695

FUND FOR TUBERCULOUS WOMENMr. W. H. TOWNSEND, of the Margaret de Sousa Deiro

Fund, writes :This Fund exists for the treatment and relief of women

who, normally supporting themselves by their own exertions,are temporarily incapacitated by pulmonary tuberculosis.There are grants to cover the cost of treatment, when thiscannot be carried out in suitable conditions under the NationalHealth Service, and grants towards convalescent holidaysfollowing institutional treatment. In approved cases thetrustees also give financial assistance for rehabilitation, whenpart-time work yields an inadequate living wage. By itsconstitution the Fund cannot assist chronic cases where thereis no prospect of return to employment. Further informationcan be obtained from the trustees at 1, New Court, CareyStreet, Lincoln’s Inn, London, W.C.2.

Parliament

The Guillebaud ReportMr. R. H. TURTON, the Minister of Health, in opening

on May 7 a debate on the Guillebaud report describedit as a " welcome vindication of the .National HealthService as it now exists." The report made clear thateconomy and efficiency had increased since the servicebegan in 1948. Thus in real terms the increase in thegross cost of the service between 1949 and 1954 was small- only JE30 million out of a total of £400 million-and during these vears the service had been substantiallyimproved and extended.Perhaps the greatest problem of the service, he

continued, was the tripartite division of the administrativestructure ; and the committee agreed that cooperationbetween the different branches of the service, and evenwithin them, had not yet been fully attained. TheGovernment, Mr. Turton said, accepted that there shouldnot at this time be anv transfer to other authoritiesof responsibility for hospital or general-practitionerservices; any creation of new central or local ad-hocauthorities as the recipients of particular functions ;any changes in regional-hospital-buard areas or in theirmethods of appointment, or any transfer to those boardsof responsibility for teaching hospitals in England andWales, or any transfer of dental-clinic services from localauthorities to the central health departments. The

acceptance of these broad principles did not, however,cover the whole ground; and it was indeed dependent oncertain minor adjustments of practice, if not of organisa-tion. In the hospital service, for instance, the committeehad suggested that it should be made clear that theregional hospital boards were responsible for exercisinga general oversight and supervision over the adnlinistra-tion of the hospital service in their region. The Govern-ment accepted this principle, but Mr. Turton wished tomake it clear that this did not mean that the -It.1l.B.S

should set the H.M.C.S (or for that matter the Ministerthe R.H.B.) in a strait-jacket of prior approvals. The

conception was rather one of review—and, if necessary,rebuke-after the event, and not of reference upwardsbeforehand.

It was in the home health and preventive services,Mr. Turton thought, that the tripartite administrativestructure raised must problems, and our first objectivemust be " to place at the disposal of the patient inhis home, equally with the patient in hospital a

coordinated team acting under the clinical guidanceof his personal medical attendant." This would call forthe closest cooperation between the general practitionersand the local health authorities. It should be the aim ofthe home team, which must include welfare as well ashealth workers, to keep out of hospital, including mentalhospitals, all patients who could equally well be treatedat home. In his view health and welfare were so closelylinked that in the domiciliary field at least they ought tobe administered as one.Turning to finance Mr. Turton recalled that the

Guillebaud Committee had suggested £30 million a

year as a desirable rate of capital expenditure for thehospitalservice for the coming seven years. The programmefor hospital building announced last year, providing£17½ million for new major projects and £13 millionfor capital expenditure, was a major step in the directionproposed by the committee. It would not be affected

by the cuts in capital expenditure. The committee’srecommendation that charges for dental treatmentand spectacles should be reduced raised the questionof priorities between the different parts of the serviceand must be reserved for further study.However the service was organised, Mr. Turton

concluded, so long as unlimited financial resources werenot available, questions of priority would arise. In hisown mind the three needs which could claim precedencewere hospital accommodation, the mental-health services,and old people.

