I beg to move, That the Bill be now read a Second time.
This Bill is designed to effect a number of improvements some of them minor and some more important in our health and welfare services. Since we do not very often get an opportunity in this House to debate the National Health Service, perhaps I may use this occasion briefly to survey the progress we have made in the service over the past three years before I come to the details of the Bill itself.
I imagine that it is inevitable that more publicity should attach to the occasional failures of the Health Service than to its undoubted achievements. I calculate that every single working day 1½ million of our fellow citizens have direct contact with some branch of the National Health Service either as hospital patients, callers at the doctor's or dentist's surgery or as recipients of some other local health service.
As in any human organisation, there arc bound to be errors and failures here and there, and I am not asking that they should be concealed from the public. But I think that the public could also have been told, for example, that the National Health Service does provide in this country specialist service of high quality, not just here and there but wherever and for whomsoever it is needed; that fewer of our old people are going blind, simply because under our system they can be diagnosed and treated for cataract in time; or in Britain everyone who needs a hearing aid can have one.
Beyond this they could have been told that medical care for all has not been bought at the expense of progress; that intermittent dialysis has been developed—and has been saving as many lives relative to the population—in this country as in any in the world; that the newest development in preventing haemolytic disease of the newborn has been pioneered here and will now be generally applied; and that we too have our specialised units pioneering in heart surgery for small infants, organ transplantation and the like.
There was a headline in a London evening newspaper a short while ago which read, "Stop Knocking our Hospitals". As a bit of advice, it may be worth pondering. I make no complaint on my own behalf, but I would only say to those who control the mass media two things about this kind of selective reporting. It does little to sustain the morale of those who day in and day out are giving so much devoted service to the sick and disabled. Secondly, though stories and features seeking to show that the Health Service is in imminent danger of collapse are frequently published and broadcast they hardly chime either with the facts of the situation or with the public's own views.
Hon. Members may have seen the recent opinion survey on the Health Service carried out by "New Society". Of those who were asked to state their opinion of the Service, no fewer than 95 per cent. considered it either good, very good or excellent. If one were to take these jeremiads seriously, a little research would reveal that according to its critics the Health Service has been about to collapse ever since it was established 20 years ago. Indeed, in 1948 it was prophesied that it would never start. The facts, of which I propose to give a brief selection, tell a somewhat different story. Almost every statistic testifies to steady improvement, expansion and development especially during the past three years.
The foundation on which we base our comprehensive health service is general practice. On coming to office I found the situation of general practice extremely disturbing—morale was low, numbers of general practitioners had begun to fall a year or so earlier, and lists were in consequence rising. Frustrations were rife among family doctors and a crisis soon blew up, as hon. Members may recall, ostensibly related to pay. The prolonged negotiations which followed dealt with not only the whole method of remunerating general practitioners, but with their pattern of practice and conditions of service.
Together the profession and my Ministry hammered out what was, in fact, a new deal for general practice, with a new system of payment which got rid of the old "pool" method and incorporated real incentives towards the modernisation of practice methods and the grouping of practitioners. Despite setbacks resulting from prices and incomes policy, the new system has been fully in operation since last April and I believe we have turned the corner.
There has also been a quite remarkable upsurge of interest in health centres, stemming, I would think, at least in part from the new deal for the general practitioner. During the last three years 23 centres have been opened compared with 21 in the previous 16 years, 38 centres are now being built, 50 more have been approved and a further 71 are being actively planned.
I recognise that the long-term solution to the problem of shortage of doctors both in general practice and elsewhere in the service lies in training more of them, and, of course, keeping them in Britain. Thanks to the co-operation of my right hon. Friend the Secretary of State for Education and Science, we have expanded the capacity of our existing medical schools to permit an intake of 2,431 British-based students at the beginning of this autumn term compared with 1,788 to which it was allowed to fall in 1960–61 by the party opposite. By 1970, total intake will have further risen to an estimated figure of about 2,800, and the new medical schools with their associated university hospitals to be built at Southampton and Nottingham will be taking their first students in 1970 and 1971.
As to nursing staff, although there are local shortages and temporary shortages here and there, the numbers of nurses in post today are the highest ever in our history.
I know well that the demand for trained people is insatiable, not only here, but everywhere, but we can record a real improvement and this will be further enhanced by better organisation.
Hon. Members will recall that in conjunction with hospital authorities I carried out a radical review of the hospital building programme. We now have a realistic programme, which is going forward at an accelerating pace. This year we shall spend on new hospital building no less than £100 million in Great Britain, compared with £67 million in the last financial year for which hon. Members opposite were responsible.
I repeat that, nevertheless, the difference between £100 million and £67 million represents a very considerable increase in real terms, even allowing for the difference in the value of money. During our three complete years of office we shall have spent £262 million, as against £162 million during the last three years of Conservative government, and the programme is increasing each year. Under the revised programme both geriatric and psychiatric provision are receiving a higher priority and a greater share of resources than before.
Productivity in our hospitals, if I can use the word in a somewhat unusual context, is increasing steadily all the time, measured by the number of in-patients treated in the same number of, or fewer beds, and by the number of hospital out-patient attendances. The earliest year for which my statisticians tell me that there are reliable figures is 1953. The number of in-patients treated in that year was a little over 3½ million. In 1966, there were nearly 4·9 million, a rise of almost 1½ million. In this period the number of hospital beds actually fell by 10,000. This remarkable growth is due largely to advances in medical technique and procedures and to more efficient organisation within the hospital, but it also reflects greater effort on the part of doctors, nurses and others concerned with the care of patients, and I should like to pay my tribute to them for this.
Had I more time I could recount a similar story of progress in almost every area of the health service, not least in the rapid growth of the local authority mental health services and of modern residential homes for the elderly. But I must come to the details of the Bill, which I see was described in quite a friendly way by one of the weeklies as a hotch-potch. That I could hardly deny, but since it is the first general Health Service amending legislation for 17 years it may not be altogether surprising.
The House will recall that I announced on 6th November that I had set in hand a full and careful examination of the administrative structure of the medical and related services. The Bill does not seek in any way to anticipate the results of that examinaton. As I indicated to the House at the time of my announcement, I am considering administrative structure because I am not satisfied that the existing structure is really suited to the challenges the Service will face in the 1970s and the 1980s. We ought, therefore, to form a considered view about the kind of administrative arrangements which are needed in the future and to lay the foundations for them at the same time as we are considering, as we shall soon have to do, the conclusions of the Royal Commission on Medical Education; of the Seebohm Committee and of the Royal Commission on Local Government in England.
I shall be publishing tentative proposals in due course in the form of a Green Paper. There will then be full opportunity for public discussion and consultation. It would, therefore, have been premature to have included in the Bill provision for any major changes in the administrative structure of the health and welfare and public health services, and no such changes are included.
There are, however, a number of minor alterations in the administrative structure of the services which would be brought about by the Bill, and I will describe the more important of these later. Most of the Clauses have an application in Scotland as well as in England and Wales, and some apply only to Scotland. These will be described by my hon. Friend the Under-Secretary of State for Scotland if he is fortunate enough to catch the eye of the Chair at the conclusion of the debate. I cannot hope in the time available today to describe all the Clauses. I shall, therefore, refer only to the more important provisions.
I would like to start by speaking briefly about the first two Clauses, if only because they have been the subject of some misunderstanding. Their purpose is not, as has been suggested, to reduce or abolish the number of pay-beds. I announced the result of my review of pay-beds on 6th November in answer to Questions from hon. Members. The Bill in no way affects what I said then. The principal changes made in the Bill regarding private patients were foreshadowed in the statement I made in the House at the end of January, 1966, in the reply to a Question from my hon. Friend the Member for Willesden, West (Mr. Pavitt) about the measures I proposed to take following my review of pay-bed policy and my discussions with the Joint Consultants Committee. These were a series of related measures designed to promote the more effective use of consultant manpower and hospital beds. Some of the measures I referred to then—the review of the number of pay-beds; the introduction of amending pay-bed regulations—have already been implemented, but the remainder required amending legislation and have had to await the opportunity which the Bill provides.
The main changes effected by these Clauses are to introduce a degree of flexibility in the use of accommodation by private patients and to enable pay-bed charges to be determined on a national basis for different classes of hospitals, instead of by reference to the cost, after a very complicated calculation, at the particular hospital.
The Bill also enables me to dispense with regulations in determining hospital charges for private out-patients and, under Clause 4, for amenity beds. Apart from this, the two Clauses merely repeat the provisions in the original Act which have been in force for nearly 20 years.
I can assure those hon. Members who dislike private practice on principle that I have no intention whatever of using these powers to extend the area of private practice in our hospitals. I can equally assure the medical profession that the Clauses do not enable the Minister to abolish their right to treat private patients Nor is this, as they well know, my intention. These powers will, I believe, make possible a more rational use of all hospital beds, public and private.
I turn to Clause 5, which contains, as far as the hospital service is concerned, what is probably the most significant administrative change the Bill will bring about. To increase the facilities for medical education, the Government have approved the creation of medical centres at the Universities of Nottingham and Southampton. At both places facilities for students to receive their clinical training will be needed in hospitals which do not provide teaching facilities at present.
Under the 1946 Act the Minister of Health may designate hospitals providing teaching facilities as teaching hospitals, and any hospital or group of hospitals so designated must be administered by a board of governors independent of the regional hospital board. If the Minister does not designate them as teaching hospitals, then they must be managed by the hospital management committee appointed by the appropriate regional board according to the constitution laid down in the Third Schedule to the Act. There is no other alternative.
I believe that the Minister should be free to consider other possibilities. I am aware that there is much close and fruitful co-operation between regional hospital boards and boards of governors, but I consider that the creation of new medical schools provides an opportunity to link more closely the regional boards, which have responsibility for the overall planning of hospital services in their regions, with these new centres of medical education. This is the conclusion reached also by a committee appointed jointly by the University of Nottingham and the Sheffield Regional Hospital Board in relation to the hospitals which will provide clinical teaching in Nottingham.
It is desirable, however, that the university should be assured of a voice in the planning and administration of such hospitals, which is not provided for in the normal constitution of hospital management committees. I am, therefore, seeking powers under Clause 5 for a new form of designation of hospitals which will be known as university hospitals. The Clause requires me to consult the university concerned before designating a university hospital.
The body responsible for the management of a university hospital will be a hospital management committee appointed by the regional board, but with a special constitution which will ensure, for example, that the university has adequate representation. In the interest of flexibility, it is proposed to empower the Minister to make the necessary modifications, after consultation with the university, by an Order subject to annulment rather than to try to lay down a modified constitution in the Bill itself.
I hope that these provisions will be welcomed both in university and in hospital circles. I am confident that the new university hospitals and their associated medical schools will become centres of teaching and research on a par with the existing teaching hospitals, and that they will benefit also from the close association with the hospital service in their regions which this new form of administration will provide.
The Clause is not confined to hospitals associated with new medical schools. It will also allow latitude in devising suitable administrative arrangements in places where there is already a medical school and where, in order to accommodate larger numbers of medical students, a second main hospital is to share the teaching responsibility with the existing teaching hospital. It is not, however, my present intention to use the Clause to effect sweeping changes in the administration of teaching hospitals already controlled by boards of governors.
There are several provisions in the Bill dealing with the financial affairs of hospital and other Health Service bodies, but I shall not describe them now. If any hon. Member has questions on these Clauses, my hon. Friend will gladly deal with them, and with other matters affecting the hospital service, at the end of the debate. There is, however, one further proposal under this head which I shall mention. Clause 38 gives power to reimburse housing authorities with the net cost to them of rehousing families whose existing houses have to be demolished to make way for new hospital building and where no suitable alternative accommodation is available.
I come now to those parts of the Bill which deal with local authority health services, which introduce a number of relatively small but useful changes in the powers and duties of local authorities. Clauses 10 and 11 extend the existing National Health Service legislation so that local health authorities may employ midwives, health visitors and district nurses to attend women elsewhere than in their own homes, which is the limit of their existing duty.
Clause 10 allows local health authorities also to make arrangements with hospital authorities so that their midwives may, if necessary, work in hospitals. These changes should promote the more efficient deployment of staff and encourage the close co-operation between these local authority services and family doctors on which the future development of care in the community will increasingly depend.
Clause 13 makes the provision of the home help service by local authorities a statutory duty, in common with most other local authority services provided under Part III of the 1946 and 1947 Acts. The Clause also enables authorities, in discharge of this duty, to arrange for articles belonging to the household to be laundered either at the house or elsewhere, and empowers authorities, subject to my approval, to recover such charges as the authority considers reasonable.
Is the right hon. Gentleman aware that some local authorities which provide domestic help on a very limited scale will not increase it for long-term chronic sick patients who are in their own homes? Does he intend to lay down any standards for the performance of local authorities in this respect?
I have already given quite extensive guidance to local authorities, which, I understand, is being followed by the greater part of them. If the hon. Gentleman has a particular case in mind, I hope that he will get in touch with me about it.
I turn now to the welfare services provided by local authorities under the National Assistance Act, 1948, and I shall mention two Clauses which, I believe, will be generally welcomed to improve the welfare services for the elderly. At present, local authorities may provide residential homes for elderly and handicapped people in two ways. First, they may provide homes directly them- selves. There has been a steady increase in the number of residential homes opened and this will continue. But authorities have always had to rely also on making arrangements with voluntary organisations to look after some of those who needed help. As demand continues to rise, with the growing number of old people, we need to look for still further ways of meeting it.
Clause 42 is designed to do this by allowing authorities to contract for the provision of accommodation not only with voluntary but with private organisations, as they can do already under Health Service and other legislation. The arrangements to be made will be exactly like those with voluntary homes now. A charge will be agreed by the authority and the owner, and then, as with other homes, the resident himself will be asked to pay so much of it as he can afford. I would expect that local authorities will develop this side of their services gradually.
Clause 43 will, in time, come to affect considerable numbers of elderly people. The background to the Clause is that Section 29 of the National Assistance Act, 1948, read with the Mental Health Act, 1959, provides a wide range of powers to promote the welfare of those who are substantially and permanently handicapped and whose handicap arises from illness, injury, or congenital deformity. No provision is made for the common case in old age of considerable, but still not substantial, handicap arising simply from the infirmity of old age.
Moreover, while in health legislation there are adequate preventive powers, there are no provisions which enable preventive social welfare measures to be taken, apart from recreation and mealson-wheels. The purpose of Clause 43 is to fill this gap, by giving welfare authorities general powers parallel to those they already have for the handicapped but extending to all elderly people.
The kind of powers envisaged are similar to the powers under Section 29 of the 1948 Act. They fall broadly under three heads. First, there are practical forms of help which can be given: houses can be adapted, and small personal services and aids offered, which will make it easier for elderly people to go on living in their own homes.
Second, there are preventive and advisory forms of service. Preventive services would, for example, include the very valuable and growing special housing services where a warden can keep a friendly eye on the need of tenants. There have been doubts about the welfare authority's powers to provide these services, doubts which the Clause removes. Authorities will also be able to offer, as their resources grow, a general advisory service to elderly people in their own homes.
Third, there are visiting services, visits to find out needs, to give practical help, to advise, or may be—no less important—just to make and keep contact to help fill the void of loneliness which afflicts so many elderly people living on their own.
The arrangements which the major authorities are empowered to make will be subject to my approval and I intend, in approving them, to see that they are as flexible as possible so that an authority will be free to develop its services as it wishes. It is right, however, to stress that as with all new services there will be small beginnings. Authorities will need to decide where their priorities lie and will need to build on the services which they now have. I shall not, therefore, for some time set a date by which all authorities shall have made arrangements, still less direct them to do so. A start, however, must be made, and Clause 43 provides the power.
The developments foreshadowed in the Clause will depend for their success to a significant extent on the availability of voluntary help. Voluntary visiting services are, for instance, already well established. But to make full use of these and similar services there must be not only co-ordination between the voluntary bodies and local authorities, but more financial and practical help for voluntary bodies. The powers sought in Clauses 60 and 61 will make it easier for this help to be given.
Clause 60 puts on a statutory basis the present payments which I make to voluntary bodies in the health and welfare field and also provides me with a general power to make grants or loans to such bodies. I expect any further exercise of my powers to be concerned with bodies and projects of nationwide scope, leaving essentially local matters to local authorities. The present powers of local authorities to help voluntary bodies financially and in other ways do not adequately cover the potential field, and Clause 61 consolidates and extends these powers.
Clause 57 makes amendments to the Nurseries and Child Minders Regulation Act, 1948. Broadly, that Act provides for the registration by local health authorities of premises other than private homes where children under five are looked after for a period of anything from
a substantial part of the day
to a maximum of six days, and of persons who for reward and for similar periods look after in their homes more than two children under five who come from more than one household. There are now a large number of private nurseries, play groups and crêches and, in particular, there has been a spectacular increase in child minding.
Nineteen times more children in England and Wales are now being looked after in this way than in 1949. The reports of local authorities to my Department and other evidence suggest that, while the general standards of care give no cause for concern, inadequate standards do sometimes exist, and in the interests of the children my right hon. Friend and I now propose some tightening of the requirements of the Act.
I will not deal in detail with all the changes proposed, but the House may like to know that the Clause removes the provision that registration is not required where fewer than three children are being looked after in someone's home or where the children come from the same household. Evidence points to the need for supervision whatever the number of children, and the fact that they may come from a single household does not diminish this need. I should, however, stress that the Clause does not interfere with the arrangements a mother may often make for the care of her child by a relative, or for occasional periods by a neighbour or friend, since the care of children by relatives is expressly excluded and in other cases registration is required only where the person looking after the child is paid for doing so.
I now come to a number of provisions in the Bill affecting executive council services. First, the ophthalmic services—the relevant parts of the Bill are Clauses 15 to 18 and Schedule I. Temporary institutions die hard, but it has for many years seemed anomalous to regard as temporary those services which cater for the bulk of our ordinary optical needs and cater for them very well. In 1946, it was expected that hospital ophthalmic clinics would eventually be responsible for all sight testing and the supply of optical appliances. Consequently, the interim arrangements made to provide these services were to be ended in each area as these clinics were established.
The clinics did not, in fact, develop along the lines intended. Instead, the hospital eye service has, in the main, dealt with the more specialised requirements, whilst the supplementary ophthalmic services, far from becoming redundant in any area, have been the normal means under the National Health Service of meeting the ordinary optical needs of the population. The Bill recognises this by making the services permanent and marks it by renaming them "general ophthalmic services".
It is appropriate in England and Wales—conditions are somewhat different in Scotland—that the permanent "general ophthalmic service" should be administered directly by executive councils, and that membership of the councils should be altered, as proposed in the first Schedule, so as to reflect the three groups of practitioners involved—the ophthalmic medical practitioners, the ophthalmic opticians, and the dispensing opticians.
The other main provisions in the Bill concerning the executive council services are found in Clauses 17, 18, 20 and 21 and concern health centres. Originally, only National Health services were to be provided in health centres, but since 1949 doctors have been able to practise privately there, and this has made some health centres more attractive to doctors and patients alike. There will be localities where similar extensions to the other services provided in health centres could be beneficial to patients attending at the centre, either now or in the future, and the Bill accordingly makes it possible for dentists, opticians and pharmacists to engage in private practice at health centres to such an extent and subject to such conditions as I may determine in the case of each centre.
I also have proposals to improve the arrangements which can be made for the postgraduate education of family doctors, dentists, pharmaceutical chemists and opticians concerned with providing family practitioner services. Clause 25 accordingly confers somewhat wider powers than those contained at present in Section 48 of the 1946 Act. It will not only apply to those who are actually engaged in family practitioner services, but also to those who are thinking of doing so, and will enable a wider range of instruction to be given.
The development of postgraduate education in the National Health Service is one of the subjects in which I am keenly interested. I know that many Members of the House share that interest and will join me in wishing to facilitate the expansion of postgraduate education.
Hon. Members will have noticed that the Short Title of the Bill refers to public health. For England and Wales the majority of the provisions relating to public health are those set out in Part III of the Bill. None of the changes which will be brought about by those provisions are fundamental and no new concepts are introduced.
My description of the main proposals in the Bill would be incomplete if I did not, before closing, refer to one further matter, which I know to be of considerable interest to hon. Members on both sides of the House. I am referring to Clause 31, which deals with the provision of invalid vehicles for the severely disabled. My right hon. Friend and I, in common with our predecessors, have been providing single-seater invalid carriages under a liberal interpretation of the general powers contained in Section 3(1,b) of the 1946 Act, and a corresponding Scottish provision, but it has always been held that we were not enabled to provide anything other than a single-seater vehicle for the sole benefit and use of a disabled person. We have provided cars for war pensioners under general powers contained in the Royal Warrants and we have in recent years provided some cars for small groups of National Health Service patients without specific authority under the National Health Service Acts.
The House will remember that we completed at the beginning of the year a comprehensive review of all our arrangements for the provision of vehicles for the disabled and in my statement on 15th February last I promised that we would seek new powers to enable us to do more for the disabled driver as resources permit. Clause 31 is the fulfilment of that promise.
The Clause serves two main purposes. It provides, for the first time, explicit powers for the supply of invalid carriages to severely disabled persons and for the various facilities of adaptation, garaging, repair, allowances, and so on, that make up the comprehensive service we provide. It also provides powers to make motor cars available to severely disabled National Health Service patients. Successive Governments have often faced criticism for the alleged shortcomings of the invalid carriage, but many of the criticisms have been exaggerated or ill-founded and these vehicles have over the years restored a considerable measure of mobility to many thousands of disabled people.
Many of them will not want to exchange their present machines for a car, or will be incapable of managing any other type of vehicle, and we will continue to develop and produce a satisfactory invalid carriage for these people. But we accept that, for social reasons, a passenger carrying vehicle would be regarded as a more convenient method of transport particularly for the family man and, although the Clause does not itself extend the classes of those entitled to be supplied with a car, it will enable us to make progress in this direction as the resources of the National Health Service permit us to do so. I should perhaps make it clear that in present circumstances I do not see any very early prospect of substantial advance.
The Clause also provides statutory authority retrospectively for the vehicles we have already supplied and it extends to the vehicle service the arrangements in the 1946 Act which enable charges to be made for more expensive appliances than those normally prescribed.
Once the Bill goes through, will those who qualify for the new type of car be able to apply more or less immediately, bearing in mind what my right hon. Friend has said about lack of funds? Can they make application and see what response the application will receive from the Ministry?
No, Sir. That is not the way this will be dealt with. I announced in February one or two limited categories of the disabled to whom we would be prepared to supply cars instead of individual carriages. When we are in a position to make a further advance, I shall announce a further category or further categories of existing disabled people to whom cars will be made available. So there will be no change as a direct result of the Bill receiving the Royal Assent.
I would rather not at this stage, if only because I have not really worked out a detailed programme yet. But I assure the hon. Gentleman that, when we are in a position of being able to go forward, I will announce it in good time to the House.
These, then, are the main proposals of the Bill. As I have said, it will enable a wide range of improvements to be made in the organisation and provision of existing services. I am happy to commend these proposals to the House and I believe that they will receive a wide measure of support.
The Minister introduced the Bill with a long and interesting account, starting with what I thought was a somewhat selective analysis of the relative merits of the National Health Service over the last few years. I had thought of being equally selective in the reverse direction, but, as this is a long Bill of 74 Clauses and four Schedules, I think that, after some 45 minutes of the Minister—for which I am not blaming him, for this is a long Bill—I should try to take as little of the time of the House as possible.
It is fair to say that a great deal of the improvements the right hon. Gentleman is now bringing forward in the Bill are made on foundations laid by successive Ministers of Health and I welcome without hesitation the tribute he paid to all who work or have worked in the health and welfare services for the complicated work they have done and continue to do.
This is not only a long but rather a mixed Bill—inevitably. It is a sort of stodgy bun of consolidation with a few currants and one or two cherries of innovation. In some ways, it is complicated and obscure, not least in the considerable amount of delegated powers and the mixture of mandatory and permissive powers for the Minister and the various other authorities concerned.
