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Socialist Medical Association

The health service and the welfare state

THE HEALTH SERVICE

AND THE

WELFARE STATE

AN S.M.A. PUBLICATION Price 9d.

Written by a medical practitioner who is an active Labour Party member, this pamphlet will greatly assist those who wish to defend and extend the National Health Service. Additional copies available: single copies IHd. including postage; one dozen or more 7s. 6d. a dozen post free; from our distributors, T.T.P. Ltd., 13 Prince of Wales Terrace, London. W.8.

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THOMAS WAKLEY, by Charles Brook, c.b.e.

IS OLD AGE A PROBLEM? . . CHILD EYE CARE . .

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THE HEALTH SERVICE AND THE WELFARE STATE

THERE COMES A TIME when it is expedient to stand back and survey social policies in action, to reconsider the past, or to weigh up the present, or to try to look ahead to the future. At this stage, half-way in the present life of the Conservative Government, it may be worth while to consider the outlook and actions of this Govern- ment in these social fields, and to compare them with the avowed intentions of the Opposition, for it is not unlikely that the Labour Party may form the next Government.

To look at Labour's Social Policy means studying Signposts for the Sixties, its precursor Labour in the Sixties, and also Labour's Policy for Health. The objective of this study is the winning of this next election, and although these documents are not Election Manifestos, yet, their function is related to it.

This sort of survey or study does not mean going into details of these papers, but concerns itself with the basic philosophy of a socialist ethic.

To evaluate the document Signposts for the Sixties we could try to determine it as an Absolute. This is not really practical, and would probably amount to chasing after an illusion. Instead one can attempt to measure it against age-old socialist doctrines and dreams and visions. Or, finally one can treat it relatively, that is to say, one can compare it with any alternative social policies, which means, in practice, a Conservative Social Policy.

If we look at modern Labour's Policy and also consider the last Conference at Blackpool, many of us may look back, with some nostalgia, to the " Good Old Days "... when the author of this pamphlet was young. The " Good Old Days," when social condi- tions were so bad ! Yes, for they were also the days when hearts were filled with a certain hope and glory and joy, when those who worked for the Movement believed passionately and sincerely that, in their lifetime, they were going to end all the poverty and miseries and insecurities.

Yes, these pioneers thought they were going to build a socialist and democratic state, to create almost a Utopia. Furthermore, they believed that, by constitutional means, they would achieve a govern- ment of socialist-minded politicians (all idealists) who would intro- duce legislation and this would, somehow, result in a different and better way of life — more noble, more moral, more satisfying in all ways. All that was needed was a majority in Parliament — the rest would follow. The rest would be easy.

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For example, The Health Service. A very long time ago, now, H. G. Wells wrote about a Society motivated by altruism and selfless- ness and idealism. The first practical step, he asserted, would be a National Health Service in which Medicine would be taken out of the Market-Place. Even in those days, this was the facet of life in which a sense of dedication and service was more manifest than in any other.

Well, to-day, one might be excused for being cynical and saying, " How naive can one be ! "

In 1946 Nye Bevan introduced a Bill, and the appointed day for the inception of The Act was in 1948. In 1950 the Labour Majority in the House was almost ended, and in 1951 a Tory Government came into oflice and has been in power ever since. In other words, this new health service, while still in its infancy was under Labour administration for less than forty months. It has been under the Tories for ten years. It is important to remember this.

For some time now, there has been an interesting manoeuvre going on . . . the Tories boast about the National Health Service as though they created it. At the same time, they undermine it wherever and whenever possible. When certain aspects of the service are criticised, they try to point out that these defects are all part of some- tliing they call socialism. Then they add they are doing their best to put these defects right. Finally, they add for good measure that they were never really in favour of it, and would be glad to get rid of it . . . for your sake, of course !

More than half the nation already believe this claptrap. Maybe more will do so, if the plugging goes on as at present. Now, there is no doubt that the introduction of a comprehensive health service was, in terms of legislation, the greatest socialist measure in our political history. Yet articles in the press, and propaganda in general convey the impression that the many defects are part and parcel of the new service, whereas innumerable wrong things before the introduction of the service still flourish, and the service is accused of having produced these defects ! It is true that one of the weak- nesses of the National Health Service is that it failed to eradicate these evils of the old ways.