Dr. EDITH SUMMERSKILL agreed with the committeeand the Minister that no major administrative changesshould be made in the service anyhow at this stage.The proposal to restore certain kinds of hospitals to thelocal health authorities would, in her view, be a retro-grade step because it would establish a central and alocal hospital authority. She would like to see closercollaboration between the local authorities and thegeneral-practitioner service. The conditions of serviceof the practitioner should bear a closer resemblance tothose of the medical officer of health. The salariedmedical officer’s approach to medicine, with the emphasison prevention, had been dissimilar to that of the generalpractitioner occupied with the curative side. Unfortun-ately the N.H.S. still made the doctor dependent onfees-there were still capitation fees-and that gapbetween these two doctors, working in two differentmedical worlds, was unfortunately not made smaller.The time was coming when we must consider the bestmeans of remunerating the general practitioner.

She was disappointed that the Minister had notaccepted any of the financial recommendations of thecommittee. 45 % of our hospitals were built before 1891.The capital expenditure on hospitals was three timesas high in 1938-39 as it was in 1952-53. The teachinghospitals, she thought, should be integrated with theregional hospital boards. It was an anachronism forthem to be autonomous. The splendid isolation of theteaching hospitals tended to introduce a snob elementinto the health service which militated against coöpera-tion and the closing of the human gap.The shilling prescription charge was, she held,

unjustifiable. It had reduced our huge medicine billof B46 million by £24 million. It deterred not the hypo-chondriacs or the better off but the poorest in the com-munity who should have no financial barrier betweenthem and the doctor. With the expensive high-pressuresalesmanship of the drug houses, was it any wonder thatthe Minister had to keep on asking for more moneyfor proprietary drugs ? She found it difficult to reconcilethe colossal sum spent on drugs, and the Minister’sweak attitude towards it, with the decision to cut themilk-supplies to the under-5s in the nursery.

Sir FREDERICK MESSER regretted that the Guillebaudreport had not said more about preventive service.In his view it was worth considering whether thematernity and child-welfare services and domiciliaryservices should not be transferred from the countycouncils to the large boroughs. Mr. JOHN BAIRDsuggested that, in considering priorities, we shouldremember that the N.H.S. was in fact a money-savingservice. Sir HUGH LINSTEAD believed that doctorsdid not need Ministerial protection against the advertisingmethods of the drug firms.

Colonel MALCOLM STODDART-SCOTT thought that theGuillebaud report confirmed that the N.H.S. wouldbecome in the very near future the first priority of oursocial services. He besought the Minister to persuadethe Cabinet to spend no less than £50 million a yearfor the next five years or so on building and modernisinghospitals. He regretted that the Guillebaud reportremained so silent on the needs of mental health andof preventive health and said nothing at all about thedevelopment of the industrial health service. In hisopinion there should be one national health serviceboth for industry and for the civil population.

Mr. ARTHUR BLENKINSOP had been impressed byProfessor Titmuss and Mr. Abel-Smith’s financial survey.What hope was there, he asked, of the regular productionfor the public of information about how the health servicewas going ? As the Guillebaud report showed, the servicewas not extravagantly run, and he thought that everyonehad been influenced to some extent by the aura ofunfounded charges. The Minister, he thought, had little

696

reason to be proud of estimates for the present financialyear. True, another £12 million was provided for hospitalboards, an increase of about 4%, but a little over

£7 million of that would go to meet wage-claims and risingfood costs. Precious little improvement of the servicewould be available out of the extra money.

Training of Mental-health WorkersRaising this subject in the House of Commons on

April 30, Mr. KENNETH ROBINSON said that ideally thefuture of the mental-health services lay not so much inhaving more and more beds as in emptying the mentalhospitals and in preventing people from having to beadmitted to them. This could only be achieved byextending and improving outpatient facilities and com-munity and domiciliary services. The local healthauthorities were responsible for these latter services, andtheir instruments in carrying out these duties were themental-welfare officers and the psychiatric social workers.He thought it odd that though both carried out highlyresponsible duties the P.S.W.S were highly trained and theofficers not trained at all.

