§ "If the Insurance Commissioners are satisfied that the insured persons or any considerable proportion of them within an area, or part of an area, are not receiving satisfactory medical treatment under the panel system the Commissioners may authorise the insurance committee to make, or may themselves make, such other arrangements as will secure to insured persons within the area, or part, such better medical service as is practicable having regard to the funds available for the purpose, or arrangements whereunder insured persons within the area, or part of the area, may be required to make their own arrangements for receiving medical attendance and treatment, including medicines and appliances, and whereunder the Insurance Committee or the Insurance Commis- 3389 sioners undertake to pay the cost of such medical attendance and treatment, or such part thereof, as may be practicable having regard to the funds at their disposal for the purpose."
§ Clause brought up, and read the first time.
§ Mr. RAMSAY MACDONALD
I beg to move, "That the Clause be read a second time."
This Clause is meant to give b the insurance Committees, when they have received the sanction of the Commissioners, power to deal with those very few cases where, owing to certain local difficulties, the panel system has broken down. There are unfortunately one or two of those cases, and the dislocation which is caused is a very serious one. It is not fair to the insured person, and we have from our trade unions and friendly societies, from sections of friendly societies at any rate, complaints, sometimes proposing one method and sometimes proposing another method, and we think on the whole this is the fairest method. If the Commissioners had this power, I believe it would put them in a far better position to bargain for the carrying out of the Act as it is now being carried out. Certainly there is a very strong feeling growing up on the part of the members of Insurance Committees that some such power ought to be given, not exactly for the purpose of using it but for the purpose of being able to protect the insured person whose interests are sometimes grossly neglected and are often not well looked after under the present system. Therefore I have nut this Clause on the Paper.
§ Mr. HARRY LAWSON
This Clause seems to me to tinker with a very big question. The hon. Member knows as well as I do, when he speaks of a few exceptional cases in which the panel system has broken down, that there are many such cases, and one of the most prominent is that of London.
§ Mr. HARRY LAWSON
In the East End the panel system has to a large extent broken down. The hon. Member contradicts flatly. He is a great authority in the matter, but I do not think he will deny that in the East End of London there has been the greatest dissatisfaction with the working of the panel system. The population of the East End are not very vocal or 3390 voluble; they have not the advantage of having the hon. Member as an advocate to bring forward their case in the House of Commons, but there is not the least doubt that there has been a great paucity of panel doctors, and the hardship has been considerable. I am not going into the question of the firms registered in six boroughs, and the distances the insured person has to go from one borough too another, nor into the other difficulties of working the system. I take the statement of Dr. Roberts, of Stepney, who is very far removed in sympathy from those for whom I act, and he confesses that in his own case it has broken down. He says, "all we can do is to give medicine to those who do not want it. Of real diagnosis there is hardly any." He said that in an interview in the public Press, and he is a very prominent practitioner in the East End. It is a fact that the system has broken down, and what has saved it ties been the great London Hospital, which serves the whole district. But for the action of that hospital, there would have been a complete collapse. Its services have been available to everybody; it did not refuse anyone. The doors have not been shut against a single insured person, and, therefore, the work has been saved.
Let not the Secretary to the Treasury wrap himself up in the belief that in the East of London—I do not know about the South—the Act has been working well with respect to the panel system. It has not worked at all. The Chancellor of the Exchequer said that in time a remedy would be provided because medical men would be attracted to settle in those districts where the panel system was imperfectly worked, and that they would obtain a livelihood there. Whatever the future may bring, that has not been done to a large extent yet. There still remains a great grievance among the bulk of the people, and how it is going to be remedied by this Clause, I do not know. It allows the Insurance Committees to make other arrangements. Does that include, I suppose it would include, the provision of a special service of doctors to whom some premium would be given to settle there, supposing they wish to do so. It is wide enough to cover that. It is a very wide departure, and it merits more explanation than has been given by the Member for Leicester (Mr. Ramsay Macdonald). When you have a great working class district like that, it means that there are hundreds and thousands of insured persons. Is it meant to deal 3391 effectively with those classes? I ask the Secretary to the Treasury to tell us what it is intended to cover. Are we going to have a satisfactory service of panel doctors provided in the East End, or is this merely flying a kite in the hope that something will come of it? If it is intended to suggest to the Insurance Committees of London or in the East End, that they are to take steps to provide a medical service themselves, that is a very big thing and we ought to know something more about. This Clause gives a wide discretion; it makes a great change in the bargain between the Government and the doctors in regard to the panel system, and I think we are entitled to know from the Secretary to the Treasury authoritatively what is intended by it, and what it is likely to bring forth.
