The matter I wish to draw to the attention of the House is that of the physiotherapy treatment of patients in their own homes. I would like to thank the Parliamentary Secretary to the Ministry of Health for remaining to this late hour to reply to the debate. I have advised the hon. Member of some of the points I wish to raise and I would like to put them as succinctly as possible.
I wish, first, to refer to the case of a comparatively young man of 45 who suffered a stroke and who at various times during the course of his long illness, was quite unable to attend hospital, partly because of the weather conditions at that time of year and partly because of his general unfitness. He was, nevertheless, able to take a full course of physiotherapy at the hospital, and also got much benefit from physiotherapy in his own home.
Because of the lack of provision in the National Health Service, to which I shall refer, this home treatment had to be provided by private resources, and had to be paid for. Here, I should like to pay tribute to the Luton Branch of the Royal Air Forces Association and others who met the bill for many months, so that my unfortunate constituent might have the physiotherapy treatment at home. I am sorry to say that he died during the last two or three months, but he enjoyed very much improved mobility over the last few months of his life. I saw him about earlier this year and I am sure that this was because he had been able to have this physiotherapy treatment at home when he was unable to go to hospital.
This matter was raised at the R.A.F.A. conference at Edinburgh a month or two ago, where a resolution was passed about this which will, no doubt, find its way to the Ministry. I hasten to say that neither my constituent nor have I, any complaint about the hospital, or the consultation or treatment given there. This is merely a matter of the circumstances of a man being unable to go there and obtain treatment because of his state of health and the weather. As an urgent and desperate matter he had treatment from private sources, for which fees were paid, and which was not provided under the National Health Service.
There is the question of minor injuries where a patient is not ill enough to be hospitalised, but where a course of physiotherapy at home would be very advantageous to make him fit again. I am thinking of broken limbs. No provision is made under the Health Service for payment for outside physiotherapy. This is a considerable gap in the provisions for the benefit of health. The treatment might have been to hospitalise this man for some months. There must have been a considerable saving to the State because he did not go to hospital for any length of time at all. I would have thought it would have been worth while for the State to provide physiotherapy at home in place of hospitalisation at a much higher cost.
As evidenced by Answers to Questions which I have had in the last few weeks, the trouble is that the Ministry and the executive committees take the line that this treatment is a hospital service. All well and good. The Parliamentary Secretary, in reply to one of my Questions, said that it was a hospital service, but that consultants could give instructions for the physiotherapy treatment to be given at the patient's home in necessitous cases. But the plain fact is that there are no physiotherapists to spare in the hospital to carry out this treatment and we are, therefore, up against the impasse that it cannot be effected and the patient has to go without this domiciliary treatment.
Hospitals have demands for more Physiotherapists than they can obtain to give treatment inside the hospital, but there are State-registered physiotherapists available under the Act governing services ancillary to medicine and their fees are not excessive. It seems quite proper that such treatment if authorised should be given by these State-registered physiotherapists. There are analogies in the Health Service. Chiropody is one and there are others. It is curious that this domiciliary physiotherapy service should be eliminated from the Health Service scheme.
There are also many cases—and I do not refer to those where the general practitioner would naturally wish to have the views of the consultant at the hospital—where the general practitioner should be able in his own right to order domiciliary treatment for the benefit of his patient to improve his well-being and make him fit for work again. This is not the situation at the moment. No one except the consultant at the hospital can order physiotherapy either at the hospital or at home. It seems to me that considerable benefit would be obtained if the general practitioner were able to order it to be given in the patient's own home in cases which he approved. The general practitioner has considerable authority and power in many other respects in the National Health Service and I do not see why this power should be denied to him.
The general practitioner should also be able to order minor personal equipment such as a tripod walking stick. Under the present arrangement such equipment can be authorised only by the hospital consultant.
I feel very strongly on this matter. Like the subject of many Private Members' Bills and Adjournment debates, this is a point which has come to my notice in a tragic way. I have also met over the years other people who have paid for domiciliary physiotherapy for wives or husbands who are bedridden. They have improved the health of their bedridden relatives by providing this treatment at home at their own expense.
