NATIONAL INSURANCE ACT (1911) AMENDMENT BILL.

HC Deb 05 August 1913 vol 56 cc1377-440

Postponed proceeding resumed on Question proposed on Clause 10.

Which Question was to add at the end of Sub-section (2) the following Sub-section:—

"(3) An insured person, on satisfying the local insurance committee that he desires the services of a medical practitioner who has not entered into arrangements with such committee under Sub-section (1) of Section 15 of the principal Act, and that he understands the consequences of making arrangements under Sub-section (3) of that Section, shall be at liberty to take such services under that Sub-section."

Question again proposed, "That those words be there inserted in the Bill." Debate resumed.

Mr. G. LOCKER-LAMPSON

I was pointing out to the House that this Amendment was supported by a joint committee, and a very important body indeed. I may now read a statement in the "British Medical Journal" showing that the British Medical Association are also in favour of this Amendment. In its issue of the 12th of this month, the "British Medical Journal" says in a leading article:— Both on public and professional grounds, it appears to be essential that no obstacle should be put in the way of placing at the disposal of the insured the services of medical men whose practices lie among the working classes. They go on to say:— Full opportunity should be taken on Clause 15, Sub-section (3). As I have already pointed out, the provision under the Sub-section is merely to obtain the permission of the insurance committee to allow private arrangements to be made. That is to say, unless the insurance committee agrees, the member of a society is not able to make private arrangements outside the panel. I do submit that it is enormously important, and, as the Chancellor of the Exchequer has told us, faith is nine points of all healing, that the insured person should really have confidence in his doctor. I believe it is one of the most important parts of pathological treatment that you should really have confidence in the doctor attending you, and confidence cannot possibly exist if you are forced to accept the services of a doctor whom you do not want and whom you do not believe in. I really think I have said enough on the point, and I trust that the Government will do their best to accept the Amendment. I cannot see any reason why they should not do so. I make it quite clear in the Amendment that if a person wants to make private arrangements outside the panel he is to be made to understand exactly what the consequences will be. If he makes a private arrangement outside the panel he, of course, stands the risk of receiving the sum of money which he gets under the Act, and of the doctor who is outside the panel asking him for more for the treatment of his particular disease. I mean by that that the doctor outside the panel may say, "I will take the fee which you have got under the principal Act, but you must pay so much extra in addition." I made that quite plain in the Amendment, and, therefore, I really do not, see that there is anything in the way of the Government accepting this Amendment. The approved societies want it and the British Medical Association have no objection to it, and I believe if hon. Members in this House really voted, as I hope they will to-night, according to their consciences, there would not be the slightest doubt whatever of this Amendment being passed into law.

Sir ROBERT FINLAY

I consider this a very important Amendment, and I hope after what has been said by my hon. Friend that the Government will give it their most favourable consideration. A great deal has been said about the advantage to the patient of choosing the medical man in whom he happens to have confidence. In addition to what has been recalled to the memory of the House by the hon. Member who moved, I desire to draw attention to Sub-section (3) of Section 15 of the principal Act, where it is provided that the regulations made by the Insurance Commissioners shall authorise the insurance committee by which medical benefit is administered to require certain persons and to allow any other person in lieu of receiving medical benefit under such arrangements as aforesaid to make their own arrangements for receiving attendance and treatment, including medicine and appliances, and in such cases the Committee shall contribute from the funds a proportionate sum in respect of medical attendance which the insured person under such circumstances would get for himself. Why is it that that is to so great an extent a dead letter? The Insurance Commissioners have, I believe, authorised the insurance committees to make such arrangements, and why is it that arrangements of that kind have been made in so few cases? I think that some explanation is desirable upon that point, and, inasmuch as freedom of choice has not been given to insured persons to anything like the extent the country was led to expect, I hope that the House will see its way to adopt the Amendment of my hon. Friend, which ensures that the intention which Parliament expressed in that Sub-section will be carried into effect. I consider this a most important Amendment, and I earnestly hope that we shall hear from the Treasury Bench that effect will be given to it.

Mr. MASTERMAN

I thank the hon. Gentleman for the way in which he has moved this Amendment. He did so on strictly business lines. He realised that all the old complaints as to what was said and what was not said were appropriate in their right position, but are not appropriate to the Report stage of this Bill. I wish the hon. Gentleman had seen his way to doing what we agreed to do on the Committee stage of the Bill—that is, that all Amendments as to the relations between the insurance committees and approved societies on the one hand, and the medical profession on the other, should be withdrawn, and that those who sought to obtain further Amendments desired by the doctors should withdraw at this time their suggestions, on the condition that all those who sought Amendments which might put the doctors in a worse position, or which the doctors might think would put them in a worse position, should also withdraw their proposals. Curiously enough, the hon. Gentleman occupies the position of proposing both those kinds of Amendments, and one of them he has put on the. Paper again on this Report stage and the other he has not. So, while on the one hand he is now advancing an Amendment, which I have no doubt will be supported by a considerable bulk of the medical profession, he is not advancing an Amendment which drove the medical profession into a special arrangement at their last conference to, alter their business in order to pass resolutions repudiating that Amendment altogether. The carrying of the one, as I think, would carry as an inevitable consequence the carrying of the other. If the one was carried, I think the other ought to be carried also.

Mr. RAWLINSON

Which Amendment is it?

Mr. MASTERMAN

The hon. Gentle-man who moved this Amendment proposed an Amendment allowing the friendly societies to make their own arrangements with the insured persons who were their own members with certain doctors, such doctors as they could get to become whole time servants under the societies. The doctors, as I think everyone knows, at once entered into a very considerable agitation in order to prevent that Amendment being carried.

Mr. G. LOCKER-LAMPSON

As the hon. Gentleman has mentioned that Amendment, may I say it contained a contracting out Clause which would have probably the same effect as the Amendment I now propose.

Mr. MASTERMAN

In that case I cannot quite understand why the whole British Medical Association opposed the Amendment. There is not the slightest doubt, and I do not want to misrepresent the doctors, of what they think of that particular Amendment of the hon. Gentleman. Apart from such questions as that, what does this Amendment mean? It means by the use of an autocratic power from above, to break through the discretion given to the insurance committees. The hon. Gentleman said his Amendment had the support of the approved societies. I doubt if it has of the actual rank and file. The insurance committee is the most democratic body existing in this country more than guardians or borough councils or any other body, and we are keeping them democratic by a Clause later on in this Bill which allows opportunity for poor men to serve on those committees. Three-fifths of each of those committees, that is a clear majority, are appointed by approved societies, and their sole object in being on the insurance committees must be to look after the interests of the approved societies, including all the members of the approved societies. These insurance committees have absolutely unfettered discretion to give free choice of doctor outside the panel system to any member who chooses to ask for it. You are going to fake away that discretion. You will smash the insurance committees, you will lose the panel doctors, who have come in to the number of 18,000 to work the panel system, and you will violate the principle which the insurance committees were set up to carry out—that of local autonomy suited to the needs of the particular districts which they represent. Hon. Members seem still to wonder why the insurance committees have a difficulty in giving this free choice. I cannot tell anyone at present to what extent they exercise that discretion. Many of them have exercised it on a comparatively large scale; some on a comparatively small scale. They have to consider what we here and the Insurance Commissioners have not to consider, and that is how they can provide an efficient medical service for all the people in their locality. As I have repeated again and again, and have never been answered, if the conditions are such that persons who want to contract out with their own doctors are persons of healthier lives than those persons who do not want to contract out, the insurance committees have no moral right to see all those healthy lives going out from the panel system, at the same time leaving all the bad lives to be treated at the same cost by the panel doctors.

That is really the vital position. It is because the insurance committees must of necessity have that discretion that I ask the House not to smash it up by such an Amendment as this. I think that this question will settle itself if hon. Members are not too impatient. A committee is to be appointed to consider certain aspects of the Question, and I believe that if time is given—we have had only six months since the great fight with the doctors—hon. Gentlemen will find that the great majority of the doctors in any possible area will come in either fully under the panel system or for a limited number of patients so long as there is an average number, or that in the few exceptional cases which remain the insurance committees, without any fear as to what will happen to the general bulk of their insured persons will be able to allow insured persons to make their own arrangements. I am quite sure that if this Amendment is carried the whole controversy, which we hope is dying down, will flare up again, and we shall be in. the midst of a controversy, not between the Insurance Commission and the doctors or the insured persons, but between the insured persons themselves and the committee which represent them on the one hand and the medical profession on the other—a controversy above all things to be avoided. Those who speak for the medical profession cannot have it both ways. If we are to make it compulsory, without any discretion in the insurance committees, that anyone is to be allowed to have medical attendance outside the panel system, they must be allowed to choose any medical treatment they like outside the panel system. Hon. Members below the Gangway had an Amendment on the Paper suggesting that we should compel insurance committees to allow insured persons to choose institutes, medical clubs, or any of the various kinds of arrangements which treat not only insured persons, but women and children as well—the arrangements which we sanctioned under Section 15 (3), but not under Section 15 (4). In large parts of the country the controversy now developing is not whether persons will be allowed to have free choice of doctor, which means the institute, but the medical profession them-selves are asking us not to allow this free choice. If you have free choice of doctor outside the panel system you must have free choice of institute as well, and there inevitably follows free choice of friendly society doctors.

That is why I urge the hon. Member and his Friends not to carry this question further. If the Amendment were carried it would mean the destruction of the panel system. It would mean the friendly societies trying to reassert the old friendly society system, which may be quite right, but out of which the House, by a large majority, helped the doctors under the implied agreement that the doctors in their turn would come in and help us under the panel system. I would appeal to the House to leave the discretion as at present to the insurance committees, and to consider the situation as it develops between the doctors and the insured persons during the coming time. We shall then have the report of the committee which is to be appointed to consider whether insured persons are receiving a satisfactory medical service; whether there are any suggestions by which they can receive a more satisfactory medical service, and what relation the present medical service has to any excessive sickness which exists. When that Committee has reported and that time has elapsed, if the panel system with possibly contracting out permitted by the insurance committees is not working satisfactorily, then, and not now, will be the time to make such proposals as are made by the hon. Gentleman.

Mr. LYNCH

I desire to support the Secretary to the Treasury. If this Amendment is carried the whole Insurance Act will be placed in jeopardy. It will be familiar to all that when the Insurance Act passed there was great doubt whether it could be made workable. The great majority of the doctors believed that the whole status of their profession had been lowered by the passing of that Act, but with a magnanimity which I think was not fully recognised, they decided to give the Act a fair trial. The panel system was not very palatable to them at the beginning, but they are now giving it a fair trial. If they are to have all the existing disadvantages of the panel system, it is unfair to them to introduce in this Amending Bill still further disadvantages, which would make their position almost intolerable. After the Act has been in operation for some considerable time it may be necessary to revise the position of the medical profession with respect to the panel system and the whole working of the Act, but I seriously ask the House not to entertain this Amendment which would again place the whole Act in jeopardy.

Sir P. MAGNUS

The hon. Gentleman who has just sat down has told us that if this Amendment is carried the whole Insurance Act will be placed in jeopardy. That is a remark which has also fallen from the Secretary to the Treasury. Of course, all—

Mr. MASTERMAN

I do not want to be misreported as having said that.

Sir P. MAGNUS

What the hon. and right hon. Gentlemen pointed out only goes to show how unworkable the Insurance Act is in its present state, and what radical and drastic Amendments are required in order to make it a measure adapted to the needs of the people. The whole of the hon. Member's speech went to show that the Act, even with the Amendments which are introduced in this Bill, still falls far short of what we have reason to expect from the speeches that were made in this House and throughout the country in regard to the advantages which the working classes and the people generally would derive from the Act. I think it was the right hon. Gentleman the Secretary to the Treasury whose whole speech I have not had the pleasure of hearing—who said that we on this side of the House were speaking for the medical profession. I want to say in regard to this Amendment that we are not speaking for the medical profession, but distinctly for the insured persons. It is not the medical profession who cry out for a choice of doctors; it is the insured persons. They desire to choose their doctor for the very substantial reasons which were given by the Chancellor of the Exchequer in the passages quoted by the hon. Member who has moved this Amendment. What is the position which the Government at present take up in regard to this important question of the choice of doctors? We know quite well that over and over again—I am not going to repeat any of the quotations referred to by my hon. Friend—that the Chancellor of the Exchequer pointed out that the Act would allow choice of doctors. He further stated that medical benefit could not be advantageously given unless the insured person had the opportunity of the choice of doctor. What now is the position of the Government? It is that choice of doctors is absolutely impossible. "If," they say, "you have choice of doctors the Act will be in jeopardy," and therefore you cannot expect choice of doctors. I think I must leave it in that position. If this Act is to be enforced under the conditions imposed there can be no choice of doctors, and everything the Chancellor of the Exchequer has said, and the Chancellor's promises, cannot be carried into effect. I am afraid that is not a happy position in which the Members of the Treasury Bench now find themselves; but I think they will realise, as we have realised from the beginning, that this Act requires drastic amendment from its very foundation in order that it may be a workable measure and calculated to improve the health of the country.

