§ (1) Every approved society and local health committee shall for the purpose of administering medical benefit make arrangements with duly qualified medical practitioners for insured persons to receive attendance and treatment to the satisfaction of the Insurance Commissioners from such practitioners.
§ (2) Every such society or committee shall also make provision for the supply of proper and sufficient drugs and medicines to insured persons, and no arrangement shall be made with a medical practitioner under which he is bound or agrees to provide drugs or medicine for any insured person at an inclusive fee, without the consent of the Insurance Commissioners, which consent they shall not give unless the circumstances of any locality situate in a rural district are such as to make it expedient to do so.
§ (3) An approved society may enter into an agreement with the local health committee for the administration of medical benefit among such of the members of the society entitled thereto as may be resident in the county or county borough for which the committee is established; and on any such agreement being made the committee shall take over such administration and there shall in each year be paid out of moneys credited to the society such sum in respect of every member of the society entitled to the benefit and resident in the county or county borough as may be agreed between the society and the committee.
§ (4) If in any year the amount payable to a local health committee in respect of all persons for the administration of whose medical benefit it is responsible is insufficient to meet the estimated expenditure thereon, the committee may, through the Insurance Commissioners, transmit to the Treasury and to the council of the county or county borough an account showing the amount so payable and the estimated 382 expenditure, and the Treasury and the county council or the council of the county borough shall, if satisfied that the amounts so payable and the proposed expenditure are reasonable and proper in the circumstances, sanction the expenditure.
§ (5) The Treasury and the council of the county or county borough sanctioning any such expenditure as aforesaid shall thereupon each be liable to make good, in the case of the Treasury out of moneys provided by Parliament, and in the case of the council of a county or county borough out of the county fund or borough fund or borough rate, as the case may be, one half of any sums expended by the local health committee on medical benefit in the course of the year in excess of the amounts so payable to the local health committee as aforesaid.
§ The CHANCELLOR of the EXCHEQUER (Mr. Lloyd George)
I beg to move, in Sub-section (1), to leave out the words "approved society and" ["Every approved society"].
A few Amendments of this kind are now necessary in consequence of what happened last night.
§ Amendment agreed to.
§ Mr. SANDYS
had given notice to move-an Amendment, in Sub-section (1), after the word "benefit" ["administering medical benefit"], to insert the words, "to insured persons whose total income from all sources does not exceed two-pounds a week."
§ Sir PHILIP MAGNUS
and other hon. Members had given notice to move an Amendment, in Sub-section (1), after the word "benefit," to insert the words, "in respect of insured persons whose income from all sources does not exceed one hundred and four pounds a year."
§ The CHAIRMAN
The Amendment of the hon. Member for Wells (Mr. Sandys) deals with the question of the income of those who are to receive medical benefit. I think that would be better dealt with on a. later Sub-section on another Amendment rather than here.
§ Sir PHILIP MAGNUS
It was understood that the Amendment was to be moved on Clause 14, and it Would be very 383 much better to have it moved here than as an Amendment to an Amendment by the Chancellor of the Exchequer. If it is moved at this point there will be no necessity to discuss the question raised by the hon. Member for Hoxton (Dr. Addison) over again. I think it is very important that the discussion of this £2 limit should not be discussed on an Amendment to an Amendment. It "Was understood, when we considered Clause 8, that the matter should be discussed on this Amendment.
§ Mr. LLOYD GEORGE
On the point of Order, it was quite understood that the matter would be discussed on this Clause but not on this particular Amendment. May I point out as a matter of order that if this Amendment is decided and a particular income limit negatived, then a subsequent Amendment of mine might be out of order.
§ Sir ROBERT FINLAY
I submit that this is the proper place to move this Amendment. The object of the Amendment is to provide that medical benefit in the form prescribed by the Bill, which is distinguished from money benefit, shall not be given in the case of persons whose income exceeds £2 per week. As regards what the Chancellor of the Exchequer said about the Amendment being out of Order, I submit that would not be the case at all. The subsequent Amendment is an Amendment giving discretionary power, and that would operate on those whose income is not £104 per year.
§ The CHAIRMAN
Of course, it does not matter in the least to me when this Amendment is taken, but I think it can be taken perfectly well as an Amendment to the Amendment of the hon. Member for Hoxton. My objection to it is that at this point it would leave a hiatus which would want filling up and which is not filled up by subsequent Amendments. It is really a matter of place. I am quite certain it can be moved as an Amendment to the Amendment of the hon. Member for Hoxton, and therefore that is really the better place.
§ Mr. JOYNSON-HICKS
I submit it would be difficult to engraft this Amendment, which is of a legislative character, on to a discretionary Amendment.
§ The CHAIRMAN
If that is the case I think it is better to take it now. I am quite sure the Committee would like a definite decision on this particular point; and if it really comes in better here I am quite agreeable to allow it.
§ Mr. H. W. FORSTER
I should like to understand clearly that if this Amendment is moved and negatived it will not preclude us from discussing the Amendment of the hon. Member for Hoxton at a later stage?
§ Mr. LLOYD GEORGE
I do not want to prevent a decision on this question. It is simply a question whether we discuss it now or in about half an hour's time. What I want to prevent is having two discussions on exactly the same point, with the same arguments advanced for and against.
§ Sir R. FINLAY
The two points are very distinct, and there need not be any undue repetition of argument.
§ The CHAIRMAN
Unless the discussion really covers the Amendment of the hon. Member for Hoxton and the decision on it, in my opinion, if it is in the negative, covers that as well, I see no reason why the Amendment of the hon. Member for Hoxton should not be moved later.
§ Sir P. MAGNUS
I beg to move, in Subsection (1), after the word "benefit," to insert the words, "in respect of insured persons whose income from all sources does not exceed one hundred and four pounds a year."
I am very much obliged for your ruling allowing this important question to be discussed on its own merits apart altogether from any Amendment which may be subsequently moved. The Chancellor of the Exchequer may rest assured that there will not be two discussions of the same kind on two different Amendments. I am greatly encouraged by the reception given both by the Committee and by the Chancellor of the Exchequer last night to the Amendment of the hon. Member for Hoxton, and I can only hope that the same favourable consideration may be given to this Amendment, which everybody will recognise as being one of the most important Amendments that can come before the Committee. The Amendment must be taken into consideration in close connection with other Amendments further on on the Paper, in the names of myself and my Friends. When we come to those Amendments it will be seen that any hiatus which may exist, as you suggested, will be en- 385 tirely filled up. This Amendment is one on which the whole medical profession are practically agreed; there is no difference of opinion among them, and if it is carried the medical profession will be willing loyally to co-operate with the Chancellor of the Exchequer in giving effect to the important provisions contained in the Bill. As the Chancellor of the Exchequer knows, the members of the medical profession have throughout placed the proposal underlying this particular Amendment in the forefront of their requirements. There were six points which they submitted to him, and this was the first. The Amendment does not interfere in any way with the principle or structure of the measure. It does not increase the cost to any of the persons who have to pay. On the contrary, there is good reason to believe that the cost of medical benefit may be somewhat lessened if this wage limit is accepted.
The Amendment fully recognises that medical benefit is to be provided for all persons whose income is, as stated in the Schedule, less than £160 per annum. But what the Amendment does is to widen the definition of medical benefit so as to include medical treatment and attendance, including medicine and appliances, and also a certain sum of money, to be carefully fixed after due consideration, which should be paid by the approved societies in lieu of medical attendance. There is every probability that the payments by the societies will be less if this Amendment is accepted than they would be under the Bill as it stands. The Chancellor of the Exchequer pointed out very truly last night that the cost of medical benefit as the years go on is likely to increase, because the doctors will require to be better paid than they have been hitherto. But if this Amendment is passed there may not be the same necessity for the friendly societies to pay larger sums to the doctors, because they will pay such money as is the equivalent of what they would pay for medical attendance to the insured persons, and the insured persons will, if they think fit—and many will think fit — pay out of their own pockets an additional amount in order to have better medical attendance for themselves and their families. Therefore, I really believe that by this Amendment being passed the friendly societies will be in a better position than otherwise. The Amendment proposes that all persons whose income is between £104 and £160 per annum shall be entitled to receive a money equivalent in lieu of 386 medical attendance. It further states— thereby giving local option, which is very important—that all persons whose income is under £104 may accept, instead of medical attendance treatment, a sum of money. So that the Amendment proposes that, whilst no person whose income is over £104 can claim medical treatment as part of the medical benefit, but must be prepared to receive a sum of money in. lieu thereof, all persons whose income is under £104 may claim medical treatment as part of the medical benefit; but, if they prefer, they may receive a sum of money in lieu thereof and make their own arrangements. That is the object of the Amendment.
The Bill as it stands proposes to extend medical treatment under contract to all insured persons. At present there are not more than, I believe, six millions of persons receiving medical benefits by contract, and that number includes members of friendly societies, of trade unions, and of large industrial works. The proposal of the Bill is to extend that principle by the addition of nine millions of persons, making a total of fifteen millions of persons who will come under the contract system. Experience has shown that the contract system is not on the whole a satisfactory one, and has not been in the past entirely successful. It may be necessary in certain cases, although it is not the best system for curing illness, or even for the prevention of disease. The medical profession as a whole is of opinion that, if practicable, it would be far better to substitute payment for services rendered in lieu of medical attendance under the contract system. I have received, and I suppose other Members have also received, numerous letters and pamphlets recommending generally the substitution of payment for services rendered for the contract system. I would just like to quote a word or two from a memorandum prepared by the British Medical Association, who state that:—they believe firmly that the treatment of disease, at all events by the ordinary medical attendance on the patient, will be carried out with most benefit to the patient, and most satisfaction to all parties, on the lines of private practice. This conviction springs mainly from the recognition of the peculiarly personal character of the relation of doctor and patient.I might quote many other passages from letters which I myself have received, some of which have been published, but I do not wish to occupy too much of the time of the Committee. I would like to 387 refer to two short sentences which occur in the letters of two distinguished doctors. One writes:—Contract practice is bound to be inefficient, and with absolute unanimity the profession have affirmed this view.Another doctor says:—Contract practice has always been held, both by the public and by the profession, to produce bad work, and to degrade the profession. Then why make it universal?The Bill, as it stands, remember, enormously increases the area of the population over which this contract system, which is so generally condemned, will be extended. The Amendment I am pressing will act, I think, as a sort of brake upon the too sudden extension of this system. We are often told that in Germany this system operates very well. The Chancellor of the Exchequer, I am sure, had the German system in his mind when he framed the Bill now before us. But if he had investigated the matter a little more fully, he would have found there were loud complaints against the German system. He would have found that it is not operating as beneficially as persons might suppose when they first heard of it.
We are too often urged to imitate what is going on in Germany. I would like to say that all things made in Germany are not necessarily good. I am strongly of opinion that this particular system of insurance which owes its origin to Germany is attended with many disadvantages which we ought in a Bill of this kind to endeavour to avoid. The value of this Amendment is that it will exclude by statute—which is very important—large classes of persons who are differently employed from claiming as a right medical treatment on the contract system. It will do this, without placing doctors in the invidious position of either refusing to cooperate—as we certainly hope they will not do—or of combining amongst themselves to fix in certain districts a lower wage limit than that contained in the Bill. The principle of option underlies the Amendment which may be accepted by the Chancellor of the Exchequer. What I want to avoid is that doctors should be required to combine amongst themselves in order to fix conditions under which they think it right to carry on their practice. After all, we must remember that doctors are not commercial men, and the Bill should endeavour to protect them from having to adopt methods of commerce applicable to trade unions, or from being 388 placed under the necessity of securing by combination what they justly regard as essential to the discharge of their duties.
As a fact, I do not think that the medical men have ever been so united or have ever combined together to the same extent as they have at present in face of the great danger which they see is threatened to themselves and to their profession by some of the Clauses in this Bill. When this Bill passes into law the necessity for combination amongst medical men should cease, and it is very unfortunate if by this Bill we should introduce into the medical profession the same methods of combination as may be, and perhaps are, necessary in trade unions. I think, moreover, I may say on behalf of the profession—I could not say it if I were a member of the profession myself—that the members of no other profession have ever shown such active sympathy with the poor, such disinterestedness and willingness to help them in trouble or in sickness, such humane consideration in their relations with all classes of the community as the members of the medical profession. I think it would be really unfortunate if this Bill should do anything to disturb those relations. I do not know whether it was realised in Debate yesterday in regard to the hospitals that medical treatment and surgical treatment in the hospital are given gratuitously by members of the medical profession. By the statutory reduction of the wage limit which this Amendment proposes, while we should, in what after all is a great and important experiment, be excluding none of the poorer classes, we should exclude from the operation of the contract system those who in most cases prefer to make their own arrangements with their doctors and can in nearly all those cases afford to do so. I should just like to enter a caveat. It must not be supposed that the doctors, in advocating this important change, are influenced, as has been suggested, wholly by selfish considerations. That is not true. There are many, as I know, who will be absolutely ruined if this Bill as it now stands becomes operative. I have received most piteous letters from members of the medical profession, and others have received similar letters, saying that this would be the case if the Bill as it now stands became law. In one large city, returning three Radical Members to Parliament, I was told that out of 214 doctors 198 have refused to co-operate unless some 389 such Amendment as I have proposed is introduced. And the man who told me that was himself a doctor, a graduate of my own university, but who, being a Radical, did not, of course, vote for me. What most concerns the medical profession is not their own immediate interests, it is the injury which this great extension of the contract system will effect on the status of medical men, on the character of their practice, and also upon the insured persons who will be treated by them, and on the progress of medical science and on the general position of the hospitals, I am not going to produce evidence now in favour of these five propositions, because I should be travelling over a large part of the discussion that took place yesterday, and the day before, but I think it is well to bear in mind that this Bill affects far more than is supposed the whole future of the hospitals, and I think it would be very unfortunate if, in consequence of this Bill, the voluntary system, which works so well in our hospitals, should be broken up, as in other countries, where a similar system to this now prevails. These matters are very serious. I should like to refer for one moment to the speech that was made last night by my hon. Friend the Member for Hoxton. He said:—I do not think … that the great objection which medical men entertain against contract practice is the outcome of mere cantankerousness. It is not that. It is really because they find there is something in it which is against not only their own interests, but their ideal of work."—[OFFICIAL REPORT, Aug. 1st, col. 253.]I can add nothing to what the hon. Member for Hoxton, with far more knowledge and experience than I possess, has said upon that point. But I would like to make it clear that I am not suggesting now any more than my hon. Friend the Member for Hoxton suggested last night—the absolute substitution of payment for service instead of the contract system, although I am bound to admit that the profession are generally agreed that such a substitution would be very advantageous. I want the Committee to realise that, while the doctor is able to combine as he now does his private practice with club practice, the contract system is at least tolerable, but it would be quite intolerable if, as under the Bill, the contract system occupied the whole time of the doctor. In that case the doctor would really have no leisure. And speaking of leisure, I would like to remind the Committee that I received a letter from a doctor in a distant part of the country whom I asked to attend a meeting. He wrote to say that 98 per cent. of his prac- 390 tice was club practice, and he could neither afford the time nor the money to leave the place where he was. For four years he never had a holiday, indeed, the only occasion that he had a holiday was when he got married. If club practice is to take up the whole time of the doctor he will not be able to enjoy any leisure, he will have no opportunity to keep himself abreast of the application of science to the medical practice. He will have no chance of rising in his profession by withdrawing gradually from club practice as his private practice increases. In that case you take away from him the stimulus of the hope of rising in his profession, and you compel him to do bad work. I cannot help thinking that such a system is bad for the doctor and equally bad for the insured persons, and bad for the progress of science. I do not want to labour this point, because I believe the Chancellor of the Exchequer recognises it.
It is not so much the contract system in the abstract that I am combating, as the vast extension of it that will take place under this Bill, so injurious to the medical profession generally, and the value of the Amendment I am moving is that it would have the effect, undoubtedly, of restricting in a considerable measure the extension of the application of the contract system. Many remedies are good if applied in a limited way, but carried to excess they become injurious. The Chancellor of the Exchequer no doubt saw that club practice worked fairly well in a great many districts, but what he has tried to do under this Bill is so to extend it that it may become harmful. The members of existing friendly societies have hitherto been voluntary members; under the Bill 15,000,000 of persons will become compulsorily insured. What I wish to impress upon the Committee is that whereas the system may work well confined in narrow limits it becomes injurious to doctors and to the medical profession generally if extended as far as it would be under the Bill as it stands.
With regard to the objections raised to the Amendment I take it that the main objection is the difficulty of enforcing the £2 limit, and I believe that is the Chancellor's only objection to accepting the Amendment now proposed. I need not say that an arbitrary limit of any kind is difficult to enforce. The Chancellor has pointed out that the Treasury are in possession of the names of all persons whose income is above £160 a year, and therefore there will be no difficulty in ascer- 391 taining whether a particular person's income was £160 or more. That is true, but there would be no difficulty, I take it, in ascertaining whether a wage earner's income was over or under £2 a week, and there would be no necessity to go to the Treasury for that information. Every person claiming medical treatment would have to show the local health committee that his wages were under £2 a week. The onus of proof would rest upon him, but the medical profession have distinctly stated that they are not desirous of absolutely insisting in every individual case upon this figure. In their own statement of their case they say:—As to the supposed administrative difficulties on the income limit, the question of income limit has often been considered by the profession. It has never been proposed that any inquisitorial investigation should be made for the purpose of giving effect to it; it is sufficient that the principle should be recognised that a person above a certain limit is not entitled to claim attendance under the same arrangements as are made for the attendance of a person below the rate. He must make his private arrangements with the doctor who attends him upon such terms as are agreed upon. This principle being recognised, the work can easily be adjusted locally between those concerned.All the doctors require is that it should be generally known and recognised that the right of claiming medical treatment belongs to those only whose incomes are under £2, whereas all those whose incomes are over that would have the right to claim an amount of money equivalent to the amount that would be paid to the doctor, allowing them absolutely to make their own arrangement with the doctor. I am willing to admit that there are certain districts in which the £2 limit is considered high. There are many workmen in the agricultural parts of the country earning less than £2 a week, who with the spirit of independence which characterises our workpeople generally would prefer to pay their own doctor for the actual attendance they receive. The Amendment which comes later on on the Paper provides for such option, and states that any insured person whose income does not exceed £104 shall be entitled in lieu of medical attendance to receive an equivalent pecuniary allowance. It might easily be left to the local health committee to arrange the lower level in certain districts in connection with certain members. Indeed, so long as this £2 limit is recognised, the more elasticity you leave in the Bill the better for all parties concerned. The Chancellor of the Exchequer referred to an Amendment on the Paper in the name of the hon. Member for Hoxton. I may say that goes a long 392 way towards meeting the position I have endeavoured to submit, and probably if the Committee absolutely refuse, as I hope they will not, to accept this proposal we may be able to make some Amendment in the Amendment of the hon. Member for Hoxton which shall meet our view What I would like to point out to the Chancellor of the Exchequer is that, having gone as far as he has done to meet the views of the medical profession, he would be rendering a very great service to the medical profession generally if he would accept the Amendment which I am now proposing. By doing that he would at once bring all the doctors into line with him, and they would all be eager to cooperate with him in giving effect to the provisions of the Bill. If the right hon. Gentleman considers the difference between this Amendment and the one which he is prepared to accept, he will see that it is only very slight. Surely it would be better in his own interests, and in the interests of the Bill, which he is anxious to see passed, that he should accept the proposal which the medical profession is practically unanimous in asking for, and to which they attach the greatest importance. Only at their representative meeting in Birmingham a few days ago, after a lengthy discussion and after considering various questions and forms of resolution, they finally resolved on the motion of the Chairman of the Representative Committee:—That the council be instructed to use their best endeavours to have the £2 limit fixed in the Bill, with provision for a lower limit to be fixed locally, but failing that to obtain as best they can the fixation of £2 as a maximum limit with such local option.I do not quite understand the latter part of that resolution, but it distinctly states that whatever is done the representatives of the medical profession are to endeavour as best they can to obtain the recognition of the fact that the £2 limit in the Bill is essential to the requirments which they have put forward. I am prepared to say that if the Chancellor of the Exchequer will assure me that he is willing to accept this £2 limit, and will allow a few words to be inserted in the Amendment to his Amendment to be proposed by the hon. Member for Hoxton, so as to make it perfectly clear that this £2 limit shall be-accepted, I, for my part, would be quite willing to withdraw my own Amendment so as to make room for the Amendment which is to be moved in the name of the hon. Member for Hoxton. I cannot, of course, consent to do so, unless the 393 Chancellor of the Exchequer is quite prepared to give an assurance that he will allow words to be inserted in that Amendment which distinctly provide that the medical treatment and attendance shall be granted as a right under the contract system to those only whose income does not exceed £104 per annum. It is quite possible to make such an Amendment in a very few words, and they might be introduced into the Amendment I have suggested. If the Chancellor of the Exchequer is anxious, as I am sure he is, to facilitate the passage of this Bill through Committee and through the House, and to obtain the assent of the medical profession generally to the provisions it contains, I cannot help thinking that he will be well advised to accept the Amendment which I have proposed.
§ Mr. LLOYD GEORGE
I am not sure every Member of the Committee fully realises what this Amendment means if it is carried. It means that all those who are earning above £2 a week are excluded from the arrangements for medical benefit provided by this Bill. I hope everybody who records his vote for this Amendment will realise what that means. It means the exclusion of all those who are earning over £2 a week from the benefit of the medical arrangement.
§ Mr. LLOYD GEORGE
It excludes them from the benefit of the medical arrangements. It means that in districts where from the time when the memory of man goeth not, all medical practice in industrial populations has been on contract terms, and in future they will be ruled out from the benefit as far as national insurance is concerned.
§ Mr. LLOYD GEORGE
Surely the hon. and learned Gentleman cannot mean that. Does he mean that where you have got a miners' club paying by contract terms that in future they will pay no more, although they earn over £2 a week? [An HON. MEMBER: "NO."] Then I really do not know what the Amendment is. Either they pay less, or the same, or they pay more. Which is it?
§ Sir P. MAGNUS
Let me read the Amendment we propose:—
"(3) Every insured person whose income from all sources exceeds one hundred and four pounds a year and who has become entitled to medical benefit shall be entitled, in lieu of medical attendance and treatment (including medicines) to receive an equivalent pecuniary allowance towards the expenses of medical attendance and treatment (including medicines) to be calculated and paid to or for him in accordance with regulations made by the Insurance Commissioners, and any insured person whose income from all sources does not exceed one hundred and four pounds a year, and who has become entitled to medical benefit, shall be entitled to elect in lieu of medical attendance and treatment (including medicines) to receive such equivalent pecuniary allowance as above mentioned."
§ Mr. LLOYD GEORGE
What I said was that the men who are now entitled as a matter of contract and bargain to medical benefit in future will not be entitled to it. They will be entitled to something else. They will be entitled to a sum of money which the hon. Gentleman says will be an equivalent. But surely that is a very different thing, and I realise how different it is when I come to the Amendment of the hon. Member for Hoxton. It is a totally different thing to say to a man "the medical benefit is worth 5s. or 6s. a year." There is a difference between that and entering into a contract whereby whatever the medical benefit may be he will get it.
§ Sir ALFRED CRIPPS
I understand the right hon. Gentleman to say that the existing arrangements will be interfered with, but they will not be interfered with at all.
§ Mr. LLOYD GEORGE
That really is not a sound argument, because these societies will be absorbed in the Bill, and in future the arrangement will be carried on under the Bill. If not, we propose that they shall not have the benefit of the State subsidy and the contribution from the employer. You cannot have it both ways. If the hon. Member proposes that they should carry on under the old system they cannot get the benefit of the employer's contribution and the State contribution. In those whole areas where people are earning over £2 a week, where they and their 395 fathers and grandfathers have made arrangements for contract terms to be attended and receive medical benefit, in. future they will have to pay their Bills, and they will not receive the benefits they are at present entitled to.
§ Sir HENRY CRAIK
These contributors are carrying on under an arrangement. They can continue to make their payments to the system under which they are now and towards that payment they would receive the equivalent which is referred to in this Amendment, which will lessen for the future the sum which they pay to the other organisation.
§ Mr. LLOYD GEORGE
That is the same point which has been raised, and it is the point which I am traversing. Let us understand this point. I think it is a point of first-class importance and we ought to understand what we are voting upon. I say the meaning of this Amendment is that where you have got now an arrangement in a mining district or a textile district and the men are earning 30s., £2, or £2 10s. a week, where they enter into a contract to receive medical attendance, whatever it costs those societies, if those societies become approved societies under this Bill, they will cease to receive the benefit of that contract.
§ Mr. LLOYD GEORGE
The hon. Gentleman says they will not be able to command the services of a doctor, but they will get the money, and then they make their own arrangements.
§ Sir H. CRAIK
I did not say that. I said they would have the same command of the services of the doctor by payment to this organisation that they have now, and that the payment to the organisation they make would be reduced by the sum they receive under the Amendment now before the Committee.
§ Mr. LLOYD GEORGE
This Amendment is supposed to have some effect, or it is not. The hon. Member's argument was an attack upon the contract system, and he wanted to destroy that system in respect of people who have means to pay their own doctor. [HON. MEMBERS: "No."] Then what on earth is the object of the Amendment? I thought that was the object of the whole of this agitation. I thought the argument was that it is not fair that we should call upon a doctor for 396 a fee of 6s. per year to cure men who are receiving £2 a week. This Amendment will deprive people who are earning over £2 of the services of the doctor on contract terms. If this Amendment has not that meaning, what on earth is the object of it? I want to point out what happens. I say that in a district now where it is the tradition that the medical practice is a. contract practice, where the men earn especially in good times over £2 a week, in districts like the mining and textile districts, they will be deprived of these benefits. This is what one of the doctors says—it is in a report of the British Medical Association—he comes from the Durham district, and he explains that the Durham miner becomes so used to paying his fortnightly subscription to the doctor that he has a horror of doctors' bills. He says:—I am almost convinced that private practice would be a failure among miners. There would be no getting one's bills paid; and as there is a considerable floating population among them (say 10 to 15 per cent.) the loss in bad debts from this cause alone would be considerable.That is the view of a doctor practising in a mining district, where the miners certainly earn over £2 a week, and he protests against an Amendment of this kind. It would not be operative in a district of this kind. And a man may be earning £2 a week at one moment; then his wages drop down. Is he entitled then to the benefit of the club doctor. I cannot imagine anything more ridiculous than that. He has already paid his money to the other doctor.
§ Mr. LLOYD GEORGE
The right hon. Gentleman said he was attending to this branch, which is benefit societies. He would find the £160 limit does not apply to the industrial population. The £160 applies to the other branch. The man may be entitled to the club doctor at the time when he is not ill. He just gets over £2 a week, and he gets ill, and is not entitled to the club doctor. It is a perfectly preposterous Amendment.
§ Mr. LLOYD GEORGE
The hon. Gentleman is apparently rather annoyed at my exposure of the character of his proposal. There are two things I want the Committee to consider. These difficulties are really very largely difficulties of a local character. In cer- 397 tain districts you have got contract practice—almost universal in the industrial population. In other districts you have not got it at all. From the point of view of the doctors themselves this is a thoroughly bad method. In some districts of the country the man who earns £2 a week is a very exceptional person. If you insist on the £2 limit, it is not of the slightest use to the doctors of that district. In these districts—and there are districts where you have no contract practice, or very little contract practice— you get men earning 25s. or 30s. a week paying their doctor on the fee system. What complexion is this for the doctors in these districts. They are not protected at all. One pound a week is as much as 30s. a week in another district. The £2 a week is a perfectly artificial limit. It is not representing anything like the merit of the case. In rural districts a man earning 30s. is better off than a man earning £2 a week in London. In Lancashire they object to the contract system altogether. There are doctors there who tell me that, if we support this contract system there they will not have it at any price. That is not a £2 a week limit; that is an objection based on the tradition of the neighbourhood. It is an understanding accepted by their patients, and in that district your £2 limit would be absolutely of no use. The Amendment of the hon. Member for Hoxton would be applicable there. You say we shall have that as well. It is first an agitation for a £2 a week limit; then somebody says, let us have a compromise; then the friends of the medical profession say, we shall have the £2 limit and the compromise as well. If the champions of the medical profession have as their object to put their friends in a position which entitles them to no sympathy from any reasonable man, this is the attitude to take.
§ Sir PHILIP MAGNUS
We merely carried out a suggestion of the Chancellor of the Exchequer that the £2 limit is not applicable to all districts, and it is to give the man of the 30s. district the option to elect if he so chooses.
§ Mr. LLOYD GEORGE
I listened for half-an-hour to the hon. Gentleman, and I can see other hon. Gentlemen prepared to speak on the other side. If he would allow me to proceed with my argument.
Sir GILBERT PARKER
The right hon. Gentleman has just said that if he was in 398 any way misrepresenting the hon. Member he would be very glad to have it pointed out to him. I would point out to him the Amendment says £104 a year. A man may be getting £3 for a certain number of weeks in the year, but the whole sum may not be more than £104 a year. The hon. Gentleman was not quite fair in putting a point of the £2 a week.
§ Mr. LLOYD GEORGE
That is not to correct misrepresentation. That is an argument right in the middle. If I have misrepresented I shall give way, and I should be sorry if I did so. What he says is, we will make £2 a week the compulsory limit everywhere—that is what I understand—but, in addition to that, we shall have an optional limit, which may be 25s. or 30s. Is not that exactly what I am complaining of? Do the doctors state: "We are perfectly prepared to consider the local conditions, and arrangements shall be made between the local health committee and the doctors, which shall take into account local traditions"? I think every doctor admits it can only be a rough-and-ready limit which can be set and which can be enforced in any neighbourhood. If you follow a line of that kind it suits the doctor very much better, because it means, in districts where there is now really a sort of rough-and-ready means limit when a doctor says you can pay, that in eases of that kind an arrangement can be made by the local health committee. The £2 limit in some districts in my country would be useless. I suppose in many rural districts you do not get 5 per cent. of the workmen with £2—I think I am putting it very high. Is it not very much better to leave it to the local health committee and say that in these districts where men have been in the habit of paying fees to doctors they can do so in the future where their income is, say, 25s.? There, is a sort of rough-and-ready line which is created by the medical profession and the county health committee and representatives of the friendly societies. What would happen then would be this. With regard to a class of the population you get the guarantee of the health committee that they shall pay their doctors.
The doctors would be better off, for the simple reason that now the doctors are losing heavily upon the lower-waged people in the country. A doctor in the country hardly ever refuses to attend a man. I do not know of a case, though there may be cases where a man has run up bills until at last the patience of the doctor has 399 been exhausted. I have never heard of a case of a doctor saying "No, that man is a poor man, and I am not going near him."
A doctor has sometimes 40 per cent. of bad debts. That is the sort of thing which happens to the country practitioner. He will get 6s. or 4s. or 5s. in respect of that class of the population. What happens in the case of the people who can pay? If the Amendment of my hon. Friend is carried you will not impose a limit. You cannot average for administrative reasons; you do not know who your £2 men are. You would enforce a rough-and-ready line which should be agreed between the practitioners and the Public Health Committee. In this case the doctors would say, "We decline to attend people of that kind except upon the old system. "The 5s. or 6s. you would roll up, and put to credit. Thus, if a man who is ill pays his doctor's fees, he can draw upon the reserve which is placed to his credit in the friendly society.
§ Mr. LLOYD GEORGE
I mean the capitation fee. That would be placed to the credit of the man. He may roll it up for years, and then, when it becomes due, if he happens to be above the means limit, he can draw on these reserves to pay the doctor. There is another advantage in that. It is not merely a local option; it is a personal option. There are many doctors who will not take contract practice under any terms. I was talking to a very distinguished German doctor who was here giving evidence the other day, and he said there are doctors there now who will not work under contract terms. A working man may say, "I should like to obtain the services of that man; I prefer him to any man on the panel." Unless you have a personal option he will be compelled to take somebody on the panel, which means somebody who is prepared to work on contract terms. A man of that kind would go on the panel, so long as he knew he could serve people upon fee terms. The working man would be able to have his own doctor, a doctor probably who would refuse to work on contract terms. He would say, "I do not want you to work on contract terms; I only want you to be on the panel so as to enable me to draw on the medical reserves on the books of the Commissioners for the purpose of paying your bill." There is an 400 advantage there for the doctor and for the workman. The workman has a wider scope of selection, and he has access to the best men of the profession which he probably would not have under a purely contract system. I suggest to those who have the interests of the doctors and of the national health at heart that it is far better to have an elastic system of that kind than to have a sort of attempt to fix a rigid income limit. It would certainly be better in the rural districts where this £2 limit would not be worth the paper on which it was printed. It would be absolutely no use at all in my district.
On the other hand, a free and open and elastic system of that kind would, I think, work admirably. You cannot arrive at the £2 limit, because incomes fluctuate so much. They fluctuate from season to sea-son, from year to year, and even very often from week to week. A man may at one time be over £2 and another under it. You may have a man earning 30s. who may be worth £2 or £3 a week because he has savings of his own. A doctor knows pretty well who has the means to pay, and, if you have an elastic means limit, it will work, but, if you have a £2 limit, you will have to set up huge machinery, just as in the case of the Income Tax. There is at present a huge system in this country which enables you to find out who has over £160 a year, but you have no system to enable you to find out who has £104 a year. We have really got the same object at heart, but I am sure this is the better system. I have seen a good many medical gentlemen, and those who came from Lancashire felt that on the whole this was a Letter system than a mere rigid limit. Such a limit would be of very little use to them, because a considerable portion of their practice is not over the £2 limit. There are thousands of medical practitioners in this country who live on men who earn 25s., 30s., or 25s. a week. They may have a few of the middle class, but they have very few workmen on their books who earn over 30s. a week. An elastic system of that kind would meet that kind of case. It would enable the doctor to carry on his present practice, it would enable him to get his bills paid because there would be something to assist the workman to pay, and it would also enable the workman to secure the services of his present medical adviser, even though he refused to act on contract terms. I do therefore suggest it would be better if we could get on to the Amendment of the hon. Member for Hoxton (Dr. Addison) because 401 that meets the realities of the case, and does not attempt to fix an artificial limit which suits neither the doctor nor the patient, and which certainly is not in the interests of national health.
