HEALTH EDUCATION

§ LORD SHACKLETON

My Lords, I welcome very much the opportunity of replying to the noble Lord, Lord Cohen of Birkenhead, on behalf of the Government, and I am sure all of us, including all those noble Lords who were primarily here to listen to the Statement on the Common Market, have benefited from the noble Lord's wisdom. We are also grateful to him for his tireless promotion of the cause of health education, not least in his capacity of Chairman of the Joint Committee whose Report we are debating to-day. I was about to say that I am a great admirer of the noble Lord, but I think the whole of your Lordships' House would share that view because of his very widely based activities, many-sided, in the field of medicine, and I think the Government and the country were fortunate in having him as the Chairman of the Joint Committee about which he spoke.

It is, I hope, for the convenience of your Lordships that I enter this debate early on, in order to make what I hope will be a fairly short speech, purely on the Government's part and the Government's action in regard to this Report, and later, with the leave of the House, I hope to deal with some of the points raised by the distinguished group of Peers who are to take part in the debate to-day. The fact that in these initial remarks I do not deal with any particular aspect of health is simply in order to help the House by explaining the position of the Government. I am sure we are very glad to see that there are two maiden speakers. Lord Donaldson of Kingsbridge and Lord Garnsworthy, whose speeches we shall look forward to hearing.

1465 One of the difficulties of debating health education is to decide what is health education and what is health, and I am sure this is a subject on which the noble Lord, Lord Cohen of Birkenhead, in his chairmanship of this Committee, was trying continually to steer a sort of dividing-line. But of course it is an indivisible subject, and inevitably, therefore, there will have to be some move across into subjects on which people might say, "Surely that is not health education". We cannot discuss it without looking at it pretty widely.

I think I should be prepared frankly to admit, and I believe your Lordships would, that in the past health education has not always had the priority it deserved. We are all accustomed to the admirable health education that the noble Lord, Lord Hill of Luton, single-mindedly used to give on the radio, and the noble Lord to some extent was a health education policy. But we want to give it a more organised basis than it has had in the past. It has not been as well done as it should have been, and in this I do not in any way impute blame or failure to those people who did labour in this field with little resources and sometimes not much encouragement.

The most important step the Government have taken to remedy the deficiencies was taken last year when my right honourable friend the Minister of Health announced for England and Wales that the Government accepted the Joint Committee's conclusions that increased effort was needed in health education and that the first priority was a new and stronger organisation. He went on to explain that the Government proposed to establish a new Health Education Council for England and Wales, and the scope of this was later extended to include Northern Ireland. Its functions would be broadly as proposed in the Cohen Committee's Report, and its task would be in particular to work out the detailed implications of the proposal in consultation with the local authority associations and the professional and other bodies concerned. I perhaps should make that clear; it is, of course, for the Government to work this out in the first instance, and then for the new Health Council to take on that responsibility, with the Government, as I hope, always behind giving support.

1466 The Government did not arrive at this decision either lightly, or indeed, as the noble Lord, Lord Cohen of Birkenhead, would say, quickly. They did take some time to make up their mind. If I may say so, this is not a purely technical defence; it was in a sense a tribute to the wide range of the work of the Joint Committee. There was a good deal of food for thought and there had to be the fullest consultation with the many interested parties. The Government realised that the decision they were going to take would have a far-reaching effect on people's lives in this country. The work to be done by the new body proposed in the Report would be a preparation for the years ahead, an investment in the future health and wellbeing of the community.

Immediately following the Minister's announcement the Government went into detailed consultations with the local authority associations and professional bodies in England and Wales about the constitution and functions of the proposed new Council, and on questions of staffing and finance. I am afraid the processes involved have taken a great deal longer than the Minister would have wished, but it is obvious that we were laying foundations which we should hope would last for many years ahead and would be of a kind that would be sound from the point of view of the work to be done.

The new Council's main functions will, therefore, be to plan and promote national programmes of health education in selected subjects, to assist local authorities in the development and execution of local programmes, to undertake research into health education techniques and to evaluate the results, and to foster the training of staff engaged in health education. And this is right on the line with those subjects to which the noble Lord, Lord Cohen of Birkenhead, and his colleagues attached importance. It will take over the functions, among other bodies, of the Central Council for Health Education. It will absorb the present health education promotional activities of the Ministry of Health.

At this point it would be right to pay a tribute to the body it replaces, namely the Central Council for Health Education, It has been operational in this field for some forty years and it has made an 1467 admirable contribution to this cause, having regard to financial limitations. I think we should draw particular attention to its role in the training of those working in health education, and its work, too, in sustaining interest in the subject by way of its training courses, seminars and summer schools. It is, I think, very much to its credit that during this recent period of uncertainty over the future direction of health education it has continued its work with the traditional diligence that it has shown over the years.

I should like to turn now to the constitution of the proposed new Council. In their Report the Joint Committee foresaw the Council as having the same sort of relationship with the Government as the Board controlling the Public Health Laboratory Service in England and Wales. In other words—and I quote from the Report: it would, through its constitution, membership and financial dependence, maintain a close working relationship with Government departments, including the education departments, and yet remain freer to experiment, to adopt unusual courses and to take risks". I should like to turn to the particular points on which the noble Lord asked for an assurance, and I am happy to say I can give him a complete assurance on those points that he made in the concluding part of his speech. The Minister had to bear in mind the need for a body no larger than was essential for the effective carrying out of its policy-making and executive functions, while, at the same time, he had to ensure that its membership included the range of qualities, knowledge and experience that need to be brought to the Council's activities. He concluded that it should be made up of 16 members. The Chairman and three members would be appointed by the Minister of Health, and one member each by the Secretary of State for Education and Science and the Minister of Health and Social Services of Northern Ireland. Of the remaining ten members, the Minister would appoint from nominations by the local authority associations—the County Councils Association, the Association of Municipal Corporations, the U.D.C. and R.D.C. Associations—and there would also be one each from nominations made by medical, educational, dental and nursing organisations. But I 1468 should like to make clear that they are not being appointed as representatives of those bodies.

The Minister is making the appointments. Names have been submitted. Indeed, in most cases, if not in every case, the Minister has asked for a list of names from which he has made the appointment. So I hope I have been able to meet the noble Lord on this point. As the noble Lord said, the Minister has appointed the noble Baroness, Lady Serota, to the chairmanship of the new Council, and I absolutely agree with the noble Lord that there could not be a more promising start to the work of the Council than the appointment of the noble Baroness. I do not know whether it is the application of the Addison Rules or the general custom of the House, but it is sad that she feels she is unable to speak. But I am sure this appointment gives us all great confidence. The Minister hopes shortly to announce the names of the other members. Indeed, we had hoped that I should be able to announce them to-day, but the list is not yet quite complete. The expectation is that the Council will begin its work early in the New Year and become fully operational from April next.

I have been referring to the new body as the Health Education Council, but it may be that when it meets it will decide to call itself by some other name, such as the Health Education Board. One of the Council's first jobs will no doubt be to appoint committees or advisory bodies to provide specialised professional advice and help on particular aspects of health education. These of course could include representatives from organisations who are not already directly linked with or specifically represented on the Council.

The intention, to begin with, is that the Council will be incorporated under the Companies Act 1948. Its Memorandum and Articles of Association will prescribe the relationship between the Council and the Minister, and so ensure broad agreement between their respective policies. Although the Council will be expected to work closely with the Health Departments I have the Minister's assurance that he will exercise his power of direction exceptionally and only where he is satisfied that it is necessary in the public interest. As we know, it is rare that 1469 Ministers exercise their powers of direction in this form. We expect that there will be good relations and close understanding and co-operation. This will impose a responsibility, which we acknowledge, not merely on the Council itself but also on Ministers, to understand the work of the Council. Its new independence, therefore, will be real, and it will be freer to experiment and pursue unusual courses of action than would have been the case if health education had remained an entirely departmental function within the ambit of the Ministry of Health.

The detailed financing of the Council is something which remains to be worked out in consultation with the local authority associations and with the Council itself. Until the Council has been able to plan its work and budget it will not be possible to determine exactly what sums will be required. However, the Government fully accept that the major part of any increase in expenditure should be met from Exchequer funds, and they envisage a rising level of expenditure on the work as the Council develops, accompanied by a rising Exchequer contribution. The Government are confident that local authorities will accept the view that it is wholly appropriate—and indeed essential—that they also should contribute at a higher and, if necessary, increasing level, having regard to the extent to which the work of the Council can be expected to supplement and even replace some existing local expenditure on health education.

Experience suggests that centrally directed action in the field of health education in the future will be conducted increasingly through the mass media which can be organised and deployed effectively only by a single central body working on behalf of all those engaged in the field. However, the Government take the view that since local authorities will retain primary responsibility for health education it follows that they should be involved, both financially and otherwise, in responsibility for its central planning and direction. Contributions by local authorities to the expenditure of the Council will be taken into account in the calculation of Exchequer grants to local government, as indeed will local expenditure by the authorities themselves on health education. It will thus rank for 1470 Exchequer grant. It is also hoped that the new Council will attract contributions from industry and commerce and voluntary organisations.

Earlier I described the decision to set up the new body as a most important step. We hope that it marks the beginning of a completely new era in health education. For the first time the central organisation and direction of health education in England, Wales and Northern Ireland will be unified and in the hands of one body alone. The new Council, with greater resources at its disposal, will be expected to carry out a thorough and exhaustive review of all that is being done. What new initiatives will emerge I cannot say, but clearly the new Council! will have very wide scope for making a lasting impression on the health of the nation.