Mr. WORTHINGTON-EVANS

I am going to support the Amendment which has been moved by my hon. Friend for the reason that it gives the insured person a greater freedom—a freedom which is necessary, I believe, if he is to have the benefits which are supposed to be secured to him under the Act. The right hon. Gentleman the Secretary to the Treasury seemed to blame my hon. Friend the Member for Salisbury for having brought forward this Amendment. He seemed to think that because in Committee my hon. Friend had moved two Amendments, both of which he believed to be in the interests of the insured person, one of which apparently was liked by the doctors whilst the other was disliked by them—that that balance having been maintained in Committee it also ought to be maintained on Report—that he ought not to move any Amendment on the question of free choice. I cannot myself see what Amendments in Committee have to do with the immediate position that is before the House. The immediate question before the House is this: Has the insured person to have free choice of doctor, or has he not to have free choice of doctor? The Secretary to the Treasury has answered that by saying: "Oh, no, we cannot give free choice of doctor: if we chi it will break down the Act: if we do, we drive a bureaucratic power through the democratic insurance committees and we prevent them exercising their discretion." The case of the right hon. Gentleman is that it is impossible to do what, when the original Bill was going through, the Chancellor of the Exchequer so constantly told Members of this House, and told the insured public at White fields, the Opera House, and many other places Although the right hon. Gentleman opposite does not like it, I am going to remind the House what his right hon. colleague did say when this question was being discussed three years ago, and when the Bill was in Committee. The Chancellor of the Exchequer said:— Though free choice of doctors will, to some extent increase the charge, I personally have always been in favour of it. After all confidence in your doctor is essential. No Mall who can afford to do otherwise would have a doctor prescribe for him by any club or society. He wants his own doctor to doctor him the doctor in whom he has full confidence. He wanted it two years ago, when the Chancellor of the Exchequer promised it. He wants it to-day and the Secretary to the Treasury replies, "Oh", it is impossible: if so, you are going to alter the factor of discretion of the insurance com- mittees." Just for a moment see what is the case of the Insurance Committees in practice! In theory they have the right to say to each individual who applies, "Oh, yes, you have made out a case which entitles you to choose your own doctor from amongst the doctors who are not on the panel, and, therefore, we will let you have what you ask for, and give you 8s. 6d. or 9s. towards the cost of your medical benefit." That is their theoretical discretion. How is it possible, either in London, Middlesex, Lancashire, or in many other places where there are a large number of insured persons, for any insurance committee to really exercise the discretion of treating each case on its merits? I know they are not doing it. They are refusing the people in batches, for the simple reason that it is quite impossible for them to take the case on its merit and inquire into it and see whether or not there is some special reason which requires that a certain individual shall be entitled to choose his own doctor. Surely our business is not to set, up an official body which shall inquire into the circumstances of every insured person's case: Surely it is for us to trust the insured person to exercise his discretion to-his own best advantage, either by taking a panel doctor or by using a medical institute. I quite agree, if a free choice of doctor is allowed, it must be allowed in favour of medical institutes, provided that the medical institute is-carrying on a practice which does give sufficient and proper medical benefit. With that proviso I quite agree, if you do allow a free choice, you must allow the insured person an unfettered judgment in who is to treat him when he is ill.

I believe myself that the discretion that is placed in the insurance committees is very pretty in theory, but that in practice it actually breaks down. Take the Cumberland Insurance Committee. In February last—I have not the information up-to-date —they refused, without any inquiry at all, all applicants leave for power to make their own arrangement. They did not exercise any discretion at all. They simply refused all applications for the right to-select a doctor who was not on the panel. In Wisbech and in Chatteris in February last, the insured person had no choice and was obliged to take the doctor who was sent down, originally by the Insurance Commissioners, who was adopted by the local insurance committee, paid a salary, and turned into a full-time man. The locally insured person had to take that doctor's service whether he wished it or not. Application for power to make a free choice or to contract out was absolutely declined without considering the merits of the case—and there are cases which have merits! I have had dozens of letters from people who have really thought that they had a right to choose their own doctors. There is a case that I have in mind, that of a man who had some hurt in his limbs which prevented him from walking. He had been attended for eight years by a doctor who did not go on the panel. He applied for permission to continue to be treated by that doctor. He was refused and was referred to the panel doctor. His doctor had treated him for eight years and presumably knew more about him. Why on earth in a case like that, if the doctor is willing to continue the treatment, should that man be sent to a panel doctor whom he had never seen. I quite admit that the panel doctor might be the better doctor, but why should the man be forced to change his medical attendant because the insurance committee were too busy to consider the details of his claim, and that is not the only case. There are hundreds of similar cases. The right hon. Gentleman the Secretary to the Treasury said that if this Amendment were accepted we should run the risk of losing the services of the panel doctors. Surely that cannot be a serious statement. What risk is there of losing the services of the panel doctors because men are entitled to choose either panel doctors or doctors off the panels? Surely the free choice would increase the number of doctors who would be willing to look after insured patients. You would get a larger area of choice and a larger number of men coming to the service of the insured people. It. seems to me that, far from running any risk of hurting the medical service, you would be improving it, not only by increasing the number of men who would serve the insured people, but also by preventing a division of the profession into two classes, panel doctors and non-panel doctors, and you would raise the tone of the medical service and put the insured persons much more upon the level of those who do not have to rely on contract practices for their medical attendance.

Mr. JONATHAN SAMUEL

I do not desire to give a silent vote upon this matter, because it is one that really affects the constituency I have the honour to represent, perhaps almost more than any other in the country, because we have a very large number of insured persons who are anxious to take advantage of Subsection (3) of Section 15, and who are refused by the insurance committee of the county, acting, I believe, under instructions from the Insurance Commissioners. The Government must deal with this question one way or another; there is no doubt about that, because in the North of England we have a large number of well-paid workmen and others who are anxious to have their own medical men. They do not and will not go to the panel doctors, and you really cannot compel them. I am told that something like over 2,000 men have signed their cards and applied for exemption and leave to contract out under Section 15, but in every case they have been refused. We heard it stated distinctly, and it was always understood, and we always argued and explained this Act in that light, that there was a free choice of doctors, and when these men and women —a very large number of them teachers—have applied to contract out, and were ready to make their own arrangements with their own doctors, in every case, without exception, they were refused. I have scores and scores of cases brought to my own knowledge, appealing to me as Member for the borough to try and have this matter put right, but in every case the county committee has refused to give them the right to contract out.

I think we ought to have some reason why it is that this right is denied these persons. If the Government is not prepared to state the reason why, then I think it must be this: There is no doubt, and there is no use denying it, that there was a fight between the Commissioners and the doctors as to whether the doctors would go on the panel or not. That fight is over, I believe, to a great extent. We have a very large number of doctors in my own town on the panel, but there are a very large number of doctors who are not on the panel, men who have not done what is called contract practice in the past. These men have attended hundreds and thousands of these insured persons who are desirous of keeping their own doctors. I have gone so far as to bring the doctors to the Insurance Commissioners, but up to the present time there has been no settlement and I think we are entitled when there is such a large demand in many towns in the North of England to have this matter put right. The demand is general. I know that in the county of Durham there has been a very large number of applications for free choice of doctors, quite apart from the town in which I live. Therefore, I contend if the Government are not prepared to insist that regulations of the Insurance Commissioners shall be made so that these persons may claim the right under Sub-section (3) of Section 15, some other steps ought to be taken to meet their case.

Mr. J. WARD

That has already been dealt with.

Mr. J. SAMUEL

I do not very often speak, and I think I have a right to place a case like this before the House, and to press it upon the Government as I did in Committee upstairs.

Mr. J. WARD

I merely observed that the hon. Member would have heard that point answered had he been here a moment ago.

Mr. J. SAMUEL

I am sorry I was not here., but I know it was not answered upstairs, and when I am requested by hundreds of my own Constituents to press this point upon the Government, I think I have a right to do so. I have gone so far as to try to bring the parties together, and I think I now have a right to place the case before the House of Commons, even if it delays business for a short time. I press upon the Government that they should instruct the Insurance Commissioners that where people who are insured persons claim the right to contract out, and where they are prepared under Sub-section (3) of Section 15 to take the money in lieu of medical benefit and to make their own arrangements with their own doctors, to meet these people once and for all and tell them they are prepared to deal with this matter either through regulations or by an Amendment such as is before the House at the present moment. I do not say that that Amendment is a satisfactory one. I prefer the Sub-section in the Act as it stands. If that Sub-section were carried out, and the regulations of the Commissioners were not as onerous as they are, we should not have this conflict of interest in our boroughs and towns with regard to medical benefits.

Sir JOHN SPEAR

I desire to support this Amendment. If a doctor before he goes on the panel has the right to choose whether he will attend insured persons or not, surely an insured person ought to be equally at liberty to secure the services of a medical man who is not on the panel! When the Bill was passing through the House it was declared over and over again that the insured person would have the choice of his own doctor. Unless this Amendment is carried that promise cannot be fulfilled. We all feel that it is important that a person who is ill should be able to choose the doctor in whom he has the most confidence, and that cannot be secured unless this Amendment is adopted.

Major MORRISON-BELL

I cannot quite follow the arguments of the Financial Secretary to the Treasury or those used by the hon. Member below the Gangway when they say that the adoption of this Clause would wreck the Bill. After all, it is open to an insured person to contract out and choose his own doctor, but under the Bill only a small number will be able to exercise that right. To say that this is a question which will affect 18,000 doctors is pressing that objection much too far. It is well known that in doctoring faith in the doctor has a great deal to do with the matter, and I can quite conceive that the curing of a sick person might be put back owing to the fact that he felt a grievance because he could not choose his own doctor. If a sick man is told that he must have a doctor on the panel, and not one of his own free choice, it might retard his recovery altogether. If it is really true that this Clause is going to wreck the whole Bill, then we might have to consider whether it is worth carrying this measure at all. If it is only intended to deal with a small percentage of exceptions and give this right which may mean so much to the sick person, I cannot see why the Government is opposing this proposal so strongly. If the hon. Member carries his proposal to a Division I hope we shall receive a strong support from the other side of the House in trying to defeat the Financial Secretary to the Treasury on this point.

Mr. RAWLINSON

I happen to know one or two cases in point where an injustice has been done under this Act. They were persons who were anxious to continue the attendance of the doctors who had attended them before the Insurance Act, and they were not able to have this privilege, and they had to call in fresh doctors. Of course I do not say a word against those doctors. I know some of them are hopelessly over- worked, and have not time to give full attention to all the cases sent to them. The Under-Secretary made an attack upon my hon. Friend, and stated that he moved some objectionable Clause in the Committee upstairs. I wish to place before the Committee the absolutely simple point that these poeple who have been attended by certain doctors before the Act was passed should be allowed under this Bill to have the right to say, "I do not wish to have a panel doctor, but I will take a small sum of money and go to the doctor I have had before." I think that is reasonable. The right hon. Gentleman says that we must not pass this Amendment because it would smash up the medical benefit under this Bill, and the hon. Member below the Gangway said that, we should wreck the Bill by this Amendment.

Mr. LYNCH

I am sure the hon. Member does not wish to misrepresent me. I said that this Amendment would place the whole Act in jeopardy on account of the agitation it would be sure to arouse amongst the medical profession.

Mr. RAWLINSON

That means that there are so many people under this Act dissatisfied with the attendance of panel doctors that they would make use of this Amendment to such an extent that it would make it impossible for the panel doctors to continue. That is something like the case of a railway company who took off a refreshment car because there were so many people wanted to use it. Here we have a statement from the Government, that if this Amendment were carried such is the feeling of dissatisfaction with the panel doctors, among insured persons, that it would jeopardise the whole Act and smash up medical benefit. I was perfectly amazed that the right hon. Gentleman had nothing stronger than that to say against this Amendment. Surely this is a simple Amendment which the Government ought to accept. It is simply a proposal that the people who have paid their insurance money, and who are offered the services of a panel doctor, who may be overworked or who may be distasteful to them, should be allowed to have the doctor who has previously attended them, and pay him out of their own pockets. The right hon. Gentleman says that this would be monstrously unfair, because all the good lives would go to doctors who were not on the panel and only the bad lives would go to the panel doctors. I do not think it would have that effect, because, as a rule, it is the bad lives who are anxious to stick to their own doctors. A patient does get attached to a certain doctor, although he may not have been thoroughly successful in curing him. For these reasons I shall support the Amendment, and I hope the Government will meet this point and do what I am perfectly certain is a thing wished for by a very large number of people in this country at the present time.

Mr. HAMILTON

I think that a good deal of that which we heard earlier in the day about the breaking of contracts applies to this Amendment. It appears to me that the House of Commons has arranged and directed that these people who are compulsorily insured shall have the choice of doctor. That was made perfectly clear in the Act, and it was made still clearer by the speeches of the Chancellor of the Exchequer in the country. We have undertaken to give the insured person free choice of doctor, and we ought to stick to that point. I do not think that the medical profession are opposed to this Amendment; indeed, from what I know of them, they are keenly in favour of it. I do not think that you would have any strike of doctors, I think that they would support the House of Commons if we gave this free choice of doctor. This is really a democratic matter. It is the working classes of this country who want the right which has been promised by the Chancellor of the Exchequer. I notice that none of the hon. Members below the Gangway have taken any part in this Debate, and I should like to hear what the leader of that party has to say. I am convinced that the working classes of this country look to the representatives of labour they have returned to this House to specially watch their interests, and my vote in this matter will be very largely guided by what the Leader of the Labour party has to say on the subject. At the present, moment I am convinced that the working men of the country want this Amendment, and, unless the Leader of the Labour party can convince me the other way, I shall vote for it.

Mr. DAWES

I fail entirely to understand the object of this Amendment, because it seems to me that it does not carry the matter in the least bit further than Section 15, Sub-section (3) of the Act. That gives insurance committees full discretion to do what they think fit, subject, of course, to certain circumstances warranting persons being allowed to make their own arrangements. The last speaker said that this was really a democratic Amendment. Let us see who really are the people who have the discretion. Who are the insurance committees to whom this discretion is permitted? They are not Government officials. They are not persons selected by the doctors, or by the Government, or by anybody else. Three-fifths of them are people democratically elected, people representing insured persons who have in the last two or three months been actually elected by a democratic vote, and I believe by proportional representation of which hon. Gentlemen opposite are so very fond. Those are the people who have the discretion. My hon. Friend the Member for Stockton (Mr. J. Samuel) said that he believed instructions were sent out by the Insurance Commissioners to do this or that. No such instructions at all have been given in the county of London, and I cannot understand that the insurance Commissioners would interfere in a matter with which they have absolutely no concern, and as to which the insurance committees could tell them to mind their own business.