In 1951 the Mackintosh Committee recommended thatthere should be a substantial increase in the number ofP.S.W.s and pointed out that the mental-health servicedemanded a large number of trained mental-welfareofficers. These officers were responsible for preventionand aftercare among mental patients and perhaps theirmost important work was done in their capacity as dulyauthorised officers. The duly authorised officer ofteninitiated the whole procedure of certification, and hemight indeed be the first contact between the membersof the public and the mental-health service. He could,and often did, override the opinions of general practi-tioners on patients suffering from mental disorder. Onewould imagine that these officers would undergo a

rigorous and extensive course of training and obtain somekind of national qualification, but nothing of the kindhappened. The Minister of Health in reply to a questionhad admitted that there was no national scheme oftraining, though some local authorities arranged courses.The Minister had added that the position was beingstudied by a working party. But immediately after theissue of the Mackintosh report, Mr. Robinson recalled,an ad-hoc committee was formed, with representativesfrom the universities, the Royal Medico-PsychologicalAssociation, the National Association for Mental Health,and the Society of Mental Welfare Officers. They hadsubmitted proposals about training to the Minister in1952. After 18 months the Minister wrote saying thatthe question could not be considered until the WorkingParty on Health Visitors, under Sir Wilson Jameson, hadreported. The mental officers themselves appreciatedthat their increasing responsibility demanded a highstandard of competence, national training, and qualifi-cation, especially for new entrants into the service.Some months after the receipt of the Minister’s letter

the various bodies worked out an actual syllabus for ayear’s course. The National Association for MentalHealth agreed to organise a scheme and a furtherapproach was made to the Minister with the samenegative result. Now, when the Jameson Working Partywas almost ready to report, the bodies concerned wereasked to await the findings of yet another committee,the Younghusband Committee on social workers, whichmeant a further delay of anything up to two years.

Turning to the psychiatric social workers, Mr. Robinsonsaid that for them there was an established training of ahigh quality, but there were not enough training facilitiesand not nearly a large enough output. In its recentreport the Committee on Maladjusted Children estimatedthat for a satisfactory child-guidance service alone fourtimes as many P.s.w.s were needed-420 instead of thepresent 109 ; hospital authorities also needed more, forvacancies existed in every mental hospital. There wasthus an acute shortage of these workers and the trainingwas stiff. In his view the salary range of £495-750 p.a.was not sufficient incentive for the right kind of people.

Miss PATRICIA HORNSBY-SMITH, parliamentary secre-tary to the Ministry of Health, said there were 1100mental-welfare officers in the local health authorityservices. Many had considerable experience from thedays when the local authorities ran their own mental

hospitals, and it should not be suggested that theywere not doing their job satisfactorily. The advice ofthose who had had long experience was available to new-comers. Many local authorities were providing trainingcourses, some at universities and some within their ownorganisation, including secondment to a mental hospital.She realised, however, that more courses were neededand she appreciated that the professional associationsrepresenting welfare officers felt strongly that thereshould be a properly recognised training.The Mackintosh Committee were set up before the new

pattern in the mental health service evolved. By theirterms of reference they necessarily considered mental-health workers in isolation. But barriers between themental and the physical health services were breakingdown and we no longer regarded mental-health work ina vacuum. It might well be that from the reviews ofthe Working Parties on Health Visitors and SocialWorkers there would emerge a new concept of socialwelfare workers and the kind of training suitable for them.

Another report which the Government could notignore in plans for mental-health work was that of theRoyal Commission on the Law Relating to Mental Illnessand Mental Deficiency (now sitting).

She sympathised with welfare officers who had waitedso long and patiently,ebut while it was essential that theyshould be properly fitted to discharge their functions shedid not agree that social work for the mentally ill couldnever be combined with work for those who were indifficulties in other ways. Sometimes it might be anadvantage in obtaining the cooperation of a family if thetrained worker came to them as a welfare visitor and notexclusively as a mental-welfare worker. There was alsoan advantage in the hospital p.s.w. having a wider sphereof activity, since he was the link between the patientand his home and friends and the medical and nursingstaff of the hospital or clinic. These workers took atwo-year social science course at a university, followedby a vear’s practical experience, and then a universitymental-health course. The Minister assisted with grantsfor the university mental-health course. Since 1949-50the grant had been £8000 and the average yearly intake ofstudents for these courses was about 50. She did not

deny that there was a shortage of these workers, butestimates of the number needed varied from 870 to 1500.According to the Association of Psychiatric Social Workersthe number of qualified workers was 447, but that didnot include many local-authority workers who, thoughthey had not taken the recent specialised training, werequalified by long experience. Similarly hospital returnsshowed that they had 311 whole-time workers of whomonly 182 were included in the association’s estimate.The Government did not believe that greater numbers ofstudents would automatically be forthcoming if morecourses were provided or if tlie scale of the Governmentcontribution were increased.