One criticism, however, is unjustified. " The service should not have been introduced in the immediate post-war period, when there were so many difficuhies." This is totally a bad attack. It was in accordance with socialist ethic to do what was done. As Nye Bevan himself said, " If there are shortages of the facilities to provide a first-class health service for all, all the more reason was there to introduce it, so as to see that, of what there was, there was a reasonable and fair distribution for all the people."

If we look at the pamphlet Labour's Policy on Health, we find . . . '' Britain's NHS is a practical expression of the ethic which has inspired the Labour Party since its earliest days."

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" High ideals must be translated into practical action."

" Ten years later, the Lancet described the service as one of the

biggest improvements in the life of the country since the war."

" The Times states . . . ' as judged by the health of the nation since its

introduction, the service has been an unquahfied success.' "

The pamphlet then deals with hopes, plans and programmes when returned to office and power. This everyone should read, discuss and advertise everywhere.

Nevertheless, the service is in a poor way in many respects to-day. The pamphlet adds that under Tory rule . . . " Nearly half a million are waiting for hospital beds." " Too many doctors' surgeries are grim and gloomy." " Too many hospitals are still out-of-date and makeshift." " Mental hospitals are overcrowded and dilapidated." " Committees and staff frustrated by endless administrative delays." "THIS IS BECAUSE THE CONSERVATIVES ACCEPTED THE SERVICE AS A MATTER OF EXPEDIENCY RATHER THAN WELCOMING IT AS A HIGH IDEAL."

Nowadays we are told that things have changed and are changing. A commonplace observation is that there is no real difference between "right-wing labour" and "progressive Toryism." There are, indeed, many supporters of the Tory party to-day who sincerely believe they are supporting progressive policies in the light of present realities. But there are others in the Tory party, which has its fellow-travellers also. For example, Tom Driberg has pointed out in Reynolds News a pamphlet called Health Through Choice. Its main theme ..." medical services are not essentially different from any other consumer goods or services; hence, if people can choose between different brands of detergents or margarine there is no reason why people should not be free to buy health services from competing suppliers by paying for them directly or with the aid of private insurance."

For those who cannot afford to pay for good health ? Well, there is National Assistance !

" Major medical expenses," said the pamphlet, " are ideally suited for insurance, because the cost per family, which is so high for the victims, is small, if spread over the whole population." But this, adds Driberg, is precisely what was done when the cost of the NHS was met almost entirely out of general taxation !

Between this sort of disguised attack on the Health Service as such, made by organisations more or less associated with the Tory Party, and the views of some Tory members of a more enlightened outlook, where can we find the official Tory party line ? What is the real present-day underlying ethos or philosophy ?

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At the last Tory party conference in Brighton, there took place a lecture, away from the hurly-burly of the conference itself. The address, usually accepted as a more profound dissertation on current social matters, was given by Mr. Enoch Powell, the Minister of Health, and this was published as a pamphlet called The Welfare State.

In assuming this might be regarded as an expression of the prin- ciples underlying up-to-date policy, we immediately are faced with two dynamic utterances.

One. " Acceptance of a proposition in principle and rejection of it in practice is a perfectly normal human attitude, as common outside politics as inside."

Two. Pericles said, "' It is not the lack of what we never experienced but the depri\ ation of what we are accustomed to, that we feel and regret."

If the Minister agrees in principle about certain social rights and wrongs, one must not expect too much from him in practice, for he may decide, on any issue, to act as a perfectly normal human being ! And. those who have always been poor and deprived should never compare their lot with those who have been well-off and then come down economically, for, after all, they have never known any better !

Again we quote from his address : " The NHS was created by nationaUsing the hospitals and placing comprehensive state con- tracts for medical and dental and ophthalmic services. The new- structure replaced the previously existing variety of organisations through which medical care had been financed; national health insurance, a multiplicity of forms of private insurance, local govern- ment finance. pri\ ate contracts and payments, charity and endow- ments in all manner of guises. Comparison with other advanced countries where medical care is financed in different ways, and with the trends of this country before the National Health Service, sug- gests that if the forms of the organisations which the NHS replaced had continued and developed, the quantity, quality and distribution of medical care here to-day would not be very substantially different from what it is under the National Health Service."

Not a very enthusiastic supporter of the Service, you might say ! But one must be fair, and read on . . .