§ Sir R. FINLAY
The Chancellor of the Exchequer has at least done one thing for the medical profession which no one has over achieved before. He has made it an absolutely united profession. I can assure him that on this point the profession is absolutely united. The Chancellor of the Exchequer says this point, which the profession has at heart, and which it regards as vital, is absolutely preposterous. That is the expression used. I do not desire to argue the Amendment solely from the point of view of the doctors. It affects them most seriously, but it also affects the public, and, but for the speech to which I have just listened, I should have hoped I might satisfy the Chancellor of the Exchequer himself that in the interests of the public and in the interests of national health, this is an Amendment which ought to be accepted. There is only one point on which I feel inclined to disagree with the hon. Member for the London University (Sir P. Magnus). He called the arguments of the Chancellor of the Exchequer sophistical. I think, in saying that, he paid him an extravagant compliment. What were the arguments of the Chancellor of the Exchequer? They were two, repeated with a great many variations throughout his speech. The first was that a fixed limit is of no use in many districts. There are many districts where £2 would be too high and where it would be no good at all. He put it to the Committee, as if the choice were between a fixed limit of £2, as he constantly said, and not £104 a year as is actually proposed, and an elastic system with no fixed limit at all. There could be no greater fallacy, and I hardly think the Chancellor of the Exchequer has not now realised the fallacy into which he fell. What possible inconsistency is there in having a fixed limit of £104 a year and yet recognising the fact that there are many districts of the country where £104 a year would be too high and of no. use and where you do want a discretionary limit so that it may be brought down further? The two things are absolutely consistent.
I think the Chancellor of the Exchequer owes an apology to the medical profession for what he said when he charged them with trying to get it both ways, with trying to have a fixed limit and a discre- 402 tionary limit. Where is the inconsistency in saying that in no case should a man who has £104 a year get medical attendance as proposed in the Bill and saying there are many districts where the conditions vary and where there ought, therefore, to be a discretionary power given to the health committee to adopt a lower limit? I shall wait with some curiosity to see whether any hon. or right hon. Gentleman on the Treasury Bench will venture to repeat what did duty with the Chancellor of the Exchequer for an argument on this point. The Chancellor of the Exchequer went on to say it would break up existing arrangements. The existing arrangements, as were pointed out by my hon. Friend the Member for Glasgow and Aberdeen Universities (Sir Henry Craik) would go on. The only difference would be that a man who desired to take advantage of these arrangements would have the help of the money equivalent, which he would get, instead of the relief in kind which the Bill at present proposes. The Chancellor of the Exchequer, in the opening sentences of his speech, said the Committee ought clearly to understand that the object of this Amendment is to take away medical benefits from those who have more than £104 a year.
§ Sir R. FINLAY
The right hon. Gentleman qualified it a little when he was interrupted, and I perfectly accept his assurance that he did not mean it.
§ Mr. LLOYD GEORGE
I do not mind the hon. Gentleman's comments but I do mind his misrepresentations. What I did say was that where a man was now receiving medical attendance under a contract, he would not command that attendance under that contract in future. That was all I said.
§ Sir R. FINLAY
That is another point altogether. The right hon. Gentleman is not dealing with the point upon which I was speaking. I will not argue with him. I now know what he meant.
§ 5.0 P.M.
§ Sir R. FINLAY
As the right hon. Gentleman thinks fit to say that, I will only say we know his intentions, but for a 403 master of the English language, his expressions were singularly ill-chosen. The object of the Amendment is not to deprive those with more than £104 a year of medical benefits, it is to give them these medical benefits in another and preferable shape. That is the object of the Amendment. Instead of getting medical benefit in kind, as proposed by the Bill, under a contract system, they will get a money contribution which will help them to make their own arrangements with their own doctors. I am going to submit to the Committee this is an arrangement which in the interests of the insured persons ought to be adopted as an Amendment to the Bill. The contract system is universally condemned by everyone who has had any exeprience of it. The great flaw in this Bill is that it proposes to supersede a system of private practice under ordinary arrangements between doctor and patient by a universal system of contract attendance with regard to all persons under £160 a year. The object of the Amendment is to restrict the area of the contract system. You do not get as good results from medical attendance under contract as you do from medical attendance in the ordinary way. In the first place, you do not in all cases get as good a class of medical man to undertake attendance under these terms. There is a strong feeling in the medical profession against the contract system. There is a very strong feeling that it is bad in its effects alike on the doctor and on the patient, and a great many medical men will not take contract practice. You do not get the same choice of medical men, and in many cases you do not get so good a man as if the attendance were on the ordinary professional terms. In the second place, you get inferior work under contracts. Do not the Committee realise the position of a doctor with a large number of contract cases coming into his surgery in the manner described by the hon. Member for Hoxton (Dr. Addison) yesterday. Is it possible to suppose that each and all of these patients get the best of the energy and skill of the medical man. His surgery is crowded with contract patients, and he has his private practice to attend to as well. More than that, the contract system has a very bad effect on the relations between doctor and patient. The patient is apt to think he 404 may treat the doctor as a servant, that the doctor is paid to attend him, that he may send for him unreasonably, and may demand his services whenever he thinks fit. These things are all calculated to produce, and in fact have produced, friction between doctor and patient. The fact that a fee is payable for a visit promotes self-respect on the part of the patient; it prevents unreasonable demands on the medical men, and it secures the medical man giving the best of his skill and attention to the patient. The contract system is a bad one. I think I may say this, that the only good contract system as regards medical attendance I ever heard of was that in the case of the Emperor of China, who has his establishment of physicians-paid by salary. If he falls ill the salary is stopped, and it does not begin again until the Emperor recovers. That is a system of contract attendance which may be commended as a good deal better than the contract system of which we have heard so much in connection with this Bill.
This contract system, with all its objectionable features may be necessary for the poorer class of patient. No one would be inclined to deny that it always must exist; but it ought to exist side by side with the private practice. Whatever reason there may be for applying it to the poorer classes there is no reason for forcibly applying it to a class of persons who can and do pay. I do not know if the Committee realise one matter of which I have evidence in many communications of which I have been the recipient. It is that a very large part of the income of the ordinary medical practitioner is derived from persons whose income is under £160 per year—whose income, in fact, varies from £100 to £160. You will find in the case of many practices that patients earning that income contribute no less than nine-tenths of the professional earnings of the doctor. These practices have been bought and sold. Many a man has bought a practice, paying a very considerable sum for the goodwill; but, under the Bill as it now stands, the value of that practice will be annihilated. I do not desire to unduly labour the fact that a great many doctors may be ruined by the Bill as it stands. What I do desire to point out is that there is absolutely no demand for this change as regards the class of persons with incomes between £100 and £160 a year. The present system promotes the self-respect of the patient and the efficiency of the doctor's work.
405 I desire to call the attention of the Chancellor of the Exchequer to the fact that if he does not accept some Amendment of this kind he will allow this Bill to become law with a very great blot in it. In more than one way this is a retrograde measure, so far as the national health is concerned. We heard a good deal yesterday about the hospitals. It was recognised that the effect of the Bill on the hospitals will be such that we are brought within a measurable distance of contemplating the necessity of subsidising the hospitals from national resources, after an interregnum of diminished efficiency, owing to the falling off of the voluntary subscriptions by which they are at present supported. In that respect the Bill, unless it be amended with reference to the hospitals at a later stage, is a retrograde measure. It is also a retrograde measure with regard to the matter at present under discussion, because it proposes to substitute for the ordinary relations of doctor and patient this contract system, which is universally condemned. The contract system does not work well in any case. I dare say many hon. Members will remember an incident in Scott's novel, "The Antiquary," when Jonathan Oldbuck, on reaching Queensferry, found one of his horses had cast a shoe, complained to his driver, and on ordering him to stop at the next smithy, was informed that: "It's Jamie Martingale that furnishes the naigs on contract, and I am not entitled to stop." The Antiquary replied: "Who do you think will uphold you on contract?" In fact the; contract system is not good for either man or brute. It is really a very great blot upon this Bill that it proposes to make the contract system universal as regards those who are affected by the Bill. Why disturb the existing system as between the £100 and £160 limit; why not leave it to go on as it is to the mutual satisfaction of both parties, and supplement it by giving to the insured person a money contribution which will help him to make his own arrangement with the doctor. I submit, with some confidence, to the Committee that no case has been made out for such a sweeping alteration. There are many districts where the £104 limit may be too high, and where it ought to be lowered. Let them be dealt with under some discretionary power. But I do say there is no part of the country where the £104 limit is too low. I admit to the Committee that the acceptance of this Amendment, to be supplemented by 406 the Amendment which the hon. Member for London University referred to, and by embodying in it the element of discretion with regard to those who are under the £104 limit, will remove a very serious flaw from the Bill. It is perfectly plain that this Bill was introduced without sufficient inquiry from those qualified to give information as to the conditions which actually attend medical practice. I, therefore, hope the Chancellor of the Exchequer will reconsider his position and accept this Amendment, to be supplemented by discretionary power in the districts which have been referred to.
§ Mr. GILL
The hon. Member who moved this Amendment commenced with the statement that the whole medical profession was in favour of it. Let me tell him, with regard to that matter, that there is a larger body interested than the medical profession—a body consisting of the working classes of this country who are against it—and we have something to say on behalf of that larger body. The object of the Amendment, of course, is to rule the artisans out as far as the medical benefit is concerned—artizans who earn more than £2 a week. I happen to represent a very large number of working men, who in good times earn more than £2 a week, and under this Bill they will have to pay exactly the same contribution as other classes of workmen, and yet by this Amendment they are to be deprived of the benefits which the other classes will possess. I do not think that can be considered equitable in any way whatever. I object to this Amendment, also, because of its inquisitorial character. Under it you are going to inquire what a man earns. I well recollect the way in which hon. Members opposite objected to the Super-tax proposal because of its inquisitorial character. They did not want inquiry to be made as to incomes exceeding £3,000. But what is sauce for the goose is sauce for the gander. Let them be perfectly fair in regard to this matter; let them treat everybody alike; let them treat the working classes in the way they want to be treated themselves. [An HON. MEMBER: "We would all like to be in a position to pay the Super-tax."] Under this Amendment everybody earning over £2 a week will be ruled out. But that is not all. The doctors claim to be entitled to refuse people earning under £104 a year, because in the Amendment with regard to the panel of doctors I think will be found the words, "the doctors willing to attend." Thus they want it both ways.
407 I understood the hon. Gentleman who moved the Amendment to say he did not desire that a profession like that of the doctors should have to form a trade union for the purpose of protecting their own interests. They want those interests, in fact, to be protected by law, while they are content that the poorer classes shall have to use their own combination to protect their interests. I think the working classes are entitled to the protection of the law as much as any other class, and even if they earn less than £104 a year they should have the same treatment in this matter as the doctors. The doctors have gone outside their sphere in making a suggestion of this description. Their business is not to say who they will attend, but to see to it that, so far as they are concerned, they get properly paid for those they do attend. I object to this Amendment, also, because of its impracticability. How are you going to get to know if a man earns £2 a week? When you have got the information is it to be applicable for all time, or will it apply to only a limited period. It may be that he earns £2 a week in one year, and much less in another year. I very largely represent cotton-workers in this House. We have periods in which there is a boom in trade and we have periods of depression. In connection with my own industry, a very large number of the spinners get over £2 per week in good years, but then there are years, two or three in succession, when they have to work a good deal of short time, and when their wages may average the year through 35s. a week, and even as low as 30s. Which year is to be taken in applying the £2 limit? Is it to be the good year or the bad year? If you make it the good year it may be followed by a year of depression when the man may be earning only 30s. a week, and that is the year in which you are proposing to deprive him of the medical benefit, the year in which he is least able to pay for a doctor's advice. I say it is absolutely impracticable to work on these lines.
There is another feature which should be borne in mind, and that is that the £2 per week is not of the same value in all cases. Thirty shillings in some districts is equal to £2 a week in London. Then there are the circumstances of the individual to be borne in mind. A man with a large family earning £2 per week is in a much worse position probably than a man with no family at all who earns 30s. 408 per week. There is no equity at all about this proposal. We are told that if the Amendment is carried it may be extended and that the man may get some equivalent back, but what is that equivalent? This is an insurance scheme. The man may be ill three or four months in a year and he may get back the 6s. or 8s. 6d. which would not be paid over to the doctor, as under the pooling system he will get the whole attendance during three or four months, and have nothing to pay at the end. I understood the hon. Gentleman who moved the Amendment to speak of elasticity. My idea of elasticity is that it should stretch both ways, but his idea was that £2 was to be the maximum. One begins to wonder what limit they would fix if they had their way. I think the agitation that has been conducted by the doctors is a splendid example of a trade union movement. They have put up a great fight for the purpose of protecting their interests, and it only shows what can be done by combination. But I think they have gone a little too far, and in this particular case they have outstepped their own sphere. They have no right whatever to say what the income limit shall be. Their business is to see whoever they attend that they are properly paid. I would give my vote in favour of their being properly paid, but I would not let them cut out a great portion of the working classes, who have to pay the same contribution as other people. On this ground I object to the Amendment, and think those with whom I act will vote against it.
§ Sir ALFRED CRIPPS
In imputing the motive that anyone on this side wants the, poorer classes put in a worse position than the better-to-do classes, the hon. Gentleman is really introducing prejudice. In a matter of this kind we all want to arrive at the best possible solution.
§ Sir A. CRIPPS
I would much rather have a voluntary than a compulsory system, but if you have a compulsory system a certain' measure of inquisition is necessary, and cannot be avoided. But I want to say a word in answer to the Chancellor of the Exchequer. More than once 409 during these Debates I have submitted that the Bill works very hardly in the poorer rural districts, and that is particularly the case as regards this question of the income limit. It is quite true that in the rural districts you get a very large number of persons who would be below any limit you fixed, because, as a rule, their income is less than £104 or any other limit which ought to be fixed, but the result of that is that if you want to have doctors of sufficient capacity in our rural districts, you must not cut off from them the advantages which they derive from attending better-to-do persons, and in our rural districts there is a very large number of people who employ their own doctors, and still desire to, who have an income in many cases ranging between £104 and £160. Let me give an illustration as regards Buckinghamshire. Every doctor in Buckinghamshire desires to do what he can in order to make this Bill work well, but they have a unanimous opinion on this point, that they cannot carry on their professional business as professional men, they cannot incur the cost of education and of research if the only profitable portion of their business is cut off, which is practically that between £160 and the average of £2 a week. It is very difficult, as everyone knows, in country districts, to obtain doctors of sufficient experience and eminence to deal with this small class of practice, but if, in addition to that, you cut off from them what really means in many cases 95 per cent. of their profits, you will inevitably have in these poorly paid districts a class of doctor below the national requirements if you are to have poor people properly treated, and to have a proper level as regards medical education and knowledge.
I think the Chancellor of the Exchequer misunderstands the effect of his proposal in these poorer districts. In the richer artisan districts the difficulty I am referring to would not arise, at any rate to the same extent, but in these poorer districts it arises every day, and I do not think any professional income in those districts would be sufficient to maintain a professional man under the conditions in which a professional man is entitled to be maintained if you take away from him his profit income between £104 and £160. I hope the Committee will not misunderstand this point. It is an extremely important one. The poorer the district the greater reason there is to introduce proper medical attendance by properly qualified medical men. That appears to me to be 410 unanswerable, if we look at the Bill from a. national standpoint. Under those circumstances, why should you seek to deprive the medical man of that part of his profession which at present enables him to carry it on in a decent manner with sufficient professional knowledge and attainments? The hon. Member (Mr. Gill) says very rightly that no one in the House desires that the doctors should be underpaid, but the only guarantee is that people who are able to should pay ordinary professional charges. When you come to these country districts you will find a considerable number of people between the £104 and £160 limits, who are employing doctors.
Let me deal with two other points dealt with by the Chancellor of the Exchequer. As regards elasticity, you can equally give elasticity either within one limit or the other. Suppose you have the £104 limit. If you want elasticity, if you want to give special power to the local health committee, you can do it. It would appear to me to be a good thing to do, but it is no good giving elasticity of that kind if the conditions are such that you cannot induce properly qualified medical men to take up practice in these poorer districts at all, and it appears to me that throughout this Bill there is an utter disregard for what I may call the proper claims of the poorer districts in this country. The Bill makes ample provision for the richer districts as regards wages and employment, but as regards the poorer men in the poorer districts, in every direction almost, the Bill operates unfairly to them. As I represent a rural constituency with various small towns in it, I know the conditions there perfectly well, and I know the opinion of every medical man in that district, and I urge this alteration on the ground both that the people concerned and the doctors are entitled to it, the doctors in order to obtain a fair return for their professional work, and the poorer people because they do not want to drive doctors of adequate attainments out of their district altogether.
There is one other point which the Chancellor of the Exchequer referred to which appears to be quite incomprehensible. He referred to what he called existing contracts. What possible interference is there with existing contracts under this proposal? I want to take the case of some of the smaller friendly societies with which I am connected in my own district. They have the contract system. To a certain extent I think the contract system must be allowed, If, you try to 411 extend it too far there are objections to it, but you cannot get rid of it and you ought not to try to get rid of it altogether. At present the members of these friendly societies are getting contract terms. In the future they will get the same terms from their friendly societies as they are getting now. Without that the effect of this Bill is to destroy the friendly societies altogether. It will not be altered in any respect at all except that the payment to be made will assist the poor man in the contributions which he is now making to his friendly society for medical attendance. All these people to whom the hon. Member (Mr. Gill) referred, who are getting contract service now, will get it to exactly the same extent in the future so long as the friendly societies maintain their present position, and it is right that they should.
If the Bill was intended to destroy the friendly societies and the medical benefit which they give, I for one would certainly oppose it to the utmost. I support this Bill because, though it is proposed in connection with a compulsory system, at the same time it preserves the voluntary efforts and the voluntary arrangements of our great friendly societies, and so long as that is done there will be no interference with existing arrangements at all. I think the Chancellor of the Exchequer, in charging us with not putting clearly the nature of this Amendment, hardly appreciated it himself. I quite understand that he has a great knowledge of the Bill, but he has not a monopoly of that knowledge. Various Members on this side of the House have studied the Bill in connection with medical men in their districts and with meetings of friendly societies. I had such a meeting with the Grand Master of the Manchester Unity and representatives of the Foresters and Hearts of Oak only last Friday, and their view was that as regards existing arrangements such as had been referred to, they will not be interfered with if the Bill is passed. Indeed, they went further and said, if in their view there would be any interference with the medical benefits which they are now giving, they would not support the Bill either directly or indirectly, and I think that is quite right. We must have regard to the facts as they stand. Therefore, I plead in favour of the Amendment, not only from the doctors' point of view, but from the point of view of the poor man in our poor agricultural and 412 other districts, because if you put this limit as high as £160 a year, you will deprive every professional man in these poorer districts of what may be the chance of earning a decent professional income, and if you do that you lower the whole level of medical attendance in the poorer districts of the country. It is on these grounds that I heartily support this Amendment. I think the Chancellor of the Exchequer can hardly have appreciated it, and I plead for it in favour of the poorer districts, which I am personally connected with as regards my political life.
§ Sir ARTHUR MARKHAM
The right hon. and learned Gentleman (Sir R. Finlay) seemed to me to do his best to raise all the difficulties he could between the medical profession and the Chancellor of the Exchequer. To say that the Chancellor had any intention of insulting the medical profession is very far removed from the actual facts. But this Amendment, from the point of view of the mining industry, which is one of the largest industries in the country, does not meet the case. May I put the case before the Committee as regards the mining industry. It is absolutely impossible, owing to the system under which work is carried on in the mining districts, to tell what a man's wages are from year to year. At some of the collieries I am connected with men have good wages, sometimes running up to 15s. a day. We do not know in cases where men work under the contract system what their yearly income is. Therefore, in connection with the Income Tax these men are returned as having an income of about £160, but it is impossible in point of fact to find out what their income is. The Treasury have done their best to find out. and they have failed. Here we have a limit of £104 proposed. Trade varies, and with trade variations wages vary from month to month. Therefore, the proposal is wholly impracticable, and I would ask the Committee to reject it. It may be that men earn 45s. or 50s. a week at certain times of the year, but they have long periods of unemployment, and therefore to make the limit of £104 would not work in practice. The friendly societies which we have had working in connection with collieries and like undertakings have enabled the men who are earning wages to have the benefit of medical advice in years past. You are actually going to put them in a worse position than before the passing of this Bill. I say that the doctors have done uncommonly well.
413 The number of people is to be increased from 6,000,000 to 15,000,000. That will immensely increase the facilities of the doctors for dealing with these people. The expense of dealing with insured people depends very much on the number of people in any particluar area. In an area which is thickly populated the Bill will be of advantage from the point of view of medical practitioners who are working in that area. They will be able also to provide medicines at a considerably lower price than those who are working in areas with scattered populations. Therefore, the claim that is now put forward on behalf of the doctors is one that cannot be entertained. It is not well founded. We have given the doctors a further increase of £4,000,000 a year. That is in addition to what they will derive from private practice among people who have over £3 a week. In districts I am connected with the workmen in the past paid their doctors well. They paid salaries varying between £700 and £800 a year, and it is quite wrong to say that the working classes are not entitled to get the benefit of open and free competition, for, after all, it is they who suffer, and not this House. I do not think that anyone has cause to complain of the provision made in the Bill with respect to medical attendance. No one wants to see the medical profession underpaid. I believe the members of that profession are going to get enormous benefits under the Bill. The Chancellor of the Exchequer has already given way far more than he should have done, simply for the purpose of coming to an arrangement with the doctors; and yet we have the medical profession pressing their claims in the way they are now doing. It only illustrates that the members of the medical profession and barristers belong to the strongest and most tyrannical trade unions we have in this country.
§ Mr. LANE-FOX
I cannot agree with the last remarks of the hon. Gentleman in regard to the legal profession. I hope hon. Members will consider the position of the doctors before condemning them. It is only fair to remember that there are totally different conditions in the country in regard to medical practice. I want to support the principle of this Amendment, though I do not think it is quite so good in form as I should like. I am perfectly certain that the argument used by the hon. Member for the Wycombe Division of Buckinghamshire (Sir Alfred Cripps) is correct that, unless something of this sort is done, the proposed system will tend to 414 lower the general level of medical practice throughout the country. That is more especially true in relation to the rural districts which will suffer under the Bill. It is not easy for those in towns where contract practice is usual and lucrative to realise what are the conditions of doctors in scattered rural districts where contract practice means travelling over great distances, and where, consequently, the practice is very much more expensive. In all these rural districts the main income of the medical practitioner is derived from farmers and small tradesmen. I hope it will be remembered that there are comparatively few doctors, and that there are a large number of the working classes. The object we have at heart is that fair pay should be given to the doctors, and in this matter I am afraid the minority has to suffer.
I wish to emphasise that in these rural districts the classes the doctors have found a profitable source of income in the past are people who have no desire to sweat them. They do not wish to be brought under the provisions of this contract system at all. I am perfectly certain that if you consulted them you would find that they would far rather go on as they are doing. They would far rather pay their doctor than have a general level of the medical profession, and a general level of medical attendance. I certainly prefer the suggestion contained in a subsequent Amendment, because it is very much more elastic. There are objections to this Amendment, because it would be very difficult to work. I wish to oppose the proposal, in so far as it affects districts inhabited by classes who are satisfied with the present system. It is not the rich who are going to gain, but the poor, who are going to suffer if a general level is allowed to come in. In rural districts it will affect very largely the poorer classes, and it will lower the scale of remuneration. Apart from that, I hope that the House will definitely settle some sort of limit. Those who have gone into the subject and examined the books of doctors who have been in practice for many years know that if this limit of £160 is maintained the members of the profession will suffer. I am sure that the Government, on considering this matter, will see that some change is necessary.
§ Mr. GEORGE ROBERTS
I have given some consideration to this principle, and personally I confess to having considerable sympathy with the Amendment. Never- 415 theless I cannot get away from the utter impracticability of the proposal. I fail to see how you are going to apply it. The principle of the Clause included in the scope of the measure is understandable, although I recognise that any limit must be of an arbitrary character. It may well happen that some people are not paying Income Tax who ought to pay, but nevertheless you have machinery in existence for collecting Income Tax, and you may say generally that it has succeeded in embracing all those who ought to pay. My hon. Friend the Member for Bolton (Mr. Gill) pointed out the varying value of £2 in different parts of the country. I have had experience of £2 a week in London, and I know that that sum in London is not worth so much as 30s. a week in my own native town, and if I were to be excluded in London from the benefits of the Bill I think that would be extremely hard. I represent in this House a body of working printers. Their minimum wage in London is £2 a week, while the minimum in my native town of Norwich is 30s. But so far as we are able to ascertain the actual standard of life differs very little to the man who has £2 in London. He gets no higher standard of life than the man who has 30s. in the Eastern counties, and therefore I say the proposal must operate very harshly as regards a number of worthy people who reside in the larger centres. Therefore I submit that the proposal has not the merit of equity which some would claim on its behalf. Again we are told that the conditions will not be in any way altered. The hon. and learned Member (Sir Alfred Cripps) wanted us to believe that the contracts now in existence would in no way be varied owing to this legislation. The societies which have created the contracts might wish to contract out of the scheme, but, on the other hand, we are desirous of bringing all these bodies in as approved societies, and certainly if you contemplate the conditions of the approved societies you must recognise that the existing contracts no longer prevail. I have had a deal of experience of the contract system, and I repudiate the implication underlying the speeches of some hon. Gentlemen in this House.
It is not correct to say that the medical men who are engaged in contract practice do scamp their work. I believe that in the main they have performed that work satisfactorily. On the other hand, I recognise that in some respects they have been subject to injustices, and I believe that the 416 operations of this Bill will very largely remove those injustices, and, of course will be a benefit to the medical man. One hon. Member took up the case of the rural districts. I believe that the medical practitioner in the rural districts is going to be greatly benefited under this measure. Those whom he has to attend are invariably very low-paid labourers. They are the class from whom he has had great difficulty in getting a discharge of the bills they have run up. In this connection he is certain of being paid whatever sum may be agreed upon between the societies and the health committees. So simply to credit a man with 6s. or 8s. a year, as the case may be, is not an equitable proposition. It entirely destroys the basic principle of this measure, which is the principle of insurance. If you are simply going to credit an individual with a sum of that character in so far as that class is concerned you entirely destroy that principle.
If I associate with my fellows in the anticipation that in some contingency I may receive some benefit my interest in that organisation is far larger than the sum represented by the contribution that I paid. I submit that that applies equally in this case, and that it would not be either just or equitable simply to credit the insured person with the sum that you may ultimately agree upon as the per capita allowance to the medical profession. I stated that my main difficulty is that of the practicability of carrying it out. Necessarily it would involve some considerable amount of supervision and investigation. I am not going so far as to say that it cannot possibly be done because medical men in my own constituency have in existence an agency which works very largely on this principle. But it is simply a rough and ready fashion of doing it. I do not think that it will be capable of extension to the whole country, there are so many difficulties in the way. Simply judging by appearances, one man may-keep a home in very good condition, and to all outward appearances may seem fairly successful. Other persons with an equal wage may not be able to keep up that appearance, and they will get the advantage and the other more worthy person will not get it. The point I want to submit is, you have no right to contemplate wages week by week. In some of the better-paid industries the wages are higher because of the character of those industries: £2 5s. a week in some industries is not equal to 35s. a week in others, because of the fact that the men in these 417 others are worn out in a short number of years. Therefore I submit there is every reason to say that it is utterly impracticable and would be most inequitable in its incidence.
After all, I want to see wages contemplated as covering the whole liability of life. That is, that men should receive sufficient wages not merely to cover their actual weekly need, but in order to make provision for all the contingencies that beset them through life. If you are going to fix an arbitrary limit of £2 a week I say it must strike unfairly against this very large class, because in the main that class receive higher wages because of the arduous nature of their trade and the shorter working life which is inevitably their fate. While I have expressed myself as possessing considerable sympathy with the medical men, and there is no member of the Labour party but believes that all classes of the community ought to be equitably paid, and I am prepared to acknowledge that many cases have been brought to my notice where medical men have not been suitably treated under existing conditions; yet from a general survey of this measure, as far as one can precipitate himself into the future with a view to gauging what may be its operation, I believe that the general standard of the medical profession will be raised owing to the provisions of this Bill. But in respect of the particular Amendment before the House, I say that while I am not unsympathetically disposed towards the aim of the medical man to preserve his private practice as far as he possibly can, nevertheless I am bound to submit that this Amendment, if carried out, would inflict this great injustice on large groups of the working classes, and would be so unjust in its incidence that, while it might placate the medical man, it would set up such an amount of resentment among the working classes themselves that, just as we recognise that the measure cannot be completely successful without the hearty co-operation of the doctors, so we have to recognise also that unless the provisions are such as will commend themselves to the great bulk of the thoughtful and worthy section of the working classes, the Bill might be doomed to failure, a failure which I am sure nobody desires to see.
Sir GILBERT PARKER
I wish to associate myself with a great deal of what was said by the hon. Member who has just sat down. I have great doubts about this Amendment. The hon. Member has 418 spoken of the difference in wages and the difference in the cost of living. There was pointed out the other day at a conference called in my Constituency, the difference in wages in brick-making and other industries between adjacent districts such as Dartford, Ashford and Chatham. The difference is considerable. They pointed out that the effect of fixing an arbitrary limit of that kind would be to differentiate between the same classes of workers in contiguous districts. I do not think that is good. I am very doubtful of the ultimate result. If you are going to fix an arbitrary limit of the kind it seems to me you are bound to produce injustice and grievances which would make the working of that successfully very doubtful indeed. But while I cannot discuss the Amendment of the hon. Member for Hoxton, which has been referred to so much this afternoon, I can say this, contrasting the principle embodied in this Amendment, it does appear to me a better one, because if, as the Chancellor of the Exchequer and others believe, the result of this Insurance Bill will be to create a new feeling regarding national health in general, and a better understanding of our responsibilities undoubtedly it is absolutely certain that local option will work very effectively in regard to this Bill; because it is quite certain that local health committees constructed as they will be of the best classes, medical and otherwise, in the particular districts will be much more open to conviction in the first place, and in the second place will feel ultimately such pride in administrating a great national benefit that they will be sure in their decisions to deal justly not only by the working man, but also by the medical profession.
Personally, I feel that the contract system is one which has grave demerits, but at the same time I think that it is almost inseparable from our present industrial system, with the rate of wages such as they are, and with the immense amount of casual labour that exists; and while I would do away with it if it were possible in a better organised and healthier community, since it does exist I should like to see it brought into touch with the responsibilities which the health committee will have in regard to this very question of fixing the limit. I cannot imagine that the medical profession would greatly object to that because in each district they can bring influence to bear, not an undue influence, but an understood influence, that personal influence which will affect the local health committees, and so with regard 419 to the Amendment of my hon. Friend, while I recognise what he is aiming at, I think he would do well to withdraw his Amendment. As this is not a party question at all, I am trying to put the case as I see it, and I believe that the Amendment of the hon. Member for Hoxton embodies all that is best in this Amendment, and will at the same time give the elasticity desired. I have more faith in those local health committees than my hon. Friend.
I believe that those local health committees will become bodies with a highly judicial and a highly generous and just estimate of the situation as affecting the doctors on one side and the working people on the other, but I, for one, would repudiate the suggestions made this afternoon, that the medical profession were trying to treat the working classes unfairly. The hon. Member for Mansfield (Sir A. B. Markham) suggested that they were harpies in the way they extracted from the poor and the working classes their return for the benefits conferred, or at least I understood the hon. Member for Mansfield to speak of the medical and legal profession as those who prey upon the public, or rather get a higher rate for their labour than they deserve. I think that a more unjust reference to the medical profession was never made inside these walls. I believe that half of the services of the medical profession are given practically for nothing. There is not a country doctor throughout this country who does not continually wipe off bad debts, and the people who owe him, and have continued to owe him, fees for years he still attends as though he were being paid on each occasion to the full. Let us free our minds of prejudice absolutely in regard to this matter, whether with regard to the working man and the friendly societies, or with regard to the medical profession, and I believe that on the Amendment of the hon. Member for Hoxton we shall come to a decision which will offer, whatever Amendment is made to that Amendment, a way out of the difficulty, which I think is not met by this Amendment.
§ 6.0 P.M.