I accept that the Bill is not concerned with the structure of the National Health Service, that we are awaiting the Minister's researches and eventually the publication of a Green Paper. Therefore, most of the points which cause or have caused disquiet outside the House—and this has been the subject of newspaper correspondence, and so on—are much better dealt with in Committee, when I hope that we shall be able to have some debates on principles, where appropriate, as well as in detail, so I shall now consider these matters only in general.
I hope that we shall have time between now and the Committee stage for more detailed consultation. A large number of outside bodies are involved in the Bill. There was, until this debate, a considerable degree of uncertainty, to which the right hon. Gentleman referred, about his intentions, and consultations in these circumstances are, therefore, perhaps of even greater importance than usual. But since, in general, we on this side welcome the Bill, I assure him that, subject to proper debate and proper time for consultation, we have no intention of delaying or obstructing its passage.
I think that the right hon. Gentleman realises this. He appealed in a speech last night to the need for greater partnership and referred again today to the impression of antagonism given by some leaders of the medical profession among whom, he felt, according to a Daily Telegraph report, some suspicion of himself, the Ministry and the National Health Service still lingers.
Indeed, and previously.
I am not very surprised that the suspicions are lingering in some ways in view of the question of consultation. Recently, I asked a Written Question of the right hon. Gentleman about consultations concerning the White Paper on Forthcoming Legislation on the Safety, Quality and Description of Drugs and Medicines and the Sainsbury Report, because those consultations were undoubtedly rushed. According to his Answer, the B.M.A. was told on 20th October and the matter was briefly discussed by the Joint Consultants Committee on 24th October. The views of the Royal Colleges of Physicians, Surgeons, Obstetricians and Gynaecologists were sought on 30th October. Yet the Minister indicated that the objective was to complete all consultations by the end of November.
I accept that, as in this case, there had been prior consultation on the White Paper which, perhaps, made a further degree of consultation less urgent, and the Minister assured me that there would be further opportunity for full examination of all relevant matters before legislation reached final form.
It is up to the Minister to set an example now and give time for full consultations between the Second Reading and the Committee stage, particularly because there has been no consultation, so I am informed by the bodies concerned, prior to publication of the Bill. Indeed, some of them consulting his Ministry on other matters only a month or two ago were unaware and not informed of any possibility of legislation affecting their professional bodies being brought forward at this time.
I hope that the hon. Gentleman will make this more specific, because there has been very extensive consultation over vast areas of the Bill. If there has been a particular failure to consult, we would like to know about it. I would certainly express my regret if it were so.
Both the doctors and the pharmacists have publicly stated that they have not been fully consulted. The fact that there were such widespread misgivings over pay-beds and Clauses dealing with the manufacture and supply of drugs, for example, is an indication that, on these matters at least, consultation was not sufficient. There is a certain amount of uncertainty in the public Press over the health centre provisions and the new university hospitals and the implications they may carry.
I am not saying that there is anything sinister, as some people have implied in what the Minister is up to. I am only saying that it is partly his fault at least if this impression has got about. I think that the relevance or otherwise of the Bill to the Minister's statement of 6th November about the inquiry into the administrative structure of the National Health Service has in itself perhaps led to a certain greater confusion than would otherwise be the case.
The Bill has very wide powers. A great deal is to be left to the Minister's decision and our judgment of this must depend entirely on his intentions. There is a difficulty here about the whole question of delegated powers. Obviously, it is desirable that the Minister should have some delegated powers, because he must have the capacity to alter and improve and experiment with the National Health Service in order to keep it up to date. Indeed, part of past difficulty has been the cumbersome mechanism of the original Act which did not adequately provide for the rate of change which was not perhaps fully expected at that time.
I regret in a way that the Bill does not make more of the opportunity to integrate some of the services, both cash and care, which the right hon. Gentleman and the Minister of Social Security provide. In this context, the local authority Clauses are most helpful. Clause 42, of course, must give a greater degree of flexibility in the care of old people and, I hope, prevent the necessity of moving people a long way from their homes to get them into National Health accommodation when there is voluntary or other accommodation of a suitable nature closer to hand. I imagine that this is part of the right hon. Gentleman's intentions in this context.
Clause 43 treats the inevitable disability of old-age equally with other forms of difficulty in coping with ordinary life and is also very much to be welcomed. But I wish we could get a little more integration between the right hon. Gentleman's Ministry and the Ministry of Social Security, particularly when it comes to the health of those who live in their own homes, to which the right hon. Gentleman has also referred. Not only is help needed in the practical sense, especially for disabled old people and disabled housewives, but also some form of allowance which is not now available under our Social Security provisions. We should also like to hear something in this context about the capacity to avoid using high-intensity care for geriatric and other needs which require less intensity.
It is important that both sides of the House should emphasise the need in public and all other forms of care for what might be called protection for those who must inevitably rely on others than themselves and relations for protection. The economies of scale are not everything, and nor can we rely on the same methods being effective in every area, in town and country, among different income groups and different occupations.
I very much welcome the Minister's emphasis, which I detected, on flexibility, but flexibility must mean flexibility for the good of the patient as well as ease of administration of the Service. Reviewing the book "Sans Everything" in, I think, New Society, my right hon. Friend the Member for Wolverhampton, South-West (Mr. Powell) pointed out that the aged were not only sans teeth and sans everything, but also sans influence and sans votes, on the whole, and did not have the freedom which the public provision should give, or the protection in the administration of the service which most of us can secure for ourselves in one way or another. In this as in other respects these provisions must depend a great deal for their efficacy on how they are affected by the future organisation, administration and structure of the Service.
I am sure that this is realised, but it would reassure a number of people if the Under-Secretary could take up this point that the care of the aged and the problems of the mentally sick and the whole subject of the care of pre-school children depend not only on the provisions of the Bill, but on what the Minister may put forward in his bigger efforts in future. On this side of the House we welcome Clause 57, but we would like some indication that the right hon. Gentleman intends to make a more constructive approach to the whole subject of the pre-school child and to have an effective liaison with the Department of Education and Science on nursery education and nursery schools, a subject which is not irrelevant in this context.
We would also like some assurance about rising costs. There is no doubt that this is inevitably a problem in the Health Service, not only because of the fall in the value of money but because of the achievements of medical research and the development of medical techniques which, although they perform great wonders, involve high cost. The Minister ought not to economise simply where economies are easy. There is a danger that economies are effected at the expense of the freedom of choice of treatment and may militate against the use of prophylactic drugs which are particularly important for the lower-income groups with their lower standard of living and lower nutrition and in general suffering from the difficulties described so often in our social security debates.
Of course, there are savings to be made, but I hope that they will not be made simply because they are easy. Some would be administratively very complicated and difficult but could well be made without any effect on standards. A notable example is hospital building and the utilisation of manpower, particularly manual labour, in which respect the Prices and Incomes Board said that there was room for great improvement. I do not want to make too much of this, but I agree with the Minister, as all of us on this side of the House do, that the future of the Service requires the highest possible degree of co-operation and partnership among all those involved; and I am glad that he agreed with us that this also involves some sort of partnership between the public and private sectors of the Health Services.
This subject of the private sector brings me to Clauses 1 to 4, the provision of pay-beds. No doubt we shall debate this subject in great detail elsewhere and I hope that we shall do so constructively. As I have said, this requires some time for consultation by our side of the House as well as by the Government and I have no doubt that my hon. Friends will have something to say about it. We are all very glad of the Minister's assurances and we accept that the Bill is neutral in its approach to the provisions for private patients and gives the Minister no more or less power to increase or decrease these provisions than he had before. There are and have been some worries about his intentions which I hope his words this afternoon have tended to dispel.
What will this provision for pay-beds and this greater flexibility do to the waiting list and how will adjustments be made now that beds are not to be designated? This could do harm to the overall provision of care in both the private and public sector. It is extremely important that there should be no question of private patients jumping the queue for medical need and, equally, no question of their being prejudiced, or, more important, of the Bill being so administered as to lessen the freedom of choice of the consultant and militate against part-time consultants and their use in the Service.
We shall be asking the same sort of questions about charges. Of course, we have approved of the new proposal that charges should be regularised and decided, according to the nature of the care provided, on a national basis. That is obviously sensible. But it is equally obvious that the Minister could price the private patient out of the market, although I am not saying that he wishes to do so. As the private patient now has the right to use the national hospital service although a private patient of the family doctor, that could result only in a situation unsatisfactory to either side. We have the same sort of questions about out-patient charges, detailed questions with which I will not now weary the House.
I hope that the significant change towards private patients which the Minister has introduced will lead to what he called a greater degree of partnership, especially in view of other Clauses by which the Minister proposes to make use of private facilities in special cases, especially in the care of the old. There seems to be scope for relieving the high-intensity care in Health Service hospitals by using low-intensity care, where suitable and adequate, even for Health Service patients and even when it is voluntary or private. There are some obvious dangers, but these, too, must depend on the Minister's intentions. We shall be going into all this in much greater detail at a later stage.
There is one specialist point. It is whether this will sharpen the distinction between the teaching and non-teaching hospitals in that the teaching hospitals generally have their private sectors in a separate unit or separate building, while the non-teaching hospitals, especially in the provinces, have their private accommodation scattered about the rest of the hospital.
I welcome Clause 5 and say merely that some concern is being expressed, especially when the Clause is read in conjunction with Clause 7, about hospital endowment funds, as to whether it foreshadows some future attack on the teaching hospitals and an attempt to bring them under regional boards. As the Minister knows, it is fair to say that the medical profession itself has a somewhat mixed view of the teaching hospitals. During the debate we would like some assurance about their future and about the use of funds by teaching hospitals to initiate work or research which, at the moment, is not being undertaken by regional boards. I am prepared to admit that the Minister has a genuine difficulty in dealing fairly between different types of hospital and the need to prevent too great a diffusion of effort especially when considering innovation.
The Minister referred to the power which will enable him for the sake of flexibility to make changes in hospital designation subject to our negative Resolution procedure. I agree that he needs flexible manœuvre in this respect, but we would regard this as an experiment. Only two proposed university hospitals are involved, those foreshadowed for Nottingham and Southampton. We should be happier if the Clause were so drafted as to indicate that this power was experimental and subject to review in the light of English experience—Scottish experience in this respect is not altogether applicable.
I come now to the subject of health centres. The Minister spoke of doctors, dentists, opticians and pharmacists practising together in health centres on equal terms. Clauses 15 to 18 are welcome by the professions generally, although there are some reservations about representation on the committee, a subject which we can discuss on another occasion. As in most of the Bill, the wording of these provisions is rather vague and permissive—"on such terms and conditions as may be determined by the Minister".
Perhaps the Under-Secretary will say something about the terms and will confirm that there is no intention of imposing a general pattern throughout the country. It seems a little odd that there is to be a limit on the amount and sort of dental treatment provided in private practice in a health centre and there is the curious exclusion of sight testing from the work of the opticians.
I am a little concerned about the rôle of the pharmacists and chemists in health centres, both how this service is to be administered, which seems to present certain difficulties, and also about what may or may not be sold, since Clause 20 refers to all items ordinarily supplied by pharmacists, which seems to give very wide powers of trading in health centres. We need considerably more detailed information, especially in view of the proposed growth in health centres, which I certainly welcome, but also in view of the uncertainty about their nature and what they are to do. I hope that we shall not once more lose the patient in the difficulties of administration. I was grateful for the Minister's implied admission that private practice in health centres might be more attractive not only to doctors, but to patients.
We have a number of queries. The right hon. Gentleman stated that he had changed the Ministry's priorities and had given instructions and advice to go ahead as fast as possible. I should like to know a little more about what the local authorities themselves think about these matters. Some are afraid of what the reaction of local doctors may be to such issues as rent, and so on.
We should like a little more information about costs. Some health centres now cost between £150,000 and £200,000. Are they excluded from the standstill, or expenditure cuts, which the Chancellor of the Exchequer will have to impose? We have been told that hospital building is to be especially privileged and exempt from any new version of the Geddes axe. Are health centres included in that general dispensation? I hope that we shall debate that point in detail later, and that the debate can take place in a non-doctrinaire atmosphere,
I also hope that the question of group practice will be considered, with that of health centres, and that the recommendations of Mr. Justice Danckwerts—as he then was—in 1952, which have so far produced 711 interest-free loans amounting to £4·3 million, will be remembered, particularly in view of the question of cost. The Minister should consider group practice and the encouragement that local authorities and the Ministry can give.
We very much welcome Clauses 10 to 14 and 42 to 43, since a clear improvement and a much higher degree of flexibility is introduced, especially in routine care and prevention and prophylactic care. I shall leave the whole question of Clause 14 to my hon. Friends from north of the Border. As a mere English Member, I should not like to intervene on the moral aspects of the problem.
We wish to be reassured that the proposal about midwives in hospitals is not a question of trying to ease a shortage of doctors, when their care is needed in a delivery, but simply a convenience to see that the patient receives the same attention throughout for her own sake. No doubt that is so, but it would be as well to make it clear.
We should like to see something in the Bill about a positive approach to preventive welfare, and especially the need to collect more information and have more research to ensure the maximum co-operation between the Ministry of Health and the Ministry of Social Security. I cannot resist saying that there is a danger that lack of co-operation at the centre may well lead to a diffusion of effort and confusion on the part of the user.
We should also like a great deal more information about Clauses 23, 29 to 30 and 62. Perhaps it is a bit like Alice in Wonderland to say that we want more information, because so far we have had precisely none. It is admitted by the Minister and in the Ministry Press hand-out, no doubt for good reasons, that both the B.M.A. and the British Pharmaceutical Society are worried about the Clauses. For example, Clause 30 empowers the Minister to produce or manufacture drugs, among other things, in excess of requirements. He now has the power to compound bulk-purchased raw materials in hospitals, but only for the hospitals' own use. The Clause gives him power to extend that manufacture beyond the needs of the hospital doing it.
Clause 23 enables him to supply the professions—doctors, dentists, chemists, opticians—through arrangements made by the executive councils. The general practitioners are in a contractual relationship with the executive councils and I think that there is a fear that this may lead to pressure on them to take the drugs so provided, rather than those provided by industry, and handicap their freedom of choice, particularly of branded specialities.
On the whole, the general practitioners are very glad to take the free sterile syringes which are provided for them by executive councils. The trouble is that I am not sure that I have statutory authority to do it until the Bill is on the Statute Book.
I am not surprised that doctors, like other people, will take things that are free and perhaps argue about the strings afterwards. Nevertheless, the Clauses give the Minister very wide powers.
Clause 62 enables him to purchase, store and supply goods, and he can sell, give away or otherwise dispose of drugs and appliances. As far as I can see, in this group of Clauses the Minister takes to himself the power to enter into supplying the Health Service as a manufacturer, wholesaler and retailer. Although I have no doubt that he has no intention of nationalising the pharmaceutical industry, it looks rather as if the Bill gives him power to do so. We should like reassurances on this. I have had a number of representations on the point, and a great deal of misapprehension could have been removed if there had been more consultation. Now is the time to remedy that error, if the Minister really wants the partnership to succeed.
In his speech last night, the Minister referred to the need for doctors to be able to consider their patients' needs and not their means, and to feel that they could prescribe and carryout whatever treatment they considered necessary. No one on this side of the House would quarrel with that. But the treatment includes drugs, and I warn him of the dangers of trying to standardise supplies. One of my hon. Friends has examples of the difficulties which have been met in Australia and elsewhere. I also remind him that expenditure on drugs may well save some hospital costs as well as lives, particularly in mental health and in the use of prophylactic antibiotics. It is very important to establish at this stage that the Minister is seeking to provide what the doctor wants and not what he, however well-advised, may decide.
I have inevitably missed out enormous parts of this long and prolix Bill. I should not like those with special interests to think that we on this side of the House regard them as unimportant. There is the question of notifiable diseases and food poisoning, the improved definition of welfare foods, the whole question of voluntary organisations and the help for them to be statutory rather than permissive—and even the question of public health in hovercraft seems to come into the Bill.
I have left out what is perhaps the most important matter, saying nothing about invalid vehicles. We are grateful to the Minister for what he has put in the Bill on that subject, but to avoid repetition I am leaving it to my hon. Friends with special interests in the matter to discuss it.
The Minister has made significant improvements on several matters, notably compensation, and he has partially dealt with the problem of children below school age. The Bill contains many sound provisions, but it also poses many questions, some of which are left unanswered, and some doubts are also left unresolved. There are indications that there are still too many authorities, resulting in confusion of responsibilities for different health matters. I hope that that will be borne in mind when the further review is carried out and the Green Paper is due to be published.
There is a danger that over-centralisation in the point of contact with the patient, especially over-concentration in health centres, and the difficulty of the remoteness of district general hospitals will create problems. I have considerable doubt whether the Minister has resolved the definitions of the rôles of the hospital, health centre, family doctor, local authorities and the Ministry of Social Security. It is necessary to rethink many of these problems in the light of new information and research which has yet to be completed, and there is a danger of acting too quickly, which the Minister showed that he appreciates.
It is clear that more information is needed throughout this field and that there is room for more experiment, but one difficulty remains in the control by Parliament of the wide powers for the Minister in the Bill. Of course, I see why he is doing this. There is a need for flexibility and some changes must be possible without complicated legislation. But this means that the technique of Parliamentary Questions will be suitable only for specific cases of maladministration or individual difficulties and not for matters of administrative reform and day-to-day shifts of emphasis in the Service or changes in administrative policy. There is a strong case for a Specialist Committee, not necessarily for health alone, but working in social welfare generally.
There is a great deal to examine. Can we relieve the Health Service by "subsidising" people to remain at home and helping them to care for themselves in the light of some of the proposals of the Disablement Income Group? Are we in danger of concentrating geriatric care in too few areas? There is a case in my constituency in which this might happen because of new hospital buildings. There are changes and advances in methods and techniques and all bring their own problems, not only of organisation but of finance.
The Bill is evidence of the need for delegated powers and a procedure such as a Specialist Committee which would enable a continuing constructive criticism, which is more than merely a presentation of a specialist point of view or the demands of pressure groups. The time which the Minister and I have taken up today is in itself a reflection of the need to revise our procedure. If we had had Specialist Committees over the years, the Bill's proposals could have been brought forward in a more regular and piecemeal fashion, and we should not have needed what the Minister himself described as "a ragbag".
I have tried to approach the Bill constructively and we on this side will continue to be constructive in Committee, but we will keep a vigilant watch for anything like a doctrinaire distortion of the Health Service and the part to be played by private practice. It is very important in this discussion to remember that we are dealing not only with organisation and methods, but, essentially, with people, their place in society, their health and, indeed, their whole happiness.
It always worries me when praise is poured on Ministers by hon. Members opposite and even more when I have to agree with much of what they say. I agree with the hon. Member for Farnham (Mr. Maurice Macmillan) that the need for a Specialist Committee is self-evident. This Service has existed for 20 years and is so complex, involving so many different spheres of action and Departments, that there is a powerful case for such a Committee to inquire into it at regular intervals. It is some time since we had a Health Service debate and it now seems that, after today, our next opportunity will be next summer, towards the end of the Session.
The Minister described the Bill as a "hotch-potch" and the hon. Member for Farnham as a "ragbag". I believe that it is a bit of a dog's breakfast, because this is the first amending legislation for 20 years. But we are in danger of putting the cart before the horse. It is ironic that we should have waited 20 years for amending legislation when, early next year, we are to be presented with a Green Paper giving the thoughts of the Minister and his Department, which will be discussed at great length, followed by a White Paper, in which, presumably, we will be told of proposed legislation to amend the Health Service. As a result of those deliberations, we might want to change much of this Bill. I would, therefore, have preferred it the other way round.
I welcome the Bill in many ways, but it still tinkers rather than deals with the fundamental faults of the National Health Service. No one will say that, after 20 years, a Service conceived in the 1940s is necessarily right for the 'sixties, or for the 'seventies and 'eighties. The main fault is the structure of the Service and I with that the Minister had included this in a Bill. We should remember that we are dealing with the fifth largest industry, employing well over half a million people. It is vital to our welfare and health and has an economic effect in terms of production in so far as it seeks to make people well enough to do their jobs. So it is crucial.
The Bill should have included some provisional legislation for altering the functioning of the Health Service. There is fair criticism on this side that regional hospital boards and hospital management committees do not represent all sections of the community affected by the service. I would like trade unions to have the right of representation, and also patients, who are after all, closely involved.
I would also have liked a recognition that chairmen or members of hospital boards or management committees should be drawn from a much wider circle than at present—[An HON. MEMBER: "Including patients."]—Certainly. The hon. Member for Peterborough (Sir Harmar Nicholls) is a more potential patient than many others in some ways. The Minister seems to feel that this can wait and be dealt with later.
The other great omission in the Bill, and one which many on this side have been advocating for some time, is something which affects the lifeblood of the nation. That is, the crying need for an occupational health service. There can be no doubt that, in our society, 300 million working days are lost every year not through strikes, but through sickness. We make a great song and dance about strikes, but for every 1½d. lost through strikes about 19·10½d. is lost through sickness, and it is time that we considered this. The Bill should have been an opportunity of at least setting up the type of occupational service which is needed.
This problem is not just a simple question of cuts and bruises. Other factors are involved, like noise and fatigue and it should be the responsibility of the Department to ensure that there is an adequate number of factory inspectors who could see that working conditions in factories are decent and other facilities were right. Ten thousand factories employ more than 1,000 workers and a start could have been made there and extended to include every employee.
I wish to deal with two main topics in the Bill—Clauses I and 2, dealing with private pay-beds, and Clauses 26, 27 and 28, dealing with finance. I may be a rather suspicious soul, but I do not like the way that Clauses 1 and 2 are phrased. If the Minister intends to make available accommodation for private patients without its having been definitely set aside, what will this mean for general patients? Does it mean the end of private patient wings? If so, has it already been argreed or will it be agreed that no hospital in future should be built with such wings? I hope so. Does it mean that private patients will be able to take over the amenity beds of the single bed wards for the general patients and that normal individuals who enter hospital may be pushed to one side so that the private patient may be where he can be best dealt with? These are the kind of questions which should be examined.
Let us have no illusions. No matter what hon. Members may say, there is a deeply-rooted suspicion of pay-beds among the public, not solely confined to supporters of this party. I therefore welcomed, as, I am sure, did many of my hon. Friends, the Minister's announcement a few weeks ago about a reduction in the number of pay-beds. This is a step in the right direction. The Labour Party has repeatedly gone on record at its annual conferences and elsewhere as wanting the complete abolition of the system. This is right.
If I am told, as many of my hon. Friends have been told by other Ministers, that they cannot run a Department on the decisions of annual conferences of the Labour Party, I would reply that this may be true, but that it could equally well be said that, if it were not for the Labour Party, Ministers, whatever Department they head, would not be sitting on this side of the House. I hope that note will be taken of that, since we will be on this side for a long time to come.
People have said that this is already in the Act, and of course it is, but we must look at it more closely. When Nye Bevan introduced the Service in the teeth of the opposition of people who now pour praise on it, he had to make some concessions to the medical profession to get it off the ground——
What was said 20 years ago does not necessarily bind our present actions. If it did, there would be a tremendous number of contradictions on both sides of the House. Let us wake up to the facts of life as they are. Aneurin Bevan had to make this concession to get the Health Service off the ground. It was right then, but is it right now, 20 years on? Is it right when over 97 per cent. of the people are in the public sector of the Health Service? Must we be so dogmatic and say that we should not consider this whole matter again?
What has altered today compared with 20 years ago? In other words, are not the circumstances of that categorical assurance the same in relation to the relationship between doctor and patient?
When the Health Service was first introduced it was not known what this private sector would be like. If one looks at the figures in the Annual Report of the Ministry of Health for the last two years one sees that in 1965 there were 5,616 pay-beds in our hospitals, with an average daily occupancy rate of 2,890. In other words, for 51 per cent. of the time they were occupied by paying patients, but 907 non-paying patients occupied them at other times, a total occupancy rate of 67 per cent. In 1966, the story was much the same. There were 5,572 pay-beds and they had an average daily occupancy rate of 2,864 private patients—51 per cent. Those beds were also occupied by 874 non-paying patients—a total occupancy rate of 66 per cent.