Mr. J. SAMUEL

The Sub-section itself says that it is subject to regulations made by the Insurance Commissioners, and we have been given to understand that those regulations have been sent out.

Mr. DAWES

The hon. Member is entirely mistaken. No regulations have been issued fettering the discretion of the insurance committee. We have had no trouble in London except at the beginning when we had a circular sent out by a few members of the British Medical Association, and it has since been admitted to me that it was done intentionally with the idea of breaking down the medical system. That was absolutely admitted to me by one of the gentlemen who sent out the circular. The last statistics of the hon. Member for Colchester (Mr. Worthington-Evans) were apparently in February, which, of course, was when this agitation was at its highest. Since then every application has been considered on its merits. I, myself, had certain lines laid down by my committee, and I this morning went through forty or fifty applications, and there were only two which had to be refused. When you get a case, such as that quoted by the hon. Member for Colchester, where a person has been treated for eight years, it is granted as a matter of course, and I believe that it would be granted by any insurance committee. I believe that even the Stockton Committee or the committee for the county of Durham would grant it. Such cases are the very cases which come under Section 15. I do not believe that the trouble exists at all or that the Amendment is of the least use, and, if it were carried, it would stir up the whole of the agitation again.

Mr. FORSTER

I think that it would be a very good thing if the Amendment were put in the Bill so that definite directions might be given to the insurance committees as to the way in which the House, and I think the insured community, would wish them to exercise the discretion which they have now. The hon. Gentleman who has just sat down, and who is chairman of the London Insurance Committee, tells us that the Insurance Commissioners have not sought in any way to affect the discretion of the insurance committees. Of course, the Insurance Commissioners have not sought to influence the discretion of the committees. That was done by the Chancellor of the Exchequer. Just when the negotiations with the medical profession were hanging in the balance the Chancellor of the Exchequer made a speech in which he made it clear that the Government would not allow insurance committees to use their discretion in this matter, and it is because the insurance committees have acted as the very faithful servants of the Chancellor of the Exchequer that so much of this difficulty has arisen. The Insurance Commissioners just about that time, recognising the right of the insured community to the free choice of doctor, as well as the right of the insurance committees to allow that free choice, issued to insured persons the pink ticket, at the bottom of which was printed a notice as follows:— To doctors and insured persons.— If you are arranging with the insurance committee to obtain your treatment from a doctor not on the list, and wish to claim a contribution towards the cost of treatment, you must send this ticket to the insurance committee. That shows perfectly clearly that the Insurance Commissioners recognise the right of insured people to exercise that choice which the Chancellor of the Exchequer promised them. I have been tempted to look back upon the history of this question by what has fallen from the hon. Member, but I do not wish to be unduly controversial. I want to give my view with reference to the necessity for passing the Amendments proposed by my hon. Friend. He has said that he does not wish to break down the panel system, but that he wishes to supplement it. We are told by the Government that the panel system is securely established. We are told that they have got upwards of 18,000 doctors on the panel at the present time. We were told by the Chancellor of the Exchequer some time ago that if he could only get the services of 10,000 doctors he could work the Act under the panel system. He has therefore now got nearly double the number of doctors he declared to be essential. If you have really got the panel system firmly established as you say that you have, then you will not be running any risk in giving the insured person the right of choosing his doctor. I know that the hon. Member for Stockton (Mr. J. Samuel) speaks with great authority in this matter and has a great knowledge of the real wishes of the people who live in his constituency. I know from my own experience the real wishes of a great many of the working classes in my own Constituency. I know, we all know, that it used to be even under the old friendly society practice quite a common occurrence for friendly society members to pay out of their own pockets the fees of their own doctors, although they were entitled by the subscriptions they paid to their society to the contract service of the society doctor. You have not in the least removed the objection which is sincerely felt by a great body of the working-class population in this country to contract medical service. You have not removed that simply by passing the Act. The objection to contract service still remains. I believe it is largely at the bottom of what appears to be the neglect of a great many people to select their doctor on the panel at the moment. Evidently they do not intend to have a panel doctor. You compel them to subscribe for one, but you cannot make them go to one. They are driven, when ill, to call in a medical man of their own free choice, because the insurance committees exercise their discretion in the way pointed out by hon. Gentlemen opposite, and, consequently, these people are denied the right which I say the Act gives them, and which they ought to have.

Dr. ADDISON

What is the meaning of the various Amendments on this point which have been put forward? The first proposal was that you should inaugurate a system in which you have no choice at all. This Amendment proposes there should be indiscriminate choice, and the next Amendment suggests it shall be limited to 2,500. They are absolutely incompatible, and I want to find out what system the Opposition really want. That is the whole question before us. It was the question in February. What was the reason why the insurance committees declined the wholesale applications from people who wanted to make their own arrangements? The object of the applications was to break down the system, and it would have been broken down. There is no question about that. The powers which it is proposed to confer under this Amendment are already in the Act, in Section 15, Sub-section (3), and, as the chairman of the London committee has explained, they are now being carried out in all cases where they are really needed. Insurance committees did not carry them out in February because of the campaign to defeat the whole system and take away the foundation stone. Now this discretion on the part of insurance committees is being largely exercised.

But I have no doubt that, if we introduce this Amendment into the Bill it will only have the effect of stirring up strife again, and that I am inclined to think is the main purpose of the Opposition. It is of no use the hon. Member for the Wilton Division to shake his head. It is the inevitable effect of an Amendment of this kind. The powers are already in the Bill, and there can be no other result of introducing an Amendment of this kind than to lead to another wholesale agitation against the panel system. Hon. Members opposite are incurring a responsibility which some day they will regret. They tell us not to draw this distinction between panel doctors and non-panel doctors. But who has drawn the distinction? It has arisen because a most malicious campaign was engineered in January and February to depreciate the qualities of the men who went on the panel. We have had the hon. Member for Glasgow University talking to-day about "mere panel doctors," but I know for a fact that in a large number of counties every man in general practice is on the panel. This is a vast campaign to detract from the very large number of men on the panel. That campaign has been dying down. I want it to die down. This Amendment will only resuscitate the whole thing, and I hope the House will not make itself a party to putting into the Bill words which will simply reopen these miserable controversies. We have already in the Bill what is proposed in this Amendment, and I believe that the insurance committees will exercise the power with wisdom and discretion.

Mr. C. BATHURST

I should not have risen to speak on the Amendment had the hon. Member opposite not suggested that it was put down deliberately in order to stir up strife. I should like to say that a very large number of the organisations of approved societies have requested this House to support this Amendment, and, in addition to that, the Medical Association, through its journal, has also invited support of an Amendment of this nature. I am a member of an insurance committee and I resent the suggestion which has been made on the other side of the House that insurance committees would object to greater latitude being given to them in the emphatic way such an Amendment suggests.

Dr. ADDISON

This Amendment does not give any greater latitude whatever.

Mr. C. BATHURST

I do not care how you put it, but I suggest that this would emphasise what we desire to see—it would emphasise the latitude which already exists and which enables insurance committees, if they so choose, to allow a person to obtain a privilege which is specifically given him under the principal Act. Three-fifths of the insurance committees are representative of approved societies. Speaking for my own insurance committee, I am quite satisfied that two-thirds will be emphatically unanimously in favour of this Amendment. Why is it that insurance committees have taken this line all over the country? It is because they do not want to appear to be contumacious towards the Government. They do not want to appear to be inspired by party spirit in their administration. That is the sole reason why they have not oiled the wheels and have not given a greater number of persons desiring to have separate medical attendance the opportunity of obtaining what the Act has provided for them. I am certain a large number of the provincial insurance committees, so far from considering that it would upset their administration, would welcome such a Clause as this. In fact, they would be enabled thereby, especially if the Government gave their assent to this Amendment, to carry out what they desire; they only want the assurance that the Government and the Insurance Commissioners are not opposed to the line they would like to adopt.

Dr. CHAPPLE

If this Amendment were carried, it would pull down the whole superstructure of the Act about our heads. It is essential that each doctor should be loyal to the approved society as well as to his patients, and it is necessary, too, that he should be under a certain amount of control. It is claimed that this is a democratic Amendment. The principle of democracy is that those who pay should control. Now approved societies pay the fees and they should, therefore, exercise control. It is necessary that doctors should come under a certain amount of discipline. If a doctor does not consider the interests of the society and his duty towards it as well as his duty to his patients, it will be quite possible for him to make rules and regulations of his own. He might prescribe expensive medicines without regard to the funds of the society. He could also discriminate between panel patients and ordinary private patients, and he could make rules and regulations by which the private patients should attend at certain hours and the panel patients be relegated to less convenient hours. If he has a vested interest in the society you will find he will consider the interests of the society as well as of his patients.

Mr. HAMILTON

He is not paid by the societies.

Dr. CHAPPLE

If you allow him to take patients outside all disciplinary control he may indulge his pet patients. There are doctors to-day who are taking extra fees; they are getting the ordinary panel fees, and the patients are arranging to provide an additional fee every year, thus supplementing the ordinary fee. How are you going to keep control over the doctors, seeing that human nature is what it is, if they have no sense of loyalty to the approved societies themselves? Every doctor can be on the panel if he likes. The campaign against panel doctors has tended to divide the doctors into two great classes—those who are panel doctors and those who are not, and to show that those who are not panel doctors are more skilful and able than those who are. That is a false discrimination. You will find that doctors will come on to the panel more and more if they think they cannot get patients unless they do. An actuary I know went through the books of a doctor who was on the panel and he found that the doctor was getting 16s. per visit for all the panel patients he visited. From the number he had on the panel and the amount he got at the end of each quarter it worked out at 16s. per visit. When doctors find that out, you will find them coming on the panel. If you allow them to make private arrangements with patients you will destroy that kind of disciplinary control which is necessary for the successful working of the Act.

Sir H. CRAIK

I suppose the two speeches to which we have just listened from the hon. Member for Hoxton (Dr. Addison) and the hon. Member for Stirlingshire (Dr. Chapple) are intended as the model of the spirit which will drop all hostility and spread peace generally among the various interests. I wonder what the attitude of the medical profession can be expected to be in face of such denunciations as those of the hon. Member for Hoxton. "A base conspiracy" were the words he used.

Dr. ADDISON rose—

Sir H. CRAIK

I ant not going to give way. The hon. Member is fond of getting up to make a violent attack on the Members of his own profession, and then of interrupting those who follow him. The hon. Member has thought it not unworthy of his position here to make accusations against members of his own profession which I do not hesitate to say are libellous. As my hon. Friend pointed out, it is not merely in the interests of the doctors and professional interests that a free choice of doctors is insisted upon, but it is in the interests of the ordinary insured persons and of the friendly societies themselves. If the hon. Member will allow me to say so, of the two royalties—loyalty to his Government or loyalty to his profession—he has chosen the first rather than the second. We now see the spirit with which the supporters of the Government treat the profession. We are now told plainly and straightforwardly that they are to be under the discipline of the friendly societies that they are not to use expensive drugs which they may think necessary for their patients, because the friendly societies might object to it. This is one instance in which the interests of the profession are the interests of the country at large and of the insured persons. The profession is standing up for what they consider to be an essential point, the choice by the patient of a doctor, which is the only foundation of that confidence between a patient and doctor, which is the first condition of success. I do not attach significance to the various sarcasms which the hon. Member for Perth (Mr. Whyte) and the hon. Member for North-West Lanarkshire (Mr. Pringle) have addressed to myself. I do not withdraw a single word of the speech I made, and I am perfectly ready to answer to any of my own Constituents quite as much as the hon. Member for North-West. Lanarkshire or the hon. Member for Perth.

Mr. J. HOGGE

You never meet them.

Sir H. CRAIK

I meet them a good deal oftener than some Members think, and I am in contact with them in a way perhaps hon. Members do not know. I know their wishes, and that they are not likely to misunderstand the words I used when I said that a large number of the respectable middle-classes of this country, however well they may think of the panel doctor, are not prepared to take hint because he is on the panel. They wish to choose their own doctor, however respectable the panel doctor may be, because they select him for themselves, and there is sympathy between them. In supporting, as I do most heartily, the Amendment of the hon. Member for Salisbury (Mr. G. Locker-Lampson) I am convinced that I am acting not only in the interests of one profession, but in the interests of the health of the community generally, and in the interests of the insured person to whom it is a privilege which they highly prize and which can only be secured by an Amendment of this kind. The hon. Member for Hoxton told us that the discretion of the local insurance committees is being used. Then what harm is there in the Amendment? If it is being used, why not put in a permissive provision of this kind. Hon. Members opposite know perfectly well that it is not being used as largely as it ought to be, because the insurance committees are acting under the dominating influence of the Commissioners, who are against this plan, and who are inclined to be animated by the feeling to which the hon. Member for Hoxton gave expression, that if you once allow this to be done generally it would break down the foundations of the Bill. Let the Bill take care of itself. We are looking after the interests of the insured persons, the health of the country, and the establishment on a sound basis of the relations between the medical profession and the patients.