It appears to me that if you do not carry this Amendment, the amount the medical profession will expect for their services will be very much greater, and you will be putting those people with Tinder £2 a week in a very unjust position. Take the case of a doctor who has got a 420 practice in which he has a great number of people who receive from £2 to £3 a week. These people are already paying him in his practice for work done. You are proposing that these people should be cut out of his private practice and that they should be put in as club patients. This medical man will have to recoup himself, just the same as in any other profession. The consequence will be, when it comes to the question of the capitatation grant—I presume there will be a capitation grant—that undoubtedly the medical man will require a larger capitation grant from every one, whether over or under £2 a week than ho would if there were a uniform limit of £2 a week. That means you are penalising the poorest and most deserving portion of the community. The hon. Member for Norwich (Mr. George Roberts) based his arguments on the fact that if you take those people, earning £2 a week out of the Bill, it would not be fair, because they lead a hazardous life, they have a shorter life, and have more illness. That exactly shows the truth of the argument I am trying to put to the Committee. Here are-people who are following a hazardous employment, who are getting more wages, and whom you want to bring into the Bill. Medical men know perfectly well that these men will have more illness, and they will require more capitation grant. This Bill ought to be framed for the poor and unfortunate people who cannot pay for the best medical attention in the country. This Bill ought not to be framed for those people who can very well afford to pay extra for a doctor. We as Members of this Committee ought to remember, if we do pass this Bill, and establish compulsory insurance for the working classes of this country, that it is our duty to see that they get the best possible medical attention. Do not let it be a question of a few shillings here or a few shillings there. The medical men of this country will not enter into this Act heart and soul unless they can see that it is not going to damage their own position and their own incomes. You cannot expect them to do so. But if you grant them the terms for which they ask, I think you will put them upon their mettle, and I feel absolutely confident that, if you will only show a leaning towards what they are asking for, they will do everything possible to make this Bill a thorough success. They will look upon it not from the point of view of an individual treating a patient only, but 421 from the point of view of a great profession undertaking great responsibilities for the State at large.
§ Sir H. CRAIK
I do not wish to reopen many of the questions already dealt with, but I desire to deal with some of the arguments against the Amendment. As to what was said by the hon. Member for Gravesend (Sir Gilbert Parker), I cannot myself accept the view that local option in this case is desirable. The difficulties in the way of local option are very great. The medical profession as a whole are anxious to avoid—and I am certain the Committee will understand the motive—a fight in every parish. I have in my hand a statement by a member of the medical profession, who says a uniform limit is what they want. It is final, and it would prevent their having a fight in every separate parish. I submit that the administration of this Bill as it stands would lead to an acrimonious debate in every parish throughout the country. I quite recognise the reasonableness, the constant reasonableness, which our experience teaches us, is always to be found in the speeches of the hon. Member for Norwich (Mr. George Roberts), but I do not accept his view as to the impracticability of the Amendment. I can quite understand many of the motives which animated him in what ho said, but I think we can get over the question of impracticability. The hon. Member used the argument as to wages varying in different parts of the country, and he referred to the fact of a man having a family or not as a consideration which is applicable to the case. But these are arguments which are applicable to almost every case you can possibly conceive, and, if you carry them to a logical conclusion, they might be applied to the Super-tax, the Income Tax, or anything else, where in individual cases there are varying circumstances. But that would be no argument against the taxes. I do not think that we shall ever treat this £2 limit as a hard-and-fast limit to be ascertained by any inquisitorial system; but I do say that if this House lays down a plain indication of the general level which they think ought to be acted upon, I believe that any inquisitorial system, that any friction, that might be expected would, in the vast majority of cases, disappear, and that the plan would really operate fairly when it came to be worked.
If a man desired to avail himself of the contract practice it would soon be ascer- 422 tained whether he was above the limit of income which the contract practice allowed. Therefore, I think this Amendment could be made perfectly practicable without anything like friction or an inquisitorial system. The hon. Member for Mansfield (Sir A. Markham), as he generally does, managed to introduce a good deal of acrimony into the discussion. He said that we had already assigned £1,000.000 or possibly more to the medical profession, and that this Bill would enrich that profession. But the hon. Member forgets that there are 76,000,000 who will avail themselves of the contract practice, and yet he said that the whole of the four millions of money is going to benefit the doctors, though the doctors are to lake 150 per cent. more on their hands for that sum. Let me put the case of the doctor under contract practice. Take the instance of a middle-aged practitioner who has got also a contract practice, and has acquired for himself a small but fairly lucrative practice amongst people whose income ranges from £2 a week to £3 or £4 a week. All that will be swept away. What will be put in its place? Supposing he had 1,000 patients assigned to him on contract practice. That would amount to £225 a year. One thousand patients would require, according to the ordinary calculation, 9,000 visits a year; that is to say, that they would require about thirty visits a day in a year of 300 days. Can any man work very much more? If he gives only a quarter of an hour to each visit he would have nearly eight hours constant work, not counting anything for his travelling from place to place and the time that is necessarily occupied in getting about. Is that a living wage? Is not that sweated labour? And yet that is what would be established by this munificent measure which the hon. Member for Mansfield is not ashamed to hold out as one which is fair and beneficial to the medical profession. It is against such conditions that I enter my protest. I am quite certain that the hon. Member for Bolton will agree with what I say. I am not speaking in the interests of the medical profession only. I am just as anxious as he is to see that this Bill will work to the benefit of the class he represents. I am quite sure it will not work well if you confine the preservation of the health of that class to the attention of ill-equipped practitioners, and if you leave them to the tender mercies of those who are prepared to undertake this sweated contract work. The hon. Member will see that this is very much 423 against the interests of the labouring classes, who would be benefited by the proposal we are now making. Does he not think that many men with 30s. or 40s. a week would, of their own free will, even if they had the right to contract practice, for the sake of themselves and their wives and families, seek the help of a private practitioner of their own? Is the hon. Member prepared to admit that there are such cases in which a desire will arise?
§ Sir H. CRAIK
Yes, but I come to the working of the Bill as it now stands. If the person chooses to take his private practitioner he surrenders the medical benefits under the Bill, and he would not get a penny. Under this Amendment which is now being discussed, he would have the right to demand for that money the equivalent of what he has given up. I submit that if this Amendment were adopted, it would bring about a better state of things for the labouring classes. I see that the Chancellor of the Exchequer has returned to the House, and I should like him to give me his attention for one moment. I think some of his arguments were, if not sophistical, at least dexterous. The point was taken against the medical profession that they were endeavouring to take away medical advantages that now exist in the case of those who have made contracts with friendly societies. Is the Chancellor of the Exchequer not prepared to admit that this is an unfair representation of our position? We do not desire to take away a single benefit that now exists, but that a man who takes such benefits shall have the help of the financial allowance which is to his credit. The financial allowance due to him year by year, and what very largely diminishes the contributions that he makes to his medical society.
I do not think the right hon. Gentleman can quite say that that was a fair representation of our position, namely that we wished to sweep away existing benefits. The right hon. Gentleman used another argument, he said that the medical profession tried to get a limit of 40s., and then immediately turned round and said "we will have both the limit and local option." Is that quite a fair reading of the Amendment that stands in my name on page 30 424 of the White Paper? We asked no local option which can benefit the doctors. We only ask that if a private contributor desires to have his own private practitioner he should be at liberty to do so. The medical profession is not acting in that very slim way which the right hon. Gentleman described. I think he did so rather as a debating point than as a sincere description of our position. He says that this proposal is impossible and cannot be carried out, that in many cases the man's wage would vary, but if that be the case, how would he get over the difficulty in the voluntary Amendment of the hon. Member for Hoxton (Dr. Addison). Would it be any easier because the limit was fixed by the, local health committee than if it was fixed by this House, so as to prevent all the disputes that might arise? Then the right hon. Gentleman said that; in innumerable cases the 40s. would not apply at all, and that it was utterly absurd and that in Wales it would not apply. If it would not apply, what harm would it do?
§ Sir H. CRAIK
The doctors are not going to get any more private patients, whether you pass this Amendment or not. We ask for what we think is an advantage to the community generally. We are certain that this contract practice will injure the public health, and that it will get you a low and ill-equipped class of practitioners, and that you will have an unfair distinction between well-to-do working men and a lower class working men who are forced to go to doctors under this contract practice. I know the opinion of the medical profession is united on this point. I am perfectly certain I am expressing the opinion of those whom I have the honour of representing, the opinion of the vast majority, or I would say, the unanimous opinion, so far as I know it, that we do not desire that the question should be sent down to be fought over in each district throughout the country. We desire that Parliament should give a fair indication of the limit of wage in the case of those who ought to come under the benefits of this Bill, and that those benefits should not be absorbed by the well-to-do class who could very well pay for their own attendance, and who, in the vast majority of cases, would rather have that medical attendance.
§ Mr. BOYTON
Representing a Constituency which contains within its dimensions something like a thousand medical men, I may, perhaps, be permitted to state to the Committee what is their opinion upon this proposed Amendment. The attainments of the medical profession in the part of London which I represent are very high, and although they are not so very much interested, they have a very wide knowledge of the conditions under which medical practitioners generally live throughout the country, and no less than 800 of them have signed the resolution which was adopted by the Medical Association in favour of the Amendment which is before the Committee. I desire to register on their behalf, and on behalf of no less than 800 representative medical men, their adhesion to the Amendment.
§ Amendment negatived.
§ Dr. HILLIER
I beg to move, in Subsection (1), to leave out the words "duly qualified" ["duly qualified medical practitioners"], and to insert instead thereof the word "registered."
I submit that the term "registered" is preferable to "duly qualified." If the Attorney-General will assure me that "duly qualified" is sufficient, then I will withdraw.
§ Amendment, by leave, withdrawn.
I beg to move, in Subsection (1), after the word "practitioners" ["medical practitioners"], to insert the words, "or duly qualified, certificated herbal practitioners."
I know there will be a good deal of prejudice in this Committee against this Amendment, which I move, because it appears to me that the Bill is going to emphasise what I believe to be an injustice under which certain qualified men are suffering at the present time. There can be no doubt about it that, while the people who believe in the herbal treatment of medicine are in the minority, still there is a considerable number of persons who do believe in that system. When I remember the remarks of the Chancellor of the Exchequer uttered on more than one occasion, namely, that you cannot expect that in treatment from someone in whom the man has no faith to get the best results from such treatment, I do submit there is a case for further consideration as to those people who believe in the herbal treatment. Obviously, if such a considera- 426 tion weighed with men who are under medical practitioners, it certainly is no less germane and no less important when applied to those people who are a little unorthodox in regard to their opinions as to medicine. I desire to submit for consideration the position of those men with regard to friendly societies as it appears to be determined by the Medical Act of 1858. If I understand that Act aright, it appears that they are to be outside, and are not allowed to administer to the members of friendly societies unless they come within the category of those persons mentioned in that Act. Therefore, I suppose the argument will be put forward that there was going to be no change in regard to the practice in this matter, and that no harm can be done by allowing the same principle to continue.
I submit there is a vast difference. A member of a friendly society is a voluntary member. He can please himself whether he joins the society or stays outside, and if he does join he docs so with his eyes open. He knows well that the medical practitioner will be the person to whom he will have to go if he receives medical benefit from the doctor appointed by the society. He makes up his mind to do one of two things, either to accept the medical practitioner or to sacrifice the benefits, and have his own particular form. The case is now altered. There is going to be no option to this particular man. Here he is with his unorthodox views with regard to medicine. He prefers the herbal treatment, and he is compelled to join this particular scheme. He can only join and suffer by doing so. I submit there is a great change, because in one case the man acts voluntarily and is a free agent. I expect I shall be charged with defending quacks. I assure the Committee I have no wish to do anything of the kind. It is not that class of person who is irresponsible, who has neither education nor training, nor ability, nor any honour, nor anything else that is worth considering, that I have in mind, but it is a certain class of persons who have, at least in my opinion, just as good a training, though of a different character, for the understanding of the human body, for the understanding of the working of diseases, and for the understanding of the results which follow the application of certain remedies to certain diseases and certain ailments.
It appears to me to be altogether beside the mark to suggest, simply because the ordinary medical practitioner has the hall- 427 mark of the State, that he is right and everybody else wrong. I have no particular interest in this matter, I am not a herbalist, nor am I a particular believer in herbal medicine, although I think there is more virtue in herbs than in minerals, generally speaking, for medicinal purposes. But when we are contemplating a scheme of this kind we ought not to emphasise the disability under which these people labour These herbal practitioners have their own board of examiners, who expect a certain routine to have been gone through and certain qualifications obtained before they grant certificates justifying a person to practice in herbal medicine. They have established at Southport a medical herbalist college. I am sure the Committee will listen to me while I say a few words about that college, because it will be admitted that those of us who are not so enamoured of the doctors as some Members are have listened quite patiently to speeches, some of them lasting over half an hour, in which repetition after repetition was made in reference to ordinary medical practitioners. Before a course of instruction is entered upon, candidates entering that college are expected to possess certain qualifications. The entrance examination covers such subjects as English, mathematics, French, Latin, German, physics, chemistry, and geology. Provision is made in certain instances for the omission of this particular examination, and it is provided that persons who have passed Responsions at Oxford University or the similar examination at Cambridge— broadly, those who have passed matriculation from any British university—shall be accounted as sufficiently educated and as having sufficient standing to commence a course of instruction at the college.
As to the statement that these people are merely quacks, perhaps some Member will point out presently how it is that these people, after having spent a number of years in preparing themselves for the work, are to be regarded as quacks, when a similar examination under other auspices gives the hall-mark of respectability and genuineness to the ordinary medical practitioner. The first year's course at the college includes such subjects as chemistry, organic and inorganic, physics, biology, including botany and zoology. The second year includes anatomy, osteology, embryology, histology, and physiology. The third year includes medicine, the principles and practice of herbal medi- 428 cine, pathology, bacteriology, pharmacology, materia medica, and toxicology. Many of these subjects are the very subjects which form the training of the ordinary medical practitioner. I will not trouble the Committee by reading the subjects taken in the other years. I merely want to claim that these people who spend five years in preparing themselves for their work ought not. to be ruthlessly brushed aside without some consideration being given to their case. I am anxious that the best case should be made for them. I do not know that I am the best man to make it. but at any rate, I am the only man willing to try. I am not at all sure that those who oppose this proposal, because in their opinion it would have disastrous results, are right. In America, for instance, where they do not hug superstitions to themselves with quite the same warmth that we do, they have already acknowledged this system of medicine.
In the public hospitals of America the two systems of medicine are working side by side, so that it has been possible to compare the two systems and to find out which has had the best results in reference to certain diseases. According to a circular in which the comparative results are set out, under the herbal treatment, to which they give the name "eclectic system," and the ordinary treatment respectively, there have been the following percentages of deaths in different diseases: pneumonia, sixteen, as against forty-one; pleuritis, three, as against eight; peritonitis, fourteen, as against sixty-one; dysentery, throe, as against eighteen; small-pox, five, as against twenty-eight; diphtheria and croup, eighteen, as against 37.5; typhoid fever, five as against fourteen; yellow fever, twelve, as against thirty-five; cholera, 23.3, as against forty; and "all diseases," 4.2, as against 6.2. I have no means of judging whether or not that list is correct, but from what I have seen in my own experience, I should think it probably is. At any rate, we have a right to demand serious consideration for these people, because if insured persons believe that they will receive more benefit from the herbal treatment than from the ordinary medical treatment they ought, under a Bill of this kind, to be able to make their choice. Some people have a very strong objection to ordinary medical treatment. In my own trade union I have known a man. to sacrifice six weeks' sick benefit rather than go to an ordinary medical practi- 429 tioner. Under this Bill such a man will be compelled to pay whether he wishes or not, and I submit that he ought to have a choice as to the sort of treatment he shall receive.
§ The FIRST LORD of the ADMIRALTY (Mr. McKenna)
I do not think the hon. Member seriously expects the Government to accept this Amendment. My right hon. Friend has already stated that he proposes to take into favourable consideration an Amendment later on the Paper standing in the name of the hon. Member for Hoxton. That Amendment provides that any persons may make their own arrangements for receiving medical attendance and treatment, and in such case they will receive the full amount to which they are entitled under the head of medical benefit. If, in making their own arrangements, they desire to employ a duly qualified herbalist, they will be at liberty to do so, and the practitioners for whom the hon. Member speaks will be entitled to receive precisely the same payment as any other medical practitioner. I think the committee will agree that my right hon. Friend has done as much as can be expected.
§ Mr. JOYNSON-HICKS
This Bill is entitled "A Bill to provide for insurance against loss of health and for the prevention and cure of sickness." Does the right hon. Gentleman really mean that when the taxpayers are taxed for that purpose, people are to be allowed, instead of going to proper medical men, to go to people who call themselves herbalists? I can hardly think that that is what is meant; that in his Amendment the hon. Gentleman the Member for Hoxton really claims to cast his mantle over herb doctors. Seriously, we are entitled to say that when the money of the taxpayer is spent——
§ Mr. JOYNSON-HICKS
My right hon. Friend (Mr. McKenna) has appealed to the hon. Gentleman below the Gangway, us I understand it, to withdraw his Amendment because the Amendment of the right hon. Gentleman the Member for Hoxton provides that medical benefit may be paid to a herb doctor. Surely that is impossible? Surely the right hon. Gentleman's desire for conciliation has got the better of —I shall not say his senses, that would not be Parliamentary—but his judgment? I do not wish to say a word against herb 430 doctors, if any man wishes to go to a herb doctor and pay for himself; but the money of the taxpayers——
§ Mr. JOYNSON-HICKS
I am in the hands of yourself, Mr. Emmott. I am prepared to discuss the Amendment when we get to it, but the right hon. Gentleman has asked the hon. Member below the Gangway to withdraw his Amendment on the assurance that the Amendment of the hon. Member for Hoxton does include this.
§ The CHAIRMAN
I think that the right hon. Gentleman was explaining how far the Government would go in the matter.
§ Amendment negatived.
§ Mr. LLOYD GEORGE
I beg to move, in Sub-section (1), to leave out the words "for insured persons to receive attendance and treatment to the satisfaction of the Insurance Commissioners from such practitioners," and to insert instead thereof, the words "in accordance with regulations made by the Insurance Commissioners.
(2) The regulations made by the Insurance Commissioners shall provide for the arrangements made being subject to the approval of the Insurance Commissioners and being such as to secure that insured persons shall, save as hereinafter provided, receive adequate medical attendance and treatment from the medical practitioners with whom arrangements are so made, and shall require the adoption by every local health committee of such system as will secure—
Provided that if the Insurance Commissioners are satisfied after inquiry that the practitioners included in any list are not such as to secure an adequate medical service in any area, they may dispense with the necessity of the adoption of such system as aforesaid as respects that area, and authorise the committee to make such other arrangements as the Commissioners may approve."
- (a) the preparation and publication of lists of medical practitioners who have agreed to attend and treat insured persons whose medical benefit is administered by the committee and resident within the area to which the list relates;
- (b) a right on the part of any duly qualified medical practitioner who is desirous of being included in any such list as aforesaid of being so included, but where the Insurance Commissioners, after such inquiry as may be prescribed, are satisfied that his continuance in the list would be prejudicial to the efficiency of the medical service of the insured, they may remove his name from the list;
- (c) a right on the part of any insured person of selecting for such period as may be prescribed from the appropriate list the practitioner by whom he wishes to be attended and treated, and, subject to the consent of the practitioner so selected, of being attended and treated by him;
- (d) the distribution amongst and, so far as practicable, under arrangements made by, the several practitioners whose names are on the lists of the insured persons who after due notice have failed to make any selection, or who have been refused by the practitioner whom they have selected;
The Amendment provides for a free choice of doctors. There are just one or two small alterations which I have got to make in order to meet the Amendments which are down on the Paper. The one is in paragraph (b). It is suggested that Insurance Commissioners should have no right to exclude any duly qualified medical practitioner from the list who is prepared to act on the panel. I agree. Therefore I propose to leave out the words "inclusion or" ["satisfied that his inclusion or continuance in the list"].
It is also suggested that the Insurance Commissioners may conceivably exclude such a man as is referred to because he has certain theories in regard to medical practice. That is what my right hon. Friend referred to. I agree that it is not the province of the Insurance Commissioners to decide between one theory or another in medical practice. That is no business of theirs. So long as a man is a duly qualified medical practitioner he ought to have a legal right to appear on the panel. Therefore, with a view to meet that and other objections, I propose to leave out of the Amendment the words I have mentioned, to add at the end of the paragraph, "they may remove his name from the list."
§ Mr. CASSEL
On a point of Order. I have given notice of a manuscript Amendment which comes before this——
§ Mr. LLOYD GEORGE
I am not moving an Amendment to my Amendment. I am simply moving the Amendment on which I have spoken. Paragraph (b) will read:—
(b) A right on the part of any duly qualified medical practitioner who is desirous of being included in any such list as aforesaid of being so included, but where the Insurance Commissioners, after such inquiry as may be prescribed, are satisfied that his continuance in the list would be prejudicial to the efficiency of the medical service of the insured they may remove his name from the list."
Therefore inquiry with regard to the doctor's conduct will be confined to the time after he has been included in the list. It must be perfectly clear that you must have some control over the practitioner, otherwise a grave evil may be encouraged on the part of those who know that by a lenient interpretation of their duties they may add to their practice.
§ Mr. LLOYD GEORGE
There is no appeal. The Insurance Commissioners, it is suggested, should have the final voice in. the matter. I suggest that, on the whole, they are the best tribunal. I believe in Germany the matter is very largely left to the practitioners themselves. A man may be unpopular because he is successful. He may be unpopular because he is popular. Therefore I do not think the doctors themselves would be the best tribunal for the purpose. The Insurance Commissioners will be perfectly impartial. When it is suggested that there should be an inquiry probably they will appoint someone, to go down into the district and hear the case. After inquiry there will be a report to the Commissioners. That is really giving an appeal to the Commissioners. First of all, there is the report of the gentleman who is sent down to investigate the fact; then the Commissioners themselves will adjudicate upon that report.
§ Mr. BOYTON
On the question of appeal, would the right hon. Gentleman make the final court of appeal the General Medical Council? [HON. MEMBERS: "NO, no."]
§ Mr. LLOYD GEORGE
From experience of what the general practitioner thinks of the British Medical Council, I do not. 433 think for a moment that they will be satisfied with the General Medical Council. I think on the whole the Insurance Commissioners will be the best judges in this matter. I have no doubt that we will have at least two doctors upon that body. With regard to paragraph (c), it has been suggested, with regard to friendly societies, that if you allow a man to chop and change doctors constantly the doctor will be entirely in the hands of the malingerers, and that there ought to be some check upon that. Therefore, I propose to insert in paragraph (c), after the word "selecting" ["person of selecting from"], the words, "for such a period as may be prescribed." I want to make it perfectly clear that a man does not choose once for all. There are two sides to the question. A man may have exhausted his right to choose; also he cannot change from day to day. We must preserve the independence of the doctors so far as we possibly can. These are the alterations which I propose to make in the Amendment, and I move it in that form.
§ Question, that the word "for" stand part of the Clause, put, and negatived.
§ Question put, "That the words proposed be there inserted."
§ Mr. FORSTER
The Committee will agree that the Amendment of the right hon. Gentleman is a great improvement in the Bill. It will be welcomed in all quarters in the House, but I hope the right hon. Gentleman will reconsider the question of allowing the Insurance Commissioners to decide appeals. The Chancellor of the Exchequer and the Committee generally will realise that if a man is struck off the list it means the complete loss of his livelihood, and I think this is putting into the hands of the Insurance Commissioners, who, after all, will practically govern the officials, too great a power, unless there is an appeal beyond. I do not think that the House ought to take any steps which can put into the hands of any Government official, however fair-minded, however impartial, however able he may be, the power practically of wrecking a man's livelihood without appeal. Surely whenever the liberty of the subject is concerned there should always be allowed an appeal to the High Court or other court? I hope the Chancellor of the Exchequer will reconsider this matter, believing, as I do, that the cases which would occur, on which this power of the Insurance Commissioners would be exercised would be few and far between, and 434 would not be imposing undue strain upon our courts of law. I think this protection ought to be afforded to every British subject.
§ Mr. LOUGH
I would like to thank my right hon. Friend for so altering his Amendment as to include the Amendment that I intended to move, and which stands upon the Paper. I should say, however, that the words which my right hon. Friend has met me with are not those which he suggested at first. And after the most careful consideration I could give the matter I am satisfied that these words cover the whole point of the Amendment. If the Committee will look at my Amendment they will see that the words are:
"Provided also that duly qualified medical practitioners shall not be excluded … because they adopt the practice of any particular theory of medicine or surgery."
That is the pith of my Amendment, and I think it is fully met by the words of my right hon. Friend the Chancellor of the Exchequer, because his Amendment provides there is to be no right to exclude anybody coming upon the list who is a duly qualified medical practitioner. But my Amendment was not to cover that alone, there was to be no power to exclude a man because he adopted the practice of any particular theory of medicine or surgery. I am told on good authority that there is no such power now, and that a man can only be excluded because of bad conduct or of malingering, and that applies to the whole of the profession. There is no power to exclude a man for the reasons I have given in my Amendment, and therefore I think the Chancellor has fully met me. Perhaps I might say in reference to the suggestion of the hon. Gentleman opposite I have not the slightest objection, to his point being fairly considered. I think perhaps there is something in it, but it does not touch the point of my Amendment, and so I shall say nothing about it. I thank the right hon. Gentleman once more for the generous spirit in which he has met me.
Sir GILBERT PARKER
I desire to associate myself with what has fallen from the right hon. Gentleman who has just sat down in regard to his Amendment, with which I associated my name. With regard to the point made by my hon. Friend (Mr. Forster) I hope the Chancellor of the Exchequer will consider it.
§ Mr. CASSEL
On a point of Order. I handed in an Amendment which gives an appeal to a Court. I do not know whether this discussion will rule it out.
§ Mr. CASSEL
I have got another Amendment which comes earlier which I think the right hon. Gentleman will see raises a serious point.
§ Mr. LLOYD GEORGE
This Amendment of mine has been on the Paper for some time, and I think the hon. and learned Gentleman might have put his Amendment upon the Paper. He is now, I understand, going to move one of a series of verbal Amendments which we have had no time to consider. I think we have some reason to complain that they are put upon the Paper.
§ Mr. CASSEL
The Amendment of the Chancellor himself was only put upon the Paper yesterday, and there have been a lot of alterations made in it, and that being so, I submit I am entitled now to move my Amendment.
§ Mr. CASSEL
I do not more this Amendment in any captious spirit or of any spirit of obstruction. The right hon. Gentleman I think will agree that the point I am making is of some importance. It is to omit the words in his Amendment "and resident" ["administered by the committee and resident within the area"]. To whom do these words refer? Do they apply to the doctor or to the patient? I think they must apply to the doctor, because the words before are "whose medical benefits are administered by the committee." That applies to the patient. You have got here an absolute condition that a doctor can only be put on a panel for a district in which he is resident. There are many cases of doctors practising in districts where they are not resident, and this is a very important point to many doctors. Take the case of the county of London. The county of London as at present consituted is to be one county. I have an Amendment dividing it into boroughs. Suppose these words apply to each borough? A man may be resident in my constituency of St. Pancras, and he may practice in Paddington, Islington, and other boroughs. Take the case of a 436 doctor who lives outside London; and who practises in London. These words would absolutely exclude him from going upon a panel in London if he is resident outside. I submit that it is not the intention of the Government, and my only object is to enable them to give effect to their real intention and to prevent their doing what I consider would be an injustice to particular practitioners. Take the case of a doctor who lives in one county and practises in a county borough. If these words are kept in, it will be impossible for him to get on the panel of a county borough at all. If he lives on the borders of two counties he could only practice in one county. These words ought to be omitted. That is assuming they apply to the doctor. Let me assume they apply to the patient. What is to happen in the case of people suddenly moving as they do in London. A bout 25 per cent. of the people of London move every year. At least I find that to be so by my register. Supposing you have paid a man for a year for a particular district and he moves out of it.
§ Mr. CASSEL
I think this matter requires further consideration. You have got your panel of doctors, say, for Brighton, and a man from London gets ill in Brighton. I will assume he can select some doctor upon the Brighton panel. I suppose that doctor would require extra payment, and if extra payment is made from what funds is it to come? The friendly societies have a very complicated system which enables them to deal with such a case. I think this presents a real difficulty, because the doctor to whom the patient was attached, if I may use the phrase, would not treat him and the doctor in Brighton would treat him. It is not as if this was a single case. As I say, people are constantly moving about. I submit that these words ought to be omitted. It is quite clear that a man ought not to be disqualified from practising in a borough or a county in which he does not actually reside, and therefore I ask the right hon. Gentleman to consider this matter both from the point of view of the doctor and the patient.
§ Mr. HARRY LAWSON
I venture to think these words cannot stand in the light of reason. The local areas of this country are not clear cut and well defined. Taking only London, there are three separate Londons with which we have to deal. There is the administrative county of London, there is London as approved by statute for the purpose of police, and there is another London approved by statute for the purpose of water supply. There is absolutely no boundary—east, north, south or west in London which ought to prevent the practitioner being able to use his privilege of being put upon the panel of doctors for the adjoining districts. It is impossible to see any real distinction, and I venture to think the right hon. Gentleman will be obliged to take out words which would in working be absolutely impracticable. Then I should like to ask the right hon. Gentleman this question, whether it will be possible to adhere to the present practice of the friendly societies in respect of those who go out of one area into another. Take the Hearts of Oak, which is the great example of a centralised society. There, of course, if one of their members who is a subscriber for medical benefits moved out of his own area to another the medical officer appointed by the Hearts of Oak for that district would take him over. I do not know how far that would be possible in the case of the affiliated societies, and I do not know how far that system would be effective under the Bill. But I am quite clear that these words ought to go in the first place, and that then we ought to consider the words to be inserted, if other words are necessary. What this Bill really does is to alter the legal status of the medical profession. It is most important that that should be done by precise words or the consequences will be very different from what the House could wish or the medical profession itself suggests. I venture to suggest that considered words should be brought up, and the practice under the Bill should be assimilated as far as possible to the existing practice of the friendly societies.
§ Mr. AUSTEN CHAMBERLAIN
I suggest to the Government that these words are quite unnecessary and that they will prove quite unworkable. The difficulties of boundaries are not confined to London alone. Take any case on the borders of two counties. The doctor will practice in both counties, but he cannot be resident in both. I do not see the necessity for 438 a limitation of this kind in areas under statute, because the practice of the doctor would go on without any limitation being required. A man is not going to keep his name on the list of a place in which he cannot attend for the sake of pleasing some individual subscriber to the fund who would like to select him if he was ill. I think the Government should simply accept this Amendment and leave these words out.
§ Mr. LLOYD GEORGE
I am inclined to agree with the right hon. Gentleman. I think the words are not necessary and may in certain cases lead to unnecessary complications, especially in the case put by the right hon. Gentleman where a man. lives upon the border of two counties. I will therefore accept the Amendment.
§ Mr. JOYNSON-HICKS
Would the Chancellor of the Exchequer say in regard to the other part of the speech of my hon. and learned Friend, what he intends to do in the case of a man who moves from one district to another.
§ Amendment agreed to.
§ Mr. CASSEL
I beg to move, at the end of paragraph (b) of the proposed Amendment, to add the words "every refusal of the Insurance Commissioners to continue any medical practitioner in any such list shall be subject to an appeal to the High Court."
If ever there was a case where a man ought to have an opportunity to go to the Courts it is a ease like this. This is a case where a man's livelihood or his character might be at stake. I could cite a good many cases where inquiries by Government Departments and Government officials in judicial matters affecting character have proved most unsatisfactory. There are numerous cases of that kind, but I will not cite them now because I do not want to say anything more controversial than is really necessary. Under these circumstances I will simply move the insertion of those words to secure to a doctor a trial before a judicial tribunal.
Sir GILBERT PARKER
I rise to support this Amendment. Allow me to point out to the Chancellor of the Exchequer that the Insurance Commissioners will have very great power indeed and very great authority. In any regulations they may make and in the ordinary procedure of carrying out the law, they will be subjected constantly to criticisms which will 439 result in the revision very likely of some of the decisions they have come to. Some of those results may be serious and even fatal, and so far as the Insurance Commissioners are concerned, irrevocable. No decision ought to be given which destroys a man's livelihood without an opportunity being given to him to appeal to an authority higher than that which has condemned him. There has only been in this case one court and one inquiry. Even under the Criminal Law there is an appeal. It is in effect a penalisation which these Insurance Commissioners decide against these men. The doctor is, in effect, so far as his profession is concerned, in the position of a criminal. He may be in a position of being guilty of inefficiency, of a misdemeanour, or of something else. I therefore suggest that the right hon. Gentleman would do well to allow this Bill, since it gives to the individual citizen who has suffered at the hands of the Commissioners deprivation of privilege, a chance of the review of the decision against him which may be so serious in its consequences.
§ Mr. LLOYD GEORGE
I am sorry I cannot accept this Amendment for reasons which I am sure will appeal to the Committee. I think the High Court would be the very worst tribunal in the world for settling this kind of question. Hon. Members talk as if the High Courts decided now questions affecting the livelihood and character of the medical profession. May I point out that all that is done by the Medical Council. I have seen some of their decisions, and I do not want to express any opinion about them. No doubt they have decided cases very fairly and indulgently, but at the same time there is nothing about their system which would appeal to a lawyer. A man may be tried, and not merely be deprived of practice, but of his position as a medical man, purely upon inquiry in a room up in London by two or three doctors. I think that is a very serious thing. That is the way the medical profession inquire into these cases at the present time. What I propose is much fairer. I propose that there shall first be an inquiry. The inquiry I propose does not settle it, because the Insurance Commissioners can decide after, and that is something in the nature of an appeal. I think that is the better system than the High Court, which is not adapted for this purpose.
If you go to the High Court you must have witnesses. You may have to deal with a case arising somewhere in the 440 country involving the attendance of fifty or 100 witnesses, and if you have an appeal to the High Court you might have to drag all those fifty or 100 witnesses up to London, where you can never tell when a case may come on. Those witnesses may have to hang around for days, and it is a difficult thing to get them up to London. At any rate, I do not think that is the best method of investigating the matter from the point of view of the medical practitioner, Here you have a body dealing with this matter perfectly impartially. The hon. Gentleman opposite says he knows of cases of miscarriage of justice where there has been an inquiry by a Government official. I suppose he has never heard of any miscarriage of justice in a trial in the High Courts. You cannot expect infallibility either in a judge or in a Government official. The point is which of the two is most conducive of fair play to the medical practitioner and to the efficiency of the Insurance Fund. I am sure that to be tried by the High Court is the very worst method of conducting this investigation.