If this is a matter affecting an enormous number of people it should be put in hand right away. If it is a minor matter from the point of view of the finances of the National Health Service, but not at all minor to the patients in these cases, that surely should not be a stumbling block to the Ministry in bringing it within the provisions of the Service. Either way, it is a matter for urgent action and I hope that the Parliamentary Secretary will say something of benefit tonight.
The hon. Gentleman the Member for Bedfordshire, South (Mr. Cole) has no need to apologise to me at least for raising this matter even though the hour is a little late. He has raised it with his usual courtesy and put the matter very clearly, for which I thank him, for he has rendered a service in spotlighting a problem.
In practice, there is not a great deal between us. The hon. Gentleman, as I do, wants to ensure, as far as is humanly possible, that the full range of services is given under the National Health Service to everyone in our society. His raising of the matter this morning gives me an opportunity to explain in a little detail the problems with which we are faced in trying to ensure that the fullest and best service is given.
Let us be quite clear about the present position. The hon. Gentleman may be under some misapprehension about what domiciliary service can be given. A general practitioner can request a domiciliary consultation, and if the consultant, once he has attended the patient at his home, considers that domiciliary physiotherapy is the adequate and proper treatment for him, the consultant himself can see to it that the patient receives domiciliary physiotherapy. I am sure that this is being done in South Bedfordshire, although it is true that, because of various problems at present, it is done largely in urgent cases only.
I am very sympathetic to the case which the hon. Gentleman mentioned and which he described as urgent and desperate. I do not wish to be thought to imply any criticism either of the general practitioner or of the hospital, but, if what the hon. Gentleman has said is absolutely correct, I think that the service would have been available to that particular patient if the case was so urgent.
This is quite right in theory, of course, but the hon. Gentleman knows as well as I do that there is a limited source of physiotherapists in our hospitals and they really have not time to spare to go out on visits. It is always a question of trying to get the patient to hospital or of waiting until he is well enough to atttend. The hospitals have a problem, and the consultants know this, so the theory does not really work.
I was saying that, within certain limitations, this is what applies. It is the desire of the Ministry that every possible effort should be made to see that urgent cases are given domiciliary treatment if that is appropriate.
There is a problem, as the hon. Gentleman himself says, which we have to face. The problem is really in two parts. First it is a question of the shortage of staff at present. The numbers of the staff that we have are by no means adequate, as the hon. Gentleman says. There has been a slight increase in the number employed in the hospital service in the last year, and our job is to try to create the conditions where we can get an adequacy of physiotherapists working inside the National Health Service. We have tried to do this, and we are trying to do it, by various means.
But let me put this to the hon. Gentleman. If there is an overall shortage of staff then, obviously, we have to deploy that staff to the best possible advantage. It is no good extending the use of physiotherapists in the domiciliary services, if we find that that method of employment of the staff within the context of the shortage is expensive—not in terms of money but rather of time.
We find that under the present system, very often if one has got a physiotherapy department attached to a hospital, then one can get treatment on a group basis. I do not say there will not be cases where it is necessary to treat the patient in an individual way, but very often the group basis is found to be to the advantage of the patient. And we have to bear in mind that what we are faced with is the need to give this service to the greatest number of people we possibly can.
The hon. Gentleman referred to the possibility of using the State-registered physiotherapists who are in private practice in the domiciliary field. Although he referred to a number of analogous services and quoted the case of the chiropodist, I would not accept that there were a number of analogous cases, nor would I accept that the chiropodist is analogous in any way. The fundamental reason, of course, is that the chiropodist does not need to work under medical supervision.
I want now to deal with the second leg of the problem which we are having to face. There have been changes in concept in the use of physiotherapists in recent years. Recent developments in medicine have had a marked effect on the practice of physiotherapy. In 1962, the Minister's Standing Medical Advisory Committee observed that many patients still asked for massage because it gave a symptomatic comfort at the time of application and they assumed it must be doing some good, but in the long run it was kinder to teach them how to use modern aids to minimise their disabilities.
They went on to say that it was perhaps noteworthy that hospitals with fuller facilities for rehabilitation made little use of massage. The Committee also found that whilst there had been a marked reduction in the use of massage and electrotherapy there had been a greater increase in the demand for other forms of physiotherapy, notably the modern type of remedial exercises, which are used in all stages of medical rehabilitation in a steadily increasing number of hospital departments and special centres.