Mr. ALBERT SMITH

I desire to give a reason or two why I cannot support the Amendment proposed by hon. Gentlemen opposite. I do not want to question their sincerity in moving the Amendment, and am quite prepared to admit that in a case of this kind it is impossible to make a Bill to the liking of every individual. But if this Amendment is carried, I am convinced that not only will it not improve the Act, but that it will make the administration of the Act worse. Secondly, there is the question of the insurance committees. The Amendment says that the insurance committees are to be satisfied whether applicants should have the right to choose a doctor outside the panel. What is to be the standard of satisfaction; and will every insurance committee have the same standard? I fear that by this Amendment you will set up internal disruption that will do more harm to the individuals concerned than the Act does at the present time. You are going to have a certain number of persons who can satisfy the committee, and other persons who will make applications which will be refused, and who will go back to their societies and want to know the reason why. The whole thing in a very short time would be in a turmoil. The same thing applies to the doctors. You have a certain class of doctors who may be given the privilege of having increased fees for their services, while some of the doctors on the panel may not, and they will want to know the reason why. I do not wish to impute for a moment that the Mover of the Amendment wishes to smash up the panel system, but I am perfectly sure that if there is anything which is calculated to do that, it is the setting up of jealousies between the doctors as to the amount of the fees they are getting. Whether I am right in my opinion or not, I am perfectly convinced that if this Amendment is carried it will do more to smash up the panel system than anything that has been proposed. Could anybody conceive that 14,000,000 of insured persons could be satisfactorily dealt with by any system in the short time that the Act has been in operation? We have to face the fact as it is. The short time the Act has been in operation could not give anybody the best idea as to how medical benefit can be worked on a satisfactory basis, and if we could only get it in efficient working order so as to ascertain where the real difficulties are, and thus find a real remedy for the real defects, that is the only way in which we can do any good in this direction. I know something about the working of the Act from the approved society point of view, and I also know how things are going on with regard to insurance committees, and I am more than afraid that if the Amendment is carried, not only will there be dissension and disruption in the insurance committees, but it will be carried from there to the approved societies, and the same thing will apply amongst doctors, and it will do more harm than it could possibly do good. I hope the House will reject the Amendment.

Mr. MASTERMAN

This has been very elaborately discussed for some considerable time. If controversial matter has been introduced on either side, I regret it. Considering how much we were able to keep aside from controversial matter in Committee and how Gentlemen of all parties helped us in Committee, I suggest that Gentlemen of all parties might abstain from taunts, and controversies on the Report stage of the Bill. I am very grateful to the House for having allowed us to make the progress we have made, but we seem to have come to a sort of hitch on this Amendment. I think the arguments have been fairly presented, and everyone has made up his mind how he is going to vote, and we might now go to a Division. The only point I would make in respect to the hon. Member (Sir H. Craik) is this: I do not think he heard my speech, but those who were unfortunate enough to hear it will recognise that my appeal was for conciliation and for the healing influences of time. We have only had six months' experience, and we could not arrange a system under the present Act which would be satisfactory to all parties.

10.0 P.M

Mr. GWYNNE

I do not think the right hon. Gentleman can have heard the speech of the hon. Member (Dr. Addison), for any thing more provocative we could not well have had. He told us that the Amendment was a base campaign, and all sorts of things which were very undesirable. Therefore, I think the right hon. Gentle- Man's appeal should be directed, in the first instance to his own colleagues. I was interested to hear the remarks of the hon. Member (Mr. Albert Smith). He told us it would be quite impossible to form any scheme which would give satisfaction to 14,000,000 insured persons in regard to medical benefit. I quite agree it will be very difficult to frame any rules which will meet with everybody's satisfaction; but why close the door to alternative schemes? Why not make the scheme as elastic and as wide as we possibly can? It is a most extraordinary argument to come from those who represent the Labour party that everyone is to be brought into one compartment whether he likes it or not, and forced to have a doctor to attend him whether he is the doctor of his choice or not, when he knows perfectly well that even in the old days, when friendly societies could manage their own affairs, many people refused to have the friendly society doctor because they wished to have the doctor of their own choice. We have been referred to former promises of the Chancellor of the Exchequer, and my hon. Friend (Mr. Worthington-Evans) quoted some of his sayings, but I do not think he quoted this one, which is the gist of this Amendment. The Chancellor of the Exchequer, during his Tabernacle

speech, definitely put forward the proposals which are contained in this Amendment. He said:— The first thing to happen is that he will have free medical attendance. He can have the doctor of his own choice.… Does the hon. Gentleman opposite think the panel doctor is necessarily the doctor of his own choice? He knows it is not. He is not obliged to go to Doctor A because there happens to be a majority in the Club which prefers Doctor A. Doctor B has pulled him through before. He says, 'That is the man I put my trust in,' and faith is nine points of belief, spiritual, mental, or physical. What a tine thing it is to get the doctor you want, and to get someone else to pay for it! That is the Government Insurance Bill. I ask the hon. Member opposite if he claims that in opposing this Amendment he is doing the best he can to give the working men free choice of the medical attendance he wants It is perfectly absurd. You may say a man ought to be forced to go to a doctor he does not want, but you cannot say that you are carrying-out the Chancellor of the Exchequer's promise or the wishes of the working classes in this country if you force them to go to a doctor they do not believe in.

Question put, "That those words be there inserted in the Bill."

The House divided: Ayes, 114; Noes,. 245.

Division No. 260.]	AYES.	[10.5 p.m.
Agg-Gardner, James Tynte	Eyres-Monsell, Bolton M.	Lloyd, George Ambrose (Stafford, W.)
Baird, John Lawrence	Fell, Arthur	Lloyd, George Butler (Shrewsbury)
Baker, Sir Rondolf L. (Dorset, N.)	Finlay, Rt. Hon. Sir Robert	Lowe, Sir F. W. (Birm., Edgbaston)
Baldwin, Stanley	Fisher, Rt. Hon. W. Hayes	M'Neill, Ronald (Kent, St. Augustine's)
Banbury, Sir Frederick George	Fitzroy, Hon. Edward A.	Magnus, Sir Philip
Baring, Major Hon. Guy V. (Winchester)	Fletcher, John Samuel	Markham, Sir Arthur Basil
Barlow, Montague (Salford, South)	Forster, Henry William	Morrison-Bell, Major A. C. (Honiton)
Barnston, Harry	Gibbs, George Abraham	Mount, William Arthur
Bathurst, Charles (Wilts, Wilton)	Glazebrook, Captain Philip K.	Newdegate, F. A.
Beach, Hon. Michael Hugh Hicks	Goldsmith, Frank	Newman, John R. P.
Benn, Ion Hamilton (Greenwich)	Gordon, Hon. John Edward (Brighton)	NieId, Herbert
Bentinck, Lord H. Cavendish-	Goulding, Edward Alfred	Pease, Herbert Pike (Darlington)
Bigland, Alfred	Grant, James Augustus	Perkins, Walter Frank
Bird, Alfred	Greene, Walter Raymond	Pollock, Ernest Murray
Blair, Reginald	Gretton, John	Pryce-Jones, Colonel E.
Boyle, William (Norfolk, Mid)	Guinness, Hon. Rupert (Essex, S.E.)	Randles, Sir John S.
Boyton, James	Guinness, Hon.W. E. (Bury S. Edmunds)	Rawlinson, John Frederick Peel
Bridgeman, William Clive	Gwynne, R. S. (Sussex, Eastbourne)	Rawson, Colonel Richard H.
Bull, Sir William James	Hall, Frederick (Dulwich)	Roberts, S. (Sheffield, Ecclesall)
Burn, Colonel C. R.	Hamilton, C. G. C. (Ches., Altrincham)	Salter, Arthur Clavell
Campbell, Captain Duncan F. (Ayr, N.)	Harris, Henry Percy	Samuel, J. (Stockton-on-Tees)
Cassel, Felix	Henderson, Major H. (Berks, Abingdon)	Samuel, Samuel (Wandsworth)
Cater, John	Henderson, Sir A. (St. Geo., Han. Sq.)	Sanders, Robert Arthur
Cecil, Evelyn (Aston Manor)	Hibbert, Sir Henry F.	Scott, Leslie (Liverpool, Exchange)
Cecil, Lord R. (Herts, Hitchin)	Hills, John Waller	Spear, Sir John Ward
Clay, Captain H. H. Spender	Hoare, Samuel John Gurney	Stanier, Beville
Clive, Captain Percy Archer	Hope, James Fitzalan (Sheffield)	Stanley, Hon. G. F. (Preston)
Craik, Sir Henry	Hope, Major J. A. (Midlothian)	Steel-Maitland, A. D.
Dalrymple, Viscount	Horne, Edgar (Surrey, Guildford)	Stewart, Gershom
Dalziel, Davison (Brixton)	Horner, Andrew Long	Swift, Rigby
Denison-Pender, J. C.	Houston, Robert Paterson	Talbot, Lord Edmund
Denniss, E. R. B.	Hunt, Rowland	Terrell, George (Wilts, N.W.)
Dickson, Rt. Hon. C. S.	Ingleby, Holcombe	Terrell, Henry (Gloucester)
Duke, Henry Edward	Jessel, Captain H. M.	Thomson, W. Mitchell- (Down, North)
Duncannon, Viscount	Kerry, Earl of	Thynne, Lord Alexander
Tryon, Captain George Clement	Wood, Hon. E. F. L. (Yorks, Ripon)	Younger, Sir George
White, Major G. D. (Lancs, Southport)	Wood, John (Stalybridge)	TELLERS FOR THE AYES.—Mr. G. Locker-Lampoon and Mr. Harry Lawson.
Wills, Sir Gilbert	Worthington-Evans, L.
Wolmer, Viscount	Yate, Colonel Charles Edward
NOES.
Abraham, William (Dublin, Harbour)	Goldstone, Frank	Muldoon, John
Acland, Francis Dyke	Greig, Colonel James William	Munro, Robert
Addison, Dr. Christopher	Griffith, Ellis Jones	Munro-Ferguson, Rt. Hon. R. C.
Adkins, Sir W. Ryland D.	Guest, Hon. Frederick E. (Dorset, E.)	Murray, Captain Hon. Arthur C.
Alden, Percy	Gulland, John William	Needham, Christopher T.
Allen, Arthur A. (Dumbartonshire)	Gwynn, Stephen Lucius (Galway).	Neilson, Francis
Allen, Rt. Hon. Charles P. (Stroud)	Hackett, John	Nolan, Joseph
Arnold, Sydney	Hall, F. (Yorks, Normanton)	Norton, Captain Cecil W.
Baker, Harold T. (Accrington)	Harcourt, Rt. Hon. R. L. (Rossendale)	O'Brien, Patrick (Kilkenny)
Baker, Joseph Allen (Finsbury, E.)	Harcourt, Robert V. (Montrose)	O'Connor, John (Kildare, N.).
Balfour, Sir Robert (Lanark)	Harmsworth, Cecil (Luton, Beds)	O'Connor, T. P. (Liverpool)
Barlow, Sir John Emmott (Somerset)	Harmsworth, R. L. (Caithness-shire)	O'Doherty, Philip
Barnes, George N.	Harvey, A. G. C. (Rochdale)	O'Donnell, Thomas
Beale, Sir William Phipson	Harvey, T. E. (Leeds, West)	O'Dowd, John
Beck, Arthur Cecil	Hayden, John Patrick	O'Grady, James
Benn, W. W. (T. Hamlets, St, George)	Hazleton, Richard	O'Kelly, Edward P. (Wicklow, W.)
Bentham, George Jackson	Henderson, John M. (Aberdeen, W.)	O'Malley, William
Bethell, Sir John Henry	Henry, Sir Charles	O'Neill, Dr. Charles (Armagh, S.)
Boland, John Pius	Hewart, Gordon	O'Shaughnessy, P. J.
Booth, Frederick Handel	Higham, John Sharp	O'Shee, James John
Bowerman, Charles W.	Hinds, John	O'Sullivan, Timothy
Boyle, Daniel (Mayo, North)	Hodge, John	Outhwaite, R. L.
Brace, William	Hogge, James Myles	Palmer, Godfrey Mark
Brady, Patrick Joseph	Holmes, Daniel Turner	Parker, James (Halifax)
Brocklehurst, W. B.	Holt, Richard Durning	Pearce, Robert (Staffs, Leek)
Brunner, John F. L.	Howard, Hon. Geoffrey	Pease, Rt. Hon. Joseph A. (Rotherham)
Bryce, J. Annan	Hughes, Spencer Leigh	Phillips, John (Longford, S.)
Burke, E. Haviland-	Illingworth, Percy H.	Pointer, Joseph
Burt, Rt. Hon. Thomas	Isaacs, Rt. Hon. Sir Rufus	Ponsonby, Arthur A. W. H.
Buxton, Noel (Norfolk, North)	John, Edward Thomas	Price, C. E. (Edinburgh, Central)
Byles, Sir William Pollard	Jones, Rt. Hon. Sir D. Brynmor (Swansea)	Priestley, Sir W. E. B. (Bradford, E.)
Carr-Gomm, H. W.	Jones, Henry Haydn (Merioneth)	Primrose, Hon. Neil James
Cawley, Sir Frederick (Prestwich)	Jones, J. Towyn (Carmarthen, East)	Pringle, William M. R.
Cawley, Harold T. (Lancs., Heywood)	Jones, William S. Glyn. (Stepney)	Radford, George Heynes
Chancellor, Henry George	Jowett, Frederick William	Rea, Rt. Hon. Russell (South Shields)
Chapple, Dr. William Allen	Joyce, Michael	Rea, Walter Russell (Scarborough)
Clancy, John Joseph	Keating, Matthew	Reddy, Michael
Clough, William	Kellaway, Frederick George	Redmond, John E. (Waterford)
Clynes, John R.	Kennedy, Vincent Paul	Redmond, William (Clare, E.)
Collins, Godfrey P. (Greenock)	Kilbride, Denis	Redmond, William Archer (Tyrone, E.)
Condon, Thomas Joseph	King, Joseph	Richardson, Albion (Peckham)
Cornwall, Sir Edwin A.	Lambert, Rt. Hon. G. (Devon, S. Molten)	Richardson, Thomas (Whitehaven)
Cotton, William Francis	Lambert, Richard (Wilts, Cricklade)	Roberts, Charles H. (Lincoln)
Cowan, W. H.	Lardner, James C. R.	Roberts, George H. (Norwich)
Crumley, Patrick	Law, Hugh A. (Donegal, West)	Roberts, Sir J. N. (Denbighs)
Cullinan, John	Lawson, Sir W. (Cumb'rld, Cockerm'th)	Robertson, John M (Tyneside)
Davies, David (Montgomery Co.)	Leach, Charles	Roche, Augustine (Louth)
Davies, Ellis William (Eifion)	Levy, Sir Maurice	Roe, Sir Thomas
Davies, Timothy (Lincs., Louth)	Lewis, Rt. Hon. John Herbert	Rowlands, James
Davies, Sir W. Howell (Bristol, S.)	Low, Sir Frederick (Norwich)	Rowntree, Arnold
Dawes, James Arthur	Lundon, Thomas	Runciman, Rt. Hon. Walter
Delany, William	Lyell, Charles Henry	Samuel, Rt. Hon. H. L. (Cleveland)
Denman, Hon. Richard Douglas	Lynch, Arthur Alfred	Scanlan, Thomas
Devlin, Joseph	Macdonald, J. Ramsay (Leicester)	Scott, A. MacCallum (Glas., Bridgeton)
Dickinson, W. H.	Macdonald, J. M. (Falkirk Burghs)	Sheehy, David
Dillon, John	McGhee, Richard	Shortt, Edward
Donelan, Captain A.	Maclean, Donald	Simon, Rt. Hon. Sir John Allsebrook
Doris, William	Macnamara, Rt. Hon. Dr. T. J.	Smith, Albert (Lancs., Clitheroe)
Duffy, William J.	MacNeill, J. G. Swift (Donegal, South)	Smyth, Thomas F. (Leitrim, S.)
Duncan, C. (Barrow-in-Furness)	Macpherson, James Ian	Snowden, Philip
Edwards, Clement (Glamorgan, E.)	MacVeagh, Jeremiah	Stanley, Albert (Staffs, N.W.)
Edwards, John Hugh (Glamorgan, Mid)	M'Callum, Sir John M.	Strauss, Edward A. (Southwark, West)
Elverston, Sir Harold	Manfield, Harry	Sutton, John E.
Esmonde, Dr. John (Tipperary, N.)	Marks, Sir George Croydon	Taylor, John W. (Durham)
Esmonde, Sir Thomas (Wexford, N.)	Marshall, Arthur Harold	Taylor, Theodore C. (Radcliffe)
Falconer, James	Masterman, Rt. Hon. C. F. G.	Taylor, Thomas (Bolton)
Fenwick, Rt. Hon. Charles	Meagher, Michael	Tennant, Harold John
Ferens, Rt. Hon. Thomas Robinson	Meehan, Francis E. (Leitrim, N.)	Thomas, J. H.
Ffrench, Peter	Meehan, Patrick J. (Queen's Co., Leix)	Thorne, G. R. (Wolverhampton)
Field, William	Middlebrook, William	Thorne, William (West Ham)
Fitzgibbon, John	Millar, James Duncan	Toulmin, Sir George
Flavin, Michael Joseph	Molloy, Michael	Trevelyan, Charles Philips
France, Gerald Ashburner	Molteno, Percy Alport	Ure, Rt. Hon. Alexander
Gill, Alfred Henry	Morgan, George Hay	Wadsworth, John
Gladstone, W. G. C.	Morrell, Philip	Walsh, Stephen (Lancs., Ince)
Glanville, Harold James	Morison, Hector	Ward, John (Stoke-upon-Trent)