I am quite willing to consider between this and the Report stage whether it is desirable to have any form of appeal, but I say emphatically that in my judgment now, an appeal to the High Court would be the very worst method. I am, however, quite willing to consider that suggestion amongst others, and perhaps the hon. Gentleman opposite and others will use their ingenuity to suggest some other method of appeal. I quite see that it is a very serious matter for the medical practitioners. I think they ought to have fair play, and ought not to be dismissed upon the mere caprice of anybody. If there is any other alternative suggestion I should be glad to consider it. It may be moved on the Report stage, because it does not involve any charge. I hope under these circumstances the hon. Member at this stage will withdraw his Amendment.
§ Sir R. FINLAY
I see the actual words are:—
"Except in cases where the Insurance Commissioners after such inquiry as may be presented are satisfied that his inclusion or continuance in the list would be prejudicial to the efficiency of the medical service of the insured."
Is it contemplated that the inquiry should be before the Insurance Commissioners, or that the inquiry should be held and adjudicated upon by the Commissioners?
§ Mr. LLOYD GEORGE
The suggestion which I made was that the Insurance Commissioners should appoint such an inquiry.
§ Sir R. FINLAY
I think there should be some form of appeal, because it seems to me that this may mean absolutely ruin in some cases. I think you should give an appeal upon the material facts upon which the Insurance Commissioners have decided. Could you not give an appeal to a judge with medical assessors? I think this is a matter in which the judge would want skilled assistance. At any rate, I make that suggestion.
§ Mr. HARRY LAWSON
Surely the first thing is that the medical profession itself should be satisfied that this is a fair and just tribunal, and would the right hon. Gentleman undertake to consult the medical profession on this point before the Report stage? I do not see why it should be left to hon. Gentlemen on this side to decide a matter of this kind. I think the right hon. Gentleman might try to find out exactly what their views are in order that an agreement may be reached.
§ Mr. LLOYD GEORGE
As a matter of fact, I have already done so. I did not put down this Amendment without a very long consultation with those belonging to the medical profession, and I have no alternative suggestion from them. I will consider the suggestion of the right hon. and learned Gentleman opposite.
§ Mr. CASSEL
I shall be prepared to withdraw the Amendment on the assurance that this question shall be considered on the Report stage, because I feel the difficulty of dealing with it upon a manuscript Amendment.
§ Amendment to the proposed Amendment, by leave, withdrawn.
§ Mr. JOYNSON-HICKS
Clause 14 is the only Clause which deals with the administration of medical benefit. The Chancellor of the Exchequer's Amendment which we are now going to pass deals with the making of the rules for the providing and administration of medical benefits. I think there should be included rules providing for the case where the insured person moves from one district to another. I think that has not been considered so far, and no arrangement has been made for dealing with this point. I ask the right hon. Gentleman if he will consider between now and the Report stage this point.
§ Mr. CASSEL
As the Clause stands at the present time it does not in the least define the sort of persons to be dealt with. Presumably they are persons resident in their area. Certainly the case will have to be more fully considered, both from the point of view of removal and also the point of view of persons who are temporarily away from the district. Those points have to be considered. There seems to be a real difficulty in the case I put of the man who is taken ill while he is away for a weekend at Brighton. Then I suppose one of the Brighton doctors on the panel would have to attend him, and that doctor certainly would require additional pay, and certainly that would have to be met from some fund. I do not know from what fund it would come. I do not see how the doctor would be called upon to treat a particular patient when he was not one of the patients on his list.
§ Mr. LLOYD GEORGE
You cannot, in an Act of Parliament, legislate for every conceivable case of the kind. You want to lay down general principles. If you start with what is to be done for the man who shifts from one district to another you will have to provide for the weekender. It would make an interminable list of cases. This person is provided for.
§ Mr. BOOTH
Paragraph (c) gives the right to an insured person to select a practitioner, but suppose the practitioners in the panel decline to attend this man, how can he get medical benefit? I want to put a case, brought to my notice, where a man, perhaps, brings a false charge against a doctor. He does it in a rash moment and afterwards declines to apologise. He charges the doctor with indecent assault upon his daughter. These cases have occurred. The man is asked to apologise and declines. Years pass away, and the doctors do not like the man. The point is, can he get the medical benefit?
§ Dr. ADDISON
(who was indistinctly heard): I wish to move to add at the end of the Clause, "and
(ii) the regulations made by the Insurance Commissioners shall authorise the local health committee by which medical benefit is administered to require any persons whose income exceeds a limit to be fixed by them, and to allow any other persons, in lieu 443 of receiving medical benefit under such arrangements as aforesaid, to make their own arrangements for receiving medical attendance and treatment (including medicines and appliances), and in such case the committee shall, subject to the regulations, contribute from the funds out of which medical benefit is payable towards the cost of medical attendance and treatment (including medicines and appliances) for such persons sums not exceeding in the aggregate the amounts which the committee would otherwise have expended in providing medical benefit for them."
In moving this Amendment I have no desire whatever, as it seems to have been attributed to those of us who belong to the medical profession in this House, to put forward some special plea for the medical profession. There is no intention of that. Some hon. Members below the Gangway have seemed to suggest that we were exalting the medical profession—" dictating" to this House. Against that I would enter a very respectful and modest protest. We have all listened, and I would gladly listen again, to the statement of any class of workers in this country who are concerned with any legislation. An hon. Member seemed to complain of the length of the statements submitted to this House, but it has been with no other desire than to put the case fairly before this House, so that a proper resolution may be arrived at. With regard to this question of the income limit a considerable number of medical men have been making representations on deputations and elsewhere, and have said things which they were not altogether warranted in saying. I think the same thing would have occurred in regard to any section of people who had to make representations.
I sincerely hope the House—and I am saying this because of what was said yesterday—will credit us with sincere intentions to have the medical service placed upon a sound footing. We have no desire that the medical profession shall be placed in an unduly privileged position. The hon. Member for Mansfield made a suggestion an hour or two ago, and I would respectfully ask him to reconsider that we only want the matter dealt with fairly. Doctors up and down the country, quite unnecessarily, say they will be ruined by this Bill. These representations have often arisen owing to their not quite 444 understanding the Bill. They have overlooked the fact that they will be paid for people who are well, and that they will have no bad debts. They have overlooked the fact that many families will not really be dependents of insured persons, and that they will be entitled to charge for these as hitherto. A great deal of the alarm, as I believe, is unwarranted, but still a certain amount of the alarm is quite real. It may be unfounded, but it is genuine. With regard to the Amendment which stands in my name, I do not wish to waste the time of the Committee, but I desire to explain the point of local option. I think the principle of local option as laid down is very much preferable to the definite statutory limit as indicated to the House for the reasons then set up. A number of medical men practising under quite different conditions in different districts may have a number of private patients who become insured persons. I think the people should be consulted, and an opportunity given to those who have been private patients, so that under a satisfactory arrangement they may have their wish to continue on the same lines. The principle is that those who have-hitherto been private patients under a satisfactory arrangement shall still be accepted, if they wish to continue on the same lines. There is another very important consideration which has not hitherto been pointed out. If a number of persons in any place continue to pay fees under arrangement, the demand for higher capitation payment for those of lower means will, of course, be correspondingly diminished. If this payment could be reasonably called upon by fees which are not on. a universal scale, there is not the same necessity for asking for a high capitation rate for the lower classes. An arrangement of this kind would be a great advantage.
This Amendment allows for the conditions of diverse arrangements. There is an Amendment later on which specifically deals with this part of the question. Do the Committee think the present Amendment will introduce elasticity into the whole system? The thing is experimental, and I think it would be quite a mistake if the Committee straightaway laid down hard and fast lines. The Amendment will leave it open to evolve a satisfactory system both of work and pay. It is applicable to the whole country, and I believe it would conduce to the smooth working of the whole if the Committee were to accept it now. I ask those hon. Members who, I 445 believe, are somewhat inclined to oppose some of the principles laid down, to refrain from doing so as far as they conscientiously can, because after all I feel that in the course of a few years there will be evolved an equitable system of contract throughout the country generally. The experience of contract practice has been used with some misunderstanding. I do not think the whole medical profession is against a contract. It depends upon the terms of the contract. This Amendment would apply equally to the rural districts of Yorkshire and elsewhere, and the crowded parts of London. This Amendment would provide a basis for gradually working out an equitable system.
§ Sir A. MARKHAM
I have been in the House, except for two or three minutes, but I was not aware of it. The doctors are going to be immeasurably better off than before, and you are going to deprive persons of that medical advice which they have previously had.
§ Mr. LLOYD GEORGE
The hon. Gentleman was not here, and I will repeat for his benefit what I said. I indicated that I was prepared to accept the Amendment, and would also accept an Amendment in the name of the hon. Member for Luton (Mr. C. Harmsworth), which protects the existing rights of everybody.
§ Sir A. MARKHAM
I am perfectly aware the right hon. Gentleman made that statement, but there is a conflict of opinion between the hon. Member for Luton and myself as to the actual meaning of his Amendment. I speak, of course, subject to the correction of the learned Attorney-General, but, if the Amendment of the hon. Member for Luton means what I believe it does, it only applies to members of societies who are to-day members, and, so far as I can see, existing societies who have a certain membership to-day will not be entitled to increase their membership or to continue their membership.
§ Mr. LLOYD GEORGE
That is not so. It means, not existing members of organisations, but existing organisations.
§ Sir A. MARKHAM
The hon. Member for Luton is not moving the words on the Paper. He is moving additional words, and, as a business man, I do not think they will carry out that intention.
§ Mr. LLOYD GEORGE
My hon. Friend cannot really have the words or he must have forgotten them. They are as clear as, possible: "Any organisation existing at the time of the passing of this Act."
§ Sir A. MARKHAM
That deals with workmen's institutes and clubs alone. It does not deal with existing friendly societies. Is that so, or not?
§ Mr. CHIOZZA MONEY
I am one of those who view this Amendment with great apprehension, and I am surprised the Government agree to it. May I ask my hon. Friend with whom the local option lies? It lies with the local health committees, and not the approved societies. I would ask him to consent to the insertion of words to cover that point, and to make the Amendment read as follows:—
"The regulations made by the Insurance Commissioners shall authorise the local health committee by which medical benefit is administered, with the consent of the approved societies concerned," etc.
The other point is with regard to the income limit. The Amendment reads:—Whose income exceeds a limit to be fixed by them.I suggest the limit should be defined at that point, and that the limit should be £104 a year, a sum which was discussed in a previous Amendment. I appeal to my hon. Friend to allow those words to be incorporated in the Amendment before it is accepted.
§ Mr. SNOWDEN
I am simply amazed at the Chancellor of the Exchequer accepting this Amendment. Earlier this afternoon he spoke at great length on an Amendment moved by the hon. Member for the University of London (Sir P. Magnus), in opposition to the proposal to exclude from medical benefit those who are in receipt of an income of more than £104 a year. Everything the Chancellor of the Exchequer said then applies to this proposal. If I were compelled to make a choice between the Amendment of the hon. Member opposite and giving the health committees power to fix what limit they please, I would accept the Amendment of the hon. Member opposite. The hon. Member who moved this Amendment recommended, it to the Committee because 447 it embodies the principle of local option. What is going to happen? You are going to have one local health committee in one part of the country fixing £l a week as the limit, and another health committee in another district fixing 30s. or £2 as the limit. There is no doubt this Amendment is moved in the interest of the doctors. I admit we must get the sympathetic cooperation of the doctors if this Bill is going to be worked satisfactorily, but I do not think this is quite the way to meet the doctors. I should be sorry to vote for any proposal to reduce the present remuneration of the doctors. I want them to be well paid, but the Amendment of the hon. Member means that people who pay fees for the doctor will have to make up the lower charges for which the doctors are prepared to treat the poorer part of the population. Why should a man with 30s. or £2 a week be called upon to pay more because the doctor is treating somebody else? That is not fair. I do not think we want elasticity in the sense in which the hon. Member used the word. I think it is better we should have uniformity, because, if you do not have uniformity, you are going to add to the number of cases of injustice which will exist under the Bill. There is no doubt, as I have said, this Amendment is moved in the interest of the doctors. Let us try and meet them in some other way. If the capitation fee suggested is not sufficient remuneration, then make it higher; but for Heaven's sake do not try to make working people
§ who are just a bit above the poverty line pay for those who happen to be below it. For those reasons, if this goes to a Division, I shall certainly oppose it.
§ Sir A. MARKHAM
I do not think the House really wishes to put it in the power of the health committee to say a man may be put outside the scope of this Bill. It is no use hon. Members referring to the county councils, because, although they are publicly elected bodies, the county council in my Constituency at any rate is reactionary and conservative. Workmen cannot afford the time to go to a central town to attend the meetings of a county council, and they are consequently shut out. It will, therefore, rest with the health committee, a conservative body, and the doctors to say what is to be the limit.
§ Mr. LLOYD GEORGE indicated dissent.
§ Sir A. MARKHAM
My right hon. Friend knows the doctors are entitled to representation on the health committees. I therefore think that to put it in the power of a health committee to say a man shall be outside the scope of the Bill is perfectly monstrous. I do not see the slightest justification for the Amendment, and, if I can get anyone to tell with me, I shall certainly divide against it.
§ Question put, "That those words be there inserted."
§ The Committee divided: Ayes, 279; Noes, 41.449
|Division No. 302.]||AYES.||[8.0 p.m.|
|Abraham, William (Dublin Harbour)||Bigland, Alfred||Chancellor, Henry George|
|Abraham, Rt. Hon. William (Rhondda)||Bird, Alfred||Chapple, Dr. William Allen|
|Acland, Francis Dyke||Boles, Lieut.-Col. Dennis Fortescue||Clive, Captain Percy Archer|
|Addison, Dr. C.||Booth, Frederick Handel||Clough, William|
|Ainsworth, John Stirling||Bowerman, Charles W.||Collins, Stephen (Lambeth)|
|Allen, Arthur A. (Dumbarton)||Boyle, Daniel (Mayo, North)||Condon, Thomas Joseph|
|Allen, Charles P. (Stroud)||Boyton, James||Cornwall, Sir Edwin A.|
|Arkwright, John Stanhope||Brady, Patrick Joseph||Cotton, William Francis|
|Armitage, Robert||Bridgeman, W. Clive||Cowan, W. H.|
|Ashley, Wilfrid W.||Brigg, Sir John||Craik, Sir Henry|
|Astor, Waldorf||Brunner, J. F. L.||Crawshay-Williams, Eliot|
|Baird, John Lawrence||Bryce, J. Annan||Crumley, Patrick|
|Baker, Harold T. (Accrington)||Burn, Colonel C. R.||Davies, Sir W. Howell (Bristol, S.)|
|Baker, Joseph Allen (Finsbury, E.)||Burns, Rt. Hon. John||Davies, M. Vaughan- (Cardigan)|
|Balcarres, Lord||Burt, Rt. Hon. Thomas||De Forest, Baron|
|Balfour, Sir Robert (Lanark)||Butcher, John George||Delany, William|
|Baring, Maj. Hon. Guy V. (Winchester)||Buxton, Rt. Hon. Sydney C. (Poplar)||Devlin, Joseph|
|Barlow, Montagu (Salford, South)||Byles, Sir William Pollard||Dickinson, W. H. (St. Pancras, N.)|
|Barran, Sir John N. (Hawick B.)||Cameron, Robert||Dillon, John|
|Barrie, H. T. (Londonderry, N.)||Carlile, Sir Edward Hildred||Dixon, Charles Harvey|
|Barry, Redmond John (Tyrone, N.)||Carr-Gomm, H. W.||Danelan, Anthony Charles|
|Bathurst, Charles (Wilts, Wilton)||Cassel, Felix||Doris, William|
|Beach, Hon. Michael Hugh Hicks||Cave, George||Doughty, Sir George|
|Deck, Arthur Cecil||Cawley, H. T. (Lancs., Heywood)||Edwards, Enoch Hanley|
|Benn, W. W. (T. H'mts, St. George)||Cecil, Evelyn (Aston Manor)||Edwards, John Hugh (Glamorgan, Mid)|
|Bennett-Goldney, Francis||Chaloner, Col. R. G. W.||Elverston, Sir Harold|
|Bentham, George Jackson||Chamberlain, Rt. Hon. J. A. (Worc'r.)||Esmonde, Dr. John (Tipperary, N.)|
|Essex, Richard Walter||Keating, Matthew||Rea, Walter Russell (Scarborough)|
|Esslemont, George Birnie||Kelly, Edward||Reddy, Michael|
|Eyres-Monsell, Bolton M.||Kennedy, Vincent Paul||Redmond, John E. (Waterford)|
|Faber, George D. (Clapham)||King, J. (Somerset, North)||Richards, Thomas|
|Falle, Bertram Godfrey||Kyffin-Taylor, G.||Richardson, Albion (Peckham)|
|Fell, Arthur||Lardner, James Carrige Rushe||Roberts, Charles H. (Lincoln)|
|Ferens, Thomas Robinson||Larmor, Sir J.||Roberts, S. (Sheffield, Ecclesall)|
|Firench, Peter||Leach, Charles||Robertson, Sir G. Scott (Bradford)|
|Field, William||Lee, Arthur H.||Robertson, John M. (Tyneside)|
|Fiennes, Hon. Eustace Edward||Levy, Sir, Maurice||Robinson, Sidney|
|Finlay, Sir Robert||Lewis, John Herbert||Roch, Walter F. (Pembroke)|
|Fisher, Rt. Hon. W. Hayes||Logan, John William||Roche, Augustine (Louth)|
|Flavin, Michael Joseph||Lough, Rt. Hon. Thomas||Roe, Sir Thomas|
|Fletcher, John Samuel (Hampstead)||Low, Sir Frederick (Norwich)||Rolleston, Sir John|
|Forster, Henry William||Lowe, Sir F. W. (Birm., Edgbaston)||Ronaldshay, Earl of|
|Furness, Stephen||Lundon, T.||Rose, Sir Charles Day|
|Gardner, Ernest||Lyttelton, Hon. J. C. (Droitwich)||Rutherford, Watson (L'pool, W. Derby)|
|Gelder, sir William Alfred||McGhee, Richard||Salter, Arthur Clavell|
|George, Rt. Hon. D. Lloyd||Mackinder, Halford J.||Samuel, Rt. Hon. H. L. (Cleveland)|
|Gibson, Sir James Puckering||Maclean, Donald||Sanders, Robert A.|
|Goddard, Sir Daniel Ford||Macnamara, Rt. Hon. Dr. T. J.||Sanderson, Lancelot|
|Goldman, C. S.||Macpherson, James Ian||Sandys, G. J. (Somerset, Wells)|
|Goldsmith, Frank||MacVeagh, Jeremiah||Scanlan, Thomas|
|Gordon, John (Londonderry, South)||McKenna, Rt. Hon. Reginald||Schwann, Rt. Hon. Sir C. E.|
|Gordon, Hon. John Edward (Brighton)||McNeill, Ronald (Kent, St. Augustine)||Sheehy, David|
|Greenwood, Hamar (Sunderland)||Magnus, Sir Philip||Sherwell, Arthur James|
|Gretton, John||Mason, David M. (Coventry)||Shortt, Edward|
|Grey, Rt. Hon. Sir Edward||Masterman, C. F. G.||Simon, Sir John Allsebrook|
|Griffith, Ellis Jones||Meagher, Michael||Smith, Albert (Lancs., Clitheroe)|
|Guest, Hon. Frederick E. (Dorset, E.)||Meehan, Francis E. (Leitrim, N.)||Smith, H. B. L. (Northampton)|
|Guinness, Hon. Walter Edward||Middlemen, John Throgmorton||Spear, Sir John Ward|
|Gwynne, R. S. (Sussex, Eastbourne)||Millar, James Duncan||Spicer, Sir Albert|
|Hackett, John||Molloy, M. Steel-Maitland, A. D.||Steel-Maitland, A. D.|
|Hancock, John George||Morgan, George Hay||Strauss, Arthur (Paddington, North)|
|Harcourt, Rt. Hon. Lewis (Rossendale)||Muldoon, John||Strauss, Edward A. (Southwark, West)|
|Harmsworth, Cecil (Luton, Beds.)||Munro, Robert||Sykes, Mark (Hull, Central)|
|Harvey, T. E. (Leeds, West)||Neville, Reginald J. N.||Talbot, Lord Edmund|
|Harvey, W. E. (Derbyshire, N.E.)||Newton, Harry Kottingham||Taylor, John W. (Durham)|
|Harwood, George||Nolan, Joseph||Taylor, Theodore C. (Radcliffe)|
|Haslam, James (Derbyshire)||Norton, Captain Cecil W.||Tennant, Harold John|
|Havelock-Allan, Sir Henry||Nuttall, Harry||Thompson, Robert (Belfast, N.)|
|Haworth, Sir Arthur A.||O'Brien, Patrick (Kilkenny)||Thorne, G. R. (Wolverhampton)|
|Hayward, Evan||O'Connor, John (Kildare, N.)||Tobin, Alfred Aspinall|
|Helme, Norval Watson||O'Connor, T. P. (Liverpool)||Touche, George Alexander|
|Henderson, J. M. (Aberdeen, W.)||O'Donnell, Thomas||Tryon, Captain George Clement|
|Henry, Sir Charles S.||O'Dowd, John||Ure, Rt. Hon. Alexander|
|Higham, John Sharp||Ormsby-Gore, Hon. William||Verney, Sir Harry|
|Will, Sir Clement L. (Shrewsbury)||O'Shaughnessy, P. J.||Wadsworth, J.|
|Hillier, Dr. Alfred Peter||O'Sullivan, Timothy||Ward, Arnold S. (Herts, Watford)|
|Hinds, John||Parker, Sir Gilbert (Gravesend)||Ward, W. Dudley (Southampton)|
|Hodge, John||Parkes, Ebenezer||Waring, Walter|
|Holt, Richard Durning||Pearce, Robert (Staffs, Leek)||Wason, John Cathcart (Orkney)|
|Hope, Harry (Bute)||Pearce, William (Limehouse)||White, Major G. D. (Lancs., Southport)|
|Horne, William E. (Surrey, Guildford)||Pease, Herbert Pike (Darlington)||Whittaker, Rt. Hon. Sir T. P.|
|Howard, Hon. Geoffrey||Pease, Rt. Hon. Joseph A. (Rotherham)||Williams, P. (Middlesbrough)|
|Hughes, Spencer Leigh||Peto, Basil Edward||Williams, Col. R. (Dorset, W.)|
|Hunt, Rowland||Phillips, John (Longford, S.)||Wilson, Rt. Hon. J. W. (Worcs., N.)|
|Isaacs, Rt. Hon. Sir Rufus||Pollard, Sir George H.||Winfrey, Richard|
|Jardine, Ernest (Somerset, East)||Pollock, Ernest Murray||Wood, John (Stalybridge)|
|Jardine, Sir John (Roxburgh)||Power, Patrick Joseph||Wood, Rt. Hon. T. McKinnon (Glasgow)|
|Johnson, W.||Priestley, Sir W. E. B. (Bradford, E.)||Worthington-Evans, L.|
|Jones, Sir D. Brynmor (Swansea)||Pryce-Jones, Col. E.||Wortley, Rt. Hon. C. B. Stuart-|
|Jones, Leif Stratten (Notts, Rushcliffe)||Radford, G. H.||Wyndham, Rt. Hon. George|
|Jones, William (Carnarvonshire)||Raffan, Peter Wilson||Younger, Sir George|
|Jones, William S. Glyn- (Stepney)||Ratcliff, R. F.|
|Joyce, Michael||Rawson, Col. Richard H.||TELLERS FOR THE AYES.—Mr. Illingworth and Mr. Gulland.|
|Joynson-Hicks, William||Rea, Rt. Hon. Russell (South Shields)|
|Adamson, William||Henderson, Arthur (Durham)||Rowlands, James|
|Banner, John S. Harmood-||Hudson, Walter||Snowden, Philip|
|Barnes, George N.||Jones, Henry Haydn (Merioneth)||Sutton, John E.|
|Beauchamp, Sir Edward||Lambert, Richard (Wilts, Cricklade)||Thomas, James Henry (Derby)|
|Brace, William||Macdonald, J. R. (Leicester)||Walsh, Stephen (Lancs., Ince)|
|Crooks, William||Macdonald, J. M. (Falkirk Burghs)||Ward, John (Stoke-upon-Trent)|
|Davies, David (Montgomery Co.)||Wanfield, Harry||Wardle, George J.|
|Davies, Ellis William (Eifion)||Mond, Sir Alfred Moritz||Wiles, Thomas|
|Dawes, J. A.||Money, L. G. Chiozza||Wilson, John (Durham, Mid)|
|Denman, Hon. R. D.||Newman, John R. P.||Wilson, W. T. (Westhoughton)|
|Duncan, C. (Barrow-in-Furness)||O'Grady, James||Yoxall, Sir James Henry|
|Gill, A. H.||Parker, James (Halifax)|
|Glanville, H. J.||Pointer, Joseph||TELLERS FOR THE NOES.—Sir A. Markham and Mr. Jewett.|
|Goldstone, Frank||Price, C. E. (Edinburgh, Central)|
|Greenwood, Granville G. (Peterborough)||Roberts, G. H. (Norwich)|
Question, "That those words be there inserted," put, and agreed to.
§ Mr. CECIL HARMSWORTH
I beg to move, at the end of the proposed Amendment, to insert—
"(ii) the regulations may provide that, in the case of persons who are receiving medical attendance and treatment under any system or through any organisation existing at the time of the passing of this Act and approved by the local health committee and the Insurance Commissioners, such medical attendance and treatment may be treated as, or as part of, their medical benefit under this part of this Act, and may provide for the Committee contributing towards the expenses thereof the whole or any part of the sums which would be contributed in the case of persons who have made their own arrangements as aforesaid."
I am advised that this Amendment is more acceptable than in the form in which it appears on the Paper. I do not propose to make any lengthy remarks in regard to it. I intervened in the Debate yesterday, and then said almost everything that was necessary on this point, but I would venture respectfully to explain its possible effect. My object in moving it is to safeguard the interests of the great medical institutes which have been established by friendly societies, and which are to be found in many towns up and down the country. I may inform the Committee that these medical institutes exist in Birmingham, Cambridge, Cheltenham, Gainsborough, Kidderminster, Leicester, Lincoln, Northampton, Nottingham, Luton, Plymouth, Tunbridge Wells, York, and elsewhere. In the case of thirty of them they possess buildings of a substantial character, where they administer, as far as I can see, precisely that kind of medical benefit which the Chancellor of the Exchequer had in view in framing this Bill. Many members of friendly societies are naturally keenly interested in these institutes, and there has been a great deal of anxiety in regard to their position under the Bill. There can be no doubt whatever that without some such Clause as this they will be placed in serious jeopardy. The Clause will also be found to apply to those large medical associations which are connected with industrial enterprise in this country. I may inform the Committee that the Amendment as it appears on the Paper has received the approval of one of the greatest friendly societies in the country, the Manchester Unity, and I do not suppose that the words which it is porposed to insert will make any difference in the opinion of that association. These 452 institutes have cost a great deal of money. A great part of the reserve funds of some of the friendly societies are invested in them. They carry on the business of administering a medical benefit, they pay their medical officers to the complete satisfaction of those gentlemen, and in fact they have been doing what the friendly societies all over the country have been doing for a great number of years, a considerable proportion of the work which it is proposed shall be done in the Bill now before Parliament. It is the bounden duty of Members of the House to safeguard the interests of these great institutes as well as the existing benefit associations which are attached to great industrial enterprises.
§ Mr. SANDYS
There is one point I should like cleared up, and that is with regard to the last paragraph, which states that regulations "may provide for a committee contributing towards the expenses thereof the whole or any part of the sum which would be contributed in the case of persons who have made their own arrangements as aforesaid." I should like to know, before the matter is definitely settled, what the actual value of this contribution will be, supposing the whole of the sum were contributed as in the case of persons who have previosuly made their own arrangements as aforesaid. That of course refers back to the previous Amendment which has already been accepted, where I find that the amount which will be paid to such persons as are above the income limit settled by the health committee will amount to sums not exceeding in the aggregate the amounts which the Committee will otherwise have extended in. providing medical benefit for them. That is the same point which comes up in this Amendment. I conclude that the amount which the Committee would otherwise have expended in providing medical benefit for them would actually come out at the sum which the health committee arrange to pay per capita to the medical attendant, that is to say, as I read it: supposing a man who had decided to be above the income limit at which he was entitled to receive medical benefit, were lying sick for six months, he would, as a matter of fact, under the Clause, only be entitled to receive the 6s. or 8s. which the health committee would have paid to the doctor under ordinary conditions for his 453 medical attendance. What would the amount of the contribution be? Would it actually be the amount which the health committee would pay to the doctor for attendance per capita?
§ Mr. McKENNA
Yes, it would be the same amount as would ordinarily be paid per capita to the doctors, but the amount is not yet settled. The Chancellor of the Exchequer stated yesterday, when the Division took place on the question whether the administration of the medical benefit should be undertaken by the approved society or the committee, that the decision of the House would entail some alteration in Clause 14, and when we get to Subsection (3) the hon. Member will see what are the proposals of the Chancellor of the Exchequer with regard to the determination of the amount of payment.
§ Mr. SANDYS
But as we stand at present this position is absolutely correct, that a man who is above the income limit under this Clause would only be entitled, even if he was ill for nine months in the year, to that sum, whatever it may be, 6s. or 8s., which the health committee has agreed to pay the doctor. It seems to me very unsatisfactory.
§ Mr. J. H. THOMAS
I voted against the Amendment last night that the Government decided to accept, because I felt that it would make it very difficult for these benefit associations to continue in the good work they have done. The Government, in this Bill, has very clearly and fairly recognised the work of the friendly societies, the intention being to utilise, as far as is practicable, the existing organisation, and in the same sense that the friendly society has in the past provided for sick benefit, so a large number of these medical associations have made the only provision for medical benefits. In the constituency I represent there is an association which has been in existence for upwards of thirty years. Practically the whole of the friendly societies in that town subscribe to that association, and by that means provide medical benefit for the whole of their numbers. Whilst I recognise that this particular Clause allows that institution to continue in its work, there is, I must confess, some difficulty. At present the members are not only allowed to make provision for themselves, but in practically the whole of the institutions in the country they are allowed to make provision, on a reduced scale, for their wives and families. Under the 454 Clause that, I understand, is now to be accepted, these institutions will not be allowed to continue in the future as they have in the past for this reason. Whilst at the present time they engage and pay doctors, they also engage dispensaries and supply the whole of the medicine. As I understand from what the Chancellor of the Exchequer said last night, it is his intention even under this Clause, if it is accepted, to compel this organisation to separate both branches of work. That, I think, will create considerable difficulty. In any case I associate myself with the hon. Member (Mr. Harmsworth) in congratulating the Government on accepting this Amendment, and I hope every effort will be made to safeguard the institutions, and continue the good work they have done in the past.
§ Mr. LEIF JONES
I am very glad this Amendment is brought forward. It would be exceedingly undesirable for us to do anything to destroy these valuable institutions which really manage medical benefit quite admirably. I think doctors will admit that it is far better than the ordinary club practice. Many of them have acquired their premises. There is an institution at Nottingham which is very well managed. The doctors are paid on a far better scale than the average throughout the country—they have their separate departments for dispensing. It remains to be seen whether the system set up by the health committee may be improved in the future. At any rate, these people have, in a great measure, solved the very difficult problem of securing medical benefit for the workers of the country. Therefore I am glad that the operations of the societies are to be safe. I really rose to ask my hon. Friend why he is putting into the Amendment words which are not printed upon the Paper, and which, I think, do not improve it at all. He has put in the words "existing at the time of the passing of this Act," and if I gather the effect of these words aright it means that no new medical society of any kind can be established in any of the towns of the country. I have in my hand a list of the towns where there are societies, and I find that there are notable absences; that is to say, towns which have not the benefit of societies. If the societies are admittedly worth preserving, and if the Chancellor of the Exchequer accepts them as part of his scheme, I do not understand why my hon. Friend should rule out their formation in future by inserting these 455 words. I beg to move to amend the proposed Amendment by leaving out the words "existing at the time of the passing of this Act." My object is to allow medical institutes to grow up in other towns where they do not exist at present. They have done good work where they exist, and I do not see why they should not be allowed to grow up in future.
§ Mr. CECIL HARMSWORTH
I may explain—and I hope there is no impropriety in doing so—that this is an agreed Amendment. It has been rather difficult to reconcile all the interests concerned. Personally I should prefer to see the Amendment without the words which have been introduced since it was printed, but as it is an agreed Amendment I regret that I cannot support my hon. Friend's suggestion.
§ The DEPUTY-CHAIRMAN (Mr. Whitley)
As an Amendment has been moved to the proposed Amendment, I would suggest that hon. Members should confine themselves to that Amendment.
§ Mr. LEIF JONES
I am sorry the Government have come to this decision. Personally I think it is a mistake, but as they have given us a good deal by accepting the Amendment, I beg leave to withdraw my own Amendment.
§ Amendment to the proposed Amendment, by leave, withdrawn.