It is interesting to note how these figures compare with beds in the general sector. It should be remembered, too, that the number of beds available in hospitals has been decreasing rather than increasing. In this sector in 1965 there were 464,000 beds and they had an average daily occupancy rate of 397,129. In other words, 85 per cent. of those beds were occupied. In 1966, with 461,704 beds, the average daily occupancy rate was 392,563, a percentage occupancy rate of 85.
These figures show that we must have these pay-beds in the public sector small though their number may be. At present, we have long waiting lists, with people needing attention. I understand that the lists have been rising from year to year. At present, 536,000 people are waiting for beds. It is only right and proper that every available bed is used to the maximum efficiency. That is why the Minister was right to reduce the number of pay-beds, as he did recently, and that is why he should reduce the number still further.
If the hon. Gentleman looks at the figures of occupancy rate in private hospitals he will find that they are running at about the same level as the occupancy rates of National Health Service hospitals. Would he agree that the difficuly was largely caused by beds being designated and that this led to a complicated situation, which the Minister has made more flexible?
I am glad that the Minister has decided to reverse this idea of beds being designated and consultants and others being able to take on for treatment whoever they wished. There is still a case to be made for the abolition of the idea that people with money can jump the queue and buy good health. This has never been the philosophy of the Labour Party and I hope that it never will be. We should not make it easier for private patients to be treated more easily. I would like to make it a damned sight more difficult.
I hope that my hon. Friends will make it clear to the Minister that we would have liked to have seen the concept of a salaried service and the abolition of the part-time consultant. This idea of people coming into National Health Service hospitals for nine-elevenths of their time, earning lucrative money treating their own private patients, is wrong. I hold to the maximum that private practice in a public service is wrong, ethically and morally, and that it is totally unjustified. I would like to see the concept of a Health Service free to all at the time of need.
In referring to Clauses 26 to 28 I raise a matter from personal experience because, before coming here, I was employed by a regional hospital board. The sooner we get away from the annual budgeting system for hospitals the better. I know from experience that when the year is coming to an end those responsible say, "How much money do we have? We will spend more than we have left so that we will get a little more than we had the previous year". This leads to an absolute waste of public money. I know, because I did it. I did it because I wanted more money for my hospitals than I had the previous year and I went out of my way to spend it. This has been done not merely by regional boards, but by subsidiary groups such as radiography and blood transfusion groups and others.
The sooner we treat hospital boards as adult beings the better. We should say that they have every right to carry over money left at the end of the year for use on specific projects or for other special arrangements they wish to inaugurate in the future. The sooner we get away from fixed budgeting the better.
I welcome many of the 74 Clauses in the Bill. I have mixed feelings about some of them and I hope that, in making these remarks, I have not disturbed the tranquility of the debate. I urge my right hon. Friend to persuade all concerned not to think in terms of a Health Service split into three separate sections. The whole Service should be under one control or Ministry. It is ludicrous that the Minister of Agriculture, Fisheries and Food, the Secretary of State for Education and Science, the Minister of Housing and Local Government and the Armed Forces and many others should all be responsible for various health services. Why should each Department have its own Health Service? They should all come under one umbrella, including local authority services.
I still believe that the Health Service is the greatest power for good to come out of any Government this century. Its introduction recognised that we were becoming a truly civilised community. However, we must realise that it is a little tarnished in places and that it can be improved. We must get across the idea that the Service is meant for the benefit of the whole community, and we should try to get people in general to be involved in its management and running, including those working in it—not only doctors but nurses and those in ancilliary grades. We must remember that those who do the menial tasks should also have a say in what happens to the Service.
I believe in a fully comprehensive Health Service that is free to all when they need it. I recall that Aneurin Bevan said many years ago at a Fabian Lecture that the more of the world's goods that reached the consumer without going through the price mechanism the more civilised that community becomes. That is true of the Health Service. I can claim some privilege in quoting what the British Medical Journal said in 1948—and, in giving this quotation, I show that I wish to be bipartisan:
The Health Service, in its conception, was one of the greatest attempts at social legislation which this present generation has known. It is destined to have a profound influence on social welfare and the health of the community.
That is true. It began as a great Service, but we should constantly be trying to improve it. Although the Bill is a bit of a hotch-potch, I believe that it will help towards creating a better Health Service and I hope that, when we get the Green and White Papers next year, we can make the Service even better.
If it does not embarrass the hon. Member for Huddersfield, West (Mr. Lomas), in view of the way he began his speech, I would like to say how much I agreed with some of his remarks. I particularly agreed with him when he referred to bringing all the various Ministerial health services under one umbrella.
I have considerable sympathy with the hon. Gentleman over the question of industrial health, but I suggest that if he tried to winkle that responsibility out of the Ministry of Labour he would find that he had a major task on his hands. If the Minister of Health is able to do it, I will congratulate him. He will certainly have warm support from my hon. Friends for doing what others have failed to achieve.
The most relevant sentence in the speech of the hon. Member for Huddersfield, West was when he said, "Let us wake up to the facts of life as they are". That being so, I will leave that part of his speech, when he was referring to private practice, to the Minister to defend in relation to Clauses 1 and 2.
I congratulate the Minister on having got to the top of the legislative queue. I know that he has been patient for some time, as previous Ministers have before him. If he wants to know how to jump the queue, I will tell him of an experience I had, with the then Minister of Health, in getting the Mental Health Act brought forward a year of two earlier.
I welcome some Clauses of the Bill, particularly those which relate to old people's welfare services, in which I seem to recognise the hand of the Minister—based, no doubt, on some of the experience which he obtained when he and I served together on the Advisory Committee of the National Council for the Care of Old People. I also support what my hon. Friend the Member for Farnham (Mr. Maurice Macmillan) said about the need for a Select Specialist Committee to examine the problems of the Health Service. I could not help feeling that that suggestion would be more warmly welcomed in Westminster than at the Elephant and Castle.
Clauses 1 and 2 make provision for a change in the national scales which is long overdue. I welcome the abandonment of designation, because it will mean a better use of both private and public beds. For reasons which the Minister will understand, I wish to comment on Clause 5, in which he takes power to designate university hospitals. My hon. Friend the Member for Farnham referred to this and I hope that the Minister will understand that I for one must give a rather frigid welcome—but a welcome, nevertheless—to this proposal. I appreciate that it is an experiment and that he is, perhaps, faced with a difficulty over the Nottingham and Southampton new medical schools, because the purpose of the Clause is that they may be placed under the sway of the regional hospital boards.
I am not happy about the use of the term "university hospital". It conveys an impression of eclecticism at a time when all teaching hospitals are taking on district responsibilities. The phrase has a rather eclectic flavour about it and I therefore suggest that the word "general" or even "district" should appear between "university" and "hospital".
I appreciate that the right hon. Gentleman has been at pains to allay certain misgivings that have been held about the wide powers which he is taking in the Clause. I was somewhat disturbed when he said, "It is not my present intention". The word "present" particularly disturbed me. I would have preferred him to have said, "It is not our intention", because I do not believe that there is any real reason for any change at all. Both the Guillebaud and Porritt Reports favoured the administration of teaching hospitals being separated from the regional hospital boards.
There have been disadvantages in that separatism in the past, but I think that it has changed now. I think the Minister would agree that the joint consultative councils—certainly, in my experience—are working very well. They are bringing the regional boards and the teaching hospitals into a closer and happier relationship than they have enjoyed at times in the past.
But the fact remains that teaching hospitals are different. They are the point where the two disciplines meet—the clinical and the academic.
There has to be a very close and rather intimate relationship between a teaching hospital and a medical school. That relationship is or should be what has been described to me as a happy symbiosis—a medical term which I gather roughly means two hearts beating as one.
There are those who regret, begrudge, or even resent the privileged position of teaching hospitals. It is true that teaching hospitals retain and attract the best of medical knowledge, skill and personnel. The same applies to nursing standards. Similarly, the best equipment is usually found in a teaching hospital. However, this is surely right, because it is essential to maintain the quality of medical education and research, on which the future of the National Health Service depends.
So it is vital, and we must realise this, that unless the teaching hospitals can provide the highest standards of clinical support to their medical schools, the effect could be calamitous for the future. This presupposes that teaching hospitals should continue to be independent and have direct access to the Minister—a privilege which they very much value and do not abuse.
There is a lingering suspicion that university hospitals, coming under regional hospital boards, will not enjoy the same freedom as now. The regional hospital boards are, understandably, preoccupied with the many problems of providing treatment for patients over the widest possible range and they may not give the same measure of support to the university hospital that it would have obtained as an independent teaching hospital. The regional boards may not, therefore, encourage or produce the essential concentration of skills that is necessary. They may not intend damaging these interests, but they will be subject to many other pressures.
These may be unjustified fears, but they do exist, and I know that the right hon. Gentleman recognises that fact. Therefore, I shall support my hon. Friend during the Committee stage of the Bill in trying to limit this Clause to show that it is an experiment, and that, until it is proved that the advantages greatly outweigh the disadvantages, there should be no further extension of the power.
I am sorry that the hon. Member for Farnham (Mr. Maurice Macmillan) is not in his place. I was not sure whether he said that he did not want this to be a non-doctrinaire debate or a "non-doctor air" debate. If the latter, as a doctor I offer him my apology for disturbing the air.
I should like to take the Bill in conjunction with my right hon. Friend's statement in the House on 6th November and, of course, that of my right hon. Friend the Secretary of State for Scotland on the following day. I look forward very keenly to the Green Paper and its proposals for changes in the administrative structure of the National Health Service.
On this I refer only to one point, namely, the composition of executive councils. I would like my right hon. Friend to take into account my own personal experience of an executive council over a long period of years. Notwith-standing the fact that little more than 25 per cent. of the composition of executive councils is comprised of the medical profession, they tend to be dominated by doctors and, to be more specific, by the local medical committee which, to quote a phrase often used in this House, is a tightly-knit group of ambitious men. The executive councils, therefore, tend to rubber stamp decisions of the local medical committee whose views I may say, neither reflect the majority of their colleagues, the practising doctors, nor, indeed, of the general public.
I wish to refer to two Clauses in the Bill. The first Clause is the one which deals with domestic helps. This is a humane and effective way of tackling a serious problem—the problem of keeping in their home environment people who otherwise would be admitted to hospital but who, strictly speaking, are not really hospital patients.
Speaking from my own experience, I know that many families in my own constituency have reason to be very thankful for Glasgow's domestic help service, which often plays a very significant part in preventing families from falling apart due to illness. Indeed, I have found the local authority playing an even more humane part in permitting a daughter, for example, devoted to her parents, to have a welcome break or holiday because the domestic help came in and looked after the parents. I believe that this is money very well spent, because the cost of one week in hospital is more than three times the cost of a full-time domestic help. Therefore, it is to the financial advantage of the State, as well as to the advantage of the family, to foster this service.
I do not know whether my right hon. Friend is aware that there is a time limit. Some local authorities impose a time limit after which domestic help is not available, even on a recommendation from the family doctor. I should like my right hon. Friend to consider abolishing this limit.
As a practising doctor until recently, I am aware of the advances which have been made in the National Health Service during the last 20 years. I welcome the increase in the number of health centres. I know that when my right hon. Friend took office morale among general practitioners was low and family doctors felt frustrated.
I turn now to Clause 21, which deals with the health centres and the family doctor. I know that my right hon. Friend will not take it amiss if I seem to criticise lack of dynamic change in what I believe is a structure which has lasted for too long. It is a matter of deep regret that almost 20 years after the inauguration of the Health Service we still have a family doctor system based on the concepts of the 1920s, or even earlier. I cannot think of any profession whose practitioners on receiving their diploma or degree proceed, as it were, to set up shop in the manner of the general practitioner of old. He took upon himself every task associated with his calling, including, as we know, the answering of the telephone, arranging appointments with specialists, writing letters to hospitals, doing all kinds of testing, and so on.
He did every aspect of his work himself, including all the clerical work in addition to the work which he was trained to do, that is, to prevent disease where possible, and to treat it when prevention did not succeed. This situation might have been just satisfactory 40 or 50 years ago. It certainly bears little relationship to the needs of today.
The theory that the Health Service would be a diminishing cost to the State, and a diminishing demand on the doctors because it would overtake the backlog of work, reach a peak, and then settle down certainly shows no signs of being borne out in practice. Perhaps we tend to look at these matters within too narrow a time confine. At any rate, health centres and the family doctor must develop in such a way as to ensure the maximum effectiveness of this highly-trained and highly-skilled body of men and women.
Introducing the National Health Service Bill on 30th April 1946, Nye Bevan said:
that is the National Health Service—
will lift the shadow from millions of homes. … It will produce higher standards for the medical profession."—[OFFICIAL REPORT, 30th April, 1946; Vol. 422. c. 63.]
What worries me is that the nation is not making proper use of its 23,000 general practitioners. The average family doctor finds it impossible to practise his profession in the way that he was taught when he has to see—and this is an average—40 to 50 patients per day. Estimates vary, but it has gone on record over and over again that between 50 and 75 per
cent. of these consultations and visits do not require his skill. These patients are not malingerers. They are not dodgers, or people who want something for nothing. It is true that the illnesses are often trivial, and sometimes imaginary, but, none the less, treatment is necessary.
In most instances tablets for a cold, advice about simple cuts and bruises, and so on, could be given by someone less highly qualified than the doctor who has spent six or seven years of his life studying. This applies also to simple tests, for example, urine and blood tests, to minor treatments such as routine injections, and even—and here I may be treading on difficult ground—to the issuing of repeat prescriptions and medical certificates. The family doctor working from the health centre should be the head of a health team in which he carries out the highly-skilled work, and the clerical and less highly skilled routine is carried out by ancillary staff.
Let me go back to that momentous Second Reading debate, during which a doctor, making his maiden speech, voiced the following sentiments:
What does the average doctor want? He wants the opportunity of doing first-class work, and not to be just a clerk filling out certificates, or acting as a sorting office for different diseases and illnesses…"—[OFFICIAL REPORT, 30th April, 1946; Vol. 422 c. 83.]
That is as true now as it was nearly 22 years ago. Money alone will never solve the problems of the family doctor. The trouble is that he sees himself carrying out perhaps half a dozen different jobs, but he wants to earn his income doing the one job for which he was trained, and for which his time under our present system is very strictly limited. To be sure, some general practitioners manage very well.
Only a few months ago I received a letter from one who said:
Problems in general practice? I have no problems. I consider it an honour to be able to work in the National Health Service and to practise my art and my profession for the benefit of my patients. My life is a holiday because I love what I am doing and I do it in the knowledge that it is a privilege for which I am deeply grateful.
This doctor has, of course, a saintly concept of his calling and I am sure the House will agree that saints are scarce, but in any case I do not think that it is any part of the duty of Parliament to sanctify any section of the community.
We are on the threshold of a completely new era in medicine, when the replacement of diseased or worn-out organs of the body with brand-new artificial substitutes, or healthy organs from human donors, is developing into a new technique. The House will be aware that only this week the first operation of its kind was carried out, and the patient is doing very well at the moment. I am, of course, referring to the transplantation of a heart.
I make no apology for dwelling at some length on the subject of general practitioners. The family doctor is the first, and sometimes the only, point of contact for the vast majority of our citizens with the Health Service, and I believe that the Service must be dynamic and not static. This, of course, visualises all kinds of changes which I am looking forward to reading in the Green Paper.
I can conclude with nothing more apposite than the words of the then Lord Privy Seal in the final speech on the Second Reading of the National Health Service Bill. He said that we should not consider this Bill as final, and added:
We do not see the end of this scheme … this is a developing policy, and we shall march on to greater and greater public service by the medical profession."—[OFFICIAL REPORT, 30th April, 1946; Vol. 422, c. 398.]
All three back benchers who have preceded me have spoken with some experience of their own of the National Health Service, or of administering it. My only reason for making a short intervention is that I am one of the lay members of the General Optical Council. I have frequent contact with members of the optical profession, and representations have been made to me about parts of the Bill which affect opticians.
I am speaking only on behalf of myself. My hon. Friend the Member for Farnham (Mr. Maurice Macmillan) rightly dealt with the general principles of the Bill. He said that this was the proper thing to do on Second Reading, and that the details should be left to the Committee stage. He hoped that adequate time would be allowed between now and the Committee stage for consultations between various interests. I think that it is worth while warning the Minister of some of the points which may be brought forward in Committee if consultations do not satisfy the opticians.
The first point is one on which there is disagreement between the branches of the optical profession, the ophthalmic opticians who test sight and dispense prescriptions and the purely dispensing opticians. It concerns representation of opticians on the executive councils. In Schedule 1, it is laid down that there shall be one ophthalmic optician and one dispensing optician in addition to an ophthalmic medical practitioner.
The ophthalmic opticians think that this is wrong, bearing in mind the difference in numbers. As there are roughly 5,000 of them compared with 1,000 dispensing opticians, they would like to have two ophthalmic opticians on each executive council. That is partly justified by the representation of the two branches of the profession on the General Optical Council, which is on the basis of five elected ophthalmic opticians and two elected dispensing opticians.
Ophthalmic opticians also point out in some areas that there are no dispensing opticians who will be available to serve on executive councils. On the other hand, I make clear that dispensing opticians think the Minister's proposals in the Schedule are right because it is not so much a question of votes as of advice being given on behalf of each branch of the profession and, therefore, only one from each is required. I should like to know whether the Minister has considered the point about areas where there are no dispensing opticians available to serve on an executive council.
Other points are being put forward on behalf of the two branches of ophthalmic opticians, the Association of Optical Practitioners and the Society of Opticians, and the two branches of the dispensing opticians, the Association of Dispensing Opticians and the Guild of British Dispensing Opticians. All these bodies consider that parts of the Bill are a serious threat to the future of optical practice. For example, Clause 17(3) appears to be designed to enable the Minister, as distinct from an optician, to determine not only the price at which optical appliances are sold but the type of style of frames sold at health centres. Hitherto, these have been matters decided purely be- tween the optician and the patient. A change in the way suggested in the Clause may be a threat to the private sector of ophthalmic services.
There is also the question of employment of opticians at health centres. It is possible that local authorities could offer higher salaries and other inducements to attract employed opticians into the Health Service. The majority, of course, would come from present private practices. Instead of paying a realistic fee for National Health Service ophthalmic services, the Minister could seek to close private individual practices by employing opticians at health centres. He could also offer private and hybrid frames at prices which he determined. I hope that we shall have an assurance that that is not his intention.
I have been given a letter written by one of the right hon. Gentleman's officers to the Registrar of the General Optical Council yesterday in which this is said:
You will see that the provisions we had in mind would in the main be permissive ones subject to the Minister's approval and not mandatory. We envisage that he would agree to opticians going into the health centres only in cases where local consultations between Executive Council, local health authority and the local professional representative bodies suggested this to be the right thing to do in the local circumstances.
I hope that the Minister will repeat that assurance through his hon. Friend at the end of the debate so that it may be quite clear to all concerned.
There is a further point in the same direction of uneasiness. It was mentioned by my hon. Friend the Member for Farnham and is contained in Clause 62, which allows the Minister to store and supply goods needed by local health authorities and executive councils to discharge their responsibilities. This could lead to the Minister, as the major consumer, so to speak, of the optical industry from frame and lens manufacturers, virtually nationalising the industry by having a monopoly and to stifle such practice as remains outside health centres. I hope that we shall have further assurance that that is not his intention.
Then there is the question of representation on the Central Health Services Council. Every profession providing Part IV services under the Act except the optical profession is already represented on this important Council, but the Bill does not provide for the inclusion of opticians. I wonder why. I wonder whether the Minister will put this right in Committee. Opticians are not included in the National Health Service Superannuation Scheme. I hope that can be considered and perhaps remedied in Committee.
I hope that there will be time for consultation, because I am sure that all these points can be ironed out by consultation between the Ministry and the various bodies of the optical profession, as happened for example, in the case of the Opticians Bill, 10 years ago. If that can be done I am sure that it would be to the advantage of all. I should be grateful if all these points can be examined.
I shall resist the temptation to follow some of the very interesting paths which my right hon. Friend the Minister suggested and concentrate on Clause 57 of the Bill. My right hon. Friend referred to this, but I think that the House needs to concentrate attention more on this problem because I am quite certain that the care of the pre-school child is one which is ever growing and the resources which are being provided in the way they should be are steadily diminishing.
According to the Plowden Committee's Report, there are more than 4 million children under the age of 5 and 2¼ or thereabouts are in the 2 to 4 age groups partly in the charge of my right hon. Friend in day nurseries and partly in the charge of my right hon. Friend the Secretary of State for Education and Science in school education. My right hon. Friend the Minister of Health has the responsibility each day for only 16,500 children of the total 283,000—only 7 per cent.—who go to nurseries and day nurseries. According to the Plowden figures in 1965, there were 21,400 places in local authority day nurseries. I expect those figures have not increased, but the contrary would be the case because day nurseries are being closed steadily all the time.
In addition, there are 57 factories which run nurseries for 2,098 children of women working in factories and 2,108 private nurseries of all kinds catering for 51,000 children. There are 1,482 children cared for by minders registered by local authorities and 3,347 other registered daily minders. There are also a large number of known and unknown minders of varying degrees of suitability looking after young children.
During the war, there were 1,599 part-time and whole-time day nurseries in England and Wales, accommodating about 72,000 children. That is a very different story from today's figures. Now there are only 448 day nurseries, and the number is steadily being reduced. In wartime we always encourage women to come forward and do all kinds of jobs—in the professions, in factories, and so on. Today, we are anxious to get professional women—for instance, doctors—to return to work. Married women doctors have a great part to play in the functioning of the National Health Service and local authority health services, particularly in family planning clinics, where they have a particular niche to fill.
We have helped to create a guilt-complex among women who want to go out to work and women who need to go out to work, because from 1948 onwards—I am sorry to have to say that it was the post-war Labour Government that started the rot, and this was taken up enthusiastically by their Conservative successors—we started discouraging married women going to work, with the result that day nurseries became less in demand because women were not working.
As a result of numbers falling, prices rose. Local health authorities increased their prices. The numbers fell still more. The categories of women who are now permitted to put their children into local authority day nurseries are very restricted indeed. They practically all cater for social need. This is all right, but no opportunity is provided for a child to get into a local authority nursery although for his own sake he needs the companionship of other children, irrespective of the fact that the mother is perhaps an unsupported mother and has to go out to work.
As my right hon. Friend said, there has been a spectacular growth in the number of child minders and other alternatives simply because the State is not carrying out its duty either to provide nurseries or to provide nursery education or nursery schools and classes. Some of the alternatives are good. Some of them are less good. Some of them are downright bad and dangerous. There has been a rapid growth of play groups run privately, some run by trained people, some by untrained people. There are groups run by the Save the Children Fund, mainly in areas where there is a real social need. We have seen the growth of private nurseries in well-to-do areas where people can pay quite high fees for their children to attend. These alternatives, and the mushrooming of child-minding, known and unknown, are all evidence of the enormous need and of the changing attitudes to the whole question of women carrying out work after they have children and of the need to find suitable help for children that need it themselves.
The expedients which are being used are a direct result of the fact that the State has not carried out its responsibilities. The change in family life in large towns and cities makes the problem even more acute as more and more families with young children tend to live in tall flats. There is no provision of play space for small children on housing estates. The Minister of Housing and Local Government has refused to co-operate with local authorities in this matter. The local authority associations have not concerned themselves with the need of the young child on new housing estates. I am amazed that mothers, teachers and all the organisations concerned with child care are prepared to tolerate this situation.
There is this very great problem. If we were running an expanding economy, which we ought to be doing, based on real Socialist principles, there would be an even greater demand for the services of women to help in the running of the economy. The economy apart, the Plowden Report recommended that nursery education, as distinct from day nurseries, should be provided for all children from the age of 3 whose parents require it and that an early start should be made in priority areas. I speak with very great feeling about the problems of young children in the Midlands, and particularly in my constituency, where we have an influx of immigrants, a large number of West Indians, who tend to have at the moment rather bigger families and where the problem of the minding of the young child while the mother is out at work is very acute.
