I once had a scheme for a "mental million" for research. I tried to persuade Her Majesty's Government to give a "mental million" for research. But my noble friend Lord Sorensen and I, with our colleagues from the Medical Research Council, spent a long time yesterday going over the amount of money that was being spent. It is of the order of £1 million a year that is being spent by the Government specifically on cancer research; but there are also lots and lots of other moneys being spent on cancer research by the Medical Research Council which you cannot precisely allocate because it is research into the way that cells work, into the way that tissues function and things of that sort. To make an exact computation and an exact calculation of the amount spent is beyond the power and the wit of man.

In exactly the same way, there is a balance about these voluntary bodies. It is comparatively easy in this country to raise money for cancer research, and, in consequence, there are two large bodies for cancer research—the noble Lord mentioned them—which command large funds. Now there are many other worthy research bodies which are less popular (and yet the diseases are in some respects as tragic) and which command very small funds. If the Government start giving money to voluntary bodies which are themselves fund-raising—


My Lords, I am sorry to interrupt the noble Lord, but I wonder whether he could address this side of the House as well.


I am sorry, my Lords. I must apologise to the noble Marquess, Lord Lothian. I will speak louder and into the microphone, and hope that it will bounce back at the noble Lord, Lord Leatherland. If the Government are to give sums of money to voluntary bodies which are engaged in fund-raising, there is the risk all the time that the public will be discouraged from giving to these voluntary bodies because they know that the Government will make up the deficit. It is always a question of balancing up the scales.

The noble Viscount, Lord Waverley, used two phrases when he described his thesaurus. Whether, among all these pieces of paper, I can find the one I want, I very much doubt, because I have never had so much paper presented to me for any brief. The noble Viscount's first point, if I remember aright, was shortage. The word "shortage" can be applied to the position of every conceivable kind of person that we can deal with in the Health Service. I can hardly think of a single kind of person of whom one could not say that there is a shortage, and of whom one could not say that they ought to be paid more. The second word that the noble Viscount used—and, indeed, a number of other noble Lords used it—was "morale". The noble Viscount shakes his head; he did not use it.


No, my Lords, I did not.


Then it was another noble Lord who spoke—in fact, a number of noble Lords did—of low morale. It may indeed have been my noble friend Lord Archibald—I am not sure—but certainly low morale was mentioned. I think that the key to the situation is the morale of all of us, both inside and outside the Hospital Service. Somehow or other we must break the vicious circle. We must all push a little bit harder, if you like. We must all put up with things we do not like. We must all determine that we will make the National Health Service a success, in spite of the disadvantages, difficulties and shortages. We cannot avoid these things. There is a shortage of pharmacists, as the noble Viscount, Lord Waverley, described. I will certainly undertake to describe to my right honourable friend—and, indeed, our officers from the Ministry of Health will have heard of them—the strange and bizarre effects that such a shortage produces because of the underpay of hospital pharmacists as opposed to other pharmacists.

We could go through every profession supplementary to medicine and point out the follies and fallacies, the inequality of pay, the fact that somebody is not getting quite as much as somebody else. But, in the last analysis, it is the work that we do, or the work that each person does, that gives us our satisfaction. If we get on with the job, or if they get on with the job, and, of course, try to get a fair, decent and just remuneration, and if we all organise and work hard and try to get a just remuneration for all, it will come right in time. But the matter is so incredibly complicated, the balance is so fine all the time, that the only way to push it over and get it going in the right direction is by raising our own spirits and morale by making a positive attack on it.

As I listened to what my noble friends were saying I felt that this was not quite the way we ought to do it. I felt that we ought really to be doing it positively, rather than negatively. I felt we ought to be looking, not at how bad things are, but at how much there is that is good as well—and there is so much that is good as well. I find that it was the noble Baroness, Lady Brooke of Ystradfellte, who spoke of the low state of morale.

My Lords, I have only two or three minutes more, because I am rationing myself quite ruthlessly, but I want to say at once to every noble Lord who has raised these numerous points that we will try to answer them all. I shall try to send them the information that they want. But the Government clearly have not completed formulating their plans; the Review Body has. As the noble Marquess, Lord Lothian, thought, the Review Body has reported, and its findings are now being considered. Not only has the Review Body reported, but, equally as important, the Minister will be making a Statement about the Hospital Plan very shortly. So my right honourable friend in another place and his colleague have not been wasting their time. I do not think noble Lords should feel that the Ministry of Health has been downgraded. As anybody who knows the present Minister of Health—and the noble Baroness, Lady Brooke of Ystradfellte, knows him well, and many of us know him well—is aware, we could not have a better man in charge. But Government is getting more complex all the time, and there is, again, a real problem as to how many Ministers we ought to have, and what is the right number. Well, my Lords, we have got to work hard and do the best we can with what we have. We may not always succeed; but we must keep on trying. The noble Lord, Lord Amulree, warned me he was going to leave before the end of the debate, and I will therefore write to him.

One has a vast sheaf of paper here with which one might deal, but I will just say one final word about what I think is not perhaps the most important aspect—for they are all important—namely, how to decide how much money should be paid. There is no perfect machinery for doing this. The Whitley Councils are imperfect and the criticisms made of them by the noble Lord, Lord Amulree, were perfectly reasonable. However you do it—whether you have reviewing bodies, whether you attempt negotiation in a slightly artificial atmosphere because the true employer, as it were, the Treasury, and the ultimate employer, the British public, have no seat on the Council—you are bound to have trouble and difficulties. My right honourable friend the Minister of Health has met the members of the staff side of the Whitley Councils and of the Trades Union Congress to hear what they have to say about these very difficult problems.

My Lords, we shall make improvements. We shall improve this negotiating machinery (which I know we are already improving) as well as such things as the occupational therapy services in both mental and general hospitals, just as we are slowly improving our physiotherapy services and just as we are slowly improving our maternity services. We must watch all the time to see that we are pushing in the right direction and are winning the battle. Fortunately, there are indices such as the infant mortality rate and the maternity mortality rate to keep us informed of these things and to help us to watch how we are doing. It is only by honest and straightforward endeavour, by the application of honest, decent science, and by sticking to it and going on and on, that we shall improve the National Health Service and shall in due course build the kind of National Health Service which we should all love; although even then there will not be perfection.

7.4 p.m.


My Lords, we have had a most useful and interesting debate. The four maiden speeches we have had have been of outstanding quality. My noble friend Lady Brooke of Ystradfellte made a speech of the characteristic charm and ability which all those who know her would expect. The noble Lord, Lord Leatherland, made a most moving speech on this dreaded disease of cancer. I remember a short while ago going to a children's hospital in Derby and seeing a child with cancer of the mouth. It was one of the most tragic sights that I have ever seen. I asked the ward sister how long the child had to live, and she replied: "Six weeks". I have seldom been more nearly moved to tears.

The noble Lord, Lord Taylor, took me to task, quite fairly, for the width of this Motion. Quite obviously, this is not a Motion on which long speeches should be made; but I felt that, at a time when the medical services are in the public eye, such a Motion should be made as wide as possible so that all aspects could be considered. I was in some difficulty over its framing; but I am very satisfied with the contributions that have been made. I think that your Lordships' House as a whole has recognised the desperate shortage of doctors and physiotherapists, and there is no doubt whatever that if factory workers worked under the same conditions as some of our doctors there would be still more strikes.

My Lords, I would end by saying once again that this House and the whole nation owe a very great debt of gratitude to all who staff our medical services with, relatively, so little remuneration. I thank all noble Lords who have taken part in this debate, and I now beg leave to withdraw the Motion.

Motion for Papers, by leave, withdrawn.