§ Mr. BUTCHER
There are two questions I should like to ask the First Lord of the Admiralty in connection with this Amendment. One has reference to a point raised by the hon. Member below the Gangway, which is rather important. Under this Amendment will a medical society, formed by the friendly societies now existing, be able not only to employ a doctor but to dispense the medicines the doctor orders? I know that many medical societies keep a dispensary where they dispense the medicines ordered by the doctor. Will the Amendment reserve to them that right which they have until now enjoyed? I think it is a right to which they attach some value. The other question I wish to ask the right hon. Gentleman is whether he can tell us what amount per head, roughly speaking, will be paid over to these medical societies. Would it be 6s., or 7s., or more or less? Perhaps the First Lord will be able to give us some assurance on that subject.
§ Mr. McKENNA
In regard to the last point, I have to say that the question can be raised on Sub-section (3) of this Clause, 456 to which the Chancellor of the Exchequer has given notice of the Amendments which appear on the Paper. I have to ask the hon. Member to allow me to defer my answer until that Sub-section is under discussion. In regard to the other question, I would point out that the matter is dealt with in a series of Amendments which will come up a little later on the Clause. I do not think it arises at this particular point. I hope that we shall reach the point when the question can be discussed in half an hour from now. In this case also I would ask the hon. Gentleman to allow me to defer my answer until then.
§ Mr. HODGE
Yesterday, while another Amendment was being discussed, the hon. Member for Mansfield (Sir A. Markham) directed attention not only to cases where in large public works there is an institute of this character, but to the fact that a deduction is made from wages in respect of the service obtained by the workmen. That service includes medical attendance and medicines for the whole family. I am afraid that under this Amendment that is not covered.
§ Mr. McKENNA
Certainly. The hon. Member will see that there is on the Paper an Amendment of which the hon. Member for Hoxton (Dr. Addison) had given notice. That was withdrawn, and a wider Amendment accepted.
§ Mr. GEORGE ROBERTS
I understood from the Chancellor of the Exchequer last night that it would be in the competence of the medical institutes to continue a portion of their benefits if they simply separated them into distinct departments. There seems to be some doubt about that from what the right hon. Gentleman has said.
§ Mr. McKENNA
Not at all. I said it would be better to defer discussion on that matter until we come to the part of the Bill where it arises.
§ Mr. G. ROBERTS
I wish to understand whether the medical institutes will have the right not only to provide for medical benefits, but also to maintain departments for dispensing drugs by qualified people 457 just as they do at the present time. I have had an opportunity of going into this Amendment under legal advice—not always reliable—[HON. MEMBERS: "Oh."] After all, if it was reliable, some of you would not have much of a livelihood. I do not wish to cast a reflection on that noble profession, but I have some little doubt whether the words actually cover what we desire. So far as my information goes, I accept the Clause as fulfilling the promise which the Chancellor of the Exchequer made last night. There is one of these institutions in my Constituency with which I have been personally connected, and I know that it largely carries out what is desired under this scheme. It has been perfectly free from the charge of sweating. It has paid a medical man a very reasonable salary, and he can prescribe what drugs he likes without feeling that it involves any diminution of his salary. I think these institutes have played a useful part in giving the working classes a very valuable form of medical treatment. I am glad that the Chancellor of the Exchequer has met this case so well.
§ Mr. POLLOCK
These regulations are very important, and concern a very large body of friendly societies indeed. I believe that about 240,000 persons are served by these institutions. Personally I should prefer to see the provision made more Stringent. I should like the word "shall" instead of "may," because I wish to safeguard their position. However, this is an agreed Clause. What I want to ask the First Lord is whether he will undertake later on when we come to Clause 44, and, indeed, perhaps also in other parts, to see that powers are given to the health committee or that duties are imposed upon them for the purpose of carrying out this Sub-clause. I have put down an Amendment to Clause 44 for this purpose, and I am not satisfied to leave this Clause as it is unless we have the duty imposed under Clause 44 upon the health committee to endeavour to carry out this Clause. I hope that the agreement that has been made in reference to this Clause is an agreement which covers the future, I may say, of this Clause throughout the rest of the Bill. I hope that in coming to this agreement that purpose has been kept in view, and that the other Clauses of the Bill will be so modified and such duties imposed upon the health committees as will have the result that the intention of all the hon. Members of this Committee 458 shall be carried out, and that the interests of the associations which are at present doing such valuable work, may be safeguarded, and that very full powers may be given to them to carry out their work.
§ Sir A. MOND
I would like to emphasise the point raised by the hon. Member who spoke last, and to ask that the Government shall see its way to substitute "shall" for "may." They have given such an ample assurance as to what they intend to cover with regard to both industrial societies and friendly societies that I think they may give this assurance which would give great satisfaction outside, where this Clause naturally aroused a great deal of interest. I would also like to ask what is the exact meaning of the word "organisation," because, so far as I have been able to discover, it is not used in any other Clause in the Bill? We know of approved societies. We know nothing about "organisations." The reason I ask the question is this. The great friendly societies are very much concerned in this matter, and want to know whether they are covered by this Clause or not in the same way as members of workers' clubs are covered, as we have been told they are covered, and members of medical institutions. Would the member of such a body to-day be able, under this Clause, to continue his present method of payment on behalf of himself and his family, and would he receive the same amount of medical contribution? That is a question I would like an answer to on behalf of the large friendly societies, who naturally have been rather alarmed at seeing in the Amendment which has now been withdrawn of the hon. Member for Hoxton that their members would be left out. I understand that the word "organisation" is intended to cover all these parties?
§ Sir A. MOND
I think that a declaration on behalf of the Government that it would include all these people would allay their fears.
§ Mr. NEWMAN
Before this agreed Clause is passed I would like to receive an assurance on one small point. I hold in my hand the rules and regulations which 459 apply in the case of the men in the Royal Small Arms factory at Enfield. Clause 43 reads as follows: "All persons who are three years in continuous service are entitled to medical attendance at their residence," and so on. I take it that, under this proposed Sub-section, this medical attendance given at the Royal Small Arms factory and other factories would be continued as "medical attendance and treatment under any system, or through any organisation approved by the local health committee," and that, therefore, in the case of those men who are employed in the small arms factories and receive medical attendance the money would be paid by one Department of State to another Department of State. That is, the money would be passed by the State Insurance Department to the War Office in respect of these men. Assuming that these men paid nothing towards these benefits that would be perfectly fair, but at the Small Arms factory 6d. a week is deducted from their pay for medical benefits and sick benefits. That being so, it is unfair that these men should be treated like this, and surely they ought to get the capitation allowance.
§ The DEPUTY-CHAIRMAN
I do not think that point arises here. There is a special Clause in the Bill dealing with funds of that kind, but the question does not arise at this point.
§ Mr. McKENNA
I can assure the hon. Gentleman that rules will be framed under Clause 37 which will deal with this point.
§ Mr. NEWMAN
I am very glad to hear that. I asked questions repeatedly about it, and I am glad to have the assurance that regulations are to be provided under a later Clause.
§ Mr. MILLAR
I am glad to have the assurance of the right hon. Gentleman that this Amendment will cover the case of medical benefit associations in connection with large works which have been referred to already by the hon. Member below the Gangway. I have received a great many representations on this subject from my own Constituency in connection with the work in collieries, steel workers, and other classes of industrial enterprise, and I am glad to know that these associations which are doing very good work just now are going to be safeguarded under the provi- 460 sions of this Amendment. The chief advantage which accrues to those who are deriving benefit from such association is that it goes to their wives and children as well, and these associations can only exist because of the contributions which are made by the young unmarried men towards their funds. I have been in very serious doubt as to whether they might be seriously affected under the provisions of this Bill, and I am therefore very glad to know that under this Amendment the interests of all concerned will be safeguarded.
§ Mr. BAIRD
I understand that the Amendment which we are now discussing is not exactly as it stands on the Paper, and that some words have been inserted which were designed to affect that this Amendment shall only apply to organisations that exist to-day, and that it shuts the door on organisations which may be started in future. I think that the hon. Member for Rushcliffe (Mr. Leif Jones) raised that point, and then withdrew both Amendments. I endeavoured to get up in time to protest against the Amendments being withdrawn, as I would like to discuss that point, because I think that it has been said that this was an agreed Amendment. It is necessary to have more information on the subject when the effect of the omission of these words will be so far-reaching as it is bound to be. We all admit that it is desirable to encourage, and, indeed, safeguard these medical institutions and so on, but why should not more organisations of this kind be started.
§ The DEPUTY-CHAIRMAN
The hon. Member is discussing an Amendment which has been debated and withdrawn.
§ The DEPUTY-CHAIRMAN
The hon. Gentleman should have objected to the withdrawal of the Amendment. I do not think that future organisations are included in the word "organisation."
§ Mr. BAIRD
If it were the intention to include future organisations it would be competent for me to move an Amendment for the purpose of including them. May I appeal to the First Lord of the Admiralty whether it is the intention of the Govern- 461 ment to include future organisations, or is it simply intended to apply to organisations which exist to-day?
§ Mr. McKENNA
The Amendment on the Paper is limited to such organisations as exist. My hon. Friend moved it with the addition of the words "existing at the time of the passing of this Act," and no doubt the intention was to limit it to organisations at that time. I would remind the hon. Gentleman that my hon. Friend who moved this Amendment himself said that he was prepared to move it without the additional words, and he did so. Although I fully admit the strength and importance of the point of view of the hon. Gentleman opposite, I can assure him that if he had the conduct of a Bill of this kind he would know that you are bound to take into consideration the various interests concerned, and this Amendment is generally accepted outside as reasonable, and has been, in fact, accepted by all the parties concerned.
§ Mr. BAIRD
Though there appears to be a good deal of mystery about this, yet I fully agree with the right hon. Gentleman that it is an exceedingly difficult and complicated matter. However, if all the persons concerned are satisfied with this Amendment, then I do not know that I press the point further.
§ Mr. SANDERSON
There is one matter to which I wish to call attention. It is that the word "shall" should be inserted in the Amendment instead of "may." The hon. Member for Luton explained that it was an agreed Clause, but with regard to this question I would point out that in the Amendments which were proposed by the Chancellor of the Exchequer the word "shall" is used. And in reference to the regulations made by the Insurance Commissions, also, the word "shall" is used.
§ Mr. McKENNA
There is no change of view or intention, and the word "shall" can be substituted for "may."
§ Mr. SANDERSON
In Sub-section after Sub-section of the Clause the word "shall" is used, and then when you come to the last Sub-section the word "may" is introduced. The introduction of that word instead of the word "shall" is generally interpreted as giving to the authorities, in this case the Insurance Commissioners, a wider discretion with regard to that matter than they have with regard to others. I do not understand 462 that it is intended that the Insurance Commissioners, in framing regulations, are really to have a wider discretion in regard to institutions to be organised by friendly societies than they have with regard to regulations as to medical practitioners. I am much obliged to the First Lord of the Admiralty for the intimation he has given, and he will remember that it is in accordance with the wishes of both sides of the House.
§ Mr. GARDNER
was understood to say: There is an extraordinary difference between some of the Sub-sections lately passed and the present one with regard to the provision made for medical attendance and treatment.
§ Amendment made: In Sub-section (2), leave out the words "society or" ["every such society or committee shall."]—[Mr. Lloyd George.]
§ Mr. GLYN-JONES
I beg to move in Sub-section (2) to leave out the words "and no arrangement shall be" ["insured person, and no arrangement shall be made with"], and to insert instead thereof—In accordance with regulations made by the Insurance Commissioners, which shall provide for the arrangements made being subject to the approval of the Insurance Commissioners and being such as to enable insured persons to obtain from any person with whom arrangements have been made such drugs, medicines and appliances as may be ordered by the medical practitioner by whom they are attended, and shall require the adoption by every local health committee of such a system as will secure—463
- (a) the preparation and publication of lists of persons, firms, and bodies corporate who have agreed to supply drugs, medicines, and appliances to insured persons whose medical benefit is administered by the committee, according to such scale of prices as may be fixed by committee;
- (b) a right on the part of any properly-qualified person who is desirous of being included in any such list as aforesaid, of being so included, except in cases where the Insurance Commissioners after inquiry are satisfied that his inclusion or continuance in such list would be prejudicial to the efficiency of the service:Provided that—I move this Amendment in a form which brings it in accordance with the regulations for medical treatment. If there is one reason why this Bill should be welcomed more than another it is because the Chancellor of the Exchequer has made provision for dispensing as well as for medical benefit. This, I think, is the only country in Europe where it is the practice of medical men to dispense their own prescriptions. In my opinion the Chancellor has taken a very valuable step, now when the State is taking so large a control through the approved societies in the dispensing of medicine in this country, in recognising the advantage of distinguishing between the two functions of prescribing and of dispensing. I am satisfied that the old system whereby a doctor could not give the medicines which perhaps he ought to give, without his own pocket suffering, brought about a position which you ought not to put any man in; he should be paid for his services and he should not have to suffer by reason of the fact that the case he is dealing with might require expensive drugs. It is for that, if for no other reason, I welcome this Bill, because it will provide that the poor and the less well-off will have the chance in the future of receiving the drugs and medicines which they should receive. The object of this Amendment can be put quite shortly.
- (i) if the Insurance Commissioners are satisfied that the scale of prices fixed by the committee is reasonable, but that the persons, firms, or bodies corporate included in any list are not such as to secure an adequate and convenient supply of drugs, medicines, and appliances in any area, they may dispense with the necessity of the adoption of such system as aforesaid as respects that area and authorise the committee to make such other arrangements as the Commissioners may approve;
- (ii) the regulations shall prohibit an arrangement being."
The Committee has now decided that there shall be free choice of doctors and that the insured person may go to any doctor on a recognised panel. The pharmacists ask that exactly the same thing should apply in regard to them, and that the insured person, having obtained his prescription, may take it to any pharmacist, or any person or firm or company who 464 are on the panel. The Committee will see that unless something of this sort is done a most serious and quite unnecessary injury would be done to those engaged in the business of pharmacy. If 15,000,000 of people are to be brought into the scheme, and if institutions are to be set up, and if the insured 15,000,000 are compelled to go to these institutions, then you would be practically setting up a State monopoly in dispensing without recognising the position of those whom you are going to displace. I am not going to discuss the question of a State-organised system of medicine. If the House were going to deal with it, they would then deliberately consider what was going to happen to those now engaged privately in that service. Therefore the case which the doctors put and which has been agreed to by the House that they are to have equal opportunity of administering medical treatment is claimed also on behalf of those who supply medicines. The Amendment has been framed on the lines of that put down by the Chancellor of the Exchequer, and which has been accepted by the House, dealing with medical men. The first part of the Amendment provides for arrangements being made to enable insured persons to get a supply of medicines. There is a provision also for the publication of list of persons, firms, and bodies corporate. That will let in any institution or any company that complies with the Pharmacy Acts. In other words, it enables them by employing a qualified chemist to control the business and supply the wants, so that there can be no fear of any complaint of monopoly against this scheme. I am fortunately in the position to speak on behalf, not only of the individual pharmacists, but also of the great companies and stores who joined with the pharmacists in a deputation to the Chancellor of the Exchequer. I speak for them, as well as for the members of the Pharmaceutical-Society, in saying that this list will be open to all co-operative societies and any sort of institution which complies with the Pharmacy Act by having qualified people in charge of their places. If on the panel, it will be open to any insured person to have the prescription made up at any place. It may be said how is it going to be paid for? A scale is to be fixed by the; health committee, with the sanction of the Commissioners.
I spent the Whitsuntide Recess in going through parts of Germany, Austria, and 465 Italy, and the best answer to the question, Is a tariff scale possible? is, that throughout the whole of Germany medicines are dispensed, not only for insured people, but for the whole people upon a tariff basis. It is obvious that you cannot arrange for payment on any other basis except a scale. It would be impossible to say for how much you would be willing to provide medicine for the 670 Members of this House for one year, such medicine as the hon. Member for Hoxton might order for them, because nobody knows what medicines will be wanted. Obviously it is impossible to arrange it on a per capita basis. There is also provided the right of any properly qualified person who desires to be included to come upon the list. No one can be kept out of it except persons the Insurance Commissioners do not approve of. The Amendment as well provides that the Insurance Commissioners shall have the same power as in the case of the doctors. If this system is proved in any area to be unworkable, and should there be any attempt to ring prices, the Commissioners can put an end to the whole thing, and the committee may make arrangements with the sanction of the Commissioners.
§ Mr. McKENNA
We accept this Amendment, the purport of which has been fairly and fully stated by the hon. Member. By this Amendment we are merely applying to those who dispense the medicines the same principles which have already been applied to the doctors.
I quite agree that that which is being done for the doctors ought also to be done for the chemists. The wording of the Amendment, however, is not on all fours with what we have done in the case of the doctors. In the case of the doctors the words "inclusion or" were struck out, and the objection by the Insurance Commissioners was limited to continuance in the list. I presume the Government will accept the same form of words for the chemists as for the doctors.
§ Mr. McKENNA
We will consider what the hon. Member has said, and if the circumstances are precisely the same the alteration shall be made at a later stage.
The same reason which made the alteration necessary in the case of the doctors makes the alteration necessary in the case of the chemists. I will leave that point with the right hon. Gentleman. Then there is another point. In paragraph (b) the words 466 "a right on the part of any properly qualified person who is desirous of being included," do not correspond with the words either in paragraph (a) or in the proviso. In paragraph (a) the words are, "persons, firms and bodies corporate;" in paragraph (b) they are simply, "any properly qualified person;" while in the proviso the words are, "persons or firms or bodies corporate." It seems to me that there' ought to be the same phraseology in each case.
§ Mr. BARNES
I take it that by agreeing to this Amendment we shall not be committing ourselves to the consequential Amendment later on, in which there is a kind of definition of the qualified person or corporate body.
§ Mr. C. E. PRICE (who was very indistinctly heard)
There is nothing in this provision to insure that prescriptions shall be carried out in a definite way, and no penalties are imposed if a prescription is not carried out in accordance with the directions given by the doctor I have known a case in which the same prescription made up in London and in another town was in one case red and in the other brown. I think there should be some penalty attaching to the man who does not carrying out precisely the prescription supplied.
§ Mr. GLYN-JONES
May I say that these people are brought under the Food and Drugs Act, and will be bound by law to compound in accordance with the prescription. I have no doubt the explanation of the experience given by the hon. Member as to the prescriptions is that the one was dispensed with London water and the other not.
§ Dr. HILLIER
I think it ought to be pointed out that the Amendment accepted by the Government necessitates a further Clause to protect the legitimate interests of certain dispensers in the country, and I would ask whether it would be in order for me to move at the end of the Second. Clause the Amendment I have on the Paper. The Amendment I mean is on page 27 of the White Paper. I think it would come more appropriately at the end. of the Second Clause than where it stands upon the Paper.
§ The DEPUTY-CHAIRMAN
The hon. Gentleman rose to a point of Order. I do not think that the Amendment can be moved, but I will look into it.
§ Mr. COOPER
I rise to express my appreciation of the fact that the Government have accepted this Amendment, but I would like to ask one question. There are a certain number, I do not think a great number—probably under thirty all told—firms who are quite independent of the doctors in this country, but who do not do a general druggist's trade. They confine their work entirely to making up prescriptions for doctors. I take it that they will be included amongst the corporate bodies?
§ Amendment agreed to.
§ Mr. PETO
I beg to move my Amendment. Apparently the course of the whole procedure has been simplified. The societies have been left out, and the whole of the question has been left to the local health committees. I ask the right hon. Gentleman in charge of the Bill whether it is wise entirely to preclude any possibility of agreement between the local health committee and a doctor to allow him to continue a dispensary? I can quite understand it is very undesirable, or maybe undesirable, that any agreement should be made that should bind the doctor to provide drugs at an inclusive fee. But it is a pity to limit the power under this Bill, and entirely to preclude any agreement which might be due to exceptional circumstances between the local health committee and the doctor.
I am quite sure that quite apart from the exceptional localities which were indicated by the Chancellor of the Exchequer, where there is no chemist possibly within an enormous number of miles, there are a great many places where, if this matter is left to the local health committee, it might be exceedingly desirable in the interests of all classes that an agreement should be made which would empower the doctor in certain cases to provide drugs at an inclusive fee. Of course it opens up a 468 very wide question which I will not touch upon—that is the question of the existing dispensaries of doctors. There is no doubt, as the Chancellor of the Exchequer said, that the whole scope of this Bill will mean a great deal more medical attendance and a great deal more drugs; but if you are going to make it absolutely illegal for the health committees to make any agreement whatever, quite apart from the doctor being bound or not to provide drugs at an inclusive fee, I think you are unnecessarily tying the hands of the local health committees.
§ Mr. McKENNA
I do not think the matter is one of great importance, but I hope the hon. Member will not press the Amendment. I have not had an opportunity of speaking to the draftsmen upon the subject, and there may arise some point of substance.
§ Mr. COOPER
I do not know whether the right hon. Gentleman is quite right in saying that it does not matter, and in saying that there are no circumstances in which the thing could occur. Because in the later part of this Clause, in the rural districts where there are no pharmacists available at all the doctor is entitled to come to an agreement.
§ Amendment, by leave, withdrawn.
§ Mr. GLYN-JONES
I beg to move, in Sub-section (2) to leave out the words "at an inclusive fee" ["drugs or medicine for any insured person at an inclusive fee"].
Of course, it is quite obvious when you think about it, that the only way you can make an agreement with a doctor to supply medicine is upon a per capita or inclusive basis. You cannot, as a matter of business, make arrangements with a doctor whereby he is to be paid for materials, in the shape of the drugs, when he is the only person who knows what drugs are used. I am not at all suggesting that the medical men throughout the country would charge for expensive drugs that they did not use. But we have got to deal with this thing as a business proposition, and to say that a man could send in a bill for drugs supplied when no one but himself knows what drugs were supplied is an unsound principle from a business point of view. My Amendment will not prevent doctors dispensing where the Insurance Commissioners think that in particular dis- 469 tricts it is expedient they should do so, but where that is done the general basis of payment will have to be a per capita basis. Where the Insurance Commissioners have to make arrangements with the doctors for doing this it will be done as a business arrangement, and the doctor will not be able to charge for expensive drugs if they were not supplied.
§ Mr. AUSTEN CHAMBERLAIN
I have some doubt as to the attitude of the Committee upon this question. I imagine the general principle upon which we are proceeding in these matters is that you should not unless it be absolutely necessary for the working of the Bill destroy present rights or arrangements. That, I think, is the desire of the series of the last Amendments moved. We may not think this is the best conceivable arrangement for the supplying of drugs, but they are the existing arrangements, and if they were to be altered they ought to be altered by amendment of the Pharmacy Acts and not by a side wind in a Bill of this kind. Is the hon. Gentleman opposite carrying out that principle in this Amendment? He gives one reason only for his Amendment, that the patient will not be able to say whether in fact he has been supplied with the drugs with which the doctor professes to supply him. I know the hon. Gentleman opposite is competent to test any drugs which he would be supplied with, but does he think that the ordinary patient has any sort of power of ascertaining whether the prescription which the doctor has given him is accurately represented in the bottle of mixture which the chemist makes up.
§ Mr. GLYN-JONES
What I meant to say was this, that the Public Health Committee who pay for these drugs would receive a bill from the dispensing doctor, and no one but that doctor would know whether these actual drugs were supplied or not.
§ Mr. AUSTEN CHAMBERLAIN
That is what I understand. But what I submit to the hon. Gentleman is that that is the exact position which the Public Health Committee will also occupy in reference to the chemist.
§ Mr. GLYN-JONES
In the case of the chemist the doctor and analyst could check the drugs. The doctor knows what he ordered, and it is possible for the inspector to see that what is ordered is supplied, but in the case of the doctor who supplied his 470 own drugs it is he himself who orders them and nobody but himself knows what he supplies.
§ Mr. AUSTEN CHAMBERLAIN
I think the hon. Gentleman agrees with me so far as the patient is concerned. We choose the doctor or chemist, and we trust and rely upon them. The hon. Gentleman suggests that in the case of a doctor who supplied the medicine as well there would be no possibility of testing whether he supplied the medicine he professes to supply. I suggest that that is true in the same degree of the medicine supplied by the chemist. It is quite true that a doctor might take away a medicine supplied by a chemist and analyse it.
§ Mr. AUSTEN CHAMBERLAIN
I am coming to the inspector. The doctor might take away a medicine supplied by the chemist and analyse it and find it was not correct. I venture to say in some cases— I speak subject to correction—it would be impossible for him to tell whether the natural drug, which is expensive, or a chemical drug which is less expensive was used. I am told they are chemically un-distinguishable. I speak from what doctors have told me in advising me to go to one chemist rather than another, because in one case I would get the natural drug and in the other the artificial as they are chemically undistinguishable, but the effect on the patient is different. Therefore it is difficult to check these things. I do not think it is the practice of doctors to take samples on a large scale from drugs supplied by chemists on their prescriptions and analyse them. The hon. Gentleman says the inspector could catch the chemist, but if he could catch the chemist why could he not catch the doctor? What is sauce for the one is sauce for the other, and what is security sufficient against the chemist is, I think, security sufficient against the doctor. I do not speak at all dogmatically, and I do not feel at all confident upon the subject, but I desire to preserve the general principles upon which we are acting, and not to alter an established practice by a side-wind unless it is absolutely necessary to do so.
§ Mr. PETO
If I had known the hon. Member opposite was about to move his Amendment I should not have moved mine. I moved, because I wanted some-sort of principle established for dealing with doctor dispensers. The hon. Gentle- 471 man wishes to get these words out and to make it impossible under some other system, when this Bill becomes an Act of Parliament, for doctors to continue as dispensers. These qualifying words I regard as of the greatest importance. The hon. Member says it would not be best for doctors to dispense at an inclusive fee, but how can you create by an Act a veritable revolution in the supplying of medicine and drugs throughout the country when no new arrangement of any sort or kind will be the outcome? If these words are cut out of this Bill it would alter the whole of the Clause. I do not believe that the people in the country districts, at any rate, have suffered in any degree whatever from the fact that in nine cases out of ten their drugs have been supplied at an inclusive fee by their medical attendants. I should like to give the Committee one example from a letter written by a doctor whom I know very well in my own Division. He is one among thousands whose absolute aim and object and purpose in life is to give the best possible attendance and the best possible drugs to his patients, the bulk of whom are very poor people, and who trust him entirely. He says:—Personally I think there are so many advantages as well as some disadvantages in the country at any rate in doctors dispensing their own medicine, that I should have thought it ought to have been left in this Bill to settle itself.We cannot leave things in this Committee to settle themselves, but I do protest against cutting out these words, which, at any rate, limit the action of this Clause to the inclusive fee, and I think it would become a great misfortune if the hands of those who have to administer this Bill are tied in the manner suggested by the hon. Member for Stepney. I should like the widest possible door left open in this Clause, not only in the interests of the patients and doctors in the country districts, but also in the interests of those who have for years and years dispensed drugs satisfactorily, not only to the doctors, but to the patients, and who, if the doctors are to be entirely precluded from dispensing drugs, under any condition whatever, will undoubtedly be deprived of their livelihood.
§ Sir RUFUS ISAACS
To leave out these words will, as a matter of fact, express the intention of the Government, and it will only place the doctors in the position stated by the Chancellor of the Exchequer that he wished to separate the 472 function of doctor and dispenser. It will not prevent the doctor dispensing where there are special circumstances, because that is provided for by subsequent words. By leaving out these words we are really only carrying out what has hitherto been understood to be the desire of the Committee that you should keep these two functions separate. There may be circumstances under which the doctor should be allowed to dispense medicine, and by subsequent words we give that right. In order to allow the fullest discretion to the Committee we propose to leave out the words "situated in a rural district." The effect of that is that you may take it as a general principle that the doctor is to act as doctor and not as dispenser, atlhough there may be circumstances under which he may act in both capacities.
§ Mr. COOPER
Do I understand the Government agree to leave out these words? There is another point which occurs to me which I do not think has been referred to, and it is that in making these alterations, whether it is the desire of the Government in this Bill to allow the doctors to prescribe in such localities as they are permitted by the Insurance Commissioners to do under a per capita grant or to prescribe at the rates that are laid down. It is not advisable generally to allow the medical men to have the right of prescribing when they themselves are dispensing and when they are paid actually upon the scale and not per capita. There is human nature in doctors like other people, and they would have an incentive to prescribe in order to get the larger sums of money from the local health committee.
§ Amendment agreed to.
§ Mr. SANDERSON
I beg to move, in Sub-section (2), to leave out the words from the word "not" ["not give unless the circumstances"] to the end of the Subsection, and to insert instead thereof the words "withhold when the circumstances in any locality make it expedient for their consent to be given."
There are many country districts where there is no person except the local medical practitioner from whom the insured person could get any drugs or medicine. There are large districts served in that way, and it seems to me the arrangement there ought not to be interfered with. As the words stand in the Bill there appears to 473 be a presumption against this arrangement being left as it is at the present moment. I hope the Attorney-General will consent to the Amendment, because it carries out the intention of the Government that where such an arrangement as I have described exists it is obviously expedient that the dispensing should be left in the hands of the medical practitioner.
§ Sir RUFUS ISAACS
I really do not think there is any substance in this Amendment, and I cannot help thinking that my hon. and learned Friend is unduly anxious upon this point. I think we may trust the Insurance Commissioners to do their duty in this respect. I was not present when this question came up for discussion earlier in the Debate. I am told the right hon. Gentleman the Member for Islington thanked the Government for having accepted a former Amendment as that met this very point. I would, therefore, ask the Committee not to delay over the discussion of this, which is really one of the finest technical points in phraseology.
§ Sir R. FINLAY
I think the words moved by my hon. Friend carry out more accurately the intention of the Clause.
§ Mr. SANDERSON
There is really some substance in this Amendment. It is often the case that a medical man who is called in. a case of emergency must have some emergency drugs. He may be called miles into the country, and this Clause, as it stands, is so severely worded that it would rule out a case of this kind. I venture to think the Clause, as amended by the right hon. Gentleman the Member for Islington, really covers the ground more satisfactorily than the Clause as it stands.
§ Mr. LOUGH
I must apologise to the Committee for not being here to move my Amendment. I judged by the immense number of Amendments, when I went to attend an important gathering of London Members in another part of the building, that I was quite safe. I also wish to give my thanks to the hon. and learned Member for moving part of my Amendment, but the whole of any Amendment I venture to put down ought not to be too much for the courage of any kindly disposed Member. The Amendment is an extremely reasonable one, as may be seen by the kindly consideration which it has received, and which my right hon. and learned Friend promises to give to it. He says he will consider it with fairness. I would 474 just mention one thing. He stated that I thanked the Chancellor of the Exchequer for his treatment of the first Amendment. I think that treatment was extremely kind, but the Amendment was only one half of a series. It recognised that practitioners, whose principles were not popular with the medical profession, should have justice done them. The necessary complement to that Amendment is this Amendment. It is not the least use recognising the principles of these medical practitioners if their medicines are not allowed to be supplied in cases of emergency. I should like if it becomes necessary, to move the other half of this Amendment. The effect of the Amendment is, as it were, to insert the words of the Bill, and make it read that the Commissioners shall not withhold their consent. We are representing the case of a minority, and my Friends on the Labour benches should consider that. We had about two hours ago in the Committee from the Labour benches an appeal on behalf of herbal practitioners, who do not possess any qualification at all. I rather sympathise with that case. We say that in cases of emergencies where these special medicines are not provided in other places that the doctor himself may be allowed to prescribe. I do not wish to press the Government unduly, though I believe it is an excellent Amendment, and I am glad the hon. and learned Member who moved it gave me his hearty support. I shall consider whether it is necessary to move the other half or not.
§ Sir RUFUS ISAACS
What I would suggest is that the hon. Member should withdraw the Amendment just now. I see there is some point in it, and that there is some importance in the phaseology. We shall consider these words in view of the other Amendment and, if they are more effective, we should not scruple to use them.
§ Mr. STUART-WORTLEY
Might I draw the attention of the right hon. Gentleman to what makes the effect of this Amendment still more important, namely, the succeeding words which define the expediency of the ease. I do not know, but I think there is something there which requires looking at, and unless it is looked at the Amendment is all the more important.
§ Mr. AUSTEN CHAMBERLAIN
Is the interpretation placed on the Bill as it stands correct or not. It is suggested that a doctor might have to supply drugs in a case of emergency, and that the Bill as it stands—I admit I do not so read it—would prevent him from receiving payment for the drugs so supplied.
§ Sir RUFUS ISAACS
It would not prevent him getting payment. He would first have to get the consent of the Insurance Commissioners. If he does that, and if the Commissioners accept the supply, they would pay for what was supplied.
§ Sir RUFUS ISAACS
He cannot supply them unless he has got the consent of the Insurance Commissioners. The Insurance Commissioners have to take into account the circumstances of the locality.
§ Mr. AUSTEN CHAMBERLAIN
I understand there can be no agreement which binds the doctors to supply drugs for reward without the consent of the Commissioners. It may be that in an emergency a drug is urgently needed and the doctor cannot afford the time to send to a chemist and get it. He, therefore, takes upon himself to supply the drug. I am quite certain he would do it, and I am sure everybody would desire he should be paid for it in that case. I would, therefore, ask the Attorney-General to make sure that the doctor shall not be prevented from receiving payment for drugs which have been supplied in cases of necessity of that kind.
§ Sir RUFUS ISAACS
I quite assent to that, and, if the Bill does not permit it, it shall certainly be done.
§ Sir A. CRIPPS
Does it mean the Insurance Commissioners may lay down conditions under which payment may be made? If the Insurance Commissioners 476 can lay down conditions it will be perfectly fair, but if in each individual case you have to go to the Insurance Commissioners I think it would be very hard on the doctors.
