THE NATIONAL HEALTH SERVICE

§ LORD SORENSEN

My Lords, we are all grateful to the noble Marquess, Lord Lothian, for initiating this debate on the National Health Service, a service which has been of incalculable benefit to those who have suffered from afflictions of body or mind or have needed the means of ensuring good health. I trust that your Lordships will not think it extravagant or provocative if I say that to me it is some compensation to feel that although we have lost an Empire, we have a Health Service of which we can be proud and which can justify the appellation of "Great" to Great Britain.

In the course of my remarks I wish to provide some antidote to the more sombre and morbid aspects of the speech of the noble Marquess. Many other aspects of his speech were helpful. We appreciate them very much indeed and I will see that my right honourable friend the Minister of Health and his colleagues consider them. Many aspects of the Service have been brought to the attention of your Lordships from time to time, but we have not had a debate on the Service as a whole for some time. Therefore, I am grateful that we have this opportunity of making a general survey. Within the limited time at my disposal I cannot do full justice to the subject, and the criticisms, suggestions and inquiries expressed by the noble Marquess and other noble Lords will certainly receive the careful attention of the Minister and his colleagues. It will be impossible immediately to answer every point raised, but my noble friend Lord Beswick will do his best to reply to as many as possible later on.

My own task is now to record, as objectively and concisely as I can, the broad progress made in the development of the National Health Service since its statutory initiation in 1948. Personally, I believe this to be a fascinating and heartening story, as I presume your Lordships will agree, notwithstanding the inadequacies and imperfections of which all of us are aware. Moreover, I trust that this will provide an effective answer to any insinuations or allegations, here or elsewhere, that the National Health service is threatened with collapse or has 303 woefully fallen far short of the initial sanguine anticipations. In the more depressing parts of his speech, the noble Marquess referred once or twice to a lack of morale, to collapse and disintegration; and although at one moment he turned aside to say that he did not want to be a mere prophet of woe and gloom, I almost thought, before he said this, that part of my task to-day would be to try and rescue him from the discipleship of the prophet Jeremiah. I am glad that he showed signs that he did not want to be influenced by that particular gentleman.

Most certainly we must not be complacent, but while vigilance, imagination, enterprise, persistent drive and willingness to learn by experience must constantly be exercised, this does not preclude honest recognition of encouraging achievements. I should have welcomed a warmer note or two in the speech of the noble Marquess precisely on that point, for criticism, though valid and natural, particularly on the part of the Opposition, is likely to be more acceptable if there is an appreciation of the positive side as well as of the negative side. I submit that to see how far we have progressed we should do well to contrast the present comprehensive National Health Service of to-day with the wretched plight of many British people at the turn of the century; those who endured grievous burdens of ill-health and suffering, not only because of shameful social conditions, but also frequently because they could not afford to pay for necessary medical attention. Some of us could provide evidence of this from the experience of our own parents. Happily, that form of cruel social injustice no longer embitters human lives or haunts the conscience of a more fortunate minority. For that we can all be profoundly grateful.

None of us is unmindful of the noble efforts of philanthropic institutions and voluntary hospitals in bye-gone years, nor of the fact that in our own age medical knowledge and surgical skill have made an immense advance in preventive and remedial service. Whatever opinions we may have on birth control, certainly we cannot deny that methods of death-control have substantially extended the span 304 of human life. As I see it, our National Health Service embodies a now accepted sense of responsibility by the community for all its members who need therapeutic restoration to good health. It receives the support of all political Parties and of the overwhelming mass of our citizens, even though they may seek its improvement and may voice subordinate criticism. Many other countries also have their own form of National Health Service, and in those that do not, or where the concept is resisted, there is growing pressure to emulate our example.

With the assumption, therefore, that all noble Lords, including the noble Marquess, offer their criticism or advice because of their profound desire further to improve the National Health Service, I shall give the House some of the facts and figures that illustrate what has been achieved and what developments have been planned. This will provide material by which we can refute merely ill-informed criticism, as distinct from what is valid and constructive.

First, let me deal with the Hospital Service because that represents the greatest measure of public provision, and also involves the largest proportion of public expenditure. Of the 2,800 or so hospitals which the National Health Service took over at its inception in 1948, many were small, wrongly sited and, worst of all, had obsolete buildings, nearly half having been built in the last century. During the period of post-war reconstruction we had to wait until national resources had grown sufficiently to enable a start to be made in removing this accumulated obsolescence. A national plan for modernising and rationalising the hospital service throughout England and Wales was therefore formulated; and it is quite misleading to suggest that this plan no longer exists. The pattern outlined in the Hospital Plan, and which has already begun to take shape, is to replace numerous small and ill-equipped hospitals by a network of large, modern district general hospitals, each having a wide range of facilities for diagnosis and treatment. Four district general hospitals have already been completed and are in use, and major parts of 60 others, while substantial contributions to 50 more are currently under construction. Hospitals of other kinds will, of course, continue to be required, either to serve areas 305 where, for geographical or other reasons, a large general hospital would be inappropriate, or to serve particular purposes.

From 1960 hospital building has made good progress, and more recently there has been a marked growth, both in the programme as a whole, and in the undertaking of really large projects which will contribute to the long-term improvement of the service. Work to the value of £99 million was started in 1965–66, including 18 projects costing over £1 million each, compared with £50 million, or only half the 1965–66 figure, and six projects of over £1 million, in 1962–63. During the 1950s the value was considerably lower and averaged about £15 million a year. Actual expenditure in this year alone is expected to be more than £75 million, compared with a total investment of £336 million during the whole period from July, 1948, to March, 1966. When we speak of investment, I would maintain that this is a splendid national investment, with the dividends accruing in the better health of the people as a whole.

According to present plans, about £1,000 million will be spent on hospital building over the next ten years. At an average expenditure of £100 million a year this will be, in real terms, more than double the rate obtaining just before the last war and more than four times the average for the post-war years up to 1966, that is, £23 million. The experience gained in the highly specialised field of hospital building, and a greater measure of standardisation in both design and construction, to which the noble Marquess referred, will, it is hoped, lead to increased efficiency in the use of resources, without depression of standards. The Ministry of Health has launched two development projects: the first will attempt to design and build two hospitals providing the same standards of service, but at substantially reduced costs; the second aims at the country wide standardisation of complete hospital departments of the commonest kinds, such as wards, operating theatres, maternity and out-patient departments. The evidence is of considerable progress being made, but it is not enough. It has been urgent for years, and now it is being thoroughly and energetically tackled, within the limits imposed upon it. Swifter progress, much as it is needed, cannot be achieved without the necessary 306 resources of money, manpower and materials which are dependent on the growth of the national economy.

Turning now to the staffing of the Hospital Service, again there has been a very great quantitative increase. We hear a great deal about staff shortages, which, of course, do exist and are sometimes serious, but little about the solid achievement represented by the great number of staff in post—no doubt because good news is no news.

I present your Lordships with a few other significant facts. We have heard much in the news in recent months—we have heard something of it to-day—about the serious shortage of doctors. In 1949 there were approximately 11,700 medical staff in the National Health Service hospitals in terms of whole-time equivalents. In 1965 the number was over 18,900, and in 1966 over 19,500. The increase since 1949 is about 67 per cent., and even in the last 12 months there has been an increase of over 600 or about 3 per cent. We certainly want more hospital doctors, and my noble friend Lord Beswick will later indicate what is being done to increase the supply, but meanwhile I would say that the picture is not one of steadily declining numbers.

