§ Motion made, and Question proposed.
§ "That a sum, not exceeding £1,825,000, be granted to His Majesty, to defray the Charge which will come in course of payment during the year ending on the 31st day of March, 1913, for Grants-in-Aid of National Health Insurance (United Kingdom), in addition to the sums payable under Section 3 of the National Insurance Act, 1911."
§ Sir F. BANBURY
I want to raise point of Order upon this Vote. There is a footnote to it which I think is absolutely unprecedented. It says:The Grants-in-Aid provided on this Estimate will be paid to the respective Funds and Accounts, and no part of the sums issued out of the Vote will be surrendered to the Exchequer at the close of the year, but any balances standing to the credit of the respective accounts at the end of any financial year will be taken into account in determining the amount of the Grants for subsequent years.I admit is has been occasionally the practice of the House in granting a fixed sum such as a Grant to an exhibition or to the Uganda Railway or something of that sort, to have a footnote to say the sum will not be surrendered, but this is not a similar case. It is not a fixed sum; it is an annual and recurring payment. The last lines of the footnote say this:Any balances standing to the credit of the respective accounts at the end of any financial year, will be taken into account in determining the amount of the Grants for subsequent years.That has never appeared so far as I can ascertain in any Estimate or any Supplementary Estimate, certainly during modern years. This is a very important point. It goes to the root of the financial system of this country. It may be quite right to have something of this sort, but it is a departure from precedent, and it ought 232 not to be entered upon at this time or without due and careful consideration. I have looked at Sir Erskine May's "Parliamentary Practice," page 547, the last edition, and this is what he says:—Under established usage, however, important changes in the customary form of the Estimates should not be made without the previous approval of the Public Accounts Committee, acting on behalf of the House of Commons; and, in deference to this principle, official alterations in the Estimates are restricted to such rearrangements as involve no question of principle.I maintain this involves a very important question of principle. Put shortly it is this: that the annual system of accounts is to be departed from, and we are now under this Vote providing money not for this year but for next year, and actually stating this money is to be provided and is to be deducted from the taxation which may accrue in next year. That is a most important principle. It is a new departure, and therefore it ought not to be entered upon unless the approval of the Public Accounts Committee, on behalf of the House of Commons, has previously been obtained. Of course, it may be open for the Chancellor of the Exchequer to tell me the approval has been obtained, but I venture to say this Vote is out of order and ought not to be put from the Chair.
§ The CHAIRMAN
The hon. Member has raised what no doubt is an extremely important question, but it does not appear to me to be a question of order with which I am concerned. It is for the Government to defend the procedure they propose in this Supplementary Estimate. The hon. Baronet has stated there are numerous precedents for making payments out of the Consolidated Fund before the end of the financial year to some body or persons who may not themselves spend that money till the following financial year. That, of course, is a matter of policy for the Government to defend. I cannot find anything which requires my ruling on the matter.
§ Mr. AUSTEN CHAMBERLAIN
I should have risen at once only that I was under some misapprehension as to the course of the Debate. Since the National Insurance Act became law, I have taken no part in the discussions which have been raised as to the administration of the Act, important though these discussions have been. To-day, if the questions to be raised were merely in connection with the administration of the Act, I doubt if I should have spoken. It is a subject on 233 which other Members are much more competent to speak than I am. My hon. Friend has just put to you as a point of Order what you, indeed, have declared is not a matter of order; but it is a matter of very great financial importance, and I thought, when you explained that it was a matter for the Government to defend and not for you to rule upon, that the Chancellor of the Exchequer was going to give some explanation.
§ The CHANCELLOR of the EXCHEQUER (Mr. Lloyd George)
I propose to do that. The reason I did not get up was that I did not want to make two or three speeches. I thought on the whole it would be better if I heard all the criticisms first. My right hon. Friend (Mr. Masterman) proposes to deal with it. He had not got the precedents with him or he should have risen at that particular moment. He has now got the precedents. I do not propose to make any statement until I hear all the criticisms.
§ Mr. AUSTEN CHAMBERLAIN
I think it would be desirable to keep questions which are wholly distinct in their character distinct in our discussions. One is a question of financial procedure and the preservation of the ordinary rules which govern this House in providing for the services of the country. The others are questions of the methods of administration of the Act. They are quite distinct and it is only the former one which I want to address myself to. As I understand the position, what the Government are doing is to invite the House to vote a large sum—the exact sum I cannot say—which not only have they no expectation of spending within the financial year, but they definitely know they will not spend it in the financial year, They are asking the House to vote money in this financial year in order to provide for the expenditure of another year. That is very unusual. The normal form of our procedure is to grant money to His Majesty for the services of the year and the accounts are based upon the assumption that the money we raise in the year is so much and only so much as is required for the services of each financial year. Neither the raising of the revenue nor the expenditure overlaps from one year into another. The Financial Secretary to the Treasury or the Chancellor of the Exchequer may be able to give the precedents upon which the Government rely. I know there are 234 certain precedents of the class to which you have alluded, but so far as my knowledge goes, they afford no analogy to a case of this kind. The only precedents that I know of are Grants-in-Aid to external authorities. Grants-in-Aid to the Trustees of the British Museum or similar institutions form one of these. But there you give a fixed sum every year, and it is specially provided that they need not spend the sum within the year, because it is more advantageous that they should be able to husband their resources until some opportunity comes where some acquisition is possible for which they require not the Grant of one year, but the Grant of two or three years; and there may be lean years when it is not wise to spend their Grant at all. That is a fixed annual Grant given to them irrespective of whether they spend it in the year or not, or whether they require it in the year or not. There is no analogy there. I put Grants-in-Aid of Exhibitions in the same class, and the only other case I can call to mind is that of Grants-in-Aid of another Government—Grants-in-Aid of the West Indies or East or West Africa or the other Colonies.
These are Grants which are charged upon the expenses of one year here and paid in the same year to the authority of the Colony or Government to which they are given. That is no analogy for paying to one Department of the Government here in this year money which is going only for the next year. That is the one thing to guard against on which all our financial rules have been established. It is a thing against which, or any approach to it, the Public Accounts Committee has jealously protested. If this system is to be established in respect to the National Insurance Act I do not see why it should not be established in respect to the Admiralty or the War Office. It appears to me to break down once the whole system of annual finance upon which our accounts and Budgets are based and to destroy the foundation of our House of Commons' check and control over Ministers and the Sovereign. I should have been glad to have had an explanation from the Government of some primâ facie case for taking this extraordinary step before I made any comment. As no Member of the Government rose, I have risen to explain very briefly what I believe to be the very strong objections on purely financial grounds to the course the Government are taking, without prejudice to the merits of the expenditure on the objects to which it is to be devoted.
§ Mr. CASSEL
I have called attention in the House before to this matter, and I think the Committee should bear in mind, in considering this Vote, the answer given to me by the Prime Minister that no part of this money is required for any period antecedent to the 14th April, 1913. When this question came up on the special Grant I did my best to try to have it discussed in the House before any arrangement was made with the doctors at all. I thought that was the time when the House of Commons ought to have its opportunity of saying what it desired in this matter. I was met with the statement that it had nothing to do with the first three months, that it was going to be paid simply out of the funds already provided under the National Act, and that therefore it was perfectly right to make these definite contracts, which were not subject to the sanction of the House of Commons because the contracts for the first three months were entered into with the doctors without being in any way provisional upon the sanction of the House of Commons. That we acknowledged in the answer of the Prime Minister on the 9th January this year. I asked him:—Whether it is proposed that any additional Grant out of public moneys should be made towards medical benefit in respect of the first three months from the 15th January, 1913: and, if so, when it is proposed to obtain the sanction of the House thereto?His answer was clear and explicit:—The Prime Minister: The answer is in the negative.That is, that no Grant out of public moneys is to be made towards medical benefit in respect of the first three months from the 15th January, 1913. He went on to say:—The whole cost of the provision of medical benefit for the period referred to in the question will be met out of funds available under the National Insurance Act."—[OFFICIAL REPORT, 9th January, 1913, cols. 1373–4.]That was the answer given at a time when I was anxious to obtain a discussion in the House of Commons because, rightly or wrongly, I believed that some of the methods which were being adopted to induce the doctors to go upon the panels were such as ought not to have been adopted, and that some of the courses of action held over their heads were such that legal effect could not be given to them. However that may be, I was met in my endeavours with that statement. Do the Government adhere to the statement of the Prime Minister, which induced me to refrain from further action, that no part of the additional money was in respect of the first three months? If so, this special 236 Grant is only in respect of the period which begins on 14th April, 1913. At the very most you can only ask that in respect of that period one quarter should be paid in advance. May I tell the Committee why it is important from their point of view that they should retain control? I put this not only to Members on this side, but also to hon. Members opposite. The agreements for the first three months are only provisional arrangements, and new arrangements will have to be made with the doctors after that. Before we hand over the money for the whole year we ought to take great care that we still retain control over the new arrangements which may be made. It is really the coming arrangements with the doctors with which we are concerned, and it is in order to retain control over them, quite apart from the great constitutional consideration put forward by my right hon. Friend, that it is vitally important, in the interests of the House of Commons, that we should not grant ahead a year's money to the Commissioners, and in that way place it outside our control altogether. Probably some discussion in this House would lead to very important modifications being made in the new arrangements with the doctors. The House ought to retain its control over those new arrangements.
Upon the constitutional question advanced by my right hon. Friend, you, Sir, said that it was a matter which had to be regarded from the point of view of degree. We are now being asked to double the original Estimate for the year 1912–13. The original Estimate for National Insurance was altogether a little over £2,000,000. We are now asked for another £1,850,000, the bulk of which is not for this year's charges at all. We are asked to pay out of this year's money almost as much again as the original Estimate for what is really not a proper charge on this year. Let me also point out with reference to Section 61 of the Act, to which the Chancellor of the Exchequer referred in answering one of my questions, that that Section deals only with the amount required for medical benefit, which is paid to the Insurance Committees at the commencement of each year. I agree that so far as the amount agreed upon between the societies and the insurance committees is concerned, they will have to pay the whole amount for the year at the commencement. That is no reason why the House of Commons should pay the whole 237 of this special Grant at once. It is rather a reason the other way. At the beginning of the year the insurance committees will be in funds, and will not require the additional Grant except quarterly, as and when the demand for it arises. Under the medical regulations the doctors and chemists send in their bills at the end of the quarter. On that ground I think we ought, apart from the constitutional consideration, only to pay at the most the money for the first quarter, and keep to ourselves control of any subsequent expenditure of this money in regard to a matter about which we know so little, and in regard to which subsequent developments may render it desirable to make alterations.
§ Sir F. BANBURY
May I put my point to the right hon. Gentleman once more? It will be admitted by everyone in the Committee, after the speech of my right hon. Friend and my hon. and learned Friend, that this money is not required for the expenditure of the year; therefore the question arises, Why should we alter the whole system upon which our finance has hitherto been built, a system which has been maintained against every encroachment by the Liberal party, headed by Mr. Gladstone? The fact that the sum is a very large one does not touch the question. The question is, shall we, when we do not require money for the service of the year 1912–13, vote money for the service of the year 1913–14? It is possible that the Secretary to the Treasury will say that according to the provisions of the Act it is better that the year should date from the 1st January rather than 1st April. I gather he will say that from an answer he gave to my hon. and learned Friend (Mr. Cassel). If he says that, I reply that it will make no difference to the doctors whether the financial year begins, as it does for every official or partly official body paid by the Government, on the 1st April or on the 1st January. That is only a question of book-keeping, but it is surely best to have your book-keeping similar in every case. I see there is a foot-note about Section 3 of the National Insurance Act, 1911. That Section does not touch this question at all. If the right hon. Gentleman will turn to page 19 of the Supplementary Estimates he will see it stated that—the Grants-in-Aid will be paid to special accounts in the National Health Insurance Funds for England. Wales, and Scotland, respectively, and will be applied by the several Commissions in Grants by way of 238 additional payments at a rate not exceeding 2s. 6d. for each insured person.That is to say, this is the result of the negotiations between the Chancellor of the Exchequer and the doctors and that their remuneration is to be increased annually by 2s. 6d. a year for each insured person. There is 1½d. per day for the cost of administration, but that really does not touch my point. Section 3 says:—
"Except as otherwise provided by this Act, the funds for providing the benefits conferred by this part of this Act and defraying the expenses of the administration of those benefits shall be derived as to seven-ninths thereof for contributions made by or in respect of provisions by this Act and as to the remaining two-ninths thereof for moneys provided by Parliament."
That does not touch this at all. It has nothing whatever to do with the remuneration of the doctors. I quite admit that in an insurance scheme you must have a fund which gradually will be built up in order to provide for benefits as the demands upon the fund increase, but that is not touched by this. This £1,800,000 will not go to any reserve fund. It will not be expended this year, but in the following year, and therefore Section 3 does not apply in any kind of way. If this is going to be the custom, if there happens to be a surplus at the end of the financial year of, say, £5,000,000, there is nothing to prevent a Supplementary Estimate of £5,000,000 for the Navy being brought down which will not be required for the expenses of the year, but which will have a foot-note to say that it will be deducted from the cost of the Navy in the following year. As a result of that the Act of 1875 will be abrogated and repealed, not by another Act of Parliament, but by a footnote on the Estimate, which is not part of our procedure. You do not put this footnote to the Committee. It is merely a note put for the guidance of the Committee. It is not part of our procedure, and you cannot repeal an Act of Parliament by a foot-note to a Supplementary Estimate.
I believe every single Member of the Committee who has taken any interest in finance will agree with me that the real reason of this proceeding is that the Chancellor of the Exchequer expects that he will have a surplus at the end of this year. That surplus will have to go, under the Old Sinking Fund, to the reduction of the National Debt, and the Chancellor of the 239 Exchequer also fancies that next year he will have to provide increased taxation to pay for the doctors and for other extravagances of this Administration. Being an extremely acute person he has said, "How can I get over this difficulty? I have a surplus at the end of the year. By the Act of 1875 I am bound to surrender it in order that the Commissioners of National Debt may pay off debt, but I will avoid that by bringing in a Supplementary Estimate, trusting that the Opposition will be asleep and will not notice this foot-note." Consequently the Chancellor of the Exchequer will be doing what he tried to do last year and appropriating the Sinking Fund to purposes for which it was never intended. This is too important to be treated as a party question, because it goes absolutely to the whole root and foundation of our financial system. The whole idea of our financial system is that the accounts and expenditure of each year shall balance and that any surplus shall be devoted to a certain purpose as provided by Act of Parliament. Now comes the Chancellor of the Exchequer and asks us to do away with all that, and to allow him to use the surplus, which ought to be used for the redemption of debt, for this particular purpose. Whatever the purpose is, good or bad, does not matter. I am not arguing this from the point of view of whether there ought to be an additional payment to the doctors or what it should be. I am arguing it solely upon the ground that it is a departure, and a bad departure, from that system which has been the strength of this country and the admiration of everyone and every Parliament in the world. We have suffered a good deal, at least we think we have, for the vagaries of right hon. Gentlemen opposite. Do not let them add to all that by upsetting our financial system. It cannot make any difference to them. If it is necessary to have additional taxation, let us say so. Do not let us attempt to conceal anything. Let us have the additional taxation and proceed in a decent and orderly manner, but do not let us, by foot-notes and other subterfuges, endeavour to evade an Act of Parliament, and a tradition which has been maintained for years by both sides of the House.
§ The FINANCIAL SECRETARY to the TREASURY (Mr. Masterman)
The hon. Baronet, in his concluding remarks, has read into this Supplementary Estimate 240 something which certainly is not there, being, as he said, suspicious of my right hon. Friend.
§ Mr. MASTERMAN
Two challenges have been made to this particular Estimate. One is the general challenge of the question of a Grant-in-Aid and the question whether money should be surrendered when it is voted as a Grant-in-Aid at the end of the financial year. The other is the question raised, more especially by the hon. and learned Gentleman (Mr. Cassel), why it was desirable to vote this money for this particular purpose at this particular time. On the question of the Grant-in-Aid, the hon. Baronet, I know, with his large financial experience, will ralise that the granting of Votes-in-Aid does not come under the same condition as the granting of Votes in the ordinary Estimates. This House, in dealing with financial matters, has always proceeded along one of two ways, and has always kept open both ways as being desirable. One has been to present Estimates as detailed Votes, to discuss and to approve detailed Votes of each particular item in that Estimate, to vote that money in the Appropriation Act, and, under conditions laid down by Statute, the money which has not been spent on any particular Vote is surrendered on 31st March. But it has also retained an alternative method and that is to vote moneys as Grants-in-Aid to particular services in which no detailed Estimate is given in the form of detailed Votes and in which there is no surrender at the end of the financial year, and always on the face of the Estimate that statement is borne, as the statement is borne on the face of this Estimate. I need hardly state that this footnote makes no difference to the Estimate at all. It is merely for explanation. The Estimate stands or falls and you cannot alter or influence the action of the House by footnotes on Estimates.
The right hon. Gentleman (Mr. Austen Chamberlain). I think, stated that Grants-in-Aid were only given in cases in which the funds to which the money was given in aid was something quite independent of the central Government, such as distant Colonial services, but that is no so. Of course, there are a large number of funds at present open, similar to the National Insurance Fund, to which the State from time to time, as necessity arises, votes money in the form of Grants-in-Aid which 241 are not surrendered at the close of the financial year. Take, for example, the Development Fund. That fund was formed in an Estimate of 1910–11, and £400,000 was voted as a Grant-in-Aid of it. It was paid for, and I do not think any of the money was spent during the financial year nor was it surrendered at the end of the financial year. But it was given and from time to time further sums have been given from the Consolidated Fund into the Development Fund. Of course, if none of this money is paid out actually from the Consolidated Fund into the National Insurance Fund by the end of the financial year that money will be surrendered, as all other money is surrendered, and ultimately falls into the Sinking Fund. The National Insurance Fund is a different fund and directed to different purposes. None of the money paid into the National Insurance Fund ever reaches the Consolidated Fund. Take another case—the Small Holdings Fund which was instituted when the Small Holdings Act was passed. The money was voted as a Grant-in-Aid to the Small Holdings Account, and money has been voted from time to time to the Small Holdings Account. The Small Holdings Account is a separate account from the Consolidated Fund, and Parliament decided that the Commissioners would receive by Grants-in-Aid money from time to time to carry on the work of the Small Holdings Account.