My right hon. Friend the Secretary of State for Education and Science said recently that there is to be no start on the carrying out of the Plowden recommendations as regards the provision of nursery education in the priority areas. This is most disappointing. The £16 million that his predecessor found for the demands of Plowden, mainly as regards primary schools, is not likely to be allocated for nursery schools and nursery classes.
So now it has been decided to patch up what is already extremely inadequate. My right hon. Friend the Minister of Health is introducing part of the Bill in order to do that in regard to the registration of child minders. In so far as this has been carried out by local authority health committees, my right hon. Friend has been concerned mainly with numbers in premises, with the numbers of lavatories available for those numbers of children, with whether there are washing facilities, and with whether there are facilities for cooking a meal. He has not been concerned with what goes on in the premises during the hours that the children are left there.
Will my right hon. Friend accept that he should be concerned with what happens to young children when they are in the care of child minders, registered and unregistered? We know from our experience in the Midlands that there have been large numbers of accidents because unsuitable heating appliances—paraffin stoves, for example—are used in rooms containing large numbers of small children. We know that children are kept confined on a bed or in a cot the whole day, hours on end, without toys to play with, without books to look at, without any exercise, without proper play and without contact with their peers, simply because this is the easiest way of minding a child. The children suffer mentally as a result.
Does my right hon. Friend intend to say whom he regards as a "suitable person" to be registered as a child minder? Is it to be a trained nurse, or a nursery nurse, or a nursery assistant, or a nursery teacher, or a mother of one, two or eight children? What is it to be? Will he refuse to register premises where the heating is provided by paraffin stoves or by other unsuitaible appliances which are a danger to children? Will he absolutely insist that children left with minders are fed, because we have experience in our area that children are in fact not fed during the day? They are given milk to drink, but no properly cooked meal. Will my right hon. Friend refuse to register minders who keep children confined in a small space the whole day without the proper equipment and proper exercise?
How does my right hon. Friend intend to deal with the obvious cases where the law is flouted, where children are taken round to a different woman every day and are in a different household every day? This is dodging the law as it stands. I think that these expedients could well be used when my right hon. Friend has carried the Bill through.
I hope that my right hon. Friend is correct, but much of this goes on at present. If local authorities are to carry out the provisions of the Bill when enacted effectively to stamp out the difficulties which now occur, they will need a greatly increased number of inspectors, simply to go round knocking on doors behind which it is suspected that women are minding children that they are not authorised to take. The inspectors will be largely non-productive for the rest of the local authority's work. I wonder whether my right hon. Friend has made an estimate of the number of additional inspectors who will be required by local health authorities and of the additional cost which there is likely to be for the local authorities.
I must say that I am sorry to be rather dampening about the effect of these proposals which my right hon. Friend has, but I am quite convinced that the only way to make proper provision for the young child, and the only way we can stamp out abuse, which exists now and, I am sure, will continue, even after the Bill becomes law, is to provide proper State day nursery provisions and nursery schools provisions. There is no other way. We in this country tolerate conditions affecting our very young children which would not be tolerated in many other countries, whether in Western Europe or Eastern Europe, or America, or anywhere else.
It is clear that we need to know more about the needs of the young child. There is certainly a very strong case for the setting up of a Government inquiry to inquire into the whole problem of the young child, the pre-school child. Its needs are a divided responsibility between the Minister of Health, the Secretary of State for Education and Science, the Minister of Housing and Local Government, and the Minister of Social Security. All these Ministers are involved.
It is fundamental that we have got to decide as a Government and as a nation on our priorities. We shall have to decide whether it is more important to spend as much money on one Polaris submarine and its base as would be needed to provide for all the recommendations in the Plowden Report in so far as they affect the young child. This is the decision which we as a nation still have not made.
The hon. Lady the Member for Wolverhampton, North-East (Mrs. Renée Short) has gone at some length into the problems of Clause 57. She will forgive me if I do not pursue those matters, not because I regard that Clause as not being important—indeed, I believe it to be very important—but because I feel that what she has said points to the importance of the whole matter, and I do not think I need add to it in order to draw the Minister's attention fully to it.
At the same time I would underline one particular point which she made, and that was with regard to the question of the employment of married women doctors. It has relevance to other parts of the Bill. Indeed, it is absolutely essential that the measures outlined in Clause 57 should be implemented to the full if we are to make full use of the very important reserves of trained, medical womanpower, which includes all the medical women and doctors. We spend a great deal of money and a great deal of time training women to become doctors not merely because we want to fill the country with housewives with a clinical background, but because we want them actually to engage in medical work, and the only way to induce them to do so is to pursue the kinds of argument which the hon. Lady dealt with.
I hope the House will not be alarmed, and I am sorry if it should be, at the prospect of a second speech this afternoon by a doctor. However, I think the nature of our profession is such that it is unlikely to find two such speeches agreeing in any particular at all. Indeed, if we had the whole of the general practitioners, all 23,000 of them, here today they would all say different things about this Bill.
I would underline one thing which the hon. Member for Glasgow, Kelvingrove (Dr. Miller) said in paying particular attention to the general practitioner. He said he felt that the general practitioner should be the leader of a welfare team. I would endorse that as fully as I can from my own sometimes pleasant, sometimes unpleasant, experience. Perhaps the House will forgive me if I remind it of a document, a report by the Liberal Party Health and Welfare Committee, which appeared in 1963. It is a very interesting document, and I agree with every word of it. Perhaps that is not surprising since I wrote it myself. It dealt with this subject at very great length and it said:
The G.P., with his knowledge of the patient's home and circumstances should be the leader of a team of welfare workers.
Then it went on to state:
The present system hinders rather than helps this to come about.
I see the right hon. Gentleman nods his head, and indeed, I thought he would, because I think many of the things he is doing, or hopes to do, by this Bill are designed to remove the hindrances and obstacles.
I want to try to resist the temptation to go into Committee points which can be dealt with later, but there are one or two things I should like to deal with in passing before coming to the more general implications of the Bill.
Clause 13 is an important Clause with regard to home helps, but it goes on about the question of a soiled linen laundry service. I would like to see this mandatory rather than merely permissive, as it is spelt out in the Clause.
I should like to explore the Minister's general intentions with regard to Clause 31 at greater length, about the provision of vehicles, and I should like to know whether there will be provision for adaptation of vehicles for patients suffering from haemophilia. I have a Question on the Paper for Monday, and I should like to know whether I ought to remove it in the knowledge that it is the Minister's intention to use this Clause to apply to the particular circumstances which I envisage.
One would like, too, to support more attention being given to the provision of vehicles for one category of disabled person who, I think, has hitherto been very much neglected, and that is the disabled housewife. One would like to know whether she, too, is to be brought into the general scope of the provisions of that Clause.
There is a Clause which has not been mentioned at all by anybody, and I confess that I am not entirely clear what the right hon. Gentleman's intentions are in Clause 24 regarding tribunals. This is, of course, as the Minister knows, a somewhat delicate subject. There is a need for disciplinary machinery within the whole of the Health Service. Indeed, there is a need for proper investigation of complaints. My own view, quite honestly, is that if the administration of the Health Service were to be opened up to the activities of the Parliamentary Commissioner it might well be that these tribunals would not be quite as busy as they now are.
There is, nevertheless, a need for proper investigation of complaints which people make. Of course, we need to be equally fair to everybody, and the right hon. Gentleman is, I understand, having consultations with the profession at the moment about possible methods of altering the procedure of investigating complaints against doctors, and so on. Complaints are made sometimes without justification. Indeed, there are people who seem to believe that ever since 5th July, 1948, when the Health Service came into being, everybody must live for ever, or else it is somebody's fault, and there is a general tendency for complaints to be made, perhaps in a way which it is not thought likely to lead to a logical conclusion, but the fact that they have been made has only aroused a certain amount of frustration and unnecessary resentment in the profession. Now the right hon. Gentleman is having consultations on this matter, and I would welcome any information which the hon. Gentleman who is to wind up the debate can give as to what observations the profession has made on this.
I would prefer to leave some of the Committee type points for a later stage of the Bill, and I assure the right hon. Gentleman that if I get the opportunity of ventilating them I shall do so in a spirit of endeavouring to assist him rather than of in any way impeding him in the progress towards what I hope and believe to be the common goal we have in mind in regard to the Health Service.
As for the general implications of the Bill, I think we ought to remind ourselves from time to time that the efficiency of the service, and whether it can do its job, depends upon four fundamental things. The first of them is the number and quality of the people doing the work, the doctors, nurses, technicians and so on. Second, the adequacy of the places in which they do the work, the hospitals and the clinics; all the places where the chemists and all the other persons do their work. The third is the tools for doing the work, and they include drugs, apparatus, all the appliances, kidney machines: all these are the tools. And fourthly, there is the administration by which all these three things are integrated. There are deficiencies in all four of these material particulars. I say that not with any suggestion that the Health Service is on the rocks, but it is a fact, which the Minister will accept, that there are deficiencies. I turn now to one or two of them in order to consider how they are affected by the Bill.
There are acute deficiencies in terms of personnel, a shortage of doctors and of nurses. The Minister is doing what he can about that. He has spoken of his new moves as regards general practice, and I confirm that progress is being made. He may be interested to know that I have personal knowledge of two doctors who emigrated and who have now come back to practise in this country. It seems that the brain drain may be beginning to reverse.
I confirm, also, what the hon. Member for Kelvingrove said about this not being only a matter of money. Money is important, and there was a time when doctors did not seem to have a lot of it. It seemed to be cheaper to have the doctor every day than buy apples. But it is the facilities and circumstances of their work which are important to doctors. I know many doctors who have left this country to work abroad not for more money but for less. I think of one or two practising now in the neighbourhood of Toronto. Their gross and net incomes there are less than they were when they practised in the Health Service at home, but they went because they had better facilities, hospital beds, their own X-ray apparatus, their own facilities for special investigations, and so on.
The Minister is right to concentrate on matters of that kind. If he puts more emphasis on the Clauses in the Bill dealing with the provision of health centres and facilities, he will find that doctors will stay. He will keep them here in a sense of harmony with his Department, and their frustrations will be removed.
I welcome what the Minister said about post-graduate education, another directly connected matter. This is another means of keeping doctors here or bringing them back, and it is of importance, also, in encouraging married women doctors to continue in practice.
The shortage of nurses is patchy and not universal throughout the country, but I am not satisfied that everything necessary is being done to remedy it. I am particularly concerned about a statement in a report recently made to the Minister by the General Nursing Council for England and Wales, covering the period 1st April, 1966, to 31st March, 1967. I quote these words:
It is a matter of grave concern to the Council, the body on which Parliament itself has placed the responsibility for the education of nurses in England and Wales, that they are forced, through lack of adequate funds, to place restrictions on the extent to which the standards of training can be improved at a time when facilities to provide improvement are seen to be available.
I shall not go into the matter at length. I accept that the Minister has many competing priorities, but I am certain that this particular priority ought to compete very strongly with all others. I
should welcome his comments on the matter.
I wonder whether we are making the best use of existing resources. There is a shortage of resources, and, until we have overcome it, no amount of administrative manoeuvring within the limits of the shortage can put things entirely right, but we can do something by making sure that we make the most economic and efficient use of the resources which we have. There seems to be a considerable degree of maldistribution of present resources. This is certainly true as regards doctors, with a shortage in one place and practically none in another.
In this connection, I am interested in the Minister's propsals for new medical schools. There is clear evidence that doctors tend to settle in practice fairly close to the place where they were trained. They establish personal and professional contacts which tend to make them settle in the area. Therefore, there is a strong incentive on the Government to establish new medical schools, when they are able to open them, in areas such as the West Riding of Yorkshire, the North-East, South Wales and parts of the Midlands where there is an acute shortage of doctors.
The Minister spoke of the new arrangements for general practice, which, he said, arc now working smoothly. There is one way in which they are not working entirely; I receive a great many complaints from individual doctors about the amount of form filling which is necessary. I entirely accept that the new arrangements were pushed upon the Minister by the present representatives of the profession. I was interested to hear the hon. Member for Farnham (Mr. Maurice Macmillan) say that the leaders of the medical profession did not have entirely undiluted confidence in the right hon. Gentleman. It is equally true that the ordinary rank and file members of the medical profession have not entirely undiluted confidence in their own leaders, either.
There is quite a lot of resentment among ordinary general practitioners about the complexity of the arrangements which they are now forced to make as regards details of their employees, ancillary help, the size and nature of surgeries and other matters of which, I know, the Minister is well aware. The right hon. Gentleman will say that he has not been approached on this matter by the representatives of the profession, but, as he is concerned to see that resources are used efficiently and economically, there is a strong case for saying that, if there is waste of resources in this way, he should himself initiate discussions if he feels that they are likely to be fruitful. If we are short of doctors, the more time doctors spend actually doctoring rather than doing other things, the better for us all.
There is waste also as a result of duplication. I know that the Minister is aware of this, and it is one of the crucial elements behind the Bill. Duplication tends to arise from our fundamentally divided Health Service, the tripartite system which has been referred to so often. Many people who ought to be working in collaboration and close association with one another often work in dangerous and damaging isolation. Many of the provisions in the Bill are designed to bring people together, to bring the general practitioner closer to the local authority services, to bring the local authority services closer to the hospital service, and so on. One cannot underestimate the importance of any measures taken to bring people together in this sense.
It is most unfortunate, when people are all doing their very best on a job designed to serve the community or the family in health matters, if they find themselves working in isolation, duplicating one another's effort and getting in one another's way, instead of working in a sensible co-operative system which enables them to move forward together.
Here is one example. A woman in pregnancy, if she decides to have her baby at home, will be attended by the local authority midwife. She will probably attend the local authority ante-natal clinic. There may be matters on which she has to see her own medical practitioner. If something is found to be wrong, she will go to the consultant's ante-natal clinic at the hospital where she will be seen by another doctor and midwife. In the fullness of time, when she goes into labour, she may be delivered by yet another midwife who has had very little to do with all the ante-natal proceedings. If something goes wrong at that stage, she will go into hospital and be delivered by another midwife who has never set eyes on the previous one. When she comes out of hospital, she will be visited at home by a health visitor who, perhaps, has never set eyes on any of her other medical attendants. It is not that these people want to be isolated. It is the administrative machinery which isolates them one from another.
The school medical service provides another example. I wish that the right hon. Gentleman had greater responsibility for it than he has, and I hope that, in Committee, we shall be able to discuss this question in relation to certain of the Bill's provisions. The school doctor was brought in, very rightly, at a time when there was a financial barrier between many children and the doctor. It was necessary to institute the school medical service then, but that financial barrier has now happily been removed. I hope that no one in any part of the House wishes to bring it back. This means that the school doctor's rôle is changed, and one wonders what it should be.
If we are to make effective use of our resources, we must try to bring into close contact all the other people with whom the Minister deals. The school doctor does medical examinations. He examines healthy child after healthy child. Then suddenly the look of knowledge comes into his eyes and he says, "This boy wants his tonsils out", and the mother says, "He has been on the waiting list for two years". Very often he is used as a second opinion. A parent may take a child to the family doctor and ask him what he thinks his condition is. The doctor may say that it is so-and-so, and the parent says, "We will go to the school doctor and see whether he says the same thing". Nine times out of ten he does not, which is not very helpful for the people concerned.
These people could be of immense help to each other if we had a structure in which they were all working together instead of a structure which put them in totally separate compartments.
I turn to the very important question of the rôle of the local authority. The Minister is right in placing increased responsibility on the local authorities, but if he asks them to do more and more things—and I welcome particularly the more things which they will do for old People—clearly he must provide the resources for them to do them. It is local authorities which have the least need of resources of this kind which have the most money. Local authorities with the greatest need have the least money. If one considers the 12 areas with the highest rateable value, one will find that they have the least need for local authority health services. Therefore, I hope that something will be done to assist in this matter.
If a local health authority provides, as the Minister is asking it to provide, accommodation for old people, then it is spending the ratepayers' money. But it probably saves the regional hospital board about £30 a week in providing a geriatric bed, and yet there is no machinery for making any payment as between the regional hospital board and the local authority, that is, the ratepayers. Therefore, while this system remains, there is a continuing disincentive to local authorities to provide services for which they have to pay which would, in the long run, save the community a great deal of money.
I ask the Minister to reply to one other point. In an earlier debate on the welfare of old people, I raised the question of the appointment by local health authorities of a new category of officer, to be known as an old persons' officer, who would be responsible for integrating all the services which are provided from many sources and who could be approached with great benefit because he would know where to go for what. He would work very much on the lines of the children's officer. Many hon. Members showed interest in that idea, but the Minister who replied to the debate did not refer to it. I wonder whether the right hon. Gentleman would see whether it might be referred to tonight?
The idea is not without interest, but it is a matter on which we should await the report of the Seebohm Committee because this was exactly the sort of problem which came within its terms of reference.
I agree, but there is a need for this kind of officer, and I see no reason why we should not say so.
I hope that not much of the rest of the debate will be preoccupied with talk about private practice. I say that to hon. Members opposite for this reason. I believe that private practice should disappear, but through lack of need. We have heard arguments today about queue-jumping. There should be no queues to jump. I hope that the Minister will be able so to develop the Health Service that private practice will decline, but I believe that until he has developed it to that extent private practice remains as a valuable stimulus to the public service.
I note with interest what the hon. Gentleman says, and I agree with him. But would he not accept from his knowledge of his profession that every indication is that the demand for private practice is growing?
I do not accept that. This is an involved subject and I do not wish to be drawn into a discussion on it. I said that I hoped that the House would not deal with it because it is a red herring. Let us get the Health Service right. Britain can provide a fully comprehensive, humane and efficient health service on an entirely non-fee-paying basis. I say that for the benefit of anybody who wants to talk about prescription charges.
There might be an argument for a charge for use of the service, although I would not agree with it, but I think that a prescription charge is utterly illogical. Why should we levy a charge on the random and accidental need for a prescription? A patient at home suffering from pneumonia may pay 18s. A patient in hospital suffering from pneumonia gets food, drugs and laundry free. Why should a patient who takes two minutes of a doctor's time for vitamins or iron tablets pay 6s. while a patient who consults me for an hour to discuss her matrimonial problems but does not have a drug pays nothing?
Some very important words appear in Section 1 of the original Act. They impose this duty on the Minister of Health:
… to promote the establishment in England and Wales of a comprehensive health service designed to secure improvement in the physical and mental health of the people of England and Wales and the prevention, diagnosis and treatment of illness …
I see no reason why we should vary that duty in any way, but I wish that we could
concentrate a little more on the preventive element.
I welcome the Bill in general. I believe that it is a move, perhaps a slow move towards what I should like to see—a fully integrated health service covering the whole field. Perhaps there is, however, some virtue in the inevitability of gradualness.
It is always a pleasure to follow the hon. and qualified Member for Cheadle (Dr. Winstanley), but it is difficult because there is so much meat in his speeches that one is tempted to take up his points and to forget what one originally wished to say. I should like to refer to only two points which he made.
The first concerns the Liberal policy of 1963. If we spell the word "liberal" with a small "1", I think that we can say that we are all "little liberals" now. The concept of the general practitioner as the leader of a Health Service team has been accepted and put forward from all quarters of the House. The big problem is that fundamental changes need to be made in the way in which the general practitioner is educated. He is not, at present, trained in welfare work. We need to wait, not only for the Seebohm Committee's report, but also for the report of the Royal Commission on Medical Education to get this matter straight.
The second point which the hon. Member raised to which I refer is shortages. There are shortages, but we should not forget the tremendous strides which have been made. We are short of nurses, but there has been a 47 per cent. increase in their number since 1949, and we now have 184,000 in full-time employment. Hospital medical staffs have increased by 60 per cent. since 1949; physiotherapists have increased by over half; radiographers and occupational therapists have increased twofold; and laboratory technicians have increased threefold. While realising that we still have a long way to go, we should not neglect to applaud the way in which we have made huge advances in the 17 or 18 years since the setting up of the Health Service.
I very much welcomed the opening remarks of my right hon. Friend the Minister in that respect. We do not cry the success story enough. I have sympathy with members of the Press. They know that in the climate of emotional opinion, hospital drama—Emergency Ward 10, and that kind of thing, one operation which goes wrong is a story which gives them space. The 2 million operations a year which go right make no story. I say this to the Press. This is not a political matter. The continuous "knocking" of hospitals is something which is affecting the doctor-patient relationship. The constant stream of disturbing stories is undermining confidence in what the doctor in the hospital service is doing and his ability to heal his patients.
I cannot ask members of the Press not to print a good story when they get one, because a newspaperman has his job to do. But I do ask them to give equal prominence to the large number of success stories and the devotion of the doctors and the many dramatic cases in which they save lives. These, too, can make a good story if they are done in the right way.
I welcome the hon. Member for Farnham (Mr. Maurice Macmillan) as shadow Minister of Health. I believe that this is the first debate in which we have had the pleasure of his presence in that capacity. I was surprised, though, that he complained of lack of consultation. As a layman, one often gets the impression that the General Medical Services Committee and the Joint Consultants Committee of the B.M.A. spend most of their time with the Minister. Indeed, I sometimes wonder whether they have permanent lodgings near the Elephant and Castle. Every time I read the British Medical Journal and The Lancet, there seems to have been another to-ing and fro-ing between them and the Minister. From the patient's point of view, sometimes one feels that perhaps they have too much influence with my right hon. Friend.
My right hon. Friend has been very modest about his part in the great crisis of 1965, when 17,000 out of 22,000 general practitioners put in their notices of retirement from the National Health Service. In a quiet and unorthodox way, of which the public did not take a great deal of notice, he held long, continuing negotiations and consultations, with the upshot that within 12 months, all 17,000 notices had been withdrawn. Some one should say to him how much we appreciated his efforts.
The hon. Member for Wembley, South (Sir R. Russell) spoke of ophthalmics and opticians. Like other hon. Members, I have received representations. Many of the points are really Committee points rather than for discussion now, but I warn my right hon. Friend that the pressures being put on by the Association of Dispensing Opticians on the one hand and the Association of Optical Practitioners on the other could lead to an A.S.L.E.F.—N.U.R. type of struggle. I hope that he will bear that in mind in all the representations being made to him.
I welcome the Bill as a limited and tidying up Measure. My right hon. Friend knows that we on this side are expecting a major and radical reconstruction of the National Health Service before the next General Election. This is already foreshadowed in the Green Paper which he is to present shortly. We shall have discussions and consultations. But the next Bill on our health services will not be minor. It will be the second storey after we have had the successful building of the first floor.
This Bill must be judged on whether it facilitates that change or strengthens the vested interests and the powers of those who regard health as another commodity to be purchased and sold in the profit motivated market place. Clause 5 passes this test very well. The proposals for new university hospitals lead to the possibility of further integration of the hospital services under Regional Hospital Boards. We have to recognise that, in the last two or three years, the trend has been in the other direction. We have already had five hospitals that were general hospitals under regional hospital boards designated as teaching hospitals—1,416 beds have gone over. My right hon. Friend has proposals to designate 8,283 beds.
I venture the hope that we shall integrate the teaching hospitals with the general district hospitals. I do not expect this to happen quickly but I want to see the process continuing. But if my right hon. Friend continues the present trend of designating beds from district hospitals to teaching hospitals, and should this be applied mainly to teaching hospitals of the London area, this could mean for Londoners that, out of the present 23,500 beds, only 3,000 would be left under the regional boards and the rest would be in teaching hospitals.
I exaggerate the argument, for not all the hospitals concerned are in the London area. But many of them are. Clause 6 I take it to mean that designation will no longer be necessary and arrangements can be made to increase the facilities of teaching hospitals without taking general district hospitals away from the responsibility of serving the communities in which they stand.
Clauses 1 and 2 are the most controversial part of the Bill. One only has to say "pay-bed" to this side of the House and we react. I am glad we do. Any suspicion that anything other than that it is the need of the person who is sick taking the scarce time of surgeons, doctors and nurses is something we resent. Does the new flexibility mean that the unused pay beds now designated specifically can move from one specialty to another?