Let us consider nurses, at least in respect of the National Health Service. Here I share with the noble Marquess the tribute he paid to this branch of the Service, as well as to many others. Here we have a particularly good record of recruitment, although we must of course continue our efforts. In hospitals, the overall numbers of nursing and midwifery staff in England and Wales—and all my figures relate to this area—have risen steadily over the years from 148,812 in 1949 to 258,675 in September, 1966. With all the difficulties, there has been this remarkable and encouraging progress. This shows an increase of 47 per cent. in whole-time staff, while part-timers more than doubled—that is, there was a 221 per cent. increase. In the last five years alone, the strength of the nursing and midwifery services, after taking into account the effect of the introduction of a 42 hour week by January 1, 1966, has increased by 12½ per cent. This compares with a rise in the overall working population of the country of 3 per cent.

307 Similarly other professional and technical staff in hospitals concerned with diagnosis and treatment have doubled in number since 1948. Nearly 30,000 staff are now engaged in the para-medical professions and as scientists and technicians. Many present technical occupations did not even exist in 1948. Of the long-established professions, I will mention that physiotherapists have increased in number by more than one-third, and dietitians by more than one half. Radiographers and occupational therapists have doubled, and in some categories, such as medical laboratory technicians, numbers have nearly trebled. I forbear to stuff more staffing statistics into the sympathetic ears of your Lordships, though I fear that for public purposes I must deal with some other statistical material. I hope, however, I have made it clear that, perhaps contrary to popular belief, over the years the resources of man and woman power devoted to the Hospital Service have spectacularly increased—much more than the increase in the population. It is not unreasonable to deduce from this, therefore, that the standard of service has also risen, despite what the noble Marquess has said.

Numbers of staff and expenditure of money are not, of course, by themselves decisive. As the noble Marquess has pointed out, efficient and effective use of resources is crucial, and constant efforts are being made to ensure this. The nationalisation of resources—one of the greatest benefits of a National Health Service—has lead to a planned reduction of beds which had increased after the appointed day to a peak figure of 483,000 at the end of 1958. At the end of 1965 they totalled about 470,000. But such has been the improvement in the management of resources that the number of in-patients treated has increased from 2,900,000 in 1949 to 4,800,000 in 1965, an increase of 65 per cent., and the number of new out-patients seen at consultant clinics increased from 6,100,000 in 1949 to 7,500,000 in 1965. New attendances at accident and emergency departments increased from about 4million in 1949 to nearly 7 million in 1965, and this is not simply accounted for by motor-car accidents; industrial and domestic accidents also are far too high. These achievements are due in 308 large part to the efforts of doctors, nurses, medical auxiliaries and all the other hospital staff who labour so tirelessly for the sick and injured, and also to the giant strides in medical progress which have, for example, enabled the average length of stay of a patient in an acute hospital to be reduced from 18.2 days in 1955 to 12.7 days in 1965, without there being any deterioration in treatment.

Admittedly there are areas of strain in the Hospital Service; there are bound to be. There are growing pains. Waiting lists have begun to rise again, and totalled 529,000 on September 30, 1966, but this rise must be viewed against the steadily increasing population of England and Wales, and against the background of nearly 5 million hospital admissions each year, and also it may in part be due to increased attention to gynæcological ailments. Patients needing immediate treatment admitted without delay account for half of all admissions. Hospitals are making every effort to reduce waiting lists and are constantly examining the possibility of transferring patients from long to shorter lists, of utilising under-used resources—for example, by making use of operating facilities in psychiatric hospitals for general patients—and of making optimum use of the resources they have.

I turn now from the Hospital Service to local authority health services. These complement the hospital and specialist services and the general medical and dental services, and aim at the cardinal necessity of promoting health and well-being and preventing illness and disability. I entirely share the observations of the noble Marquess in this respect. Where illness and disability nevertheless occur, the local health services aim at providing domiciliary care within the community or in centres or in residential and other accommodation. These services comprise, first, the personal services given mainly in the home by health visitors, midwives, home nurses, social welfare workers, home helps, and the ambulance service. Then there are the facilities provided in residential homes and training centres or social centres for the mentally and physically handicapped. Care in the community by these services supports, and is supported by, the care given by the invaluable family doctor.

309 Since the inception of the National Health Service this type of service has expanded considerably. This can be illustrated by the increase in the number of staff employed and by the rise in the level of capital investment. Statistics for local authority staff were not, regrettably, collected from the outset, but the figures now available show substantial increases up to date, and surely this is heartening. Between 1949 and 1966 there was an increase in health visitors from about 3,750 to 5,290, 41 per cent.; in home nurses from about 5,780 to 8,390, 45 per cent.; and in home helps from about 10,510 to 30,240, 188 per cent.

Regarding the home helps, I would interpolate that I know what a tremendous boon they have been to numerous persons who are harassed or infirm or sick in their homes. One hopes that more will volunteer, at least to give part-time work in this splendid part of the service.

Between 1959 (earlier figures are not available) and 1966, the number of mental health social workers increased from about 910 to 1,830, 101 per cent. After a decrease to 1956 the number of midwives increased in the next ten years to 1966 from about 4,650 to 5,200, or 12 per cent. This I think indicates some progress, and in giving these figures I do not seek to imply that all needs are met—indeed I know they are not; and there are many unfilled posts—but the figures do show that the local health services have secured a creditable increase in the man and woman power they employ.

For capital investment in the local community health services the annual amount of loan sanctions recommended by the Ministry of Health has risen over the years from an estimated £1.2 million in 1949–50 to about £9.5 million expected in 1966–67. To these figures must be added capital expenditure by local authorities from revenue and other resources. In recent years this has been running at about £3 million to £5 million per annum on health and welfare. All this registers in general a significant level of improvement and expansion achieved in the capital assets of the local health services. These figures, with those for staffing, reveal that these local services have had vigorous development over the years—a matter for which the country 310 should be grateful to the local authorities who plan and run the services.

Time does not permit me to describe the growth of each particular local authority service separately and there would only be complaint if I even started to do so. But there is one group of services that demand special mention because they represent not just an increase in volume but a change in approach as well; namely, the services for the care of the mentally disordered in the community. Having served on a county mental hospital committee for twenty-one years I am greatly impressed by the remarkable progress made in this sphere. These services have grown particularly fast in recent years. Revenue expenditure has been rising by about 20 per cent. per annum and it is expected that this rate of increase will be exceeded in the current financial year. There is now a fuller recognition that the needs and capacities of people suffering from mental handicap or disorder differ more in degree than in kind, from those of others. More social workers, of whom a higher proportion have completed recognised courses of training, are employed year by year, and the development of social work services is doing much to assist mentally handicapped people and their families to understand and cope with the situation with which they are faced.

A number of local authorities now provide residential accommodation to relieve families for short periods of the most exhausting task of looking after their mentally handicapped members; and all of us have had some experience of this type of tragedy in our own homes, ending in the more balanced members of the family breaking down under the strain. There has been a rapid growth in the provision of places in training centres run by local authorities for teaching the mentally handicapped, especially for children, and since 1964 the Training Council for Teachers of the Mentally Handicapped has done much to promote the provision of regular instruction for the teachers who work in these centres, so that the benefits of the latest developments in teaching practice and theory will be available to the handicapped.