§ Mr. AUSTEN CHAMBERLAIN
The right hon. Gentleman says that the money expended under these Grants would be audited by separate auditors. What, then, is the meaning of the statement that the amount will be audited by the Comptroller and Auditor-General?
§ Mr. MASTERMAN
The detailed accounts of the money spent by the National Insurance Fund will be audited by the auditors of the Insurance Fund. When money has been liberated and paid to the National Insurance Fund all that has to be shown to the Comptroller and Auditor-General is that the money has been spent under the National Insurance scheme.
§ Mr. AUSTEN CHAMBERLAIN
If the right hon. Gentleman will look at the note he will see that it is not the payments to the separate account that will be audited by the Comptroller and Auditor-General, but the expenditure out of the special account into which this money is payable.
§ Mr. MASTERMAN
The right hon. Gentleman will see that the money has to be spent in accordance with the scheme which is subject to the consent of the Treasury. The right hon. Gentleman will see from the footnote that the Comptroller and Auditor-General will have to see that the money is spent in accordance with the scheme. The detailed audit of the National Insurance Fund is performed by the auditor of that fund.
§ Sir F. BANBURY
The note says that the expenditure out of the special accounts will be audited by the Comptroller and Auditor-General. Then, on page 19 of the Supplementary Estimates it is stated that the Grants-in-Aid are to the National Insurance Fund, and therefore it is the special account that will be audited by the Comptroller and Auditor-General.
§ Mr. MASTERMAN
No, I do not think that is so. The Comptroller and Auditor-General has to see that the money is spent in accordance with the scheme which is laid down, but the detailed audit of these accounts rests with the auditor of the-National Insurance Fund.
§ Sir F. BANBURY
May I point out to the right hon. Gentleman that there is nothing on page 19 about the Special Grants being audited in that way, but if he will turn to the note on page 18 he will see that the expenditure out of these Special Grants will be audited by the Comptroller and Auditor-General.
§ Mr. MASTERMAN
The Comptroller and Auditor-General controls the Grants under the scheme to the Committees, but the Grants out of the National Insurance Fund and the detailed audit of the Grants are not under the control of the Comptroller and Auditor-General, but under the control of the National Insurance Fund, and unless this money is paid from the Consolidated Fund before 31st March, then, I agree, it must be surrendered to the extent that it is unexpended. I could quote a large number of Grants-in-Aid given from time to time—some of them, I think, when the right hon. Gentleman the Member for East Worcestershire was Chancellor of the Exchequer. When he 243 was in office there were Supplementary Estimates for £8,000,000, partly in the form of Grants and partly in the form of loans for South African purposes. That was not surrendered at the end of—
§ Mr. AUSTEN CHAMBERLAIN
It would be more to the point if the right hon. Gentleman would give a single instance of a Grant for a continuous and fluctuating service.
§ Mr. MASTERMAN
There are certain services with annual expenditure for which Grants-in-Aid are paid from time to time. For instance, the Small Holdings Account is for the general assistance of small holders, and Grants have to be made to it from time to time. Take the Teachers' Pension Fund, of which the system was established by Sir Michael Hicks-Beach, now Lord St. Aldwyn, who was, if ever anyone was, a purist in matters of finance. The Grants-in-Aid which are paid to that fund are not subject to surrender, and the expenditure to the teachers is paid many years after it is actually paid into the Pension Fund. The right hon. Gentleman has given Grants to the Universities and Colleges Fund. As I have said, there was over £8,000,000 voted after the South African war, although none of the money was contemplated to be spent in the year. I do not know whether that was to avoid a surplus or not. The hon. Baronet seems to think that is the object in this ease. I think I have shown that we have followed precedent and what Parliament has always recognised as a desirable thing to do.
I now come to the point why, in this National Insurance matter, we have done this. The hon. and learned Gentleman is perfectly correct in saying that this has not been pursued before, but it has been pursued in connection with the National Insurance Act in regard to this very benefit. What are the conditions? The conditions laid down are that at the beginning of the year, on 1st January, there is to be paid to the National Insurance Fund, or credited to the fund by the insurance committee, the full medical benefit for the twelve months. Why did the House decide on that? It was that the insurance committee should be able to make contracts for the year with doctors, and that is where the hon. Gentleman falls into a misunderstanding in connection with the 244 expenses required for the year. It is perfectly true, as I have said in reply to many questions, that the National Insurance Fund can meet the first quarter for medical benefit without the assistance of Grants-in-Aid, but it is not true that the National Insurance Fund should only pay the first quarter to the National Insurance Committee. The Act definitely lays down that it must be credited for the whole of the calendar year, from January to January.
§ Mr. MASTERMAN
I would refer hon. Members to Clause 61 of the Act, which deals with that point. I assure the hon. Member opposite (Mr. Cassel) that the matter was discussed in the House at the time, and it was decided that it was essential that the insurance committees should be able to make contracts under the Act for twelve months.
§ Mr. AUSTEN CHAMBERLAIN
I do not think the right hon. Gentleman understood my point. I do not dispute the statement that the money has to be paid at the commencement of the year for the year. It does not say it is to be the commencement of the calendar year. Our financial year is not the calendar year.
§ Mr. MASTERMAN
In any year, at the commencement of the year. The year referred to in the National Insurance Act is the year commencing on 15th January, six months after the Act comes into operation. Not only so, but last year, without any opposition from hon. Gentlemen opposite, this was done. The Estimates for the National Insurance Act, which were presented last year, included the sum for medical benefits, not up to the 31st of March this year, but the sum which would have to be credited to the insurance committees on 15th January for the whole of the year up to the following January. All we are now doing is getting a Grant-in-Aid supplementary to the service which we voted last year for the whole of the twelve months. The hon. Gentleman misunderstands when he talks about public money. It is perfectly true so far as the Consolidated Fund and the central Executive are concerned that the money is not required before the 31st of March. The money is required for the Insurance Fund if the Insurance Commissioners are to be credited 245 with the money which they have a right to expect under Clause 61 of the Act. The insurance committees are independent bodies, and it would be just as absurd to say that if you gave a Grant-in-Aid to a local authority all the moneys spent by the local authority would have to be spent in the financial year as to say that all the money credited to the insurance comet must be spent in the financial year. That is a reason why in the strictest and purest financial view the Supplementary, Estimates should be taken at this time, so that at the earliest possible moment the insurance committees should be credited with the whole of the money required for the whole year, so as to be able to do what the Act requires, to enter into contracts of service for the whole year.
Over and above that I am amazed at the action taken by the hon. and learned Gentleman. Week after week he was pressing me for the voting of this money. I said we were under no commitment to spend this money up to next April because the National Insurance Fund could bear the amount for the first quarter. But he said, "You are entering into moral obligations which will last beyond the quarter, for the whole year, and Parliament ought to vote the money in order that those moral obligations may be carried out." Not only that, but the fact that we have entered into contracts with the doctors for only the first three months has given rise to every kind of malignant suggestion that we do not intend to carry on those contracts beyond those first three months, and that the National Insurance Fund has not got the money to carry on those contracts for the whole year. Friendly societies have been told that Parliament has not voted, and probably will not vote the money, or if a Conservative Government comes in the Act will be repealed, and they have been told therefore, instead of this extra half-crown being provided from money voted by Parliament the ordinary money which is required for sickness benefit would be raided to that amount, and consequently there a good deal of apprehension as to what will happen. The course adopted is one urged under the strongest pressure by the hon. and learned Gentleman who now turns completely round, and is a system which will allow this House definitely to say whether it wants this money to go to the doctors or not, and such a Vote will enable the insurance committees to do what this House desired them to do at the 246 beginning of the year, that is to enter into a contract with the doctors, not for a quarter, but for the whole year for the full amount which the doctors have a right to expect for the year. We are following precedent, we are following accurate finance in connection with this Vote in aid of services for which we voted the entire amount last year. We are simply carrying out what I think is absolutely necessary in view of what has been said all over the country in order that men may be sure that they will get the money through the money being voted by Parliament.
§ Sir F. BANBURY
In order to show my appreciation of the explanation given by the right hon. Gentleman I move, "That Item A (National Health Insurance Fund, England) be reduced by the sum of £500."
§ 1.0 P.M.
§ Mr. CASSEL
The right hon. Gentleman, in making a personal reference to me, said that my attitude was inconsistent. That is not so at all. What I endeavoured to obtain was that there should be a discussion in this House before the first three months were arranged with the doctors. That is the whole point to which I addressed my attention. When once you have made arrangements for more than the 6s. 6d. in the original estimate for the first three months it practically commits this House for all time.
§ Mr. MASTERMAN
I have already stated that those hon. Gentlemen understood that the original Estimate was not for the first three months. We had already voted money for the doctors for the whole of the twelve months. This is a Grant-in-Aid there.
§ Mr. CASSEL
It was in reference to a Grant-in-Aid that was contemplated that I pressed the right hon. Gentleman it should be discussed before any arrangement for any period at all was made. That was refused on the ground that those first three months were not covered by the additional Grant. But now that the fresh arrangement has been made and is going to be continued, my contention was not that no Vote should be allowed at all, but that we should only deal with what was required, namely, the first quarter, in accordance with our ordinary practice, any subsequent amount required to be dealt with on a subsequent Vote. I do not wish in the least to suggest that the additional remuneration should not be 247 given. What I had originally intended was that there should be a discussion on any arrangement going on for three months. That was refused, and now there is nothing inconsistent in saying that we should only give such amount as is required for the time being.
§ Mr. BOOTH
I am indeed astonished at the action of the hon. and learned Gentleman. I give him credit for being one of the few patient attendants at the Debates on the Insurance Act. Those who did not attend were generally going about the country saying that the Act was not discussed. Those who did attend I do not think would have been guilty of that untrue observation. But the hon. Member did attend, and in most cases I think the House generally felt that he had some definite contribution to make when he intervened. I am sorry therefore that he should have taken up the attitude which he has taken up to-day, if he is going to support this reduction of £500, because what is his complaint? He has drawn the attention of the Government to the fact that moral obligations have been incurred, that arrangements are being projected and discussed with a great and noble profession which involve their bread-and-cheese as well as their ordinary expenses for at least twelve months, and the hon. and learned Gentleman comes down and reminds the Government that this is a matter of supreme importance and should be brought to the attention of the House. The Government bring it to the attention of the House and give it first place to-day. They make a clear statement, and so anxious are they to fall in with the hon. and learned Member's idea that they provide for the full twelve months which is a matter of such distressing concern to the hon. and learned Member and his Friends. When they find that the Government are doing exactly what he asks in a straightforward way, then they become more uneasy. The hon. and learned Member wants to do what the hon. and learned Member for Cork (Mr. T. M. Healy) suggested yesterday we should occupy our time in doing, that every Committee stage should be occupied in hammering a Minister. That is what I understood the hon. and learned Gentleman to say as an old Parliamentary hand. The hon. and learned Member (Mr. Cassel) is of the same opinion. He is consumed with the idea that the one thing to do to-day is to hammer the Minister. Hon. 248 Members opposite, I am firmly convinced, do not want the Government to do what is right in this question. They want a grievance. They want something with which they can go into by-elections; and the welfare of the medical profession, which ought to be our chief concern to-day, and perhaps something even higher and nobler than that, the welfare of the patients who are to be attended, will be put back later and later until hon. Members run away to luncheon, having consumed the time in these legal quibbles. I quite agree that the right hon. Gentleman, who is a purist in finance, is taking the right stand; but when the hon. and learned Member, who is really concerned about proper provision being made for the twelve months, occupies time in discussion from this standpoint—
§ Mr. BOOTH
I have not yet begun to take my orders from the right hon. Gentleman opposite. [An HON. MEMBER: "Nor his party."] I ant not surprised to hear the Front Opposition Bench repeatedly asking for the Closure. This is a Debate affecting the welfare of fifteen millions of insured persons and the medical profession, and immediately an hon. Member on the back benches of this side of the House, who has facts and figures in his possession, rises to take part in the discussion the right hon. Gentleman asks to apply the Closure.
§ Mr. AUSTEN CHAMBERLAIN
If the hon. Member will permit me, my observation was called forth by his remark that this discussion was a waste of time, and if that be so, why should he prolong it?
§ Mr. BOOTH
I am not prolonging it. I got up to deal it its death blow. I got up with the intention, and, I believe, I will execute it, that no more hon. Members on the other side shall rise to cut so sorry a figure as those who have already spoken. After all we have got an Amendment before the House to reduce this item by £500. I defy the hon. Member for Colchester (Mr. Worthington-Evans) to support the reduction. The hon. Member went down to Colchester and boasted to his constituents that he had breakfasted with the Chancellor of the Exchequer, and I do not think that he will follow the example of the hon. and learned Member 249 for St. Pancras (Mr. Cassel). Before the Committee goes into the general discussion upon medical benefit, I should like to state some important facts which have been compiled only this week, and, if I may modestly say so, which are not in the possession of any one else. The Committee is aware that even the Insurance Commissioners are not in a position to give exact figures of what has happened week by week in the homes of the poor in the administration of these benefits, and, before we pass to a discussion of the position and remuneration of the doctors, it may be interesting to hear a few figures as to what has actually taken place. The common idea among the doctors was that they Would get a certain amount per head for each patient. One of the chief difficulties I have experienced in going about the country and in having interviews with medical men, which were arranged for me through the instrumentality of friends, was that the doctors were under the impression that they would be paid so much per head per patient. They did not seem to realise that it meant that the insured person's would be so many annual subscribers to their remuneration, and that the number to be actually treated would be very small. I am able to give the Committee the figures relating to 5,000,000 insured persons. It is quite true they are furnished by societies most in touch with the insured classes, and perhaps the best organised to supply returns quickly. I do not claim for those societies any merits as against other approved societies, but it will be admitted that the industrial and collecting societies generally are well organised to pay weekly visits to insured members, I find that out of 5,000,000 insured persons there are about 5,600 receiving weekly maternity benefit. I am mot now mentioning some prophetic forecast; I am stating what is actually going on.
§ This present week, in connection with societies dealing with 5,000,000 persons, there are out of that total, 6,500 maternity claims of 30s.
§ Mr. FORSTER
On a point of Order, Sir. How does the hon. Gentleman bring in maternity benefit on this Vote?
§ The CHAIRMAN
Perhaps I had better point out what is the effect of the Amendment to reduce the item by £500. The effect of it is, for the time being, to confine the discussion to the question of medical benefit in England, and no reference to Wales, Scotland, or Ireland will be in order until that has been disposed of.
§ Mr. LLOYD GEORGE
Although on the Amendment we are confined to a discussion of medical benefit in England, I think it is rather undesirable to split up the Debate in that way, and, unless the hon. Baronet is really very anxious to go to a Division on this point, I would suggest that he might withdraw the Amendment.
§ Sir F. BANBURY
It is really a very important financial point on which we should have a Division, and we could discuss the general question afterwards.
§ Mr. LLOYD GEORGE
That is a very relevant interruption, and I accept it without a word. I think we might have a Division on the Amendment, and then proceed to the general discussion.
§ Question put, "That item A (National Health Insurance Fund, England) be reduced by £500."