My local hospital has nine designated pay beds which are, in the main, sorted out between the senior consultants. Some are not fully occupied because the consultant concerned does not have a good deal of private practice so they are used for ordinary N.H.S. patients. Does the new flexibility mean that a bed which stands empty can be immediately transferred to another specialty, so that all pay-beds are always occupied by pay-bed patients? If so, this is an increase in the private sector at the cost of a decrease in the public sector.
I welcome Clause 4 because it has been a headache for all hospital accountants to try and work out whether it is a £33 2s. 7d. charge or how much it is for amenity beds financial processes applied to each individual hospital. This is a cleaning-up provision that is long overdue.
On Clause 2, we must take into account the Minister's recent decision to abolish any upper limit on the fees consultants may charge private patients. When my right hon. Friend takes power to charge for the services the consultant then uses within the hospital service I trust he will bear this in mind. I am interested to know whether, in the new St. Thomas's Hospital across the river, how many private suites are being built for consultants so that they can have private practice within the hospital. What proportion of the resources of St. Thomas's will this take?
If there is to be a special arrangement whereby private patients are able to use all the diagnostic tests of a hospital, I hope that my right hon. Friend will bear in mind the charges he may make for these services. The whole question of priority treatment for fee paying patients is in direct conflict with the available time of hospital staff to care for those in need. Clinical need must be paramount and we may well need to amend these Clauses in Committee to safeguard that principle.
The Clause dealing with the local authorities gives a valuable extension of existing functions. I hope that this will mean that there will be more relief, for example, for the daughter who stays unmarried to look after her elderly parent. This relief is needed not just for two weeks a year but at shorter intervals. Where the family takes on the responsibility of looking after elderly grandparents, for example, not only should it be possible to give residential care for these elderly persons to enable those looking after them to have a holiday for two weeks but there should be flexibility so that they can get relief at other times from the constant strain, especially when, in the later years, all kinds of acute mental problems can arise. The present methods of relief should be extended.
In due course, all the services envisaged in this part of the Bill will, I believe, help a good deal in tackling the problem of incontinence in old people by extending the laundry service facility. I hope that it will go much further. In an ordinary hospital, there are arrangements for the use of incontinence pads and machinery for dealing with geriatric malfunctions which arise. It should be possible to integrate what is going on in domiciliary care, local authority services and hospitals and effect much saving of resources, equipment and purchasing. We can do this if we recognise that the problem is a common one either inside or outside hospitals and must be dealt with wherever it is found.
I welcome the fact that the limits placed previously on midwives, health visitors and social workers will be removed. We must take the trend in this part of the Bill further in a major overhaul. We have succeeded in the last 20 years in breaking down the high walls and the barbed wire surrounding our mental hospitals, but in other parts of the hospital service there is still an inward-looking, institutional approach that often separates the hospital from everything else going on around it.
In the extensions to be given by the Bill, I hope that we shall go further by not only giving midwives, social workers and health visitors the opportunity to move freely through all three sectors but in getting other "walls" pulled down—for example, to enable mental nurses to follow their patients home for some domiciliary care rather than merely transferring the patients to the care of psychiatric social workers under the local authorities.
The whole shift in medical care is away from the institutional to the domiciliary and the only way domiciliary care can be properly undertaken is by strengthening all those services which make it possible. It is no good saying to a general practitioner, "You must be the leader of the health team", and then giving him inadequate resources—not enough social workers and not enough time. Domiciliary care is, I believe, only possible if we can make a massive inroad by tapping the resources of people to help voluntarily.
Recently I had the experience in my constituency of going around and delivering 40 meals to old people living alone in just over 1¾ hours. I went with the Women's Royal Voluntary Service. This is splendid work which is done voluntarily in my area. But it is only done two days a week, so the old people get two hot meals a week. It should be possible to give at least five and possibly seven hot meals a week if we can expand this kind of service, if necessary bringing in more volunteers.
International Voluntary Service, Task Force and other youth organisations taking an interest could be directed along these lines to be able to play a very useful part. More than 4,000 people live alone in single rooms in my area. When the meals on wheels service goes in to a home, it reveals other kinds of social problems with which it cannot cope. But the mere fact that one knows of a problem can give the possibility of other welfare services, statutory or voluntary, moving in to give that little bit of help in their later years of life that our elderly people need. Having said this we must give credit to the Minister. Last year, 7,300,000 meals on wheels were delivered and 1,400,000 meals were delivered to old people in clubs and senior citizen facilities.
The Bill recognises the great break through that has been achieved by using industrial therapy for mental patients. For a long time, we used to think of occupational therapy but that, although useful, has not been as effective as industrial therapy. The fact that a mentally disturbed person is able to do a similar job to someone else in the community starts the process of rehabilitating him back to the community, and for this the Minister is taking powers to follow through with facilities that can be given and this can mean a massive expansion in this service.
The Bill takes into account the recent trend towards the rather belated acceptance by general practitioners of the usefulness of the health centre concept. I congratulate my right hon. Friend on the eight new centres built last year, on the 13 being built and the further 27 approved. My right hon. Friend has the right to make additional services available in these centres but there are a number of technical problems which we shall need to examine in Committee.
One of these smaller, minor aspects is the extension of ophthalmic services into health centres provided by Section 21 and I hope that my right hon. Friend will make it obligatory on practitioners to display all free frames for spectacles available of which there are about 57 different varieties. Most people never see these free frames, unless they be those which, apparently, are not very favourable to the visage of the person concerned.
Clause 23 is especially welcome in view of the Sainsbury proposals, but I should like to know whether it also covers the bulk purchase of medicine. Do the Sainsbury proposals mean that this part of the Bill will be used so that the taxpayer can be saved money in the purchase of medicines used by general practitioners? Will the purchasing officers of hospitals and of local authorities be able to extend their services?
I do not want to deal in detail with cars for disabled people, because a number of hon. Members have already dealt with the subject. However, I hope that my right hon. Friend will address himself to the problem of the garaging of these cars or invalid carriages. In an area like mine, which was built up in the time of Queen Victoria, there are no garages and there are no spaces for garages, and it does not help a person who cannot walk to tell him that the local authority is prepared to find him a garage one and a half miles from where he lives. I hope my hon. Friend will relax the present regulation which insists that a disabled person can have a car only if he can find adequate means to garage it.
I regret very much that my right hon. Friend has not taken the opportunity in Clauses 34 and 35 to deal with the remuneration of the chairmen of hospital boards. The chairman of the board on which my right hon. Friend served before being elevated to his present august position manages a budget of more than £50 million a year and he has 23 groups and 160 hospitals. If he is to do his job adequately, he needs to spend at least three clays a week doing it, and the present chairman of the North-West Metropolitan Regional Hospital Board does so.
Under another Ministry which I shall not name the part-time chairman of a similar body with a similar expenditure and spending about three days a week on the work gets £4,500 a year. Why should the hospital service of all public services be expected to be a part-time voluntary job when it is one of the largest industries in the country, and why should we expect the work to be done by retired people, or housewives, or those who have jobs from which they can be released to do the work in a part-time capacity. Even though we do not get it in the present Bill, I hope that my right hon. Friend will look forward to doing something about this reorganisation when we get further legislation.
In all our N.H.S. legislation it is essential that we maintain the basic policy which went right through the original Act; that those people who have the good fortune to enjoy good health should pay for those who are sick. It is a principle which we have preserved through all our discussions and debates. I agree with the hon. Member for Cheadle that in the first 20 years we have built a curative service second to none. I have had the privilege of seeing the services in many other countries, developed and underdeveloped, in Asia, Africa, Europe and America, and I can say that the curative services of the N.H.S. are second to none.
We have now reached the stage when we must turn over to prevention and to using all possible resources to preventing people from becoming sick in the first place. It is because the Bill is one step in tidying up the machinery towards that end that I give it a very warm welcome.
The Bill is of grave importance and it is also extremely complicated. With such a labyrinth of provisions and prognostications it would be extraordinary if clarity reigned at all points. The Minister will not be astonished if we press him on some key matters on which we must ask him to be a little more explicit.
The right hon. Gentleman referred to pay beds, but in view of what has been said by some of his hon. Friends I must ask him to make it quite clear whether we can take it that there is to be no further deterioration in the number of pay beds. Does he recognise that there is a desire for them and is he prepared to gratify that desire? One assumes that he is not averse to a system by which the National Health Service is a ready-cash bonus beneficiary.
I must also point out that the B.M.A. is concerned about this matter, feeling very strongly that there is to be a squeeze on private beds, not those which are in separate wings, about which the position is clear, but those which are not in separate wings. Hospitals outside London and the other big cities would be particularly affected by any change.
I must take up a comment on this subject which was made by the hon. Member for Huddersfield, West (Mr. Lomas) who, unfortunately, has not found it possible to remain in the Chamber for the rest of the debate. He referred to the late Mr. Aneurin Bevan. In the past I have frequently attacked that gentleman's philosophy, but I have never questioned his sincerity and it ill became the hon. Member for Huddersfield, West clearly to say that the provision of pay beds was permitted by Mr. Aneurin Bevan only as a sort of concession to get the rest of the things which he wanted from the medical profession.
I draw the hon. Member's attention to a speech by Mr. Aneurin Bevan when, as Minister of Health, speaking of pay-beds he said:
I know this is criticised and I sympathise with some of the reasons for the criticism, but we are driven inevitably to this fact, that unless we permit some fee-paying patients in the public hospitals, there will be a rash of nursing homes all over the country. If people wish to pay for additional amenities, or something to which they attach value, like privacy in a single ward, we ought to aim at providing such facilities for everyone who wants them … If the State owned a theatre it would not charge the same prices for different seats".—[OFFICIAL REPORT, 30th April, 1946; Vol. 422, c. 57.]
That is clearly Mr. Aneurin Bevan's attitude on this subject, and it would be an extremely good thing if the hon. Member for Huddersfield, West read it and bore it in mind.
There is an alternative explanation of what Mr. Bevan was saying. What in fact he was saying was that if he was forced, as he said he was forced, to acknowledge the need for pay-beds, he would rather have them in hospitals where he exerted some control than allow a big section of private practice to develop outside the hospital service in nursing homes. That is not what the hon. Lady is representing to the House.
That intervention does not detract from the words which I have quoted which clearly indicate Mr. Bevan's attitude on this subject. That cannot be denied.
However, I point out to those hon. Members opposite who are concerned about it that there is a proviso—it is extraordinary that I should be a kind of female latter day Galahad springing to the defence of the Minister against his own side of the House—that nothing in Clause 5 shall prevent such accommodation as would be available for pay beds from being used by any patient who urgently needs it on medical grounds.
I am glad to see that the Minister nods.
Clause 17(2) speaks of the provision of ophthalmic services in health centres. There is cause to suppose that the Minister seeks to impose on local authority health committees a mandatory duty to provide opththalmic services in health centres. Is it to be mandatory or permissive? This is very important as the whole structure of the ophthalmic services could be altered. I take the point that there are some areas in which such a provision would be helpful and certainly one can imagine the public being benefited if opticians were practising in health centres and certainly they must have the right to do so, but in other circumstances and other areas it could be disastrous.
The right hon. Gentleman reminded us of the position at the inception of the Health Service when it was originally envisaged that all optical services and ophthalmic examinations would in future be carried out within the hospitals. He sensibly conceded that time had shown that that was not a viable proposition. Similarly, it could be said that whereas some health centres might usefully provide ophthalmic services in future, it must not be held that the services now provided in premises in the High Streets must of necessity go, so that all such services are provided from health centres.
There are many reasons for this. One is that many people want frames rather better than those which they can get from the Service. The hon. Member for Willesden, West (Mr. Pavitt) was a little less than fair to the opticians when he suggested that they somehow hid the available Health Service frames so as to be able to sell frames to patients privately. Their ability to sell a private frame would be very much strengthened if all the Health Service frames were always prominently on view, because most people would certainly prefer a private frame. If people want such frames they will either go to the optician completely privately, or have private frames glazed with Health Service lenses. The Minister cannot complain, because the principle by which the long-suffering taxpayer pays once to do his share of financing the Health Service and a second time to be allowed his own choice of what he wishes to wear cross his face has been accepted for a long time.
Equally, it is true that this system is not in the interests of the opticians, because it tends to mean that they are not paid enough for their services as professional men and therefore have to make up a living wage through their services as frame salesmen, and I know that this is a cause for concern for many of them. But the system has the merit of permitting the public a choice, a choice which could well disappear under the rather woolly wording of some parts of the Bill.
Does the Minister really mean that in future the poor overworked local authority health committees, already labouring to deal with a vast range of responsibilities from sewers to bad food and the provision of training centres and homes for old people must—not "can", but "must"—provide health centres where people will have to go to get their eyes examined? If he means that, the choice permitted would be controlled by him, and I am sure that the public would not like that and I do not think that the health committees would.
For years there has been pressure from the profession for ophthalmic services to be termed general and not supplementary and ore warmly welcomes what the Minister has done to get these services on the right footing, but it is probably true that stemming from that very change is a deletion of the optical services committee from health executive councils. Probably this is a mistake which can be rectified in Committee.
Hon. Members who have mentioned this subject have not recognised the possible source of the mistake, which is that the optical services committees are to go, with nothing to replace them. I do not think that the Minister has decided that these committees have not been doing a good job or that they have in any way fallen down on their duties. Having served on a health executive council for 10 years, I have some little experience of these matters. But whatever the reason for the dissolution of optical services committees, I urge the Minister to make regulations to provide instead for a committee to be set up under paragraph 6(b) of Schedule 1 to deal with such ophthalmic matters which may be delegated by executive councils. That is important. Anyone who has sat on a health executive council knows that there are various technical matters that need to be relegated to such a committee.
Similarly, I am sure that by now the Minister realises that the proposal to include only one ophthalmic optician on executive councils is inadequate. I stress the point made by my hon. Friend the Member for Wembley, South (Sir R. Russell) that we must bear in mind the high proportion of work they undertake and the huge mass of the public whom they serve. I hope that the Minister realises the importance of the point and will permit it to be rectified in Committee.
I note from Clauses 5 and 8 that the Minister does not intend at present to interfere with the present teaching hospitals. But can he clarify the future position? Does he intend that beyond the experimental period the teaching hospitals and university hospitals should co-exist with equal status and similar functions, or is it his intention ultimately to standardise the designation for all hospitals with a teaching function, placing them all either under boards of governors or regional hospital boards? The explanatory memorandum tells us that the new form of designation as "university hospitals" will be
… an alternative to designation as a teaching hospital under existing provisions.
That seems to imply co-existence. I am encouraged in that view not only by the Minister's nod but by Clause 6, which seeks to widen the powers of the board of governors of a teaching hospital.
But it is reasonable to press the Minister about this, because there is a classic precedent for the subsequent amalgamation of teaching institutions originally designed to be of equal status although administered differently. I refer to the colleges of advanced technology and the university colleges. What happened there has passed into history, and like most history it can give us a lesson. If the Minister should be tempted to consider eventually bringing all teaching hospitals under the aegis of the regional hospital boards, I hope that he will give full weight to the recommendations of the Porritt Committee on the subject. The Committee said that in England and Wales the teaching hospitals should continue to be administered by separate boards of governors with direct access to the Minister.
Another part of the Bill which rather disturbs me is Clause 62, which says that the Minister of Health may:
(a) purchase and store and, on such terms as may be agreed between him and them, supply to authorities which are local health authorities for the purposes of Part III of the National Health Service Act, 1946, any goods or materials required by them …
What does that mean? They require an awful lot of goods and materials. What are the mysterious commodities that the Minister will shop for, store and supply with such busy intensity? Are they bandages, false teeth, spectacle frames, medicines, maternity supplies and surgical supports? Why does he need to give himself the task of marketing them anyway? Is there a deep malaise in the present system of supply, or does he reckon to get them cheaper from a munificent bulk supplier? All members of the medical professions will be deeply interested in the replies to that question.
Throughout the Bill we constantly meet the words found on lines 26 and 27 on page 14,
… on such terms and conditions as may be determined by the Minister …
Is it too much to ask for an assurance that he will reach his determinations only after consultations with the various professional bodies involved? Much as we respect the Ministry officials and admire the way in which they work, we must press for consultation to be carried out with all branches of the medical profession who are concerned—and I can think of none who are not—because they feel that there has not been sufficient consultation.
I now turn to a completely different part of the Bill, dealing with the provision of invalid vehicles. I am most anxious that the provisions of Clause 31 shall be further widened. What is to be done is welcome as far as it goes, but does the Minister think that it goes far enough? What does he intend to be the criteria for extending the provision of cars and tricycles? The Bill is not clear on that.
I feel very strongly that at present there is something rather unfeeling about the provision of transport for physically handicapped persons. It is not only a question of the provision of an invalid tricycle or car. There is also a great need for something to be done to help handicapped people who buy their own cars and subsequently convert them to hand controls. Many such people must buy a car for themselves because of their jobs or for other reasons. It is very hard that they should also have to pay for the conversion, the cost of which is rising steeply and is now, I think, between £25 and £30.
I am particularly anxious about war-disabled pensioners who face the problem. For many months I have been pressing the Minister, with a sad lack of success, about a constituent of mine who lost both legs as a result of his war service. He went to war a strong and healthy young man and returned a cripple. The sad fact is that he is within an inch of getting help for the conversion of his car to hand controls, but he will never get it. I believe that if the legs are removed one inch above the knee it is not possible to give the help, but if they are removed an inch higher it can be given. It is something like that, but the precise number of inches does not alter my point. If a man is so badly disabled as a result of his war service that the Ministry of Transport does not allow him to drive an ordinary car without having it converted to hand controls the Ministry of Health should help him meet the cost.
There is a real need for such cases to be helped, but I am sorry to say that for many months the Minister has said at some time in the golden future something will be done, and that he has the point in mind. But along comes this Bill, which includes a great deal about invalid tricycles and cars, and yet it includes not a thing that will help my constituent and those in his position.
Clause 13 makes it a statutory duty of local authorities to provide home help. I do not want to say much about that or to speak for much longer. But is the Minister aware of the great difficulties of providing home help? It is not a question of saying "Let there be light", and simply switching on. It is very difficult to get these valuable ladies, and rates of pay for such domestic help must be far higher than the normal rate paid by housewives for the help they get for a couple of hours a week. I know this very well because of my work on a local authority health committee. Most health committees have great difficulty in filling their existing vacancies.
The Minister should also be aware that other local authority departments take home helps from them—particularly the children's department, where, because of recent legislation, it has been thought wise, I think absolutely correctly, that families in danger of breaking up should be given every possible help. This frequently involves a special home help who helps to get the family over the difficult" and even teaches the wife to run her home more happily.
More and more are being used in this department. This is a most important branch of the service. It has been said that it can keep people out of hospital, and that is true. Home helps provide an extremely important service, but it is not so easy to get them as the Bill envisages and the Minister seems to imagine.
I tremble at the statutory headaches which the Minister is imposing on local authorities, such as the duty to provide laundry services. I do not argue that it is highly desirable, and we have heard how it helps elderly people, but it could be expensive and this has not been recognised. It could give a great good to a certain section if all local authorities set up a laundry as a sheltered workshop for mentally and physically handicapped. A very few have done this, as I know from having been involved with one which did. If, instead of using existing laundries, we could set up laundries for the handicapped, who do this work very well, this would be a good thing.
I hope that the Minister knows how to finance all this bountiful help. I have a good deal of information about the effect of devaluation on local authority services and most hon. Members know that the 8 per cent. Bank Rate has had a dreadful effect, since so many of these services must be financed by loans. I was surprised to see, in the first part of the Bill, a reference to financial effects which implied that it will not cost very much and I was reminded of precisely the same mistake on the inception of the Health Service, when people were told that it would cost very little yet the costs have been rocketing ever since. They could not do otherwise.
The passage in question says:
Some increase of expenditure under the powers conferred on local authorities under Clause 43 to promote the welfare of the elderly may be expected, and may lead in
due course to increased Exchequer support for local authority expenditure …
That has too much of the flavour of the sweet by and by. This will have to be financed fairly soon and it should be done properly since it will cost a lot of money. It goes on:
No significant net financial effect is expected from the other improvements
to public welfare and health services. This is a sublime example of optimism. It will cost money and it is no use pretending otherwise. I do not quarrel with being asked to provide more money for these necessary services, but I plead for realism and not claims that this will cost little or nothing.
I welcome Clause 43 warmly. Perhaps by now the Minister will have recognised that many hon. Members feel that something should be done by way of a register or survey to determine the size of the problem or elderly people. This is of great importance. So far, the Minister has given only a lukewarm response to this. While many old people get to know what help is available to them through their doctors, we must remember that some never go near doctors. It is important that we should know where they are and who they are and explain clearly to them what can be done for them.
I have one word of warning. In dealing with elderly people, we need welfare workers of exceptional calibre, because so many old people far prefer to stay at home rather than enter hospital. I know that in some local authorities, an old lady or gentleman may be found in dirty surroundings, unable to cope and look after themselves. Such people may he removed much against their will and taken to hospital, where they usually die miserably soon afterwards. I hope that great stress will be laid on domiciliary services in this respect, with more help through Meals on Wheels. Until quite recently it has been difficult to get enough money for this extremely valuable voluntary help, which would keep people in their own homes and should therefore be encouraged with all our energy.
There are many points on which we hope that the Minister will give his blessing to Amendments in Committee. I welcome the spirit in which the Bill has been introduced.
I wish to refer to the matter raised by my hon. Friend the Member for Wolverhampton, North-East (Mrs. Renée Short)—Clause 57, and the proposed amendments to the Nurseries and Child-Minders Regulation Act.
I am conscious that, when a Minister has shown himself sensitive and responsive to a lobby, it seems churlish to criticise his attempts to meet many of the criticisms of this Act by hon. Members. As a member of that lobby, I know that he has tried to meet the main objections and to close the loopholes in the 1948 Act. The proposed amendments are to be welcomed in so far as they extend the conditions for registration and give local authorities wider powers in connection with people minding children, whether organisers of day nurseries, child minders, play group leaders or anyone else. As my hon. Friend said, the abuses of the Act have been widespread and recent surveys, including the one produced by Dr. Simon Yudkin and his party demonstrated the need to tighten up the regulations in many respects.
I have one or two other proposals which perhaps my right hon. Friend would consider. First, some unregistered child minders flourish because of the way in which they advertise their services: through local newsagents and newspapers. One way of controlling this might be to oblige a newsagent or newspaper either to ask for the certificate of registration before placing such an advertisement or to inform the local health authority that such an advertisement had been placed so that the health visitor can check whether the person is registered. One of my local newspapers, the Slough Observer, has already undertaken to investigate registration when advertisements are placed.
Second, we should tell local authorities to give more attention to provisions relating to the means of informing parents, and particularly young mothers who wish to have their children minded, that registration is essential. This could be done through doctors or welfare clinics, perhaps. Many young mothers are not even aware that they may be handing over their children to the care of a person who is not in touch with the local authority and over whom it has no control.
The amendments proposed relate to only a tiny part of the problem. Many of us have repeatedly asked both the Department of Education and Science and the Minister of Health to inquire into the whole field of the pre-school child. The proposed amendments are no substitute for such an inquiry, but only strengthen the need for it. If they are successful, they will either—as they should—reduce the number of places for children to be minded, because we will have succeeded in outlawing many of the unregistered and undesirable child minders and making it more difficult for them, or they will merely cause them to go further underground and out of the knowledge of the local authorities.
This fear must be considered, because the lobby for amending this Act favoured closing the loopholes and making it more difficult for the unregistered and the undesirable to mind children, but this should be accompanied by an increase in local authority day nursery provision, which is the main cause of the problem facing local authorities. Unless we get this accompanying provision, the proposed amendments, which in isolation appear to solve the difficulties will really only aggravate the problem.
The crux of the matter is simply that 750,000 working mothers have children under school age and 250,000 work full time. The local authority provision in no way meets that demand and anyone with anything to do with local health authorities knows this, as does my right hon. Friend. Many of these mothers have to work and many will go on working even if they do not. Most local authority day nursery provision is inadequate. It caters only for the priority cases and not for the woman who needs or has to go out to work if she is from a normal family.