I have not so far mentioned the general dental service. There have been considerable improvements in the dental treatment received by the country since 311 the inception of the National Health Service. The trend has been steadily towards the conservation of teeth. Whereas in 1935 a sample of National Health Insurance returns showed that 6.15 teeth were extracted for each filling done, and even in 1949 2.36 teeth were extracted for each filling, by 1965 over 3 fillings on permanent teeth were inserted for each extraction carried out. The amount of treatment given to children has increased yearly, and in 1965, 5,815,000 courses of treatment were provided for the 7½ million school children aged 5 to 15 in England and Wales by the general dental service and the school dental service. This is in addition to some thousands of children treated in hospitals. Here again treatment was directed towards the conservation of teeth, and in the permanent teeth of these age groups seven fillings were done for each extraction.

The one branch of the Health Service I have not so far mentioned in any detail is the vitally important one of the family doctor service. We are all well aware of the family doctors' central position in the Health Service. Because this is a service provided by 20,000 individual doctors, comparative statistics for buildings and staffing are not available. There has again been a substantial increase since the early days of the Service, from some 17,000 to some 20,000. There are special problems here, and the special action that has been taken, which we hope will transform the future of the Service, will be described by my noble friend Lord Beswick, who will wind up the debate.

So much for the development of the physical framework for the provision of health services. I feel sure your Lordships will agree that the picture is one of steady development and expansion and emphatically not of decline. In the hope that the lively interest your Lordships will transcend a natural inclination to exhaustion, I trust noble Lords will bear with me while, towards the end of my speech, I give a little more information. I should like to say something of the advances to which all this development is geared and for which it exists—the advances in medical care itself.

Since 1948 scientific and medical research have made wonderful strides forward. The medical knowledge acquired 312 has enabled new therapeutic procedures to become available for the treatment of disease, and also new techniques to establish accurate diagnoses so that diseases can be identified at an earlier stage. With the development of more powerful means of diagnosing and treating illness, the medical team is more in a position to help the patient than ever before and to employ methods in which the margin of error is reduced. Similarly there have been considerable changes in the pattern of disease and medical care, resulting from the introduction and development of immunisation procedures for an increasing number of infectious diseases (diphtheria, whooping cough, poliomyelitis, tuberculosis and tetanus), the increasing use of existing antibiotics and the discovery of new ones. The result has been extraordinary changes in the mortality rates for some of these diseases. Whereas in 1948 there were over 21,000 deaths from tuberculosis, in 1965 there were only 2,282. Diphtheria, which claimed 155 deaths in 1948, claimed none in 1965; and finally poliomyelitis, which cause 326 deaths in 1948 caused only 2 in 1965. This, I submit, is part of the dividend to which I referred, as a result of our national investment.

In maternity care the most important developments have been the emphasis on ante-natal care, the need for proper selection of mothers for hospital confinement and the progressive increase in the percentage of mothers delivered in hospital. The maternal mortality rate fell from 1.17 per 1,000 total births in 1947 to 0.25 in 1965 and the length of stay in hospital consultant beds of maternity patients has been falling for the last ten years from 12.1 days in 1955 to 8.6 in 1965. The infant mortality rate has also fallen between 1944 and 1965, from 40 per 1,000 live births to 19 per 1,000. This is relevant, too, to the amazing fact that whereas, when I was a small boy, the expectancy of life was just over 50, it is now 70 years of age.

In relation to psychiatric services, the application of new advances in pharmacology and the expansion in use of electroplexy have revolutionised the pattern of medical care. To-day the accent is increasingly on early return of the patient to community life. Stay in hospital has been dramatically reduced. In the 10-year period from 1954 to 1964 the number 313 of occupied mental hospital beds fell from 3.4 to 2.7 per 1,000 population, and there is good evidence that this trend will continue. The psychiatric hospital of to-day needs to be closely linked to other hospitals, family doctors and local authority health and welfare services and, of course, the community they serve.

Modern anæsthetic techniques and the introduction of antibiotics have made great advances. Scientific methods and the use of new materials have led to the development of a new range of surgical procedures, such as open-heart surgery, replacement surgery using human organs and tissues, and intermittent hæmodialysis for renal failure. Hospital authorities are seeking to increase the facilities for this specialised treatment in hospitals with full departments of renal medicine.

Lastly, I would emphasise that preventive medicine is playing an increasing role. Mass miniature radiography for early detection of lung disease is playing a valuable part in the control of tuberculosis, as the figures indicate. In addition, the examination of cervical smears for evidence of cancer of the neck of the womb, about which Questions have been asked in this House, has now reached the scale of more than 1¼ million examinations annually. More, of course, still has to be done. It is probable that other screening tests for early treatable disease will be developed and applied to groups at special risk or even to the whole population.

My Lords, developments in medical science issue from the skill, knowledge and initiative of professional people. The organisational framework of the National Health Service provides the means by which the benefit of these developments is conveyed to the population at large. Because without that their value to us all would be less, it is legitimate to claim some credit for the National Health Service in what has been achieved.

I repeat, we can never be complacent, whether we are professionally or administratively involved. We certainly recognise how much is still to be done, even though we are grateful for so much that has been achieved. Such is the pace of development in medicine that there are always new problems to overcome and new developments to find room for. But 314 any suggestion that the morale of the Service is failing because it is being starved of resources, or is being wasteful is, I am positive, ludicrous, even if it is not mischievous. The demand for health services is limitless. All of us would like to see greater and faster expansion, and an even larger share of national resources devoted to health. On this we can all agree. But I am sure your Lordships would not wish to minimise, as I am sure the noble Marquess does not, the really great achievements of the National Health Service in its first twenty years of existence. It is an institution for which, with all its defects, most people have gratitude and of which most people can be proud. Again I thank the noble Marquess for initiating an invaluable debate, and I apologise if I have kept your Lordships too long.

§ LORD AMULREE

My Lords, the National Health Service, as the noble Lord has said, was instituted about twenty years ago, and I believe it is valuable that from time to time we should take stock of what has gone on. So far as I can recall, there has not been a general debate on the Service since 1952. Various points have been discussed, but there has been no general debate. Therefore we are all very grateful to the noble Marquess for putting down this Motion to-day. I do not want to follow him in the very broad look he took at the Service; nor do I want to follow the noble Lord, Lord Sorensen, in the detailed account he gave of the Service as a whole. But I should like to touch briefly on one or two points which seem to me to be important and in which I am particularly interested. Before I begin, I would say that I do not think that the suggestions that one has seen in the Press and elsewhere, that the Service is in danger of collapse, are really true. There are certain strains on the Service which cause difficulty, but to say that it is in danger of collapse is quite wrong.