Wardle, George J.	Williams, Llewelyn (Carmarthen)	Wood, Rt. Hon. T. McKinnon (Glasgow)
Waring, Walter	Williamson, Sir Archibald	Young, William (Perthshire, East)
Warner, Sir Thomas Courtenay	Wilson, Hon. G. G. (Hull, W.)	Yoxall, Sir James Henry
White, J. Dundas (Glasgow, Tradeston)	Wilson, John (Durham, Mid)
White, Patrick (Meath, North)	Wilson, Rt. Hon. J. W. (Worcs, N.)	TELLERS FOR THE NOES.—Mr. William Jones and Mr. Webb.
Whyte, Alexander F.	Wilson, W. T. (Westhoughton)
Williams, John (Glamorgan)	Wing, Thomas Edward

Mr. C. BATHURST

I beg to move, at the end of Sub-section (2), to add,

"(3) The regulations of the Insurance Commissioners shall provide for arrangements being made by every insurance committee for the provision of adequate medical attendance and treatment, as required by the principal Act for insured persons entitled to medical benefit whose condition does not require the services of a specialist or consultant."

This Amendment, which I move as a Sub-section of Clause 10, was ruled out of order as a new Clause when I endeavoured to move it as such. By Section 8 of the principal Act it was provided that every insured person shall receive medical treatment and attendance, including the provision of proper medicines and such medical and surgical appliances as may be prescribed by regulations of the Insurance Commissioners. When we come to Section 15, to which I particularly draw the attention of the House, it will be found that the Insurance Commissioners regulations are to provide for arrangements being made to secure that the insured persons shall receive adequate medical attendance and treatment from the medical practitioners with whom arrangements are so made. The object of this Amendment is to ensure that every employed contributor shall receive adequate medical attendance and treatment as provided by the principal Act. In a great many cases of trifling ailments, particularly those connected with the eyes, nose, throat and ears, all ailments, which under the old voluntary system insurance doctors used to treat as a matter of course, are being regarded as diseases which require the services of a specialist, with the result that doctors are declining to treat them altogether under their contract, or else they: are in some cases handing them on to their own partners, not being doctors on the panel, as being specialists in this particular type of disease, and this treatment which they give has to be paid for out of the pockets of the insured persons. This sort of thing is happening, I am sorry to say, in a great many cases to my knowledge in my own district, and also in South Wales. I am sure that the House will agree that this is certainly not what is intended by the Act in Section 15 when the expression "adequate medical attendance and treatment" is used as being the doctor's services to which the employed person is entitled. The object of this Amendment is to ensure that every employed contributor shall have as a matter of right, and as the result of his own contributions all such ordinary medical attendance and treatment as does not necessarily require the attendance of an expert specialist or consultant. This Amendment is framed in very moderate language, much more moderate than that in which I intended to move it in Committee. I have already got the support of at least one doctor in the House to this particular form of my Amendment, and I hope that it may receive the approval of the other medical men in the House. It is intended to throw upon the doctor, in every case in which he refuses to attend to these trifling ailments of various organs, the onus of showing that such ailment requires specialist treatment or else that it should be brought under the contract.

Mr. GOULDING

I desire to second this Amendment, to secure for these insured people what was guaranteed to them under the principal Act—that they should have adequate medical attendance. I understand that the Insurance Commissioners have issued a regulation which leaves ground for a great deal of the action of the doctors in claiming that certain ailments come under the heading of special treatment. I understand that they have indicated in their regulations, at any rate, that medical attendance and treatment are such services as may be given by a practitioner of as may be given by a practitioner of ordinary professional competence and skill. The interpretation which the Commissioners have put on medical attendance and treatment is not such as would guarantee it to the people, who are compelled to come under this Insurance Act and under the principal Act. My hon. Friend has stated that the treatment of cases of affection of the eye and nose is frequently regarded as an exceptional service, and not a service which the ordinary practitioner should deal With. One is perfectly aware, certainly in country districts, that in days gone by, before we knew of the Insurance Act, treatment of the eye and nose was given by the ordinary medical practitioner. I have a case within my own knowledge of a servant girl whose eyes were inflamed, and unfortunately in their treatment difficulties arose. The services in that case were not considered ordinary services which ordinary practitioners render. She at any rate did not get adequate medical treatment, and she had to incur the expense of being treated by a specialist. That is not really giving a fair and generous interpretation of the very simple and complete words of the principal Act, namely, "adequate medical attendance and treatment."

Mr. MASTERMAN

This Amendment would worsen the conditions instead of making them better. I hope the hon. Gentleman, who is always fair in these matters, will withdraw it. Every insured person has a claim to all kinds of treatment and medical benefit, except that which alone a specialist can give is already included in the Act and regulations, and if the regulations are not being worked, it is not a question of amending the Act, but of amending the administration. On the other hand, as to specialist treatment, I know of no definition which is generally accepted, and if the Amendment were passed, it might be possible for the doctors to refuse treatment which he now gives under the Act, which would be very bad for the insured person, because the doctor on the panel might happen to be a specialist in brain or heart disease. But at present he is giving the full influence of his intelligence to the advantage of the insured person, although he happens to be a specialist in heart disease. If, however, you rule out all specialist treatment that practitioner will be enabled to charge, because he is experienced in this particular disease, extra fees beyond what he is now charging. I think that would be disastrous in regard to the insured persons. What is it now that the Act and regulations give to the insured person? They give to the insured person who chooses his doctor on the panel the right to the treatment which that doctor can give, except treatment which may be interpreted as specialist treatment. Instead of interpreting that in an Act of Parliament, which would involve a Schedule of five or six pages saying what specialist treatment is—and then we could not do it, as my right hon. Friend says—in the case of any dispute as to whether it is specialist treatment or not, we provide ample apparatus for arriving at a decision. If the doctors are doing as the hon. Member for Worcester (Mr. Goulding) suggests, and are refusing to treat simple cases that do not require specialist treatment on the ground that they are not under obligation to treat those cases, the proper course is not to amend the Act, because the Act fully provides that they shall treat those cases, and the regulations also provide a course as to the usual ordinary apparatus and channel of complaint which is open to insured persons and the friends of insured persons to see that those doctors really do carry out what they have agreed to do in the contract. I agree, and here I repeat what I said on a former Amendment, that difficulties have arisen in cases, but I submit those difficulties have arisen in six months of working of the Act, which completely changes the conditions of medical treatment. I believe in many cases those difficulties are bonâ fide on the part of the doctors, and in a little time a few decisions will make those difficulties no longer exist. I had cases brought to my notice in which I am sorry to say the doctor seems to have been violating the actual regulations laid down under the Act. I would ask Gentlemen who represent the doctors here to realise that I am not in the least putting any general charge against the doctors. It may be through ignorance, just as much as through deliberate intention, and I think, without doubt, in a very short time and with the co-operation of the best leaders of the medical profession, we shall be able to eliminate those cases. If we are able to eliminate those cases it is far better than making any alteration in the Act. As it stands under the regulations, I think we shall be able to ensure that every insured person in the country shall receive medical benefit, apart from what everyone will agree is specialist treatment, in conformity with the Act as laid down, and if that is so, and we are appointing a Committee to investigate the subject, then I would very much rather not produce an Amendment which, in a sense is, though the hon. Member for Wilton (Mr. C. Bathurst) may say he has captured one doctor in the House, an Amendment which is a challenge and in part a censure on the doctors.

Mr. C. BATHURST

made some remarks which were inaudible.

Mr. MASTERMAN

I am working for conciliation.

Mr. BATHURST

So am I.

Mr. MASTERMAN

There is another point which I think is vital in connection with the Amendment. If the Amendment were carried it would throw the obligation of all institutional treatment on the approved societies without any contribution from the State, and it would bring up the whole question of the hospitals, which everyone interested in the hospitals would agree had better be deferred. It would compel the societies to arrange for hospital treatment without any kind of help from the Government. That would be the worst possible way in which to settle this question. For those reasons, and as I believe that those cases, which have been amongst doctors, enormously in the minority of the doctors, can be very largely met if hon. Gentlemen on both sides will let us go on putting what pressure we can to nut the Act into force. I would ask the hon. Gentleman to see his way to withdraw his Amendment.

Mr. GWYNNE

The right hon. Gentleman, in answering the case put forward on behalf of this Amendment, told us it was superfluous, and that the Act as it stood provided for adequate medical treatment and attendance, and as far as that part of his argument was concerned I think he was right, and I think the Act does clearly provide for that. But I think the reason the hon. Gentleman the Member for Wilton (Mr. C. Bathurst) has for moving his Amendment is that the purposes of the Act have not been given effect to, and cases were put forward both in Committee upstairs and just now, both by the Proposer and Seconder of the Amendment., to show that the interpretation which should be put on the Act as to what adequate medical attendance and treatment should be given has in fact not been given. That is why this Amendment has been placed on the Paper. The right hon. Gentleman, after saying that the Amendment was superfluous, went on to say that if it were pressed it would directly challenge the doctors. Upon which argument does he rely? If it only emphasises the wording of the Act, how can it challenge the doctors, seeing that they have agreed to work the Act? The right hon. Gentleman is not entitled to use the argument both ways. Another argument was that it would stop specialists who were on the panel from giving their peculiar or particular knowledge to cases which needed it. How many brain, eye, or ear specialists are there on any panel throughout the United Kingdom?

Mr. MASTERMAN

Quite a large number.

Mr. GWYNNE

If I put down a question will the right hon. Gentleman tell me how many there are? I think he will find that there are not many specialists on the panels at all. The right hon. Gentleman says that theme has been only six months' working of this Act, and that there have been some difficulties, but that if time is given those difficulties will diminish. I think we are entitled to argue that if there has been a certain amount of difficulty in six months there will be much more in the year, because when people realise what they are paying for, when they get more acquainted with this complicated Act, and learn what they are entitled to, we shall hear of many more difficulties. The right hon. Gentleman says that we must have a few decisions upon these points, so that people may know what their exact position is. My experience of decisions so far is that they only make confusion worse confounded. Some of the decisions under certain Sections of the Act contradict each other, and you do not know where you are at all. The right hon. Gentleman has not in any way answered the case made by my hon. Friend. We must have either an Amendment of this sort or a definite undertaking from the right hon. Gentleman that people will not be promised benefits which cannot be given. If the right hon. Gentleman cannot provide proper attendance and treatment let him say so and amend the Act in that respect, but do not let him go on having promises made all over the country which promises cannot be carried out.