§ Mr. MASTERMAN
This Clause does not make such a great change as the hon. Member who has just spoken suggests. In Clause 15, that much discussed Clause, the Commissioners are given an alternative to the panel system. If the panel system breaks down they must be given an alternative.
§ Mr. MASTERMAN
We have been told hundreds of time that the insured persons have got to get medical treatment somehow or another.
§ Mr. MASTERMAN
I am glad to join with the hon. Member in congratulating the great London Hospital on what they have done, and in expressing my gratitude to them and the gratitude of those who are concerned with the working of the Insurance Act. I promised yesterday that I would accept no Amendment which would worsen the position of the doctors on the panel system so long as the panel system works satisfactorily. But supposing there is no panel system, in any district, that no doctors will work on the panel system; supposing again, the doctors who work on the panel system are only that kind of doctor against whom the insured persons feel that they have a grievance, and that they are not being properly treated, the position of the Government is this: They have not entered into a legal contract, but they are under, what I should regard as a binding obligation to supply the insured persons with medical 3392 treatment and attendance. In those circumstances I cannot see how the hon. Member for Mile End (Mr. Lawson) can oppose the Amendment.
§ Mr. MASTERMAN
I hope he will agree that it is a perfectly reasonable suggestion to put this power in the hands of the Commissioners and the Committees. The position then will be that as long as the doctors work under the panel system, arid it is satisfactory, the panel system will continue, as the Government contemplate that it should continue. But if in any district the panel system does not supply the insured persons with the medical treatment for which they have a right to ask, then you must have an alternative. There is an alternative in a sense in Section 15, but it is rather cumbrous and roundabout in operation, and I suggest to the Committee that, being placed in the position of having to provide an alternative, they will be well advised to accept the proposal of the hon. Member for Leicester.
§ Mr. FORSTER
I am sorry I cannot come into line with the right hon. Gentleman on this Amendment. I think it belongs to the category of Clauses which it is desirable we should not press upon the Committee, because I can assure him that there is not that general measure of agreement which would make such a Clause desirable. If he takes the view that a Clause like this should be put into the Bill, I would ask him to do it on the Report stage, which it will be quite possible for him to do, and not to press it to-day. Personally, I think that the powers which are given by the principal Act are sufficient. These enable the Commissioners to give every insured person the opportunity of receiving the medical attention that was promised to them. I am not in the least convinced by anything that I have heard so far that this new Clause is necessary. Perhaps on reflection the right hon. Gentleman will say that it would hardly be fair under the circumstances to press this on the Committee. If he thinks it necessary let him put it forward on Report.
§ Mr. GWYNNE
It seems to me that this Clause opens the door to something quite new. It is importing something quite 3393 fresh into the whole spirit of the Act, and that is this: the medical benefit is in future, if this Clause is passed, as I read it, to be limited to what is practicable, having regard to the funds available for the purpose. There is nothing in the original Act which says that medical benefit has only to be given so far as funds are available. There is a definite undertaking there that medical benefit shall be given. If it cannot be given there is Section 15 of the Act which says that the Commissioners are to make regulations. I was surprised to hear the right hon. Gentleman just now talking about Section 15 as being—I think his words were: "cumbrous and unsatisfactory."
§ Mr. MASTERMAN
I said the methods which would have to be adopted under the Act, if the panel system broke down, were cumbrous and unsatisfactory.
§ Mr. GWYNNE
Well, leave it at that. But has not the right hon. Gentleman told us time after time in the House when we were criticising the arrangements of the Commissioners in connection with Wisbech and other places that it was quite intended in the Act that they should make these arrangements, and that it was perfectly satisfactory? I never heard anything about "cumbrous" then. He apparently did not think it was not quite satisfactory. The suggestion was that these difficulties were being got over, stamps were being put on by the million, and there was no objection to it at all! Now you are bringing this in by this side way! This is an entirely new proposal and as such certainly requires more explanation than the right hon. Gentleman has given. I for one shall most strenuously oppose this Clause, if for no other reason that you are going to try and limit benefits which you already promised men that they should have. You have already compelled them to enter into insurance under certain conditions you are now withdrawing from that. If you refer to the principal Act there is in Section (8), Sub-section (A), paragraph (a), the following:—Medical treatment and attendance, including the provision of proper and sufficient medicines, and such medicines and surgical appliances as may be prescribed by regulations to be made by the Insurance Commissioners (in this Act called medical benefit).3394 I know the Commissioners have made a great many regulations on this subject. Can the right hon. Gentleman point to one in which they have limited medical benefit to such funds as may be available, or that may be available for giving it? It is a definite promise and the right hon. Gentleman has no right now to get out of it by bringing in this proviso which limits it. After all, there is the power at present. If the Commissioners cannot give medical benefit, and if medical benefit cannot be given in a certain district, the proper way is to allow people to contract out and not try to make these "hole-and-corner" arrangements by which they can be given what really the Commissioners or Insurance Committees like—because that is really what it comes to. I hope that hon. Members of this side of the house will press a Division on this point.