Let me now turn to the position in Scotland. I hope your Lordships will not think that what I now say "unsays" everything I have said with regard to England and Wales; but, as we know, Scotland is a different place; her problems are different, and there are valid reasons for the Scots to tackle their problem in a different way from that in which we have decided to do it in England. The Joint Committee agreed that it would be advantageous to Scotland to have its own self-contained health education body. They envisaged a Board independent in its day-to-day work but accountable in broad terms to Government and local authorities which would absorb the health education functions of the Scottish Home and Health Department and of the Scottish Council for Health Education.

Like the Minister of Health, the Secretary of State for Scotland accepted the Joint Committee's recommendations that increased effort was needed and that for this purpose a new and stronger central organisation was required. He has, however, decided to establish a new Health Education Unit within the Scottish Office, rather than a new body outside it; and he has also arranged for this Unit to work in close association with the Scottish Council for Health Education, which has agreed in principle that, in future, its real role will be to provide training for local authority staff engaged in health education.

1471 The Joint Committee, in their Report, said it seemed to them that cogent arguments could be put forward for entrusting the functions they had in mind for a central body either to the central Departments of Government or to a new body. And in favour of the central Departments they pointed out that health education was an integral part of the National Health Service and should be administered from the same source. The Secretary of State took the view that this was a particularly important consideration in Scotland, and he felt that it would be preferable and would give expression to his own concern to foster health education if the new body were set up within the Scottish Office. There is no reason why different arrangements should not be adopted in England and Wales and in Scotland. As the Joint Committee themselves said, there is much to learn about health education.

This new Scottish Unit will be responsible for stimulating health education, for developing the most effective methods and techniques, and for evaluating results. In due course, it will take on the health education work at present undertaken by the Scottish Home and Health Department and the Scottish Council for Health Education, apart from the latter's responsibility for providing training for local authority staff. In the Unit, staff with appropriate skills in medicine, education and publicity will work together under a Director from the medical field. The staff will be built up gradually, and it is hoped that the principal officers, who are now being recruited, will be in post in time to bring the Unit into operation in April, 1968. Later on there may be added to the staff a nurse and a part-time sociologist and research officer. The Unit will be wholly financed by the Exchequer.

The Director of the Unit will enjoy a considerable degree of autonomy in the conduct of the day-to-day work, and the Unit will be accommodated in premises to be shared with the Scottish Council for Health Education. It will be able to appeal for help from commercial sources. Help will be provided also, in the form of advice, by the Scottish Standing Committee on Dental Health Education, and in due course there will be consultations with the professional organisations to find the right people. 1472 Again, I would pay tribute to the Scottish Council for Health Education which, despite slender resources, has made a notable contribution; and the instructional work will continue. These arrangements have been accepted by the local authority associations, and include an agreement for continued financial support of the Council by local authorities.

§ THE EARL OF SELKIRK

My Lords, if the noble Lord is leaving that aspect, may I ask whether the Council will be an integral part of the Home Department in Scotland?

§ LORD SHACKLETON

My Lords, I should like to make this clear. The existing Council will continue its activities primarily in the field of training local authority staff. Scotland, unlike England, will have a Unit within the Government Department, under a Director, with a certain amount of autonomy. Therefore the Scottish solution is different from the English one.

I had the impression when listening to the noble Lord, Lord Cohen of Birkenhead—and, indeed, in reading his Report—that he regretted (and I think I regret, as perhaps do the Government now) that we did not earlier recognise the close correlation between the education side and the work of health education. I should like to congratulate the noble Lord, Lord Cohen of Birkenhead, and his colleagues on finding a way of overcoming this difficulty and hoisting it in, possibly not so easily as they might otherwise have done; and it illustrates the great importance of this aspect.

My Lords, I should like to end my remarks by saying something about the school side, because the schools provide unrivalled opportunities for health education. Although my right honourable friends the Secretaries of State have no powers to prescribe the contents of school curricula, which are the responsibility of the local education authorities and schools, they do advise local education authorities in various ways. The Department of Education pamphlet, Health Education, is a handbook of suggestions for the consideration of teachers, and it covers every conceivable topic in the health and education field. It is being revised to take into account some of the more vital topics of the day, such as 1473 smoking, sex education, drug-taking and alcohol. The very special role of the teacher is explained at some length, and also the need for the teacher to have a sound general knowledge of health education principles. Health in Education, another pamphlet issued by the Department, attempts to draw attention to those features of the life of schools which contribute most to the physical, mental and social wellbeing of pupils, and it disseminates information about the ways in which many schools are dealing with personal aspects of health education. The appointment of two members from the field of education to the new Health Education Council in England and Wales and the inclusion of an educationist in the staff of the Scottish Health Education Unit will ensure that there is a real concentration on this vital sphere of health education.

Because we are concerned with individuals, it is fitting that I should conclude my remarks with a reminder that, whatever can be done at national level, the main responsibility for health education must ultimately rest with the local authorities. They are the bodies in the best position to judge the needs of their areas and how these needs can most effectively be met. It is they who employ the staff, such as the health educators, to which Lord Cohen of Birkenhead attaches great importance, and it is this staff who will bring home to the public the ways in which they can achieve high standards of health. The Government's sphere of action is limited. Indeed, I have said nothing at this stage (though I may in my winding-up remarks) about the direct education of all those—whether they be doctors, nurses or others—who are engaged in the field of health education. The Government can ensure that the local authorities receive the support which can most effectively be organised at national level. It was with these considerations in mind that it was decided that local government should have the major voice in the affairs of the new Health Education Council.

This has been far from a complete account of the health education that is currently being undertaken—indeed, it is little more than an introduction to it; but it illustrates the very wide range of activity that will face the new Council as soon as it commences operations. I 1474 look forward to hearing the speeches of a number of noble Lords, and I think it is right that this debate should take place since it will in itself be an important contribution to the health education of this country.

§ BARONESS BROOKE OF YSTRADFELLTE

My Lords, first of all I should like to thank the noble Lord, Lord Cohen of Birkenhead, for the way in which he introduced his Motion. I have for a long time had a great admiration for the work which the noble Lord has done; and I knew that he would give us a fascinating account this afternoon of one of the many subjects on which he is so well informed. His speech was certainly no disappointment to us. I should like also to congratulate the noble Lord the Deputy Leader of the House for the way in which he is able to move from one post to another. At one moment we are, sending him to Aden, and at the next moment we are welcoming him for his part in a debate on health education. It just goes to show what a spendid Deputy Leader he is.

My Lords, it is four years ago this month that the Joint Committee of the Central and Scottish Health Services Councils on Health Education, under the chairmanship of the noble Lord, Lord Cohen of Birkenhead, presented their Report. The Committee had been appointed four years before that and much good work had been done in the tine. In the introduction to their Report they say: We take this opportunity of expressing our appreciation of the great assistance rendered to all those who prepared written evidence or attended our meetings to give oral evidence. Your Lordships will no doubt have picked up the misprint where "to" is used instead of "by"—and yet it may not be a misprint. It may be that all those giving evidence were rendering assistance only to themselves, because four years have passed and neither the Government nor anybody else appear to have, done very much about the Committee's work until the noble Lord initiated this debate to-day, and the Gov-eminent have at last spoken their mind as to what they are intending to do.

I should like at this moment to take the opportunity of welcoming the setting up 1475 of this Council which, I understand, is to come into being in January of next year and hopes to start work in April. I should like to congratulate the Council—which seems to be a somewhat nebulous body which has yet to be appointed—on their chairman. The noble Baroness, Lady Serota, and I, although we sit on opposite sides of the House, for many years have worked together, particularly in the field of health. I have every reason to know how extraordinarily lucky that Council is to have her considerable ability placed at its disposal with her in the chair.

This is yet another Committee or Council or Board of busy people to be set up. There is something to be said for that, but what guarantee is there that whatever the Council recommends will not be left by this Government to suffer the same fate as the recommendations of the Cohen Committee's Report? We spend much time and money in providing education in a myriad of subjects for all ages of our people. We are so busy in the pursuit of academic knowledge with our brains, and technical and practical expertise with our hands, that scant time seems to be left for health education. Most boys and girls emerge from the process of general school education with little information on the subject at all, though many of them may have received instruction in sex. Surely, if we strive after quality in the character and ability of our people, we should also strive after a knowledge of how to develop healthy bodies for ourselves and our children, and how to maintain them in first-class condition throughout our lives.

The Cohen Report described four main types of health education programmes. First, there was specific action; in other words, vaccination and immunisation. Secondly, there was habit or attitude-changing; in other words, avoidance of over-eating, attitudes to mental illness, alcoholism, smoking, exercise and the bringing up of children, all of which the noble Lord, Lord Cohen of Birkenhead, referred to in his speech. Thirdly, there was support for community action and preventive measures; that is, anti-noise legislation, clean air, clean food, fluoridation and good housing. Then, fourthly, there was education to encourage people to consult their doctors at an early stage of illness.

1476 The Committee recognised that much health education was already being carried out. They referred to the considerable success which had been achieved in vaccination, immunisation, community X-ray campaigns and screening clinics. They pointed out that there had also been marked improvements in the standard of maternity and child care, in sanitary cleanliness, food hygiene and probably in attitudes to mental illness. They thought that insufficient health education was being directed towards particular groups, notably schoolchildren, teenagers, fathers, middle-aged men and those of limited intelligence in all groups. I wonder whether the Minister, when he comes to speak to us again to-day, could tell us what advances have been made in respect of these groups since 1964. If the National Health Service is truly to live up to its name, rather than being just a national ill-health service, a far greater effort will have to be made to bring health education to all sections of the community. This means dealing not only with physical health but also with mental health, which is equally important.