QUESTION TIMESmoking and Lung Cancer

Mr. J. K. VAUGHAN-MORGAN asked the Minister of Healthwhether he was now in a position to make a public statementas to the effect of smoking in producing carcinoma of thelung.—Mr. R. H. TURTON replied : Since my predecessor madea statement in February, 19i3-l, investigations into the possibleconnection of smoking and cancer of the lung have beenproceeding in this and other countries. Two known cancer-

producing agents have been identified in tobacco smoke,but whether they have a direct rôle in producing lung cancer,and if so what, has not been proved. The extent of the problemshould be neither minimised nor exaggerated. The number ofdeaths from cancer of the lung has risen from 2286 in 1931to 17,271 last year. To place the figures in perspective-in 1954, out of every 1000 deaths of men aged between 45 and74, 77 were from bronchitis, 112 were from strokes andapoplexies, and 234 were from cancer, of which 85 were cancerof the lung. Deaths of women from cancer of the lung arestill not very significant and represent a small fraction of thetotal.The chairman of a committee of the Medical Research

Council which has been investigating the subject considersthat the fact that a causal agent has not yet been recognisedshould not be allowed to obscure the fact that there is,statistically, an incontrovertible association between cigarette-smoking and the incidence of lung cancer. The statistical

697

evidence from this and other countries to which he referstends to show that mortality from cancer of the lung is

twenty times greater amongst heavy smokers than amongstnon-smokers. The Government will take such steps as

are necessary to ensure that the public are kept informedof all the relevant information as and when it becomesavailable.Mr. W. D. CHAPMAN : While thanking the Minister for

at last saying something very forthright on this issue, mayI first ask him what line of action he will take to informthe public about this danger ? Has ho in mind somethingas widespread as the campaign against diphtheria and infavour of diphtheria immunisation ; and secondly, will he

give us an assurance that the Government will take theinitiative in such a campaign and will not leave it simplyto the local authorities to do so if they wish ?—Mr. TURTON:

In my view, in the present stage of our knowledge, a nationalpublicity campaign would not be appropriate.Mr. VAUGHAN-MORGAN: Is there any evidence, particularly

with regard to pipe-smoking ; secondly, is there any evidencefrom the statistics as to how those who give up smoking areaffected ?-Mr. TURTON: It would appear that pipe-smokersface a heavier risk than non-smokers, but the risk is sub-

stantially less than that incurred by heavy cigarette-smokers.There is some evidence that the risk of contracting cancerof the lung decreases when smoking is given up.

Dr. EDITH SUMMERSKILL: In view of the fact that theMinister for the first time is informing the country that tobaccosmoke has certain carcinogenic properties and has made anemphatic statement, would lie not agree that it was ratherunfortunate that this statement came after the statement

by eminent authorities on the radio and on television ?I understand that a film was even shown in this buildinglast week. Is it not unfortunate that the -Iliiiister’s statementshould follow these statements and not precede them, andin view of the gravity of the present statement, will lie saywhy he will not give us a periodic review of the situation ’-Mr. TuRTON: Whenever any more knowledge be(,oines

available, I shall deem it my duty to put it before the Houseat once. That is what I have done in this case, but I mustfirst of all see what has been the increase in knowledge sincethe last statement made. I did tell the 1-fou-,(- some time agothat two cancer-producing substances had been identifiedin tobacco smoke.Dr. BARNETT STROss : Will the Minister agree that there

is now at least ample evidence to suggest that lie shouldconsult the Minister of Education and that all efforts shouldbe made to bring this knowledge before school-leavers,boys and girls, in order tliat they at least may have some

warning as to what may be the result of becoming as addictedto this habit, as so many of us are ‘! Mr. TURTON: I have

given my decision regarding a national publicity campaign., Any matter regarding what is done by the Minister of Educa-

tion should be addressed tu him. Mr. ARTHUR BLENKINSOP:

Surely the Minister will review his statement with regard to, a national campaign ? Is it not highly important that any

information that may become available should be reviewedfrom time to time ?—Mr. TURTON: I quite agree. I certainlyshall review it.