" This does not mean, however, that it is practicable to switch out of the system again. The old channels through which the relevant resources flowed have dried up or been dug up. Without under- estimating the possibility that we may still witness some increase of private medical insurance, it would not be reahstic to pretend that one can see an alternative system could now grow up beside, or be substituted for. the channelling of the £1.000 millions of the national income through government agencies."

" Indeed, this institution is self-perpetuating not only through inertia but actively. When the responsibihty for providing medical care is focussed and vested in a department of government, all the aspirations to improvement are bound to strengthen the institution. In the hospitals, a Minister of Health who is trying to do his duty must aim at increasing the corporate sense, morale and public esteem of the service, because he knows this is one of the ways of raising standards. In proportion as he succeeds, the institution itself will be that much more deeply rooted."

Mr. Powell's analysis of human beings and human institutions is quite correct so far as they go . . . that is to say, if you judge every- thing by capitalistic yardsticks and your basic faith is in Mammon and human greed and selfishness as irremediable and permanent. If the reader will get a copy of the Tory official document and the official Labour documents and read them carefully, he can then compare the real attitudes to Social Policy ... of the two major political parties.

It is true that the Government has made a great flourish in its announcement of a lot of money to be spent on the hospitals of the future . . . just as it did some time ago about the road developments, until financial stringencies had to cancel, or abandon or postpone this part or that part. It should also be remembered that Dr. Charles Hill announced soon after his return to Parliament, that we needed over two hundred million pounds to bring the hospitals of the nation up to a decent standard of efficiency and well-being . . . and from that time practically nothing has been done at all in terms of new hospitals. So the promise for the future is merely a making- up for the neglect of the past ten years, on top of the deficiencies which had already existed before then.

What is the position of the NHS to-day ? The SMA slogan is " Defend and Extend the NHS." At present, even while there is some politicians" talk about extension, it would appear that a great effort is needed to defend it. Let us look at the people who do the actual work, and forget for a moment the high-powered polemics of the professional politicians.

Doctors

How many doctors are to-day really satisfied with the service ? How many would like to see it abolished to-morrow ? No one knows. One cynic asserts that most doctors declare they want it ended, but do so with their fingers crossed behind their backs ! They are glad to have the security and assurance of the regular payments guaranteed by the state ! In other words they are full of grievances which they express by saying, " To hell with the NHS " but they do not really want to see it ended.

There are quite a few who would like to see it abolished to-morrow . . . out of general political prejudice (it's a blooming Socialist thing anyway !).

There are many who want it ended because they have been bewitched, bothered and bedevilled by bureaucratic ineptitude and stupidity.

There are some who interpret every administrative act as bureau- cratic interference, because they have the kind of personahty to resent the slightest attempt to control or direct them.

There are some who, although generally quite humane and decent in dealing with patients, do regard their calling as merely a way of making a living, and who feel they could make a bigger and better living under some other scheme.

These above, and others, tend continually to point out all the weaknesses and defects of the service, all the more so if they have not been able to contract out of it !

There is another large group who were originally doubtful about the service, and who have now expressed themselves in favour now of a fully salaried service, as originally visualised by the SMA. But this is not because of a political change of heart. Although many of them have stated they like being able to deal with patients without the question of money being raised on each occasion, this is not the reason for their new outlook. This group maintain their only way to get some peace of mind, when coping with the bureaucratic administrators, is to cease being so-called free non-civil servants, and just to become another group of civil servants and be done with it. Then they could be organised and fight back . . . e.g. about fitting-up and maintaining surgeries, holidays with pay, provision of a locum tenens and so on ... in other words, have rights and privileges granted to them instead of merely duties and regulations to be fulfilled !

There have always been a few doctors who, to put it bluntly were never up to standard. They are still no different, but now they attribute their own shortcomings to the N.H.S

There, are, in addition, a number of doctors, mostly first-class men professionally, who hold strong convictions against the service, and did not join in it — and who campaign as hard as they can against it.

Then there is a group like Dr. "A." A man dedicated to his profession, a little sceptical about the service at its inception, but willing to do his best in it for the sake of his patients. In a recent influenza epidemic with many cases of broncho-pneumonia among the elderly, he visited these patients in their homes, daily or even oftener, giving them injections of expensive but necessary drugs. Only one of his patients was admitted to hospital, while neigh- bouring doctors sent all such cases into hospital to save themselves a lot of trouble and worry and work.