§ Mr. WING
I have great pleasure in supporting this Amendment because it seems to me to be an alternative. We have had two different sets of opinion. On the one hand we have had an hon. Member stating that the panel system has practically broken down, and then we have the hon. Member for Sevenoaks saying that everything is perfectly in order.
§ Mr. WING
Both sets of hon. Members cannot be right. I am supporting this resolution in order that the people of East London should have an opportunity of meeting the difficulty which has been described by the hon. Member. I should like to enlarge the scope of the Amendment by giving to approved societies, in addition to the Committees mentioned, power to provide their own medical dispensaries where people are unable to get proper treatment from the panel doctors in the districts. I should like that alternative to be given. Shall I move my Amendment now?
§ The CHAIRMAN
The hon. Member can move his Amendment when it is proposed to add this Clause to the Bill.
§ Mr. BOOTH
I think possibly this addition will make the Clause very contentious indeed. I have an objection to put in the Bill what is likely now to involve the Committee in controversy when trying to get rid of a small difficulty. If it suggested that the approved societies shall organise something in competition to the panel system, speaking myself with a fair oppor- 3395 tunity of knowing, I say they do not want to have any such duty. I want to ask the Government if they consider the Amendment quite satisfactory? If the Government say the words will satisfy the point I will not put forward an Amendment which I have by me on the table, and which I purposed putting forward. It runs this way: "The Commissioners may authorise the Insurance Committees to make such other arrangements"—or may themselves make them. What I want to secure is this, that if the Commissioners authorise a Committee to make some arrangement they will have the final say. It seems to me that under this Amendment that we are discussing the Commissioners may authorise a certain county or a certain committee to make some alternative scheme, and that then the Commissioners are free from all responsibility. I do not know what the Government view of these words is. Is it only that the Insurance Committee may prepare a scheme for approval by the Commissioners, or that the Commissioners themselves may make it, or when they authorise a committee to make a scheme that they must submit that scheme to the Commissioners before it come into operation? Otherwise I think that there would be danger, if it simply means the Commissioners authorising a certain town or a county to make some alternative scheme, that we who administer the Act may find all over the country schemes springing up which are not really defended by the Commissioners at headquarters, therefore I should like to see, if the Commissioners authorise a committee to formulate a scheme that it should came back for the comments of the Commissioners before being adopted.
§ Dr. ADDISON
Section 15, Sub-section (2), paragraph (e), refers to the point raised by the hon. Member for Sevenoaks. It says:—
"Provided that if the Insurance Commissioners are satisfied after inquiry that the practitioners included in any list are not such as to secure practical medical service in any area they may dispense with the necessity of the adoption of such system as aforesaid as respects that area …"
That area, I take it, would be in general the area of the Committee in question. There is nothing in the proposed Clause of my hon. Friend which confers upon the Commissioners any powers at all in addition to these provided in the words I have read out. They are all additional powers 3396 provided, but it does limit them in one sense. Under the principal Act, for example, to take the case put forward by the hon. Gentleman for Mile End—and I am sorry that I contradicted him so brusquely, but it was because I was in such absolute disagreement with him upon a question of fact—assuming what he said is correct, and assuming that in Hackney the system is not satisfactory, it would still be possible to adopt other arrangements for Hackney and not to interfere with the arrangements in other parts of London where they are working satisfactorily; they would have to suspend the panel system as respects that particular area. That practically would be London, south of the Thames. But they would leave alone the area where it was found satisfactory and deal only with the places where it was not. In that case it is a matter of the Commissioners' power under Section 15 (2) of the Act.
§ Mr. HARRY LAWSON
May I ask a plain question as to the difference between the principal Act and this Amending Clause I ask it having regard to the interest of the insured person under the proviso of paragraph (e) of the principal Act, which says that the Commissioners, if they think fit, may do away with the panel system and pay to each insured person a sum equal to the estimated cost of his medical benefit. In the Amending Clause they are to pay what they may, having regard to the funds available for the purpose. What would be the difference in the position of the insured person under this Clause if it be passed into law and his position under the principal Act?