Mr. HOGGE

I had on the Paper an Amendment to Clause 1 dealing with practically the same point as that raised by the hon. Member opposite. I wanted to raise the question whether or not an insured person was getting the adequate medical treatment which he is definitely promised under Section 15 (2) of the original Act. I wanted to draw attention to it on this occasion, because in this Bill, which is primarily a Bill to make legal certain previous payments to doctors, to which are attached a lot of other things, you are spending about £2,000,000 of the nation's money. This is equal, obviously, to a capital sum of well between £60,000,000 and £70,000,000. Therefore this seems to me an opportune occasion on which we should determine what really "adequate" treatment means. I do not think that the Amendment of my hon. Friend opposite goes far enough. I do not think he is entitled to leave out those other things, if the word "adequate" has any meaning at all in the English language. I would like to draw the attention of the House to another, what I consider, very objectionable proceeding in these regulations which are submitted to us from time to time, I presume by the Commissioners. I do not know whether we are ever to have the opportunity of discussing them. It would have defied the leisure of any Member of this House to read the various publications that came from the Commission during the last Session. You find one of these which has more Clauses really than the present Bill. The Regulation which I am reading from now has sixty-one Clauses, in addition to Schedules. In the first Schedule of this particular Regulation the Commissioners presumably proceed to write off something from what was promised in the original Act. They say definitely here:℄ The practitioner shall give to persons who are for the time being entitled to obtain treatment from him, such treatment as is of the kind which can consistently, nod in the best interests of the patient, he properly undertaken by the general practitioner of ordinary professional competence and skill. Did the House of Commons mean that, when it passed this Act? Did it mean that "adequate" medical treatment meant more than the bottle of medicine treatment which is so popularly associated with the kind of thing that obtained before this Act came into operation? Did it mean that the Insurance Act was only to deal with the kind of diseases through which we make our way in childhood? Or did it mean that we were to deal with diseases which arise from our contact with industrial pursuit? Because if it did not mean that, then it meant preventing the insured person receiving what I conceive Parliament meant him to receive—full and sufficient medical treatment. I very respectfully submit that when, in this Bill, we are increasing the charge so considerably, a charge which is going again to go to the medical profession, that we have a duty to perform to the person who is affected by this Act, and that we should attempt to secure to him all that "adequate" really means. Because I believe that I am prepared to support this Amendment, although personally I think it falls short of what we are entitled to claim for the people who are insured.

Sir P. MAGNUS

I only rise to ask my hon. Friend to withdraw his Amendment. I cannot see that the Amendment will avail in the least or do more than the provisions and the Act already effect. There is nothing in this Amendment, as far as I can see, that is not contained in the original Act. I agree that the wording of the Act does provide that every insured person should receive from the medical practitioner adequate medical treatment, and that if he does not receive adequate medical treatment, there ought to be some means of bringing his case before those who should take care that such adequate medical treatment is provided. But when it is suggested that the ordinary medical practitioner shall give treatment which is only given by a specialist, I cannot help thinking that we are doing an injury to the insured persons rather than helping them. Who is to be the judge whether a specialist is required in any case? Surely it is the medical practitioner. What happens in our own cases? If we consult our medical adviser, and he says, "This is a difficult case, and I should like to have the advice of Mr. So-and-so," we feel we should consult the specialist suggested. Why not let the insured person have the same voice as we would, have in similar circumstances? If you would define the case in which a specialist is required, you would have to put in a whole schedule of cases which would be most difficult for anyone here to determine. I cannot help thinking that in this matter, as in other matters, you must really trust the doctor. If you have not confidence in one doctor you must have some other doctor. Under the panel system you can change from one doctor to another. I do not see that insured persons would gain anything if you required the ordinary medical practitioner to treat a patient in cases in which he thinks some other person would be better able to treat him. I cannot see that any advantage would be gained from this Amendment, and I cannot help thinking great disadvantage would result if this Amendment were carried. I hope my hon. Friend will, in the interest of the insured persons, withdraw this Amendment.

Mr. LYNCH

I rise to say a few words because although my name was not mentioned I could not help seeing that I was twice alluded to. I wish, therefore, to offer an explanation. The hon. Member in his original Amendment used the words "beyond the competence of the ordinary practitioner." I rather took objection to that phrase, because in the medical profession it would be held that no case was beyond the competence of the duly qualified practitioner. I consulted the hon. Member, and, with that agreeable commerce of a man of the world and invariable courtesy which distinguishes him, he listened to my argument and substituted the words in the present Amendment, so that the words referring to specialists and consultants are really mite. But that does not imply I endorse the whole Amendment, and still less does it imply that the hon. Member captured me. On the contrary, it is the Financial Secretary to the Treasury that has captured me, because I have followed him through the entire Bill. I have followed him, at least with the eye of faith—the evidence of things unseen. Now if I have any influence left with the hon. Member for Wilton I would join my appeal to that of the hon. Member who has just sat down in asking him to withdraw this Amendment, not because I do not think it contains the germs of much that is good, but because I think when the Insurance Act is in operation for a few months longer this question can be again reverted to and the whole matter can be threshed out from the point of view he has in mind; and, perhaps, later his proposal can be brought up in a more substantial and considered form, and a form which would be acceptable not only to him but also to the Financial Secretary to the Treasury.

Mr. PRINGLE

I regret that the hon. Member has hoisted the white flag on this point. It seems to me that the Amendment proposed by the hon. Member for Worcester is calculated to serve a very useful purpose, because it has drawn attention to the regulations issued by the Commissioners in reference to medical benefit which seem to whittle down the amount of medical attendance promised in the original Act. It is for the purpose of reinforcing the provisions of the principal Act and to secure the adequate medical attendance therein mentioned, that this Amendment has been proposed. If the Financial Secretary to the Treasury were to state that in administering medical benefit and interpreting these regulations, something more was to be expected than is secured under the attenuated wording of the Clause as it exists, then those who feel dissatisfied might not press this Amendment. In view of the regulations which have been issued, I think we are entitled to something further than has been stated by the right hon. Gentleman. In reference to this Amendment we have had a completely different defence of the existing system from the hon. Member for the London University, and the Financial Secretary to the Treasury. According to the hon. Member, no general practitioner would ever think of performing any operation or any treatment requiring the service of a specialist. On the other hand, the right hon. Gentleman told us that among the "mere panel doctors" there are persons who are experts upon all conceivable illnesses. In these circumstances I think it is well that the Commissioners should indicate to these experts that the full amount of their skill should be at the service of insured persons. If the phrase which stands in the regulations is to determine the treatment of insured persons, then the attention of the Financial Secretary is right. If the regulations are limited in the sense of the proposal now before the House it will be obvious to these distinguished panel doctors that not only the ordinary competence of a duly qualified medical practitioner is required, but also any expert knowledge and special skill they may have attained. In those circumstances I think we should at least have an assurance that the wording of the regulations should be amended so as to be brought into conformity with the wording of the original Act.

Mr. BATHURST

I ask leave to withdraw my Amendment.

Amendment, by leave, withdrawn.

Mr. BATHURST

I beg to move, at the end of the Clause, to add the following Sub-section:— (3.) A person entitled to medical benefit shall be entitled to be provided with adequate medical attendance and treatment in whatever part of Great Britain he may happen to be at the time of his illness, whether notice of his leaving home has or has not been previously given; and the Insurance Commissioners shall as soon as may be practicable make arrangements under which the several insurance committees shall provide such medical attention and treatment as may be required by such persons for the time being within the areas of such committees, and the expenditure involved thereby shall be shared among all such committees in proportion to the total number of insured persons residing in their areas respectively. I move this Amendment in consequence of the failure of what is called the green card system. I dare say that the House is aware that an insured person who leaves the area of his own insurance committee is expected to obtain a green card from that committee, ensuring for him or her medical attendance and treatment in the district to which the person passes. Perhaps I may instance the case of the domestic servant, who is the greatest sufferer under the present system. The servant does not as a rule know, a long time beforehand, when she is going away from home. It is a matter entirely in the discretion of her mistress or master, as the case may be, and very often she either does not know how long she will be away or she is wholly ignorant of the green ticket system. The employed person finds herself, we will say, at a seaside place, not having made any provision for medical attendance outside her own area. What actually happens? This domestic servant, finding herself in a fresh environment, falls ill and sends for a doctor. The doctor informs her that he is not her panel doctor and cannot attend her, and she asks, "What am I to do?" He there-upon says, "Write to your society." She writes to her society, and the society write to her, and says, "You ought not to write to us; you ought to apply to your insurance committee." She then writes to her insurance committee, and, if it happens to be the last fortnight in August, the insurance committee probably does not meet, it being holiday time, and the unfortunate servant does not get any relief at all. A month passes during these communications, and there is no one whose services she is entitled to claim, with the result that she either has to pay for a doctor out of her own pocket or, possibly, she dies because she does not receive any proper medical treatment. This Amendment is simply to ensure that every person shall, as the result of his or her contribution, have a right to receive medical treatment within the area within which he or she may be for the time being. It would require very little adjustment as between the various insurance committees if they were instructed, according to the latter part of this Amendment, to make provision for the time being for those who happen to be resident within their area. I desire to move this Amendment in justice to a very large class of insured persons who have very little control over their movements.

Mr. THOMAS

I beg to second the Amendment.

In addition to domestic servants, there is a very large class of ordinary working men affected by this Clause. Probably 30 per cent. of the railway men of this country spend three days out of every week in a foreign station. They do not know from day to day the particular station to which they are going to run. The result is that those men may require medical treatment in that particular town, and, although they pay in the same way as other insured persons, they are deprived of medical treatment because they happen to be in a town away from their own home. Therefore, I quite conceive that the application of this particular Amendment will be equally effective to them. That is a point which ought to be met, and I consequently support the Amendment.

Mr. MASTERMAN

The first part of the Amendment is unnecessary; it is clearly stated in the Act that the insured person has this right. The second part is unfair, and I hope it will be withdrawn. The Government refuse to accept it. There is not the slightest doubt that an insured person is entitled to medical benefit, even if he moves from one part of the country to another. It is laid down in the Act that insured persons shall have medical treatment wherever they happen to be. The hon. Gentleman criticised the methods adopted by the Commissioners to carry that out. But I have no indication in any of the complaints I have received, that the methods adopted by the Commissioners do not carry it out. The censure rests, not on the methods, but on the administration of the Insurance Commissioners. The last part of the Amendment is unjust. The hon. Member suggests that the expenditure involved shall be charged upon the committees in proportion to the total number of insured persons residing in their areas, respectively. We are not adopting that method. We are adopting the method that the Commissioners shall spend the money required for those who travel in proportion to the number who travel outside their area. I will give an illustration. The number of insured persons in Dorset is about the same as the number in Oldham. The hon. Gentleman says the payment should be on the basis that the number of those who move out of Dorset is the same as the total who leave Oldham. We say that that is unfair to the Dorset doctors, because they would be deprived of a certain amount of their medical money, whereas very few of their patients actually move. The doctors in Oldham, on the other hand, would not have to give up any medical money, although a large number of their patients actually pass from their responsibility during the holidays and go to places like Blackpool and Southport.

11.0 P.M.

The principle adopted by the Commissioners is that the doctors in each district from which insured persons move, having taken twelve months' responsibility for those insured persons, shall contribute towards the expense incurred in connection with those who do move out of the district, whereas the hon. Member would mulct all doctors alike, whether or not their patients move out of the district. I repeat that that is unfair. I believe our method is working; if it is not we will endeavour to see that it does, and its working will be great facilitated by the Amendment moved by the hon. Member for Leicester. If there is not a sufficiency of panel doctors in places where people go in great numbers in certain months, the Amendment suggested by the hon. Member for Leicester will enable us to meet that case, and I can guarantee in the name of the Insurance Commissioners that the cases of the people who go in great numbers to watering-places will be met by our green certificate under our ordinary panel system, and we shall take care that doctors are provided to meet the great rush, so that every one who demands medical attendance even for the whole twelve months of the year shall have it wherever he may be. I cannot accept the suggestion that the levy should be upon those doctors who, perhaps, are responsible for their patients for the whole twelve months in the year, and yet who have to contribute in relief of doctors, who, perhaps, are responsible for only five, six, seven, eight, or eleven months in the year.

Mr. FORSTER

I think my hon. Friend has rendered good service in bringing this matter before the attention of the House. I am bound to say that, until I heard the concluding portion of the right hon. Gentleman's speech, I certainly intended to vote with my hon. Friend if he went to a Division. But the right hon. Gentleman has now given a guarantee—it is rather a bold guarantee to give—that, under the arrangements that have now been made by the Insurance Commissioners, the people who move will get adequate medical treatment, to which they are entitled.

Mr. MASTERMAN

I do not wish there to be any misunderstanding. I said it would be done, given the addition made, without a Division of the House, at the instance of the hon. Member for Leicester (Mr. Ramsay Macdonald).

Mr. FORSTER

Under the arrangements which have been made, or are in course of being made, he guaranteed that adequate medical benefit will be available for those persons who travel. That is what we want. It was to secure adequate medical treatment for them that my hon. Friend moved the Amendment, and it was upon that account that I should have supported him if he went to a Division. I do not know whether he will be satisfied with the guarantee the right hon. Gentleman has given. If he is not satisfied, and still intends to press the matter to a Division, I shall support him.

Lord ROBERT CECIL

This matter happened to come before me yesterday when I was visiting my Constituency. A gentleman there, who is an employer of labour, a contractor, told me only yesterday that he employed a considerable number of men on works in different counties. The men naturally go from one works to another. As he opens new works he has to send men to carry them out. He certainly informed me that, in point of fact, they did not get any medical attendance as a result of the practical working of the Act. It is very difficult for us to criticise the right hon. Gentleman, who has a great amount of official information at his back. He tells us that the whole thing is arranged on the green card system. As a matter of fact, it is not working. This Amendment is designed to call the attention of the House to the fact that it is not working. I confess I do not feel satisfied with the mere assurance of the right hon. Gentleman that it shall work. No one doubts that the right hon. Gentleman desires, and has always desired that the Act should work. We never thought of charging him with a male- volent desire to secure the non-attendance of insured persons by medical practitioners. Of course he wishes it to work, and has done his best, and so have the Commissioners, to bring it into operation. The practical effect, with all their efforts, is that it is not working at all at the present moment in a very large number of cases. Three separate classes have been brought before the right hon. Gentleman—the domestic servants, of whom my hon. Friend has spoken; the railway servants, of whom the hon. Gentleman opposite (Mr. Thomas) has spoken; and the contractor's men, of whom I have personal information. It is a very serious matter indeed, and I trust my hon. Friend will go to a Division. If he does, I shall certainly support him.