One of the matters on which the Government are frequently chided is that they have not produced more modern hospitals in the time the Service has been going. But we must remember that when the Service was introduced in 1948 the Government were faced with the prospect of taking over about 50 per cent. of hospitals which had been Public Assistance institutions, Poor Law institutions, 315 built in the nineteenth century; and the first job was to turn these into good modern hospitals. And that I think we may say, is something which has been done with very great skill and, on the whole, with great economy. In most of these buildings the walls and roofs were well built and strong; the builders in the nineteenth century did know the right way to build. Speaking as one who has spent my whole seventeen years in the Service working, together with many of my colleagues, in what were formerly the infirmary or the Public Assistance institution, modernised in a very skilful and proper way, I can say that this has been a very successful policy. The time is now coming when not much more can be clone with these hospitals, but they tided us over very well for a very long time.

Another cause of strain has been the lack of doctors in the Service. The noble Lord, Lord Sorensen, said that the hospital doctors have increased in number. That is true, but they are not quite so important as the general practitioner side, where the numbers have tended to fall. It is a curious thing that a number of new universities have been started in the last ten years, but not a single one has a medical school attached to it and functioning. The Robbins Report did not refer to medical education, because I think it was not in the terms of reference which were put to the noble Lord when he conducted his inquiries. I think I am not completely accurate there: there is one paragraph, or possibly two, in that large Report which mentions medical education. We have been told that there are to be new medical schools at Nottingham, Southampton and Durham, but nothing has yet occurred, and one must not forget that even when a school is started it is at least ten years before a doctor able to practise will come out of that school. One would have thought that Durham, which has part of the school already there, because the Newcastle University has only just split off from it, would have been a place where a school could have been started almost at the present time.

It has been said, too, that even if we train more doctors, it only means that more doctors will be leaving to practise in foreign countries. I do not think that is true for one moment. I think that the 316 cause of quite a number of doctors leaving the country is not lack of money or the difference in remuneration received, because I do not believe that my profession is quite so mercenary as all that. It is the overwork, the strain and the lack of facilities generally. I think that if we got more doctors, that situation would be eased.

Again—and this is most important—we ought to know what number of doctors go permanently to work abroad Although it would be difficult to find out, by an intelligent inquiry I think it could be done. It seems to me a most proper and correct thing that as many young doctors as possible should go and spend a year or two in some country where they can get further experience. I think one should encourage that by every possible means, in the same way as one should encourage as many doctors in the developing countries to come to this country, provided they can get proper training and experience when they come here. But we do not know at all what are the total numbers who go abroad and never come back again.

One subject which the noble Marquess mentioned was the care of the chronic sick. That aroused great interest in me, because the first time I addressed your Lordships' House was in October, 1946, on the occasion of the Second Reading of the National Health Service Bill, as it then was. The burden of my speech was the care of the chronic sick, to which the Government made no reply at all. So I should like to come back to this subject again after twenty years, and the type I am referring to, and perhaps the type that the noble Marquess referred to—I do not want to deal with the old people; I have done that frequently in your Lordships' House and probably you have heard all I have to say on that many times—are the young, the disabled, the middle-aged, those suffering from the chronic nervous diseases and those suffering from various forms of arthritis who need a good deal of care and attention.

The National Health Service makes some provision for them. I think there are 400 beds all told, with about another 200 contractual beds. Perhaps the noble Lord will correct my figures later on if I am wrong. But we do not know really what the size of the problem is. We do know that these patients stay in 317 these beds, roughly speaking, until they die. Supposing they are well taken care of, their expectation of life can certainly he nearly as long as that of a person living at home.

I must declare some interest in this subject because for a number of years I have been a member of the Board of Governors of the Royal Hospital and Home for Incurables at Putney. This was a big home of about 250 beds which, together with one or two similar homes, was disclaimed by the Minister when the National Health Service first came into being. There we provide an extensive nursing service and a good deal of therapy. There is a large occupational therapy department and a large physiotherapy department. This is not done with the purpose of curing people; it is done with the purpose of maintaining what functions they have, which is most important, so that they do not become too much of a strain on the nursing care. It is done also to encourage their morale and make them feel that something is being done for them.

We have a waiting list there—and I think this must apply also to the rest of the country—of about two years. This does not really mean anything. If you get a waiting list of that length, it means it is much longer really but that people do not bother to put down their names. We have a turnover there of 15 people per annum which comes about through people dying. So you can see that it takes a long time to deal with this problem. These people are the type of patients who demand urgent attention, and one would like to see something more done for them. At present some of them go into welfare homes under the local authority, where they get kind care and attention. But they get practically no medical treatment, and little in the way of physiotherapy, because the welfare homes do not deal with that kind of treatment. One wonders whether it would not be possible to connect some of these beds in the welfare homes with the Regional Hospital Boards, or that some of the staff of the hospitals should have access to them, so that treatment such as is desired could take place.

I do not believe that this would be a costly affair. In the long run it would probably save a certain number of beds—not many, but a certain number. It would 318 do one important thing: it would be one step towards breaking down the tripartite system upon which the National Health Service is at present based: that is to say, the Regional Boards on the one side with the boards of governors, and the local authorities and the Executive Councils. That has always seemed to me to be a wasteful and difficult way of doing things, because one sees these bodies run on parallel lines, and, as we were taught at school, one of the characteristics of that is that they never meet but go on into infinity. It is a pity that we have these parallel lines. Any contact made is purely on a personal basis, and not officially. I think if we could get something of that sort to which I have referred it might be a start towards breaking this down. One has got to look forward one day to some kind of regional set-up for the care of people of all sorts. I do not want to go into this subject further, because what happens will depend largely on what is said in the Report of the Royal Commission on Local Government when it appears. I should have thought they would be bound to deal with this among some of the other problems.

I should now like to turn briefly to the care of the junior hospital medical officers, about whom there has been a good deal of talk in the Press, and a good deal of discussion as to their troubles and future. I have a certain sympathy with them in some of their troubles. One of the things I should like to see encouraged is the provision of simple married quarters for these young men and women who have got married. It may be said that it is most improvident of them to get married. I do not agree. People are getting married now much younger than they did in the past. Why should doctors be told that they cannot marry merely because nobody can provide them with a simple room in which to live with their wives? I should like to see more encouragement in that respect. I am told that if you go into some of the more unattractive parts of the country, like the North-West, which does not draw people to it willingly, married quarters are more frequently available than they are down South, where conditions are more attractive to people coming to settle there. Supposing that is true, what can be done in the North can be done in the South. It may be one more case of Manchester 319 showing London what is the right thing to do.

Certainly the strain on these young men can be extremely great if they have to keep up two homes. It is no doubt more simple now that they no longer have to pay a lodging allowance if they are compelled by their job to live in hospital. However, I do not understand why they have to pay for their meals instead; because the difference between the amount they have to pay for meals and the amount of the former deduction of lodging allowance is so small that it hardly seems worth commenting upon. I wonder whether this matter could be looked into again in relation to the people who are forced to live in and who have to take their meals in the hospitals.

One must not forget that these young men and women, who work extremely hard, are a unique body of people in this country. They are training in order to get experience in their work, but at the same time they are learning to take on an enormous responsibility which very few people of their age are called upon to shoulder. Therefore, they need very good food to be provided to them by the hospitals, and I do not see why they should be forced to pay for it. As the noble Marquess mentioned, it is a sad thing that in many hospitals such a large amount of food is wasted. On the face of it one would think that it would be a quite simple exercise for a hospital to cater for its population, because it knows exactly the numbers whom it has to feed. This is quite unlike catering in a restaurant, where a fine day may mean very few customers, and a wet day may bring in a large influx of people, and where the whole matter is so uncertain.