§ Mr. MASTERMAN
As I understand this Clause, if it pass, the whole amount of money available, say, in a district like Hoxton, supposing there was not a satisfactory medical service there or no panel service in the district—if the insurance Committee and the Insurance Commissioners were assured that the insured persons were not receiving satisfactory treatment in the district, you have available for this service the money which is at the present time provided by insured persons and the extra money voted by the Government—half-a-crown for insured persons. They would then be authorised to make a scheme, and to use that money to provide medical benefit for insured persons in that area. Of course, if they decided, for instance, to ask for authorisation to employ a whole-time medical officer, they could provide a much better service than the present. It would be cheaper, though not the same as the 3397 panel system. On the whole, I recognise the action of the hon. Gentleman opposite, but. I ask him to face this question—
§ Question, "That the Committee do continue to sit, notwithstanding the sitting of the House, and apply for leave to sit after 4 o'clock," put, and agreed to.
§ Mr. MASTERMAN
I was saying that I have no objection to this matter being raised upon Report stage, if it be the general wish of the Committee, but I ask hon. Gentlemen opposite to face the fact. This matter has been put to me again and again during the last six months. I ask, suppose you cannot give an efficient medical service under the system laid down in Section 15 (2), are you going to let the insured persons go away without any medical service at all?
I do not think there is the slightest desire on the part of anybody sitting on this side to let the insured persons go without medical service, and for my part it is because I fear that this new Clause will limit the right of the insured person to be provided with medical service that I object to it. Under the original Act, if the Commissioners or Committee cannot give medical benefit in the ordinary way, they are bound to return to the persons in respect of whom they cannot give medical benefit a sum equal to the estimated cost of medical benefit—that is the full sum of 7s. or 7s. 6d., or whatever the actual full sum is. The insured person is entitled to have that money and make provision as best he can for himself. But under the new Clause, as I understand it, the Insurance Commissioners may authorise the Insurance Committee to make such arrangement as they can in any area or part of an area, and they can only get for medical benefit such a sum as the funds available will allow. Within these areas the committee might have set up a quite expensive system which applies only to relatively few of the insured people, and the remaining insured people may not be able to get any benefit, and instead of the 7s. or 7s. 6d. they may only be returned 3s. or 4s. or 5s. That is as I understand the new Clause, and I have not heard anything which in any way removes my fears in that connection. I would ask the Financial Secretary, as he is supporting this Amendment, how this new Clause differs from the powers in the Act, and if it does not do an injustice in the way I have 3398 described? In the principal Act you have the power, if the medical benefits break down, to pay over to the insured persons the full cost. Under this new Clause you have power to pay over something different. In what other way does this new Clause extend the powers of the Act in giving medical benefits already in the Act? In the Act you have the panel system and the alternative to the panel system, full medical service by medical men, or payment in cash. All these ways are in the Act, and as far as I can see there is no new way in this Clause except that it might reduce the money.
I feel bound to oppose this Clause. The Act says that when a person has paid 4d. and his employer 3d. he has a right not merely to medical attendance and treatment, but, as is stated in Section 15 (2),to adequate medical attendance. That Section goes further and says—and the Section is mandatory—that the regulations made by the Insurance Commissioners shall be such as to secure that the insured person shall receive adequate medical attendance and treatment from a medical practitioner. In this Clause you get altered phraseology and instead of adequate medical treatment you have it cut down to satisfactory medical treatment. Who is going to decide what is satisfactory medical treatment? The employed contributors are entitled to adequate medical treatment as defined by the Act. And the Clause goes on to say that the Commissioners may authorise the Insurance Committee to make arrangements for such better medical service as is practicable. What the Act says is that the Insurance Commissioners and the Insurance Committee must themselves provide this adequate medical attendance, and if it is not practical then they have to make it practical. It is their business to put forward a practical scheme, and if Section 15 means anything it means that. If the scheme is impracticable they have to find a way out of the difficulty. Instead of that this Clause would limit Section 8 and Section 15 and is ultra vires of the principal Act. But it does not stop there, for it goes on to say "having regard to the funds available for the purpose." These men have paid money and entered into a contract with the Government and if the funds are not available it is the business of the Insurance Commissioners to see that funds are forthcoming sufficient for the purpose. I shall oppose this Clause because I think it is a breach of contract with the employed contributors under the National Insurance Act.