Dr. " A " did not expect any medals or praise for his efforts. Nor did he expect a visit from a charming old gentleman, who admitted he had never been in practice, but had come on behalf of the Ministry

... to inquire why Dr. " A " had a higher prescribing cost than the average for the district ! When it was pointed out that the average cost of his so-called expensive treatment was about one-fifth of what it would have cost to treat them in hospital, his visitor said he had never thought of that !

It has, of course, been difficult, to convince Dr. " A " that this NHS is a good idea !

It may be thought that the older doctors, brought up in a different system, are now dying or retiring and that things will be different in time, as the younger men, entering the profession, take their places. What is happening ? The number of young doctors leaving the country to take up appointments overseas is now five times as great as pre-war. The junior appointments in our hospitals are being more and more filled with doctors from the Dominions and the Colonies . . . who, in due course, will return to their own countries.

The number of doctors qualified each year, and the number leav- ing our shores, and the probability that things are going to get worse in this respect makes the future bleak indeed.

Nurses

There is a shortage.

Not of beds but of nurses.

In the old days there were only two acceptable occupations for a young lady. Governess or Nurse. Nowadays, practically every occupation and career is open to them, while their main occupation and pre-occupation still remains . . . marriage. The hospitals have to compete. Pay has improved a little, some conditions bettered, discipline less harsh, but still this career compares badly with the other fields of opportunity which now exist.

Well, what about altruism, dedication, service ? There never was a sufficient number of noble minded idealists. To-day, modern medicine with its complications and organisations enables a much higher standard of diagnosis and treatment, but in order to achieve and maintain this, there is need for a much larger number of nursing personnel, both relatively and absolutely.

So there is a shortage of beds in actual use, and one hears now and again, outcries against coloured immigrants taking up " our beds." In fact, the boot is on the other foot. If certain govern- ments were to prohibit their girls working in our hospitals, and arrange for intensive courses of study for them in their own coun- tries, we should have even more empty and useless beds in our hospitals.

Then of course the Government, which is still involved in denying reasonable increases of pay to nurses, would issue a "patriotic appeal " for English girls to come forward in the national interest to save " the Empire Ward " from closure. Or maybe some people

would welcome this as the beginning of the end of the NHS Hospital service. Then we might, in modern practice, have take-over bids by private firms to run them. HOW ARE YOUR HOSPITAL SHARES THIS MORNING?

Of course this could not happen for we would carry on with the trained sisters and nurses already working in these wards. Or \\ ould we ? It must be noted that every month one hundred trained sisters and nurses leave our shores to go to the USA and elsewhere for better jobs.

The truth is that we, who dreamed long ago about idealism and service and suchlike have nothing to smile about. We have not developed a nation of idealists at all. It is true we have a govern- ment which for the past ten years has been dedicated to the principle of FM ALL RIGHT. JACK ! It is true that the spurious prosperity, the advertising, the gimmicks and all the rest have made a nation ever more selfish and more materialistic than ever before.

Administration

In proportion to the size of the organisation, the money spent and the work done, the percentage of administrative staff is smaller than in any comparable organisation, public or private. The public image of a swollen bureaucracy costing unnecessary millions is rubbish.

Yet there is much wrong here. This is due to a feature of British way of life which applies to a wider field also. It has been and still is a characteristic of administration to regard the administrators as superior, as higher, and more educated, as more worthy of high pay than the scientists, the technicians, the professors, the people trained and qualified to carry out the skilled duties involved. In the past, medicine was less caught-up in tliis attitude. The doctors, through their different committees, ran the hospitals to a very great extent. In a few places, a strong-minded chairman, usually with a huge fortune behind him, did dominate the scene.

To-day the administrators say, " At last, in hospitals, we have caught up with the general national atmosphere. Now we, the administrators, can look the senior consultants and the speciaUsts in the face — for now we are all equal — and some of us are more equal than others I

And all power corrupts. More so and more rapidly and more markedly among little people. The trouble with the bureaucrat is that he beheves people exist for paperwork, while others work on the assumption that paper is merely an instrument to be used in the dealing with people.

And patients are people, and so are the doctors and the nurses, and the others who collaborate in treatment.

A deeper analysis of the problems and troubles of the NHS indicates . . . MONEY. Even those who have a philosophy which hates the power of money in a society must admit its importance. Nye Bevan long ago pointed out the absurdity of what he called the pastoral psychology of our accountancy. God made four seasons. These make a year. God is identified with sacred Mammon, hence all book-keeping must be fitted into a calendar year. At the end, you draw a double line and then begin again. Perhaps if you have a pagan hogmanay orgy, you can start the new year with a magical belief that all will be well.