§ LORD SORENSEN

My Lords, what the noble Lord says is quite right, but I am sure he appreciates that the patients do not always eat the food that is provided for them.

§ LORD AMULREE

I agree that it is not a simple matter, and perhaps one may tend to over-simplify; but that is no reason why the food should not be absolutely first-class.

A further point which troubles some of the younger people in the medical world is uncertainty about the career structure with which they are confronted. 320 Many of these young men and women are the consultants of the future, the people upon whom medicine depends. It would appear that in some specialties there are more people training than there are posts for them to fill when they have completed their training. I must say that this is not so in some cases, certainly not in my own field. When I started in 1949 we had four or five consultants in the geriatric field. Now, we have more than 200, so I cannot complain there. But certainly in some specialties that is not the case. One wonders whether the number of consultants is growing as fast as was expected when the plans were first thought out.

I should like to make brief reference to two more points. First, I should like to see some sort of experiment carried out on the preventive side. Would it not be possible in some centre of population, particularly in places where there is a university, for a complete preventive service to be established? Cytological examination of cells for cancer, regular X-ray, health checks on babies and old people, checks on industrial hazards, and so on, could be evaluated properly by a social service department, say, in a neighbouring university which would give some idea, fairly quickly and on a large enough scale, as to what preventive services should be encouraged and what should be left to take second place. It would be difficult to push them all along at the same speed if one did not know which were really important.

Finally, I would join with the noble Marquess in the kind words he said about the Ministry of Health. It is a body which is frequently attacked, by all sorts of people, for not doing its job properly, for being difficult and awkward, and so on. We have at present one of the best Ministers who has ever held office. He is not now on the Steps of the Throne, but he was there a short time ago. Speaking from my personal experience in the various capacities in which I have worked in the Health Service, I have had a good deal of contact with the Ministry and its staff, and have always found them to be friendly, co-operative and prepared to help, and certainly willing to do all they can to improve the Service for which they are responsible. Of course they have certain difficulties. The proportion of the 321 national budget available to the health services is not so great in this country as in some other countries, but I would far rather regard the Ministry of Health as my friends, with whom I can argue and discuss, and with whom from time to time I do not necessarily agree, rather than as my enemy who must be fought all the time.

§ BARONESS SUMMERSKILL

My Lords, I find it extremely difficult to reconcile the statement made at Question Time by the noble Viscount who sits on the Back Bench, when he expressed his warm appreciation of the casualty services—which he himself, having had an accident, experienced—with the speech of the noble Marquess, which was gloomy and despondent, and which in its opening words, as he will see when he reads Hansard to-morrow, prophesied the imminent collapse of the National Health Service. I was very surprised, because the noble Marquess has had a great deal of experience of the Health Service, and he could have summed up the situation a little more constructively. Indeed, his whole approach was destructive—in fact I cannot recall his making one constructive suggestion.

If I criticise the National Health Service, I do it a little as I would criticise my own family. I may appear to be a little severe, but I feel strongly possessive, very friendly, and only too anxious to improve matters. I say to the noble Marquess that his criteria are wrong. The chief criteria which he levelled at the Service was one of cost, but he did not make the very important equation of equating the cost with the human happiness and well-being of the population. My noble friend Lord Sorensen summed-up the whole matter in the last 10 minutes of his speech. He applied the right criteria—the morbidity rates, the mortality rates, the expectation of life, and indeed the increased well-being of the people, their health consciousness, and all those matters. Perhaps I should not say "all", because we are evolving; and in this evolution our social services and our conditions of life have improved. But to a great extent we owe this tremendous decrease in our morbidity and mortality rates to the National Health Service.

I have taken part in many of these debates, and I am going to begin what I am 322 going to say with what a noble Lord opposite always calls my ritual dance. Once more I have to say how deeply sorry I am to see the appalling consumption of pills, tablets, powders, and indeed all those medications for which patients go to their doctors. The years have passed, and to-day drug addiction makes headline news. It is now proposed to place stricter limits on over-prescribing, which the Brain Committee believed was responsible for much of the supply of heroin and cocaine. A tribunal is to be empowered to investigate cases of over-prescribing, and the final sanction may be the removal of a doctor's name from the register. He will be struck off the register, which means, of course, that he will be deprived of his means of earning his livelihood. It is a terrible sanction on the medical profession.

Many doctors believe that this development is not surprising, and I am one of them. The drug bill has been rising every year, and I see from the Annual Report of the Ministry of Health that this year drugs will cost us £111 million. Indeed, many patients get these tablets, pills and powders on demand. The pressure on the doctor is such that he finds it difficult to refuse. Also, of course, there is no cessation of the avalanche of advertisements which doctors receive, and their surgeries are still besieged by glib young salesmen recommending their inadequately tested wares.

My answer to this is not to put a 1s. or 2s. charge on the prescription. In view of the high costs of drugs to-day, I do not believe that that would make an appreciable difference. I believe that, while doctors are paid on a capitation basis and are therefore deprived of their real freedom, there will be no effective control on prescribing. I have said on many occasions that the real control which should be applied is that doctors should be asked to prescribe from the National Formulary, which is supplied by the Ministry of Health, and that if they have to prescribe outside that Formulary they should say why. It would appear from the Brain Report that the worst offenders do not adopt a higher moral standard when drugs of addiction are demanded from them. In consequence, we are now faced with further expenditure. We have to embark on fresh 323 expenditure to try to remedy the injury done to those dependent on drugs.

It seems to me that the administrators view the Health Service from an entirely different angle from that of the doctors and others engaged in the essential work of healing and preventing disease. While statistics dominate the thoughts of the administrator, the medical worker is motivated first by his vocation. I listened to the noble Lord, Lord Amulree, and heard him describe the lot of the young doctors in the hospitals. What makes those doctors go forward comparatively cheerfully is the fact that they have a vocation. Their vocation comes first, and secondly, of course, they consider adequate remuneration and leisure. Unhappily, the administrator has allowed his calculations to blind him to the importance of this second consideration. The result has been that the Service has excited powerful public pressure, which has manifested itself in an unprecedented threat of strike action from the general practitioners. I think we should congratulate ourselves on the fact that that strike never took place. But, of course, there have been organised protests from the junior hospital doctors. In my opinion, administration is the art of getting people to work cheerfully and effectively together, and this should be a fundamental objective of the National Health Service, as, indeed, it should be the objective of any organisation, any factory, or any profession.

I join with others in welcoming the untiring efforts of the Minister to remove some long-standing grievances. But he should be vigilant, lest there be a tendency—attributable, in my opinion, to a petty and punitive attitude in some places—to perpetuate certain practices. For instance, while it is of course necessary to overhaul the financial structure and ensure that adequate salaries are paid, it is equally necessary to ensure that the doctors—and indeed all the medical workers—have adequate leisure.

§ THE PARLIAMENTARY UNDER-SECRETARY OF STATE FOR COMMONWEALTH AFFAIRS (LORD BESWICK)

Hear, hear!