§ Mr. RAMSAY MACDONALD
I am not in favour of any Clause which is going to worsen the position of the employed contributor under the principal Act. If there is any error in the wording of the Clause which I have moved, I think it could be amended in the ordinary way after the Clause has been read a second time. We know the conditions under which we are working today. It is all very well to say that the commissioners have got power now to deal adequately with insured persons. As a matter of fact that is not the case, judging by experience. As I stated when I moved this Clause, we are having complaints from all over the country, and we are told on very good authority—that is the authority of the Insurance Committees and others we have consulted—that the principal Act does require amending. This Clause has been drafted for the purpose of making that necessary amendment in the Insurance Act. We are determined, as far as we can secure it, that the insured person shall have his medical benefit adequately and properly supplied, and if there is any conspiracy on the part of anybody, either by the paralysis of the panel system or any other part of the machinery necessary for carrying out the principal Act, we are determined to put an end to it. That is why this Clause has been introduced. I am perfectly willing, in view of what has been said, to ask the Committee to allow me to withdraw this Amendment in order that we may reconsider some of the phrasing that has been used in this new Clause, and bring it up on the Report stage. Then we shall see exactly how things stand, and we shall see whether the parties who have spoken in favour of this principle are prepared to support it when we bring it up in the House of Commons. In the interests of insured persons I say that unless some such proposal as this is adopted those interests are going to be sacrificed. Under these circumstances I ask leave to withdraw the Clause.
§ Mr. GOULDING
Before this Clause is withdrawn, I think we ought to consider first whether there is likely to be any opportunity on Report of considering the matter. There is quite a chance that it will not be discussed at all on Report. This point, was raised by the hon. Member for Wilton (Mr. C. Bathurst), and I drew attention to the inadequate treatment given to a girl in one case. I think we had better read this Clause a second time and see if we can amend it, but I am perfectly certain in my own mind, seeing how things are being rushed through, 3400 unless we start here with the foundation for a discussion downstairs, this question may be ignored altogether.
§ Mr. MASTERMAN
The hon. Member is discussing a totally different point. The point dealt with by this new Clause is what is to be provided when there is no panel system. The point which the hon. Member has been discussing is connected with the panel system. I must appeal to the Committee in connection with the arrangement we came to yesterday. The hon. Member for Glasgow asked me a question, and I gave him a very definite answer. He asked me if we would agree, supposing there were no Amendments moved to worsen the condition of the panel doctors, that, no Amendment should be moved to put the balance on the other side. I agreed with him, and I made an arrangement with the hon. Member for Salisbury that his Amendment should not, be moved. Therefore I think it must be on the Report stage that any question should be raised in connection with the medical arrangements of the panel system. The case we are contemplating is where the panel system breaks down. If my hon. Friend can withdraw his Clause and submit a more practical scheme on report whereby no insured person will be worsened, and under which we shall be able to give medical attendance and treatment as good as on the panel system, I will do my best to support such a proposal.
§ Mr. HARRY LAWSON
I am very unwilling to see things left exactly as they are now. There is, however, one thing which you must provide. We must see that every insured person and every employed contributor gets the full benefit he is entitled to under the principal Act.
§ Mr. RAMSAY MACDONALD
I am asking leave to withdraw my Amendment because I understand that there is a general agreement upon the Committee that the intention which we are trying to carry out shall be carried out on Report. The intention is that all insured persons shall have medical benefit on the scale and in accordance with the provisions of the principal Act. I confess what has influenced me is the arguments made against certain words that have been introduced into this new Clause and certain phrases which seem to indicate that if this new Clause was added to the Bill it would lower the standard of medical treatment to which insured persons are entitled. I am not willing to be a party to that. I am prepared to take the risk of 3401 the Report stage, because I am sure, if there is ay sort of general agreement as to our intention, the Government cannot possibly refuse us an opportunity of embodying this new Clause.
§ Mr. CASSEL
The hon. Member says that there is general agreement, but I would like to know exactly what he means. I understand that the hon. Member wishes to secure adequate medical treatment for every insured person through the panel system.
§ Mr. CASSEL
Through the panel system in the first instance, and if not by some other means. If what the hon. Member means is that he intends to secure adequate medical treatment for every insured person, I quite agree with him. The principal Act says that in so many words, and if anybody took the question to a legal tribunal I think that is the way in which it would be decided. Before we come to the conclusion that we are in agreement, I think we ought to understand that point clearly. I understand the hon. Member for Leicester's object is merely to secure adequate medical service for every insured person and I am willing to agree to any Clause which carries out that object.
§ Proposed Clause, by leave, withdrawn.