Much as we may admire the Report of Lord Cohen's Committee for the studious and detailed way in which it deals with its contents, it is a little disappointing in what it excludes and passes over. I regret that the place of hospitals in health education is virtually discounted. This is perhaps less surprising when we note that not a single hospital organisation gave evidence to the Committee. One may agree that in-patient education may necessarily be concentrated on the individual, but in outpatient departments the scope is very different. The number of out-patients grows yearly and, whatever laggardliness there has been in providing hospital beds, everywhere one sees new and modernised out-patient departments.

What is the purpose of health education? Presumably, the answer is to make us more aware of the effects of our everyday actions and environment on our personal mental and physical health. Next, perhaps, we ask who should be responsible for educating us in health matters, and where should they do it? The idea of health educators is a good one and very necessary, and so are the formal courses in schools and colleges, and the public talks and exhibitions arranged by the local health authorities. 1477 But as important, too, is the imparting of knowledge at the point of maximum impact. Courses are already run for expectant mothers and fathers, because they are vitally and immediately concerned with this learning, and consequently courses of this sort are well attended and very effective. It is a pity that courses for potential mothers and fathers, however inexorable the eventual need, are not seen to have the same immediate relevance, and so those for whom they are intended take less interest in them.

A great deal of emphasis is rightly laid upon the health educator, to whom much reference is made in Chapter 8 of the Report. It must also be remembered that people seem to take full notice of the doctor when he speaks to them personally, and of the advice of, say, the sister or the staff nurse. This is likely to be acted upon, whether it is a carefully considered opinion or merely a casual word. Hospital in-patients, indeed, are subject to subtle pressures. Advertisers seek to encourage the sales of patent foods because they are used in hospitals, and in their advertisements we are shown pictures of benign doctors and glamorous nurses. It has often surprised me that the tea firms have not used this tack. There must be more tea made and drunk in hospitals than all the other beverages put together; ergo, the advertisements could well say that it must be the most health-giving drink.

But to be more serious, health education is a continuing and co-operative enterprise. I should regret it if, when we are making slow progress towards practical integration between the three arms of the Health Service, something which is the province of all three was preempted by one or the other. On the detailed account of the setting up of the new Health Council, to which the Deputy Leader of the House referred, I should like to say that until I have had the opportunity of reading the whole of that speech in Hansard it is a little difficult to make full comment on all the implications that arise from it.

The Report rightly dwells on the progress made in combatting tuberculosis, and this is an extremely good example of socially orientated medicine where doctors, hospital nurses, health visitors, social workers and research workers have all 1478 played their part. Patients have been carefully followed up and given help and encouragement throughout their treatment, whether in hospital or at home, and then they have been helped to rehabilitate themselves for their return to the community. Such co-operation is of inestimable value. It is a pattern which should be adopted wherever possible. It is also interesting in that it provides one of the few instances where local authority staff and hospital staff are housed together, and thus work more easily as a team despite their separate administrative accountability. The relevance of this to health education is merely to underline its indivisibility. The only field I know of, in which the lesson taught by co-operation over tuberculosis seems to have been well-learned, is that of mental health where co-operation is being practised between the various authorities.

People are most receptive when they are personally involved and obviously affected, and I feel that hospital out-patients' departments provide a first-class point of contact. Whatever we may piously hope is being done to develop the appointments system in hospitals, we still hear of, and often see, long lines of patients waiting. Some patients, I know, regard their visits to the out-patients' department as something of an outing. They arrive at 9 o'clock in the morning and they stay for the morning, having their "elevenses" from the canteen. Here is a captive audience, and good use could be made of modern methods of getting ideas across to it. Instead of serried rows of waiting patients looking bored, irritated or apprehensive, we might entertain and educate them with film strips, closed circuit television, recorded talks illustrated by photographs or slides, and even attractive posters on the walls, which should be regularly changed, plugging home a point or two of health education after the manner of the wayside pulpit.

If these media are to be used, then additional staff and facilities must be provided and the money to do so made available. In every sense this would be a good investment: first, because better health education would be a preventive measure; and, secondly, because a patient better able to understand what he is being told and advised ought to be a better patient. Then there is the scope 1479 of health education. The Report seems to limit itself to the usual themes for health education as they presented themselves nearly eight years ago.

But is there any major aspect of behaviour which results in patients' requiring medical treatment that ought to be excluded from the definition? If any organisation is to be set up—and we have learned this afternoon that a Central Council is to come into being next year—to implement the recommendations of the Cohen Committees Report, together with any fresh ideas which may emerge as a result of to-day's debate, I hope that it will be flexible and wider-ranging. The old saying, that "Men do not make passes at girls who wear glasses" may never have been true; but it is far less true if girls who do not need glasses wear them as an aid to beauty. Thus it works out that this is a great help to those who are trying to persuade people to wear glasses to improve their eyesight.

In making a virtue of necessity in health education, as elsewhere, we must employ every known device of commercial and inventive ingenuity, and I am quite sure that the noble Baroness will bring her inventive ingenuity into play, together with the help of all these splendid people who are going to be appointed to assist her when the time comes for her Council to come into being.

§ LORD SHACKLETON

My Lords, may I interrupt the noble Baroness? I was trying to follow her very closely, but I was not sure when she moved on from the point. I thought she slightly implied that the Committee's work had not been fully comprehensive, and that there were perhaps other areas of health which they ought to have covered. She then broke into this thing about glasses, and I was not sure whether she was in fact suggesting some field in particular that had been neglected on the health education side.

§ BARONESS BROOKE OF YSTRADFELLTE

My Lords, the answer to that is that the point I had been trying to make was that the whole of the hospital field had been neglected, so far as the Report was concerned.

Accidents in the home and on the road are two of the major causes of "illness", broadly defined, of our time. No educa- 1480 tional plan to help combat these can exclude the health side. The visual horror of a burns unit or an orthopædic ward sears the mind and the conscience in a way that no amount of lecturing can do. I shall never forget the day when I was taken by the Medical Officer of Health of Baltimore, Dr. Huntingdon Williams—who, incidentally, gave evidence to the Cohen Committee—to the Montebello Hospital, just outside Baltimore. Every patient we saw was young, and all were suffering from the results of motor accidents or of diving into too shallow water. Paralysed and crippled—what cruel futures lay ahead for them and their families! Surely it is better to risk wounding sensitive susceptibilities by bringing them into contact with the appalling results of carelessness than to let fine young lives be ruined through ignorance.

We are constantly reading of the growth of drug-taking by young people. This is an evil that has reared its ugly head even more viciously since the Committee's Report was presented. I am sure we are all agreed that we must grasp this nettle and deal with it; and deal with it, incidentally, by using every means of communication necessary to get the measure across, however enterprising or unorthodox these means may have to be. Similarly with the elderly: education for retirement must include its health aspects; and with the population growing older this is a social necessity, as well as a requirement to enable the older person to live his longer life more fully.

My Lords, we must tackle this whole question of propaganda intelligently. And in doing so we must not overlook or sweep aside the splendid work that is being done by the voluntary organisations, such as the King's Fund, the Nuffield Trust, the Queen's Institute, the Red Cross and St. John, to instance only a few. In our attempts to centralise we sometimes run the risk of smothering, by lack of interest, of encouragement and of appreciation, what has been done in the past. Your Lordships will remember the extinction of voluntary help to hospitals in 1948 by the Government of that day. When the National Health Service came into being it was to be State-provided. There was to be no room or scope for the voluntary workers of the past.

1481 Since that foolish suppression it has taken years to rebuild the leagues of hospital friends, as we know them to-day. The good will, enthusiasm, experience and hard work of the voluntary workers of the linen guilds and ladies' associations was killed—and the patients were the losers. I hope very much that, whatever the new Health Council decides to do in the future, it will not repeat that mistake. Voluntary effort is very precious. It springs from the heart; and this country would be a poorer and colourless place without it. Public figures who are looked up to can play their part in this field, as in other fields. One can have no finer preceptor than Richard Dimbleby, whose lasting memorial will be his courage in making us realise that cancer is a problem to be faced up to and tackled, rather than a hideously terrifying word from which to run away.

Three years ago, in a Written Answer to a Question put in another place by Mr. Woodhouse about the number of health education officers employed by local authorities, the then Parliamentary Secretary to the Ministry of Health, Sir Barnett Stross, replied—and I quote: Local authorities organise their health education work in many different ways. I understand that about 50 authorities in England and Wales have designated an officer to take special responsibility, either whole-time or part-time, for organising health education. I am not aware of any special training in cancer education. That was in Hansard of December 16, 1964, at column 101. Can the Deputy Leader of the House tell us whether there has been any increase in the number of health education officers since then, and would he also tell us whether anything is being done to encourage education about cancer?