Or you can simply pray that it will be so.

It is true that recently we have begun to grow out of this concept. We are now getting some monetary plans based on five or even ten years periods. Unfortunately, some experiences in this field lend colour to the suggestion that some people promise the electors things which, they hope, will be forgotten by the time of subsequent elections.

But sacred departmentalisation still goes on. A saving in one department in the books is a thing for jubilation, and an OBE or even a CBE for some official, even although everyone knows the result is an overall increase in outlay, due to increased expenses for some other departments . . . plus some added delays and ineffi- ciencies !

How much should a good health service cost ? To state a certain fixed amount in coinage is absurd . . . except to the economists. At present it is less than five per cent, of the national income. Is that too much or too little ? How do you measure it ? How can you measure it ?

( We omit any detailed references to Mental Health and to the Prob- lems of Old Age because they will be the subjects of later pamphlets).

We have to consider the question of the inter-relationships of NHS with other social policies.

The NHS cannot be considered in a vacuum. One must relate it to other matters, which may be standing still, moving backwards, or forwards in differing rates and directions. As Signposts for the Sixties says: " One of the characteristics of the ever more complex civilisation in which we live is the need it imposes on the State to allocate more and more of the national resources to community services — health, education, social security and transport for ex- ample, not to mention defence."

If a few millions more had been spent in the last five years on the roads, how many millions would have been saved by the NHS ? For the Government to take, say, £300 millions by Road Tax and spend £100 millions of it on the roads, well that is good business and good book-keeping. For the Government to encourage motor manufacturers to produce two new cars for every six inches of roads

they make, that can be called good business and good book-keeping. What matter if they lose sight not only of the true book-keeping, but also of stagnation, impaired productivity, human suffering, physical and mental ?

Again, if sufficient factory inspectors had been trained and ap- pointed, how many pounds would be saved on the budgeting of the i>JHS ? The author of this pamphlet used to hawk around Labour Conferences some data, which was believed to be relevant. In- dustrial injuries and diseases caused nine months loss of productivity for every day lost by strikes.

The Labour Party plans for the future now include an Occupa- tional Health Service, and there is no doubt that it will repay its cost many times over ... in real bookkeeping nationally. Equally there is no doubt that economists will produce a statement showing how extra\'agant these sociaUsts are.

The truth is that you cannot measure socialist policies by purely capitalistic yardsticks.

We are now told that medicine is too big and important to be left in the hands of the doctors. That is true. In fact it never was entirely left in their hands. Equally one might argue that Econo- mics is far too serious matter to be left in the hands of the econo- mists ! It would probably be more realistically dealt with in the hands of the doctors . . . preferably psychiatrists !

The policy of the Labour Party is based upon the acceptance of the NHS, as a fine concept, and that although a Tory Government has messed it about, while paying lip-service to it. a future Labour Government will go ahead and improve it — if this means paying out more money, it will do so. A great part of this extra expenditure will be recouped within the service, and there will be additional gains from other sources, e.g. increased productivity from a larger force of healthy people.

What does it all add up to ? There is a climate of opinion at present, critical of and hostile to the National Health Service, both within and without, and, if the present trends continue, there is a real and grave danger of its complete collapse, despite its great benefits to so many people.

Broadly speaking, this applies to all the social services — to the Welfare State. There is a disguised attack all the time implying that any weaknesses and defects in our present society, its moral standards, its characters, its endeavours are to be attributed to the inception of this system of the Welfare State. No wonder Signposts for the Sixties feels it necessary to proclaim its belief — " The failure of our economy to keep pace with its main competitors is not due to the mollycoddling of the Welfare State or to the lack of effort by British Labour."

On the other hand, if we turn to Mr. Powell's address, we find at the outset an extract from the Plowden Report, viz : " The social changes of the last fifteen years have altered the incidence of hard- ship so that there now may well be excessive social services for some purposes and inadequate for others."

One may ask what his party in office for the past ten years have done about the inadequate services ?

He begins with what he calls the " Queerest of the Social Services " — subsidised housing.