§ Sir RUFUS ISAACS
You may have the assent of the Commissioners to the payment either before or after. I agree with the object of the criticism, and the Bill shall be carefully looked at to see that in cases of emergency the doctor shall be able to supply drugs.
§ Mr. SANDERSON
I feel myself in some difficulty. I moved part of the Amendment which stood in the name of the hon. Member for Islington, and, as he apparently desires to withdraw on the undertaking of the Attorney-General to consider the whole of the Amendment, I feel there is nothing left for me but to fall in with his views. Under those circumstances, I ask leave to withdraw.
§ Amendment, by leave, withdrawn.
§ Mr. DAVID DAVIES
I beg to move, in Sub-section (2), to leave out the words "situate in a rural district."
§ Amendment agreed to.
§ Mr. GLYN-JONES
I beg to move, at the end of Sub-section (2), to insert:— "(3) Subject to the foregoing provision as to dispensing by a medical practitioner, the regulations shall prohibit arrangements for the supply of drugs and medicines being made with persons other than persons, firms, or bodies corporate entitled to carry on the business of a chemist and druggist under the provisions of the Poisons and Pharmacy Act, 1908, who undertake that all medicines supplied by them to insured persons shall be dispensed either by a registered pharmacist or by a person who, for seven years immediately prior to the passing of this Act. has acted as a dispenser to a duly qualified medical practitioner or a public institution."
This Amendment is a corollary to the-other Amendments moved, and it provides that arrangements may not be made with any persons or firms to come upon the panel to supply drugs unless those persons or firms are entitled, by reason of their compliance with the Pharmacy Act, to carry on the business of a dispensing chemist or chemist and druggist. Those words would let in any corporate body, institution, or persons who have an estab- 477 lishment which they put under the control or management of a qualified person. In order that the person who dispenses shall be a qualified person it is a condition to those firms coming upon the panel that the medicines which they supply to the insured person shall be dispensed either by a registered pharmacist or by a person who for seven years immediately prior to the passing of this Act has acted as a dispenser to a duly qualified medical practitioner or a public institution. It is quite clear the object of the words is to meet the case of those dispensers in institutions or in doctors' surgeries who may otherwise be thrown out of employment. This recognises the right of those dispensers to doctors or surgeries to dispense.
§ Mr. GLYN-JONES
A certified assistant is a person qualified to act as a dispensing assistant to an apothecary, and if he has done it for seven years he will be entitled to come in under this Bill.
§ Mr. BOOTH
I beg to move, in the proposed Amendment, after the word "pharmacist" ["dispensed either by a registered pharmacist"], to insert the words, "or by a military dispenser who has been qualified as such for not less than two years of his Army service."
If the hon. Member for Stepney could see his way to include those words, the way would be clear at any rate for me to give him my hearty support. I was very glad to hear the right hon. Gentleman the Member for Worcester (Mr. Austen Chamberlain) a few moments ago say he understood it was the basis of the Bill in all these matters to do no harm to any existing institution or to persons in their present positions, and it is wholly to carry out that object I suggest this Amendment. It would include these military dispensers who are at present engaged in this very work. I do not see how they can be included unless these words are put in. It must be borne in mind that the examination is a stiff one. I appeal to the Committee on behalf of these men, because they are at present recognised as dispensers by the Local Government Board, and that fact should have some weight with hon. Members. I do not think any of us want to do old soldiers out of a job, and I hope that a man who has faithfully 478 served his country in this way will receive-consideration, and not be subjected to any disability.
§ Mr. GLYN-JONES
I have been appealed to accept this Amendment. Let me at once say that if I were the only person in the House prepared to divide against it I certainly should do so. I am extremely surprised the hon. Member should have moved it. I could have understood it coming from the War Department, but I do not understand why we should introduce into an Insurance Bill this attempt to put military compounders in a position of qualification which they do not at present possess. The Pharmaceutical Society has done all it could to improve the status of these military compounders, and they never got any recognition of their efforts. Had a Motion like this been proposed on behalf of the Navy I could have understood it, because the Navy treat their dispensers properly, and they have to-be trained and qualified pharmacists. As to the military compounder, of course, if he has been engaged as a dispenser to a medical man or to a public institution, he will come in, like other people, under this Bill, but I do not see any reason why any special privileges should be granted to military compounders. The fact is the Army do not treat their dispensers properly: they do not get the proper men for the work, and this proposal really means that there will be held out as a bait for men to join the Army and become compounders, the opportunity of having a cheap road to qualify as dispensers after leaving the Army. There are about, twenty-two depots under the War Office where these men are employed, the claim is not confined to these, though we know that their qualification is a very poor one indeed as compared with that of the pharmacist.
§ Mr. GLYN-JONES
My hon. Friend says; "No, no," but I must be allowed to know. First of all, in regard to the preliminary examination you have an entirely different status. A man to become a pharmacist. has to pass the London Matriculation examination or its equivalent, and we well know that the ranker in the Army has no-such status or education.
§ Mr. GLYN-JONES
He is in a worse position because he is not put in the position which similar men occupy in other 479 countries. In Germany and France the pharmacist is treated as a commissioned officer, but in our Army he holds a very different position. Many of them only dispense drugs in emergencies, they are supplied with a small assortment of drugs in a handy form, and deal with them in the same way as mere retailers would do. Can such a man be trusted to make up any prescription which a medical man may place before him. I am surprised that the Army should try to get their men treated on these lines, and should endeavour thus to provide them with a cheap way of becoming qualified dispensers. I say that Army compounders have no right to any treatment other than that granted to ordinary dispensers, they must come in like other people. I therefore most strongly object to this Amendment.
§ Mr. PETO
I strongly support the view of the hon. Member for Stepney. I am much interested in the case of those who act as dispensers to medical men, and I am not satisfied that the words of the Clause are going to include them in the way I should wish to see them included. I do not desire to include Army dispensers as necessarily qualified under this Bill. They are not in the same position as dispensers who have been working for years under medical practitioners. Many of these Army compounders are eligible for pensions, and, in any case, this Bill will not interfere with them. It will however, interfere with the class in whom I am interested. In addition to that, I understand that under the Pharmacy Act of 1908, these Army compounders are eligible for registration if they choose to pass the necessary examinations, and therefore it is in their power to make themselves eligible for inclusion in this Bill. I do not think there is the slightest excuse for including them in the way proposed by the hon. Member.
§ Sir RUFUS ISAACS
I think really the Committee is indebted to the hon. Member who moved this Amendment for bringing this matter before it. At the same time it is a difficult question, and it is scarcely fair to invite the Committee to deal with it without notice. I do not propose to follow the hon. Member for Stepney into the discussion he opened out, but I do most emphatically say, from what has been told me by those familiar with the subject, that the position of these men is quite inadequate. I would suggest to 480 my hon. Friend, however, that he should withdraw the Amendment and take another opportunity of bringing the matter forward.
§ Mr. AUSTEN CHAMBERLAIN
Before the Amendment is withdrawn, I would like to say a few words. I admit I am not competent to pronounce an opinion on this point without more information than I at present possess. We have been told by the hon. Member for Stepney that naval dispensers are a much more highly qualified class of men, and that if he had been pressed to include them in his Amendment he would have had no objection from the chemist's point of view. All I ask is that the Attorney-General should consider their case.
§ Mr. AUSTEN CHAMBERLAIN
I thought they were. I only rose to put their case. If they are already in the Bill the Amendment is not needed.
§ Amendment to proposed Amendment, by leave, withdrawn.
§ Dr. HILLIER
I beg to move, in the proposed Amendment, after the word "pharmacist" ["dispensed either by a registered pharmacist"], to insert the words "or by certified assistant to an apothecary under the Apothecaries Act, 1815."
If this Clause be carried as it stands without this Amendment the effect will be that several thousand men who are held to be fully qualified under the existing law as dispensers will be deprived of their employment. I am aware that the hon. Member (Mr. Glyn-Jones) has a proviso about a person who for seven years immediately prior to the passing of this Act has acted as a dispenser to a fully qualified medical practitioner or public institution, but that does not cover the case of all these certified assistants, many of whom are assistants to chemists and others in the capacity of dispensers.
§ Mr. GLYN-JONES
I hope the Amendment will not be accepted, because it will create fresh qualifications for a certified assistant to an apothecary. The certified assistant to an apothecary possesses the right under the Act of 1815 to act as an assistant dispenser to an apothecary. His training at present is quite inadequate. What is required is evidence of six months' 481 dispensing with possibly one medical man. It is not an apprenticeship where the prescriptions of hundreds or thousands of different doctors are brought in, but one medical man who may ring the changes on about a dozen mixtures. I could quite understand a person who has had six months' experience in a doctor's surgery being qualified to hand out and deal with the particular mixtures that the doctor trades in——
§ Dr. HILLIER
The hon. Gentleman him-self proposes dispensing for a medical man as a sufficient qualification in his own Amendment.
§ Mr. GLYN-JONES
Yes, if he has been seven years at it. The Amendment you are now moving is that future apothecaries assistants, who have no vested interest at all at present, shall come in if they have had six months' training. May I appeal to the hon. Member and the House not to set up here any new qualification for a dispenser. It is quite obvious, now that the conditions of pharmacy and medicine will be so altered by this scheme, that the qualifications for an assistant dispenser will have to be set up. The Pharmaceutical Society is the statutory body that deals with this matter. I am authorised, on its behalf, to say that it passed a resolution this morning to the effect that if this Bill passes in its present form it will take immediate steps to promote a Bill to provide for the qualification of dispensers all round, and that in doing so it would seek the support of the Medical Council, the Apothecaries Society and the War Office. If we are going to provide a new qualification for dispensers, that is the way it ought to be done, and that is the reason why, I hope, the hon. Member will not press this Amendment.
§ Mr. LYNCH
I desire to say a few words in support of the hon. Member for Stepney Mr. Glyn-Jones). It is important that all the qualifications for dispensers should be sufficiently stringent. At present there are various ways in which a person may become qualified as a dispenser. I think it is of the highest importance that the means by which a person may become a qualified dispenser should not be increased. It is in the interest of the public generally as well as of those who are to have the benefits under this Bill that the means of qualifying as a dispenser should not be made easier than at present. I hold that if a change is to be made in the qualification, the preliminary training of 482 a dispenser should be more scientific. Drugs, after all, are very important in. connection with the treatment of disease, and I venture to say, not merely that no dispenser at the present time, but that no chemist—I use the word chemist in the scientific sense—has sufficient knowledge to enter into the secrets in relation to the properties of the drugs which are used day by day. I think it is of the utmost importance that any man who desires to become a qualified dispenser should have a preliminary scientific training, and that subsequently the most severe tests should be used to see that he is not merely a compounder who dispenses drugs, but one who really understands the science of the work in which he is engaged. Therefore, I corroborate all that has fallen from the hon. Member, and I hope if any change is made it will be in the direction of making the qualification more stringent than it is at present, so that the standard of this profession may be raised.
§ Mr. LLOYD GEORGE
I hope the hon. Gentleman will see his way to withdraw this Amendment. It is a pity to introduce a new qualification for dispensers without giving time to go carefully into the matter. Practically the same point was raised in an earlier Debate. I think this Amendment should not be pressed until we have had time to examine the proposal. I am not complaining at all that more time for its consideration has not been given by the hon. Member.
§ Mr. LLOYD GEORGE
It has been on the Paper, and it is my fault if it has not been looked into. I trust it will not be pressed at this stage. It would be a serious matter if you were to introduce a new qualification at present. I think the proposal ought to be looked into much more carefully.
§ Dr. HILLIER
I think that the right hon. Gentleman is under a misapprehension with regard to the effect of this proposal. I do not propose to set up any new qualification whatever, but merely to prevent a certain number of people who are now regarded as perfectly qualified to dispense being deprived of their occupation. I do not suggest that they should be persons with whom contracts should be made for the supply of medicines, but that after this Bill is passed they should retain the right to dispense 483 which they already possess. If it is necessary to amend their present qualification in some such way as suggested by the hon. Member for Stepney, that should be done by special legislation, but it certainly would be an injustice if this Bill were to disqualify 7,000 or 8,000 persons at present qualified, as would be done under the proposal of the hon. Member for Stepney.
§ Mr. LLOYD GEORGE
I do not know how this matter stands, as I have only been listening to what was said on both sides. But I understand that they are only qualified so long as they have the supervision of a qualified chemist. They must have the responsibility of a certified chemist before you can enter into a contract with them. There is nothing to prevent them ever from dispensing from the store of a qualified chemist at the present moment.
§ Dr. HILLIER
This would not be under the Bill, so far as I can see, but there would be a disqualification of these men if this Amendment was carried, because it specifies those who may dispense, and it omits this particular class.
Would the Chancellor of the Exchequer tell us definitely whether this Amendment as it stands cuts out any people who are now qualified, because I confess I am quite ignorant? I think that many Members of the Committee are ignorant of the various qualifications. I have tried to find out what they are. They are under three or four separate Acts of Parliament, and there are different examinations, some not as valuable as others. I think what the Committee ought to do is to protect those now carrying on business, and not by a side-wind deprive them of their business. Perhaps the learned Attorney - General, who has the Acts at his fingers' ends, can reassure us as to that."
§ Mr. LLOYD GEORGE
It is not the intention of the Government to cut out anyone who is qualified at the present moment. If it turns out, on further inquiry, that anybody is cut out, I shall be glad to agree to any Amendment that will put the matter right, but I should be very both to accept any Amendment without further inquiry.
§ Mr. PETO
The hon. Member for Stepney's Amendment puts in a double qualification. He admits anybody who has been 484 a dispenser to a medical man for seven, years. If he has been a medical man's dispenser for seven years and is also an apothecary's assistant under the Act of 1815 he may dispense, but if he does not hold the double qualification he is undoubtedly cut out. Therefore I support the Amendment of the hon. Member for Hitchin, because I have had a great many letters from different people pointing out that they are going to have their living taken from them, and it is simply a question of giving an opportunity to those who are at present dispensers to carry on their business as dispensers. The words proposed by the hon. and learned Gentleman are absolutely necessary.
§ Dr. HILLIER
In order that there may be no misunderstanding I will repeat what I understand the Chancellor of the Exchequer said, namely, that if anything in the Bill has the effect of depriving any men who at present have the right to dispense-of the right to dispense under the Act, then the Bill will be so amended as to prevent their being deprived of that right.
§ Mr. LLOYD GEORGE
We do not propose that anybody who is qualified to dispense at the present moment shall be cut out.
§ Amendment to proposed Amendment, by leave, withdrawn.
Mr. J. W. WILSON
Seven years, the period named in the Amendment, is a rather long period, and, being entirely retrospective, it will gradually die out. I beg to move, in the proposed Amendment, to leave out the word "seven," and to insert instead thereof the word "three."
§ Amendment to proposed Amendment agreed to.
§ Proposed Amendment, as amended, agreed to.
§ Mr. LLOYD GEORGE
I have on the Paper a series of consequential Amendments, and last night I indicated that it would be necessary to introduce Amendments of this kind. I beg to move, in Subsection (3), to leave out from the beginning. 485 of the Sub-section down to the word "there" ["committee shall take over such administration and there "].
§ Amendment agreed to.
§ Mr. LLOYD GEORGE
I beg to move, in Sub-section (3), after the word "paid" ["paid out of moneys credited "], to insert the words "to the local health committee for each county or county borough."
§ Mr. C. BATHURST
I would like some explanation as to this in view of what occurs in the two following Sub-sections. I understand it contemplates in the first instance some measure of agreement between the society and the health committee, and in default of such agreement, it rests with the Insurance Commissioners to decide what sum, if any, shall be paid for medical benefits in regard to each member. Reading that with the following Clauses does it not amount to this, that supposing the society declines to enter into any agreement whatever with regard to its members with the local health committee it will be necessary for the Insurance Commissioners to say what sum shall be paid. If they do so, and if the society declines to be any party to any payment being made out of its funds in view of what follows in the two subsequent paragraphs, it will involve the whole of the medical benefit with regard to those particular societies falling in equal shares upon the ratepayers and the Exchequer. I would like an explanation on the point.
§ Mr. LLOYD GEORGE
It will be in the same position exactly as with regard to sanatoria benefit where there is a fixed amount. When we come to the Subsection I propose to accept an Amendment which leaves it entirely to the county council whether they will pay or not.
§ Mr. C. BATHURST
As I understand it passes into the coffers of the society, but is diverted at its source.
§ Mr. C. BATHURST
But failing agreement, it never passes into the hands of the society but is diverted at its source.
anther right hon. Gentleman give us any idea what the figure is. The sanatoria benefit is a fixed figure.
§ Mr. LLOYD GEORGE
That will of course depend on the agreement. I have no doubt the society will come to an agreement with the vast majority of cases. The agreement will depend on local conditions and circumstances, all of which have to be taken into account. If it is a fixed sum then from that time forward it will be the same as the sanatorium benefit.
§ Amendment agreed to.
§ Further Amendments made: In Sub-section (3), leave out the word "the" ["credited to the society"], and insert instead thereof the words "each approved."
§ After the word "society" ["credited to the society"] insert the words "which has members resident in the county or county borough."
§ After the word "of" ["in respect of"] insert the words "the medical benefit for"
§ After the word "every" ["every member"] insert the word "such."
§ After the word "member," leave out the words "of the society entitled to the benefit and resident in the county or county borough as may be agreed between the society and the committee," and insert instead thereof the words, "as, in default of agreement, may be determined by the Insurance Commissioners."—[Mr. Lloyd George.]
§ Mr. SANDYS
had given notice of the following Amendment: At the end of Sub-section (3) to add the words, "A registered medical practitioner who, for the purposes of this Act, signs or gives any certificate or signs any report shall not be liable to any civil or criminal proceedings if he has acted in good faith and with reasonable care."
§ The CHAIRMAN
The Amendment standing in the name of the hon. Member for Wells (Mr. Sandys) does not come in at this point.
§ The CHAIRMAN
It does not belong to this Clause. If there is no other Clause to which it belongs, it must be moved as a new Clause. But I am not sure that the Amendment is within the scope of the Bill, so that the hon. Member must not understand that I am promising to take it, even as a new Clause.
§ Sir A. CRIPPS
I beg to move, to leave out Sub-section (4).
487 Provision is made that, under certain conditions, in the event of the amount payable to a local health committee being inadequate, half the deficiency shall be made good out of the rates and the other half by the Treasury. I understand that the Chancellor of the Exchequer is prepared to alter "shall" to "may," but that does not meet my objection. I submit that in such a matter as national insurance there should be no possibility of any charge at all falling on the rates. It is not a matter for the ratepayer; it is essentially a matter for the National Exchequer. I have had to complain more than once, particularly so far as the Government are concerned, of an entire disregard of the right principle in the matter of contributions by ratepayers. The real principle—going back to the Report of the Royal Commission— is that national matters should be a charge upon the national Exchequer. The true reason for that, which is some time overlooked by Members of this House, is that if you put a charge on the rates as opposed to a charge on the Exchequer, two-thirds of the wealth of the country escapes contribution. That may be shown by the fact that a penny on the Income Tax produces three times as much as a penny on the rates. What I am going to say in the first instance is this: that if in a matter of national insurance a deficiency is to be made good, everyone ought to contribute in proportion to their ability. You ought not to allow rich people to escape from their share of contribution. Further, if we are really to keep any principle at all in this matter, we ought never to allow national charges of this kind, which are properly applicable to the national Exchequer, to be under any contingency chargeable to the rates at all. I also give this further consideration to the Committee: Charges upon the rates fall very heavily upon the industries—I need not specify the smaller industries— of this country. It is surely unfair to select a particular class only, and to place upon that particular class a burden which ought to be placed upon every taxpayer of this country, and to which he ought to contribute in proportion to his means?
I do not, of course, want to raise jealousies between one class of taxpayer and another, but I would like to ask the Chancellor of the Exchequer why should a national deficiency be made up by contributions from the industries of this country only? I am not now seeking to raise the question about the income 488 derived from investments abroad, but if you in this country put a charge upon the rates, incomes derived from investments abroad are absolutely exempt; they escape altogether. Is that fair in such a matter as that of national insurance? It is a question in which everyone has an equal concern. It is not a matter of localities or of one local authority or county council against another, or one ratepayer against another. The real question is that everyone in this country should, through the National Exchequer, in proportion to his means and ability, contribute to a great national purpose of this kind. What is the answer to that? It is too often forgotten in this House that the ratepayers are not directly represented, whereas the Exchequer is directly represented by the Chancellor of the Exchequer. The ratepayer, unfortunately, has no Minister in this House.
May I say one or two words further with regard to the particular provisions of this Bill? The Chancellor of the Exchequer says "That the county council or council of the county borough, if satisfied that the amount so payable is a reasonable and proper expenditure, 'may' sanction that expenditure." I am not going to suggest for a moment that such expenditure may not be reasonable and proper. Suppose it is reasonable and proper, it is quite impossible to suppose that in a matter of this kind the county council or the council of the county borough can refuse to contribute. It would be their duty to contribute, although the word "may" is used. But they are not the proper persons to contribute to charges of this kind. On no previous occasion when discussing this subject have I felt so certain than an obligation of this kind ought to be assumed a? a national obligation, and not specially placed upon the ratepayer at all.
There is another matter which I cannot help referring to in this connection. I am not for the moment going into the constitution of the local health committee. But let me point out that what is called the local health committee here ought really to be called the local insurance committee. Its duties ought to be limited to insurance matters, and not to matters of local government, which at present are carried on by other bodies of a representative kind. This local health committee will not be a representative committee, either as regards local government or the rates. If properly constituted it will be representative of the insurers of the friendly societies, and of the people 489 interested in the proper administration of these insurance funds. That is an entirely different duty from that of a representative body which is entitled to put charges upon the ratepayers or a representative body interested in matters of local government. The local health committee ought to be restricted either from interfering with the rates or interfering with the local authorities now dealing with matters of local self-government. I ask the Chancellor of the Exchequer in these circumstances what justification there is for allowing a body of that kind, in no sense representative of the ratepayers, if they make an expenditure which may be quite reasonable and proper, then to apply to the county council or to the council of a county borough in order that half the charge may be placed upon the rates.
I say it is a monstrous proposal, absolutely inconsistent with every true principle as regards the obligation of the ratepayers as compared with the obligation of the National Exchequer. There is no excuse whatever for it, and you ought not to put a charge of that kind except upon the proper body. You assume in the National Exchequer you get contributions from all persons equally, and, therefore, ought to bear burdens of that kind. I am not going to say the amount of the deficiency ought not to be met from some source or other. What I am protesting against is seeking to make it fall upon the ratepayers, who are heavily enough burdened at the present time. There are a large number of matters of national concern which are placed upon the ratepayers which ought to be borne by the National Exchequer. On this very point the Chancellor of the Exchequer took away from the ratepayers the proportion of half of the fund they were entitled to from the Land Taxes.
§ Sir A. CRIPPS
I am very glad the Chancellor put it in that way. I do not consider he gave anything except what the ratepayers were entitled to, and I entirely dissent from the doctrine that by gifts or by philantrophic ideas you can upset the true principle in the business matters. It is no argument for putting an unfair charge upon the ratepayers that in some other way assistance may be given to the ratepayers of this country. I say there is no matter of finance in which it is so important to maintain the right principle as 490 in the allocation of charges between the Exchequer on the one side and the ratepayer on the other. I should like this matter to be considered. The rates press, and press very unduly upon some of the smaller industries of this country. Why should they be made heavier than on a true principle they ought to be? I am perfectly certain if this matter is considered there can be no answer to the proposition I am making that the charge for national insurance ought to be a charge upon the National Exchequer, and the National Exchequer only. Perhaps I speak rather warmly upon this topic, because I feel if you once allow inroads of this kind, based upon improper principles, to be made upon the purse of the ratepayers where can you draw the line. There is nothing local in a system of national insurance; it is not a principle which is to apply to a particular rural district or to a particular urban district; it is a matter for the nation, and we who are seeking to institute a great principle ought to see it is paid for by the national Exchequer, which has her representatives in this House, and not by the ratepayers, who, unfortunately, have no representatives here at all. [HON. MEMBERS: "Oh, oh!"] The ratepayers are not represented in this House at all. I say most emphatically that they are represented in the various local bodies throughout the country, and when you are going to put a charge upon people whom we do not directly represent, we ought to be careful to do so only if the principle upon which it is done is right. Always recollect that when you put it upon the ratepayer you allow two-thirds of the wealth of the country to escape altogether It is assumed that you are putting charges on people who ought to bear them. I disagree with that in this case, because you are exempting from the burden the very people who in a charge of this kind ought to bear their due and proportionate share of the burden. On those grounds I move this Amendment. I think no charge of this kind ought to be placed upon the ratepayers at all. This is the first time we have had an oportunity of raising the most important question that the finance of this Bill should be properly adjusted in accordance with sound financial business.
§ Mr. LLOYD GEORGE
The hon. and learned Gentleman has delivered a very emphatic speech, and I think he has allowed his passion this time to run away with his judgment in view of the know- 491 ledge which I know from experience he has on this question. He has laid down some extraordinary propositions, one of the most remarkable of which is that the ratepayer is not represented in this House. [An HON. MEMBER: "Not directly."] As a matter of fact there is not a ratepayer in this country who is not represented in this House. [An HON. MEMBER: "Yes, women."] I should have thought it would have occurred to the intelligence of the hon. Member who interrupted me that the same observation in that case applies to the taxpayer, and therefore there is no difference between the ratepayer and the taxpayer on that point; consequently it is a perfectly irrelevant interruption. The hon. and learned Member seems to think that this is a Sub-section which for the first time imposes upon the ratepayers of the country a burden which they do not now bear with their little finger.
§ Mr. LLOYD GEORGE
Surely the hon. and learned Member cannot mean that. Does he not know that the Majority Re-port of the Royal Commission found that at least one-half of the total cost of pauperism is swallowed up in directly dealing with sickness. Why, therefore, does he say that it is a new charge upon the ratepayer? On the contrary, it is a heavy charge upon them which runs into millions at the present moment, and it is an increasing charge, and had it not been for this Bill it would have increased by hundreds of thousands each year. The hon. and learned Member cannot have taken the slightest trouble to look at this matter.
§ Sir A. CRIPPS
The Chancellor of the Exchequer is misrepresenting what I said. I am very cognisant of the nature of that report, but this an entirely different matter. A scheme of national insurance has nothing to do with what the right hon. Gentleman has just said.
§ Mr. LLOYD GEORGE
I really must object to this system of interruptions. It is not to correct any misrepresentation, but to argue the point. It is not a fair method of conducting Parliamentary discussion. Other hon. Gentlemen who are prepared to speak can reply. It is remarkable that the hon. and learned Gentleman should have ignored some of the most significant and salient features of that Report. It pointed out the growing 492 charge of sickness upon the rates. You have not merely the poor rate, you have in the last few years municipalities taking charge of, and dealing with, the sick. They are building infirmaries, hospitals, sanatoria. They have got medical officers of health to assist in curing sickness. This is a growing charge upon the rates. The hon. Gentleman has not thought fit to remark that this is the first time any Chancellor of the Exchequer has proposed that any portion of this charge should be thrown upon the Treasury. We are finding six millions of money for purposes which have hitherto confined their burden to the rates. I remonstrated with the hon. Member for, Fulham because he ignored that. I have not the faintest doubt, nor has anybody who has examined the problem, that this will involve a direct and considerable relief to the ratepayers of the country. Every deputation of employers of labour puts this point to me. They ask why we should charge the employers 3d. in respect of this Bill. They say it is a direct contribution to the rates, and they do not see why they should be the only people called upon to contribute to the relief of the rates of the rest of the community. What the Government is proposing is a great contribution to relieve the burden upon the rates which grows because the municipalities have responsibilities cast upon them. This is a proposal that the Treasury should meet half. You would think the only thing in what is proposed to be left out was to put half of the excess upon the rates. The only thing which is really there is that the Treasury should take half the burden. Can the hon. and learned Member give me the name of any Act he supported when here before which proposes that any proportion of the charges of sickness in this country should be borne by the Treasury?
§ Mr. LLOYD GEORGE
If the hon. Gentleman thinks it is necessary to refer to such Grants-in-Aid, the Liberal Government have done that from time to time. This year we found £1,500,000, which is a great relief to the rates. The hon. Member contradicts by shaking his head. I said I had to find £1,500,000 this year, which is a direct relief to the rates. It has had the result that many workhouses are almost empty. Under this Sub-section the Exchequer says to the local authorities for the first time that it is prepared to find 493 half of the excess charge for the cure of consumption. If the local exchequer is prepared to find half the excess for curing other sickness, then the Imperial Exchequer is prepared to come forward with another half. Why did not the hon. Gentleman point that out? This is the first time it has ever been proposed in this House. The hon. Gentleman proposes to out out Sub-section (4). Does he think the ratepayers will thank him for that? Supposing we cut that out and the Exchequer withdraws from the offer to find half the excess of sanatoria and half the excess of curing sickness, does he really think the ratepayers will thank him for that?
§ Mr. LLOYD GEORGE
I have already said, days ago, that I am prepared to accept an Amendment including sanatoria, and I propose to do so. The cost of curing consumption is a very heavy charge on the local exchequer now, and we are prepared to find half the excess in addition to the 3d. or 4d. we are finding in the Bill. That is a relief of the ratepayers, and the hon. Gentleman thinks that in the interests of the ratepayers he will cut out a Sub-section which offers to pay half the charges which now fall on the ratepayers. I do not suppose the ratepayers will be very thankful to him for the proposition. He entered into an argument with regard to the incidence of the rates. It is common ground with both parties in this House that the incidence of the rates is not very satisfactory. We hope to cure it. [HON. MEMBERS: "When?"] I am undertaking now a very heavy responsibility, which is a relief of the local ratepayers to a very large extent, but you cannot carry all these things at the same time. I agree with the hon. Gentleman that the incidence is very unfair, but what on earth has that got to do with this? That is a matter for another Bill. You cannot possibly cure the incidence of the rates in a Bill for National Insurance. In the meantime, if the hon. Gentlemen representing the ratepayers in this House and if the ratepayers are prepared to accept the responsibility of refusing the offer of the Exchequer to meet half the excess, all I can say is the rate- 494 payers show much less intelligence in approaching the Exchequer now than they have ever done in the past.
§ Mr. HAYES FISHER
Doctors and chemists have found champions in this House to-night, and I am glad to say the ratepayers have found one champion in the person of my hon. Friend the Member for South Bucks (Sir A. Cripps), who knows more about the incidence of local taxation than anyone in this House. It is high time the ratepayers had some champions in this House. We have constantly complained that the ratepayers' interests are neglected, because they are not as ratepayers directly represented. I will undertake to say if the ratepayers had been represented in this House some Bills would not have been passed in the shape that they have been passed. There has never been a Chancellor of the Exchequer against whom the ratepayers more needed a champion than against the right hon. Gentleman who occupies that post at the present time. He has been the most notorious raider of the ratepayers' war chest. He has feathered his nest time after time at the expense of the ratepayer, and he is seeking to do it again to-night. In introducing this Bill he did not make any mention of the ratepayer. Ho persuaded this House that his scheme was self-supporting: that it relied only on three columns; one was the contribution of the employer, the second was the contribution of the employed, and the third was the contribution from the National Exchequer. I do not think a word was said about any contribution from the local ratepayer, but now whenever the right hon. Gentleman is in a difficulty he says: "Well, after all it may create a deficit, but if there, is one there is the local health committee which can go to the ratepayers to find the money." Again and again, the right hon. Gentleman has given a most direct invitation to these local health committees to dip their hands deeply into the pockets of the ratepayers. He has said that the medical benefits are to be handed over to these committees, and any excess of expenditure will have to be divided between the rates and the taxes. He has told the friendly societies not to draw on their own funds: not to be such fools as to do that, but to put their arrangements for medical benefits in the hands of the local health committees, and societies which transfer the whole of their medical benefits to 495 these committees will be able to draw for their excess whenever they want to do so from the rates.
§ Mr. HAYES FISHER
In the passage which I quoted from the right hon. Gentleman used the word "rates" not "taxes." I am quite ready to admit that the right hon. Gentleman has so framed his Bill that half of the deficit is to be paid by the National Exchequer and half by the rates, and he claims to be much more generous than anybody else has ever been in that respect. But the old principle was always whenever the House imposed a great burden on the rates to make a grant in aid for the benefit of the ratepayers. This is the first Government that has cast burden after burden on the ratepayers without giving a grant in aid for the purpose of carrying out the onerous obligations imposed. This is a matter to which the Committee should pay attention: this constant pointing by the Chancellor of the Exchequer to the fact that there will be deficits which the ratepayers will have to meet. What becomes of his £25,000,000?
§ Mr. LLOYD GEORGE
I do not want to be constantly interrupting the right hon. Gentleman, but I would point out that the deficit is to be equally provided by the ratepayers and the Treasury.
§ Mr. HAYES FISHER
I do not think I have misled anybody. I admit the deficit is to be met half by the Treasury and half by the ratepayers. This is preponderatingly a national service. It is a national health matter, it is not a local matter. There is a debt due now from the National Exchequer to the local exchequers for many services which have for years been discharged by the local exchequers and which ought to have been discharged by the National Exchequer. Then they say it is misleading the House to talk about £25,000,000 as the expense of the scheme. I do not know that the industries of the country can stand £25,000,000, but they cannot stand £25,000,000 plus an unlimited amount of millions which the Exchequer will have to find in half and the ratepayers in half. The invitation to these local health committees is, "If you cannot agree with the doctors for 6s. or 8s. or 10s. per head, make any other arrangements you like. Present your bills to the county councils and the 496 Treasury. Each will have to pay half." That is a direct incentive to waste and extravagance.