Mr. HARRY LAWSON

The Secretary to the Treasury said that this system is included in the Act. What is much more important than the Act is the fact. The fact is that the green ticket system has broken down, and very great hardship is being inflicted on the classes already mentioned. The Domestic Servants' Society, containing 75,000 members, says that, as a matter of practice, its members are not getting any advantage under the Act. You may say it is due to their own ignorance or their own neglect, but they are not getting the advantages. That being so, as the system is not working, I cannot see that the guarantee of the Secretary to the Treasury carries us much further. He says we are going to have some changes under the Clause of the hon. Member (Mr. Ramsay Macdonald), adopted this afternoon. I never thought it touched this particular grievance. It was introduced for other purposes, and I do not see how it can be twisted into making any change which will be in the least satisfactory. What is the good of having paper benefits? What we want is that they shall have the real benefits under the Act, and if, as a matter of fact and practice, all these people who are working under the green-ticket system are failing to obtain medical benefit it is only right that these words, particularly the latter part of the Amendment, should be adopted, and I hope my hon. Friend will press the matter to a Division, and that we shall make it incumbent upon the Government to give those people who are transferred from district to district by reason of their calling the benefits to which they are entitled.

Mr. J. WARD

I think I have special knowledge relating to this class of people and the only part of the Amendment which is of the slightest importance to them is these words, "whether notice of his leaving home has or has not been previously given." We have discovered in working the Act that there is a great difficulty in a man having to give the notice. First of all he has to find out the Insurance Commissioner's address in the locality he proceeds to and then to give notice to the secretary of the fact that he has removed within his jurisdiction, so that a medical man shall be appointed for the purpose of giving him proper attendance. If we could get over that or if we could understand that in principle these words will be adopted there would not be the slightest difficulty.

Mr. R. GWYNNE

The right hon. Gentleman has said that he will give us a guarantee that the difficulties which have presented themselves up to now shall be done away with. Has he come to any arrangement by which the delay will be obviated, because my experience of the green-ticket system is really the delay which an insured person has to suffer if he moves his place of residence in getting medical attendance at once. The green ticket has to be submitted to the insurance committee, and he has to get a doctor, and so forth. If the device which is guaranteed as meeting this particular difficulty gets over the delay and the ticket can be presented at once, and some doctor will be seen, we need not press the Amendment, because what the hon. Member (Mr. J. Ward) said is to a very large extent right, that the giving notice is one obstacle and that the delay in getting the officer to accept him is another. The ticket ought not to have to be approved by the insurance committee.

Mr. BOOTH

I do not know that I should have risen but for the suggestions of a breakdown. If there had been any general complaint I think I should have heard something about it myself, and many of those who, like myself, are connected with very large societies would have known something of it. It is all very well for hon. Members to talk as if there was any great breakdown. I have made inquiries to find out what has been the experience of the societies, and they say they have seen no complaints. I quite admit that there may be something in what was said as to railway servants. I see that there is a possibility—and it has occurred—of railwaymen away from home not getting medical benefit. I wish hon. Members to see this matter in its real perspective. As a rule, railwaymen are not sent away from home for a long time. It is a very rare thing for the men to be sent away more than two or three days to work, and when it is so, I agree it should be made quite clear what they are entitled to. I do not wish the House to be led away with these exaggerated statements. The cases are few and far between.

Mr. RONALD M'NEILL

We all know from a great deal of experience that the hon. Member for Pontefract (Mr. Booth) holds the view on this subject that, what he does not know is not knowledge at all. That is quite an amiable delusion which does not do us any harm. I should like the right hon. Gentleman to inform me what happens in the case of insured people who take their holidays in Ireland where there is no medical benefit under the Act. Does the guarantee which the right hon. Gentleman has given extend to people who go to Ireland for holidays? Suppose that people who are taking holidays fall ill in Ireland, how are they to derive the medical benefit for which they have paid in this country? I shall be personally grateful to the right hon. Gentleman if he will explain how that is to be done.

Mr. MASTERMAN

People who go to Ireland must comply with the conditions which prevail in Ireland. They cease to pay for medical benefit, and consequently they are not insured persons in respect of that benefit. [An HON. MEMBER: "They pay partially."] They are paying week by week during the year for insurance against illness which requires medical attendance, and while in Ireland they will pay less, and they will not be entitled to medical benefit. I can assure hon. Members on all sides that the Commissioners are with them in this matter. Their only desire is, as soon as it can be effectively done, to provide medical attendance and treatment wherever a man goes. In the normal case at present, the green ticket can be presented to any panel doctor in the neighbourhood, and it must be received by any panel doctor, and while the insured person is in the neighbourhood the panel doctor is responsible for medical attendance.

Mr. RUPERT GUINNESS

There is one other class of person who has not been mentioned. I know of a case of a servant who was sent home sick, and for three weeks could not get the attendance of a panel doctor in the district to which she went. Such a case as that must be dealt with under this particular Amendment.

Mr. WILLIAM REDMOND

There are many people insured in Ireland who come over here for a certain portion of the year, servants and others. I understand that while here they pay according to English rates, and I would like to know if they are entitled to the services of a panel doctor?

Mr. MASTERMAN

Persons who are unfortunate enough to emigrate from Ireland to England temporarily pay the extra rate while in England, and are entitled to medical attendance while here.

Mr. WORTHINGTON-EVANS

I understood the Secretary to the Treasury to say that he opposed this Amendment because the first part of it was unnecessary, and the second part was unjust. I do not think that he appreciates the point made by my hon. Friend, because the object in moving the first part of the Amendment is to get rid of the notice which is now necessary before a person can get a green ticket. I called the right hon. Gentleman's attention the other day to the case of a man, who, having left Leicester and moved into Northampton, applied for a green ticket, and it took him six weeks to get it. Meanwhile he would have been without medical attendance, but that the doctor trusting that he would get it in time did, in fact, give him medical benefit without a green ticket. My hon. Friend moved the Amendment to force the right hon. Gentleman to so arrange the system that this notice should not be necessary. The second part of the Amendment is said to be unjust because it sets up a method of remuneration that would be unfair to one set of doctors or the other. I think that the right hon. Gentleman did injustice to my hon. Friend because my hon. Friend does not suggest any particular form of remuneration, except that it shall be shared among the Committees in proportion to the number of insured persons residing in the areas generally. The Insurance Commissioners and the right hon. Gentleman have issued a pamphlet which is called the "Medical Benefit Temporary Residents Memorandum, 171, I.C." It consists of thirty-nine Clauses and ten pages, and is an extremely complicated document. It talks about case value machinery. If the right hon. Gentleman has discovered case value machinery embodied by my hon. Friend in his Amendment it would be quite easy to have met that point by adopting the case value machinery of the district. In making regulations to carry out the provisions of the Act the Commissioners would not have the slightest difficulty in putting right any little inequality that might arise from the exact words of this Amendment. In substance we get this, that my hon. Friend's Amendment is intended to force this one

thing—the right of the insured person to medical benefit wherever he is without the long clumsy form of notice and also to provide that the doctors who look after those temporary residents shall be paid a proper proportionate fee. I believe that the Amendment means that, and I shall support my hon. Friend if he goes to a Division.

Question put, "That those words be there inserted in the Bill."

The House divided: Ayes, 128;. Noes, 215.