§ The Committee divided: Ayes, 50; Noes, 206.251
|Division No. 584.]||AYES.||[1.14 p.m.|
|Anstruther-Gray, Major William||Fletcher, John Samuel||Mills, Hon. Charles Thomas|
|Barrie, H. T.||Forster, Henry William||Newton, Harry Kottingham|
|Bathurst, Hon. A. B. (Glouc., E.)||Gibbs, George Abraham||Peto, Basil Edward|
|Bathurst, Charles (Wilts, Wilton)||Gilmour, Captain J.||Rees, Sir J. D.|
|Boyton, James||Grant, J. A.||Samuel, Sir Harry (Norwood)|
|Burn, Colonel C. R.||Guinness, Hon. W. E. (Bury S.Edmunds)||Sanders, Robert A.|
|Campion, W. R.||Gwynne, R. S. (Sussex, Eastbourne)||Stan ier, Beville|
|Cater, John||Harris, Henry Percy||Stanley, Hon. G. F. (Preston)|
|Cautley, Henry Strother||Harrison-Broadley, H. B.||Talbot, Lord Edmund|
|Chaloner, Col. R. G. W.||Henderson Major H. (Berks, Abingdon)||Thynne, Lord Alexander|
|Chamberlain, Rt. Hon. J. A. (Worc'r.)||Herbert, Hon. A. (Somerset, S.)||Tullibardine, Marquess of|
|Clive, Captain Percy Archer||Hewins, William Albert Samuel||Willoughby, Major Hon. Claud|
|Cooper, Richard Ashmole||Hope, Major J. A. (Midlothian)||Worthington-Evans, L.|
|Craig, Captain James (Down, E.)||Ingleby, Holcombe||Yate, Col. C. E.|
|Crichton-Stuart, Lord Ninian||Jessel, Captain H. M.|
|Dalrymple, Viscount||Locker-Lampson, G. (Salisbury)||TELLERS FOR THE AYES.—Sir F. Banbury and Mr. Cassel.|
|Eyres-Monsell, Bolton M.||Lyttelton, Hon. J. C. (Droitwich)|
|Falle, B. G.||Mason, James F. (Windsor)|
|Abraham, William (Dublin, Harbour)||Harmsworth, R. L. (Caithness-shire)||O'Malley, William|
|Acland, Francis Dyke||Harvey, T. E. (Leeds, West)||O Neill, Dr. Charles (Armagh, S.)|
|Addison, Dr. C.||Hayden, John Patrick||O'Shaughnessy, P. J.|
|Ainsworth, John Stirling||Hazleton, Richard||O'Shee, James John|
|Alden, Percy||Herbert, General Sir Ivor (Mon., S.)||O'Sullivan, Timothy|
|Allen, Rt. Hon. Charles P. (Stroud)||Hlgham, John Sharp||Outhwaite, R. L.|
|Balfour, Sir Robert (Lanark)||Hinds, John||Parker, James (Halifax)|
|Barnes, G. N.||Hogg, David C.||Parry, Thomas H.|
|Barton, William||Hogge, James Myles||Pearson, Hon. Weetman H. M.|
|Beale, Sir William Phipson||Holmes, Daniel Turner||Pease, Rt. Hon. Joseph A. (Rotherham)|
|Beck, Arthur Cecil||Home. C. Silvester (Ipswich)||Phillips, John (Longford, S.)|
|Benn, W. W. (Tower Hamlets, St. Geo.)||Howard, Hon. Geoffrey||Ponsonby, Arthur A. W. H.|
|Boland, John Pius||Hughes, Spencer Leigh||Price, C. E. (Edinburgh, Central)|
|Booth, Frederick Handel||Jardine, Sir J. (Roxburgh)||Prlngle, William M. R.|
|Sowerman, C. W.||Jones, Edgar (Merthyr Tydvil)||Radford, G. H.|
|Boyle, Daniel (Mayo, North)||Jones, J. Towyn (Carmarthen, East)||Raffan, Peter Wilson|
|Brady, P. J.||Jones, Leif Stratten (Rusticliffe)||Rea, Rt. Hon. Russell (South Shields)|
|Bryce, J. Annan||Jones, William (Carnarvonshire)||Rea, Walter Russell (Scarborough)|
|Buckmaster, Stanley O.||Jones, W. S. Glyn- (T. H'mts, Stepney)||Reddy, Michael|
|Burke, E. Havlland-||Jowett, Frederick William||Redmond, William (Clare, E.)|
|Burns, Rt. Hon. John||Joyce, Michael||Redmond, William Archer (Tyrone, E.)|
|Buxton, Noel (Norfolk, N.)||Keating, Matthew||Richardson, Thomas (Whitehaven)|
|Byles, Sir William Pollard||Kellaway, Frederick George||Roberts, Charles H. (Lincoln)|
|Carr-Gornrn, H. W.||Kennedy, Vincent Paul||Roberts, George H. (Norwich)|
|Cawley, H. T. (Heywood)||Kilbride, Denis||Robertson, Sir G. Scott (Bradford)|
|Chancellor, Henry George||King, Joseph||Robinson, Sidney|
|Chapple, Dr. William Allen||Lardner, James Carrige Rushe||Roch, Walter F.|
|Clancy, John Joseph||Law, Hugh A. (Donegal, West)||Roche, Augustine (Louth)|
|Clough, William||Lawson, Sir W. (Cumb'rld, Cockerm'th)||Rowlands, James|
|Collins, G. P. (Greenock)||Leach, Charles||Russell, Rt Hon. Thomas W.|
|Collins, Stephen (Lambeth)||Lewis, John Herbert||Samuel, Rt. Hon. H. L. (Cleveland)|
|Cotton, William Francis||Low, Sir Frederick (Norwich)||Scanlan, Thomas|
|Crawshay-Williams, Eliot||Lundon, Thomas||Scott, A. MacCallum (Glas., Bridgeton?|
|Crean, Eugene||Lyell, Charles Henry||Seely, Col. Rt. Hon. J. E. B.|
|Crooks, William||Lynch, Arthur Alfred||Sheehy, David|
|Crumley, Patrick||Macdonald, J. M. (Falkirk Burghs)||Sherwell, Arthur James|
|Cullinan, J.||McGhee, Richard||Smyth, Thomas F. (Leitrim, S.)|
|Davies, Timothy (Lines., Louth)||Macnamara, Rt. Hon. Dr. T. J.||Strauss, Edward A. (Southwark, West,|
|Dawes, J. A.||MacNeill, J. G. Swift (Donegal, South)||Sutherland, John E.|
|Delany, William||MacVeagh, Jeremiah||Sutton, John|
|Denman, Hon. R. D.||M'Callum, Sir John M.||Tennant, Harold John|
|Dewar, Sir J. A.||M'Laren, Hon. F.W.S. (Lincs.,Spaldlng)||Thorne, G. R. (Wolverhampton)|
|Dickinson, W. H.||M'Micking, Major Gilbert||Thorne, William (West Ham)|
|Donelan, Captain A.||Martin, Joseph||Trevelyan. Charles Philips|
|Doris, William||Mason, David M., (Coventry)||Verney, Sir Harry|
|Duffy, William J.||Masterman, Rt. Hon. C. F. G.||Wadsworth, John|
|Edwards, Sir Francis (Radnor)||Meagher, Michael||Walsh, Stephen (Lanes., Ince)|
|Elverston, Sir Harold||Meehan, Francis E. (Leitrim, N.)||Ward, John (Stoke-upon-Trent)|
|Esslemont, George Birnie||Millar, James Duncan||Wardle, George J.|
|Farrelt, James Patrick||Molloy, Michael||Warner, Sir Thomas Courtenay|
|Ferens, Rt. Hon. Thomas Robinson||Mond, Sir Alfred M.||Wason, Rt. Hon. (Clackmannan)|
|Ffrench, Peter||Money, L. G. Chiozza||Wason, John Cathcart (Orkney)|
|Field, William||Mooney, John J.||Watt, Henry A.|
|Flavin, Michael Joseph||Morgan, George Hay||Webb, H.|
|George, Rt. Hon. D. Lloyd||Morison, Hector||Wedgwood, Josiah C.|
|Ginnell, L.||Muldoon, John||White, J. Dundas (Glasgow, Tradeston)|
|Gladstone, W. G. C.||Munro, Robert||White, Patrick (Meath, North)|
|Glanville, H. J.||Munro-Ferguson, Rt. Hon. R. C.||Whitehouse, John Howard|
|Goldstone. Frank||Murray, Captain Hon. Arthur C.||Whyte, A. F,|
|Greenwood, Granville G. (Peterborough)||Neilson. Francis||Wllkie, Alexander|
|Greenwood, Hamar (Sunderland)||Nolan, Joseph||Williams, Llewelyn (Carmarthen)|
|Griffith, Ellis J.||Norton, Captain Cecil W.||Williams, Penry (Middlesbrough)|
|Guest, Hon. Major C. H. C. (Pembroke)||Nugent, Sir Walter Richard||Wilson, W. T. (Westhoughton)|
|Guest, Hon. Frederick E. (Dorset, E.)||O'Brien, Patrick (Kilkenny)||Wood, Rt. Hon. T. McKlnnon (Glas.)|
|Gwynn, Stephen Lucius (Galway)||O'Brien. William (Cork)||Young, W. (Perthshire, E.)|
|Hackett, John||O'Connor, T. P. (Liverpool)||Yoxall, Sir James Henry|
|Hancock, J. G.||O'Doherty, Philip|
|Harcourt, Rt. Hon. Lewis (Rosscndalc)||O'Dowd, John||TELLERS FOR THE NOES.?Mr. lltingworth and Mr. Gulland.|
|Harcourt, Robert V. (Montrose)||O'Grady, James|
|Harmsworth, Cecil (Luton, Beds)||O'Kelly, Edward P. (Wicklow, W.)|
Question put, and agreed to.
§ Original Question again proposed.
§ Mr. BOOTH
I have no special claim to speak about the medical profession except to assure the Committee on behalf of the approved societies, for which I have any right to speak, that there is not the 252 slightest antagonistic feeling on their part against the medical profession now that the controversy is over. I would rather prefer that anything I should say should be a welcome to the members of that noble and self-sacrificing profession to their work under the Act. I do not think it would be 253 unbecoming to say, on behalf of the great insurance corporations, that they have never taken up a position hostile to the medical profession upon any of these points. They simply stood aside and watched the negotiations, and now that an agreement has been come to, although I personally think the amount now granted to the medical profession is very handsome, still I advise that we should sink all expressions of regret and unite in welcoming this profession in giving its best services under the Act. I would like to assure the medical profession that they are not coming in to an overwhelmingly burdensome and harassing work. They will find the work under the Act congenial to them, and they will find the approved societies trying to smooth the way as far as possible, so that the co-operation may be harmonious and the best services given to the insured persons. The Committee will remember, when the Division took place, I was saying that out of five millions of insured persons weekly maternity benefits last week and this totalled 6,500 weekly. Those are not organisations which select their members entirely from a particular class. In the selection they have opened the doors wide and they have dispensed with medical examination on entry, and have only sought to receive the average insured persons, and have welcomed the ordinary normal persons into their society. The sickness pay—
§ Mr. FORSTER
I do not wish to interrupt or to offer any discourtesy to the hon. Gentleman, but I should like to ask the ruling of the Chairman as to the limits within which this discussion will be confined. As I understand, this Estimate relates only to medical benefits. Should we be in order in referring to any aspects of the working of the Insurance Act outside the medical aspect?
§ Mr. BOOTH
May I say exactly what it is I am seeking to prove. Under this arrangement, for which this Estimate provides a fixed pay on business lines for the doctors for twelve months, I want the Committee exactly to see what the position of the doctors will be, so that the Committee can judge if the remuneration is fair. A large portion of this maternity money must go to the medical profession. That has been passed without challenge, and I am now coming on to the actual sickness cases. Those cases must be patients of the doctors, and therefore I submit I am in order.
§ The CHAIRMAN
Only for expenses of administration of medical benefit. This Vote is for additional money towards the payment of the doctors and I think it necessarily raises the whole question of the arrangement that has been made with the doctors. Further than that I do not think it goes, and I think the Debate ought to be confined to that. I understood the hon. Member (Mr. Booth) in his figures was addressing himself to the point of whether or not the arrangement now made with the doctors was an adequate one.
§ Mr. GEORGE ROBERTS
May I ask whether your ruling also covers the arrangements made with the chemists?
§ Mr. MASTERMAN
I may point out that this money is a Grant-in-Aid for the medical benefit, which includes the provision of drugs.
§ The CHAIRMAN
That is true. It includes the provision of drugs. An hon. Member has asked me privately a question as to registered or unregistered chemists. That, I am afraid, does not come in. That, I think, must be dealt with on the Act, and is not a matter to be raised on the Estimate.
I take it that you are not ruling at this moment with regard to the question of registered or unregistered chemists. I wish to say a few words on that question, but it does not seem to me to arise now. Would it not be as well to wait until a Member wishes to speak on the question, and let the point of Order be taken then?
§ Mr. BOOTH
The number of sickness cases among 5,000,000 insured persons is 36,000 per week, and they receive 9s. each as sickness pay. This is not a mere estimate; these are sickness claims actually being paid. Each one of these cases, I frankly admit, means a case for the doctor. I do not suggest that the doctor's work is confined to these cases, but these will be the cases which demand most attention. It is quite true that people who do not draw sickness pay may require a doctor, but those cases cannot take a large amount of the doctor's time, because people who are able to pursue their work and do not claim sickness pay, while they may require 255 medical attendance, cannot be considered as burdensome patients in the same way as those who are so ill that they cannot go to work. These figures convey to me that a huge and mighty machine has commenced work. I will not go into the controversy whether it ought to have started later or earlier, or whether the machine is perfect or not. What I want the House to realise is that the machine is getting into its stroke, that the Act is in full operation, and that it will be a terrible thing, for party purposes, or from mere quibbling about machinery and detail, to try to put a spoke in the wheel of the machine or to interfere with its beneficent work.
I do not propose to follow the hon. Member opposite with regard to the number of maternity and sickness claims, because it seems to me that this Estimate is confined to medical benefit, and there is already such a large field to cover if the Committee is to consider the administration of medical benefit, that it would be impossible within the ordinary limits of time to deal with anything outside the strict limits of the Estimate. Every Member of the Committee will admit that this is one of the most important and serious parts of the Act. A bad service of medical attendance is worse than none at all. We have not only to consider what the Act is doing, but to compare the Present position with the position of members of friendly societies and other people in regard to medical benefits before the Act came into operation at all. We have to remember that we are not setting up a system of medical attendance for poor people for the first time. Doctors existed long before the National Insurance Act, and people who needed it could get the attendance of a doctor for from 3d. to 3 guineas. The importance of the subject induces me to deal with it as uncontroversially as possible. I am going to make some quotations from speeches of the Chancellor of the Exchequer, but I assure the House it is not with any controversial intention. It is in order to show the Committee that from the first it has been recognised by the Chancellor of the Exchequer that this Act was intended to give a better medical service than had hitherto existed, and that for that purpose the system of averages was brought in and mutual insurance created. It was also recognised from the first, that in order to 256 give that better system you had to give the patient a free choice of doctor, and to leave the doctor free to refuse any particular patient whom for any reason he preferred not to attend.
The Chancellor of the Exchequer has admitted, and it must be obvious, that the full and hearty co-operation of the doctors is absolutely essential if the medical benefit is to be successful. The House of Commons, when the Bill went through, undoubtedly thought that it had secured to the insured person that free choice of doctor, but it seems to me that the Government have done their best to take away the free choice which the House of Commons gave. A free choice of doctor means a free choice of any doctor who is willing to attend the patient, quite irrespective of whether that doctor is on the panel or not. There is no doubt at all that the Chancellor of the Exchequer recognised the value of that free choice when the Bill was in Committee in August, 1911. He then said:—The free choice of doctors rill to some extent increase the charge. I personally, have always been in favour of that. After all, confidence in your doctor is essential. No man who could afford to do otherwise would have a doctor prescribed for him by any club or society. He wants his own doctor to doctor him—the doctor in whom he has confidence.When it was pointed out in Committee that the Bill, as it then was, provided only for a free choice of doctors on the panel—that is to say, before the insured person could exercise his free choice the doctor was to go on to the panel—an Amendment was moved, now known as the Private Arrangement Amendment, and embodied in Section 15 (3), enabling an insured person who found that his doctor had not gone on the panel to make a private arrangement with the doctor, and thus, in fact, to get the free choice which had been promised him. The Chancellor of the Exchequer, in accepting that Amendment, said:—An elastic system of that kind would meet that kind of case. It would enable the doctor to carry on his present practice, it would enable him to get his bills paid, because there would be something to assist the workman to pay, and it would also enable the workman to secure the services of his present medical adviser, even though he refused to act on contract terms.Throughout the Debates "contract terms" and the "panel system" had been treated as synonymous. There is no question that, so far as this House is concerned, right up to the moment of the Adjournment, when that Clause had been put into the Bill, it thought it had secured for the insured person a free choice of doctor, whether the doctor was on the panel or 257 not. And so did the Chancellor of the Exchequer, because when, at a later date, he made at Whitefield's Tabernacle an important speech dealing with medical attendance as provided by the Act, he said:—The first thing that happens is that he can have free medical attendance….. Under this Bill he can have the doctor at his own choice. He is not obliged to go to Doctor A. because there happens to be a majority of the club that prefers Dr. A. to Dr. B. He He puts his confidence in B.: he has pulled him through before….. He says, 'That is a man I put my trust in.' Faith is nine points of healing—spiritual, mental, or physical….. What a fine thing it is to get the doctor you want, and get someone else to pay for him. That is in the Government Insurance BillThat is what we want, the Government Insurance Bill! That is what we hope, if the Government will alter the method of administration, may, in fact, prove to be in the Government Insurance Bill. There are only one or two other quotations that I wish to refer to the Committee. After the Bill was passed on 13th February, 1912, the Chancellor of the Exchequer, in a speech at the Opera House, again dealt with the same matter, especially with the contracting out or with the private arrangement. He said:Doctors who are already engaged in contract practice will get 50 per cent. more than they are getting now. Doctors who are not engaged in contract practice need not take it for the future. The only thing that will happen to them will be—that they will charge exactly what they charge now—they can send in their bills just as they are sending them in now. The only difference will be there will be a fund to help their patients to pay the bill. I wish there was a fund like that to help to pay lawyers' bills.That was the Chancellor of the Exchequer's statement. That clearly presupposed in the administration of the Act that any patient who did not go to the doctor on the panel with contract practice would be entitled to go to the doctor of his choice, would be entitled to ask that doctor to send in his bill, and then would be entitled to have the insurance money for the purpose of helping him to pay that bill. We were getting very much closer to the Act coming into operation. The last quotation which I propose to make was when the Chancellor of the Exchequer was addressing the Advisory Committee on 24th October, 1912. This is a very important quotation, because it directly affects the position that now has arisen in the Isle of Ely and Loughborough. I would ask hon. Members to bear this in mind when I deal with some of the details of that case. The Chancellor of the Exchequer—who was then anticipating that perhaps after all the panel system might break down, and that 258 a national medical service might have to be established—said:—A national service established under the Insurance Act is quite compatible with free choice of doctors, because it means that if you have a number of whole-time doctors, and if any workman does not care to be attended by the whole-time doctors appointed, he can choose his own doctor. Under the Act a contribution would be made for the purpose of assisting him to pay his own doctor, so that to that extent the free choice of doctor would be safeguarded in the case of a national service.As I think I can show the Committee presently, the free choice of doctors in the two instances of national service which has been established by the Government in carrying out this medical benefit has not been allowed to the insured patients. Quite otherwise. The insured patient has been obliged to go, whether he likes it or not, to the doctors brought down into the district. I do not think there can be any longer any dispute that the Act itself compels the Insurance Commissions to make regulations permitting the insurance committees to allow any insured person to make a private arrangement. I do not think there is the slightest doubt now about that. The Insurance Commissioners have, in fact, acted upon that assumption, and have made regulations which do permit the insurance committees, if they choose, and at their discretion, to allow or disallow an insured person to make his own arrangements. There is no doubt either that insured people have been allowed to suppose that they could make their own private arrangements, and not by any unofficial statement, but by actual official documents. I hold here a pink medical ticket. At the bottom are these words:—To doctors and insured persons. If you are arranging. with the insurance committee to obtain your treatment from the doctor not on the list—That means not on the panel—and wish to claim a contribution towards the cost of treatment you must send this ticket to the insurance committee.There is no exceptional, no special arrangement, there. This is a ticket which is issued by every approved society to all its members under sixty-five years of age. It tells them that if they wish to make a private arrangement, send the ticket to the insurance committee. There is no qualification of any sort. I will not go again through the other documents that have been issued by the Insurance Commissioners. I would just remind the Committee of Form 135, C and E, which I quoted on a previous occasion as to the exceptional terms of medical benefit. Both are drawn up upon the assumption, 259 not that they will be allowed in special cases, not that private arrangement will be allowed in special cases, but that private arrangements are one of the ordinary alternatives provided by the administration of medical benefit under the Act. That one particular form, No. 136, says there are three alternatives. Either the panel doctor sytem, through institutions, or private arrangement. There was nothing at any time or until a much later period that was said to make anyone suppose it was only under special circumstances that a private arrangement could be agreed to. There came this Form 21, which was to be used by those who applied for leave to make private arrangements.