Directly you tell these local health committees that they can dip their hands deeply in the pockets of the ratepayers they have no incentive to economy or good management, and for the first time the friendly societies, whose pride and glory it has been that they have never come on the rates, who have saved the rates, are being invited to come upon the rates, to send their doctors' bills and chemists' bills in to the ratepayers. It is unfair to the ratepayers who have no adequate representation on these local health committees. It is violating the good old rule of representation going with taxation. Let me examine the position of the local rating committees. County councils have to pay half the bill. Have they half the representation? Have they a fourth of the representation? No. I do not know that they will get any representation at all. They are to have one-third, but of that the majority, if not the whole, must be drawn from the present sanitary authorities. In London I doubt whether we shall have two representatives on that committee and yet we shall have these bills sent in and pressure will be brought to bear upon us to pay these bills. It is another example of the right hon. Gentleman violating the spirit of the Act of 1888, which said to the county councils, "You must establish finance committees to regulate and control your finances." Under the present Government we are no-longer able to regulate and control our finances. They are regulated and controlled for us, and when right hon. Gentlemen opposite get into a difficulty they put their difficulties upon the ratepayer.
Then this is not a matter in which all ratepayers can participate. There are tens of thousands of very poor ratepayers who have no opportunity whatever of coming into the Bill, and yet they will have to pay for the insurance of people who are far better off than they are themselves. For the first time, men who are as a rule strong and healthy and in good work, drawing as much as £150 a year, are invited to come into the insurance scheme, on which there is a deficit, and that deficit is to be presented to the ratepayers for payment. That is as contrary to every principle that ever governed the friendly societies or the trade unions, as it is contrary to every principle that ought to govern the financial expenditure of this country. 497 I say we have no representation on that matter, and we shall have something to say when we come to the Clause as to the way in which this singularly constructed body, the local health committee, is set up —one of the most curious bodies ever constructed by any Government at any time. It would not be in order at the present time to analyse the composition of the local health committee, but I may be allowed to say that there is not a day that this House does not cast new duties on the, local health committee, and therefore it behoves us to see that the committee is composed of the best men we can get to serve on it. The Chancellor of the Exchequer says, "Consider what I am doing for the ratepayers. Look at the great gain of my scheme for the ratepayers." I have heard him advance that argument again and again, but whenever we have tried to put it in figures we have found that it is a gross delusion so far as any saving to the ratepayers is concerned. If you take the whole Bill and analyse it in this way, putting on one side what it will cost the ratepayers, and on the other side what the ratepayers will gain, invariably there has been a large debit side to the ratepayers.
I frankly admit that the scheme undoubtedly will save something on one side to the rates, but I am confident that if the local health committees are to produce deficits which will have to be met half by the rates and half by the Exchequer, the loss to the ratepayers will be far greater than any benefits they are going to get under the Bill. If the right hon. Gentleman will not meet us in any way, then we shall do all we can to obtain a much larger representation of the county councils than is allowed by the Bill. After all there are many examples of the kind of legislation I am going to suggest. Will he put into the Bill that the deficit should not amount to more than a penny rate? Will he give us some limitation? If he does not want to dip too deeply into the pockets of the ratepayers and tempt them into waste and extravagance, let him put some limitation of that kind in the Bill. As long as I am here, and have other duties on the Finance Committee of the county council, I will always champion the interests of the ratepayers. I am thoroughly alive to the fact that many industries will perish if these additional burdens are put upon them. I am thoroughly alive to the fact that rates do influence the lives of the working classes, and I will do all I can to see that the 498 burdens are properly apportioned between the national Exchequer and the local taxpayers.
§ Mr. ELLIS GRIFFITH
The right hon. Member opposite (Mr. Hayes Fisher) referred to himself as the champion of the ratepayers in the London County Council. I know the history of that institution, and I think it may be said of some of its members that their championship of the ratepayers is more pronounced before an election than afterwards. The answer to all this passion is to be found in the words of the Clause. May I invite the attention of the Committee to the words of the Clause we are discussing. The two hon. Gentlemen were very bitter on the fact that the ratepayers were not represented on the local health committees. Whether the ratepayers are properly represented or not the power of the local health committees under this Clause is to transmit. That is all. There is no power of levying a rate. I do not know why the Committee should think that the local health committees are going to be extravagant, but in any event they are going to transmit to the Treasury and the county council, and remember this, the county council need not pay the money unless they are satisfied that the expenditure is reasonable and proper. Who would have thought that that was the provision in the Bill when listening to the very eloquent words of the two hon. Gentlemen? It is a very wise precaution by the Chancellor of the Exchequer that if there be any excess the expenditure should be divided between the local ratepayers and the Imperial Exchequer.
The arrangement between the local health committee and the friendly societies is an arrangement from year to year. It is not an arrangement for all time. If the friendly society contributes too little this year the matter may be put right the next. It might very well be that if the Exchequer had to bear the whole-burden of the excess there would be no motive to the local health committees to limit that excess. But when the local health committee, on which there are representatives of the county council, bear in mind that the Exchequer pays so much and the local ratepayer pays so much, that will be a great check on wanton expenditure. The ratepayer is already saved money by the provisions of this Bill. The hon. Member (Mr. Hayes Fisher) says he is quite certain that the ratepayer stands 499 to lose. I accept him as a county councillor and as a Member of Parliament, but I do not quite accept him as a financial prophet. I do not think that the school of thought to which he belongs, the Moderates, on the County Council of London, have turned out to be such astute prophets in the past that we can trust to their prophecies in the future. I feel certain of this, that although we have had a sort of Second Reading Debate on this Clause it is high time that we should deal in detail with the Amendments, because in passing the Second Reading of the Bill we passed the principle.
MARQUESS of TULLIBARDINE
I would like to ask the right hon. Gentleman what he intends to do in the case of some parts of Scotland where the rates at present are over 20s. in the £. I would also remind hon. Members that we are not doing everything we can to keep down rates in other departments of the Government. At the present moment we are passing a Small Holdings Bill for Scotland, which is going to free a great number of people from rates, and thus throw increased rates on other people. Hon. Members are perfectly justified in seeking to know the exact sum by which the rates will be increased. It is perfectly obvious that the rates have been very much increased. The Chancellor of the Exchequer has been letting us off rates by handing over money for the relief of the rates; but I would remind Members of the House that under the Development Grant last year everybody was promised relief of the rates for the roads. Speaking for my own county, the very first thing that happened, was that the rates were increased by £4,000 in order that we might get another £4,000 out of the Government—a total expenditure of £8,000 upon the roads. That sort of beneficial kindness may certainly improve the roads, but I am rather afraid that it will add to outlay from the rates. Of course, it is perfectly right to tell people that if they want help they must help themselves, but these heavy burdens are getting beyond the limit, certainly in my own county, where in some cases the Poor Law rate is 28s. in the £— a pretty fair rate, which we are not anxious to further increase.
§ Mr. CROOKS
There are a few people in this House who do know something about local taxation, and who may by a stretch of the imagination claim to repre- 500 sent the ratepayers. They may also claim to have made a great number of conversions on the other side, where they have suddenly come to the conclusion that the ratepayers ought to be assisted and that certain local services ought to be made national charges. But when we said that a little while ago we were held up to ridicule and scorn, and asked whether the National Exchequer was to find money for "the reckless extravagance of these local agitators." Of course it sounded very well, and I have since seen it on placards, something in this way, "It is your money we want." But there has been a marvellous change since then, and we have seen a little of what they have done. One likes to believe people, but one cannot always believe them.
§ Mr. CROOKS
It is on Sub-section (4), and reference was made to local extravagance. The Noble Marquess spoke of his county having spent £4,000 on roads in. order to get another £4,000 from the Government. Fifty per cent. is not a bad speculation. [HON. MEMBERS: "Order."] I notice that a Labour Member is always out of order if he follows some other learned Gentleman. The fact of the matter is hon. Members opposite have missed one or two important points. When they speak about taking the medical service away from the friendly societies, there was never a word in the whole course of the Debate about the whole of the money paid to the medical officer, and that the friendly societies never made a profit upon that money. They handed the whole of it over. That work is going to be done by the local health committee. Whoever they may be, they will certainly be better than the board of guardians. A man will ask the committee for medical service as a right, and not in the "if you please if you would be so kind I should be much obliged to you for God's sake come and help me" kind of way. It seems to me the greatest crime of all that any person should have to go to a body that can raise rates and ask for help in that sort of fashion. But here is a national fund, and the health committee, with the allowance from the State, may say to the people—not people on paper, but real human beings—"We want to help you and your family. If you have to spend sixpence, the State spends sixpence also." The House need not be 501 surprised to know these champions of ratepayers will always be champions to save the rates instead of saving human beings. I have had experience of the Underfed Children Act and the way it was administered, and I know that in this matter we are going to save human beings and to save the rates, and to save the manhood and womanhood of the nation because they are going to ask for their own.
They may talk as they like about this being "pauperising," but it is going to stop recruiting for pauperising which is the worry of the whole thing. Men are going to stand erect and women will know what to expect when their husbands are down, and that they will get the best that can be given to them. God knows if the House knew anything about the need for sanatoria they would not stand for a minute in the way if they realised that in all the workhouses and infirmaries you have scores of those who ought to be breadwinners, and who are there because they worked too long, and the whole family are in pauperism because those men were not saved in time. The ratepayer will have to pay, we are told. Who were the people who stood for the saving of human lives years ago, and who were the people who were put on their trial and denounced for giving the common necessaries of life? We were denounced when we were saving lives out of the rates and saving sick men and unemployed men. Here for the first time poverty-stricken men are going to have a chance to have the best medical attendance. And who is going to protest because over and above that there is likely to be something. I have never found the ratepayers very willing to help the poor except under very hard conditions. Look at some of the sanatoria started out of the poor rate, go and visit them and see the convalescent homes for which the boards of guardians pay ten shillings or sixteen shillings or a pound per week, and ask whether that is the kind of thing which you expect is always going to be enforced on the poor consumptive. We are going to have the best which can be got for money. After all, do not forget that you are saving life, and, you will save ratepayers and the ratepayers' money, because if you do not save the breadwinner you will have to keep the wife and family. I am a little sick and tired of hearing when you want to do something, "for love of God do not, it will cost something."
§ Mr. AUSTEN CHAMBERLAIN
I do not propose to follow the hon. Member into the ancient history of local government in Poplar. I do not think it helps to the consideration of the Amendment now before the House. It is on that Amendment I want to make one or two observations. I do not think that the Chancellor of the Exchequer can be surprised that those who are specially interested in questions of local government, or who have personal responsibility to the ratepayers' protest, and protest with some warmth, against the action which the Government have taken. After all, it is within the recollection of the Committee that the Chancellor of the Exchequer himself, and another Member of the Government in still stronger terms, announced last year that this year the whole question of local rating and the division of the burden between the local ratepayers and the taxpayers must be dealt with. They sweep those declarations wholly on one side, and the only method by which they deal with the admitted grievances of the ratepayer is by adding to his burden.
§ Mr. AUSTEN CHAMBERLAIN
The Chancellor of the Exchequer may answer me if he wishes by argument, not by mere denials. I do not know what he denies. Does he deny my statement?
§ Mr. LLOYD GEORGE
Certainly. If the right hon. Gentleman means that by this Bill I am adding to the burdens of the ratepayers, the statement is grossly inaccurate. On the contrary, by this Bill I am relieving the ratepayer enormously. At present the ratepayer is the only person who is bearing the burden of the public charge for sickness in this country, and I am bringing in the Exchequer for the first time as a partner.
§ Mr. AUSTEN CHAMBERLAIN
I do not think the Chancellor of Exchequer's statement is accurate. On the balance, as the Bill is working out, with the alterations which the right hon. Gentleman is making, I do not think he is giving enormous relief to the ratepayer. I do not think that the ratepayer is the only person who now bears the charges, part of which will be borne by the Treasury in the future under this Bill. The fact of the matter is that this Clause, as I understand the Chancellor of the Exchequer intends to amend it, deals with two entirely different things—medical benefit and sanatorium benefit. The sanatorium 503 benefit is in the nature of part of a health campaign against one of the gravest diseases of the country. I have said before, and I do not unsay it, that the health campaign against consumption is not merely a suitable thing to be paid for by the State and the local authorities in conjunction, but that it is more suitably so met than by an insurance fund of the kind constituted in this Bill. But this Sub-section, without the Amendment, deals not with the sanatorium benefit at all, but with medical benefit. It deals not with the poor dependents of whom the hon. Member was speaking just now. but with the payment of the doctors' and chemists' bills.
I do not understand, in the first place, why there is any necessity for paying the doctor's bill or the chemist's bill out of public funds other than that provided in the Bill; or, in the second place, why this particular charge should be put upon the rates. Why should there be an excess of medical expenditure at all? The Chancellor of the Exchequer has framed an estimate on the assumption that these medical benefits were to exist; he allowed in his estimate a sum which he thought sufficient to meet the payment both of the doctors' fees and of the doctors' and chemists' bills. He not only allowed a sufficient sum, but he so drew the scheme that he thought that the societies which administered their funds wisely would have an ample margin. Why then should there be any deficit on the medical benefit for which you should require to come to the ratepayer or taxpayer at all, except in so far as the taxpayer is already paying two-ninths of the benefit. Why should there be an excess over what is provided for? Why if there is an excess should that charge be made upon the rates? That is what I do not understand. It seems to me there is good cause for striking out that part, at any rate, of this Sub-section, which, as it stands, is all that the Subsection contains.
§ Mr. CASSEL
As I have on the Paper a similar Amendment to that of the hon. Gentleman the Member for South Bucks, and have an especial interest in this question, perhaps the House will bear with me in supporting this Amendment. In the first place, I do not think the Committee has realised, and if I may say so, I do not think the Chancellor of the Exchequer has realised, what a possibly 504 terrific burden he is, under this Sub-section, imposing on the rates. Assuming that the doctors get what is given to them for attending the people in the Post Office, that is 8s. 6d. per medical attendance alone; and assuming that there is an excess—it may be greater—of 3s. per individual, to be met out of some fund. That, for the 15,000,000 persons that we expect to insure, amounts to about 2½ millions of money to be met under this proposal, half by the rates and half by the taxes. In addition there are sanitorium benefits—an amount I cannot calculate— and in addition again, you have to consider the factor that these local bodies themselves are employers of labour. The London County Council has calculated that on that account alone they will be liable for £12,000 a year, even allowing that all those who get superannuation benefit are exempted under the exemption in the Schedule. If you take the local authorities. all over the Kingdom that will give several hundreds of thousands of pounds a year more. In addition to these several additional burdens you have Clause 46, by which the Chancellor of the Exchequer is to make local authorities spend more upon housing and drainage. In that alone you may have a tremendously additional expenditure. One of the reasons why the local authorities at present are not able to spend money upon what properly comes within their functions is because we place all sorts of burdens upon them for national purposes. The argument was advanced by the hon. Gentleman the Member for Anglesey that the Clause as worded was permissive. The Clause says:—They shall if satisfied that the amounts"—At present it says "shall." I will assume that will be altered to "may."—"so payable and the proposed expenditure are reasonable and proper in the circumstances, sanction the expenditure.It comes to this that if the expenditure is anything like reasonable and proper the local authority will practically be bound to meet its share. And it is intended by the Chancellor of the Exchequer that this excess should be met. The only question is out of what fund should it be met? I submit, being a national charge, it ought not to be met out of local funds. As against all this liability which the Bill imposes, or may impose, the Chancellor has told us it may to some extent relieve the local authorities in respect to Poor 505 Law. It is possible it may to some extent, but in Germany the insurance scheme is not doing that. On the contrary, since the scheme was introduced into Germany, the cost for Poor Law has gone up. I have the figures here. I do not believe that the people who come upon the Poor Law—the inmates of workhouses—are really the people who will benefit by this Bill. However that may be, I submit that the very small off-set in connection with the Poor Law that may possibly arise, is nothing like an answer to the tremendous expenditure to which I have referred. There is a point of principle in connection with it -also, namely, that Poor Law itself is a national charge, and was so declared to be by the Royal Commission on local taxation. That Commission reported that there was £2,500,000 overdue to the local authorities in respect of Poor Law relief and therefore, that sum being due to the local authorities, any possible benefit which, in the German experience I do not admit, would only go a small way towards meeting that liability which the Commission reported existed towards the local authorities. I would point out also that when national legislation incidentally affects local authorities adversely the Chancellor of the Exchequer never talks of giving them any compensation. Under the Finance Act London has lost £359,000 in rateable value, but the Chancellor of the Exchequer never talks of giving them any compensation in respect of that. Now he suggests that because some national legislation may incidentally benefit them they are to contribute in respect of it. The Chancellor himself has said that it is not a proper procedure to give doles to the local authorities from time to time. If that is so, is it not also an improper procedure until the whole thing is placed upon a proper footing, to place new burdens upon them? No one could express that view more strongly than did the Chancellor himself, who said this:—Suddenly to put burdens upon local authorities is to arrest the true growth of local development and to prevent them from really being able to carry out those things for which they exist to carry out.Let me give the Chancellor a quotation from his speech to a deputation of which I was a member. He said:—There are points which I have to consider and come to a decision upon, as to a good many of them, at any rate, before the Finance Bill leaves the House of Commons, and I am fully alive to the grievances which Lord Midleton has referred to, the growing grievance of putting new burdens and new duties, involving new liabilities, upon the local authorities. They are put on 506 very casually, I agree very often without much consideration as to what the actual amount will be, and they, in the course of a few years, aggregate a very enormous sum.I was present at a very influential deputation which I think was either introduced by Mr. Hayes Fisher, or at any rate where the case was presented by him, and I think it was a very typical case which was put before the Prime Minister and his colleagues on that occasion. The growth in rates is not merely a burden, but in a certain sense I think it is becoming a peril which is stopping or at least arresting development. There are a great many things which municipalities think they might from time to time well do in the interests of the community, but they have always got to look at the effect on the rate, and this arrests healthy enterprise in several directions owing to the danger of increasing beyond tolerance the burdens of the ratepayers.That accurately expresses one of the points I wish to bring forward in supporting this Amendment. You will be defeating the very object of encouraging the local authorities to spend money upon housing and drainage if you cripple their resources by this enormous financial responsibility which ought to be met out of the Exchequer. After all the Treasury and the local authorities are mere abstractions. The question is, who are the right persons to bear this charge? The persons who have to bear these liabilities are the employers, and they are also the ratepayers. The railway companies are large employers of labour, and in their capacity as employers already contribute very largely towards the fund for this scheme. Again they are the largest ratepayers. [An HON. MEMBER: "Where do they get their money from?"] Therefore they ought not as ratepayers to be called upon to pay again. The persons who escape are the people who have got investments abroad. [HON. MEMBERS: "Oh, oh."] That is perfectly true.
§ Mr. CASSEL
That is an irrelevant interruption of which I shall not take any notice. Other persons who escape are the people who have large professional incomes and who employ very few people, and they pay very little as ratepayers. It is the employer who pays as employer and again as ratepayer. If you judge this not as an abstraction between the Treasury on the one hand and the local authorities on the other, but if you consider the people, then those who are better able to bear the burden—and upon whom it would be more properly put—are the taxpayers and not the ratepayers. Finally there is this ground, that after all the ratepayers have no control over this expenditure, whilst over every other form of their expenditure, the 507 ratepayers have always had control. The Chancellor of the Exchequer said that in regard to the local health committees he was going to keep the control for the friendly society members. That is an additional ground why he should not call upon the ratepayer to pay this charge, which is really a national charge.
§ 12.0 M.
§ Mr. RAMSAY MACDONALD
I rise to say a few words to the Committee on the Clause. Either I do not understand the Sub-section, or hon. Gentlemen opposite do not. My reading of the Sub-section is this, that the local health committee will at the beginning of a year submit to the Treasury and to the local authority and Insurance Commissioners an estimate of the income and expenditure for the coming year. Before a farthing is spent by the local health committee, the local authority must say whether, in the event of the estimate showing expenditure greater than income, they think that expenditure is reasonable. Only in that event is the local authority and the Treasury liable for the payment of any deficiency. What, then, is the use of the speeches we have heard about local authorities and rates, if my reading of the Subsection is right? I am bound to say that my hon. and learned Friend who opened the Debate was so full of enthusiasm that he infected me with it, and I began to assume my reading was wrong. But thinking it over in the course of the more calm speeches, delivered subsequently, I have come back to my old conclusions. I think the local authority is not responsible for one farthing unless, before one farthing has been spent, the local authority sanctioned the expenditure. If that is the meaning of the Sub-section the Debate can be much shortened, and we can come to a decision which will be more in accordance with the intention of the Clause than appears from the various and somewhat lengthy speeches delivered on what, I consider, a misunderstanding of the Sub-section.
§ Mr. HICKS BEACH
It is true the county council and the Treasury have the right of sanctioning or disallowing the expenditure. But does the hon. Member realise that the local health committee are the people who have to submit this estimate and that, on the public health committee the representatives of the local authority are not in a majority. Suppose that the county council refuse to sanction 508 the expenditure suggested by the public health committee, and that the Treasury sanction it. You can think of the pressure the Treasury would exert upon the county council. I doubt that, if the Treasury presses, the county council would have to-pay. I do not think the committee realises what a change has been made since an Amendment was adopted last night. Before that the people who were to pay for medical services were the people who contributed under this Bill, either as employers or employed. Under the Amendment adopted last night the medical service is to be transferred to the county councils and the taxpayers. What does the Chancellor of the Exchequer say about this medical benefit. He says:—Medical benefit is a thing of which you cannot estimate the cost. All you know is that the tendency will be for it to go up and not down, and these societies will be only too glad to make an arrangement with the local health committees by which they will get rid of an increasing charge on a limited fund.. …If the friendly societies are willing in the future to undertake the cost of the medical benefits which will inevitably increase, they will either have to make an additional levy, or depress their other benefits. Therefore it is to their interest to part with this charge and to hand it over to the local health committee at the very outset of the administration of the Act."—[OFFICIAL REPORT, 1st August, 1911, cols. 318–319],That is what the Chancellor of the Exchequer told us last night. Under the Amendment a wholly additional charge is being placed upon the ratepayers and the taxpayers. We who take up the case of the ratepayers to-night have always maintained that a national charge for a national service ought to be borne by the National Exchequer, and we have stood out on a good many previous occasions against any more of these national services being paid for out of the local rates. The Chancellor of the Exchequer has made himself out to be a very great friend of the ratepayer. I frankly admit that when he granted old age pensions to people who were formerly in receipt of Poor Law relief he did to a large extent relieve the ratepayers, but what he gave with one hand he took away with the other. He forgot to mention that this Government by placing upon the rates the cost of the medical inspection of school children, and by the Housing and Town Planning Act imposed heavy charges on the ratepayers. I think we are perfectly justified in once more bringing before the House the grievance of the ratepayers in being called upon to pay what is a national charge, and, if my hon. Friend goes to a Division, I shall support him.
Mr. CLEMENT EDWARDS
I was one of a very small minority of fifteen who went into the Lobby last night against the changed attitude of the Government in substituting the financial responsibility of the health committees for that of the friendly societies in the matter of medical benefit. Much to the surprise of some of us the Chancellor of the Exchequer departed from the position that had been occupied by the Government of adhering to the friendly or approved societies by saying he was in favour of the health committees, and I have no hesitation whatever in saying he stampeded hon. and right hon. Gentlemen opposite into the Lobby in support of that proposition because of the vision he held out of the local rates as a limitless milch cow available for the medical profession. I suggest, if hon. and right hon. Gentlemen opposite are perfectly sincere in this matter, they should recognise, to use a very homely simile, that they cannot have their pudding and eat it. They cannot say the local health committee is to be the responsible financial authority from which the doctors are to get their limitless recompense without following out what the Chancellor of the Exchequer said, that they would come upon the rates. The sole argument utilised by the Chancellor of the Exchequer last night in emphasing the advantage of the local health committee as compared with the approved society was that the funds available in the approved society from which medical benefit might be paid to the medical men was limited whereas the funds available in the local health committees were practically unlimited. He was, in fact, challenged by the hon. Baronet the Member for Swansea (Sir A. Mond) as to where this extra money was to come from, and he specifically pointed to the proposal contained in this Sub-section, and said the money was to come from the local ratepayers. I say hon. Members cannot hunt with the hounds and run with the hare; they cannot play the game of giving the doctors limitless recompense and at the same time pose as the best and firm friends of the ratepayers. On the point whether the doctors are to be recompensed by the approved society they themselves without a single exception walked into the Lobby last night in favour of the proposition that they should not be so paid. It is therefore inconsistent for them to come to-day and say they are in favour of the doctors being paid without stint and without limit. They cannot say, "We are in favour of their being so paid, but not by the approved 510 societies. We say that we are the special friends of the ratepayers." A perfectly logical sequence of their action last night is to be found in this Amendment that the ratepayers shall be liable. Personally, I was one of the solitary fifteen who went into the Lobby last night against this proposal. [HON. MEMBERS: "'Vide, 'vide."] It is all very well for hon. Members to try and prevent me speaking. [An HON. MEMBER: "We are cheering you."] If by crying, "'Vide, 'vide," you are cheering that may possibly account for the incident that transpired here last week. Hon. Members must on that occasion have been in a merry mood indeed when they cried, "'Vide, 'vide" with so much vehemence.
Mr. CLEMENT EDWARDS
I am sorry I took notice of the interruption. But I do suggest there should be some element of sincerity on the part of hon. Members opposite and that there should be a little less charlatanism displayed by them over this Bill. There is one other point I desire to make. The hon. Baronet who moved this Amendment now suggests that the societies who invest their funds locally will practically be exempt from the burden of paying qua ratepayers for the medical benefit. This is said in face of the recommendation so often urged of late that money ought to be invested abroad, so as to escape the burden of national taxation. I gather that his proposition is that the great capitalists of the country should escape national burdens and by special legislation be exempt from having to bear any burden when ratepayers in the locality where money might be invested.
I fail to understand why it is that the ratepayer is going to-be asked to pay for his medical attendance. On the Second Reading the Chancellor of the Exchequer told us that the first charge on £25,000,000 was going to be for medical attendance and that it was to be the first cut off the joint. The whole question is raised at present because there has been an under-estimate of the cost of medical attendance. It is very hard, if there has been an under-estimate, that the local ratepayers should be obliged to find that deficit and it would be very well at this stage, if it were possible, and it would clear the air very much if we knew 511 what was in the mind of the Chancellor of the Exchequer as regards the amount of capital grant which he thinks the doctors are likely to want. If it is merely a question of what is put in by the actuaries in the statement sent to all of us, we are aware that 6s. has been put down, but the Chancellor must realise after all the friendly interviews which he has had with the medical profession that that will scarcely cover the medical expenditure. Suppose it does not you have the position that the local health committee are going to make a contract which can afterwards be repudiated by the county council and by the Treasury. The medical profession throughout the country are taking a very lively interest in this matter, and it would be very well if it were cleared up in some form whether, if the local health committee decided that 8s. 6d. or some such sum were the proper figure the county council could repudiate that and refuse to pay half their share. It would be a very much better way if the Chancellor of the Exchequer would take the bull by the horns and recognise that he must take some more of the £25,000,000 on which he said the medical profession had the first charge and see that we have a really satisfactory attendance for the working classes. The hon. Member for Bolton to-day mentioned the figure 8s. 6d.
§ Mr. HOHLER
The point made against the proposal in the Bill is that the deficit will have to be met to the extent of a half by the rates. It is said that it is unfair to cast this charge upon the rates because it is a national burden. The Chancellor of the Exchequer defended the proposal on the ground that he is relieving the ratepayer, and if his defence is sound I am inclined to agree with him. My view is that when he says so he is grossly inaccurate. I think the Chancellor of the Exchequer has forgotten for the moment what his Bill is—his Bill as I understand it. It is quite possible that my understanding is the correct one. Does the Committee bear in mind that the Clause we are dealing with deals only with the approved societies—the friendly societies, and the trade unions. I ask, would anybody who is a member of a friendly society or a trade union agree 512 to his being on the rates? I venture to say that he would entirely repudiate it. Let me turn to Clause 32, which deals with the deposit contributor. He is the man for whom the hon. Member for Woolwich spoke. Paragraph (f), Sub-section (1), of that Clause provides:—
"The sums payable in respect of a deposit contributor for the purposes of medical benefit and sanatorium benefit, and towards the expenses of administration, shall, except so far as they are payable out of moneys provided by Parliament, be deducted at the commencement of each year from the amount standing to his credit in the Post Office fund."
Where does the deposit contributor get a halfpenny out of the rates? He is the very man who will increase the rates. He may be called an outcast in relation to this scheme. An hon. Member said that this is an aristocratic Bill. Who is to get the money out of the rates? It is the friendly societies and the trade unions. I protest that they have never been on the rates. But when you come to the deposit contributor the case is different. I venture to say that in view of the consequences to which I have called attention, the statements of the Chancellor of the Exchequer in defending the Clause are grossly inaccurate. He has unintentionally misrepresented his own Bill.
§ Mr. ROBERT PEARCE
I regret the increased expenditure which will come upon the rates in regard to matters that should not be brought on the rates at all. There is to be a division of the expenditure in certain circumstances between the rates and taxes. The fact is that the ratepayer and the taxpayer are the same person. It is quite clear that this question of taxation and rating must be examined. I would like to ask the Chancellor of the Exchequer whether it would not be wise to leave out of this Sub-section any appeal to the county council in respect of this money. One reason is it appears——
§ Question put, "That the words proposed to be left out stand part of the Clause."