Housing of the Elderly

Replying to a question, Mr. DUCAN SANDYS, Minister ofHousing and Local Government, said that lie had decided toinquire into the arrangements that were being made for hous-ing elderly persons. His object was to see whether, havingregard to the requirements of other sections of the popula-tion, old people wore receiving a reasonable share of theaccommodation provided and whether this was of the kind bestsuited to their physical needs and financial circumstances.Accordingly, he proposed to ask all local authorities andcertain voluntary organisations to send him particulars ofwhat they had done to deal with- this problem. While thisinformation was being collected a qualified oflicial of theMinistry would go and see schemes of various kinds in differentparts of the country and make a report to him upon them.He also intended to seek the views of the Central HousingAdvisory Committee. The problem of housing elderly peoplewas in many respects connected with that of providing for theirhealth and welfare. His inquiries would therefore naturallybe carried out in close collaboration with the Minister ofHealth.

Recruitment of Mental Nurses

Replying to a question, Mr. TURTON, Minister of

Health, said that the basic allowances of new entrant

student mental nurses under twenty-one were being increasedby amounts varying from JE20 to 45 and of those over twenty-one by amounts varying from 80 to n 10 per year. Thediscontinuance of dependants’ allowances would howevermean that student mental nurses with a wife and one childwould have these increases reduced by 72 16s. a year.

Replying to a further question, Miss HORNSBY-SMITH saidthat the numbers of new entrants of male student nurses inmental deficiency were in 1954, 140, and in 1955, 133 ; thenumbers of readmissions were 34 and 25 respectively. Thenumbers leaving while still students were in 1954, 174, andin 1955, 121.

Nurses in Scottish Mental HospitalsReplying to a question, Mr. JAMES STUART said that at

Sept. 30, 1955, the ratio of nurses to patients was less than1 to 5 in twelve of Scotland’s twenty-nine mental hospitals,accommodating 42% of all patients in mental hospitals.At the same date this ratio was less than 1 to 6 in two of thetwelve mental-deficiency institutions, accommodating 18%of all patients in such institutions.

Colour of Milk Bottles

Replying to a question asking what consideration had beengiven to the deterioration of milk by the use of clear glassbottles, particularly when exposed to light and sun for longperiods, Mr. HEATHCOAT AMORY, Minister of Agriculture,Fisheries, and Food, said that there were no regulations aboutthe colour of milk bottles. The matter had been considered

by the Milk and Milk Products Technical Advisory Committee,and they had expressed the view, which he had accepted,that there were no adequate grounds for regulations.

Replying to further questions, Mr. Amory said he thoughtthat it was true that milk retained its high food value betterin coloured than in clear glass bottles. Milk could retain itsriboflavine andvitamin-C content better, both of which sufferedfrom long exposure to the sun. But there were practicalconsiderations which made it difficult to deal with the matter

by regulation. One of the considerations in the minds of the

advisory committee was that with clear glass bottles purchaserscould see more readily whether the milk was relatively cleanor not.

Public Health

School Milk

CHANGES in the milk-in-schools scheme are announced.From Sept. 1 free milk will be available for school-children only during term-time, and the limited arrange-ments for supplying milk at weekends and during theholidays will cease. Children in nursery schools nowreceive 2/3 pint daily, and those in nursery classes receive1/3 pint. From Sept. 1 all children will receive 1/3 pint,with the exception of delicate children attending specialschools who may be given 2/3 pint. A saving of about;E 125,000 a year is expected.

In a circular to local education authorities the Ministryof Education asks that special care be taken in theordering of milk, pointing out that the excessive pur-chasing of only 4 bottles in every 100 would involvethe Exchequer in an extra expenditure of about £500,000a year. The amount of milk ordered should be basedon the number of pupils taking milk regularly, allowingfor the usual rate of absences.

From Sept. 1 local education authorities will be respon-sible for supplying milk to pupils in non-maintainedschools as well as maintained schools. The terms underwhich local education authorities supply milk to non-

maintained schools will be determined by agreement betweenthe authority and the proprietor of the school, and shouldinclude provision by the proprietor of such information aboutordering and consumption as the authority may require.The terms should also include a stipulation that no paymentshould be made by parents for milk supplied.

Slum Clearance

Speaking at Stoke-on-Trent on May 4, Mr. DuncanSandys, Minister of Housing and Local Government, saidthat during last year, some 25,000 slum houses were