Curiously enough, according to the answer of the Secretary to the Treasury, this was not printed until 7th January, and it was not issued to Members of Parliament until shortly after that date. This is a medical form which was necessary, and which the insurance committee required to be filled up if anyone applied to make a private arrangement under the pink ticket. So that almost from the beginning every administrative difficulty, every obstacle, has been put in the way of the insured person who tries to make a private arrangement. For a long, long time we had the Chancellor of the Exchequer reassuring him and telling him that he could make his private arrangements, that there would be a free choice of doctor. Then we had a series of early regulations, as soon as it was to come to the point, as soon as the individual insured person was really going to get, or thought he was going to get his free choice, and a private arrangement. These obstacles were put in the way, and he was not allowed to do it. On Boxing Day, 26th December, there appeared in the Press a notice, which I hope the Secretary to the Treasury, when he speaks, will tell us the origin of, saying that private arrangements were only possible where the panel was formed. I suppose the Government do not now say that is accurate. I have called attention to the speech of the Chancellor of the Exchequer where he said that these private arrangements could be made. On 26th December this notice appeared in the Press, which stated that private arrangements were only possible where the panel was formed. It is not true. There was no limit whatever; it could be a private arrangement even where such doctor is appointed. The next stage was a meeting of the 2nd of January, 260 at which the Chancellor of the Exchequer addressed the Advisory Committee in a speech which has really influenced the whole of the working of the medical benefits of this Act, both by the insurance committees and by the Insurance Commissioners. The Chancellor of the Exchequer upon that occasion said that the panels were being filled up, and he added two. methods at least for dealing with cases where the panels were not quite completed. He said, "Where we find that some doctors have gone on the panels and that some vacancies are still there, I will invite those doctors to take assistants, and I will then say, 'If you take assistants that will complete the panel, I will close the panel for two or three years so as to enable those doctors to have a monopoly of the practice amongst the insured persons, and so that they shall get a good introduction amongst the families of the insured persons and shall be able to keep the practice for themselves.'" That was one threat, and that threat the Commissioners followed up and endeavoured to put into operation in Wisbech and Charteris. They did not succeed, but nevertheless they did act upon the statement made by the Chancellor on the 2nd January, and they did attempt to carry out his threat.
I say once the panel is formed that neither the Chancellor nor the Commissioners, unless they amend the Act, can possibly close that panel. Once it is formed it is open at any time for any practitioner, whether in the neighbourhood or elsewhere, to join that panel if he chooses. The second alternative the Chancellor dealt with was this: He took the case of places where twenty doctors are wanted, and he said, "Supposing there are ten doctors, then we will send down ten more and close the panels. We will then give a monoply to those twenty doctors, and we will give them ample introduction to the wives and children of the insured persons." A patient who paid his money was told, "You have a free choice of doctors whether on the panel or not." and now he finds the Chancellor of the Exchequer threatening the doctors that if they do not go on the panel he will send down assistants and close the panel and force the insured persons to take any doctor, not of their own choice, but the doctors sent down by the Chancellor in pursuance of his threats. These threats have poisoned the whole of the administration of the medical benefit under the Act, and have affected the action of every insurance committee. The 261 statement that private arrangements can only be allowed in special circumstances is often reflected in the action of every insurance committee throughout the country.
The Cumberland Insurance Committee in Carlisle declined to allow any private arrangement at all. They have declined to allow any man to make a private arrangement for his own doctor to continue to treat him under any conditions whatever. That means this, that if a man has been treated, no matter how serious his complaint, or how long his connection with the doctor, if he has been treated by a doctor who has not gone on the panel, he has got to leave that doctor. There is no alternative but to pay for the panel doctor, which a man may not employ, and privately to pay for his own doctor. That statement I see is challenged, but I will prove it. The man's society will very likely require him to produce the certificate of the panel doctor if he claims sickness benefit. Numberless cases have already occurred, and if I have time I will deal with more of them. At Ipswich five days were allowed for insured individuals to send in these pink tickets and to get a form from the insurance committee, filling in the name of the doctor and giving the reasons why they wanted to make a private arrangement and to exercise a free choice. That was a ludicrous position. Every obstacle was put in the way. The clerk to the insurance committee in the case of one applicant for a form told him that if he filled in that form he would have to pay £5 or £6, and as the applicant was not going to take that risk, he did not sign the form. As a matter of fact there was no risk at all.
The Middlesex Insurance Committee has, I believe, allowed private arrangements in exceptional cases, but each case is to be dealt with under its merits. I see the chairman of that committee present and perhaps he will tell us later on what has happened, and how he expects to be able to adjudicate upon the merits of each particular applicant for private arrangements. That is what happened in regard to the insurance committee. I could multiply the instances. It is either absolute refusal or else that each particular case has got to be dealt with upon its merits, which could not happen for weeks or months, so that no private arrangements can be made at all. Insured persons have no choice, and if he or she is sick they will have to go to some doctor on the panel. 262 I want also to call attention to what has been done with regard to other threats by the Chancellor of the Exchequer and the manner in which some of the committees are carrying them out. I propose to deal with only two, the Isle of Ely and the Leicester Insurance Committee, Loughborough. The case of the Isle of Ely was this. Before the Act there were ten doctors practising in Wisbech and Chatteris district. Of these only two were willing to serve on the panel. The Insurance Commissioners made an offer to those two doctors that if they would take two assistants they would close the panel at Wisbech for two years and allow those two doctors with their two assistants a monopoly of the practice amongst the insured people. That meant that all the insured people would have to go whether they liked it or not to those two doctors and their assistants. I am not in the least surprised that the doctors refused. They said they could not go on the panel because, though they wished to treat their patients they did not wish to absorb the patients of other practitioners in the neighbourhood, and they refused to fall in with the suggestion of the Commissioners. The insurance committee clerk went to London and the London Commissioners selected two other doctors. Then there was a meeting of the local insurance committee with one of the inspectors from the Commissioners present, and almost at once these two other doctors were appointed by the insurance committees, and so they have now got at Wisbech and Chatteris four doctors. I want to say here that I believe that every one of those doctors is an excellent doctor, and I have nothing whatever to say against the two original doctors who went on to the panel or the two who went into the neighbourhood. The merits of a particular doctor have nothing to do with the case. I do not propose to criticise the action of the two doctors who went on to the panel because that is a matter for them alone. Personally I think the reason they gave for going on was a perfectly adequate one, and I think the action they took in refusing to take assistance because they did not want to absorb the patients of their brother professionals was a proper action and honourable to them as members of an honourable profession.
Let us see what is the position of the insured person at Wisbech. There are 3,607 insured persons in the Wisbech Division, and they now have three doctors or rather two-and-a-half doctors to look 263 after them. I say two-and-a-half because one of those doctors has been given permission to go on the panels of the Norfolk Insurance Committee—three other panels. There were two original doctors at Wisbech and one London doctor imported by the Insurance Commissioners, and that doctor has also been made to do service on three other panels because there were difficulties in three other places. What sort of service is the insured person going to get with three doctors to look after 3,600 insured people and about 12,000 people depending upon them. This doctor is not confined to looking after insurance people. He has been promised a share of the monopoly of the insured people in that district, and a good introduction to their dependants. In addition he is entitled to carry on ordinary private practice. At Chatteris it is almost worse. One doctor has been sent down from London, and there are in this district 1,753 insured people. The Committee will remember that this is not a town with all the people living within a few doors of each other, but the area which is apportioned to Wisbech and Chatteris covers a good deal of country surrounding the small towns, and it is not so easy for any doctor to look after a large number of patients in such a scattered area. This so-called provision for medical benefit is utterly and absolutely inadequate both at Wisbech and Chatteris. The panel has been closed for two years, and there are now before the insurance committee applications from 500 to 600 insured people who have applied for liberty to make their own arrangements with doctors not on the panel, and the committee has said that such an arrangement will only be permitted in exceptional cases. All these insured people, instead of being given a free choice of doctor which was promised to them so often by the Chancellor of the Exchequer, have been deprived of that free choice, and they are forced to go on with the four doctors which the Chancellor of the Exchequer has selected for this purpose. There may possibly be a reason for this. It may be that the Government could not get the two doctors from London to come down into those districts unless they guaranteed some minimum or showed them that they were likely to get a certain minimum income. I do not know how that may be, and perhaps we shall be told later whether that is so or not. But the insured people at Chatteris are asked to take the 264 service of a doctor whom they have never seen in their lives or heard of, and they are absolutely forced to leave their present doctor and go to this particular doctor.
Not only is that the case, but the members of friendly societies may also be placed in exactly the same position, although not under the Insurance Act at all, because members of friendly societies who are over sixty-five years of age, or known as the sick and aged members who have not become insured under the Act, are entitled to get their medical benefits at the same rate as those who are under the Act. The only way in which they can take advantage of that particular provision, which was put into the Act in order to protect them, is that they shall go to this imported doctor, whom they have never heard of before, and give up the man who has been attending them perhaps for years. The case of Loughborough is even more interesting in one respect. I am going to complain that in both these cases the Insurance Commissioners have gone outside the law and far beyond what the Act permits, and in the Loughborough case it is quite clearly proved, because in Woodhouse and Woodhouse Eaves there are 400 insured persons, and there is one doctor who has been there for twenty years, and he has refused to go on the panel, but in order that his refusal shall not inconvenience the people in the district for three months he is attending them without charge at all. There was a resolution passed by the insurance committee and I will read it, because I want hon. Members to see exactly what the procedure adopted was. The resolution passed was in the following terms:—That the panel for Woodhouse and Woodhouse Eaves area be closed for a period according to the discretion of the Commissioners and the insurance committee, and that a medical practitioner be placed in that area, with full power to treat all insured persons and their dependants for a two-mile radius, and also any additional private practice wherever he may be called; also that his name be also placed upon the panels for the district.That resolution was carried, and I think it has been acted upon, although I do not know whether the doctor has been actually sent down. Perhaps the Secretary to the Treasury will be able to tell us. That resolution was passed at a meeting of the Leicestershire Insurance Committee, and I submit that this is entirely ultra vires, because they have no right to close the panel. It is possible under the Act to get rid of the panel system altogether and adopt another system. They can appoint a State 265 doctor but they cannot close the panel, because when once the panel has been formed there is absolutely no right whatever to close it. I know the Chancellor of the Exchequer on the 2nd January threatened the doctors that he would close the panel, but I do not think any right hon. Gentleman on the Treasury Bench will dare to get up and say that it is possible to close a panel once that panel is actually formed and in working order. I know the Secretary for the Treasury has said quite the opposite to me.
§ Mr. MASTERMAN
If a list is inadequate in any area, the Commissioners have not only got a right to make other arrangements, but it is a duty laid upon them to make other arrangements.
The right hon. Gentleman does not meet the point. He now says if the "list"—I observe he is getting a little shy of the word "panel"—
The word "panel" has been mentioned frequently by the Chancellor of the Exchequer. If the right hon. Gentleman says it is synonymous with the word "list" I shall not complain in the least, but the Chancellor of the Exchequer always talks about the "panel." If the right hon. Gentleman will refer to the Chancellor's speech to the Advisory Committee on 2nd January, he will see he used the word "panel" over and over again. It is, however, a small point, and I do not mind whether it is called a "list" or a "panel." We all know it means the names of the doctors who are willing to serve on the "list" or "panel," as the right hon. Gentleman pleases. It is true the Commissioners can supersede that arrangement altogether and send down a full-time man, or, if they choose, establish a State service, and again I use the expression of the chancellor of the Exchequer. If there is a panel once formed upon which doctors are serving, they cannot close the panel and prevent other doctors from coming on.
§ Mr. MASTERMAN
The hon. Gentleman is perfectly wrong. If the list is adequate it must be kept open, but if it is inadequate, whether at the commencement or at any time, the Commissioners may 266 declare the list inadequate and adopt any system they please in the widest possible term, including what we call "the closed panel" system.
. I do not know that there is very much between us. It really seems to be rather more a matter of words. I quite agree that both the Commissioners and the insurance committee, at the instigation of the Commissioners, can supersede, to quote the Chancellor of the Exchequer again, the panel system. If there is a list in operation with doctors on that list working the medical benefit under the Act in any given area, it cannot be closed, or, rather, no other doctor can be refused, but must be allowed to go on that list if he chooses.
The addition of a doctor cannot make it inadequate; it must make it more adequate, so it naturally presupposes that the list has been, up to that moment, sufficiently satisfactory to the Insurance Commissioners and the insurance committee. I put it specifically to the right hon. Gentleman: Is it possible in those cases to shut out a doctor or, in other words, to close the panel? I say it is not.
§ Mr. MASTERMAN
If the hon. Gentleman puts the question to me specifically, I can only repeat what I said before. If the list is adequate, the list system is continuous; but, if it is inadequate, then the Commissioners or the committee may adopt any system they please, and what they have done in these cases after inquiry is to find that the list was inadequate. There was not an adequate number of doctors prepared to carry on the list system, and they therefore adopted a different system, which we call "the closed panel."
I do not think it is worth pursuing it further. There seems to be no difference in the main between us except as to the word "list" or "panel." I think the right hon. Gentleman has admitted that once the list or panel is in operation it cannot, if it is adequate, be closed. That, however, is not what the Chancellor of the Exchequer said on 2nd January. No man could possibly have understood the statement of the Chancellor of the Exchequer on 2nd January as subject to all the fine limitations 267 which the right hon. Gentleman has put upon it. In the Loughborough case the doctor who has been imported is to be allowed private practice of all sorts, and that is also the case in Chatteris and Wisbech. The Chancellor of the Exchequer in dealing with that, as a matter of fact, said he would allow private arrangements amongst the dependants of the insured, but he was not by any means sure he was going to allow general private practice. In the Loughborough case private arrangements have been refused, and every man in that district has got to take the State doctor or have no doctor at all. The secretary of the Druids and another club, consisting of some 200 members, asked to be allowed to make private arrangements for their members. A reply has been given by the insurance committee that it is waste of time to fill up Form 21, because it is not intended to allow individuals to make private arrangements. We have got there the State service established; we have got there a state of facts which I invite the Committee to compare with the statement which I have already read from the speech of the Chancellor of the Exchequer in October last. The Committee will remember that the Chancellor of the Exchequer then said:—A national service established under the Insurance Act—and both in Chatteris and Wisbech and in Loughborough the national service has been established—is quite compatible with free choice of doctors, because it means you have a number of whole-time doctors, and, if any workman does not care to be attended by the whole-time doctor, he can choose his own doctor, and a contribution will be made for the purpose of assisting him in paying the expense.As soon as in Loughborough and in Wisbech and Chatteris application is made to carry out the promise of the Chancellor of the Exchequer the reply is made, "Do not take the trouble to fill up the form; it is not worth while; you are not going to be allowed to make your own arrangements." It seems to me, if the administration of this benefit is going to be successful and useful to the insured people, one of two things has got to be done. The insured people ought to be allowed freely and without let or hindrance to make their own arrangements with the doctors. The promises in that respect which have been made to them by the Chancellor of the Exchequer on many occasions ought to be carried out. The ideal, of course, is that there should be no list or panel at all, but that every doctor who is on the British Medical Register should be working in the service 268 of National Insurance. The creation of two classes of doctors, one to be called "panel" and the other to be called "non-panel" doctors is all wrong. It is wrong both in the interests of the doctors and of the insured people, and it is much more wrong in the interests of the insured people than of the doctors themselves. The Chancellor of the Exchequer ought to consider whether it is not possible—I believe it would meet a great many cases—that doctors should be allowed to go on the list or panel for a limited practice; that is to say, they should by their agreement say they are willing to treat either certain classes of patients or certain patients, but that they should not be obliged to run the risk of having other patients apportioned to them. If the Chancellor of the Exchequer will read the report of the meeting, I think of the London Insurance Committee, that appeared in the "Times," he will see four or five doctors in the room asked whether there would be a residue of patients to be apportioned to them, and, when the chairman of that meeting could not give sufficient assurance on that point, they said they would not go on the panel.