My hon. Friend deplored the rapid decline in local authority day nursery provision since the end of the war. The reason is that, when the day nurseries were to be closed it was assumed, on the basis of the 1944 Education Act, that there would be an increase in the number of nursery school places and that the two went together. But what happened was a complete reduction in day nursery provision and no increase, or very little during the last 20 or so years, in nursery school places.
Thus more and more children under the age of 5, particularly between 3 and 5, have been forced to find other outlets both for being minded and for playing. This is the reason for the rapid and enormous increase in the last few years in the number of people registered under the Nurseries and Child-Minders Regulation Act for running private nurseries and those minding children or running play groups.
As my right hon. Friend is aware, to the extent that the private nursery, the play group and the child minder have increased in number and registered, so have the unregistered. Although this is very difficult to get figures on, we know from statistics and evidence, particularly from accidents and problems investigated by health visitors, that, in many overcrowded areas, it is increasing. The inadequacy of these provisions does not look like being dealt with, so the real question of the problems of child minding does not arise from difficulties over the law, but from the shortage of local authority day nursery places. Unless these are increased, I fear that the problem which we seek to solve will continue.
I have repeatedly called for both a public inquiry into the sphere of the under-5s and an interdepartmental inquiry to consider the problems involved in caring for this age group. Local authority day nurseries are registered under the health authority. They belong to my right hon. Friend and take children from 0 to 5 years old and most people pay for this service, according to their means. Private nurseries, child minders and play groups are registered under the same Act. They can take children up to the age of 5 and most of this is paid for by the parents. But local authority nursery schools belong to the Education Department and take children between 3 and 5. One does not pay for this service because it is part of the education service.
Play groups are often run in church and community halls by local committees, groups of parents or just individuals, who sometimes form an organisation like the Save the Children Fund or the Association of Pre-School Child Groups. The latter belong to my right hon. Friend, but are not mentioned in the proposed amendments. However, the tendency now is, because of the inadequacy of provision under the Education Department for the under-5s, for more and more parents to send their children between 3 and 5 to play groups which are registered, but which are rapidly becoming a substitute for the nursery school.
In fact, many of the establishments to which parents imagine they are sending their children, and call them nursery schools, are really private nurseries, day nurseries, and so on. But for the Department of Education and Science there is no control. There are no inspection rights. There is no right of entry or right to say what qualifications those running these organisations should possess. Nor is there any right to question the educational content of these establishments. This belongs to the Ministry of Health—all caught up with other regulations dealing with premises, sanitation and the rest.
The figures, such as they are—and they are not particularly good; a lot needs to be done to obtain satisfactory statistics—show that there are 205 private nursery schools registered under the Department of Education and Science and that these are taking 5,500 children, and of these 205 schools, only nine are recognised as being efficient by the Department. We have 2,250 private nurseries taking 55,000 children and 3,250 child minders taking 27,000 children. Bearing these figures in mind, we should remember the crucially important point of trying to do something about the inadequacy of facilities for the under-5s. More and more establishments for this age group are being forced under the control of the Health Department. Some are very good, while others are very poor. Twenty years ago or more it was considered that the development of establishments for children in the pre-school years was an ideal development.
The Secretary of State for Education and Science is pessimistic in his reply regarding the future provision of nursery schools, despite the case put so excellently by Plowden. We have this curious confusion about who runs play groups. The Department of Education and Science recognises—or at least is beginning to—that the play group under Health is becoming a substitute for the nursery school. The Department makes a grant to both the Save the Children Fund and the National Association of Play Groups.
I have been told that more than one education authority has refused a child a place in a nursery school because the child is attending a play group. In such a case the education authority has said that the spare place should be given to a child who does not attend a play group. It is obvious that this vast mass of children under 5 being concentrated under the Health Department will, if not by legislative recognition and Departmental recognition then in some other way, rapidly be attending establishments which will become a substitute for the nursery school; and this is something to which attention must be given by both the Minister of Health and the Secretary of State for Education and Science.
The play group movement is in urgent need of educational recognition and help. It wants educational standards as well as health standards. It wants training courses for its staff and local authorities need clarification and encouragement from the Government as to their responsibilities in respect of the provision that they can make. It is ludicrous that for a group of 20, 30 or 50 children the standards need be no different from those applying to a group of only a few children.
With the best will in the world, it is difficult for many women to know precisely what should be done at some of these play groups. Many of them do not have the ability to look after a number of children in the way we would like to see them looked after and the majority of them would welcome training courses and assistance from the two Departments. There should be set up some sort of child authority between both Departments to try to get a recognised training course, with recognised educational and health standards combined, which would help to raise the standards of play groups and which would also help to remove them from the restricted inspection rights that the Ministry has in this respect.
It has been stressed many times by people who are knowledgeable on the subject that the play group movement has tended to thrive in middle-class areas. This has happened for obvious reasons. The better-off have tended to make this provision for their children. If the Plowden recommendations in respect of deprived areas are not implemented, it is time that we looked at this aspect of the problem to see what we can do. After all, this provision does not involve qualified teachers and there should be special courses for people running play groups. This is why, when we are trying to assess the needs of the pre-school child in terms of child minding and education, we need an inquiry into the whole matter because it infringes on education and health as a whole.
At present, many children who would attend these establishments if they were provided are not able to be satisfactorily accommodated. However, there are some large child minding services and this applies particularly in industry, where crôches and other play facilities are provided for the under-fives to encourage mothers back to work. These children, but for the short-sightedness of the country's education policy for the last 20 years, would have had an opportunity to attend nursery schools.
Plowden was not intended to deal with the needs of the working mother of the pre-school child, but it stumbled on the problem and, in doing so, backed up the already mounting evidence that, in this category, exists inadequacy, confusion and danger.
There are 4¾ million children under 5 in this country. The provision for their physical care is good and is improving all the time. In contrast, provision for their emotional and social needs is chaotic and is based on no philosophy. It also ignores much of what is known about the whole sphere of child development.
Modern life has changed family relationships and family patterns. The whole fabric of society has changed—that is, for all except the under-5s. We encourage women to return to work, but the only provision we make for children outside the existing band of nursery schools is if we want to encourage particular categories of women back to work, in which case we provide facilities for their children.
An adequate case has been made out certainly for the last five years, and since the child nursery provision has been running down, that provision must be increased or private provision will continue to grow. A sufficient case has been made out now to show that every time we talk about nursery schools, play groups, child minders or private nurseries, we are dealing with a very small part of the problem because the confusion that exists Departmentally makes it almost impossible to look at this whole question as one and make definite recommendations to tell us exactly where we are going.
Is enough known about the subject? My right hon. Friend was kind enough to see and discuss the topic with me at some length, although he feels that an inquiry is not needed because, in his view, enough is known about the under-5s. He must be aware that the proposals in the Bill will not meet the needs of the very problem that has been highlighted.
If we do not know sufficient about the inadequacies which exist, it is time that we discovered them because whatever the intention of these amendments—and I admit that they are good—without adequate provision from the local authority point of view, and without a raising of the standards for children who are deprived of nursery school education and who are trying to be controlled and managed in some other sort of organisation under the health authority, this problem, despite these amendments, will increase rather than decrease. Unless we decognise the need for a rapid growth in this provision, the sort of conditions and circumstances under which many of our children are at present being minded, in registered and unregistered organisations, will increase—and we will not find it so easy to tackle the problem as time goes by.
In view of the lack of time, I will not delay the House and, for this reason, I will not comment on the interesting points made by the hon. Lady the Member for Eton and Slough (Miss Lestor). I appreciate that ever since she became an hon. Member she has stressed the importance of the topic she raised. I hope that she will forgive me for not commenting on it.
The Bill has been described variously as a "hotch-potch" and a "rag bag". Whatever may be said about it, we must use the resources we have for the different forms of health services—be they local authority or Ministry controlled—to ensure that the best results are achieved for the people they are designed to help. In other words, we must break down the barriers that exist, and use all the facilities to improve the lot of those we set out to help; that is, people who are ill or unable to look after themselves in the community.
There has been a tremendous move in this direction in the attitudes of the public at large and by health authorities and hospitals. However, there are difficulties and a number of these are pinpointed in the Bill. The facilities suggested in the Measure will be of considerable help in getting over some of the tight compartments in which some of the services find themselves.
We want to make the most of all the facilities and resources we have. I suggest that one way would be to simplify the administration of the Health Service generally, and I trust that the Minister will consider this at a later stage. Often small points take up a lot of time in administering the service. Hon. Members will be aware that every time there is a car accident and someone is hurt, the driver of the car which injured the individual must pay 12s. 6d. That has to be collected by regional hospital boards or by hospital management committees. The amount of work that goes into collecting this small fee is quite out of proportion to the amount collected. I checked up with two hospital management committees. The first one had to collect 1,300 of these fees, and it had to write off 13 per cent. It estimated that the cost was near a guinea for every 12s. 6d. which it succeeded in collecting.
In the other case there were 945 fees to be collected, of which 106 had to be written off. A very small Amendment to this Bill would remove an aggravating job from hospital management committees and others and it would also make the service much more acceptable in the community.
All sorts of comments are made in the letters in reply to requests for payment of this fee—" I thought the ambulance was free"; "I thought the Health Service was free"; "I never used the ambulance"; "It was the other man's fault." All these sort of things blow up.
I am sure that when we consider the Bill in Committee the Minister would earn the thanks of every finance officer on every board and management committee were he to put down a small Amendment which would abolish Section 213, and probably Section 214, of the Road Traffic Act, 1960. I hope that this point will be considered during the Committee stage.
There are many hon. Members who want to speak, so I will be brief. I will not follow on what the hon. Member for Maldon (Mr. Brian Harrison) has been speaking about, although I find the subject that he has raised of some interest.
I would like to pick up one or two of the points that the Minister made in introducing this Bill. First, I pay tribute to him for the very significant revival of morale in the National Health Service. Those of us who have been closely connected with the Service for many years past realise that over the last two or three years there has been a significant revival in morale, which had got woefully low. I am not suggesting that all our problems are solved—far from it—but I think that we are justified in adopting an attitude of perhaps cautious optimism.
I particularly endorse what the Minister said about health centres. It is encouraging to see this increasing development in health centres, although one must underline how very far we have to go before health centre practice becomes the normal type of general practice in this country. I look forward to that day.
The hon. Member for Farnham (Mr. Maurice Macmillan) welcomed the non-doctrinaire approach, as he put it, of the Minister on a number of issues. I welcome the non-doctrinaire approach on health centres that we have had from the Conservative Party. All the old political bogeys and the extreme doctrinaire attitude of some of our political opponents has, fortunately, been forgotten. Health centres will help to a certain extent in solving the difficult problem of shortage of doctors, because one advantage of this form of general practice is that it makes more efficient use of the skills of a limited number of doctors.
Another important thing that we have to do is to increase the opportunity for training at medical schools. Whether it be in health centres, group practices, or even partnerships—I do not want to get involved in an almost theological distinction on the borderline between these three types of family medicine—team work is essential. The family doctor especially will increasingly be the leader of the team. Many doctors appreciate and welcome this sort of practice, but some do not realise how important it is to cooperate, not only with their own professional colleagues, but with other medical workers such as health visitors, social workers, district nurses, midwives, and so on.
I also welcome the Minister's announcement that we are to spend £100 million on new hospital building, and particularly his emphasis on the increasing concentration of geriatric and psychiatric work in this sphere.
My right hon. Friend also mentioned productivity. Productivity is perhaps not the sort of word one would normally use when talking about medical practice and hospital work, but I think that it is justified. Productivity has improved enormously in the Health Service as a result of medical advances, new drugs, techniques, and improved organisation. There is still a great deal more that we could do. For example, I am convinced that there are thousands of patients who are unnecessarily admitted into hospitals, or, if they have to be admitted, are perhaps admitted too early and languish for one, two or three days before their operation takes place. If one adds up these unnecessary days in hospital by thousands of patients all over the country, one realises that here at least is one factor that is aggravating the waiting list.
There are many patients who could be discharged from hospital much earlier than they are at the moment. It always strikes me as extraordinary, as a family doctor who also worked within the hospital service, but under the supervision of a consultant, that I would be looking after patients in my own general practice work who were very much worse in health and in much more need of care and attention than some of the patients who were remaining in hospital because of arbitrary rules that had been accepted by the hospital and by the consultant. For example, that somebody who has an appendicectomy shall not go home for eight days, or whatever is the arbitrary length of time. Because these rules have been adopted we find patients in hospital who are often not as ill as those being looked after outside. This is a direction in which we could look towards improving productivity.
Concerning out-patients, a very large number of people attend unnecessarily—cases which could be looked after by their family doctors if only we were prepared to give to the family doctors in all parts of the country the tools of their trade: the ancillary help and the right to send patients for investigation that the doctors in the more fortunate parts of Britain, by and large, have.
The Bill is no startling major step forward, but it is a valuable step. As was said earlier, no changes in administration are proposed. It is a pity that we have not begin to tackle the problem, because the need for unification of our tripartite service is becoming increasingly obvious as the years go by.
Some attention has been given to the section on pay-beds. I want to spend a moment or two discussing this. I am opposed to private medical practice. I always have been. I was when I was a medical student and my attitude was reinforced when I become a doctor in hospital, and it was still further reinforced when I started in general practice. I think that private medical practice is morally indefensible and, medically, exceedingly inefficient. But we are not today arguing about the rights and wrongs of it; we are discussing the points put forward in the Bill.
I welcome the Minister's assurance that he will not use his powers to extend private practice in any way, but will make a more rational use of beds in our hospital service. I hope that this will mean that not only certain private patients will be treated in beds which have previously been exclusively reserved for Health Service patients, but we will go much further along the road towards using the empty private beds that are in existence at this moment in nearly every large hospital in the country. Bed occu- pancy rates in private wards and private rooms very often fall far below the bed occupancy rates in the Health Service section of a hospital. This is a dreadful waste of desperately short hospital accommodation comparable to the waste which I think private practice makes of the desperately short skills of the medical profession.
I am interested in the new designation of university hospitals. I do not share the fears which have been expressed in the House today that some sort of precedent might be created, and that the time might come when there will be some change in the way in which we deal with our teaching hospitals in England and Wales. It is interesting to note that this is applied only to England and Wales. The Scots have been more intelligent than we have been in this respect. From the early days teaching hospitals there have been an integral part of the regional hospital board set-up. My experience of Scottish teaching hospitals convinces me that there are strong arguments in favour of their system, as opposed to ours which tends to isolate the teaching hospital from the ordinary run-of-the-garden hospitals, and therefore tends to isolate hospitals not only administratively, but professionally as well.
I am particularly interested, too, in the proposals for the midwifery service, namely, that we should enable midwives employed by local authorities to work within hospitals as well as in the district and the community. This is particularly important in those rural areas which are largely dependent on small maternity units, often staffed by family doctors, because these units have been facing serious problems in recent years. One of the problems has been to staff them, largely because it is difficult to obtain midwives.
Working in this sort of area, I have often felt that this problem could be solved, if, instead of having a divided midwifery service where there are hospital and district midwives in the sparsely populated areas, there was a midwifery service which provided care for those who needed it, whether they be in hospital, or outside it. This would have the advantage, not only of solving some of the staffing difficulties, but would get over a real and justified professional objection by midwives to the early discharge of patients from hospital.
The early discharge of midwifery cases from hospital is increasingly happening, quite rightly from the medical point of view, but, understandably, a trained and qualified midwife gets a little fed up when virtually all the cases which she has been looking after in the district are delivered by somebody else in hospital, and are discharged two or three days after the delivery. If we have a system whereby the midwife follows the patient around, so that the patient has continuity of care, and the midwife has continuity from the professional point of view, we shall be taking a real step forward.
The other Clauses of the Bill which I particularly welcome are those which help the old folk. I am referring to the insistence that the provision of a home help service shall be a statutory duty on local authorities. I regret, as one hon. Gentleman opposite did, that the provision of a laundry service is not to be statutory, too, because the problem of soiled bed linen is probably the most common single factor which results in old folk having to be unnecessarily admitted to hospital.
It is not just the economic cost, although this has been mentioned by some hon. Members. It is the cost in terms of human suffering. It is difficult to explain, unless one has had to deal with a large number of old folk, just how much it means to many of them to be removed from the home in which they have lived for perhaps 40 years and be put into the extremely strange environment of a hospital ward. When this is done only because there are not the means in ordinary people's homes to do all the washing that is necessary two or three times a day, it seems very wrong indeed.
As I say, I welcome all the Clauses which promote the welfare of the old folk, and I was pleased that when my right hon. Friend introduced the Bill he mentioned loneliness, because in old age this is one of the biggest problems which has to be faced.
I welcome the fact that more attention is to be paid to post-graduate medical education, because there is a great need for this. When talking about medical education, we sometimes concentrate too much on undergraduate education, and forget that the average doctor today will, during his working life, see a complete transformation in the medical scene. The fact is that 30 to 40 years means a complete transformation in medicine. The medicine that we are practising today is totally different from that in the late thirties, and the need for regular refresher courses is becoming increasingly great as time goes on.
I welcome the Clause which deals with invalid cars, because I consider an invalid tricycle to be virtually a sardine tin on wheels. It is wrong to expect disabled people to drive around in these abysmal vehicles. We ought to be thinking more about changing to mini cars of one sort or another.
The hon. Member for Farnham (Mr. Maurice Macmillan) mentioned the possibility of a Specialist Committee to look into health and welfare matters. This ought to be considered seriously. I have had the pleasure, the honour if one likes, of serving for the last eight or nine months on one of the two new Specialist Committees, that on agriculture. All the time that we were holding our meetings I felt that it was the sort of technique which could be usefully applied in Health Service politics, because, as we all understand, many of these issues are probably better discussed in a Specialist Committee. They do not involve party conflicts, which are better dealt with here.
I welcome the Bill. It represents a real, if not a very large, step forward. It is in some ways typical of the legislation that we have seen on this subject over the last two or three years. I think that we perhaps forget the real and significant progress which has been made since Labour came to power in 1964. We have retained the basic principle of the Service, that it should be free to all those who are in need.
I particularly welcome the fact that we are discussing the Bill so soon after devaluation. This is one of the first Measures to come before the House since then. I think that it will particularly help those sections of the community who may have to pay some of the economic prices resulting from the economic crisis which we have faced in recent months.
I shall not, at this late hour, attempt to follow the hon. Member for Falmouth and Cam-borne (Dr. John Dunwoody) in all that he said. With much that he said, I find myself in complete agreement, but I was profoundly shocked and disturbed to hear him say that he found the private practice of medicine—I hope that I do not quote him incorrectly—immoral. Observations of that kind, coming from an hon. Member who otherwise is obviously educated, humane, and balanced——
I am obliged to the hon. Gentleman. I am still profoundly shocked at his observation. That kind of observation, coming from someone of the obvious humanity of the hon. Gentleman, makes one convinced that the logical conclusion of Socialism is an ant hill in which the individual has no freedom of choice. The only consolation I feel is that if that state were achieved by the Socialists, many of them would be the first to rebel.
I shall not go through the many Clauses of the Bill, but will come directly to those which are of the most moment to me now, because lately I have been concerned with the problem of pay-beds. There is much in the Bill which has received an unqualified welcome from both sides of the House. I am thinking particularly of Clauses 42 and 43, which contain provisions for old people, Clause 13, and so on. But for Clauses 1 to 4, which deal with pay-beds, there has been only qualified approval, significantly, from both sides of the House.
That was because both sides of the House read into these Clauses a different intention by the Minister. I noted down carefully what he said about these Clauses as to his intention. He said that he had no intention of extending private practice—huzzas from hon. Members opposite. He said that he would not abolish the right of the profession to treat private patients. I give no huzza to that statement of intention, because it leaves the matter as vague and leaves us as much in the dark about his intention as we were before.
I ask the Minister the categorical question, does he intend to provide, in accord- ance with the undertaking given by the then Minister of Health when the Health Service was instituted, private treatment in Health Service hospitals in accordance with the need and demand for it? If he is to cut down the pay-beds and the provisions of pay-beds despite the demand and in inverse sense to it, he will be going back on the undertaking that was then given. He will be flying in the face of an enormous public demand, a demand which also comes from the medical profession.
We have to face the fact—the Minister would be the first to concede it—that there is a great lack of confidence between the medical profession and the Minister. The medical profession is profoundly disturbed. I have had letters from the British Medical Association and other organisations about the slightly increased flexibility in powers which the Minister gives himself and about the use he will make of them. It is the use that he will make of them that worries the doctors and an undertaking in regard to that is what we are seeking and for which we have a right to ask.
In those circumstances, it was perhaps unfortunate that on the eve of the presentation of this Bill for Second Reading the Minister took the opportunity in Glasgow last night to make an attack—for such it appears from the account in The Times—upon the representatives of the medical profession. I quote from The Times for today:
Mr. Robinson, who was giving the Maurice Bloch Lecture at Glasgow University, criticised the `official voice' of the medical profession. He said certain representatives were responsible for the impression of antagonism. Many doctors, particularly the younger ones, derived satisfaction from practising their profession in an environment where, without hesitating to consider their patients' means, they could prescribe and carry out whatever treatment they considered was needed.
If there is an impression of antagonism between the Minister and representatives of the medical profession I suggest that the fault is not, as the Minister would suggest, all on one side but lies very much with him and his conduct in regard to pay-beds over the last few months is one of the causes of that antagonism.
The fact must be faced that the consent and friendship and co-operation of the medical profession are absolutely essential to the well working of the Health Service. If the Minister puts them in jeopardy, the Service will break down. On 6th November, in answer to a Question I asked, the Minister announced that he was to cut down the number of pay-beds available in Health Service hospitals from 5,764 to 4,379. A Motion in my name, deploring this, was signed by 113 of my hon. Friends.
The Minister gave as an excuse that he was cutting down the number of pay-beds commensurate with the demand. It is quite true that there are empty pay-beds because the malady or the complaint for which a particular pay-bed is designated is not one for which there is demand at the moment. [Laughter.] I have expressed myself very badly, but hon. Members know what I mean. It is not the demand for the malady, but the demand for the pay-bed. That I know. The new flexibility in Clauses 1 to 4 will enable the Minister to make beds available as and when needed subject to such considerations as convenience in the hospital, and so on. To that extent I welcome the flexibility, provided it is properly used, but it must be properly used. The demand for private practice in medicine is not decreasing but is increasing.
I thought that it was a purely rhetorical question. I do not deny the patient the right to private treatment. What I cry shame about is that there is thought to be a need for an extension of private practice and that there should be an attempt to justify it as the kind of practice which ought to be followed. I think that it should diminish as the kind of practice which ought not to be followed.
The hon. Member is entitled to his point of view in a free country just as people are entitled to go to their own doctor and to pay him if they wish to do so. This was quite properly recognised in the National Health Service Act. It should not be taken away, but the Minister has been whittling it away. That is the complaint we make.
—of the revision in the total number of pay-beds. I do not know whether he is aware of the history of this matter. I do not know whether he is aware that over 18 months ago I discussed with the leaders of hospital doctors, the consultants, a package deal in connection with pay-beds. There were features which they liked and features which they did not like. They acquiesced in the total package and part of the package was that I would review the total number of pay-beds in order to adjust the pressure on pay beds to something like the pressure on non-paying beds. Another part of the package was to do what no Conservative Minister was ever willing to do. I lifted completely the ceiling on fees which private consultants could earn from private patients in Health Service hospitals. The hon. Member might take the whole package together instead of one particular aspect of which he complains.
The aspect I am taking into consideration is one which concerns the citizens of this country, the availability of something for which there is a demand. I am not concerned now with the fees which should be earned by the doctors attending them. The Minister has completely disregarded the rights of the citizens.
The figures which the British United Provident Association has of the demand for insurance for private medicine speak for themselves. They speak of the demand for private practice and for private beds. Over 600,000 families—about 1¼million people—are insured with B.U.P.A. Over 2 million people—about 4 per cent. of the nation—are insured either with B.U.P.A. or similar institutions.