Finally, my Lords, health education seems to me to need to be organised at two levels, national and local. The former, which must be the responsibility of the Ministry of Health and the Department of Education and Science, should make use of all the mass media available. Those words of mine were thought of before we had the announcement this afternoon of the establishment of this new Health Council, but they link very closely with what is going to happen. The Report has a very full Appendix on the use of the main publicity media available for health education, though I must con- 1482 fess that the comic carelessness in proof reading on page 86 casts some doubt on the validity of the advice. It states that booklets and leaflets can perform a public service when they are distributed as book makers through the public libraries". At local level, the responsibility must be with the public health authorities and with industry. It would make a great difference if only all industrial firms would show as great concern for the education of employees as the best of them do about avoiding accidents and other hazards to health arising from the work environment. Public health authorities, in co-operation with the hospitals and the voluntary organisations, are particularly well placed to carry out these educational functions. The midwives, health visitors and district nurses are by their employment brought into close contact with all age groups, and this is usually at a time when those they visit will be in a receptive frame of mind to accept advice and instruction from the people who are caring for them.

The Public Health and Education Departments ought to co-operate closely, so that the school health service can extend health education to schoolchildren, who should be taught the principles of good health as part of their regular curriculum. The general practitioner also has a very large part to play in preserving the health, and not merely curing the ills, of his patients—if only the National Health Service gave him time to take advantage of his opportunity. Health education should therefore be treated as a more important subject in the training of medical students, dental students, student nurses and student teachers, and it should always be imaginatively presented. Every public health authority ought to employ a health education officer to act in a supporting role to all those providing health instruction; and the health education officer should be available to advise continually, to co-ordinate effort, to provide training aids as required and to organise, and sometimes conduct, special programmes and campaigns to deal with individual health problems, such as the dangers of cigarette smoking, drug-taking, alcoholism and so on. Research needs to be carried out to assess the results of particular educational activities and campaigns so that the most effective 1483 method of influencing various groups in the community can be ascertained.

Health education cannot be obtained for nothing. Local authorities and hospital management committees must realise that they must budget adequately for it; and it appears from what we have heard to-day that the Treasury also are going to be persuaded to provide some money for this new Central Council for Health Education. In the long run there should be a net saving to the country not only from a reduction of the need for medical and nursing care and from fewer payments of sickness benefit but from the addition of thousands more man-days of useful work in the national effort. The time lost owing to preventable sickness is the greatest single element of waste in our national life. Never do we need to eradicate that waste more than we do to-day.

§ LORD CROOK

My Lords, the noble Lady referred to the lack of voluntary effort. I did not wish to interrupt her at the time, but as one of many noble Lords here who are chairmen or members of Friends of Hospitals I should like to put the question: are there not in fact as many thousands of pounds being spent by Friends of Hospitals in trying to help people inside hospitals now as there were before?

§ BARONESS BROOKE OF YSTRADFELLTE

My Lords, if I may ask the noble Lord to read what I said in Hansard, he will see that the point I put was that whereas in 1948, when the National Health Service came into being, voluntary effort was stifled at the source, since then a great deal of work has been put into the building up of this voluntary effort. As a one-time chairman of a hospital management committee, I shall never cease to be grateful to my League of Friends for the work they did in hours of time and in money collected and amenities presented. I am wholly and heartily behind voluntary effort—and especially in the hospital field.

§ LORD AMULREE

My Lords, before I commence my few words on this subject I should like to associate myself with what the noble Baroness, Lady Brooke of Ystradfellte, has said about the marve- 1484 lous adaptability of the noble Lord who is going to reply to this debate. What he does, and the way he does it, the enormous amount of work that he puts into it and the information that he manages to give us is quite remarkable. I am sorry that she has left her place now, but I was pleased to see that the noble Baroness, Lady Scrota, is going to be Chairman of the new Council. I think she will do it extremely well. One feels that with someone like that in charge, the Council should do a very good job of work.

My Lords, surely the prime object of medicine is not so much to cure disease (for that is evidence of some kind of failure) as to prevent its occurring. I think that is what we have to look forward to when dealing with health education. We were told the other day in the Reith Lectures that it would be a catastrophe for mankind if disease were to be entirely abolished from the world. I do not think there is any chance of that occurring; one finds that when one disease is conquered another comes along to take its place, so that we always keep battling on. The prevention of disease can, I think, take two forms. One is by environmental hygiene, which has done so much good over the last 150 years. The second is by education. That again, as the noble Lord, Lord Cohen of Birkenhead, has said, can be divided into two: first, the kind of education which has resulted in the reduction of diseases like diphtheria by mass immunisation and other such things; and, second, the great deal more that could be done by education on general matters. I think the Report of the Cohen Committee has set the pattern for the latter.

My Lords, I do not want to go over the whole Report. I should like to concentrate my words on two diseases or two conditions which have interested me for a very long time. The first is cancer. Cancer, as we know, is a deadly disease if it is not treated. It took a long time for people to realise that cancer could be successfully treated. That was largely because many doctors merely saw patients in whom the treatment had failed; because those whose treatment had been successful did not come back again. There was a certain feeling of gloom about the whole problem; and this persisted until a detailed follow-up 1485 of patients took place. This began properly in 1929 when the Radium Commission was set up to buy radium with funds subscribed to commemorate the recovery from illness of King George V. The Commission—on which I served as a member at one time—sent radium to various hospitals on condition that they would get complete records of all patients treated. These follow-up reports—and we expected to get about 95 per cent. or more of them—showed us that a large number of patients were being cured of cancer. By "cured", I mean that they remained free of the symptoms and signs for a period of five years after treatment: that is generally accepted by most countries as being evidence of cure. I must say, however, that there are certain sites of the disease where treatment is not promising; and two of these sites are common ones: the lungs and the stomach. But for the others, these follow-ups have revealed a great degree of curability.

I do not want to bother your Lordships with a lot of figures—I do not think they are very impressive when speaking—and I want to quote only one or two. But I should like to talk about cancer in the neck of the womb. One has heard a great deal about this cancer, the disease of cervical cancer, and about what has been done. A long inquiry has been going on which was started before the war by the League of Nations and it is centred on Stockholm. I give only the figures from their Report. Under their scheme, between the years 1952 and 1957 they treated 60,000 patients. They find that of the Stage 1 patients there is a survival rate of about 75 per cent.; and these comprise only about one-quarter of the patients who come for treatment. When one comes to the advanced stages, the recovery rate drops to 8 per cent. The same thing applies to cancer of the rectum which in my younger days, when I first qualified, was thought to be a serious disease with not much chance of recovery. Now if you are treated early there is a recovery rate of 97 per cent.

In the case of cancer of the breast—and this is the last figure I shall quote—the figures are about the same. For early treatment there are 80 per cent. cures; but for late treatment the figure drops to 9 per cent. These are very important and impressive figures when backed by 1486 the fact that it is reckoned that there are about 30,000 people successfully treated for cancer each year in this country. Surely that is a thing on which to base a good deal of education: that this is a curable disease; not entirely curable, but much more than people think.

Certain attempts have been made to undertake education regarding cancer, one at Montreal in Canada where they dealt with a large number of people. The education I am talking about was carried on between 1943 and 1947 and between 1953 and 1957, and there was a great change in the percentage of survival from cancer in the neck of the womb—40 per cent. to 70 per cent.—which showed that education was persuading women to seek medical advice earlier. In Manchester (there is a reference to this in paragraph 75 of the Report of Lord Cohen's Committee) there was an encouraging increase in the number of people who believed that cancer was curable if you came for treatment early, when you first noticed that something was wrong. One of the depressing things about cancer, when you go into the history of people, is that you find there has often been long delay between a patient noticing that something is wrong and the seeking of medical advice. The time may range from six or seven months to ten months.

These are figures which should be improved upon, and one of the questions I should like to ask the noble Lord is whether the Ministry can give any figures for the period of delay or whether they have any such inquiry in mind? Is it proposed to inquire every so often to find whether propaganda and education is making any impact? A good deal of education is being done at the present time and one of the most important centres is at Oxford, where an old friend of mine, Doctor Malcolm Donaldson, has been doing a great deal of good work for a very long time. I think we want more of that, which is why I welcome the idea of the educators who will be able to do more regular work and provide more of that very important education quality.

It is said, my Lords, that if this is done, there will be a lot of people coming and saying that they fear that they have cancer; and that numbers of patients with a cancer phobia will take 1487 up too much of the doctor's time. That has not been the case in places where these methods have been tried, either in this country or in foreign countries. I will not say that there are not one or two people who behave like that, but it is by no means a common thing. In fact, in the United States at one time they used to have "Cured Cancer Clubs" to which people came quite cheerfully, and, so far as I know, these did more good than harm. I am not sure whether they are still carried on.

A large number of people think that more education should be carried out and more publicity given. Questionnaires have been conducted in various parts of the country and the majority of people who were interviewed said that they would like more education to be carried out than is done at present. When the Royal College of Physicians brought cut their report on the connection between cigarette smoking and cancer of the lung, it caused quite an impact, but that has died away. Why cannot the Government do more to encourage people not to smoke? To me it is surprising that if you go to a theatre or to a cinema (I admit that it has to be a theatre where people talk and not one where they sing) you can smoke as much as you want. That seems to me to be wrong. It is something one certainly cannot do in most civilised countries. That people are interested in this question is evidenced by the enormous amount of money which is collected for cancer research. I have the honour to be on the Council of the Imperial Cancer Research Fund, and I am surprised at the way the money for research pours into our funds. It shows that people are really interested, and therefore I do not think that they would be frightened.

My Lords, I have spoken for longer than I should, but I should like to say a word on my second subject, and that is chiropody. As I know very well the feet of some old people are in the most appalling condition. For the most part this would be preventable if they wore proper shoes. I know that it is difficult to get young women (and middle-aged ones, too, it may be) to wear shoes which are not fashionable, but a certain amount of work has been done in this connection and a good deal of co-operation has 1488 been given by the shoe manufacturing firms. They make shoes in a greater number of styles, sizes and shapes. I am sure that this is one thing which the new Council could encourage, because I think that bad feet are a more common cause of old people being confined to their homes than any other form of physical disability.