Division No. 261.]	AYES.	[11.20 p.m.
Agg-Gardner, James Tynte	Gibbs, George Abraham	Pease, Herbert Pike (Darlington)
Archer-Shee, Major M.	Gill, Alfred Henry	Perkins, Walter Frank
Baird, John Lawrence	Glazebrook, Captain Philip K.	Pointer, Joseph
Baker, Sir Randall L. (Dorset, N.)	Goldsmith, Frank	Pollock, Ernest Murray
Baldwin, Stanley	Goldstone, Frank	Price, C. E. (Edinburgh, Central)
Banbury, Sir Frederick George	Gordon, Hon. John Edward (Brighton)	Pryce-Jones, Colonel E.
Baring, Major Hon. Guy V. (Winchester)	Goulding, Edward Alfred	Randles, Sir John S.
Barlow, Montague (Salford, South)	Grant, J. A.	Rawlinson, John Frederick Feel
Barnes, George N.	Greene, W. R.	Richardson, Thomas (Whitehaven)
Barnston, Harry	Gretton, John	Roberts, George H. (Norwich)
Beach, Hon. Michael Hugh Hicks	Guinness, Hon. Rupert (Essex, S.E.)	Roberts, S. (Sheffield, Ecclesall)
Benn, Arthur Shirley (Plymouth)	Guinness, Hon. W. E. (Bury S. Edmunds)	Samuel, Samuel (Wandsworth)
Benn, Ion Hamilton (Greenwich)	Gwynne, R. S. (Sussex, Eastbourne)	Sanders, Robert Arthur
Bentinck, Lord H. Cavendish-	Hall, Frederick (Dulwich)	Smith, Albert (Lancs., Clitheroe)
Bigland, Alfred	Hamilton, C. G. C. (Ches., Altrincham)	Snowden, Philip
Bird, Alfred	Harris, Henry Percy	Spear, Sir John Ward
Boyle, William (Norfolk, Mid)	Henderson, Major H. (Berks, Abingdon)	Stanley, Albert (Staffs., N.W.)
Boyton, James	Henderson, Sir A. (St. Geo., Han. Sq.)	Stanley, Hon. G. F. (Preston)
Bridgeman, William Clive	Hills, John Waller	Steel-Maitland, A. D.
Bull, Sir William James	Hodge, John	Stewart, Gershom
Burn, Colonel C. R.	Hope, James Fitzalan (Sheffield)	Sutton, John E.
Cassel, Felix	Hope, Major J. A. (Midlothian)	Talbot, Lord Edmund
Cator, John	Horne, Edgar (Surrey, Guildford)	Taylor, John W. (Durham)
Cecil, Evelyn (Aston Manor)	Horner, Andrew Long	Terrell, George (Wilts, N.W.)
Cecil, Lord R. (Herts, Hitchin)	Hunt, Rowland	Terrell, Henry (Gloucester)
Clay, Captain H. H. Spender	Ingleby, Holcombe	Thynne, Lord Alexander
Clive, Captain Percy Archer	Jessel, Captain Herbert M.	Tryon, Captain George Clement
Clynes, J. R.	Jewett, Frederick William	Tullibardine, Marquess of
Craik, Sir Henry	Kerry, Earl of	Walsh, Stephen (Lancs., Ince)
Dalrymple, Viscount	Lawson, Hon. H. (T. H'mts., Mile End)	Wardle, George J.
Dalziel, Davison (Brixton)	Lloyd, George Ambrose (Stafford, W.)	Wedgwood, Josiah C.
Denison-Pender, J. C.	Lloyd, George Butler (Shrewsbury)	White, Major G. D. (Lancs., Southport)
Denniss, E. R. B.	Locker-Lampson, G. (Salisbury)	Whyte, Alexander F.
Dickson, Rt. Hon. C. Scott	Macdonald, J. Ramsay (Leicester)	Williams, John (Glamorgan)
Duke, Henry Edward	Mackinder, Halford J.	Wills, Sir Gilbert
Duncan, C. (Barrow-in-Furness)	M'Neill, Ronald (Kent, St. Augustine's)	Wilson, W. T. (Westhoughton)
Duncannon, Viscount	Magnus, Sir Philip	Wood, Hon. E. F. L. (Yorks, Ripon)
Eyres-Monsell, Bolton M.	Morrison-Bell, Major A. C. (Honiton)	Wood, John (Stalybridge)
Fell, Arthur	Mount, William Arthur	Worthington-Evans, L.
Fiennes, Hon. Eustace Edward	Newdegate, F. A.	Yate, Colonel C. E.
Fisher, Rt. Hon. W. Hayes	Newman, John R. P.
Fitzroy, Hon. Edward A.	Nield, Herbert	TELLERS FOR THE AYES.—Mr. C. Bathurst and Mr. J. H. Thomas.
Fletcher, John Samuel	O'Grady, James
Forster, Henry William	Parker, James (Halifax)
NOES.
Abraham, William (Dublin, Harbour)	Bentham, George Jackson	Buxton, Rt. Hon. Sydney C.(Poplar)
Acland, Francis Dyke	Birrell, Rt. Hon. Augustine	Byles, Sir William Pollard
Addison, Dr. Christopher	Boland, John Pius	Carr-Gomm, H. W.
Adkins, Sir W. Ryland D.	Booth, Frederick Handel	Cawley, Sir Frederick (Prestwich)
Allen, Arthur A. (Dumbartonshire)	Boyle, Daniel (Mayo, North)	Cawley, Harold T. (Lancs., Heywood).
Allen, Rt. Hon. Charles P. (Stroud)	Brace, William	Chancellor, Henry George
Arnold, Sydney	Brady, Patrick Joseph	Chapple, Dr. William Allen
Baker, Harold T. (Accrington)	Brocklehurst, William B.	Clancy, John Joseph
Baker, Joseph Allen (Finsbury, E.)	Brunner, John F. L.	Clough, William
Balfour, Sir Robert (Lanark)	Bryce, John Annan	Collins, Godfrey P. (Greenock)
Barlow, Sir John Emmott (Somerset)	Burke, E. Haviland-	Condon, Thomas Joseph
Beale, Sir William Phipson	Burns, Rt. Hon. John	Cornwall, Sir Edwin A.
Beck, Arthur Cecil	Burt, Rt. Hon. Thomas	Crumley, Patrick
Benn, W. W. (T. Hamlets, St. George)	Buxton, Noel (Norfolk, North)	Cullinan, John
Davies, David (Montgomery Co.)	Jones, J Towyn (Carmarthen, East)	O'Shaughnessy, P. J.
Davies, Ellis William (Elfion)	Jones, William S. Glyn- (Stepney)	O'Shee, James John
Davies, Timothy (Lincs., Louth)	Joyce, Michael	O'Sullivan, Timothy
Davies, Sir W. Howell (Bristol, S.)	Keating, Matthew	Palmer, Godfrey Mark
Dawes, James Arthur	Kellaway, Frederick George	Pearce, Robert (Staffs, Leek)
Delany, William	Kennedy, Vincent Paul	Pease, Rt. Hon. Joseph A (Rotherham)
Denman, Hon. Richard Douglas	Kilbride, Denis	Phillips, John (Longford, S.)
Devlin, Joseph	King, Joseph	Ponsonby, Arthur A. W. H.
Dickinson, W. H.	Lambert, Rt. Hon. G. (Devon,S.Molton)	Priestley, Sir W. E. B. (Bradford, E.)
Dillon, John	Lambert, Richard (Wilts, Cricklade)	Primrose, Hon. Neil James
Donelan, Captain A.	Lardner, James C. R.	Pringle, William M. R.
Doris, William	Lawson, Sir W. (Cumb'rid, Cockerm'th)	Radford, George Heynes
Duffy, William J.	Levy, Sir Maurice	Reddy, Michael
Edwards, Clement (Glamorgan, E.)	Lewis, Rt. Hon. John Herbert	Redmond, John E. (Waterford)
Edwards, John (Glamorgan, Mid)	Low, Sir Frederick (Norwich)	Redmond, William (Clare, E.)
Elverston, Sir Harold	Lundon, Thomas	Redmond, William Archer (Tyrone, E.)
Esmonde, Dr. John (Tipperary, N.)	Lyell, Charles Henry	Richardson, Albion (Peckham)
Esmonde, Sir Thomas (Wexford, N.)	Lynch, A. A.	Roberts, Charles H. (Lincoln)
Essex, Sir Richard Walter	Macdonald, J. M. (Falkirk Burghs)	Roberts, Sir J. H. (Denbighs)
Falconer, James	McGhee, Richard	Robertson, John M. (Tyneside)
Fenwick, Rt. Hon. Charles	Maclean, Donald	Roche, Augustine (Louth)
Ferens, Rt. Hon. Thomas Robinson	Macnamara, Rt. Hon. Dr. T. J.	Roe, Sir Thomas
Ffrench, Peter	MacNeill, J. G. Swift (Donegal, South)	Rowlands, James
Field, William	Macpherson, James Ian	Rowntree, Arnold
Fitzgibbon, John	MacVeagh, Jeremiah	Samuel, Rt. Hon. H. L. (Cleveland)
Flavin, Michael Joseph	M'Callum, Sir John M.	Samuel, J. (Stockton-an-Tees)
France, Gerald Ashburner	Manfield, Harry	Scanlan, Thomas
George, Rt. Hon. D. Lloyd	Markham, Sir Arthur Basil	Scott, A. MacCallum (Glas., Bridgeton)
Gladstone, W. G. C.	Marks, Sir George Croydon	Seely, Rt. Hon. Colonel J. E. B.
Glanville, H. J.	Marshall, Arthur Harold	Sheehy, David
Greig, Colonel James William	Masterman, Rt. Hon. C. F. G.	Shortt, Edward
Guest, Major Hon. C. H. C. (Pembroke)	Meagher, Michael	Simon, Rt. Hon. Sir John Allsebrook
Guest, Hon. Frederick E. (Dorset, E.)	Meehan, Francis E. (Leitrim, N.)	Smyth, Thomas F. (Leitrim, S.)
Gulland, John William	Meehan, Patrick J. (Queen's Co., Leix)	Taylor, Theodore C. (Radcliffe)
Gwynn, Stephen Lucius (Galway)	Middlebrook, William	Taylor, Thomas (Bolton)
Hackett, John	Millar, James Duncan	Tennant, Harold John
Hall, Frederick (Yorks, Normanton)	Molloy, Michael	Thorne, G. R. (Wolverhampton)
Harcourt, Rt. Hon. L. (Rossendale)	Money, L. G. Chiozza	Toulmin, Sir George
Harcourt, Robert V. (Montrose)	Morgan, George Hay	Trevelyan, Charles Philips
Harmsworth, Cecil (Luton, Beds)	Morrell, Philip	Ure, Rt. Hon. Alexander
Harmsworth, R. L. (Caithness-shire)	Muldoon, John	Wadsworth, J.
Harvey, T. E. (Leeds, West)	Munro, Robert	Ward, John (Stoke-upon-Trent)
Hayden, John Patrick	Munro-Ferguson, Rt. Hon. R. C.	Waring, Walter
Hazleton, Richard	Murphy, Martin J.	Warner, Sir Thomas Courtenay
Henderson, J. M. (Aberdeen, W.)	Murray, Captain Hon. Arthur C.	White, J. Dundas (Glasgow, Tradeston)
Henry, Sir Charles	Needham, Christopher T.	White, Patrick (Meath, North)
Higham, John Sharp	Neilson, Francis	Williams, Llewelyn (Carmarthen)
Hinds, John	Nolan, Joseph	Williamson, Sir Archibald
Hobhouse, Rt. Hon. Charles E. H.	Norton, Captain Cecil W.	Wilson, Hon. G. G. (Hull, W.)
Hogge, James Myles	Nuttall, Harry	Wilson, John (Durham, Mid)
Holmes, Daniel Turner	O'Brien, Patrick (Kilkenny)	Wilson, Rt. Hon. J. W. (Worcs., N.)
Holt, Richard Durning	O'Connor, John (Kildare, N.)	Wing, Thomas Edward
Howard, Hon. Geoffrey	O'Connor, T. P. (Liverpool)	Wood, Rt. Hon. T. McKinnon (Glasgow)
Hughes, Spencer Leigh	O'Doherty, Philip	Young, William (Perth, East)
Illingworth, Percy H.	O'Donnell, Thomas	Yoxall, Sir James Henry
Isaacs, Rt. Hon. Sir Rufus	O'Dowd, John
John, Edward Thomas	O'Kelly, Edward P. (Wicklow, W.)	TELLERS FOR THE NOES.—Mr. William Jones and Mr. H. Webb.
Jones, Rt.Hon.Sir D.Brynmor (Swansea)	O'Malley, William
Jones, H. Haydn (Merioneth)	O'Neill, Dr. Charles (Armagh, S.)

Question put, and agreed to.

Sir P. MAGNUS

I beg to move that the following Sub-section be added to the Bill. "No insured person shall be entitled to require attendance by any practitioner other than the practitioner selected by, or allotted to, the insured person."

This Amendment is intended to supply an omission in the principal Act and I have no doubt therefore it will be accepted by the Financial Secretary. It does not refer to the cases which have been discussed already as to consulting specialists, but it refers or is intended to refer, to those cases in which the practitioner feels it necessary to perform some surgical operation, and we know quite well when surgical operations have to be performed an anæsthetist has to attend, as the general practitioner is not able to supply the anæsthetic at the same time as he performs the surgical operation. It appears that no arrangement has been made in the Act for the calling in of an anæsthetist, or for providing for his payment. It cannot be expected that the ordinary practitioner should himself pay the fee for the second doctor. Unless there is some arrangement by which the fee of the second doctor is paid, all that can happen is that a particular case may be referred to a hospital, and an operation which ought to take place immediately may be postponed to the injury of the patient. I feel certain that this point had not occurred to the framers of the Act, therefore I will simply move the Amendment in the hope that the Secretary to the Treasury will at once see the necessity of it.

Mr. FORSTER

I beg formally to second the Amendment, and in so doing, to ask the right hon. Gentleman how far the Government wish to get to night? We do not desire to shirk our duties or to obstruct in any way, but we would like to know how far the Government wish to get.

Mr. MASTERMAN

I do not quite understand the object of the hon. Member (Sir P. Magnus). If he suggests that when a second doctor is called in extra money should be provided by the State in order to pay him, the Amendment is out of order and there is nothing more to be said about it. If, on the other hand, he suggests that the doctors might make such arrangements under the present system as, without any further State contribution, would put aside a certain sum for this purpose, that can be done under the Act and there is no need for the Amendment at all. So much is that the case that the Manchester Insurance Committee, by the wish of the doctors, have adopted the system of paying such special fees from the ordinary fees which the doctors receive, and thus the position is met. It is a very small matter. According to the latest figures, there were 240,000 medical attendances in Manchester and less than forty cases where this arrangement was required. So far as the doctors agree to divide the 9s. which they may receive for medical treatment, etc., so that a certain proportion shall be left for this purpose, they are perfectly free to do it under the Act.

As to the question of the hon. Member for Sevenoaks, I am very much in the hands of the hon. Member and his friends, who I gladly agree have treated the Bill on its merits, without any kind of attempt to bring in extraneous conditions. I think it is the general wish of the House that the Bill should be finished to-morrow, and the only question is the allocation of the time as between to-day and to-morrow. As I read them, there are only two Clauses still remaining which will need substantial discussion—one dealing with maternity benefit and the other with the four Commissioners. I should have liked to get Clause 13 to-night, and so begin on Clause 15 to-morrow. But if the hon. Member for Sevenoaks says that his friends rather desire to devote the time at their disposal so that we may go straight on to the maternity benefit Clause to-morrow, I accept that suggestion. We can get what are non-controversial Clauses, the remainder of Clauses 10, 11, and 12, and we can begin to-morrow afternoon immediately on maternity benefit.

Mr. FORSTER

I think that arrangement will be acceptable to my hon. Friends, and we will do what we can to carry it through, provided that there is no shirking of adequate discussion.

Mr. MASTERMAN

Under those circumstances I shall be prepared to move the Adjournment of the Debate at the end of Clause 12.

Mr. WORTHINGTON-EVANS

The right hon. Gentleman said that there was a general desire in the House to finish the Bill to-morrow. He must not say that except subject to the condition that the Government has no further time to give to the Bill, because there is no doubt we are being rushed very badly. We are having to curtail our criticism of the Bill owing to the absence of time; in fact, my hon. Friend the Member for Salisbury is not, as he told me just now, going to move a really important Amendment, because there will not be sufficient time to do it justice, either in the discussion to-night or in the scramble to-morrow. As the right hon. Gentleman said in Committee, if we had insisted on our new Clauses the Bill would have been very seriously jeopardised, if not differed altogether. Many of my Friends and myself desire to discuss this Bill at much greater length than we are able to do, and agreement is only possible in view of the circumstances of the case.

Mr. MASTERMAN

In view of what the hon. Gentleman has said as to our conditions of working now, I think it is the desire of all parties to conclude the Session, if possible, next week. Under these circumstances it is not possible to give more than one day more.

Sir P. MAGNUS

If the Government are not willing to accept my Amendment I shall not press it, but I would point out that the responsibility rests with the Government.

Amendment, by leave, withdrawn.

Sir P. MAGNUS

I beg to move to add the following Sub-section to the Bill, "No insured person shall be entitled to require attendance or treatment for any disease or disablement caused by his own misconduct other than venereal diseases.

Sub-section (4) of Section 14 of the principal Act is hereby repealed."

Section 14, Sub-section (4) of the principal Act reads:—

"Where under any such rule as aforesaid payment of sickness or disablement is suspended on the ground that the disease or disablement has been caused by the misconduct of the person claiming the benefit, such person shall not thereby become disentitled to medical benefit."

Where the insured person has been guilty of some act of misconduct by which he has brought on disablement or disease upon himself, surely the doctor ought not to be required under the ordinary terms to give attendance he would give in other circumstances.

Mr. MASTERMAN

The hon. Gentleman must see this is a deliberate attempt to take away from the insured persons what they have a right to under the Bill, and not only what they have a right to under the Bill but what 18,000 doctors, the vast majority of whom are engaged in working-class practice, have agreed to give in return for the money they are being given. They have accepted to treat those diseases under the Bill. I think the hon. Member will realise it is very important that those diseases arising from misconduct of persons should be treated. In the circumstances that the doctors have agreed to treat them I cannot arrange, except by law, a condition that insured persons shall be deprived of treatment they are given under the Act, and what the overwhelming majority of the doctors are ready to give and for which they have signed contracts.

Question, "That those words be added to the Bill," put, and negatived.

Mr. GLYN-JONES

I beg to move that the following new Sub-section be added to the Bill, "That where under the provisions of Section 15 of the principal Act the Commissioners suspend the right of medical benefit in respect of any insured person the amount which they are to pay out to each such insured person shall, notwithstanding anything contained in that Section, be the amount payable to the Insurance Committee in respect of the medical benefit to such persons."

Sub-section (15) of the principal Act provides that the Insurance Committee may in certain circumstances suspend the right to medical benefit, and in that case pay to each such person a sum equal to the estimated cost of his medical benefit during that period. The Insurance Committees are having considerable difficulty in estimating what they are really to pay to persons whose medical benefit has been suspended. The phrase in the principal Act is that they are to pay to him a sum equal to the estimated cost of his medical benefit. What that means I am sure I do not know. The Insurance Committees receive from the Commissioners a given amount towards the cost of providing medical benefit for every insured person in the district. If we suspend medical benefit, obviously that is the amount we ought to be called upon to provide.

Dr. ADDISON

I beg to second the Amendment.

Mr. MASTERMAN

I hope that the hon. Member will see his way to withdraw this Amendment. I do not think it is quite fair to hand in a manuscript Amendment like this at the last moment.

Amendment, by leave, withdrawn.

cc1432-3
1. CLAUSE 11.—(Sickness Benefit.) 391 words
cc1433-8
2. CLAUSE 12.—(Amendment of Paragraph (c) of s. 8 (1) of Principal Act.) 1,985 words
cc1438-40
3. CLAUSE 13.—(Maternity Benefit.) 696 words