" This social service happened by accident. At the end of the First World War it was assumed that after a short time money would be back to its pre-war value and market rents to their pre-war level. As a temporary measure, wartime rent restriction was retained, and as an equal temporary measure a subsidy was introduced to bridge the gap between pre-war and post-war rents."

" Pre-war values never did come back, rent restriction never did cease to be considered necessary, and even after the building of three or four million houses, subsidies never were discontinued. So it began to be asserted that this was a social service."

After some interesting criticism of this development, the Minister went on to say, " The system grew stronger and more complex, so that the wonder is not that it lived so long, but that two men were found, at last, in Duncan Sandys and Henry Brooke, of sufficient courage and determination to lay the axe to the roots and start hewing back to sanity."

What an accident ! What an admission ! Who were the people who assumed that the pre-war values would return ? The econo- mists ? The clever business men in Government, the gentlemen who call themselves " Something in the City," the Landlords ? Who ? Yes, indeed social economics is far too serious a business to be left in the hands of the economists

There are many people now who would not classify the actions of Sandys and Brooke as being courageous, but would find other and more appropriate terms for their actions.

It is interesting and important to compare this attitude to the Social-Service-angle of Housing with the Housing section in Sign- posts for the Sixties. This deals with the Price and the Use of the Land — in terms which show some real concern with people who require homes in which to live.

Mr. Powell goes on to deal with another achievement of the Tories of a similar nature ... in a similar boasting manner. Food subsidies. " If the incoming Tory Government had not swept them away at once, it would to-day seem no less difficult to abolish the ' social service of subsidised food ' than the 'social service of subsidised housing.' Luckily we killed it before it became a fuU-

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blown institution and to-day no one seriously expects that food, clothing, or even a T.V. set should be subsidised."

It would appear that Mr. Powell is not quite sure whether he is lecturing as the wise philosopher or merely trying to make a cheap party point as a politician. In the one case he boasts about the Tories finally having courage to do something, in the other boasting because they did not wait and acted immediately, thus showing courage. But one is not really concerned with " political courage " —one is concerned with facts and their meaning in terms of an atti- tude towards Social Services.

The Tories abohshed food subsidies ! What a great claim ! Again, it must be pointed out that this was only done in one form of departmental accountancy. Has the Minister never met the Minister for Agriculture ? Has the latter never told him the facts of political life ?

For a Minister of the Crown, in a country in which in the past ten years a Tory Government have given about £3,000 millions in sub- sidies to the farmers, to claim they have abolished food subsidies is to make nonsense of the meaning of words !

Why this subsidy ? To raise the price of food for the people generally ? Even the Tories would not dare to spread such propa- ganda. To keep prices as stable and at as low a level as possible ? They would probably claim this to be so, and, indeed, that would be the justification for this course. Surely it is not merely a bribe to retain the goodwill of the farmers ? Or may be it is merely a device to maintain a standard of living for farmers ? In that case, why not openly and honestly call it a special and respectable Tory form of National Assistance for a favoured section of the com- munity ?

If this enormous subsidy over the Tory years of government is a device to help British agriculture while keeping down prices of food for the people generally, what becomes of the boast of abolish- ing Food Subsidies ?

The truth would appear to be that the old idea of the " Two Nations " still obtains in Tory thinking. Any help for the " Haves " is right and justified and given some suitable name, any help for the " Have-Nots " is a Social Service and somehow this carried with it a suggestion of something socialist, or even dirty !

What of other social services ? We leave Education and Pensions to later pamphlets by other students in these fields. We merely make a simple statement. The Labour Government came into ofiice immediately after the war, when the country was bankrupt. The austerity and stringencies were inevitable. The Tory Govern- ment could build upon the benefits derived from this. They have been in office for ten years. International terms of trade were in their favour for most of that time.

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Yet to-day, the situation as to Education and Pensions is dis- graceful and deplorable.

What of other social services ? Here, as in so many fields, there is a question of priorities.

Before the war the greatest social problem was unemployment. Since the war, the greatest problems have been Mental and Nervous Health, and the Old People, Care of the Aged and Infirm and chronic Sick.

As regards Mental Health, the SMA published a pamphlet many years ago, and it took some time for its policies and programmes to begin to be implemented. A Royal Commission, a debate in Parliament (when the pamphlet was extensively quoted) and a new act, which shows many advances . . . but a situation to-day which calls for much to be done.