§ BARONESS SUMMERSKILL

I am glad that my noble friend said "Hear, 324 hear", because I shall remind him of that in the future. Yet it would appear that the general practitioner is still to remain the only worker in the country—in the professions or anywhere else—who cannot enjoy a holiday unless he can find a substitute and can afford £50 a week for a locum. Surely this anachronism should be remedied by providing a locum service, and I hope that that will be done. Furthermore, the decision to encourage ancillary help in a practice, qualified or unqualified, is welcome. The medical practitioner can now employ a woman to help him in so much of the writing and rather boring work which he has to do other than that of medicine. But the doctor is denied the right to employ a fully qualified nurse who happens to be his wife, and this causes some resentment. Again, I would ask my noble friend to bring pressure to bear in the right quarters to see that this ridiculous anomaly is removed.

At long last the general practitioner is to be officially permitted to use a relief service, but if he demands undisturbed sleep every night and relaxation every weekend then he is to forfeit £200. I hope my noble friend will tell me that I am wrong in these figures, but unfortunately I think I am particularly accurate. Therefore, I would ask the Minister not to spoil the ship for a ha'porth of tar. He has had meeting after meeting with the medical profession, and he must be sick and tired of it. Therefore, let his final decision be one which will be accepted happily and gratefully by the whole profession.

A great deal has been said about the hospitals. I confess that when I enter a hospital, particularly one in the Provinces, my reaction is a slight sense of sorrow, tinged with shame, that we have to encourage Commonwealth doctors to leave their countries where they are desperately needed to help run our Health Service. Therefore, it came as something of a shock to me when last week I received an appeal from the British Medical Women's Federation. That Federation is a very old and highly-respected organisation, and in bold type the medical women of Britain ask: How can able young women find places in medical schools? How can a married woman be helped and encouraged to return to practice after many years devoted to bringing 325 up her children? What new openings can be found for practising medical women whose husbands' work takes them to a new district? It seems incredible to think that women have been qualified nearly a hundred years, and yet able young women in this country are denied a medical education; and, moreover, that there is this waste of qualified women prepared to work on a part-time basis at a time of great shortage.

I want to touch upon only one aspect of medicine. The scope of this debate is enormous, and having regard to the serious problems of industrial health which were revealed the other night during a very important little debate in this House I thought I would limit myself to that field. Last year there were 293,717 industrial accidents in this country, of which 627 were fatal. I know, of course, that the Minister of Health is not responsible for the prevention of accidents. Nevertheless, it is the Health Service which must make widespread provision for the victims; and in my opinion preventive medicine should embrace every man, woman and child, wherever they may be and wherever they may work. The victims in these cases are generally young people. Young people are energetic and relatively irresponsible risk-takers. Consequently, the problem of youth in industry is the problem of physical accidents. From the employers' point of view, youth is attractive because it is cheap to employ, especially on easily-taught dead-end jobs.

By far the greater number of young people who enter industry are healthy when they start, but their health may deteriorate; and, of course, there is a small number spread all over the country who are extremely vulnerable and who need careful medical supervision. I am thinking particularly of those who are subnormal though not sufficiently subnormal as to be prevented from going into a factory or workshop, and of the temperamentally unstable, who tend to drift into small, backward industries and get dead-end jobs with unsatisfactory conditions. Some of them have as many as five different jobs between the ages of 15 and 18, and they not infrequently suffer an accident soon after starting work. While I agree that training and apprenticeship schemes should be closely related to safety, the fact is that very often 326 the old hands have not the time to teach the young—and there is also the fact that an old hand often becomes a little careless himself, although he knows how to protect himself. So it seems to me that the technical and medical factory inspectorate is the most important single agency for the care of the young in industry.

I should just like to read to your Lordships an extract from a paper in the British Medical Journal of October 1 by Dr. R. C. Browne, the eminent physician and author, entitled "Health in Industry". He said: On the technical side the recruitment and training of inspectors and the coverage of factories all need to be improved. More frequent visits from inspectors should be made and, differentially, more frequent still to the especially dangerous parts of factories. The relations between medical and technical inspectorates need consideration, and not only for the reason that it seems very odd that the Annual Report of Her Majesty's Chief Inspector of Factories on Industrial Health is signed by a non-medical man … The heads of the medical and technical inspectorate should be of the same rank and should report on a level to the next most senior civil servant up the command chain. Such a change will improve the organisation and increase the impact of health and safety in general as upon young children". It seems to me that the Minister of Health should be identified closely with the plan for replacing the mid-19th century appointed factory doctor arrangements. Such doctors were appointed when children were rickety and when people had little social conscience, not being concerned with whether children fell into machines or not. Our approach now is quite different. There should be fewer but more highly trained doctors, who would examine fewer healthy young people and more of those vulnerable to accident or disease. Medical care should be concentrated where it is most needed, and only those employed in selected potentially hazardous work would be repeatedly examined, or those who had an employment problem as a result of illness. I believe the time has arrived when the departmental arrangements established to supervise the safety and welfare of young people in a different industrial setting, a different industrial age, should be fundamentally altered in order to reduce the appalling accident and death rate in modern industry.

§ BARONESS BROOKE OF YSTRADFELLTE

My Lords, we are all indebted to the noble Marquess, Lord Lothian, for introducing his Motion on the National Health Service to-day; and I hope very much that when the noble Baroness who has just sat down reads through her speech to-morrow in Hansard she will glance at what the noble Marquess said, because I really cannot agree with her that he made not one single constructive statement. The last Annual Report of the Ministry of Health mentions the setting up by the Minister of an informal group to help him in considering the long-term future development of the health and welfare services. The Minister wants to have advice about the interaction of the various services one with another. We shall await its findings with the utmost interest.

I hope very much that among the many potential developments of the services which are available for examination they will not fail to study the future of the community health service—a service which was touched on by the noble Marquess when introducing this debate to-day. The most recently published figures show that, in one year alone, this country lost no fewer than 285 million working days through ill-health. This staggering figure, with all that it represents in lost production, underlines the vital need for us to ensure that the National Health and Welfare Services are as efficient as we can make them. Here, I would pay my tribute to those splendid members who have served the Service in the Ministry of Health ever since the inception of the National Health Service Act for the way in which, often in the face of great difficulties, they have continued to develop and allow the Service to grow.

Quite apart from humane considerations, the prosperity of the country demands that our National Health and Welfare Services are as efficient as we can make them. As we have heard this afternoon, hospitals form the most costly part of the Service, and, ambitious though the figures in the hospital programme may seem to laymen, we are frequently reminded that they are barely enough to replace outworn buildings. As a former member of a Regional Hospital Board, and chairman of a hospital management committee, I am only too well aware of 328 the truth of that fact. We have got to economise in the use of hospitals and ensure that they house only patients who need the specialised care that can be given only in hospital. The latest available figure for the average cost of treating an in-patient in an acute non-teaching hospital is £61 a week. For teaching hospitals the figure is £76 in the provinces, while in London it is no less than £103 a week. So economy in the use of hospital beds is essential. People do not want to be in hospital if they can be cared for at home. The hospital programme is rightly based on a policy of early discharge. This brings out the need for properly organised health services in the community, which should not be confined to caring for the sick; but should be actively engaged also in preventing illness. That is, I think, a fact with which several of us taking part in this debate this afternoon would agree.