When I asked the Minister why he was reducing the number of pay beds in my constituency, despite the objection and recommendation to the contrary of the regional hospital board, he said that the demand for them was not there, that they were not being fully occupied. The answer to that is that designation for particular diseases prevented full occupation. The story of the development of the Nuffield nursing homes by B.U.P.A. is a complete answer to the case which the Minister has just sought to make. The demand for places in the Nuffield nursing homes is increasing all the time.
It is significant that, at the time when the Minister said there was not a demand for pay beds in my constituency of Solihull, three-quarters of all the beds occupied in the Nuffield nursing home at Edgbaston were occupied by people from Solihull. In the face of that, the Minister seeks to argue that there was not a sufficient, demand for pay beds in Solihull.
There is much in the Bill that I welcome, but I seek from the Minister an undertaking that the increased flexibility which Clauses 1 to 4 give him with regard to pay beds will not be used as a means of whittling away the number of pay beds, as he has been doing. One of the results of this attack upon private medicine has been the disgruntlement and dissatisfaction of the doctors who have to work the Service.
At Glasgow last night the Minister sought to draw a contrast between the representatives of the medical profession whom he criticised—I presume the British Medical Association and others—and the younger doctors. Is it the middle-aged or the elderly who have been emigrating in their thousands? The answer to the Minister's completely false point lies in the emigration of thousands of young doctors who are not prepared to work the Service under conditions imposed by the Minister. This is not only a matter of pay; it is the sacrifice of their freedom and the cutting-down of opportunities for private medicine.
I am sorry that in the inquiry into the administration of the Service which the Minister announced on 6th November he did not go a stage further and inquire into alternative methods of working the Service. I say this with temerity, because to many hon. Members opposite the Service is a white elephant or tin god which they worship and in which they are not prepared to see much to criticise.
There are alternative systems by which the country's limited resources could possibly—I am not convinced of this; I do not know; I should like there to be an inquiry—be used to much greater advantage. Under the French system of social security, people pay and get the money back afterwards. The same is done in Sweden. Should not such a system be investigated? Should not a system be investigated by which prescriptions are the subject of a charge? Would it not be better that there should be a small payment for prescriptions by those who can afford it so that more money is available for poorly-paid hospital registrars?
As the hon. and learned Gentleman is advocating investigations, does he not agree that there is a need also to investigate the system whereby people go to see consultants in their private consulting rooms and shortly afterwards find their way into public beds in public hospitals?
I suggest that the systems used in other countries should be investigated so that we could have a standard of comparison by which to judge our Service and by which to judge the service it renders to the community. I regret, therefore, that the Minister, for the time being, at any rate, appears to have closed his mind to this possibility. Perhaps he has not, but in announcing the inquiry on 6th November he said:
I should make it clear that my studies will relate entirely to the administrative pattern. I am not considering the possibility of what would amount to an alternative health service, as is sometimes suggested, involving,
for instance, a switch in financing from the public to the private sector."—[OFFICIAL REPORT, 6th November, 1967; Vol. 753, c. 643.]
But if some of the anomalies and some of the grave difficulties in our Health Service in the over-use of resources in one field and in their misuse in others are to be allowed to continue then the tension and antagonism between the Ministry and the medical profession will never end, and the brain drain—I have used this expression before—from which this country has suffered, and the great exodus of doctors to countries overseas, will become not a brain drain but a torrent.
I am very grateful for the opportunity to follow the hon. and learned Member for Solihull (Mr. Grieve). I was sitting here getting increasingly more depressed by reading the Bill and getting more and more depressed listening to the measure of agreement between hon. Members opposite and my own Minister upon the Bill, and I was delighted to see somebody who finds a sinister motive, a sinister aim to bring about the end of private practice which is operating in our public hospitals.
I do not welcome the Bill because of the indications in the first few Clauses of the way the Minister is thinking about the development of the Health Service. I should like to say this very briefly to the Minister. He is preparing a Green Paper and a White Paper to lay before this country his ideas about the way in which the Health Service should be developed, and I would like to tell him, before he prepares his plans and White Paper, not to fall into the same error as my right hon. Friend the Minister of Power did in the preparation of his White Paper and underestimate the feeling on this side of the House in relation to private practice.
I think that the first few Clauses of the Bill are indications that my right hon. Friend accepts that private practice should be allowed to continue in our public hospitals. I have no objection to private practice being continued outside the public hospitals. I have heard the name of Nye Bevan being called in aid of allowing private practice to continue within the public hospitals. I am sure that at the time when he was introducing the Health Service he thought there would be a mass exodus out of the Service, and the setting up of private hospitals all over the place, but I am sure that at this particular time this would not happen, because although some people would choose to go outside the Service if there were exclusion of private practice within the Service I do not think that it would be a very large section of the population and I am quite certain the Service would not suffer if that were to happen.
I would like to tell the Minister that if there should be exclusion of private practice from our Health Service there would not be an exodus of doctors out of the country. If I may declare an interest here, my wife works in the Health Service, in the hospital service; she does a number of sessions each week as an anaesthetist in the Service. What I hear from her is that the people who are leaving the country are the young doctors who are waiting for their promotion in the Health Service. They are young surgeons, young obstetricians and gynaecologists, young physicians, people who are well qualified, who are waiting for consultancy posts in this country and having to wait far too long.
These sorts of people would not be the ones who would leave if private practice were to be abolished. Their concern is to get promotion within the system; it is not their concern to acquire vast private practices. More and more doctors are, in fact, choosing to go on the 11–11 or full-time system, and are not asking for the 9–11 or part-time system. More doctors, as they reach the age of 55, chose to go on to the full-time consultancy system because they will thereby receive their full pension. It is a red herring to suggest that, if we do away with private medicine in public hospitals, there will be a mass exodus out of the hospital service.
One matter we should look at is the great disparity in pay and conditions between the junior hospital doctor and his consultant, and also, if I may add this, the disparity in pay between the well qualified junior hospital doctor and the general practitioner. If there is one field in medicine from which we are losing young doctors, it is from among the young doctors in hospitals who are underpaid, overworked and under-represented and who are dominated in hospitals by the senior consultants whose voice is so powerful in the B.M.A., as it was powerful when Nye Bevan was introducing the Health Service.
Is it not amazing that, at the time when the Health Service was being introduced, we were told by the B.M.A. that the system would not work? There were highly-paid Members advocating in this House that the system would not work. There were fundamental objections to it. Yet, suddenly, when the senior members of the B.M.A. were allowed to carry on their lucrative private practices, all those objections disappeared. That is what happened. That was the sort of thing which coerced our Minister at the time to accept this iniquitous system.
There is one particular aspect of private practice which should be dealt with, and I am disappointed that the Minister has not taken advantage of this miscellaneous provisions Bill to try to deal with it. I know, other hon. Members know, and I am sure that the Minister knows, that more and more people are jumping the queue into hospital by taking advantage of the private consultation with the part-time consultant. On a number of occasions, my wife is put in a difficult position in advising friends how to see an obstetrician or gynaecologist. The only way a woman can be sure of seeing a consultant is to consult one or other of these consultants privately, and then, by a miracle, she suddenly finds that she is admitted into the ante-natal clinic of a hospital.
Similarly in general surgery, and in medicine: one goes to see the consultant in Harley Street or, in Liverpool, in Rodney Street, and then, by a miracle, one finds one's way into the out-patients' department of a general hospital, jumping the queue and getting a bed in a public hospital. This is what is happening. If my right hon. Friend asks me for evidence, I cannot provide it, because the people who have taken advantage of the system will not admit to having done so. My right hon. Friend knows that that is so. He knows it is happening.
This Bill is a Bill produced by an administration, not by a Government—certainly not by a Socialist Government. If my right hon. Friend's thinking on private practice is the thinking which I find expressed in the first two Clauses, I assure him that I and many of my hon. Friends will do everything in our power to see that his intentions in those first two Clauses are not carried out. If he produces a White Paper on the lines of those Clauses, I shall do all I can to see that it is rejected by this party.
After nearly five hours of debate, nearly all the rags even in a rag-bag of this size have been pretty thoroughly picked over, but I am surprised that there has been very little reference, and then only in passing to the Clause which deals with the provision of invalid vehicles. I thank the Minister for bringing forward this measure, which he had promised to do. I do not blame him for the long time it has taken, and I am glad to see that what he now proposes will, as I understand it, give him power to do almost anything in the provision of vehicles for the disabled which he or the House would want.
This being so, I remind the right hon. Gentleman of a proposal which was made in the House about 18 months ago. In response to that proposal, the right hon. Gentleman said that there was no money and he had no power. The proposal was that people who had been issued with invalid tricycles which they did not like should be able to pay the difference between the cost of such a tricycle and of an adapted mini-car and thus have a mini-car rather than a tricycle. The Minister replied that he did not have power to arrange that, and he was right. Under the Bill, he will have such power.
The Minister went on to say that there was no money. The difficulty was not the cost of such an arrangement to the present drivers of invalid tricycles provided by the State but that if such an arrangement were made he thought that many thousands of disabled people who did not like tricycles would seek to have invalid cars provided by the State because mini-cars would be acceptable to them. It was this extra cost—a cost of unknown proportions because neither the right hon. Gentleman nor his civil servants knew how many people would be involved in such a choice—which made him say that the proposal was impractical.
There is a ready-made solution to this problem of providing adapted mini-cars to present holders of invalid tricycles on payment of the difference in cost, and that is that holders of invalid tricycles, at a certain date—perhaps today or 1st January—should be eligible, when their tricycles are next due for renewal, to have mini-cars adapted to their purposes if they are prepared to pay the difference in cost between the two vehicles, which would be comparatively small. That would completely remove the Minister's objection that there would be a sudden rush of applicants for vehicles at State expense from people who did not like tricycles but would accept mini-cars.
When the Bill becomes law, the Minister's powers will be clear. I believe that I have suggested a way in which the financial side of the matter could be covered. There would be no extra cost to the State at all. The extra cost would be paid entirely by individuals who wished to have such a service. Could this suggestion be examined?
I wish to mention two other small points. The honourable and medical Member for Glasgow, Kelvingrove (Dr. Miller) suggested—from me it would have been effrontery, from him it was not—that there should be a place in the Health Service for people less qualified than the doctors who have qualified over six or seven years and that they would be perfectly capable of dealing with certain minor matters which at present need the attention of the fully qualified doctor. He mentioned various kinds of tests—blood tests and urine tests—dealing with cuts and bruises, prescribing cough mixtures, and so on. To my layman's mind, this has always been a very attractive proposition. It is attractive to anybody who, like myself, has lived for most of his life in under-developed countries where, because of a shortage of skilled personnel in every walk of life, one's wife and daughter dispenses medicine to the people of those countries simply because there was nobody else to do it. One is astonished to find how easy it is to become a rough-and-ready dispenser.
I do not suggest for a moment that there should be a second-class doctor— that would be unthinkable—but, in view of the present shortage of medical men, there might be a case for investigating the possibility of less well qualified people being permitted by law to perform less rigorous tasks so that the qualified doctor, who has spent six or seven years in becoming qualified, could be released for more valuable purposes.
There has been reference to the meals-on-wheels service. My wife takes round meals-on-wheels twice a week in the poorer areas of Liverpool as a member of the Women's Royal Voluntary Service, as an agent of the City of Liverpool's Welfare Department. This arrangement happens to work very well. The meals are cooked and provided by the City of Liverpool. The drivers are employed by the City of Liverpool. The meals are carried into the houses by voluntary women helpers. Clause 43(3) states:
A local authority may employ as their agent for the purposes of this section any voluntary organisation having for its sole or principal object, or among its principal objects, the promotion of the welfare of old people.
I should like an explanation why that provision is necessary. Is it not some-what restrictive? For example, supposing that in an emergency a local authority wishes to employ any voluntary organisation, no matter what it is, to help in this valuable work. Would it be prevented legally from using, say, a youth group because of the restrictions implicit in that subsection?
I want to refer to Clause 14, which has not yet occupied the attention of the House. This basically extends to Scotland the provisions of the National Health Service (Family Planning) Act, piloted through the House so ably by my hon. Friend the Member for Bebington (Mr. Brooks) during the last Session.
I welcome this Clause. Indeed, I am rather glad and relieved to be able to make this speech. During the course of the proceedings, it was suggested by a number of people, including myself, that we might have to wait a very long time for this provision to be introduced in Scotland. I speculated on the Second Reading about hidden enemies in the Scottish Office. I was not alone and that sentiment was echoed widely in the House, during the Committee stage and in the Press. It is, therefore, with particular pleasure that I welcome Clause 14 of this Bill.
I have not the time, nor do I wish, to go over any of the arguments or merits of the provision itself. In any case, to do so would be redundant because if there were any great surprise about the progress of my hon. Friend's Act it was the almost complete unanimity of the House. It received the warmest of welcomes from my right hon. Friend the Minister of Health. The only Opposition Front Bench criticism was that it should have been Government legislation and not left to the lottery for Private Members' Bills. The tremendously overwhelming warmth with which it was received suggests that, at least in political terms, family planning is no longer a controversial issue.
It is interesting to consider the sequence of events. When that Act was introduced, there was the very cagey and perhaps understandable caution with which we were told that, if Scotland were to have such provisions also, we would have to get them through the private Members' procedure all in good time. We presumed that we would have to wait for some favourably disposed Member to come up in the Ballot. This cautious, cagey attitude cloaked a real determination to make some sort of quick progress, and we are grateful.
But the same sort of situation is developing, or is potentially developing, in relation to divorce law reform. I hope that the kind of answer I got the other day from my right hon. Friend the Secretary of State for Scotland, to the effect that, if divorce law reform got through in England, we would have to wait for a Private Member's Bill for Scotland, will turn out also to be a mere cloak.
I wholeheartedly congratulate my friends of the Scottish Office on this Clause, but I remind them that this is only the beginning of the battle. Although we have now made a sizeable break through with Clause 14, we shall still have to deal with a great deal of opposition at local level. Many local authorities will drag their feet and take recalcitrant and somewhat backward attitudes to the matter.
I am hopeful that my fears will prove to be not well founded. There is some evidence from England that, since the Act came into operation, there has been an enormous movement and progression. I am told that the London boroughs of Wandsworth and Southwark are already implementing the Act, that some 19 or so other local authorities have plans which are far advanced and that well over 70 have already been considering the matter and are consulting the Family Planning Association and other interested bodies with a view to action in the not-too-distant future.
There has been a tremendous rush to implement the Bill in England and this is a great encouragement to us in Scotland. One of the factors in England which has helped so much has been the decisive and adequate circular which followed the Act within one month of the Royal Assent. It was sent out by the Ministry of Health. In the history of circulars on this matter, I find that an earlier one—Circular No. 10/1966 from the Scottish Health Department, which preceded the Act, is word for word the same as the Circular put out in England by my right hon. Friend the Minister of Health. I hope that we can have some assurance from my hon. Friend the Minister of State that, when this Bill becomes law, there will be a fast and comprehensive circular in an attempt to encourage—I put it no more strongly than that—enthusiasm among local authorities in Scotland for taking advantage of the new powers being put their way.
Above all, I hope that the circular will include, as the English one did, a definite date by which they must report progress. In the case of England, I think the date is 31st March, 1968. I hope that there will be a definite obligation on Scottish local authorities to report to the Scottish Office on what they are doing so that we do not get a situation where people on local authorities are prepared to sit and let matters drift, hoping that their slow progress will go largely unnoticed.
It is really extraordinarily encouraging to see this Clause. For too long the Scottish Office has been saddled with the notion—or people have saddled it with the notion—of being opposed to any kind of social progress and unwilling to touch controversial social matters. By introducing this Clause and presumably being instrumental in getting it included, the Scottish Office has gone a long way to throwing off that kind of slur—which has been a slur and misconception.
The idea is too prevalent that the Scots are hostile and antipathetic to social progress and that our Ministers and civil servants are in the van of the resistance. I have never believed that and this is an example that it is not so. It encourages one to think that some things are not as far amiss as some people try to represent.
My own local authority in Aberdeen has an excellent record. I hope that it will not mind my saying that in some respects it has jumped the gun and anticipated this legislation. However, it will now find that the shackles are thrown off and that it can develop a comprehensive system as speedily as it wishes. At the same time, there is an enormous opportunity for local authorities, goaded and driven on as I hope—and I put it as strongly as that—by the Scottish Office, to change their attitudes and review positions and build up services, so that we can get the kind of comprehensive coverage of the country which we all want.
There will be a few lingering prejudices. A few will imagine that in some way the Bill is interested in limiting the size of families. That kind of misconception will continue for some time, but all of us know that for a long time family planning has been regarded at official level as having an enormous part to play in health matters, ensuring that in this difficult subject society is well informed, so that those people who want large families can undertake them in the knowledge of the social and financial strains involved. This is not a Measure which should be looked on in the wicked sense as a move towards a permissive society, certainly not towards a less moral society. It will lead in the long run to a happier society.
I endorse the sentiments of paragraph 8 of Ministry of Health Circular 15/67 which says that adequate family planning services fully integrated with other community services are an essential part of family welfare and will help to relieve the burdens placed on other local authority services by physical ill-health and mental distress arising from lack of knowledge. This is essentially a step forward and I at least am grateful. I wholeheartedly welcome Clause 14.
I am surprised by the eagerness of the hon. Member for Aberdeen, South (Mr. Dewar) to follow the example of English legislation so devotedly when, during the course of the debate, we have heard even from some of his own hon. Friends of the great merit of the legislation in Scotland and the great merit of following that example in England. The hon. Gentleman argued the advantages for doing something exactly the other way round.
I do. I do not have a prejudice about family planning, but I think that the Scots have always managed to plan their families perfectly well without these provisions. I happen to believe that families should plan their own families and not have the State do it for them. I am opposed to the introduction of Scottish provisions in English legislation. I regard it as an unfortunate and retrograde step to introduce it in a Bill of this nature, which is otherwise widely acceptable and which will help to improve and develop the Health Service.
So many points have been made that it is hard not to repeat. I very much support the provisions to extend the services provided by local authorities, the provisions of Clauses 10 to 13, and the chance to widen the spheres of activity of midwives, district nurses, health visitors, and so on. This work is extremely valuable and I hope that it can be extended as much as possible.
What is to be the position of the domestic help service in Edinburgh under this legislation? The Under-Secretary will not have missed the correspondence in The Scotsman yesterday and today. There is great concern about Edinburgh's services have been frozen at the 1966 levels and about the talk of even a reduction. If the Bill had already been passed, presumably the local health committee would now be breaking the law. I should be glad to know what is to be done about that and how the present situation in Edinburgh can be met. If the position in the cities is serious, getting suitable personnel is likely to be far more difficult in the countryside.
A question to which I have never received a satisfactory answer is why, in certain cases, a relative of a person needing a home help should not be able to do the work for the same remuneration as would be paid to someone from outside. Old people have much understandable pride, particularly when they live in rural areas. They are loath to have a neighbour do the work, for understandable reasons, and I have never understood why a daughter or daughter-in-law should not be able to perform this valuable function and receive the same reward as someone from the outside. It would mean a lot and would seem to be much more fair to the old people.
My hon. Friends have already mentioned health centres and I will content myself with referring to a particularly Scottish matter which has come to my attention. It concerns Clause 20, which provides for the Secretary of State to decide on what terms and conditions pharmaceutical services will be provided in the centres. This is a significant departure from the old arrangements of Section 15 of the National Health Service (Scotland) Act, 1947. The two official bodies consulted have opposed it, having the natural fear that the Secretary of State will be able to have a chemist's shop in every health centre in the land, and it is extremely unlikely that anybody else would be able to compete.
I hope that the Minister will reconsider this, as those whose co-operation he must try to win seem to be so completely against the proposal. I do not believe that it is impossible for him to do so and for agreement and compromise to be reached on this important subject. This bears out what my hon. Friend the Member for Farnham (Mr. Maurice Macmillan) said about consultations at the beginning of the debate. I have here a telegram from the Pharmaceutical Council of Scotland saying that it has not yet had a chance to consult on these measures and that it hopes very much that it will have a chance to do so.
I am grateful for these few extra minutes of grace, and in the brief time allotted to me I should like to add to one point raised by the hon. Member for Liverpool, Garston (Mr. Fortescue). He hoped that the Minister would take up quickly the powers to be granted to him under the Bill to change to the use of adapted motor-cars for disabled people instead of tricycles. I support him in that, although I know that this is a question of open-ended commitments and limited resources, and that it cannot be done overnight. But it is a matter of urgency. To understand this we must try to put ourselves into the position of people who use the tricycles.
At one time I was a motoring correspondent, and I have driven most types of motor cars in the past 20 years. I have never driven anything as diabolical and foul as that type of three-wheeled machine. I should like briefly to give an impression of the further handicaps imposed by using such a machine on a person who is already disabled. First, he is alone. Second, he has a machine with one-wheel drive only—think what that does on ice. Also, since that wheel is the off side rear wheel, when turning a corner one must accelerate a great deal more to turn to the left than to the right.
They are terribly cold and incredibly noisy. Many were recently fitted with safety belts, which involved cutting a hole through the engine casing through which the belt passes. This has allowed noise, draught and fumes to travel through. The safety belt is of the rigid type which does not give the necessary mobility to the disabled user. Inertia belts would be much better.
The petrol tanks hold just under two gallons, which means that the user must ask for 1¾ gallons. There is no gauge to indicate the petrol level. There is a reserve tank, but it is a gravity tank, which means that if there are bad pipe connections it may take up to a minute for the petrol to come through. Think what it means to a disabled person stopped in the middle of traffic through running out of petrol. The vehicles should certainly be fitted with petrol gauges.
To me, the terribly shocking thing about these machines is that although they will reverse one has to turn off the engine, turn another switch into reverse, then start the engine again. It is necessary to keep switching on and off if one is backing in and out of a narrow place and that runs the battery down and it can easily get flat. Disabled people make short journeys, particularly in the winter, and that does not allow their batteries to be charged while running. If they want to get the battery out of the car to charge it, an elaborate panel removal procedure is necessary, except with the recent models which have the battery in the cab, and that also is highly undesirable for technical reasons.
Steering is by tiller, which is very sensitive to road surfaces. Intermediate steering gear cannot be fitted because the inadequate reversing makes it necessary for the vehicle to be able to turn in a very small circle. If there were adequate reversing, the sweep of the tiller would not need to be so extreme and with some gearing the vehicles would not pick up the bump of every matchstick on the road, as they do at present.
A particularly shocking fact is that they are not subject to the M.O.T. testing. I wonder whether this is because there would be an outcry if ordinary garages could review these machines for their road worthiness and become aware of their general characteristic.
Another serious point is that there is only one door. One of the terrors of the users is that if the machine should turn over on to its near side they are, being already disabled, trapped inside. In that inverted position, the three-wheeled car would then have the petrol tank above the hot engine, so the chance of fire would be high.
Although I see the Minister's difficulties and appreciate the costs of transferring from this type of machine to adapted Minis, I urge him that it is a crying and pressing need.
I think that the House will agree that this is largely a Committee stage Bill, but we have had an interesting debate nevertheless, covering a wide range of subjects. The Minister would agree that the strong theme on both sides has been the calls for more information about what some of these Clauses—many of them important ones—mean, and what his intentions are. My hon. Friend the Member for Farnham (Mr. Maurice Macmillan) expressed our general support for the Bill. We will give it a fair wind and wish to assist the Minister in getting it through, but there are many ques- tions which have not yet been fully answered and on which we look for assistance from the Under-Secretary.
I must begin by declaring a secondary interest. As a director of an advertising and public relations firm which does some work for voluntary health insurance in this country, I have a marginal interest in certain aspects of the Bill.
The Minister has removed some of our doubts about his intentions, but this is essentially an enabling Bill of considerable vagueness. Most of the key Clauses seek power to legislate by Order. We do not necessarily complain about that in this context, but we wanted rather more than a declaration of intent. I certainly do not ask for letter of intent, because that might cause difficulties, but where there are doubts about the meaning, they naturally give rise to mistrust and thus to fears.