§ The Committee divided: Ayes, 178; Noes, 111.515
|Division No. 303.]||AYES.||[12.25 a.m.|
|Abraham, William (Dublin Harbour)||Greig, Colonel J. W.||Murray, Captain Hon. A. C.|
|Acland, Francis Dyke||Griffith, Ellis Jones||Needham, Christopher T.|
|Adamson, William||Guest, Major Hen. C. H. C. (Pembroke)||Neilson, Francis|
|Addison, Dr. C.||Guest, Hon. Frederick E. (Dorset, E.)||Nolan, Joseph|
|Ainsworth, John Stirling||Hancock, J. G.||Norman, Sir Henry|
|Allen, Arthur A. (Dumbarton)||Hardie, J. Keir||Nuttall, Harry|
|Allen, Charles P. (Stroud)||Harmsworth, Cecil (Luton, Beds.)||O'Brien, Patrick (Kilkenny)|
|Armitage, Robert||Harvey, T. E. (Leeds, W.)||O'Connor, John (Kildare, N.)|
|Baker, H. T. (Accrington)||Haslam, Lewis (Monmouth)||O'Connor, T. P. (Liverpool)|
|Balfour, Sir Robert (Lanark)||Havalock-Allan, Sir Henry||O'Grady, James|
|Baring, Sir Godfrey (Barnstaple)||Haworth, Sir Arthur A.||Palmer, Godfrey Mark|
|Barry, Redmond John (Tyrone, N.)||Hayward, Evan||Parker, James (Halifax)|
|Barton, William||Helme, Norval Watson||Pointer, Joseph|
|Beauchamp, Sir Edward||Henry, Sir Charles||Pollard, Sir George H.|
|Beck, Arthur Cecil||Higham, John Sharp||Ponsonby, Arthur A. W. H.|
|Bonn, W. W. (T. H'mts., St. George)||Holt, Richard Durning||Power, Patrick Joseph|
|Bentham, George Jackson||Horne, Charles Silvester (Ipswich)||Raffan, Peter Wilson|
|Birrell, Rt. Hon. Augustine||Howard, Hon. Geoffrey||Rea, Rt. Hon. Russell (South Shields)|
|Booth, Frederick Handel||Hudson, Walter||Rendall, Atheistan|
|Bowerman, C. W.||Hughes, S. L.||Richardson, Albion (Peckham)|
|Brace, William||Hunter, W. (Govan)||Richardson, Thomas (Whitehaven)|
|Brady, Patrick Joseph||Isaacs, Rt. Hon. Sir Rufus||Roberts, Charles H. (Lincoln)|
|Brunner, J. F. L.||Jones, Edgar (Merthyr Tydvil)||Roberts, George H. (Norwich)|
|Bryce, J. Annan||Jones, H. Haydn (Merioneth)||Roberts, Sir J. H. (Denbighs)|
|Buxton, Noel (Norfolk, N.)||Jones, Leif Stratten (Notts, Rushcliffe)||Robertson, John M. (Tyneside)|
|Carr-Gomm, H. W.||Jones, William (Carnarvonshire)||Robinson, Sidney|
|Cawley, Harold T. (Heywood)||Jones, W. S. Glyn- (Stepney)||Roch, Walter F. (Pembroke)|
|Chancellor, Henry G.||Jowett, Frederick William||Roe, Sir Thomas|
|Chapple, Dr. W. A.||Joyce, Michael||Rose, Sir Charles Day|
|Clough, William||Keating, M.||Rowlands, James|
|Condon, Thomas Joseph||Kilbride, Denis||Samuel, Rt. Hon. H. L. (Cleveland)|
|Cornwall, Sir Edwin A.||King, J. (Somerset, N.)||Samuel, J. (Stockton-on-Tees)|
|Craig, Herbert J. (Tynemouth)||Lambert, George (Devon, S. Molton)||Seely, Colonel Rt. Hon. J. E. B.|
|Crawshay-Williams, Eliot||Lambert, Richard (Wilts, Cricklade)||Sheehy, David|
|Crumley, Patrick||Lansbury, George||Sherwell, Arthur James|
|Davies, David (Montgomery Co.)||Lawson, Sir W. (Cumb'rld, Cockerm'th)||Shortt, Edward|
|Davies, Timothy (Lincs., Louth)||Leach, Charles||Simon, Sir John Allsebrook|
|Davies, Sir W. Howell (Bristol, S.)||Levy, Sir Maurice||Smith, Albert (Lancs., Clitheroe)|
|Dawes, J. A.||Low, Sir F. (Norwich)||Strauss, Edward A. (Southwark, West)|
|Denman, Hon. R. D.||Lundon, T.||Summers, James Woolley|
|Doris, W.||Lyell, Charles Henry||Sutton, John E.|
|Duffy, William J.||Macdonald, J. R. (Leicester)||Taylor, John W. (Durham)|
|Duncan, C. (Barrow-in-Furness)||Maclean, Donald||Taylor, Theodore C. (Radcliffe)|
|Edwards, Clement (Glamorgan, E.)||Macnamara, Rt. Hon. Dr. T. J.||Tennant, Harold John|
|Edwards, Sir Francis (Radnor)||Macpherson, James Ian||Thorne, G. R. (Wolverhampton)|
|Edwards, John Hugh (Glamorgan, Mid.)||MacVeagh, Jeremiah||Ure, Rt. Hon. Alexander|
|Elverston, Sir Harold||McGhee, Richard||Verney, Sir Harry|
|Esmonde, Dr. John (Tipperary, N.)||McKenna, Rt. Hon. Reginald||Walsh, Stephen (Lancs., Ince)|
|Essex, Richard Walter||M'Laren, H. D. (Leices.)||Ward, W. Dudley (Southampton)|
|Esslemont, George Birnie||Manfield, Harry||Waring, Walter|
|Falconer, J.||Markham, Sir Arthur Basil||Wason, John Cathcart (Orkney)|
|Ferens, T. R.||Marshall, Arthur Harold||White, J. Dundas (Glasgow, Tradeston)|
|Ffrench, Peter||Masterman, C. F. G.||Wiles, Thomas|
|Field, William||Meagher, Michael||Williams, Penry (Middlesbrough)|
|Fiennes, Hon. Eustace Edward||Millar, James Duncan||Wilson, Rt. Hon. J. W. (Worcs., N.)|
|Flavin, Michael Joseph||Morgan, George Hay||Wilson, W. T. (Westhoughton)|
|Furness, Stephen||Morrell, Philip||Wood, Rt. Hon. T. McKinnon (Glas.)|
|George, Rt. Hon. D. Lloyd||Muldoon, John|
|Gibson, Sir James P.||Munro, R.||TELLERS FOR THE AYES—Mr. Illingworth and Mr. Gulland.|
|Gill, A. H.||Munro-Ferguson, Rt. Hon. R. C.|
|Glanville, H. J.|
|Agg-Gardner, James Tynte||Bird, A.||Eyres-Monsell, B. M.|
|Aitken, Sir William Max||Boles, Lieut.-Col, Dennis Fortescue||Fell, Arthur|
|Anson, Rt. Hon. Sir William R.||Boyton, James||Fleming, Valentine|
|Ashley, Wilfrid W.||Bridgeman, W. Clive||Forster, Henry William|
|Baird, J. L.||Burn, Col. C. R.||Foster, Philip Staveley|
|Baker, Sir R. L. (Dorset, N.)||Butcher, J. G.||Gibbs, G. A.|
|Balcarres, Lord||Campion, W. R.||Gilmour, Captain J.|
|Banbury, Sir Frederick George||Carlile, Sir Edward Hildred||Gordon, John (Londonderry, South)|
|Banner, John S. Harmood-||Cassel, Felix||Gordon, Hon. John Edward (Brighton)|
|Baring, Maj. Hon. Guy V. (Winchester)||Chaloner, Col. R. G. W.||Grant, J. A.|
|Barlow, Montagu (Salford, South)||Chamberlain, Rt. Hon. J. A. (Worc'r.)||Greene, Walter Raymond|
|Barnston, H.||Clay, Captain H. H. Spender||Guinness, Hon. Walter Edward|
|Barrie, H. T. (Londonderry, N.)||Clive, Captain Percy Archer||Gwynne, R. S. (Sussex, Eastbourne)|
|Beach, Hon. Michael Hugh Hicks||Cooper, Richard Ashmole||Hall, Fred (Dulwich)|
|Beckett, Hon. Gervase||Craik, Sir Henry||Hamersley, A. St. George|
|Benn, Arthur Shirley (Plymouth)||Dixon, Charles Harvey||Hardy, Rt. Hon. Laurence|
|Bennett-Goldney, Francis||Doughty, Sir George||Harris, Henry Percy|
|Bigland, Alfred||Duke, Henry Edward||Hickman, Col. Thomas E.|
|Hill, Sir Clement L. (Shrewsbury)||Neville, Reginald J. N.||Starkey, John Ralph|
|Hill-Wood, Samuel||Newman, John R. P.||Stewart, Gershom|
|Hohler, G. F.||Newton, Harry Kottingham||Sykes, Mark (Hull, Central)|
|Horne, William E. (Surrey, Guildford)||Nicholson, Wm. G. (Petersfield)||Talbot, Lord Edmund|
|Hunt, Rowland||Orde-Powlett, Hon. W. G. A.||Terrell, H. (Gloucester)|
|Ingleby, Holcombe||Parkes, Ebenezer||Thompson, Robert (Belfast, North)|
|Jardine, E. (Somerset, E.)||Peel, Capt. R. F. (Woodbridge)||Tobin, Alfred Aspinall|
|Jessel, Captain H. M.||Peto, Basil Edward||Touche, George Alexander|
|Kebty-Fletcher, J. R.||Pollock, Ernest Murray||Tryon, Captain George Clement|
|Kerry, Earl of||Pryce-Jones, Col. E.||Valentia, Viscount|
|Lane-Fox, G. R.||Quilter, William Eley C.||Wheler, Granville C. H.|
|Larmor, Sir J.||Rawson, Col. Richard H.||White, Major G. D. (Lancs., Southport)|
|Lawson, Hon. H. (T. H'mts., Mile End)||Ronaldshay, Earl of||Williams, Col. R. (Dorset, W.)|
|Locker-Lampson, G. (Salisbury)||Rutherford, Watson (L'pool, W. Derby)||Willoughby, Major Hon. Claud|
|Locker-Lampson, O. (Ramsey)||Salter, Arthur Clavell||Wood, John (Stalybridge)|
|Macmaster, Donald||Sanders, Robert A.||Worthington-Evans, L.|
|McNeill, Ronald (Kent, St. Augustine)||Sanderson, Lancelot||Wortley, Rt. Hon. C. B. Stuart-|
|Mildmay, Francis Bingham||Scott, Sir S. (Marylebone, W.)|
|Mills, Hon. Charles Thomas||Spear, Sir John Ward||TELLERS FOR THE NOES.—Sir A. Cripps and Mr. Hayes Fisher.|
|Mount, William Arthur||Stanley, Hon. G. F. (Preston)|
§ Amendments made: In Sub-section (4) leave out the word "shall" ["enough shall, if satisfied"] and insert instead thereof the word "may."
§ In Sub-section (5), after the word "sums" ["any sums expended by the local health committee"] insert the words "so sanctioned by them and."— [Mr. Lloyd George.]
I beg to move, in Subsection (5) to add at the end the words: "That no health committee shall contract with any medical practitioner for a less fee than eight shillings and sixpence per insured person per year."
On the question of the capitation grant —I presume there will be in the majority of cases a capitation grant fixed—it cannot really be an Insurance Bill unless there is a capitation grant. I think it will be agreed by everyone in this House and by all parties that the people who come under this Bill ought to be secured against any attempt to employ doctors at a remuneration which does not afford them an opportunity of giving their very best attention and doing everything possible to cure the patient and get him off the funds of the insurance company. I understand that 6s. is the amount allocated or assumed by the actuaries to be the amount which will be required. I do not think I should have moved this Amendment had it not been that the Chancellor of the Exchequer mentioned not less than four times in a speech that the amount is 8s. I am quite confident that it is actually impossible for any doctor to undertake the duties which this Bill will require at 6s. capitation grant.
The hon. Member for Bolton spoke about 8s. 6d. as the likely capitation grant. I am quite certain that the members of the Labour party perhaps more than anybody in this House 516 thoroughly understand the necessity for the working man to receive the best possible medical attendance under the Bill. At first sight it may seem as if the amount, 8s. 6d., is large, but I want to bring home to the Committee what will have to be done. At the present time we have nothing to go upon, except the work that has been done for the friendly societies, for which an average of 4s. has been paid. I am not now going to enter into the way in which that work has been done, but I think it is agreed that the work must be better done in the future than it has been in the past. Besides the doctor now who is attending a friendly society can see a great number of persons in a very short time, and he has nobody to say that he is not attending to them properly. Under this scheme I have not the slightest doubt that a great deal of statistics will be kept. Every person will bring a paper with him which will have to be filled in with a great number of things. The patient will have to be attended to properly, to have his temperature taken and written down. If there is any suspicion of kidney disease there will have to be some sort of analysis taken, and the specific-gravity of the urine will have to be recorded.
Another point which has escaped the attention of a great many people is that the man does not come on sick pay until the fourth day, but he sends for the doctor on the first day. The doctor may see the man for two days, and on the third day the man may go to work. Thus the doctor will have a great number of cases that will never appear and will never come upon the funds of the insurance society simply because under the Bill you are compelling the man to be four days sick before he gets upon his society. Therefore there is a good deal of extra work put on the medical profes- 517 sion. In the country districts the doctor is sent for as soon as the patient is ill. He goes and gives a certificate and then the patient goes on the society he belongs to. That will not be so under the Insurance Bill. The doctor will come down to his breakfast and find half a dozen postcards waiting for him from men with bad colds, who want to be sure that they will be able to go on the fund on the fourth day. That is perfectly right, because if the Act compels them to give four days' notice they are quite right to see the doctor on the first day. But it is unreasonable to expect the doctor to go over the country, perhaps in different directions, without considerably increasing the amount. Why have I fixed 8s. 6d.? Because that is the sum already paid by a Government department, and it has been paid as long as I have been in practice. I do not see how you can logically expect medical men to give their best attention for less. If a minimum capitation grant of 8s. 6d. is fixed, I believe I can say on behalf of the profession that they will do everything possible to prove that they are heart and soul with the Government and the House in making the Bill a thorough success, and that they will spare neither time nor energy in doing everything possible for the sick persons under their charge. I have spent twenty-five years in practising throughout England, and I am certain that if less than 8s. 6d. is allowed to be fixed you will rob the working classes of that best attendance which we as Members of this House would be anxious to get for ourselves. I beg to move.
§ Mr. LLOYD GEORGE
The hon. Member on behalf of his profession is making a demand which has never been put forward before. It is really most discouraging. There are many rural districts where the amount is 2s. 6d. I say that that is unreasonable. But he asks that even in those cases we should instantly raise it to a minimum of 8s. 6d. A committee of the British Medical Association made an investigation, and out of all the suggestions received, only about thirty ventured as high as the hon. Member; the vast majority asked for something from 6s. and under.
That is not at all an accurate figure. I was in practice at the time that was brought out; I had three or 518 four clubs in my own practice, and the first time I heard of it was when it was produced in the House for an argument.
§ Mr. LLOYD GEORGE
The mere fact that the hon. Gentleman never heard of it is a proof that it never existed, I suppose. It is a report by a committee of the British Medical Association after a most careful investigation—a committee of the very association which has conducted and organised the whole of this agitation. They circularised the members of the medical profession, and the vast majority of those who sent in their grievances never asked for more than 6s. Most of them were satisfied with about 5s.
§ Mr. LLOYD GEORGE
Really the hon. Gentleman says that he never heard of this report, and yet he contradicts one who has read it very carefully. It is an investigation into contract work. The hon. Gentleman says that in contract practice you must have 8s. 6d. as a minimum. That is asking for more than his own profession ever asked for. The Post Office men is a very different case. You may have one or two men in a rural district and naturally the minimum is higher than if you had a few hundred patients in the district. I do hope that there will be no attempt to fix an amount of remuneration which may very well in some districts be higher, and in some districts lower. In his attempt to fix a minimum of 8s. 6d. the hon. Gentleman never seems to give a thought to the benefit of the workmen themselves. If 8s. 6d. is given as a minimum to the doctor he must get it at the expense of the benefits of the workmen themselves.
Mr. M. BARLOW
The Chancellor of the Exchequer deals with the difficulties raised for him in a way that excites the admiration of all of us, but he has surpassed himself in quoting that document because it was not prepared for this set of circumstances. [HON. MEMBERS: "Hear, hear."] It was prepared some years ago, and I produced it on the Second Beading in answer to questions by the Chancellor of the Exchequer. So far as the doctors are concerned—I have many in my Constituency, and they have put this point to me over and over again—the point is: "That under present conditions we have a certain small proportion of our practice 519 club practice, but when this Bill is passed the whole of our practice or nearly all——"
§ Mr. LLOYD GEORGE
The hon. Member forgets the Amendment accepted by us which makes a very serious difference. I am glad the hon. Gentleman reminded me of it. That Amendment makes it possible for arrangements to be made whereby the doctors can be paid fees.
Mr. M. BARLOW
That is conditional on an agreement being made. Clearly the thing under the Bill will be that all transactions of a medical character in industrial concerns will take place through the Committee, or the approved society, and the doctor will be unable to have that which I am sure the Chancellor of the Exchequer would "wish him to have—free trade with regard to his practice. The arguments drawn by the Chancellor of the Exchequer as to the state of things six or eight years ago are not applicable now. The doctors will under the Bill have this contract practice and nothing else. [HON. MEMBERS: "No."] I have seen and examined doctors' books in industrial areas where they are receiving comparatively large sums by means of collecting books, by payments of 1s. or so per week, from citizens earning decent wages who prefer to go to a doctor in this way rather than to a club doctor. The doctors will be deprived of that, and that fact vitiates the whole of the argument the Chancellor of the Exchequer derived from the document he has quoted not for the first time to-night, and which I hope he will not refer to again, because I do not think it will assist him in this controversy.
§ Mr. WATSON RUTHERFORD
It is impossible not to sympathise to a very large extent with the Amendment proposed. The basis of the Amendment is that we ought if possible to stop sweating in the payment of doctors, and that we ought to prevent that profession from being prostituted to some extent by outsiders coming from the wilds of Ireland and the wilds of Scotland where large numbers of rising young gentlemen in the medical profession come from and many of them attain great positions in the profession. There is, of course, a stage in their existence when they are willing to work for comparatively small remuneration, and I can well understand there will be plenty of health committees who will be induced by the fact 520 that there is no limit downwards on the amount of remuneration they give, to take on some of these raw youths from the districts to which I have referred and instal them in practice in these different places with a view to cutting down the amount that is to be paid for medical attendance. I think there is one fallacy at the root of the argument of the Chancellor of the Exchequer, and it is this; that in the case of the friendly societies and industrial insurance you are dealing with picked men who, as a rule, are healthy, and it is possible to take on a class of that sort at a comparatively small rate. Here we are dealing with a flat rate for the whole community.
We have to include the chronic and the out-of-health and all that section which at present are not insured. When you come to take this into account a very serious element arises not 'comparable to the case of the old industrial insurance societies. You are dealing with a different class of persons altogether, and you must necessarily get a considerably higher rate of ill-health if you include not merely the decent respectable class that so far have been insured, but all those who have been uninsurable in the past and would not be accepted by any of these societies. I am not inclined to vote for 8s. 6d. I confess I know no reason why it should be 8s. 6d. any more than 8s. or 7s. 9d., but I think it is a reasonable thing there should be some fair limit. I am sorry to gather from the speech of the Chancellor of the Exchequer he is not inclined to accept any limit whatever and that he is going to leave it open to the health committees to make any kind of bargain with regard to the rate to be paid, and I can very well see if this Bill is allowed to pass in this shape we shall have some very unconscionable bargains made. You may depend upon it if the medical profession find themselves placed in such a position that the remuneration is entirely inadequate it will end in the people not being properly attended to. It is on those grounds that I support the Amendment in the absence of any other suitable proposition from the Government to take its place.
§ Mr. NEWMAN
I have received several deputations of doctors on this subject, and each of them made the same point. The point was that they wanted a minimum of 8s. 6d. for picked lives, and that was to include first dressings and nothing more. They told me that they would require special remunera- 521 tion for special work done. I have had many talks with doctors on this subject, and why on earth should medical men not be paid an adequate rate of pay for the work they do? Take the National Deposit Friendly Society, numbering something like 200,000 members. How do they pay their doctors'? In a medical case they make one visit, and give medicine for two days for 2s. 6d., and for each intermediate visit they pay 1s. 6d. I could quote a long list of cases in point. Surely if the National Deposit Friendly Society can pay their medical men those rates the State ought to pay more than 4s., 6s., or 7s., which is absolutely ridiculous. If this society can pay those big rates surely the State can pay something more than that which is proposed in this Bill. I suggest that we ought to decide this question and not leave it to the local health committees. The doctors tell me that they will refuse to work altogether under the scheme unless something is done to meet their demands.
§ 1.0 A.M.
§ Mr. PETO
I want to deal with this matter on slightly different grounds from those of the hon. Member for Enfield (Mr. Newman). If this question of a minimum rate is to be left entirely to the local health committees, I should certainly argue the question of the rate of payment on different lines. The Chancellor of the Exchequer referred to the inquiry made by the British Medical Association, but he very candidly admitted that the half-crown rate in the rural districts could not be taken as a criterion in any sense. No one can really pretend that the rate of payment accepted in a rural district by a medical man for attendance upon friendly society members can be taken as a criterion of what ought to be the rate of remuneration as a business payment under this insurance scheme. Certainly as regards my own constituency, I have talked this matter over with one medical man, and I have come to an absolutely firm conclusion that in the great majority of cases medical attendance to friendly society members is purely taken up out of charity and goodwill on the part of the medical man. If you are going to do away with the whole of the present system, I question very much whether the rate of 8s. 6d., which the Chancellor appeared to say was out of the question, is not very much more nearly a fair business rate than 2s. 6d. or 4s. I think that any argument based upon the existing rates accepted for friendly society members by 522 the doctors is bound to be absolutely fallacious. One hon. Member interrupted on. the other side with a remark that there were still the women and children. There again I think we have an entire fallacy if you are going to argue that because women and children are at present left out, therefore the men who are insured should be medically attended at a wholly inadequate rate, because something is to be made out of the family. I ask you to come upon more solid ground, and to say how long will the rest of the family be left out?
Mr. CLEMENT EDWARDS
I said that the man and the whole family will come under the Insurance Bill.
§ Mr. PETO
Precisely. The interruption was to suggest that if the workman was insured everybody was not insured, and, therefore, in any case the medical practitoner, if some of his practice was taken away under the Bill, had these others left. I say that may be so to-day, but it will not be so very long, and you ought to start the thing on a business footing and on a payment which would be a fair contract between man and man. You wash away entirely the whole basis of the scale of remuneration which has been hitherto accepted on an entirely different basis. You must remember that there is a very large number of people who will now be contributing who have hitherto been paying the ordinary medical fees. On the basis upon which it has been carried on, this friendly society work has formed an almost negligable part of the medical men's remuneration, though it has been a very important part of his daily work. I think it is desirable undoubtedly that something definite should be said with regard to what the remuneration ought to be. It should not be left absolutely vague, like half of the knotty questions that have come up; it should not be left to the Report stage or left to the local health committee or left to the Insurance Commissioners—left to anybody but this committee to decide the rules by which this Bill is to be administered. I quite agree with the hon. Member who has just spoken that it is rather a big order to lay down as an absolutely hard and fast rule to apply to every district, rural and urban, throughout Great Britain, that it should foe 8s. 6d.; but I think it is a very long step from that to lay down no minimum at all, leaving everything to worse than chance, to chance regulated by erroneous data.
§ Sir ARTHUR MARKHAM
The hon. Member who moved this Amendment said it established the principle of a minimum wage. I do not think he would be in favour of that principle, when it was proposed from the Labour benches, although he is a leading authority on financial matters. I think it is not unreasonable to ask for a minimum. It is, in fact, reasonable we should get some minimum laid down. Certainly it should not be 8s. 6d. I think 6s. is an ample sum. There has been talk among the doctors to show that the latter figure is inadequate. It is very easy to say that the medical profession did not know this Bill was coming on when their own inquiry was made, and when they put forward the basis of a scale. That is all nonsense. They knew perfectly well the scheme was coming on.
§ An HON. MEMBER: That was on picked lives.
§ Sir A. MARKHAM
Are all these bad lives who are coming under the Bill? That is one of the many fallacies we hear. Are all these ten millions of people going to be bad lives? I am not going to repeat the arguments, but I should have felt grateful if the Chancellor of the Exchequer could have said there would be some minimum fixed, and that it would not be left to the local health committee. The Chancellor of the Exchequer and the House of Commons are not going to deal with this troublesome question, but it is to be left to be fought out by the local health committees and the doctors. After all this talk of the last few days, we are to leave it to the local health committees. One hon. Member was speaking about the local rates. So far as my own company are concerned £12,000 a year is the additional amount which it will have to pay for the insurance of their workmen under this Bill, and they will also have to pay a large sum of money as an addition to the local rates. I do not object to the payment. I regard it as profitably spent money on the whole. I want to see a maximum that the doctors will be paid. [HON. MEMBERS: "Minimum."] No, I mean maximum, because I know there is log-rolling, and it will take place at these local committees. It is only human nature. I think this is a thing we ought to deal with in the House of Commons, and not leave it to the local committees and the doctors.
§ Mr. POLLOCK
I desire to point out one reason which makes it impossible to 524 accept the Amendment at present. There is a good deal to be said for having something definite, and that we should take the responsibility ourselves and not delegate it to the local committees. But before we fix upon a definite sum to be paid to the doctors, it must not be forgotten that it is necessary to ascertain what the doctors are going to do for the money. There is a branch of friendly society work which I think has been overlooked by the Committee so far. Perhaps if the Chancellor of the Exchequer will allow me I will put this point to him, because it is a very important one. We have determined in Sub-section (7), Clause 8, that a certain number of persons who are at present in receipt of ordinary benefit will not be within the Act, and cannot become insured persons, or will no longer receive medical benefit, unless they still receive it through the friendly societies. At present the doctors of friendly societies are able to give medical benefits to the members of those societies because they have in them not only the sick persons, but also a large number of those who are comparatively healthy. But if you are going to hand over to the doctors by means of the health committees those who propose to become insured under this Act you will hand over to the doctors men who certainly are not accepting medical benefit at the present moment.
It must be remembered that there will be left outside this Bill a large number of persons who at present are in receipt of medical benefit, and who pay for it to their friendly societies out of the sick payments that they receive. What is to be the position of these persons after this Bill has been passed? I am told that they number something like 23,000 persons. They will require medical benefit at the present lime. If the doctors are prepared to take over and continue to serve these persons as they have served them, in the past, we may fix something for the doctors which may be somewhat higher remuneration. From the point of view of the friendly societies you must make some arrangement which will not overlook the large number of persons who will not be insured under the Bill, and who will have to look to their societies alone for benefit. The societies will ask from what source they are to provide funds to pay the doctors to look after this large army of sick persons. These persons have so far been overlooked by the Committee. When we are dealing with the duties of the health committees I hope we shall direct them to make such arrangements with the doctors as may 525 require the doctors to continue medical benefit to persons at present in receipt of it and who cannot become insured persons under this Bill.
§ Mr. POLLOCK
I am glad to hear that the point has not been overlooked by the bon. Member. I am sure he has been thinking of it, but at the present moment it has not been met. It is an objection to settling at the present time any definite rate for the doctors. Before the doctors can ask for some definite fixed rate to be provided for them we must have in return some definite statement from them that they will be prepared to continue in the future the medical benefit to those persons who have hitherto received it through the friendly societies, and for whom the societies will have no immediate fund to pay. I am glad to have had an opportunity of calling the attention of the committee to this fact, and am glad to have had an assurance from the hon. Member for Pontefract (Mr. Booth) that he is looking after this question, because it is a very important one. Because no arrangement has yet been made with the doctors for continuing the work they have done previously, I think the present time is wholly inopportune to make a definite flat rate with the doctors, and therefore it is quite impossible for me to support the Amendment.
§ Mr. GEORGE ROBERTS
I think the hon. Member who submitted this Amendment has now been pretty well convinced that it is inadvisable to pursue it much further. The negotiations between the medical faculty and those interested in the other side of the scheme are in such a delicate state that it is unwise to lay down a flat rate for the doctors.
§ Mr. GEORGE ROBERTS
I will try to settle this Amendment. I simply rise to again protest against the implication underlying some of the speeches that have been made. Hon. Gentlemen opposite have talked about friendly societies' practice as if it were one of consistent sweating. They talked of friendly 526 societies practice in rural districts. I have had some experience of club practice in rural districts, and I have never met a medical man who characterised it as sweating.
§ Mr. GEORGE ROBERTS
I have simply given a variation of the hon. Member's utterance. The implication was that the doctor was not fairly paid. I say it was a mutual arrangement between the society and the medical man himself. I have already confessed that. I do not think the arrangements are altogether satisfactory, but I strongly resent the implication that the friendly societies are alone responsible for the unsatisfactory state of affairs. I do not think the hon. Member (Dr. Esmonde) is right in submitting any fixed sum at this moment. I will give a figure which may help us to some due appraisement of what would be the right and proper figure in the circumstances. There is an institute which exists in my own Constituency to which the members pay 4s. per head per annum. They do not sweat their medical practitioners. They have three whole-time doctors in their employ. The doctors are agreed that the rate they receive is a fair one. That 4s. includes the provision of drugs, but the doctors under this Bill are entirely relieved from that, and therefore it is even more valuable to them than the case I have stated. I do not suggest that 4s. is a fair figure. I am not prepared to say that. Six shillings is unfair in some districts. But I think we should rather leave it to the local health committees, on which the doctors and the friendly societies will be represented, and whatever the doctors obtain must be the result of a mutual arrangement between them. Therefore, in the interests of the doctors themselves, we ought not to pass this Amendment. Of course I look at it from the point of view of the friendly societies and trade unions, and I strongly resent the suggestion that they desire to sweat the medical profession. I think the procedure set up under the Bill will ultimately be very satisfactory, and that the hon. Member (Dr. Esmonde) need not carry the matter any further.
Mr. FRED HALL (Dulwich)
I happen in. my Constituency to have many doctors who have been in the habit of attending those who earn from £2 to £3 a week. These are the doctors that this Bill is going to inflict a very great hardship upon. I have heard to-night many hon. Members say, "Oh, yes, but they are going to have a very large increase in the number of their patients." It cannot be the wish of the Committee to serve out to these doctors, irrespective of the number of patients they have already, a certain number more. If they are brought down to a certain stipulated price, and the fees they have been in the habit of receiving from these people—generally about 1s. 6d. per visit—are taken away, they must in the circumstances also have a larger number of patients to look after. It is impossible for any medical man to considerably increase the number of his patients and expect to make anything like the amount he has been receiving up to the present time.
I have had figures given me from one medical man in which he tells me there are 591 wage earners mostly earning between £2 and £3 per week, and from whom he received during the past year £695 7s. 2d. What would that medical man be receiving under this Amendment? The difference would have to be made up in some way or another. He would have to look after a considerably increased number of patients. I suggest it is not possible for any medical man to increase the number of patients he has to look after, and give them the same care and attention he is desirous of giving, and earn the same amount he has earned before. I trust the Committee will not leave it to the health committee to decide exactly what has to be paid. I do, however, trust that some arrangement will be come to as to what will be the minimum price that will be paid to the medical men in the ordinary course of events. I am convinced that every Member of this House is desirous that these medical men should be able to give the greatest care and attention to the patients, but that they should not have an enormous influx of patients placed under their care and to whom they could not give due attention.
§ Dr. ADDISON
I should like to point out that the British Medical Association has been very attentive to the whole of this matter, and have come to the conclusion that no definite minimum should be 528 fixed. I am sure the hon. Gentleman opposite (Dr. Esmonde) is not serving the cause of the medical profession in moving this Amendment. I sincerely trust he will not persist with it.
§ Sir F. BANBURY
The hon. Member opposite (Mr. Clement Edwards) asked me if I was in favour of a minimum wage. He knows I am not. At the same time, when I am starting an industry, as has been done here, and am imposing certain obligations on these people, I am entitled to say what the wage is to be. Under this Bill the doctors are really the servants of the State. [HON. MEMBERS: "NO."] Well, of the local health committees set up under the State. If comes to the same thing. The State is embarking on this and therefore I say the State ought to pay. The hon. Member for Norwich says he knows of a society where the members pay four shillings to the doctors and the doctors are quite satisfied. Of course I accept the statement of the hon. Gentleman.
§ Mr. G. ROBERTS
The hon. Baronet misrepresents me. They do not pay four shillings to the doctors, but four shillings per head to the society.
§ Sir F. BANBURY
That is the point we are pressing. If the doctors have a minimum salary, it will depend on that whether they are satisfied. If the doctors are satisfied with 6s., or with something the health committee are going to give them, that is not the same as the case the hon. Member has put forward. I have had meetings with a great many doctors, and they are not satisfied with 6s. a year. As to the hon. Gentleman below the Gangway (Dr. Esmonde), he has had great experience in the medical profession, but it seems a little curious the hon. Member on the other side (Dr. Addison), who also represents the medical profession, does not agree with his brother on this side. Whether the hon. Gentleman has been got at by the Chancellor of the Exchequer I do not know. It is possible the persuasive eloquence of the Chancellor of the Exchequer has overruled the desire of the hon. Gentleman who says his fraternity is earning an honest livelihood,; 529 though I do not myself know sufficient of the merits of the case to say whether 8s. 6d. is the right sum or not.
We ought to fix in the Bill a certain limit. I do not think we should leave it to the local health committees to decide what they ought to pay. You might get a health committee so economic as to accept a very small sum with the result that the people to whom the hon. Member for Woolwich referred would suffer. I think it is absolutely necessary, if we are anxious to see this Bill work well, that we should decide upon some limit and so help the local committees. Whenever we get into a difficult position I find that whoever is in charge of the Bill proposes that we postpone the difficult question or leave it to somebody else to decide what should be done. My view is that if the Committee of the House of Commons choose to embark on a Bill of this sort they should face the difficulties and say that in their opinion such and such a thing should be done.
§ Mr. LEIF JONES
Have we not decided this afternoon that we intended to leave it to the local health committees? All we have to do is to guide the health committees.
§ Sir F. BANBURY
Quite so, and that is what I was advocating. I am not sure that 8s. 6d. is the right amount, but unless the hon. Member opposite, who has the medical fraternity behind him, or the hon. Member for Pontefract, who takes some trouble in these discussions, can point to a sum that is better than 8s. 6d., I shall be compelled to vote for the Amendment of the hon. Member. I would suggest to hon. Members opposite that this really is a serious subject on which they ought to give their undivided attention, and, if they think that half-past one o'clock in the morning is too late to do it, they can ameliorate the position by moving to report Progress, which I am not at all sure I ought not to do.
§ Sir RANDOLF BAKER
We have had during the hour or so this discussion has gone on considerable divergence of opinion, and if the Committee considers what we have heard from the very few Members speaking on behalf of friendly societies it gives some idea of what is going to happen on the local health committees if there is absolutely no guidance in this House. The Chancellor of the Exchequer seems to have put the difficulty on the shoulders of the unfortunate mem- 530 bers of the health committees without giving them any guidance of any sort or kind. Cannot we get some indication as. to whether the sum which the local health committees are to pay is to include such things as journeys? I represent a Constituency which is very sparsely populated, and where doctors have to make very long journeys.
§ Sir R. BAKER
It would have helped enormously, I should have thought, if we could have had some guidance from the Government in this matter, but I, of course, bow to your ruling, Mr. Whitley. I should like to ask the Attorney-General if the Government has considered what would happen supposing no satisfactory arrangements could be arrived at between the local health committees and the doctors. Would it result inevitably in a strike in the district? Does it not mean that the question of whether or not the whole Bill is likely to break down depends entirely on whether this House gives some sort of guidance to the local health committees?
§ Sir RUFUS ISAACS
It has been already decided that the Commissioners will have to decide the question.
§ Sir R. BAKER
Supposing they fix a price to which the doctors will not agree. In that case, I suppose, the doctors would go on strike, and if you are going to import blackleg doctors to work this Act, will not doctors refuse to accept what is given? If you give some guidance in this House there is a reasonable probability that the Act will work well. Surely it is much better that the Bill should break down as a whole than that it should break down in certain districts. It would lead to an intolerable state of things if in certain localities doctors refused to accept the arrangements which were made by the local health committees, even though the Insurance Commissioners were to settle the matter finally. This Committee is putting off the question on. which the whole success of the Bill depends. I am not in favour of any particular sum. I do not say the sum of 8s. 6d. is the best, but I do say that it is absolutely essential to the future working of this Bill that we should give some guidance to the local health committees. I have had some small experience myself of local committees, and, especially in a county like 531 Dorset, where the means of communication, are not good, members of the committees would not be able to attend, and it would lead to a state of things which, I think, would militate very greatly against the interests of this Bill. Therefore, I hope the Chancellor of the Exchequer, if he will not accept 8s. 6d. as the minimum, will, at any rate, draw some line so that the local health committees will know what to do.
After the statement of the hon. Member for Hoxton that it would be a disadvantage to the medical profession that I should go on with the Amendment, and also after the statement we have had from the Chancellor of the Exchequer, which throws a very clear light on the position, I beg leave to withdraw the Amendment. [HON. MEMBERS: "No, no."]
§ Amendment negatived.
§ Question, "That the Clause, as amended, stand part of the Bill," put, and agreed to.