I believe you would ease off a great deal of the difficulties if you allowed doctors to go on for limited periods. I have had many communications on the subject, and I am sure there are many cases which could be met in that way. Some other provision has also got to be made for what we may call travelling patients. I do not mean the week-enders at Brighton to whom the Chancellor of the Exchequer referred when the Bill was in Committee, but there are lots of insured people who live in one place and work in another, and there are many who do not even live in one place all the year. What is to happen, for instance, to the commercial traveller? There are also waiters and domestic servants, and people of that class. There ought to be some method whereby they might have tickets available at a doctor's wherever they were, even though they paid a little excess themselves on their own ticket, because if that were so, it would protect the doctor in the place to which they went against being called upon unnecessarily. I feel certain that a system could easily be devised to bring that into play. It is important that it should be done before the seaside season comes on. You are going to have all sorts of trouble with the doctors at seaside places, who are going to get all the ill- 269 nesses which occur at these seaside places, and a very small proportion of the fees which would be payable by those insured persons.
There are two other matters I would like to deal with. One is medical benefit for existing friendly society men who are not insured, aged and sick members over sixty-five at the time that the Act came into operation, members who were on deferred sick pay when the Act came into operation and did not become employed people and did not come under the Act at all. The Chancellor of the Exchequer will remember that there was a special provision in the Act for them. If they ask for it, the insurance committee must give them medical benefit at the same cost or at no greater cost than benefit is given to people who do come under the Act. It seems to me quite unfair that of this Grant now under discussion no part is to be given to those old friendly society men. The intention of the House was clear. It was that the old friendly society men should be treated just as well as those who come under the Act. It is not treating them fairly, because they are not sharing in any part of this Grant, this 2s. 6d. per member. The consequence for this class of man is that in many cases he is being asked to pay several shillings a year more than he was formerly, because if the doctors are entitled to 7s. or 7s. 6d. for an average healthy man who is under the Act, certainly as regards the aged and sick it is not too much to expect that they should require at least the same remuneration. I called the attention of the Secretary to the Treasury to this, and he said that no representations had been received by him on the point, and he did not suppose that doctors would want more. I now call the attention of the Chancellor of the Exchequer to a circular letter sent out by the Ancient Order of Foresters Friendly Society, if he has not already seen it, in which they say, referring to the facts I have just mentioned:—This we feel to be an injustice, especially at a time when they are least able to bear it, and we appeal to you and the House of Commons to deal with this injustice. Whatever the difference (in cost) may be, should be met out of money provided by Parliament, and we trust to have your support in bringing this about.If there is any case which is a good case, it is this of the aged and sick members who are not a very numerous class, who are not under the Insurance Act, but who, in consequence of the Insurance Act, have found all their arrangements which have 270 hitherto subsisted for getting medical benefit disturbed. They now find that they must go without medical benefit or pay several shillings a year more. It is a small class and a disappearing class, and I appeal to the Chancellor of the Exchequer to give to these people a share of the Parliamentary Grant of 2s. 6d. Then there is medical benefit for insured persons over sixty-five who are insured. The Government have laid down two forms of alternative benefit for these men. One is a sort of annuity, and the other, minor sick pay. In neither case has the Government taken any steps to provide medical benefit. On the contrary, the Secretary to the Treasury said that all the approved societies have chosen that this money should be devoted to sick pay rather than to medical benefit, which means, if he is accurate, that no one over sixty-five who is insured is going to get medical benefit, and I do not think there is any doubt about that, because in the handbook issued by the Insurance Commission to the secretaries of friendly societies they say that no scheme has been approved by the Commissioners which provides medical benefit for persons over sixty-five. It is really a serious thing that those over sixty-five are not to get what after all ought to be the primary benefit of the Act. It is the benefit which does ensure health in a way which will not be done by any other single benefit under the Act, and I press upon the Government that they should do something to assist in getting these men over sixty-five medical benefit under the Act.
§ Dr. ADDISON
The hon. Member who has just sat down told us that he recognised the importance of the subject, and that he did not intend to offer anything in any controversial spirit. It is gratifying to find at last that there is to be no controversial spirit introduced into this subject. It is a matter upon which from one end of the country to the other the Government and the Commissioners have been denounced in every possible manner for the course they have taken, and it is rather late in the day for the hon. Gentleman to come here and tell us that he wants to approach this subject free from the controversy which has done so much to create difficulties in the way of medical men rendering service under the Act, as thousands were anxious to do. It seems to me the main objection has become whittled down to Wisbech and Chatteris. That seems a very small matter on which to 271 attack the Act and the Government. The first question is this matter of the free choice of doctors, and the suggestion which he makes is that the free choice of doctors was promised by the Chancellor of the Exchequer, and is involved in the Act, and that any insured person, wherever he may be, must have leave to have any of the doctors in that district, whether the doctors in that district have gone on the panel or not. If he reads Section 15 of the Act he will see that where the system of free choice of doctors is set out, it is followed by those words:—
"Provided that if the Insurance Commissioners are satisfied after inquiry that the practitioners included in any list are not such as to secure an adequate service in any area, they may dispense with the necessity of the adoption of such system."
That is the system of the list, with the free choice. The hon. Member dissents, but I am reading from the Act. If hon. Members would only give their time in their non-controversial opposition to the study of the Act and the Regulations, they would not mislead medical men in the extraordinary manner they have done. What he presses upon the Commissioners is this, that anybody who makes an application, say, on a form supplied by the London Medical Committee (which is now enrolled under the banners of the Moderate party of the London County Council, as announced in this morning's paper), shall have a right by merely sending in that document, and without question to choose his own doctor and make his own arrangements, and that to decline to allow this, is a departure from the spirit and intention of the Act. I would like to point out to insured persons throughout the country what the system is which he wishes them to adopt. The Section goes on to say:—
"The Regulations made by the Insurance Commissioners shall authorise the insurance committee by which medical benefit is administered to require any persons whose income exceeds a limit to be be fixed by the committee, and to allow any other persons, in lieu of receiving medical benefits under such arrangement as aforesaid, to make their own arrangements"—
that is to say, in lieu of receiving the medical benefit under the system as set out earlier. The Chancellor of the Exchequer in the reference which the hon. 272 Member made, spoke of the contract doctor receiving more money under the Act than he has done hitherto from the same class of patients. That is perfectly true. No one can deny it. The hon. Member said that the Chancellor of the Exchequer pointed out that those persons who made their own arrangements would have something provided for them under the Act to help them to pay their share. Is not that true? It is true; for a special fund is provided, as set out quite clearly in Regulation 49, out of which those who have made their own arrangements may draw, to help them to pay the cost of the medical charges to which they have become subject. What is the hon. Member's complaint? The statement of the Chancellor of the Exchequer is absolutely and literally true in every respect, and is being carried out by the Commissioners under the Regulations. The hon. Member and his Friends profess some surprise that the Insurance Committees have not fallen into the net spread within their sight so readily as he would have liked. The whole intent and purpose of this agitation is to break down the Insurance Act. They want to persuade the insured persons to make their own arrangements, without explaining to the insured persons what is the project in which they will be involved. I will now give to the Committee the draft scheme. The first ingredient in it is that there shall be an income limit of £2 a week for those who make their own arrangements under the system recommended by the hon. Member.
§ Dr. ADDISON
I know you did not, but I am going to do so. Hon. Members when they address meetings of insured persons and want them to make their own arrangements never say a word about this kind of thing. That is what I object to. If they had had the matter put fairly before them domestic servants would not have sent in the form supplied by the London Medical Committee. Here is the thing:—British Medical Association, City Division: They will be subject to an income limit of £2, except that the line will not be drawn too rigidly, the right to challenge should be preserved, and the onus of proving eligibility should rest upon the applicant or member.That is to say, any insured person who happens to have more than £2 a week may be excluded, in which case it is no use his applying to make his own arrangements. In any case they have to have 273 their incomes scrutinised. Let us understand what is meant by "income." Here is a document issued as the Public Medical Service scheme in the British Medical Association, 14th September, 1912, in which we are informed what is meant by "income":—Income for this table is to be income from all sources, and is to include the earnings of all children under 16, and also an assessment for such things as free housing, food, garden, land and all allowances, swill as firing, lighting, vegetables, etc.That is the first ingredient. Have hon. Members explained this to the agricultural labourers at Wisbech and Chatteris? The next thing they are subject to pay for is a considerable amount of extras, which they get free under the Act. Have the hon. Member and his friends explained that to the agricultural labourers in Wisbech and Chatteris? Has he pointed out to them that under the scheme he proposes and wishes them to contract out for, that they will have to pay their extras before they come into this service. The first ingredient was the income limit and the scrutiny, the second the demand for extras; what is the next? What is the main purpose of this agitation? The main purpose is not mere extras nor the income limit, but freedom from control. [HON. MEMBERS: "Hear, hear."] I am glad to hear that cheer. Hon. Members opposite are now prepared to vote £1,825,000 and have no voice in the way it is spent. It must be remembered that this London Medical Committee, which has now joined hands with the Moderate party of the London County Council, as announced in this morning's papers, issued a statement in which they assured the public generally that the Insurance Committees were staffed by people of "inferior intelligence." They wished to escape the control of these "inferior intelligences." What has been happening is this, that these hot-heads who have got control of the agitation to the detriment of their professional brethren, by ignoring the interests of the insured persons, have put every public authority in the country against them. First, they were led to denounce the societies. Nothing was too bad for the societies. On the 21st December they switched round and said they wanted to make their own arrangements with the societies, although Parliament, at their own specific request, put in the provision that the arrangements were to be made with the Insurance Committees. Having had that before them for eighteen months, they turned round and discovered that the insurance committees are composed of 274 inferior intelligences. This is a statement of the secretary of the British Medical Association himself:—It must be remembered that if the profession were to exhibit the same solidarity and determination, the conditions of medical benefits under the Insurance Act will lie not with the Government, or with tile Insurance Commissioners, or with the Insurance Committees, but with the medical profession itself.What has really happened is that in consequence of the campaign carried on in a section of the Opposition Press—I readily admit that there are prominent Members of the Opposition and leading Conservative journals who have never lent themselves to this discreditable campaign, and I do not wish to imply in any way that they are involved in it—what has happened is that medical men from one end of the country to the other have been worked up into a state of passion. I could give plenty of instances if they are required. Very often before a meeting an agenda has been sent out stating the question to be discusesd was why they should go on a panel. They have been worked up to believe that if they stand together the Government will give them anything they like to ask. I want to know what the hon. Member himself would have done in Wisbech and Chatteris.
I will certainly answer that question. I should have let the insured people make their own arrangements with the doctors in Wisbech and Chatteris.
§ Dr. ADDISON
I am very glad the hon. Member has made that statement, because I did not know what his policy was. Now we know it is to take £5,500,000, partly contributed by the Treasury and partly by the employers and the insured, and hand it over and say, "Make your own arrangements." It is absolutely contrary to anything that has ever been sanctioned by Parliament. It is absolutely contrary to the whole intention and purpose of the Act, and when the Insurance Committees found out, as they soon found out everywhere, that this was an organised attempt to break down the service under the Act, I do not wonder that they refused to sanction these wholesale applications. Here we have set out in the Regulations, quite truly, that in sanctioning arrangements allowing insured persons to make their own arrangements, if the committee find—upon such evidence as they think sufficient that the arrangements made by any person who has been required or allowed to make his own arrangements are satisfactory, etc.275 That is to say, they have to be satisfied that the arrangements the insured person is to make for medical attendance and treatment are adequate arrangements in the interests of the insured person. Does the hon. Member suggest that they should simply have handed over the money and take no further responsibility, and no cognisance of the kind of arrangements into which they entered?
I never have suggested that it should be handed over like that. I suggested that the private person should be allowed to make his own arrangements, and I quite agree it must be such an arrangement as is fair to the insured person and as gives him adequate medical benefit. I am quite prepared that the insurance committees, or the Commissioners, if you like, should say whether it is adequate, but I say the Chancellor's promise has not been fulfilled unless you allow them to make their own arrangements with the doctors, whether on the panel or not.
§ Dr. ADDISON
The hon. Member surrenders the whole position. The Insurance Committee with this money under their control are compelled, not only by the Regulations, but as self-respecting bodies, to see that adequate arrangements are made before they consent to them. As I understood the hon. Member, he expected that the London Insurance Committee was going to sanction these things, anyhow. Some of the hon. Member's friends do not realise what is involved in this. They simply look at one side of it. I quite agree that this Amendment—I myself moved it—may be exceedingly useful, and very necessary to the smooth and proper working of the Act, but it is not meant to be an instrument to break down the whole service of the Act. But whilst the provision may be very useful, it may easily happen, unless you take care what arrangements you do sanction, that very undesirable arrangements may be sanctioned—arrangements which may not always be to the interests of the medical men. It is not simply in the interests of the insured person that these Regulations are framed. We have had for the last twenty years medical men complaining, and quite rightly complaining, of unfair bargains which some of them have had to enter into. But what is there, if you allow this scheme without careful scrutiny, to prevent the amalgamation of insured per- 276 sons to make their own arrangements, which may not be in their best interests or in the best interests of the medical men. It does not in the least follow that it is in the interests either of the insured persons or of the medical men that this should be done without the utmost care and careful inquiry, and it is not reasonable to expect the insurance committee, either of Chatteris, Wisbech, or Loughborough, or anywhere else, to sanction this kind of thing unless they have made careful inquiry.
I feel very anxious to know this: We have had this one point of policy put before us from the Opposition, and I am anxious to know if there are any more. The other points, I know, have been carefully considered already, such as the case of those who go to the seaside. Have they any other kind of complaint except this one matter of allowing insured persons to make their own arrangements? We have had all manner of complaints thrown against us in the country. There is one other proposal; one which has been made by the hon. Gentleman (Sir P. Magnus). It is a proposal which I have no doubt the electors will take due note of, should ever an election recur in the constituency that he represents. I myself am one of his constituents. He suggested on 1st January:—I might ask the Secretary to the Treasury in his reply to state whether in the case of those doctors who have been admitted to the panels any inquiry has been made as to their qualifications, age, experience, or even their character?It is a very illuminating suggestion. Is it the policy of the Opposition that they should make inquiry into the character and qualifications of medical men before they are admitted on to the panel? Under the Insurance Act any registered medical practitioner can, because he is registered, have his name enrolled on the panel. It is the business of the General Medical Council, if a man is not fit so to be registered, to remove him from the register. But is it the policy of the Opposition that they should institute an inquiry into the character and qualifications, and all the rest of it, of the medical men who put their names on the panel? If it is not the policy of the Opposition, why did the hon. Gentleman make the suggestion? If it is the policy of the Opposition it would be very interesting to know how they propose to carry it out. Who is going to make inquiry into the character of the men on the panel? As a matter of fact, I have not any doubt whatever that no responsible Member of the Opposition will say 277 that it is their policy. It is an impossible policy, and one which they could not carry out, and one which no self-respecting body of medical men would allow them to carry out, and one which, if the Government had suggested it, would have been received with a howl of indignation from one end of the country to the other. But when it came from the hon. Gentleman his constituency seemed to take it quite tamely, and I have never heard a single protest. As a matter of fact, this is only another part of the general endeavour that has been made to discredit the medical service under the Act. The hon. Member (Mr. Worthington-Evans) said he objected to the words "panel" and "non-panel" doctor. Who invented them? His own Opposition Press. They have tried to make all manner of evil suggestions against the men who went on the panel. At the time the hon. Member made this suggestion there were more than 8,000 medical men enrolled on the panel. It is no use coming here at this time of day with suggestions like this and saying that this matter can be approached in a non-controversial spirit. Everything that could possibly be done to oppose and prevent this service being given has been done. Anything which would prevent medical men coming on the panel has been done, and anything which would cast a slur upon the reputation of those who have gone on the panel has always been done. It is an utter disgrace to the Opposition to give countenance to performances of that kind.
§ Dr. ADDISON
There are two accusations which are not now brought forward by the Opposition. A great complaint was made of the machinery we have set up to deal with complaints against medical men. I know well enough now that medical men when they have got to work under the Act, say that it is a fair arrangement. The opposition to it will soon die out. It is not the men who have studied the subject who have made the objection. I wish to point out that the complaint made with respect to the machinery set up for dealing with complaints is not in the interests of medical men. As a matter of fact, it so happens that the regulations for the medical service sub-committee are based in this matter almost word for word upon a resolution of the annual representative meeting of the British Medical 278 Association in July, 1911. That is the resolution from which the Commissioners got the idea. They modelled the machinery in accordance with that resolution with a sincere and honest desire to meet every reasonable ground of complaint.
It was also complained that a system of inquisition was being established by the Commissioners. We know that nothing of the kind is or ever was contemplated, but we have been told in loud language that the Chancellor of the Exchequer and the, Commissioners were going to send inspectors into the surgeries to watch them examine their patients. That is something which no self-respecting doctor or patient would tolerate for five minutes. The Commissioners and their inspectors, I am sure, will have plenty of other things to do besides wasting their time and energies in matters of that kind. But it is difficult for this House or any one of us who have been really interested in these matters to discover what is the policy and aim of the Opposition in connection with this matter. There is only one thing that has occurred to me wherein we can find the policy of the Opposition with reference to the medical service under the Act. We know that no effort has been spared to discredit the whole service, and to keep medical men from coming on the panel. Everything which could frighten them or induce them to think that they were to be badly treated has been stated over and over again. No one can complain that the remuneration is inadequate. As a matter of fact, we are finding out from medical men that the amount of work they have to do is very much less than they anticipated. Some time ago I ventured to prophesy what the amount of work would be, and I am glad to say that my prophecy up to the present is more than justified. I suggested that the basis of remuneration provided in connection with the services rendered could be calculated on these lines: If there were 2,000 insured persons, they would yield an income of £750 for medical services without any deduction for drugs. From all the facts that have come to me up to the present, it appears that eight visits and sixteen surgery attendances for six days a week are the services which the doctor will render for £750, if he has 2,000 insured persons on his list. Nobody can say it is inadequate payment. Anybody who knows the conditions of service knows that it is a great deal more than they have hitherto received for attendance on this class of people. 279 The Leader of the Opposition, however, wrote a letter on 10th December last in which he seemed to reveal the policy of the Oppposition. He said:—In regard to the Insurance Act, the action our party should take must depend on the time when the election takes place, and it would be impossible to formulate clearly now what our action will be.We know what the action of the Opposition has been at by-elections. It has been by creating any mischief or difficulties to get any advantage they could out of embarrassing the Government. That will be continued so long as it pays, and when it does not pay, it will be dropped. The policy of the Opposition does not depend upon whether the contributory principle is good, bad, or indifferent. It depends on the date of the election. It does not depend upon the extent to which the sick and unemployed are receiving benefit. It does not depend, as a matter of fact, upon any sound principle of policy whatever. It depends upon the date of the election. It does not matter if doctors have been misled and used as tools in this fight. It does not matter if maidservants have been bullied out of becoming insured persons. It does not matter if 100,000 insured persons were assured that the Act was going to break down.