Mr. Powell does mention that he used to consider mental hospitals as the most staggering bhnd spot of our times, but he indicates that he feels fairly happy about this field now.

When, after a period in office, just after the war, the Labour Government claimed with pride the improvement in health gener- ally, it was Dr. Charles Hill, in a " famous " broadcast who tried to denigrate this claim, and to attribute all progress to Penicillin and suchhke medical developments. The progress in recent years in dealing with mental illness is much more due to similar medical progress than to any positive action by the Government. The new facilities are still on blue-prints, the increased and necessary medical and nursing staff are still a theory, but it is in spite of the handicaps that progress has been made by new drugs, and new studies and the eff"orts of the people actually engaged in this work.

As far as the problems of the Aged and the Infirm are concerned, again ten years of Tory rule show a great deal of talk but little positive progress in their solution.

As far as the Labour Party is concerned, judging by their official pronouncements, these two problems are still the major ones yet to be resolved. As far as the Tory Party is concerned, what ? " What social services are inadequate ? I offer two guesses. Crime and age ? " So says Mr. Powell. '' Treatment of delinquents claims to-day the place which treatment of the lunatic but lately occupied, as a gross example of society's inadequacy to cope with its members."

He then goes on to say, " It may not be a popular view but I would dare to say that prisons are our most important and also our most deficient social service."

He then adds his view, " that, in time, things will get better, but we cannot even claim to be using existing methods when 7,500 prisoners are sleeping three in a cell, and when policies which, but

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for the war, would have been on the statute book in 1939, and policies already on the statute book for half a generation, have hardly begun to be carried into effect for lack of premises."

One cannot deny his right to determine the greatest social prob- lems as he sees fit, but one can disagree with his judgment. One can also ask pertinent questions about this. For example, how much would it cost to keep all these delinquents in prison, to arrange to receive them back again for lack of the procedures and facilities likely to prevent this. How much would it have cost to build the suitable premises ? How much, years ago, when the unemployed cried out for work ? And since Labour was in of^ce and power for about six years in the past fifty, whose responsibility is it that the statutes have not been translated into realities ?

Let us emphasise the comment ..." Our most important deficient social service."

One may wonder about the obsession of Tories about Crimes and Punishment. Nevertheless, in terms both of quantity and quality, there can be no doubt that to most sociological students, the problems in this country associated with Old Age are infinitely greater than those associated with Crime. And, those who work in the field of Mental Health, will probably agree that this is still a much greater problem also, (for much of what passes for Delin- quency is but a part of the Mental Health problem).

Still let the Minister have his opinion. We can be thankful that at the last Tory Conference at Brighton there was less of the " flog them all " stuff — even if their latent aggressions were deflected against the majority of the Queen's subjects on account of their colour, under the guise of a non-colour Bill about Immigration.

Both parties, judging by the Tory document which has been refer- red to throughout this pamphlet and by the Labour documents to which reference has also been made, are agreed that the Problems associated with Old Age is a major matter. But the implication of Mr. Powell's remarks that it will take thirty years to solve, is both depressing, doubtful and one which the Tories have not broadcast. His further approach to the heart of the matter is interesting and deserves full consideration. " At the same time, I doubt whether the State can solve it. It can be stated in economic terms ; in terms of questions of accommodation; in service; in attention; but money benefits and subsidies are not the heart of the matter. As more and more survive and are kept alive beyond the utmost limit of working life, the economic and social function of the individual provides less and less of a motive or framework for his survival and when we ask " u7;r ? " we find ourselves thrown back upon purpose in a sense which neither is economic or social nor even secular. We are brought face to face with the question, " What is the purpose of human life itself ? "

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If one reads this address again and carefully, and then studies the Labour pamphlets again and carefully, one may ask which is seeking to provide a better answer. The underlying difference between the two basic political philosophies then becomes very apparent.

Insurance against the vicissitudes of life is a good thing. Every- body says so. The Insurance Societies and Companies tell us it is so. It should follow that a system of society which provides full insurance cover against disasters for everyone is better than one which makes differences and distinctions. A system designed to carry out this high ideal should not be left in the hands of small groups of people, dedicated to the principle that the success of any- thing is measured by the amount of its profits, and what its shares are standing at ! A system which uses economics as its moral basis has no moral basis. Furthermore, a system which tries to deal with social problems on a moral basis, and then tries to fit its methods into some economic pattern is not only more moral, but is more likely to be economically viable.