My Lords, can we truthfully say that we have such services at present? I venture to intervene in this debate to-day because I have for some years been Chairman of the executive committee of The Queen's Institute of District Nursing, a committee much enriched by the presence of the noble Lord, Lord Amulree, who for the moment is not in his place but to whose speech earlier we all listened with great interest. This is a body which well over a hundred years ago pioneered district nursing and provided the majority of district nurses up to 1948. Under the National Health Service Act home nursing became the responsibility of the local health authorities, but the Queen's Institute has continued to advise and assist in training and to provide a certificate for nurses qualifying in district nursing. Now that a National Certificate has been established, the Institute intends to cease the award of its own certificate. But it will gladly continue to advise on training, something which, with its long experience and countrywide connections, it is well placed to do. Meanwhile, we plan to devote more resources to those other lines of activity that have been developed in recent years. Foremost of these is operational research to discover, within the changing pattern of community care, what are the needs and how they can best be met.

Secondly, the Institute has set up experimental schemes in training and 329 organisation. If they prove successful, they will become demonstration models. One example is the district training of State-enrolled nurses which, at present, is almost exclusively carried out under the ægis of the Institute. Thirdly, there is the provision of a whole field of post-certificate education for nurses ranging from refresher courses (which are particularly necessary for those working away from the hospitals in which most of the advances in medical careare made) to the teaching of administrators, for which there is a crying need in public health nursing.

My Lords, it is the results of our most recent research project which I think are particularly relevant to this debate and to which I should like to invite your Lordships' attention. In November last, we published a Report under the title, Feeling the Pulse. I have a copy of it here. It had a splendid reception from the Press, and I should like to hope that all noble Lords interested in the Health Service will read it if they have not already done so. It is the report of a survey in depth of district nursing in six widely separated areas. It is a disturbing document. Of course, six areas cannot be taken as representative of the whole country. We know many other areas where steps recommended in the Report have already been taken. Nevertheless, the fact that many shortcomings were common to all the survey areas suggests that there is a probability that they are widespread throughout the country.

One of the most striking was the lack of contact between various workers in the National Health field. District nurses seldom met general practitioners. The latter frequently did not even know who was the district nurse who cared for their patients. Most doctors experienced difficulty in getting in touch with a nurse, even if she happened to have a telephone at home, which often enough she did not, and messages had to be channelled through a third person—someone on the staff of the local council office, perhaps. In one area the superintendent of district nursing actively disapproved of doctors and nurses having any direct contact when looking after patients. Contact between doctors and health visitors seemed equally nebulous; and there were some complaints by doctors of 330 patients being given advice by health visitors which conflicted with their own. Very few patients were referred from health visitors to district nurses, and vice-versa.

All this fragmentation of effort could not fail to reduce the efficiency of the service offered to the patient. Arising, in part, no doubt from this lack of contact, there was remarkable ignorance among doctors as to the actual qualifications of the nurses available to care for their patients. Consequently, many of the procedures which could have been competently carried out by the nurses were undertaken by the doctors themselves, who were already heavily loaded. Many of the doctors were giving injections, dressing wounds, and similar tasks, which the trained district nurse working on the case was qualified to do. The inquiry showed that the nurses, of whom the majority were State-registered, were largely engaged on tasks which did not require their professional skill and in many cases were not nursing tasks at all. Although many were extremely busy, the time they spent in actual contact with patients was surprisingly small, the remainder being taken up by travelling and clerical work. The load of acute cases, particularly surgical and pædiatric cases, was unexpectedly light.

Where, one wonders, were the "early discharged" patients just out of hospital? Were patients in fact being retained in the hospital because those in charge of them were unaware of the professional expertise and facilities available in the domiciliary services? The survey showed poor contact between the hospitals and the domiciliary services, and this poor contact might have been responsible for such ignorance. If the "early discharge" policy was truly being followed, were patients having to continue to attend the hospital as outpatients, perhaps at great personal inconvenience, or, worse stilt, were they at home lacking the care they needed? This particular question is the subject of the Queen's Institute's current research programme. Meanwhile, whatever may be the reason for the apparent fewness of acute cases, it is clear that the district nursing service is not playing the part it should or could.

So far I have spoken mainly about the care of the sick. But a National Health 331 Service, as has been referred to this afternoon, should be as concerned with the preservation of health as with caring for those who are ill. The general practitioner is responsible for the health of his patients; and to discharge this responsibility he should practise preventive as well as therapeutic medicine. He should interest himself in the health education of his patients. But doctors are trained in hospital, taught to be hospital doctors and to look after people who are already ill and in a hospital bed. In spite of what is being done at Edinburgh University and at such places as Guy's Hospital, preventive medicine and the care of patients in their homes has curiously little place in the present curriculum. A doctor may achieve registration and still suffer from ignorance of needs outside the hospital: how patients live, how they can be kept healthy and what services there are to help them when they fall sick. If he stays in hospital posts this ignorance may never be dispelled. Only a small proportion of doctors entering general practice have any special training to fit them for it, and having started off on the wrong foot many are too busy ever to pick up the right step.

A basic requirement for a better Health Service is the revision of medical education. Happily, this is the subject of a Royal Commission, and I trust that its recommendations will include the extension of medical education to cover much in the fields of preventive medicine, social medicine and community health services generally. A broadening of medical education would help to improve health in a number of ways. First, the hospital doctor would be much more closely aware of the daily needs of his patients when discharged to their homes and of the facilities available to meet these needs. Secondly, the general practitioners, knowing the potentialities of the services they can call upon for support, could muster those services to the best effect and stop wasting their own valuable time on tasks that others can do equally well. Thirdly, this new generation of general practitioners should be much readier to organise themselves in a manner which would allow the most efficient deployment of all domiciliary health services.

332 Increasingly it is being recognised that the way to provide the closest contact between the various workers in the health field and to prevent any overlapping of effort and the offering of conflicting advice is to attach the public health nurses—that is to say, the health visitors and district nurses—to the general practitioners, so that they can work together as a team. Such a team must have adequate premises from which to work, and at long last there is a heartening interest in health centres. There are still grumblings from some doctors about loss of independence, but this is nonsense, surely, as anyone knows who has visited Witney or Hythe or Harlow (the centre which was inspired by the conviction and enthusiasm of the noble Lord, Lord Taylor, who earlier was in his place in this House).

It is now a known fact that the skill of the State registered nurses carrying out district work is largely being wasted. Many of their present tasks should be carried out by State enrolled nurses who have had proper district training, and I hope that the Minister of Health will go on urging local health authorities to employ State enrolled nurses in the district field. There is still too much reluctance to do so. But it goes further; much of the district nurse's present work is not nursing at all, it is simply doing useful jobs. These should be delegated to home helps and the other auxiliaries such as bath attendants.

It would seem to me that the ideal community health team is beginning to take shape. There are the doctors, and working alongside them is the nursing and auxiliary team, led by a State registered nurse, who might be a health visitor or a district nurse, or both. Under her she may have one or more State registered nurses, depending on the size and nature of the practice, welfare assistants, home helps and other auxiliaries. The leader will be responsible for allocating work to members of the team and she ought to carry out some of the skilled nursing herself. She will need to establish and maintain close co-operation with the social medical workers in the local hospitals. This is to ensure the smooth referral of discharged patients and the rapid provision of any care they may require when they get home.