I very much hope that they may be educated not to wear shoes which have belonged to someone else because their own shoes are worn out. I know that shoes are expensive and that old-aged pensioners live very much on the poverty line, but I would far rather their pensions were increased so that they could buy shoes than that they should need to come to receive treatment for feet which are almost beyond treatment. I hope that these things will form part of the work of the new Council.

§ LORD DONALDSON OF KINGS-BRIDGE

My Lords, I ask for the indulgence of the House in addressing your Lordships for the first time. I find the desire to speak in this debate irresistible owing to my long connection with the pioneer health centre at Peckham, and owing to the fact that in his admirable Report the noble Lord, Lord Cohen of Birkenhead, specifically restated two of the main problems which the Peckham Experiment was set up to invesigate thirty years ago. The noble Lord deals with many other things, but I shall concentrate on only those two points.

The first problem is that of bringing the sufferer to the doctor—to which reference has been made before—to enable him to receive the benefit of early diagnosis and treatment. In this connection we at Peckham were, I think, pretty successful. The second problem is the study of health itself, to which the noble Lord referred and which is, of course, a far more esoteric and difficult subject. We were not particularly successful with this at Peckham because, to be quite frank, we found practically no health to study. I shall say a word or two more about the Centre as I go along, but I should say now that we overstrained ourselves in the harsh post-war period and closed our doors in 1950. But we collected a vast amount of material and have preserved some capital, and I like to think that the Report of the noble 1489 Lord, Lord Cohen of Birkenhead, would not have been exactly the same if we had never existed. I think that some small contribution was made.

It is extraordinary, my Lords, after thirty years to find these two problems still exercising the minds of the noble Lord and his distinguished colleagues. It is extremely interesting that they describe in their Report an experiment by some Birmingham doctors which looks to me like a shot—and perhaps quite a good shot—at doing something about the first of these two problems. I shall come back to that later, but I should like to say now that it is not stirring only in this area. I have evidence of another stirring of this kind which I shall draw to the attention of your Lordships later on.

I turn now to the noble Lord's account of the first problem. He recognises the difficulties confronting ordinary people, diffident, not rich, earning their own living at various levels, in getting to a doctor at all. In paragraph 119 he sets the problem exactly. He speaks of: apathy or disinclination through fear or embarrassment directly to approach a doctor or nurse for advice, or there may be no encouragement or opportunity or encouragement to do so. I myself suffer acutely—and I think it is possible that some other noble Lords may, too—from this fear and embarrassment. I have had no fewer than three valid reasons for going to see a doctor nagging at me for the last three years, and I have not been to see him yet. I have tried to analyse the reasons. They seem to be three—two good ones, and one rather bad. The first is that my doctor is a very busy man, and I am embarrassed at the idea of bothering him with what may turn out to be trifles. I also am a busy man and cannot make an appointment at his surgery, and if I go to his surgery I have to wait sometimes half an hour at the most awkward time of day. Thirdly (and this is one of which I am not proud) the wireless is always playing. I hate that, and I feel shy of coming into a room of mothers and babies who I fancy look at me strangely. I know that this is absolute nonsense, but it has been real enough to keep me from my doctor for three years.

If you add to this neurotic behaviour, the real difficulties of a working man in industry or on the land, who has to beg 1490 a day off from his "boss" before he can go to the doctor, or, if he goes to an evening surgery, has to go home, have his tea and wash and change and turn out into the night, we see that though there is opportunity, in its broadest sense, the noble Lord is absolutely right in what he says about this question of encouragement. None of this applies if anything is seriously wrong with you. I once had a poisoned foot, and I found that all my inhibitions melted away. I limped proudly into the surgery, beamed round at the mothers and their babies, and waited contentedly for my turn to be lanced.

The point I am making and illustrating from my own experience which I think some of your Lordships probably share, is that the present system works perfectly adequately for getting treatment for serious and acute conditions, when the sufferer is aware of them, but it gives no encouragement to somebody who feels well enough but fancies he detects signs of trouble to come; and, of course, these are the people we want to get at. Yet it is a common, though not invariable, characteristic of illness and malfunction to begin small and grow bigger and to be more amenable to treatment in the earlier stages than in the later. Thus we are faced with the situation in which, having evolved truly marvellous methods of curing and only less marvellous methods of diagnosis, we are able to deploy our armoury only when the unfortunate sufferer feels ill enough to overcome his natural reluctance to go to his doctor—when in fact he has become socially incapacitated.

The trouble is that the British medical system was founded on the relationship between the general practitioner and his patients, in which the doctor knew every member of every family by name, and not only by their medical histories, and was a family friend. In modern conditions this system has gone, and gone for ever. This is the price we have paid for a vast extension of the medical services to the population as a whole, but we must do what we can to find means to replace it. As I have said, the Peckham Experiment had as one of its primary aims the creation of something to replace the disappearing world of the family doctor. We went some way towards solving this problem. We took only 1491 families as members, and made it a condition of membership that every member of every family had a regular medical overhaul on joining and periodically thereafter. The Centre was not just a clinic; it was a social club, in which the doctors moved about and made friends with patients, and they were able to build up a link comparable with the old link between the family doctor and his patients.

Peckham has gone beyond recall and we cannot recapture it, but I think we may regret it in this case, because at the time the National Health Service was set up something like it might have been incorporated in it, and it might have solved this problem of the family's relation to the doctor and with it the problem of the early spotting of disease. The Peckham doctors, Dr. Scott Williamson and Dr. Innes Pearse, who conceived and realised the Centre, set themselves this problem from the first, and the system of family membership and of family overhauls seem to have gone most of the way towards solving it. But the problem is as urgent to-day, and however much we may regret the passing of Peckham, we must look for some way of solving it now.

I have spent a long time on the first of these two problems because it is the one to which the solution is much easier. Now I return briefly to the second, which is the Centre's longer-term objective—the study of health. Here we at Peckham were less successful, because, as I said before, we found very little health to study. I am glad to see from the Report and to hear from the noble Lord's lips that he agrees that health is not just the absence of disease. In the paragraph headed "Positive Health" he is bang on the target. He speaks of: … the lives of many people being impoverished by apathy, anxiety, self-pity or lack of physical energy. These people are in striking contrast with those who live a full life and appear always to have the energy to Give of their best. Health education in the future will be increasingly concerned with helping individuals to achieve real health and to adjust themselves more adequately to their environment. We found this again and again in our work at Peckham. We found that people seemed to have nothing clinically wrong with them but were in no sense healthy. Sometimes the doctors found a reason 1492 for it; sometimes they did not. But it was clear that health was not just the absence of disease.

In the course of his Report, the noble Lord has made many recommendations, with all of which I agree, for disseminating knowledge of preventive techniques—immunisation, cervical examination, anti-smoking and so on: and money spent here is certainly money well spent. But though Government can create an environment conducive to health, positive health can be achieved only by the personal response of the individual to the environment. I wrote that sentence myself, but I do not really know what it means. However, these are the things we are trying to find out. What it does not mean is that this response can be produced by hidden persuaders. I am perfectly certain that advertising campaigns are in no way connected with the development of health, and I hope that we shall avoid spending money on advertisements of a vague and uplifting kind.

There is only one agent who can persuade people to invest in positive health, and that is the family doctor. Under the National Health Scheme the specialists have flourished and gone from strength to strength. Rich and poor alike can rely on the best treatment in the world if their affliction is really serious. But if you just feel awful, and there is nothing clinically wrong with you, only your general practitioner can help you; and you will probably put off going to see him as long as I have. So we come back to the same point. The family doctor is by far the most fruitful source of health education in its fullest sense. He has been squeezed by events, overworked and under-valued. It is most important to reinforce his position. But how?

This brings us to the attempt at a solution to which I referred in my opening remarks. To me the most stimulating item in the whole of the noble Lord's Report begins with paragraph 235, where he describes in some detail the procedure of a partnership of doctors in Birmingham. These doctors decided to try to help the patients by what is now known as group training, which means group discussions and lectures, brains trusts and (a very interesting innovation) by involving the local authority health visitors in 1493 the work of their practices. This is something new and it is one of the noble Lord's recommendations which I think must be taken very seriously. Having cleared these ideas with other doctors, these partners began to give some lectures in the waiting room. They found them successful and overflowed into a welfare centre lent by the local authority, and generally got the community moving and thinking about these things in a very satisfactory way. The meetings must have had not only a medical but also a social value. It seems to me that here there is a hint as to how we could do something of greater value than posters and advertisements in spreading health education.

I should like to refer shortly to another instance of the same sort of thing which has come to my knowledge. A group of doctors in the North-East have approached us at the Peckham Centre and told us that they have all local authority support for starting something rather on these lines. I am most anxious that the noble Baroness, Lady Serota, when she takes up the reins, should be free to spend some of her £500,000, or whatever she succeeds in getting, on experimental schemes of this kind. It seems to me that if it is possible to get a group of practitioners who are prepared to co-operate and provide a clubroom with a canteen, and some elementary provision for children, it provides a nucleus from which one can begin to build something really useful, instead of having merely exhortations and propaganda.