§ The DEPUTY-CHAIRMAN (Mr. Lyell)
I do not think the hon. Member has exceeded the rules of order. So far as medical benefit is concerned hon. Members in different parts of the House have raised criticisms in relation to the administration of the Act, and so far as I understood the hon. Member he was answering these criticisms. Allusions to other insurance benefits would not be in order.
§ Dr. ADDISON
I can understand why the hon. Gentleman opposite does not wish me to go into these matters. I was saying with respect to the policy of the Opposition in connection with the medical benefit under this Vote that we gain light upon it by their performances in the country. It does not matter to them if 100,000 of the insured persons were persuaded to delay their entry into the insurance scheme, so that to-day, if they were ill, they would not be able to get sick pay, or that a woman who had a child would not be able to get maternity benefit. The only thing that does seem to matter is the date of 280 the election. Anything to snatch a miserable party advantage from the difficulties incidental to the inauguration of a system of this kind. It is not a policy. It is the spectre of a policy, and it changes its aspect with every varying eddy in the breeze of popular opinion. It embodies no principle; it inspires no confidence. It is a repulsive, transient, and embarrassed phantom. The Government, I have no doubt, will continue, notwithstanding the great opposition which has been offered to them in this respect, to develop this service and to meet every reasonable objection. It has expressed quite clearly its sincere desire to make the service attractive, entirely regardless of political considerations. It is obviously essential to the service that everything should be done to make it easy, attractive, and useful, so that good men will come into it. I have no doubt that the Government, in the matter of difficulties raised as to records or prescriptions, or what not, will do its best to meet every legitimate objection. But we shall gain something by prosecuting this service, which is now being set up under this Vote, much more than the mere treatment of the sick. We shall obtain information.
I know myself some medical men who have from 2,000 to 3,000 insured persons on their lists. That is too many, but the reason is that force of circumstances in crowded districts, such as in my own Constituency, for example, where there is not one medical man to 5,000 of the inhabitants, has brought this about. It is all that the means of the people can afford to maintain. But we shall soon have an improved service, for these people's means are the same now as the means of the best workers. We shall soon have something more. We shall soon have the records, and we shall have records of the drawbacks and disadvantages of multitudes of the poorer homes in this respect, and they will be a revelation, when they come, which will stir people's hearts and will shame the men into silence who have endeavoured to obstruct the development of this service. The curtain will be raised on thousands of poor homes, and there will be revealed to the full knowledge of the people of this country a state of affairs of which many of them have no suspicion of whatever. All this will be revealed through the records which are established under this Act, and people will then know well enough that we have better served their interests by seeking, 281 notwithstanding any difficulties or opprobrium, to relieve their sufferings than we should do by casting about to find a fitting formula under which we can persuade them to give us power to tax their bread. Medical men themselves I know are now finding that the service can be made an attractive and a good service. They are now, I know, suggesting their own grouping with the object of having a better and more efficient service and also to obtain means for making early and an accurate diagnosis, and for giving an improved treatment. In due time, as surely as the night follows the day, I firmly believe that, notwithstanding all that has gone on, the sincere and studied efforts of the Government to make the service attractive will take away the bitterness of the recent strife and very soon attract to this service the hearty co-operation of the medical men from one end of the country to the other, and that they will be willing without demur to end the aid of their experience and counsels. There is no occasion whatever for wavering or weakening. There is every reason why the Government should press forward with confidence.
§ Sir PHILIP MAGNUS
I think that Members on both sides must regret that the hon. Member who has just sat down did not follow my hon. Friend who moved the reduction of this Vote in the non-controversial manner in which he brought the matter forward.
§ The DEPUTY-CHAIRMAN
I did not understand the hon. Member for Colchester to move any reduction of the Vote, but it is quite open to the hon. Baronet to move a reduction if he desires.
§ Sir P. MAGNUS
I beg to move, "That the Vote be reduced by the sum of £100." In doing so I have no desire that the amount of money voted for this purpose should be reduced, but I move it formally with the same object as my hon. Friend had in putting it on the Paper, simply to bring under the notice of this House some of the difficulties which exist in the working of this Act. It is a very great pity the hon. Member for Hoxton did not reply to that speech in the same spirit.
§ Mr. T. M. HEALY
On a point of Order. Will the £100 reduction take effect over the entire Votes for England, Ireland, and Scotland?
§ The DEPUTY-CHAIRMAN
What I understand is that the hon. Member moved a reduction of the whole sum, which leaves all the various items open for discussion.
§ Sir P. MAGNUS
It is over the whole Vote. The speech of the hon. Member for Hoxton really had nothing to do with the point mentioned by my hon. Friend. It brought forward a mere political question which had no reference whatever to the matter under discussion, and, further, the House should remember that the hon. Member for Hoxton, although a medical man and a graduate of my own university, does not speak in the name of the medical profession of this country, who repudiate nearly the whole of the statements which he brought forward. There are one or two matters connected with the working of this Act to which I desire to call attention, not in any controversial spirit. I do not think it has been sufficiently recognised, although the hon. Member who has just spoken ought to be the first to recognise it, that it is utterly impossible to obtain a medical service which shall be a real benefit to the insured persons unless the doctors who are called upon to act do so whole-heartedly and willingly. If there is any kind of compulsion employed to force medical men to undertake the cure of patients, we may be quite certain that they will not, however desirous they may be of so doing, be able to throw themselves into their work with the same spirit and the same effect as if they were voluntarily employed. This fact has not been taken into consideration by the laymen who have drawn up the conditions under which this service is to be carried out. Let me say, further, that you may employ thousands of clerks, you may draw up hundreds of regulations, but unless at the same time you can, create that sympathy between the doctor and his patient which is absolutely essential in order that his service may be of use, then I submit that the whole Act will become inoperative. Have you created this wholehearted desire to co-operate and carry into effect. this Act? Are there not a great many faults to be laid on the shoulders of those who brought in the Act and afterwards had to speak in defence of it? The authors of the Act have not taken into their confidence as they should have done the medical profession, without whose 283 assistance it must become inoperative, and they have not endeavoured, as far as possible, to meet their views. It must be remembered that members of the medical profession do not go into that profession as do others who enter other professions. The medical profession is a scientific one, and its members go into it for love of it, and not even so much for love of the pleasure of curing sickness as for the love of science, and the possibility of increasing the discoveries, the numerous discoveries, which have had so much to do with the removal of sickness. The members of that profession require to be treated in a different manner from that in which it is proposed they should be treated by the hon. Member for Hoxton (Dr. Addison).
I would like to say one word as to the reference made by the hon. Member in regard to our attitude. Certainly I believe that the Members of our party have not attempted to use this Act for political purposes. [HON. MEMBERS: "Oh, oh!"] I say that distinctly. When this Bill was first introduced it was admitted by the Chancellor of the Exchequer, and I believe by all parties in this Assembly, that we on this side of the House were desirous, if possible, to make the measure work well, and if there was a possibility of improving the measure it was prevented by the guillotine arrangements and the procedure adopted to get the Bill passed. Of the many grievances of which the doctors are complaining, and some of which have been brought to my notice, the question to which my hon. Friend the Member for Chelmsford referred, that of free choice of doctors is, of course, the most important, and, notwithstanding the references to that fact which the hon. Member for Hoxton has made, there is no doubt whatever that the Chancellor of the Exchequer—and he will not contradict me for a moment—himself has said on more than one occasion, as was pointed out by my hon. Friend, that unless the patient can have the doctor of his choice he will not obtain the same treatment, he will not obtain treatment of the same value, as if he had been permitted free choice of his medical attendant. I do not think anybody in the House has been more emphatic with regard to the importance of allowing a patient free choice of his medical man than the Chancellor of the Exchequer himself. It must be a matter of regret to the right hon. Gentleman that the Regulations have been so framed as practically to prevent that free choice. This is unfortunate. 284 The choice of a doctor is dependent on the question of the permission to be given to patients to make their own arrangements. Here, again, I must refer for a moment to what my hon. Friend has said as regards the difficulties that have been placed in the way of patients making their own arrangements, provided always, of course, that those arrangements are such as the insurance committee can approve. I believe it was the deliberate intention of the framers of this Act to allow insured people to have free choice of doctors and to make their own arrangements. I can see no other way in which to look at the matter, in view of the practical invitation which stands upon this card which I have in my hand, and which is given to every insured person. Upon that card appears the following:—If you are arranging with the insurance committee to obtain your treatment from a doctor not on the list, and wish to claim contributions towards the cost of treatment, you must send this ticket to the insurance committee.Surely that statement is a distinct invitation to every insured person to make his own arrangements for a doctor, provided always, of course, that the insurance committee are agreed that those arrangements are satisfactory. May I point out to the Chancellor of the Exchequer a small matter of administrative work, yet very important, namely, that whilst the ticket requires the patient to place his or her name upon it as well as the address, the medical man is only required to affix his signature without giving his address? Therefore, if an insured person is taken suddenly ill, his wife when she looks at the ticket, finds that there is no address, and she does not know where to find the doctor, besides which the doctor may have more than one address. I merely point that out as a small administrative correction which may be made. My hon. Friend referred to the medical form No. 21. I believe that originally it was the definite intention of the Insurance Commissioners to give this free choice of a doctor which is so much desired. I have reason to believe that thousands of these forms have already been printed, but they have not yet been circulated, why I cannot say. The Secretary to the Treasury yesterday informed us that the Commission were considering some different kind of form. It is a great pity that after the Act has now been in operation for a fortnight, more than a fortnight, there should be no possibility of obtaining from the insurance committee a form on which one might apply to make one's own arrangements. 285 I am told that even the hospital nurses, who, of course, can be attended for nothing by the doctors of the hospital, have sent in applications to be allowed to make their own arrangements with doctors in the hospital, and they have not yet received permission to do so. Every possible difficulty has been placed in the way of allowing persons to make their own arrangements for a doctor, notwithstanding the fact that on the card which I have placed in the hands of the Chancellor of the Exchequer there is an absolute invitation held out to them to make their own arrangements. One reason why this Act, unless very much modified, as I hope it will be in the course of time, if not by the present Government by another Government when it comes into power, cannot fulfil the objects which we all thought it would fulfil, is because a great deal too much work is at present thrown upon the medical practitioners. The Member for Hoxton and his Friends, if he will allow me to adopt that phraseology, would seem to suppose that when one is speaking on behalf of the doctors, one is speaking on behalf of them in their own interests solely; but surely everything one says on behalf of the doctors must be understood as being also said on behalf of the insured persons. If the doctors do not give good service or are prevented from giving good service to insured persons, the patients will not receive the treatment that would otherwise be possible. At the present moment there is no doubt whatever that the doctors are very much overworked. Some time before the Act came into operation a medical man said to me, "I shall watch with interest the public notices of inquests," and I am sorry to say that he did not have to wait long. I fear, unless some arrangement is made by which the medical men will not be overworked in future as they have been in the past that the number of inquests is likely to increase. In the county of London at present there are about a thousand doctors and a million and a half of insured persons, and that would give about 1,500 insured persons to each doctor.
§ Sir P. MAGNUS
I do not suppose all those insured persons will have to be treated by one doctor in any one year. Of course the number will be much less than that, but still it is a very large number to 286 be under one medical man. That is not the worst of it. Unless the insured person is prepared to have two doctors, which I thing a great many would not prefer, the panel doctor will be asked to visit and to attend the wife and family of the insured person. That will increase the number of patients whom he has to look after. A coachman of my own had a child with measles. He did not know what to do. I advised him to consult his panel doctor. A doctor will find it difficult with 1,500 patients.
§ Sir P. MAGNUS
Insured persons. A doctor with even half of that number would have an increasing amount of work to do. The position is still worse, and for this reason: there have been many cases which hitherto have been treated in hospitals and now will be thrown on the panel doctors, a fact which will considerably increase their work. I need scarcely point out that in addition there will be a large amount of clerical work thrown on the doctor. We have also to bear in mind that where the contract system, to which very grave objection can be taken, is in operation, malingering takes place on a large scale, and the doctors are called upon to visit cases in very many more instances than they would have to do if the doctors were to be paid in each particular case for their visits. The Chancellor of the Exchequer, in introducing the Bill, saw the objections to what was called the contract system. My objection to the Act as it is now in operation is the enormous extension of the contract system with all its many disadvantages. I know that the Chancellor of the Exchequer is very fond of studying German statistics in connection with some of the matters he has to bring before the House. I should like to refer him to the statistics of malingering in Leipsig. It was there found that 8,500 patients were reported to the confidential medical advisers to ascertain whether they were really unable to work. Of those, 1,259 did not come up for examination, 1,300 notified recovery before examination, and of the 5,800 who were examined, 47 per cent. were declared able to work forthwith, 12 per cent. at the end of a week, 10 per cent. to be reexamined, and 31 per cent. declared unable to work. This very fact, that under any contract system it is only to be expected that insured persons will seek assistance from the doctor more frequently 287 than if they paid per visit, means that the amount of work thrown on the medical men will be very much greater than in the past. I have received numbers of letters from medical men complaining of the amount of work which they are called upon to do. Let me read a passage from one of them:—In common with several other medical men, we were intimidated by Mr. Lloyd George's threats to go on the panel very much against our wills, and after trying to work for the week we found that the duties, clerical and medical, were so onerous that it would be quite impossible to do justice to the insured or ourselves. so we as promptly asked to be relieved of the work, and now we find the result is about total ruin. I need hardly add that we, who have still some self-respect for ourselves and our profession left, will rather desert the calling altogether and become dockyard labourers than go on the panel again under the present Regulations.That is written by a medical man of some position, and I may say that he and his friends, four in number, wrote a letter to their patients, saying they were unable to do their work in a satisfactory manner if they remained on the panel, and adding:As we have already affixed our names to the cards we request you to return them, and under the circumstances we shall he pleased to attend you in cases of illness gratuitously, if you so desire.I am quite willing to show the letter to the Chancellor of the Exchequer: it is signed by the four medical men. These are cases of which there are numbers, and surely those who desire that this Act shall work for the good of the insured persons ought not to laugh or jeer at cases of the kind, but ought to consider as worthy of serious thought how the difficulties under which medical men are labouring can be relieved, so that they may be able to make an efficient service for the insured. Take another case, showing the extreme difficulties raised by the insurance committees in allowing any person, even under the most favourable circumstances, to make his own arrangements with the doctors. I will not read the letter, but it is from a medical man of some standing. He says that he has been attending for some time a Wesleyan minister in receipt of a salary of between £200 and £300 a year. He is unmarried, keeps one servant, and lives with two maiden sisters, whom also this medical man had attended. When the Act came into operation these maiden sisters came to the medical man and said that they wished to be regarded as servants of their brother, and asked if he would attend them under the Insurance Act. He declined, but recommended them to appeal to the insurance 288 committee to be allowed to make their own special arrangements. They did so, but permission was refused. That is simply a typical case illustrating the contention of my hon. Friend that every possible obstacle is placed in the way of permission being given to persons to make their own arrangements.
Another matter to which I wish to refer is the form of contract which medical men have had to sign. This form of contract was placed in my hands only yesterday. Many medical men have had to sign it at a moment's notice under the fear that the panel would be closed. The obligations imposed on the medical men are explicitly set out in the first two pages, but there is nothing on those pages in regard to the remuneration which the doctors are to receive. Numbers of these forms of contract have been signed in blank, as the stamp and signature have to be put on the second page. Medical men, not being business men, have signed them without receiving in exchange any reciprocal contract whatsoever, and without there being in the contract any statement as regards the remuneration. Whilst the obligations are set out in full, there is a blank left for the remuneration. I do not know why that has not been filled in as well as the obligations. I assume that the Chancellor of the Exchequer had seen this form of contract. The hon. Member for Hoxton (Dr. Addison) complained that I have asked the Secretary to the Treasury whether any inquiry had been made as to the age, experience, character, and so forth, of the medical men placed on the panel. Notwithstanding the remarks of the hon. Member for Hoxton, I reaffirm that that inquiry was a very important one. It is quite true that these medical men may be upon the register. But would the Chancellor of the Exchequer care to entrust the property of himself or of his friends in the hands of every solicitor who happens to be on the roll of solicitors? If he would not entrust his friends' property to every solicitor, why should he entrust their health or their lives to every doctor on the register? The inquiry that I made was perfectly justifiable. I must not detain the Committee further, but the opportunities for discussing this Act, which everyone is desirous should be made a workable Act, are so few that I scarcely think any apology is needed for the time I have taken.