333 My Lords, I have tried to sketch out the way in which I believe the community health service should be developed and how it could enormously relieve the weight on the hospitals. The hospital service is the most glamorous and the most televised part of the National Health Service; it is also the most expensive. But I suggest that the community health services as a whole provide a field where foresight and courageous experiment, and flexible development, are most needed if the people of this country are to have a National Health Service which really lives up to the expectations of those who founded it.

§ LORD PLATT

My Lords, I rise for the first time to address your Lordships' House, and in accordance with custom I ask for your forbearance. I know that I shall have nothing but your kindness and courtesy. In accordance with custom, too, I shall endeavour to be not too controversial, which may of course be a somewhat difficult thing as we are discussing the National Health Service. I am very grateful to the noble Marquess, Lord Lothian, for introducing and initiating this debate, first, and most importantly, because I think it is a very excellent thing that the defects, such as they are, in the Health Service should be debated in this way, publicly, and, secondly, because it has given me an opportunity of making a maiden speech on a subject which I know something about. That may perhaps be unusual. I should perhaps also say that, as a member of the Royal Commission on Medical Education, I can assure the noble Baroness, Lady Brooke of Ystradfellte, that I have taken note of her remarks. I could enter into the subject a little further, but it would not be non-controversial.

My Lords, I thought that perhaps my main theme would be general practice on this occasion because I think it one of the most important issues we have to face at the present time, not only in this country but all over the world. In different countries we find different solutions, or attempted solutions, to the problems of general practice, all of them under pretty heavy criticism either from the doctors or the patients and, quite commonly, from both. But first I should like to make a diversion into another topic which has been mentioned; namely, 334 the junior hospital staffs, because I was at one time a member of a joint working party between the Ministry and the profession which worked, I think I might say, in complete harmony together for two years, and produced a document known as the Platt Report. I should say that there are at least three Platt Reports, but this is the only one that I had anything to do with. I can therefore speak of it without fear of contradiction—at any rate by Platt.

The first thing I should like to do is clear up some misconceptions and fallacies about the number of foreign doctors in our hospitals. I personally regret this, not because I think that they are all bad doctors by any means, but I think it is very bad when almost the whole staff (as is the case in some of what we call our peripheral hospitals, as opposed to the more central teaching hospitals) is composed of foreigners, some of whom have very considerable language difficulties. The first thing I wish to point out to your Lordships is that this is not a problem of our National Health Service alone. It is the same in the United States of America, where in Greater New York more than half the hospital doctors in this intermediate junior stage are foreigners. I understand that there are now 14,000 foreign doctors in the health services (in the hospitals, that is) of the United States of America, only 200 of whom are British. The rest come from South America, the Phillipines and various other places, and often have language difficulties. En passant, I might also mention that the nursing shortage in the United States is extremely acute as well.

My Lords, this is not due, as most people think, to some colossal shortage of doctors in this country. We are short of doctors in this country, but for totally different reasons. It is due to medical progress which has brought about a need for far more people at this particular stage of experience. Your Lordships will understand that, if I say that when I was a medical registrar in a fairly big teaching hospital I was the only medical registrar in that hospital. To-day I suppose that six, or possibly eight, young men are doing the job that I did. I am quite capable of taking this as a matter for personal congratulation, but I am only too aware that it is really due to 335 the progress of medical science that we now need far more people at that level to carry out the various processes which modern treatment and investigation require. As these jobs are held for only a comparatively short time, perhaps for two, three, four or five years at the most, if you trebled the number of medical graduates in order to fill these jobs it is quite clear they would then be out of work for the rest of their lives, unless at the same time you created permanent jobs for them to go to after they had spent those few years in hospital. What my working party found—and their Report is still relevant, although we would not to-day write it in exactly the same words—was, first, that we need more consultants in the Health Service, and that they are delegating too much of their work to their juniors. This is, I will not say rapidly, but more than gradually, being repaired. The number of consultants is increasing steadily year by year, and now I believe that one-third of the output of graduates will reach consultant level.

Secondly, these posts will still be filled, quite rightly, by people who come from overseas. So far from bringing them away from countries where they are greatly needed at the present time, I would hold the opposite point of view and say that, especially since India and Pakistan has started their new medical schools and are training a large number of doctors and have not got properly trained teachers (which they cannot have at this stage of the development), it is extremely important that their young men should come over here and learn the standards of British medicine. It may be said that we then send them to some of our worst hospitals, and I am afraid that I would have to agree that this is what often happens. I hope that on the Royal Commission on Medical Education we will be strong in our Report about the whole of the organisation of post-graduate training. I am Chairman of the Committee which is dealing with this but, of course, anything I say this afternoon will not commit the final Report of the Royal Commission. Some posts will have to be filled, as at present, by our own men in training. We hope that general practitioners will spend a longer time in hospital training in future. This will help hospital staffing 336 —though it is not done for that purpose, but to improve general practice.

Thirdly, some of these posts should not be filled by temporary juniors at all, but by people who want a long-term connection with the Health Service, usually on a part-time basis, so that they can spend the other part of their time in general practice, in other branches of the profession or in domestic duties. To encourage part-time posts of this kind will be good both for general practice and the hospital service, helping the integration of and better relationship between the two. This is already happening. About 20 per cent. of general practitioners at the present time have some kind of hospital appointment.

Coming to training for general practice, I am glad to say that there is a big area of agreement in all sections of the profession, including the College of General Practitioners and the British Medical Association—who have both put in excellent Reports to the Royal Commission—that the general practitioner of the future should have at least three or four years training after registration before he goes into general practice, and if he wants to stay on longer, this will be a further advantage.

We have not yet considered whether general practice has a future. There are some who may have doubts about it. But if there is one thing which I want to establish more than anything else in your Lordships' minds, it would be that in these days of specialisation, there is an ever-increasing need for the generalist. It is easy to point out that with the growth of knowledge all academic subjects fragment; the undergraduate no longer reads history, but modern history or mediaeval history or ancient history; the chemist no longer studies chemistry, but biochemistry or inorganic chemistry, and the engineer studies civil engineering or mechanical engineering or electrical engineering—and to say that in medicine we must do the same.

It is true that we will have to do something of this kind. Some day we may realise that it is not really necessary for an orthopaedic surgeon to know all the fine structure of the retina, or for an ophthalmic surgeon to know all the bones of the foot. But where the real difference comes in is in this. A man seeking the services of an engineer probably knows 337 whether he wants to build an electric power station or a bridge over the River Mersey. A man with a pain in his stomach does not necessarily know whether he needs a physician, a surgeon or a psychiatrist, and he should have a medical man properly trained for the purpose who is a doctor of first instance. I do not think that is a good name for him, but it is a good name for at least part of the job he does. The recent Citizens' Commission's Report in the United States calls him a "primary physician". We might call him the general physician. I think that there is a good reason for getting rid, gradually or suddenly, of the term "general practitioner", which to some extent has fallen into disfavour and conjures up the picture of the old man with his horse and buggy, treating patients for eczema, delivering babies and setting broken bones, which we know is quite out of date.

The practitioner of the future, as we hope to see him, will have a much better training, partly in hospital and partly in general practice, and when this has been completed he will work in a group pract