This can be approached on an experimental basis, and all the experiments would be different. It is done now with youth centres and community centres, and the new idea which comes out of the Report is that something of this kind might be supported centrally for groups of doctors who wish to make this extra provision for their patients. It is important not to expect too much. These small innovations would not revolutionise the Health Service. But any step in the right direction is valuable, and the idea could spread and help to remove some of the frustrations of the G.P., and perhaps begin to restore to the family doctor his proper role of family friend and guide through the complexities of modern life.

My Lords, I want to thank the noble Lord, Lord Cohen of Birkenhead, for 1494 his Report and for bringing it before the House, and your Lordships for the kind attention that you have given me.

§ THE LORD BISHOP OF LICHFIELD

My Lords, I should like to be the first to congratulate the noble Lord, Lord Donaldson of Kingsbridge, on his maiden speech in this House. It was a speech which was full of wise counsel and advice, and I am sure we all hope that he will make many more contributions to our debates in the future.

I feel somewhat diffident in intervening in this debate, because I am without expert knowledge on this subject; but I think it is right that someone from this Bench should speak, and as the Health Service is a subject in which I have been extremely closely interested for many years, I ventured to put my name dawn. May I say how grateful I am to the noble Lord, Lord Cohen of Birkenhead, and the fellow members of his Committee for the most valuable Report which they have produced. I think we should go on emphasising this attitude which shows so clearly that health is a positive thing to be sought and guarded, and it is our duty to the community to do that.

As we read this Report, I dare say that many of us felt our consciences troubling us, with its recital of the perils into which we can so easily fall. Speaking as one who in the past used to take a great deal of physical exercise, but who now takes all too little, as I read this Report I began to try to make, at any rate, a few half-hearted resolutions in regard to it. The trouble is that the circumstances of life make it so difficult for many of us. The people who are under the greatest fire in this Report are those who are well represented in this House; namely, the middle-aged, those getting on in years. We come out of it extremely badly. But I am impressed by the fact that the circumstances of life make it difficult for people to take physical exercise, and if they are to face up to the proper guardianship of their health I believe that they have to watch it carefully and see that their duties do not impinge upon it. Not that we should constantly be thinking about our health; I think that is a bad thing. If we do 1495 that, we may fear that we have all manner of diseases. What we need is this change of attitude, and that, as the Report justly says, is not easy.

I noted that the noble Lord, Lord Cohen of Birkenhead, said to-day that people are reluctant to sacrifice present pleasure for future gains. Those words might have come out of a mediaeval religious book. It has been the same all along. We are so reluctant to give up present pleasures for what we know we ought to think about in the future.

I wish now to make one or two brief comments on various items in the Report. First, I would say how impressed I was with paragraph 131, and with one particular sentence where it says that we should regard excessive noise as challengeable as blasphemy. If we are to take this matter of people's health seriously, I feel that we ought to tackle this question of noise, which I think is rapidly becoming one of the curses of our age. I am not surprised that people who are going to find a new airport on their doorstep, with the screaming of the jets, react violently against it. And if we come into the towns there are the pneumatic drills at work, and the motor-cycles roaring up and down. Sometimes one feels that one could almost shriek because of the noise that goes on and on. I believe that to-day noise is having a serious effect on the nervous system of many people. If we are to take this matter of health education seriously, then I think this is one matter to which we could give our attention. To-day, as I know well in my diocese, many people are living in these enormous block of flats, and I hope that a good deal of thought is given to what, to me, is a most important matter, that of soundproofing, because sometimes you simply have to get away from the noise that other people so thoughtlessly make.

I wish now to say a word or two about the question of immigrants, which is also referred to in the Report. Here I think that we should pay tribute to some remarkable achievements. Again, I see this problem on a large scale in my diocese. People arrive from different parts of the Commonwealth with their different ways of life, and the problem of integration is very real indeed. This 1496 being so, I should like to pay my tribute to the work of the medical officers of health, to whom I think our country owes a great deal. They are people who come into the limelight only when something has gone wrong—perhaps an outbreak of typhoid, or something like that. We so often take for granted what they do for us. In this matter of the integration of our immigrant population, from the point of view of health education, and health generally, I think that the debt that we owe to our medical officers of health in our towns and cities is something that is beyond all praise. I welcome this opportunity of paying my tribute to them.

As in this matter one of the secrets would appear to be the provision of the right kind of training for key people in this work, I should like to draw attention to the fact that the Richmond Fellowship is providing training courses for health visitors, mental welfare officers and others, who especially need to find these new approaches to help the people to generally rethink. It is in the matter of rethinking that we want to get the general public interested, and if we can train the people who work among them by this specialised training I think we shall have rendered a great deal of assistance.

I turn now, quite briefly, to what I think is the vital message of this Report. It is that health is not just a physical or mental affair, but that man needs to be made whole in the whole of his being. That, my Lords, is exactly the same message as is found in the Gospels. It is there made perfectly clear that a man's physical health may suffer through the ills of his soul. Certainly that is true of his mind. So I would ask that there should be trustful co-operation between all those who work on behalf of our fellow men. May I say that I think this is increasingly seen in regard to the work of our chaplains in hospitals. I think that the doctors and nurses are more and more realising how much the chaplain can do to help the patient. But could this be urged on the medical students? Could it be made more plain to them in their time of training that this spiritual factor, allied to the mental factor, is something they should never overlook; because, after all, ignorance of the way in which we can all help one another in 1497 this matter of the health of our fellow men is surely wrong.

May I say just a word or two now about the general practitioner. We had some very interesting remarks on that subject in the speech just made by the noble Lord, Lord Donaldson of Kings-bridge. I would not myself take quite so depressed a view as he did, when he said that the old system had gone beyond recall. I am afraid that very often it has been lost. If a doctor has an enormous number of patients on his list and large crowds coming into his surgery, obviously it is very difficult for him to give the full time to each case which he would like to give. But I would plead that our doctors, our general practitioners, should always try as much as they can to show that they are not too busy for this work. When the Report said that what was needed was fewer prescriptions and more counsel and advice, I thought it was saying something that was profoundly wise. In regard to myself and my own family, I can only say that I have been only too grateful for the counsel and advice that on many occasions we have received from our family doctor; and knowing people as I have done in my clerical career, and the links I have had with many people in my parishes, I would say that many of them, too, appreciate greatly the true friendship of their family doctor, and I hope that would not be lost, because it would be a very great loss indeed.

If I may refer briefly to one other point, I should like to welcome the emphasis given in the Report to the value of marriage guidance. This is something on which many of us are very keen. It surely is very obvious that a happy marriage must encourage mental health and stability. It gives a secure background for the children's early years. The institution of the family has of late been under attack, and in some well-known lectures to which we have just been listening we heard about its narrow privacy and tawdry secrets. What that exactly meant, I am not quite sure, but I believe that the vast majority of the people of this country would be horrified at the idea of the disappearance of the family. Selfish actions which break up the family are very wrong, and I think, therefore, that the Report is very wise when it states that our young people 1498 should be clearly warned of the dangers of wrong behaviour. They should be told in no uncertain terms when they are young what they should do if they want to live a really purposeful, satisfying, useful life, and they should be warned that if they fly in the face of the advice that is given to them they may well find only great unhappiness and disappointment and disillusionment. I know that the young never react very kindly to advice doled out to them by their elders, whom they may not consider to be their betters. I realise that, but nevertheless I believe it true that schools and parents, and the churches, who have these young things in their care, should point out perfectly clearly what is the way in which they should go; and in this matter they should be joined quite firmly by the representatives of the medical profession.

I believe that in the young people of to-day we have some of the finest young people this country has ever had. They are very idealistic and full of essential social service. We have heard from the noble Baroness, Lady Brooke of Ystradfellte, about the fact that unfortunately some have given way to this dreadful habit in regard to drugs, but I do not think we ought to get things out of proportion. Thank God!, it is only a very small proportion, I believe, who have fallen into that kind of habit. Most of the young people are fine young things. What we have to do, I am sure, is to give them the kind of education which they must have if they are to develop their lives, and it is true that health education is undoubtedly a part of it. But I would say that it is strongly allied with moral teaching, and it is no good saying it is not. They should be shown the clear difference between right and wrong, and I think that if we are muddled in our advice to them we are serving them ill at a very impressionable time in their lives. I should like to say how grateful I am for the support I found on this subject in the words of the Report.

As I end, may I plead for co-operation between all of us—doctors, teachers, parents, clergy. We are all trying to do our best. But do not let us practise in separate, watertight compartments. Let us get to know one another more and trust each other more. If we can do that, I believe we shall be able together 1499 to do a great deal for the true health education of the nation. I feel we must face the fact that if a man is to be able to cope with difficulties later on in life he must learn some discipline. There is no escaping that, so far as I see it. And if we can learn through discipline to discipline ourselves, I believe that in that way we shall develop to the full the talents with which we have been endowed, and thus he of the greatest service to the community.

§ LORD GARNSWORTHY

My Lords, as this is the first time I have risen in your Lordships' House to speak, I respectfully ask for your indulgence. With other noble Lords, I should like to join in thanking the noble Lord, Lord Cohen of Birkenhead, for initiating this debate, and to say how much I appreciated the work and the Report of the Joint Committee of the Central and Scottish Health Services Councils. Health education is a very big subject and I can speak only as a layman, but a layman who has been privileged for some thirty years to serve as a member of local authorities, first as a member of Banstead Urban District Council and for the last fifteen years on the Surrey County Council. Perhaps it is because of that experience that I am very conscious of the vital role local government has played and the scope it offers in the spheres of preventive medicine and health education.