This is partly why my hon. Friend asked for adequate time between now and Committee. Nobody concerned with health is not involved in the Bill in some way, in some cases very minor. The Minister says that he has had consultations but some of these bodies feel that the consultation has not been adequate and I am sure that he would wish, as would we after we have studied the debate, to have sufficient time for those consultations and to ensure informed discussion in Committee. I hope that he will acknowledge the strength of this plea.
I start on a light-hearted point. One of those gems of draftsmanship which one looks for in miscellaneous provisions Bills is Clause 44—an eminently simple application to the Isles of Scilly. What could be simpler? Yet the Clause reads:
Section 66 of the National Assistance Act 1948 (application to the Isles of Scilly) shall have effect as if the reference to that Act included a reference to this Part of this Act.
That is an example of a very simple matter made difficult to understand by legal terminology. But I must pass on to more serious points.
For reasons which are understood, the Clauses dealing with pay beds are very vague about the Minister's intentions. This vagueness comes out clearly in Clause 1:
If the Minister is satisfied … that it is reasonable so to do he may … to such extent as he may determine …
This gives him very wide powers, and although he has given some indication of his intentions, the meaning of these Clauses is still not entirely clear and we do not know what the future of private practice in the National Health Service is intended to be.
The Minister said that this will mean a better use of pay beds, more flexibility and a better service, and we on this side welcome that, but he must realise that we should consider not only his words and intentions but what is actually in the Bill and will eventually appear on the Statute Book. That is certainly not clear. If this is intended, as I believe, from what the Minister said, to translate into modern terms the original pledge by Mr. Aneurin Bevan when the Health Service was introduced, well and good, but if it should turn out to be an attempt to squeeze out private patients and the doctors who treat them, there will be strenuous opposition to that from this side.
When the Minister intervened in the speech of my hon. and learned Friend the Member for Solihull (Mr. Grieve) he talked about a package deal and I assume that he was referring to his announcement in the House on 31st January in which he referred to the removal of the ceiling on the charges which consultants can make and the rest of the package which appears in the Bill. If this is a package deal, can we assume that there will be no further cut in the number of private beds in National Health Service hospitals? I hope that we may have some reassurance on this point. As the Minister recognised in his speech, it is not only what this House may feel about this matter but it is immensely important that the future of private practice should be cleared up from the point of view of the patients and doctors concerned.
An important Clause is that which concerns the future of the university hospitals and the power to designate them within the regional hospital board structure. The Minister has given good reasons why an experiment along these lines should be conducted, particularly in respect of Nottingham and Southampton. However, the wording of the Clause is extremely vague and might be used to downgrade teaching hospitals in England and Wales. I say that because the procedure in Scotland is different. This might give rise to considerable controversy, but I will not prejudge the case one way or the other. The right hon. Gentleman will appreciate that it would be unwise to take this further than an experiment for a limited period, certainly until we have the advice of the Royal Commission on Medical Education and the report of the study which he has set up into the administrative structure of the Health Service.
The Minister referred to the upsurge of interest in health centres and, although the Bill deals with only specific aspects, it raises the whole question of the future of these centres. If the Minister is seeking more flexibility to experiment and try out different types of health centres so that they will be able to respond more quickly to the wishes of patients—perhaps, as the hon. Member for Huddersfield, West (Mr. Lomas) said, to lock in the concept of the occupation health service through health centres—all well and good. This would be a desirable flexibility and we would welcome it.
I hope that the right hon. Gentleman does not intend to try to impose a rigid structure on health centres, irrespective of local wishes and needs. In other words, I hope that he will not try to do the sort of thing that the Secretary of State for Education and Science has attempted to do in secondary education. By all means let us experiment with health centres, but do not let us impose a rigid mould on doctors, dentists, opticians and pharmacists, irrespective of local needs and wishes. In this connection, the question of opticians was mentioned by my hon. Friend the Member for Wembley, South (Sir R. Russell) and others, but we will be able to deal with that at a later stage in the Bill.
Some misgiving has been expressed by people who are not clear about the Minister's intentions in the Clauses dealing with the purchase and supply of goods, in particular Clauses 23, 62, 29 and 30. These Clauses appear to give the Minister and executive councils considerable powers to purchase or manufacture, produce, store and supply goods to local health authorities, doctors, dentists, chemists and opticians. If this is intended to gain the advantage of bulk contracts and the pooling of resources, well and good and we welcome it. But, as the right hon. Gentleman will know, there are fears that this could be an attempt, not necessarily by the right hon. Gentleman, to nationalise the tools of the medical trade and the pharmaceutical industry—to, so to speak, introduce certain aspects of Sainsbury by the side door. I hope that the Minister will comment on the intention of these Clauses.
A number of hon. Members have referred to the Clause dealing with vehicles for the disabled. In this provision the Minister is taking specific powers to provide cars, rather than invalid tricycles, to the civilian disabled. I appreciate the financial difficulties, but I hope that he will tell us more about the way in which these powers may be used. I hope, from the remarks made today, that he will have another look at the Clause to see whether he has sufficient powers—not to extend beyond the financial resources which are available at present but to deal with some of the comparatively small and inexpensive items which have been mentioned. I suspect that he does not have power in the Bill to make provision for, for example, people who convert their own cars to hand controls. This sort of matter could be dealt with even in the present financial difficulties. I hope that he has this power but, if he does not, I trust that he will take another look at the Clause.
These are some of the main questions, doubts and fears which we have about the Bill. We do not want to make difficulties for the right hon. Gentleman, but I am sure that the Government will realise that this is an enabling Measure and that it is the job of the House to discover more than we know about the right hon. Gentleman's intentions and the objects of the Bill. If we can get a better understanding of those we will co-operate in every way we can to hasten the Bill on to the Statute Book.
I propose, now, in the short time which remains to me, to do as the Minister did in his opening speech and look at the Bill in the broad context of the National Health Service and other health services generally. The right hon. Gentleman gave a very interesting figure when he opened the debate, one about which we do not think anything like enough. He said that about 1¼ million people have some contact with the National Health Service every single working day. This is a striking figure, and it shows that tonight we are speaking about one of our major consumer industries.
There is always a danger for people in politics to think of this subject from the point of view of the Ministry of Health, the Scottish Office, the doctor, the medical profession generally, and perhaps not so much from the point of view of the patient. The figure given by the Minister shows the importance of this, and the hon. Member for Huddersfield, West put it another way when he said that the National Health Service was the fifth largest employer in the country. This emphasises the importance of the doctor, the nurse, the technician, and the other staff.
I think that in that context it is encouraging to find signs that people are now prepared to ask—and they have been asked during this debate—some basic questions about the National Health Service. We have got away from the stage when anybody who dared to discuss the Service, or the possibility of reform, was automatically accused of wanting to wreck it. We have moved away from the days when people used to say, "We have the finest National Health Service in the world. Do not touch it."
We are prepared now to recognise that if our Service is to remain good, and, above all, if it is to meet the new demands which are growing up all the time, we have to overcome the weaknesses, and build on the good things which exist. The Bill is of course intending that, and in addition we have the Royal Commission on Medical Education, the Seebohm Committee looking at the personal social services, and the Minister's own Committee looking at the tripartite structure. All these things should help us to get out of the rigid mould in which our thinking has been for far too long, and to consider the best ways in which we can reform and strengthen the Service that we have.
What are the weaknesses? I make my comments having looked for three weeks recently at the Australian services, which are a complete contrast to ours. The three weaknesses in our system are, first, the overwhelming dependence on one source of finance, namely, resources provided by the taxpayer. I am certain that the Minister, when he goes to the Treasury for these estimates each year—and over 80 per cent. of that comes from the Treasury—knows what I mean, even though he may not be prepared to admit it. The second is the over-centralised administrative structure which has grown up over the years. The third, perhaps leading from those two, is that the Service is not sufficiently responsive to the needs and wishes of patients, and to the reasonable aspirations of the staff. All this is in contrast to the Australian service.
In Australia about half the money comes from various private sources—voluntary health insurance, third-party motor insurance, charges of various kinds charitable contributions, and lotteries. As a result, the Australians are spending a bigger proportion of their gross national product on health than we are. I recognise that these international comparisons are not necessarily accurate, but there is a gap of about 1 per cent. or more.
It is at least worth studying why they appear to be spending more than we are. My assessment would be that we should. at any rate, encourage some or all of these in this country, if we are to get the extra money we need, to take full advantage of the new medical techniques which are coming along, to meet the demands for rising standards, and to provide the sort of services which people want—in other words, that public and private enterprise can work together in the sphere of health to their mutual advantage.
Secondly, administrative structure. The hospital services in Australia are run by the States, and I suppose the population of the largest State is roughly similar to that covered by a regional hospital board. One of the things which I found interesting was that in the two larger States—Victoria and New South Wales—the hospital services are not run direcdy by the State Government, but by a hospital commission. There are some interesting features here, but what appears to happen is that there are speedier decisions on policy matters and, above all, there appears to be much quicker action on hospital building. The time that it takes to get a hospital plan off the drawing board and into bricks and mortar on the ground appears to be very much faster than in this country. One cannot draw too many conclusions from a short visit, but I believe that the decentralisation of their structure gives them flexibility, a chance to experiment, and, above all, perhaps responsibility and decision making nearer the grass roots than we have.
When one looks at the very great cost of our service and the need to have incentives to efficiency, one realises the importance of trying to decentralise. One has only to look at some of the figures—for example, the figures produced by the Office of Health Economics when it examined the efficiency of the hospital service—to see the very large gap that there is between the average cost per patient per week in different parts of the country. For example, acute, non-teaching hospitals: the North-West Metropolitan Region, £77 17s.; the Manchester region, £60 4s. There may be an explanation for some difference, but surely it is difficult to explain a discrepancy as large as that. That is one figure which suggests to me that there is great room for incentives to efficiency within this very large and expensive service.
In this connection the point that my hon. Friend the Member for Farnham was making about a specialist committee, supported by my right hon. Friend the Member for Reigate (Sir J. Vaughan Morgan) and also mentioned by hon. Gentlemen opposite, is well worth discussion. One of the problems in the health service—and it does not only apply to the health service—is that when this Bill is on the Statute Book it will be exceedingly difficult for any hon. Member of this House to see just how it is working in practice. We get a very good chance, while the Bill is going through, of having our say—we are having it today and we shall be having it in Committee—but when this Bill is on the Statute Book it is very difficult for the back-bench Member on either side of the House to be able to follow it up, so here a specialist committee would be of very great value.
Finally, I want to make a brief comment about the local authority health services which have been mentioned by many hon. Members on both sides. Here, again, we welcome the proposals relating to midwives, health visitors, nurses, home helps, and the proposals concerning the welfare of the elderly and the handicapped. They are admirable. They all, of course, need money—this is the snag. But these Clauses underline the need for a much clearer picture of the problem than we have at the present moment. We hope that Seebohm will help us towards that and will point the way towards a service which is not so much geared to symptoms, as our local health services are, but much more to the needs of the individual and the family.
These Clauses also show clearly how closely associated are cash and care. These Clauses deal with the care side. Through these those particularly difficult problems in regard to low income families and wage-stop families can in some way be assisted. This, I hope, will be one of the broad aspects of these Clauses which will be of value in getting a more unified service.
We welcome the general principles of this Bill. We will do all we can to help its passage, but we hope that in the Government reply we shall have more specific information on the points which have been raised in this debate.
From the hon. Member for Somerset, North (Mr. Dean) we have had a very agreeable and thoughtful speech. I am not sure that I agree with all the points he made in his analysis of present deficiencies in the Health Service, but I very much agree that, whether in a Specialist Committee of this House or in any other way, it would be useful to debate more often some of these fundamental factors affecting the progress of the Health Service.
I also add a word of greeting to the hon. Member for Farnham (Mr. Maurice Macmillan), because I think that this is the first opportunity he has had to speak from the Opposition Front Bench in a Health Service debate. We had an agreeable and thoughtful speech from the hon. Member at the beginning of the debate.
The Bill has been generally welcomed in all parts of the House. Naturally, the Government are very encouraged by that. Although it is not a major Bill, and many of the points raised today will be more satisfactorily dealt with in the detail we can go into in Committee, the fact that there has been a general welcome to the Bill must be partly because there is general satisfaction with the Health Service.
I emphasise the point made by my right hon. Friend in opening the debate that the natural tendency is always to give publicity to deficiencies and crises which we have from time to time in particular aspects of the Service and to forget the tremendous amount of very satisfactory day-to-day work done all the time, and, in particular, the very considerable devotion which the various people involved in the Service bring to their daily tasks.
I said that this is not a major Bill. Naturally, a great deal of the debate has been taken up in anticipating or giving some indication of what hon. Members think might follow from the administrative reorganisation study which my right hon. Friend in England and Wales and the Secretary of State for Scotland are carrying out at present. I take very much the point made by a number of hon. Members, including the hon. Member for Cheadle (Dr. Winstanley), that one of our great problems is how to use the resources we have most effectively.
That involves questions of administrative structure. It is very much easier to formulate the general principle that we must use our resources effectively and to say that there should be more co-ordination and integration in the Service than to find the exact form of adminitrative structure that would produce the results which hon. Members in all parts of the House want to see produced. There are some extremely difficult problems involved and these we are studying in the light of 20 years experience of the Service. The Government will be producing, not final cut-and-dried proposals, but tentative proposals on which we shall welcome the comments of all interested parties, including hon. Members.
The hon. Member for Farnham, speaking of the question of integration and using resources most effectively, mentioned geriatric care. This is one of the obvious fields where better integration and co-ordination of services could pay very considerable dividends. The Bill, in the additional responsibilities it places upon local health authorities, goes some way towards producing a more effective use of resources.
There are considerable difficulties involved. In particular, we must bear in mind always the needs and feelings of individual patients. It is not just a question of getting the full range of different types of facility available—domiciliary services. sheltered housing, local authority welfare accommodation, hospital accommodation, and so on—and then fitting people into the appropriate place and shifting them about when their state of health and their general condition change, as they inevitably do in old age. In all this regard must be paid to the individual personality of the patient.
Sometimes when we see obvious cases of patients being misplaced, we should bear in mind that, although a misplacement might be uneconomic or inefficient from the Health Service point of view, it is not necessarily the most humane treatment of an individual patient to try to fit him into a neat little category. This is the kind of problem we have in geriatrics in particular. We have it in mental health. We have other problems of co-ordination in, for example, maternity services. Therefore, these are not problems simply of administration. At the end of the day I do not think that we shall produce a neat administrative pattern and expect it to work unless we always take account of the needs of individual patients.
To turn to a question very much concerned with the structure of the Service, I would make it clear that there is no question, as some hon. Members opposite have suggested, of imposing health centres on a reluctant medical profession. It is rather the other way round now. The general practitioner, having become recently converted to the idea of practising from health centres, is now frustrated because he feels that the Government and local health authorities are not providing the money sufficiently quickly. The expansion of health centres is going on very rapidly. My right hon. Friend mentioned some of the progress which has already been made in England and Wales. We can show similar progress in Scotland.
In all this we are dealing with a co-operative effort. The general practitioners, local health authorities, and the hospital authorities, which are involved in this development, are co-operating together. There is no question of imposing this as a rigid pattern on reluctant partners in the Health Service.
These are some of the general points which I thought I ought to mention by way of introduction. I want now for a few minutes to say something about the Scottish aspects of the Bill.
I have said that this is a co-operative and voluntary effort. I am not absolutely clear about what the hon. Gentleman has in mind. There is no question of coercing local health authorities.
I was saying that I should like to say just a few words from the Scottish point of view, because this is a rather complicated Bill with English and Welsh Clauses, Scottish Clauses, Scottish application of English Clauses, United Kingdom Clauses and the rest, and, clearly, it will be very difficult for some of us to follow some of these particular points in Committee.
I do want to draw attention to the fact that in Clause 14 we are introducing, what was welcomed by my hon. Friend the Member for Aberdeen, South (Mr. Dewar), provision for local authorities of family planning powers similar to those which were introduced in the Private Member's National Health Service (Family Planning) Bill which was introduced last Session. At the time when that Bill went through my right hon. Friend the Secretary of State for Scotland said that if a similar Private Member's Bill were introduced to apply to Scotland he would give sympathetic consideration to it, but we have in fact been able to do rather better than that and to introduce those provisions in this Bill.
Another Scottish Clause I should like just to mention very briefly is Clause 39 which gives extended powers to executive councils in the more remote areas of Scotland in the provision of residential accommodation for medical practitioners. The extension enables them to provide surgeries separate from the doctors' houses and in some cases allows joint surgeries which might also be used by district nurses. I mention this because the recent Birsay Committee, which reported on medical services in the Highlands and Islands, made this one of its recommendations.
The public health provisions in the Bill—and this is the only other Scottish provision I want to mention—by and large do not apply to Scotland, although we are taking one or two provisions which we need immediately, because we are to have a complete reappraisal of our public health legislation with a view later to introducing a consolidating Measure which will bring the law up to date.
There were a very considerable number of detailed points raised today and I should like to deal with one or two of them; obviously in the time available it will not be possible to deal with every point which was raised.
If I may start at the beginning and say something about Clauses 1 and 2 and the provisions about pay-beds, I think that my right hon. Friend made the position absolutely clear in his opening speech, when he referred to the results of his review of pay-beds, which were announced in answer to a Question on 6th November. That review showed a reduction in the number of pay-beds, but it did not affect the general principle which is, of course, maintained. There is continuing provision for pay-beds in the Health Service structure. It is, of course, true that these are subject to certain restrictions.
I will not, at this point, go over them in any detail, because this is the sort of thing which we shall be able to consider in Committee, but the general intention of the new provisions which we are making here is to provide greater flexibility in the use of pay-beds, to get rid of setting them aside so that they really cannot be used for anything else. In all this, of course, we have very much in mind the necessity, the real need, the urgency which takes priority over pay-beds or indeed anything else in the Health Service.
So I think that those on the other side of the House who have looked upon this as a kind of sinister attack on the principle of pay-beds can be reassured; and equally, that hon. Gentlemen on this side, whose fears are rather in the opposite direction, can be assured that the provi- sion for pay-beds is subject to very considerable control by the Minister of Health; and, as I say, this is all subject, of course, to the review, the results of which were announced a month ago.
As for Clause 5——
I really do not have time to give way. I have had to give up a little time so that one of the hon. Member's hon. Friends could make a speech, and I shall not be able to answer all the points. anyway.
As for Clause 5 and university hospitals, again I think that what my right hon. Friend said was absolutely clear on this. I hope the House may forgive me if I do not attempt to put a gloss on what my right hon. Friend said. The House will be aware that in Scotland teaching hospitals are completely integrated in the regional hospital boards set-up. It would, therefore, be a little indelicate and certainly inappropriate if I were to try to explain what the position is in England and go into the meaning of Clause 5 and any influence it might have on the position of teaching hospitals.
Questions have been raised about the domestic help services under Clause 13 and the laundry service referred to there. I can tell the hon. Lady the Member for Birmingham, Edgbaston (Mrs. Knight) that, although the domestic help service is to be made a duty, the laundry service appears in the Clause as the subject of power only, not a duty. I know that my hon. Friend the Member for Falmouth and Camborne (Dr. John Dunwoody) would like the laundry service as well to be made a duty, but we must be realistic here and not impose on local health authorities duties which they are not at present in a position to exercise.
One appreciates that the domestic help service needs considerable expansion. There are difficulties in recruitment and there are difficulties in financial resources, too, but it is right that we should now put this important service on the statutory basis of a duty on local authorities to ensure that they provide a service adequate for their area.
Several questions were raised about opticians. Some of these were rather detailed, among them certain points raised by the hon. Member for Wembley, South (Sir R. Russell), and these can be dealt with in Committee. We shall look carefully at the detailed points which the hon. Gentleman made. There is nothing in the Bill—I am not clear how the misunderstanding arose—which provides that opticians will be forced into health centres or that ordinary private practice in this field is somehow to be squeezed out. There is absolutely no suggestion of that at all in the Bill. On the question of representation on executive councils, the difficulty is that, if we keep adding to the professional representation, we must add to the lay representation also, with the result that we create difficulties in regard to numbers, unwieldy structure, and so on. But this, also, is a point which we can discuss in Committee.
The provisions of Clauses 23, 29, 30 and 62 are matters of no great doctrinaire importance. They simply make practical improvements in the arrangements which we have at present. For example, Clause 23 gives statutory authority to what is done at the moment when executive councils supply disposable sterile syringes to family doctors. There has been some doubt about the legislative basis of this practice, and Clause 23 will put the matter right.
Clause 62 gives power to health departments to supply executive councils with certain things which they may wish to supply to family doctors. This is not likely to be a provision enabling us to nationalise the drug industry, even if that were the Government's intention. The Sainsbury Committee has come out against it. I am not yet in a position to say what we think about the Sainsbury Committee's Report, but, if we were thinking of nationalising the drug industry, I doubt that we should be able to do it by this piece of legislation.
Naturally, a good deal of attention has been directed to Clause 31. The provision of invalid vehicles is a matter in which many hon. Members take a great interest, and there is a feeling in all parts of the House that this is a service which we ought to expand when we are able to do so. Inevitably, the question of priorities comes in here. It is already an expensive service, and it is potentially very much more expensive if we were to go over, on a wholesale basis, to the supply of small cars rather than invalid vehicles.
I know that there are complaints made about invalid vehicles. I do not accept all these complaints, and I certainly do not accept all the criticisms made about the suitability of invalid vehicles. Very many people derive considerable benefit from them and find them satisfactory. But, obviously, if it were possible to make improvements here, the Government would very much like to do it. The Clause gives a statutory basis to some practices which have been going on for a considerable time on a rather artificial or doubtful statutory basis.
In February, 1967, after a considerable study of the implications and the working of the service as a whole, we extended the categories for which motor cars rather than tricycles were available. As my right hon. Friend made clear then, and as I am glad to make clear now, we shall be pleased to make further improvements in the service when resources are available and we can fit them into the other priorities in the Health Service as a whole. It would be premature for me to deal now with individual categories. One has considerable sympathy for haemophiliacs, who have been mentioned.
Reference has been made to disabled housewives who are excluded from the third category of people who qualify for invalid vehicles on the ground that they are not in full-time employment. There are many categories in which one would like to see improvements made. All I can promise is that we shall make improvements as resources permit. I know that that is something which the House very much wants us to do.
The Clauses on the welfare of old people have been very much welcomed. They fill a gap in the statutory provision. They will not be simply a paper provision, but will make a considerable improvement in the welfare facilities which local health authorities are able to offer to old people. This is very much bound up with the points made by a number of hon. Members involving hospital provision for geriatric and psycho-geriatric patients. This is a field in which co-ordination is obviously potentially very profitable.
Clause 57, on child minders, was referred to particularly by my hon. Friends the Members for Wolverhampton, North-East (Mrs. Renée Short) and Eton and Slough (Miss Lestor). I know the considerable interest which they take in this subject. It is true that the Clause is no substitute for nursery education; we do not pretend that it is. I am well aware of the recommendations of the Plowden Committee. But, again, the question of priorities comes into the picture.
The Secretary of State for Education and Science and we in Scotland have made it clear that this is not a field to which we feel we can give first priority, although it is slightly inaccurate for my hon. Friend the Member for Eton and Slough to say that the provision for making nursery education available to pre-school children of married women returning to teaching is for the benefit of the parents rather than of the children. It is for the benefit of the children in school, which is extremely important at this time when we have such a shortage of teachers.
My hon. Friend the Member for Wolverhampton, North-East was rather sceptical about some of the control which local authorities have, about the inadequacy of the premises and staff, feeding arrangements, and so on. But these are all matters specifically mentioned in the Clause. I take the point about the need for inspection and for staff at local health authority level, but I am sure that the Clause will considerably improve the position.
These were some of the main points raised in the debate. I have not dealt with the many minor points, and some of them quite important, with which we can deal in Committee. I am glad that the Bill has had a general welcome and that it is looked upon as a useful Measure. No doubt it can be improved during the Committee stage, to which we look forward. I commend the Bill to the House.