A society which is so afraid of attacks upon it by a small number of anti-social elements (called criminal) and then talks smugly in the name of conscience about doing for them now or in the future, what it should have done years ago, is responsible for economic wastage as well as, morally speaking, for human wastage.

For instance, we spend much money to ensure that people will not steal or cheat the National Health Act, the National Assistance Act and so on. It is, of course, important to try to avoid and pre- vent roguery anywhere, but must we blazon abroad every little offence ? To high-power every little misdemeanour in these fields and then try to attribute it all to something deleterious to the human character called the Welfare State — this is monstrous.

If someone asserts that the increase in delinquency is due to the Welfare State, ask him to explain the much greater increase in quantity and degree of viciousness in the USA.

It is one of the glories of this country, that the Law, despite so many defects, is respected by all because it has maintained such a high standard. The attitude — better for ten guilty to go unpunished rather than one innocent should suffer unjustly — underlies and fortifies its greatness. In the field of the Social Services, although all agree that abuse is to be avoided, the same principle should apply as in Law . . . better that ten of the undeserving poor should get a little more than the economic and statistical quota, than one of the deserving poor should go without.

If the economists tear their hair at such heresy, let us remind them of Mr. Powell's vital question: " What is national productivity for ? What is it about ? " Or, if you like, in his own words, " what is the purpose of human life itself? "

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Of course, one will be told to be realistic. That means being subservient to pastoral and departmental bookkeeping and account- ancy. We have recently been informed that the national productivity will increase annually by two and a half per cent.; hence the total available for social services must not go above this increase. This is simple and clear. But what does it mean ?

The present financial arrangements suddenly acquire a mystical value as right and proper and sacred and inviolable. This is the standard. It can only be increased when productivity itself is increased, and the national income has increased (unless some of it is drained off by a reduction in Super Tax !). Unfortunately, at the same time, other Government departments take steps which restrict and hold back productivity. Indeed, economics is far too serious a matter to be left in the hands of economists ! Already this plan has fallen flat and the Chancellor has had to admit his inability to deal with percentages is as great as a predecessor's was to cope with the " damned dots " of the decimal system !

A study of Labour's policies and programmes for their next period in Ofiice shows much attention to practical realities, so much so that some sociahsts may feel it lacks the crusading fire of the past. It does, however, show clearly to the objective student a wide gulf between its approach and that of the nearest equivalent at present available, namely the printed address of the present Minister of Health. Contrary to a commonly expressed view that there is no difference between modern Labour and modern Tory, in the field of Social Services, they are poles apart.

In the Labour Party, the spirit of socialism still is alive and dynamic, although expressed in modern terminology.

In the Tory party there is a considerable move forward from the days of the first decade of the century — but . . .

In ten years of Tory Government there have been many Ministers of Health, and the author of this pamphlet is of the opinion that the present Minister is the best of that lot. One does not question his honesty, sincerity or integrity. But it does not seem unfair to para- phrase his outlook in this way ..." While I am Minister of Health, of course, I shall do my duty, and look after this business to the best of my ability. But, really, you know there is not much point in it all. If there hadn't been this show, things would have roughly been the same. Still, we can't go back. It's too much trouble, you know. I know what you, in this audience listening to me, are thinking. But there it is. We're stuck with it."

The SMA was born to create a National Health Service. It achieved its first objective through the Labour Government and Nye Bevan. Now its objective is to " Defend and Extend the Service." Anyone who reads this pamphlet will realise that the need to defend it is paramount. Of course, it has its defects, and one of the

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functions of the SM A is to highlight them and try to have them put right in the hght of experience. But what if it crashes, collapses and disintegrates all together ?

Mr. Powell has stated his opinion that it has become a self- perpetuating organisation and organism. Also that he will do all he can to improve it. The SMA begs leave to doubt his ability to achieve his laudable aims if things go on as at present. In a few years with too few doctors, too few nurses, and hospitals perhaps still archaic, and new ones still on the drawing-boards, it just will not be possible. No organisation, whether called self-perpetuating or not, is necessarily, by divine decrees, guaranteed to be self-perpetuating and permanent.

What is needed, and what alone may yet save the NHS is a Labour Government with a Labour Minister of Health, really and truly dedicated to its defence and extension. There is a hard fight ahead, and the best soldiers are still those who know what they are fighting for and who love what they know.

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