§ Mr. WILLIAM O'BRIEN
I am sorry to be obliged owing to pressure of time to 289 switch off the English discussion by some observations in regard to Ireland. I can only plead that the extremely inconvenient practice of blending items for both Ireland and England leaves me no alternative. While I shall have some criticisms to offer about this Grant-in-Aid of £50,000, I particularly desire to elicit some information as to what the Government propose to do with the large balance due to Ireland in the way of an equivalent Grant. I leave aside altogether any controversial question as to the merits of the Insurance Act or its administration in Ireland. I want to point out, first of all, that £50,000 is only a small portion of the equivalent to which Ireland would be entitled under the proportional arrangement of 1888, and then I desire to put in a plea that this money or the balance of the equivalent Grant should be devoted to a purpose far more conducive to the health and well-being of the very poorest of the Irish population than either medical benefit or any other form of health insurance. However unjust to Ireland the proportional arrangement of 1888 was at the time, it was accepted. I may point out that the equivalent Grants have not necessarily been devoted to exactly the same purposes as the original Grants. This has been the case in reference, both to agriculture and education, and I take it for granted that it will not be held that this money granted in reference to medical treatment in England should necessarily be devoted in Ireland to exactly the same purpose. I do not anticipate that we will be met by any mere technical point in suggesting, in regard to this money, or, at all events, the balance of what is due to Ireland, that a far more valuable form of insurance to which it could be put would be to create what I might call a housing benefit by providing contributions to build houses that could be let at 1s. or 6d. per week to the poorest of the labouring population in the slums of the Irish towns and cities. There is extreme urgency in this problem, which is far the most serious problem connected with the health of that class which above all others in Ireland furnishes a larger number of cases of tuberculosis. Almost every other section of the Irish people have benefited very largely by the legislation of the last quarter of a century, while this urban labouring class is, practically speaking, the only class in the community that has derived absolutely no benefit whatever from the agitation and 290 legislation that has done such wonders for the Irish farmer and those living in the agricultural districts.
A good deal has been done in the way of housing the artisan classes. Nothing whatever has been done to provide houses which it would be possible to let to the labourers in the cities and towns to which I refer at a rent which they could pay out, of their wretched wages. All will admit, that the Chancellor of the Exchequer has a very natural, genuine, and deep interest in this question of contending against poverty and disease, and I do not think that the right hon. Gentleman would be disposed to take any narrow view of any particular method of bringing about good results, even although the suggestion I now make does not, so to speak, deal with medical benefit, which does not exist at all in Ireland. I appeal, therefore, to him with some confidence to give careful and sympathetic consideration to the proposal that we now make that he should use whatever balance may be due to Ireland as an equivalent Grant out of the—£1,800,000 that is to be given to Great Britain in trying to do for these, up to the present, entirely neglected portion of the Irish poor what has already been done with the most astonishing success in reference to the agricultural labourers, 40,000 of whom have been provided on the very cheapest terms with cottage homes. The class that I am speaking of just now earn wages which generally range from 12s. to 15s. per week, while they are very much less in the smaller towns—and this even when they have regular employment, and I am sorry to say that unemployment is a far more serious element of anxiety for these poor people than illness. These poor people are obliged to pay at present 1s. or 1s. 6d. a week for a single-roomed tenement in the most wretchedly unhealthy parts of the town. It is their children brought up under such horrid and unnatural conditions that furnish far and away the larger proportion of consumptives that has given to Ireland suck a bad name.
I do not blame the local authorities. They have done remarkably well as to building artisans' houses, but these dwellings, it would be very little exaggeration to say, are as much beyond the class of poor people I am speaking of than if they were houses in Belgrave Square. It would have been absolutely impossible for boards of guardians to do the wonderful things they have done for the agricultural 291 labourer only that they have been provided by the State with a contribution which is roughly about one-third of the cost of building the houses and the allotment. Broadly speaking, the labourer pays 1s., the local authority pays 1s., and the State pays 1s. Nothing of the kind can be done in the cities and towns, because there is no State contribution, and the expenditure would be utterly crushing to the ratepayers. What we propose is that this money, whether it be the entire sum or the balance, should be used for the purpose of making regular contributions to the local authorities of some kind—roughly speaking, of one-third of the cost—and that in that way you should enable local authorities to build upon an extensive scale in the various cities and towns, or in suburbs, cottages which they can let at 1s. or 1s. 6d. a week to this labouring population, without imposing any intolerable burden upon the local ratepayers, although you would still, of course, be imposing a very considerable burden upon them, but a burden which I venture to say the ratepayers would not object to shoulder.
I am far from wishing to disparage in any way the good work done by the Housing Act of 1908, with which the name of the hon. Member for North Dublin (Mr. Clancy) is honourably associated. That Act has done remarkably good work in the way of producing several thousands of artisans' dwellings, but, as I said, this kind of house is absolutely beyond the reach of the class of labourers to which I refer. The Chief Secretary in reply to a question of mine mentioned that there was received only the sum of £5,000 as a contribution from the State, or rather not from the State, but from an Irish fund known as the Dormant Suitors' Fund. Something on a very much larger scale will have to be done with this problem of dealing with now almost the only portion of the Irish population that has been neglected. If anything is to be done on a large scale a State contribution will have to be made of a fairly considerable size. I humbly submit to the Committee that the allocation of this money for the purpose I have indicated will accomplish infinitely more for the help of this class of the Irish population and their children than any other form of insurance that you could possibly devise. I am happy to say that this is one of the very few topics in Ireland which, up to the 292 present, is absolutely free from any party or sectional complications, and I desire to keep it so. The Cork Corporation is in most things a mixed body and is perfectly candid in ventilating its differences, but the other day the Cork Corporation passed unanimously a resolution declaring this to be far and away the most important question in connection with health. I do not really think there is a dissentient voice in the Irish towns possibly with the exception of a few of the newer manufacturing towns in Ulster—
§ The CHAIRMAN
I do not think the hon. Gentleman is entitled to go so fully into the purposes for which he would desire the advances to be used. If he did other Members might follow with particular purposes which in their view the money ought to be applied to and I do not think that would be in order.
§ Mr. W. O'BRIEN
I humbly bow to your ruling, and I do not intend to further trespass upon the time of the Committee, but before I sit down I cannot altogether ignore the fact that this question has been to some extent perhaps a little prejudged by the appointment, since I raised this question, of a so-called representative Committee to consider the question of the application of the medical benefits to Ireland. I do not intend to complain of the constitution of that Committee or the circumstances in which it was appointed. My colleagues and myself perhaps have no right to complain of being left out in the cold in the appointment of that Committee. The minority in Ulster had the opportunity of being invited to have a representative on that Committee while my friends and myself who represent a considerable urban population as well as an agricultural population in Ireland, have been kept at arm's length, and what is still very much worse, there is not a single representative of any sort or kind on this so-called representative Committee of the entire province of Munster.
I do not, as I say, want to complicate matters, by any criticism of these appointments. My hon. Friends and myself never sought and do not now seek any Ministerial recognition beyond the fair play and equality which is supposed to be given to every Member of this House, but I do appeal to the Chancellor of the Exchequer, however deeply fate has compelled us to differ with him on other matters, to look into this matter closely and conscientiously, and I think he will find that he has 293 here is this equivalent Grant a most providential means of supplying the only money that in our generation is in the least likely to be supplied for this particular purpose, and, therefore, of doing a great work to humanity for a people for whom nobody has done anything whatever. It will be a work of such magnitude, and involving so many consequences that if I may use the expression, he will have completed that trilogy of beneficent Irish legislation which has in part revolutionised the lives of the Irish farmers and labourers. I am certain there is no section of the Irish communty, rich or poor, which will not be greatly gratified if the Chancellor of the Exchequer will give us anything like encouragement in this matter.
§ Mr. H. W. FORSTER
The hon. Gentleman who has just sat down will forgive me if I do not follow him into the Irish aspect of this question, because I am more concerned with the administration of the Act in Great Britain. Before I come to say what I have to say on that point, I cannot pass over in silence the speech made by the hon. Member for Hoxton (Dr. Addison). I can only say to him that he went out of his way to make a bitter and, as I think, a disorderly attack upon the Opposition, who have nothing to do with the administration of this Act, and I am sure when he reads that attack in print he will feel thoroughly ashamed of what he has said. What did he say? He referred to the answer given to a question by my right hon. Friend the Leader of the Opposition, in which my right hon. Friend said it was impossible to lay down what Amendments we should propose to the Insurance Act until we know the date of the next General Election.
§ Dr. ADDISON
There was nothing about amendments in what I said, but about the action of the Opposition.
§ Mr. FORSTER
The action of the Opposition! The hon. Gentleman said that the Act might be repealed. [HON. MEMBERS "Certainly."] I should have thought even the right hon. Gentleman the Chancellor of the Exchequer might have remembered the declaration which my right hon. Friend made.
§ Mr. FORSTER
I should have thought that even the Chancellor of the Exchequer might be fair-minded enough to remember the latter statement as well as the earlier, because unless you can preserve a measure of fair-mindedness, it seems to me there is an end of all utility of debate. The hon. Member knows perfectly well that my right hon. Friend declared, when he found these earlier references to repeal had been misunderstood, and made it perfectly plain to everybody who did not misrepresent what he read that his reference to repeal only referred to the Act in the period which must elapse before it came into operation. The hon. Gentleman the Member for Hoxton said, "What do the Opposition care for the merits of this question? What do they care for the health of the people? What do they care for the conditions under which they work? All they care is as to the date of the next. General Election." I agree that in this particular matter the date of the next General Election is most material. We have not got any power before the next General Election to alter the provisions of this Act in any shape or form.
§ Mr. FORSTER
That remains to be seen. The right hon. Gentleman who has just interrupted me knows that no man can say how this Act can best be amended—every man agrees it wants amendment—but everyone knows that experience, and experience alone, can show where amendments should come in. [HON. MEMBERS: "Hear, hear."] Those cheers condemn the hon. Member for Hoxton.
§ Dr. ADDISON
With regard to by-elections, how does the right hon. Gentleman fit in his statement with the policy of the Opposition.
§ Mr. FORSTER
I was dealing with the statement I heard. Now let me come to things which lie near my heart, and that is looking into the merits of the working of this Act with regard to medical benefit. My hon. Friend has made an exceedingly clear and uncontentious speech in which he gave an account of the hardships and difficulties which need never have arisen at all if it had not been that the Government were in such a hurry to force this Act into operation. We have heard plausible speeches in which it has been stated that the Act is working like. 295 a miracle, and so easily that no one has any cause for complaint. Those of us who have any knowledge of the working of this Act know that in many cases there is chaos and confusion. [HON. MEMBERS: "Where?"] There is confusion in nearly every office which has anything to do with the administration of the Act. I will mention one of the difficulties which need never have occurred, and that is with regard to the election of the medical representatives on the insurance committees. The Secretary to the Treasury told us on the 4th of February that arrangements were being made to the election of medical representatives on the insurance committees, and that regulations had been issued.
§ 4.0 P.M.
§ Mr. FORSTER
The Secretary to the Treasury told us only three or four days ago that arrangements were being made for the election of these representatives, and that regulations had been issued. Nobody could tell until these difficulties had been overcome, exactly how things were going to work. If regulations were absolutely essential, surely the Commissioners might have made them long ago, and we might have had the medical representatives on the committee before this in those cases where the people were willing to elect them. This is a matter of real importance, although it may be regard as subsidiary. I met the other day a deputation of medical men from the North of England—from Bootle. They came to see the Leader of the Opposition, and I was present at the interview. They told us that in Bootle a panel has been formed, and that it is in working order. On the 20th of January a meeting of medical practitioners was held, and they applied to elect two representatives to the insurance committee and form a statutory medical committee. That meeting appointed two representatives and elected the statutory committee, and the names were forwarded to the insurance committee, who replied that the regulations for the election of representatives would be issued at an early date. The trouble these medical gentlemen have gone to in order to assist in carrying out the Act was rendered absolutely futile and wasted because the Insurance Commissioners had not 296 prepared their regulations. On the 1st February a nomination paper for the election of representatives was issued, and those regulations laid down that there can be no medical representatives on the insurance committee before the end of the month. The end of the month, as I understand it, is the earliest date upon which the medical gentlemen can serve on the insurance committee. Surely you want your medical representatives before that time, because you require the assistance of the statutory medical committees in order to carry out properly the allocation of the residue of insured people.
I now come to the question as to whether or not it is desirable or right that people should be allowed greater latitude under the regulations to make their own private arrangements. The Secretary to the Treasury has told us that in exceptional cases people will be allowed to make their own arrangements, but in dealing with a hard case that was mentioned to him, he said where a man is working in one place and living in another it was desirable that he should have the opportunity of emergency treatment. In a case of that kind we are told people can make their own arrangements, but they are not always able to do so. In some cases insurance committees do not allow anybody to make their own arrangements. The Financial Secretary to the Treasury says in exceptional cases people will be allowed. I think I am right in saying that in Bradford and Huddersfield the insurance committees do not allow anybody to make private arrangements. They say, "You must take a panel doctor. You must accept the service provided for you; we will not allow anybody to make their own arrangements." I think that is a very great mistake. Even in cases where insurance committees do not take so strong a view of their duties in this connection, difficulties are thrown in the way of people who apply for leave to do that which the Act says they have a right to do, namely, to choose their own doctor. Again, I quote from the actual experience of the medical gentlemen with whom I had an interview the other day. They say:—It is also within our knowledge the greatest obstacles are being placed in the way of insured persons receiving the official form.That is the form on which insured persons have to apply for leave to the insurance committees to be allowed to make their own arrangements. They gave me an example of four members of one family 297 who were at work all the time the insurance offices were open. It was practically impossible for any of them to visit the offices personally.
§ Mr. FORSTER
No, it is at Bootle. A sister was sent to ask for the forms for the four members of her family to fill up, and they were refused. Apparently, the insurance committee required a personal visit. That is a case where I should have thought any fair-minded body of persons in charge of the administration of this Act would have allowed private arrangements to be made. Here is a case where the doctors and other people asked what principle guided the insurance committee in allowing private arrangements. The chairman of the insurance committee said that where a person was ill and was being attended by his own doctor at the time the Act came into operation it might be said there were such exceptional circumstances as to entitle them to make their own arrangements. But these medical gentlemen told me of a case of a person who had been visited twice a week for six months by a doctor who had been the doctor of the family for twenty years, and in which private arrangements were not allowed. I do not think that is wise or desirable from the point of view either of the insurance committees or of the insured people, and I hope the right hon. Gentleman will see that directions are given that will bring about a better state of things. It seems to me, and I am bound to say I hold this opinion strongly, that we ought to approach the whole question as to whether or not private arrangements are desirable and ought to be allowed from the point of view of the insured person. The insured persons themselves are really the people who ought to have the right of saying whether or not they wish to make their own arrangements. What we have got to do, and what we shall fail in our duty if we do not do, is to provide them with the very best medical service we can get for the money we have to spend. Can anyone pretend that the medical service placed at the disposal of the insured people at the present moment is the best We can get? You have only to read the accounts in the newspapers. I am not talking about whose fault it is. I am not saying it is the fault of the Government or the doctors or of any other body, but I do say that we all owe a duty to the 298 insured people and that we have to discharge it irrespective of whose fault it is at the present moment. I say the arrangements at the present time are not satisfactory from any point of view. Doctors are overworked. There are doctors who have a great deal too many people on their list. I can give you one case. Of course, it will be said it is an exceptional case, but in my opinion it is a typical case. There was a doctor in London who gave evidence in a Coroner's Court a few days ago and who said that he had attended in the last two years 200,000 cases.
§ Mr. FORSTER
That works out at 270 cases per day. It is impossible that any doctor could deal with such a number. You may say it was before the Insurance Act, but it is going on at the present moment. He gave evidence that on Thursday last week he had attended 433 people. What. sort of treatment arc 430 people going to get by one doctor in one day? I repeat that I am not arguing whether it is your fault or my fault or the fault of anybody else, I say it is an unsatisfactory state of things and ought to be stopped.
§ Mr. FORSTER
Arrangements must be made to prevent doctors having too many people on their list. I asked the Secretary for the Treasury what arrangements had been made. He practically said none, that you must leave it to the doctors to settle among themselves, and must leave it to the insurance committees to see that adequate medical treatment is given, and that every insured person must see that no doctor had too many people on his list.
§ Mr. FORSTER
Yes, but I want to know what steps are being taken in order to secure the result we all wish to see. Are the insurance committees taking steps, and can he tell us what these steps are, so that this scandal, because it is a scandal, shall not be repeated. It is no answer to say that these are exceptional cases which are bound to occur in bringing into force a complicated piece of machinery like the Insurance Act. We owe a duty to the insured people, and we ought to take steps 299 to prevent this scandal. Everybody knows that one of the reasons why these difficulties have occurred is because the ministerial units concerned with the working of the Act have been so busy that they had not had the time which was necessary to the perfection of the details. The Government is too much concerned in preserving its own existence. The Insurance Commissioners have prepared orders, regulations, and memorandums, and discharged them in such a volume as to prevent them from giving adequate attention to the details of the machinery. The insurance committees have been trying to find a way through the haze of these memorandums and regulations, and I do not wonder that they have had difficulties. They have been overburdened and have had the most difficult task of all, to try to bring the actual provisions for medical benefit into some harmony with the various accounts of them which have been given by the Chancellor of the Exchequer in his speeches. Everybody knows that the executive officers of the friendly societies have had their hands full attending to the requirements of their uninsured as well as their insured persons.
The doctors have been concerned very largely with the conditions under which they will have to work, conditions which they believe profoundly affect the future welfare of their profession as well as their own pockets. Not one of these bodies has received adequate attention. If they had, I do not believe for one moment they would be in the unsatisfactory position they are in to-day. I am not going to quote the speeches of the Chancellor of the Exchequer. Various extracts have been quoted from them by the hon. Member for Colchester and others, and I have no doubt that the Chancellor of the Exchequer's attention has been called to them very often. You will find in the speeches the Chancellor of the Exchequer has made ample justification for the belief, which was undoubtedly widely entertained, that when this Act came into force people would have the right of choosing their own doctor if he was not on the panel. The Chancellor of the Exchequer believed, I believed, and everybody believed that once you came to an agreement with the medical profession, an agreement which would be satisfactory to them, that all the doctors would go on the panel.