What we feel is essential, because there have been these changes, because there has been a shift of emphasis from massage and heat treatment to various other types of exercises and the use of appliances, is that if we are to use physiotherapy in the proper and most adequate manner, the whole of the treatment should be given in such a way as to be under direct medical supervision all the time. We consider that there should be medical control over physiotherapists, even when they are treating patients on a domiciliary basis.
As I say, physiotherapists are in short supply, both nationally and in South Bedfordshire. Those available to the National Health Service should be employed where they can do most good. In a hospital, a physiotherapist can be used to the best possible advantage. We do not feel that we can afford to take any action that might well reduce the availability of staff to the hospital service.
If we start employing State-registered physiotherapists who are in private practice in the way that the hon. Gentleman suggests, there may well be, although I do not say that it necessarily follows, a temptation for those people who are wanting to come into the service, or who are likely to come into the service and, indeed, some of those who are in the service at present, to feel that they ought to go into private practice.
I know that the hon. Gentleman would be the last Member in the House who would want the Government to take any step that was likely to reduce the number of this type of personnel available in the hospitals. I am sure that he will agree with me that, in the normal course of events, one can use the time and great skill of physiotherapists to far better advantage in the hospitals than in domiciliary visits. One wants domiciliary visits where it is not possible or where it is very inconvenient for the patient to go to the hospital, not as an in-patient, because such people are not normally inpatients anyway, but to attend the physiotherapy out-patients' department.
I can assure the hon. Gentleman that I have looked through the papers searchingly since he raised the question with me, and that this has been the policy of successive Ministers, not merely the present Minister. The hon. Gentleman will probably know that at least three Ministers of Health before the present one have underlined, for the same reasons as we are stating this morning, the need to ensure the adequate supply of physiotherapists in the hospital service and the maximum utilisation of their time and skills, rather than dilute the service by the extension of domiciliary services.
I agree with the hon. Gentleman that where one has urgent cases and where it is possible to extend the service beyond the urgent cases that have it at present, provided there is medical supervision, that would be extremely desirable. I can assure him that the Minister takes precisely the same attitude as the two or three Ministers before him who have had to face the fact that if we could assure ourselves that we should be able to get a sufficiency of this particular skilled person to enable us to expand the domiciliary service, then we should be only too glad to do it.
I am very appreciative of the attempt that has been made by the hon. Member to get an extension of the domiciliary service in this field. I cannot accept his argument that there would not be any danger at all in using private practitioners without medical supervision.
In the sort of cases that we have at the moment the general practitioner would naturally consult the consultant—the position with regard to consultation would be as it is at the moment—but in other cases, especially in minor cases, and also in some major ones, naturally the general practitioner would have a very close liaison with the person giving the physiotherapy.
I accept that if we had an adequacy of physiotherapists that might well be so, although there is a school of thought that the general practitioner is not necessarily the best judge of what is best in this aspect of the service, and that—this is why at the moment we take the point of view that the general practitioner must call in the consultant—the person who is best able to determine the course of treatment is the consultant himself.
I hope that the hon. Gentleman will do whatever he possibly can to encourage those who are at present in private practice to come into the National Health Service side. We are doing whatever we possibly can to improve the terms and conditions of service. There was a 9 per cent. pay increase last summer, and there is at present a review going on by the Whitley Council. I pay tribute to the skill and dedication of the people in the service who are working in this field, and I feel sure that those who are at the moment working outside the National Health Service would find a very fruitful place for their services if they would come into it.
I should like a few moments to support the hon. Member for Bedfordshire, South (Mr. Cole), who has raised the important question of domiciliary physiotherapy treatment. I do so at this late hour because of the special experience in Coventry of the domestic physiotherapy service which has been provided.
In Coventry, there is the Coventry and Warwickshire Hospital Saturday Fund. At the onset of the National Health Service that organisation was faced with a change in its objects because originally it was set up for the purpose of supplying ordinary hospital treatment. When the Service came into being, part of its previous obligations were taken over by the State. As a result, the organisation had to consider what it could do to provide for its members. I say "its members".
The fund has just over 100,000 members who, through their employers generally, individually provide a small amount of money each week towards the organisation—