The services which local authorities run are not the most costly items in our National Health Service, but the value we get from them is very great indeed. Through the agencies of their health, welfare and school medical services they have achieved some very impressive results, but to help them maintain and improve the physical, mental and social health of our community a great deal more education is required. While, clearly, much of this needs to be directed at the adult population, I believe that the possibilities within our educational system itself offer a tremendous challenge, and if properly exploited would yield really impressive results.

The 1944 Education Act says: … it shall be the duty of the local education authority for every area, so far as their powers extend, to contribute towards the spiritual, 1500 moral, mental and physical development of the community by ensuring that sufficient education … shall be made available to meet the needs of the population of the area. That would seem to make quite clear that our schools have some considerable responsibility in this field. In some schools health education is taken fairly seriously, but the pattern is patchy, and the subject, as a subject, does not get the place in the curriculum it ought to have. It is true that school curricula are very crowded to-day. Everyone seems bent on hunting a certificate for something or other but education is, or should be, for life, the whole of life, and what is needed to produce healthy minds in healthy bodies, as the noble Lord, Lord Cohen of Birkenhead, put it, is surely of vital importance. Health education should feature not only in primary and secondary schools but should continue right on into establishments of further education. In paragraph 250 of their Report the Joint Committee say: Our inquiries in detail did not include schools". The noble Lord who opened the debate referred to this point. I think it was a great pity that they were not included, for I think it would have been found that in too many schools health education often tends to be everyone's responsibility and ends up as being the responsibility of no one in particular. Any future assessment ought to include detailed inquiries in our schools, for at this level we can anticipate good results from the effort that would be involved.

There are one or two particular matters to which I should like to refer. Antismoking campaigns seem to have an impact on young people where these campaigns are effectively undertaken in schools, but one feels that a great deal more needs to be done. The evidence of available statistics certainly denies that there is any room for complacency in this field, and as witness of that we have the Report of the Royal College of Physicians. I doubt whether many would question the influence of adult example in this matter, and those in close touch with children certainly ought not to avoid their responsibility. One appreciates that advertising on television has been checked, but a great deal of smoking takes place on all television channels by prominent personalities, and I think 1501 it would be a good thing if some attention could be paid to the influence that this may well have on children.

We are told that cigarette coupons are to be banned, but a leaflet in my letterbox only last week stated: The ban doesn't start immediately. There's still time to save for a gift, even if you only start saving to-day. It went on to say that a named brand of cigarette brings the gifts home twice as fast, and that if I smoke 20 cigarettes a day for 41 weeks I can get a Morphy Richards toaster. That is one of the baits that is being held out. But in order to get that toaster I not only take that bait but have to consume 5,740 cigarettes.

My Lords, the Report lays emphasis, in Chapter VI, on the widespread habit of the public of practising self-medication. Probably your Lordships will have seen the report of a statement by the President of the Pharmaceutical Society last Wednesday. He is reported to have said, and I quote here from the Guardian of December 14: There are more than 700 deaths and thousands of casualties each year due to accidental poisoning … The task of teaching the public to live safely with modern medicines has not yet been attempted on anywhere near the scale required … Advertising of medicines should be prohibited. I find that figure of 700 deaths quite staggering.

No-one can read the Joint Report without appreciating what it says on the subject of dental health and fluoridation. I do not wish this evening to be controversial, but it would seem to be desirable that the advocacy of fluoridation should at least match the efforts of the "antis" in this connection. Some excellent literature is available, but it does not seem to get wide distribution. When I think of the masses of literature that I get from the anti-fluoride people I feel that the other side are fighting this matter with their hands tied behind their backs.

There is one other point which I will mention briefly, and which has already been touched on by a number of speakers—it is a matter which I think deserves full consideration; namely, the need for educating people to meet the problems of age before they get old. A great deal of information could be made available to make life for the elderly less burdensome than it sometimes is, and here I 1502 think the rapid development of health centres could be helpful in a very big way.

I know a number of persons who are intimately involved, at county and district levels, in the service of public health and health education. People like Dr. Greenwood, of the Surrey County Council Health Department, and Mr. Powell-Johnson, who is the Health Education Officer for the county of Surrey. Such people have impressed on me that the great and urgent need is the formation of a new and stronger central organisation—a new Health Education Council for England and Wales and Northern Ireland. That Council has already been referred to this afternoon, and it should be formed as soon as possible. I am quite certain that we can look forward with confidence to some excellent work coming from that body under the chairmanship of the noble Baroness, Lady Serota. When this Council is formed I think it is most important (and I hope that we may have some reassurance on this point later) that it shall contain representatives from the teaching profession, in order to ensure that proper emphasis is given to health education in its broadest aspects in our schools.

In paragraph 202, the cost of the Joint Committee's proposals are estimated, as has already been said, to be in the order of £500,000— that is, about 0.06 per cent. of the cost of the National Health Service. Since the Minister of Health, under the National Health Service Act 1946, has the duty to promote the establishment of a comprehensive health service designed to secure the improvement of the physical and mental health of the people and the prevention (and I would underline the word "prevention"), diagnosis and treatment of illness, such a small proportion of the total cost of the National Health Service is a very little from which to expect too much. On the other hand, the more successful we are in the field of health education, the greater the reward.

In conclusion, my Lords, if this debate serves to draw attention nationally to the need for more health education, and, if I may say so, more important, to the need to provide the means for that health education, then I think we shall have even greater reason to be appreciative of 1503 the efforts of the noble Lord, Lord Cohen of Birkenhead, and his colleagues.

§ LORD PLATT

My Lords, I should like to start by adding my congratulations to the noble Lord, Lord Donaldson of Kingsbridge, on his maiden speech, and to say how pleased I am to have the opportunity of being the first to congratulate the noble Lord, Lord Garnsworthy, particularly perhaps because he touched upon a subject about which I hope to speak to your Lordships for a little time. First, let me say that their contributions to this kind of debate, for which this House is particularly noted, have been excellent ones, and we look forward to hearing them again. I also want to thank the noble Lord, Lord Cohen of Birkenhead, as we have all done, not only for his Report and his opening speech to-day, but also for the great work he has done for many years for medicine and medical education.

The question I wanted to address the House upon, fairly briefly I hope, is perhaps the biggest question in health education at the present day. That is the injury to health through cigarette, smoking. Although the present Minister of Health has devoted a great deal of attention to this subject, I think there are still ways in which Her Majesty's Government might do still more. As your Lordships probably know, I have a special interest in this because I was President of the Royal College of Physicians when we produced our now rather famous Report to which the noble Lord, Lord Garnsworthy, and others have referred to-day. I was Chairman of the Committee which produced it, though I always make it very clear that it was Dr. Charles Fletcher who initiated it and did more work than any other member of the Committee. I may also tell your Lordships that we were very particular to put two very heavy cigarette smokers on the Committee as members, and they both gave up smoking before we had finished examining the evidence. I would also make it clear that we did no research into the effects of cigarette smoking, but we examined all the evidence; and although other bodies, including the Ministry of Health and the Medical Research Council, had pronounced on the subject before, it is possible that our 1504 Report had more impact as it was particularly designed to be read by the intelligent public.

As the noble Lord, Lord Cohen of Birkenhead, has already said, the Chief Medical Officer of the Ministry, Sir George Godber, recently referred to the fact that we can be certain that more than 50,000 deaths a year in England and Wales are directly due to cigarette smoking. This he said at a recent World Conference on Smoking and Health in New York last September. He went on to say: From all this we certainty know shat we have to do, but I cannot tell you yet we know how to do it. That is quite true. At that same conference Senator Robert Kennedy was a little more outspoken. He said: Every year cigarettes kill more Americans than were killed in World War I. the Korean War and Vietnam combined, nearly as many as died in battle in World War II. Each year cigarettes kill five times more Americans than do traffic accidents. The cigarette industry is peddling a deadly weapon; it is dealing in people's lives for financial gain. In this country male deaths (or is it perhaps total deaths?—the male deaths, of course, still far exceed those in females) from lung cancer are about 27,000 per annum. That is about three to four times the deaths from traffic accidents, and it is rising by about 1,000 in each year. Deaths from coronary heart disease, the early ones in men of 35 to 54, are two and a half times as common in cigarette smokers as in non-smokers.

There is no doubt at all now that this can be prevented, because, as the noble Lord, Lord Cohen of Birkenhead, remarked, the British doctors, who have changed their smoking habits so that they smoke far less than any other group of people in the population, have, in eight years, reduced their rate of deaths from lung cancer by 30 per cent., while in the general public in the same time it has risen by 25 per cent. So this shows not only that it can be done, that this is a disease that can be prevented, but also that it is not too late to prevent it, and it disposes of the argument of those who say, "I have smoked for 20 years and it is no use giving it up now". Coronary heart disease deaths in ex-smokers are about half those of continuing smokers. The Minister of Transport announced in another place yesterday that the effect of 1505 the breathalyser had been so encouraging that it was possible that as many as 1,200 deaths would be saved in the course of a year if the figures went on at this favourable rate. What I am talking about is the possibility of saving 48,000 deaths.

I should like to say something about the effect of our Report. The first effect of our Report was this: the tobacco manufacturers, who until then had not been known as experts either in cancer or in health education, came on the television screens trying to discredit the evidence. I just ask your Lordships to imagine what would be the public outcry if whisky distillers came on the television screens and said, "Take no notice of this propaganda about drinking and driving. It is only statistical evidence".

The second effect was that within two years the cigarette manufacturers had increased their advertising by 50 per cent., so that in the year 1964 it reached a figure of £15 millions for the advertising of cigarettes alone. It is quite useless to say that this is just due to the increased cost of advertising and the increased tendency to advertise all goods, because the advertising of cigarettes went up far more steeply than the advertising of any other known commodity. At the same time, one large firm of cigarette manufacturers declared openly their intention to promote sales in countries such as Nigeria, in which the smoking habit had never really caught on. I ask your Lordships, can you imagine anything more sinister than that kind of response to evidence that enormous numbers of lives are at stake and people are dying of cancer? And, as we know, much of their advertising was specifically directed at young people.

It is well known that cigarette smoking is a very powerful addiction, as anyone, like myself, knows who has tried, in my case at last successfully, to give it up. Once you are hooked you tend to be hooked for life, and I have no doubt that this is a fact not unknown in the tobacco trade. No one would expect them to stop making and selling cigarettes—indeed, there would be a public outcry immediately if cigarettes were withdrawn from the market—and of course they did not originally know that the goods they were supplying were so damaging. But in the period to which 1506 I have referred the evidence was already quite plain. What shocked me was not only their reaction to our Report, but the fact that it seemed to be accepted as normal behaviour in commercial circles. This I do not believe, because I know many instances in which the pharmaceutical industry, having some evidence, perhaps not very strong evidence, that one of their products may be harmful, has immediately withdrawn it pending further evidence. So you may well say that what I am talking about is not health education, but anti-health education, and I think you would be right.

What have we positively achieved? There are, perhaps, one million fewer smokers than there were before, and particularly smoking has dropped among young men. Although, as Lord Cohen of Birkenhead has pointed out, this was so in 1965, the figures for 1966 were not so encouraging. Above all, there has been a general acceptance of the facts about smoking. There is, I think, much less smoking in train and tube railways than there used to be, much less among professional people, and far less among doctors.

But the need for health education is still great, directed not so much at fear but towards making the smoker the exception to the rule instead of the usual. We must not leave it to the young, because it is well known that children are less liable to smoke if their parents do not smoke. The onus is very much on teachers, both in schools and in universities. Beyond that, I would ask Her Majesty's Government whether they can do anything more to prevent the spending of these enormous sums of money which, as the noble Lord, Lord Garnsworthy, has pointed out, the cigarette manufacturers are spending on sales promotion of all kinds, sales promotion which goes on and on, the measure of its success being judged by the still rising figures of cancer of the lung.

§ BARONESS SUMMERSKILL

My Lords, may I, in the first place, congratulate the noble Lord, Lord Donaldson of Kingsbridge, and my noble friend Lord Garnsworthy, for the interesting form of contribution that they have made to this debate. We hope that on other occasions when what is sometimes called behind the scenes, the "health group" in this 1507 House meets, we shall again have the opportunity of hearing them make knowledgeable speeches, perhaps then on some other aspect. May I also congratulate my noble friend Baroness Serota on the honour—indeed it will be a privilege, as I am sure she realises—of being asked to preside over this important Board or Council or whatever it may be called. I am quite sure that her knowledge of local government will be most important, because we have been told that great emphasis is to be placed on the contribution which local government will make in this field of education. We all know that her name is known throughout the country in local government, and everybody has the greatest of confidence in her.

When I listened to the excellent exposition of my noble friend Lord Cohen of Birkenhead, I was rather struck when he told us who were going to be the educators. I must confess that I deeply regret that we have to rely upon doctors from India and Pakistan to implement some of these recommendations, when there is such a pressing need for just this teaching in their own countries. Meanwhile, so many of our teachers in our own medical schools train men to care for the well-to-do citizens of the United States of America.

Perhaps it is an association of ideas, but I was struck also by the emphasis which has been laid in this Report on the health and habits of over-indulged middle-aged men. I must say to my noble friend Lord Cohen of Birkenhead that I went through this section of the Report and I think it was mentioned about six times. I admit that I am more concerned with the circumstances which are outside the control of the individual, and with the unfortunate victim who has his health or lack of health determined by his field of work or some other circumstances over which he has no control.

However, the Christmas spirit is in the air and I do not wish to appear indifferent to the problems of the plump, middle-aged male. As I read this I thought, "His wife is now seeking a present for him". I am sure that noble Lords here who are doctors will agree with me that perhaps the most appropriate present which can be given are bathroom scales and a long strip mirror. This is the best practical advice that can be given to 1508 this kind of patient. It is advisable in these cases, in my opinion, for the moment of truth to dawn with his ablutions every day. I often find that doctors are a little hesitant about telling this kind of patient the real truth: that his symptoms arise from his indulging in either tobacco, drink or food.

Everyone is at risk, but I should like more emphasis placed on those at risk from industrial diseases and industrial injuries. The adolescent in our factories is a veritable innocent abroad, and our failure to give him adequate protection is a slur on British industry. Indeed, the Annual Report of the Chief Inspector of Factories is a reflection on our society. We had a debate on this matter a year ago. We were promised that something would be done. Little has been done. One of the Parliamentary Secretaries in another place said only two days ago that now more inspectors were being imported and so on. Nevertheless, the disease rate and the accident rate in our factories go up and up.

Again, the widespread disease, chronic bronchitis, is not new, but it is still one of the killer diseases. It is accepted by middle-aged men in our dirty, dusty factories with the same resignation as their fathers and grandfathers did before clean air was recognised as being essential to good health. I speak from experience, because for the last eight years of my time in another place I represented an industrial constituency, and I was shocked to think that in the twentieth century there were men working under such conditions. This is all preventable. Yet what is being done to-day? How are these men urged to demand better conditions? To provide good working conditions calls for expenditure, and the conflict between what is good from the standpoint of health and what is commercially advantageous is still raging fiercely.

Despite the irrefutable statistical evidence of the association between smoking and cancer of the lung—and we thank my noble friend Lord Platt for everything that he has done in this field—the advertisements that we have heard about are designed deliberately to lure their potential victims. We have heard of all kinds of instances tonight. We have heard my noble friend behind me reading from an advertisement. Last week I was in a health group in another place 1509 which is open to Members of both Houses, and the first thing that the chairman read was a letter from the tobacco industry inviting to lunch any Members in the House who would like to go, and no doubt at that lunch those Members would be told that all this talk about there being any connection between tobacco and cancer was rubbish. It is nauseating to think that the tentacles of this particular industry can reach right into the heart of the Palace of Westminster in this way. I regard it as corrupt that this should happen. But what powers have we? All we can do is to keep on telling the potential victims of the dangers.

The Report asks for more sex education, but this is always interpreted according to the attitude of those in authority, whoever they may be. It seems that television has superseded the "birds and the bees" as mentors in the mechanics of conception; but now that premarital intercourse is freely indulged in, is there any evidence that our young people are more stable, happier and less given to means of escaping from reality? While a great deal of newsprint is given over to drug-taking, little is said about the by-products of sexual promiscuity. There is a very serious increase in the incidence of venereal disease in the country, the illegitimate birth-rate is soaring, and all the misery involved for the unmarried mother is still there. Indeed, the treatment of the unmarried mother to-day, despite this permissive society, is broadly similar to that of the less permissive days since fundamentally she is treated as she was before, as an outcast. All the media of propaganda tell our young people that to have premarital intercourse means that you are "with it". I would say that the mental health of the male adolescent would benefit more from talks on the relationship of the sexes in a wide context in order to inculcate a sense of responsibility.

On this point, if I may digress for one moment—and this is relevant here—I should like to observe that the Divorce Bill which was promised some weeks ago has still not reached the Printed Paper Office. I hope that Mr. Wilson, the Member for South Coventry, and the Government who have helped with the drafting have had second thoughts, or are making fundamental alterations to 1510 make adequate provision for the innocent wife who will be compulsorily divorced. The provisions which have appeared in the Press in my opinion will embitter the relationship between the sexes which no amount of sex education will obliterate. If we are to have sex education, let us now approach these adolescent boys and girls in a more adult way and tell them of the responsibilities which they will have to carry when they are more mature.

I am very surprised to find in this Report no mention of iatrogenic or drug-induced disease. The side effects associated with consumption of inadequately tested drugs present a very grave health hazard, and our medical journals week after week contain articles, and particularly letters, from doctors who have observed these very serious side effects. I do not have to remind your Lordships of the most dramatic of them which focused the attention of the world, that is to say, the thalidomide tragedy. One of the 150 pharmaceutical firms—I repeat, my Lords, 150!—in this country may be fighting against time to get a drug on the market before a competitor captures the patent rights, and such pressures may cause clinical tests to be hurried and awkward results to be ignored. It is not the charge on prescriptions, but a curb on the prescription of proprietary drugs, when there is a cheaper equivalent, which is called for if we are to protect the patient and benefit the Exchequer.

This has been said time after time, year after year, and no effective action has been taken. The innocent, ignorant patient is still absolutely at risk. His little cupboard is full of tablets and powders, all of them unlabelled, which he takes with the same faith as some primitive savage. And yet these are being churned out by those 150 pharmaceutical firms in this country which I have mentioned, all of them competing with each other for profit. I suggest that if we are going to educate the public then we must apply our minds to this very important aspect of health. I am hoping that the Treasury—who I understand are going to look at all the social services in the country as well as the Defence Services—will recognise that tremendous savings can be made in this direction. The facts are that last year nearly half of the proprietary preparations prescribed came from United States-owned companies in