§ Mr. FORSTER
The right hon. Gentleman says so they have. He knows perfectly well that they have done nothing of the kind.
§ Mr. FORSTER
I did not hear that part of the right hon. Gentleman's statement. We should like to know in how many cases all the doctors in a district have gone on the panel. One of the difficulties we meet with constantly and continually is the difficulty of forming a full judgment as to whether this Act is working. It is due to the secretiveness of the right hon. Gentleman. He will not tell us.
§ Mr. FORSTER
Yes, and you have returned exceedingly skilful answers. I was saying that everyone believed that there would be ample opportunity given for every one to make his own private arrangements with the doctors. Why should they not? What is the merit of this panel system, which the Chancellor of the Exchequer seems to believe is so far superior to any private arrangement? What does it matter to the State, what does it matter to the Insurance Commissioners, what does it matter to anybody concerned with the administration of this Act, if people are allowed to make arrangements which they wish to make with their own doctors? They are not bound to do it. When my hon. Friend the Member for London University (Sir P. Magnus) gave an instance where he thought undue pressure had been brought on a man who wished to make his own arrangements by a member of an insurance committee, the suggestion was made, "If you make those arrangements it will cost you so much more, therefore you will be very ill-advised to do it." Is not that a matter for the insured person to settle for himself, if he wishes to do it.? [HON. MEMBERS: "You must protect him."] Is that the new Socialism? Nobody is to be judge of his own affairs; nobody is to be allowed to settle for himself whether or not he would rather have Doctor "A" promised him by the Chancellor of the Exchequer! He has got to have not the doctor he wants, not the doctor who has attended him, and he is prepared to pay; he is to take the doctor the Chancellor of the Exchequer has chosen for him and not the doctor of his own free choice. I cannot see any real 301 justification for forcing these doctors upon people who do not want them. I will quote one passage from the Chancellor of the Exchequer bearing upon free choice. When conferring with the British Medical Association, he said:—I think one of the essentials of curing is that the patient should have faith in his doctor. You cannot have faith in your doctor if you have doctors thrust on you whom you have not chosen and whom, for various reasons, most of them unsatisfactory, you do not believe in.Why not let him choose a doctor for himself? You promised it in the Act. You promised it in your speeches. You gave it in the Act. You have given it actually in the Regulations of the Insurance Commissioners. You have only denied because the Chancellor of the Exchequer will not let them have it. That is grossly unfair. I believe it to be thoroughly and absolutely unsatisfactory, and unless you take steps to give to the people that form of medical treatment which they have the right to ask, your Act will fail in its full fruition, and the Government will be responsible for its failure.
§ Mr. LLOYD GEORGE
There is only one evil effect of the Insurance Act which I have discovered up to the present moment, and that is that it has deteriorated very appreciably the manner of the hon. Member in dealing with this question. He started very rationally, very sensibly, very moderately, and with every desire, I think, to remove this question from the area of party controversy. But his lucid intervals have been more and More remote until at last, on an occasion like this, he has the privilege and advantage of delivering the only contentious speech which has been delivered on his own side of the House in this afternoon's Debate. I regret that, because he did undoubtedly approach the problem at the start with a sincere desire to assist in solving a very great problem. What has he said now? He has said, "Your Act has produced confusion and chaos." We asked, "Where?" He said, "Everywhere." We said, "Name any place or anything," and he said, "The case of Dr. Jelly." All this great confusion which has been worked up all over the Kingdom, Millions of insured persons and tens of thousands of doctors, approved societies, the Medical Association—all ends in this one case of Dr. Jelly. What is the case of Dr. Jelly? Dr. Jelly was in existence as a doctor before the Act ever came into operation. We are not responsible for him or for his method, and, as a matter of 302 fact, the very methods which are associated with Dr. Jelly are the very methods which this Act would bring to an end. He is, I believe, either a threepenny or a sixpenny doctor who cures wholesale in the district of Homerton. What has happened since the Act came into operation? All the people who used to go to him in troops have gone to him again. He attends to them. In fact, the very thing the hon. Gentleman complains about in others is what has happened with Dr. Jelly. They have faith in him, they trust him, and they are still trooping to him, and yet the hon. Gentleman asks, "Why do you allow these people to congregate in the surgery of Jelly?" It is purely and simply because we are carrying out the Act, and allowing a free choice of doctors. It may be a good or a bad thing to be cured wholesale, but under the Act we are more or less bound to allow it. I agree with the hon. Gentleman that the Committee ought to exercise a sort of legitimate power to bring to an end this very vicious system, but you will not bring it to an end in the course of a day. No Act of Parliament could possibly do that, and I do not know that it would be desirable.
The hon. Gentleman asks what we are doing to bring it to an end. What we are doing is this: One thing the Act has brought into prominence is that the poorer districts of this country are largely understaffed with doctors. Go to the well-to-do districts and suburbs, go to the districts where you have an industrial population earning good salaries, and you find a doctor for 500 or 1,000 of the population. I think you will find a doctor in Bradford for every 1,200 or 1,300. Go to the East End and you find there is one doctor for every 4,000 and 5,000, and barely that. What is happening? One result of the Insurance Act is that doctors are beginning to drift to those districts for the first time—well-qualified doctors. It is true that many of them are young men who see an opening, but why did not doctors start practising in those districts before? It was because unless you get thousands and thousands of patients you cannot make a living out of a threepenny attendance and a bottle thrown in. The medicine would cost something, and the water rate would amount to something, and therefore that was the only way they could make a living. What happens now? The well-to-do artisan and the man who is only earning ten shillings to fifteen shillings a week are 303 both getting the same payment from the insurance Fund for their doctor. What is the result? The doctor in future, although he may dislike the neighbourhood, finds that from the point of view of payment there is no distinction between the well-to-do district and the district which is not well-to-do. The doctors are beginning to find that out.
We have only started three weeks or a month, and the hon. Gentleman is condemning the system which has only been in existence for that period as if it had been in existence for three years. Take Finsbury alone—about a dozen doctors have already gone there and started a practice. They are good men. I am not comparing them with the men who were there before, but they are well qualified men. That is the sort of movement that is going to take place, with the result that the poorer districts which have been neglected and thrown upon the threepenny and sixpenny doctor will in future have excellent doctors to attend to them. The hon. Gentleman complains that things are not in perfect order. He gave no proof of it. It depended upon a sort of gassy invective that has appeared in just one or two papers, but not all. I am not attacking the Unionist Press, but there are two or three papers that have made a business out of this. They bring in every point, and they use these vague phrases, giving no case at all. But who is responsible? Up to the 21st of December the doctors did not come in. They had remained outside, and on the 21st of December, within about a fortnight or three weeks of the Act coming into operation for medical benefits, they started not an absolutely new scheme but a scheme which they themselves rejected eighteen months before, and as to which they demanded unanimously that the House of Commons should make a statutory provision to prevent it ever coming into operation. Why should the Government be blamed for that? Is it because they projected this wild-cat scheme, at the instance of just one or two men who have led them very badly—and I think that all the doctors of the country admit that quite freely now.
That is the real reason why, if there is the slightest confusion, it exists. It is because they refused up to the last moment to accept the terms offered, and they put forward terms which they unanimously had rejected eighteen months 304 before, and as to which they wished the Government to provide a statutory bar against their ever coming into operation. That was the position, and I think that the hon. Gentleman might have very well mentioned that fact in the course of his observations. And now as to overwork. There is no proof that. The only proof he has given is the mention of a certain doctor who has got thousands of patients who insist on going to him, and they will insist for some time on going to him. It is impossible to prevent that. The hon. Member for the University of London gave the case of a doctor who dropped dead in the street, and there was an inquest and evidence that it was all due to overwork. I do not want to say very much about that, but I will give the hon. Member one fact about it. The whole number, not of patients which that doctor had, but the whole number of persons he had on his list was 137. The cards had to be given up, and therefore we know. About four or five days before he had only ninety-six, and at the date of his death he had 137 persons, not patients. The hon. Gentleman made an extraordinary calculation in trying to demonstrate how overworked the doctors were, but he said that did not matter, and I quite agree that in this controversy that does not make very much difference. He gave what he understood was the proportion of doctors on the list. My hon. Friend, the Member for Walworth, who is Chairman of the London Insurance Committee, tells me that there are nearly 1,200 doctors already on the panels and the number of insured persons is 1,300,000, which means about one doctor to 1,100 persons. Then the hon. Gentleman made a remarkable calculation. He said that half of these persons would be ill.
§ Sir P. MAGNUS
I never said that half the persons would be ill. I said half might be married. It does not follow that everybody who is married is ill.
§ Mr. LLOYD GEORGE
There is one doctor for every 1,100 insured persons. Does the hon. Gentleman say that is an extravagant estimate? If he does he is certainly talking without knowledge of what the doctors do in industrial districts where a doctor attends about 5,000. One doctor attends between 3,000 and 4,000 persons, man, woman, and child, in districts like those in South Wales, in Durham, and in Northumberland. Eleven hundred persons, then, mean something like 305 2,500 at the outside, man, woman, and child, and that is far below the number attended by the colliery doctors in the mining districts of South Wales, Durham, and Northumberland. So much for the theory that the doctors are very much overworked. At any rate, it is infinitely better than the present system under which you have a doctor for every 4,000 or 5,000 poor people. It is a great advantage. I do not wish to say that you should be able at once to succeed in establishing a perfect system. It is an unreasonable demand. But you are asking us, in three weeks, to establish a system which must necessarily take years to perfect. We can always say that we have made, not merely a beginning, but an extremely successful beginning, a beginning such as the hon. Gentleman and his friends never dreamt we should make. I shall make one or two observations in order to show that later on. The hon. Member said we had not treated the medical profession very fairly. "Here you are," he said, "you have got those insurance committees, and you do not allow them to go on them." Whose fault is it that they are not on the insurance committees?
§ Mr. FORSTER
What I said was, you had not made the regulations under which they could be elected on to the insurance committees until two or three days ago.
§ Mr. LLOYD GEORGE
We formed provisional committees, which was the only thing we could do, because the constituencies were not accessible at the date the Act came into operation. You had to insure your persons in order to create a register. What did we do? We sent to the friendly societies and said, "Will you elect a certain number of members on the Advisory Committees. "We went to the trade unions, and said, "Will you elect a certain number," and we sent to the local authorities, asking whether they would elect a certain number of members. We then sent to the Medical Association asking them to supply a list of doctors in each district to represent the medical profession on the Advisory Committee in each of those districts and on the insurance committees of those districts. What did they do? They refused. And then the hon. Gentleman comes down to the House of Commons and complains that they are not on Advisory Committees, and that some 306 regulations are not ready for the purpose of their election. We did everything in our power, first of all, to induce them to come. One speaker complained that these regulations are for the control of the medical profession, and have been prepared by laymen. That is not accurate. There were laymen, of course, engaged in their preparation, because there is the drafting of the documents of this kind, which have to be prepared. Even if it had been done by the British Medical Association, they would have had to employ a lawyer, who is a layman, for they could not have gone on without a lawyer. The same thing happened here. Whose fault is it that the medical profession did not have a share in framing these Regulations? We put on representatives of the medical profession on our advisory committees for the purpose of settling these identical rules which are to control the medical benefits. What did they do? The representatives of the British Medical Association cleared out and withdrew every other man whom they possibly could. What right has the hon. Gentleman on their behalf to complain that these are not settled by doctors, when the British Medical Association did everything in its power to withdraw every doctor whom we had invited there to help us in framing the rules?
We come now to the question of persons making their own arrangements. There have been a good many quotations giving many cases. I stand by them, and not only that, I say I carried them out, and I will tell the hon. Gentleman more. I have been better than my word on them. I am not now giving the actual words, but I said that it would be possible in any district, if the insured persons did not care for the capitation system, to pool the whole of their money, and to draw upon that amount to the extent of as far as it went, and I went beyond that, and I said that the insured person would be liable for the balance. What happened in those cases? By this grant the balance has been wiped out and we are now enabling the doctors and societies, where insured persons prefer the pooling arrangements, to enter into that arrangement on one condition, that this grant is to be paid, and not a penny piece is to be charged in respect of the balance against the insured persons. In Manchester the very arrangement I suggested in the Opera House has been carried out, and throughout the whole of the great county of Lancashire. What is 307 the arrangement? The doctors there say, "We do not like the capitation system, and we do not care about treating people at 8s. 6d. per head, or whatever it may be, and we prefer that the 8s. 6d., or 6s. 6d., or 7s., should be put into a pool, and that each of us should attend, upon the old system, our patients, and at the end of a given period we should send in our bills, and that those bills should go as against that pool, and if it is insufficient we shall have a dividend." If it is more than sufficient in some districts they are going to make very good use of it. I am not quite sure if this is to be the case in Manchester, but I understand that in some districts where there is a balance, as they anticipate there will be, they propose to use it for the purpose of the setting up laboratories and systems of that kind. That is the system I indicated at the Opera House, and not only have the Insurance Commissioners stood by the promise which I gave, but actually over the whole of Lancashire to-day, and I believe in several other parts of the country, that is the system which is in operation, and I say it is a very good system for those districts. I only want to point out that that system has been carried out.
The hon. Gentleman asks, Why do you not allow people to make their own arrangements? Their own arrangements were never intended save in exceptional cases. The hon. Member for St. Pancras speaks as though I were forcing the panel system upon insured persons. The panel system is the choice of the British Medical Association. My original idea, as hon. Members will see if they read the first print of the Bill, was to allow arrangements to be made between the approved societies and the doctors. That is how the Bill was introduced. If that were the system at the present moment there would be no question of persons making their own arrangements. How was it altered? It was altered purely as the result of a great agitation by the British Medical Association. They said, "No, we will have nothing to do with the approved societies; we have had a wide experience of them; they are tyrannical." I remember speeches delivered by Members sitting in a row on the other side—eloquent speeches in which they denounced the system and insisted upon the setting up of a public authority. The hon. Member for Glasgow University (Sir H. Craik), who represents, perhaps, more doctors than any 308 other Member, gave a reason of which I thoroughly approve. He said that it is only with a public authority you can get the necessary discipline and control. Those were words spoken on behalf of the medical profession. They insisted on the panel system, and now, when it does not suit them, they turn round and say, "This is an instrument of torture, manufactured by the Chancellor of the Exchequer for tormenting an innocent profession." It is not my invention.
§ Mr. LLOYD GEORGE
Who put it into my hands? I am doing it for their own good, as they will realise by and by. They convinced me that the panel system is the best. It took weeks to do it. I had several interviews with them; I thought their reasons were sound, and I gave way. They convinced me so thoroughly that I cannot see my way to change again. What does the panel system mean? Any doctor on the medical register can go on the panel. No one can say him nay as long as he behaves. That means a free choice of doctors. There is no Act of Parliament that can compel a doctor to attend a man. I cannot compel a doctor to go on the panel. All I can do is what the medical profession asked me to do—leave an open door to the rest, without any qualification beyond those which they have won at their examinations and which they have retained. That is a free choice of doctors—a free choice of every doctor who chooses to come inside and say, "I am willing to serve." If he is not willing to serve I cannot bring an action and say, "You must serve." The hon. Gentleman knows that you cannot do that. That would be slavery. That would be bondage. The hon. Member wants to make slaves of the medical profession. We want freedom for doctors, with no respect of persons. Every man can be on that list wherever he practises—even Dr. Jelly.
§ Mr. LLOYD GEORGE
There the panel is suspended. It is obviously impossible for us, if we set up an alternative service which involves a guarantee to anybody that comes into the district to ask for free choice of doctor. That is the fault of the profession in the district. If we had been driven to set up a national service in some of the large towns the panel would have 309 been closed, because that would be the only way in which our finance could be assured. The medical profession were wise: they did not give us the opportunity.
May I interrupt the right hon. Gentleman to ask if he can say now whether he did think there was a possibility of free choice where a State service was set up, as in Ely; he will remember that he has already spoken publicly—I want to warn him—on 24th October?
§ Mr. LLOYD GEORGE
I do not quite know what has actually taken place here, but I will deal with it later on. The advantage of the panel system is that it preserves free choice of doctors; it is much more difficult to preserve that in any other alternative form. That is why we stand by the panel system; it gives free choice of the profession. There is no difficulty anywhere really except in London. Here, I am sorry to say, it is not medical but political. [HON. MEMBERS: "Look at, the municipal elections?"] All you have to do is to wait till the London County Council elections are over, and this particular difficulty will vanish. Until then I have not the faintest doubt that there will be a great demand for "own arrangements"—not from the insured persons, but from the doctors. The lion. Member for Sevenoaks asks, "What! are you going to deprive the insured persons of their doctors?" The movement has not come from the insured persons. It has come entirely from a certain section of the medical profession who have organised it. If there was a real demand from the insured persons they have their representatives. Probably 95 per cent. of the insured persons in London are either trade unionists, or members of friendly societies, or belong to industrial insurance companies. We have had no demand from these bodies that represent insured persons. If the movement were that of insured persons demanding some other arrangement than this Act gives them, cannot they say so for themselves? They are properly organised; they have their spokesmen, their leaders. The movement has been organised entirely and exclusively by a certain section of the medical profession, who worked it out and financed it in the first instance, who are holding meetings, and are sending sandwichmen about. It is not the insured persons; it is purely the doctors themselves. It is not the de- 310 mand of the insured persons; it is all a faked demand by a certain section of the medical profession who want to break down the Act for political purposes, and the proof is it is confined to London. I do not mean that there are not cases in other parts of the country where persons would like to get their own arrangements, and I am perfectly convinced that there are places where their own arrangements will be allowed—that has always been contemplated—but this is a great organised movement which is purely confined to London. Why, if there is a demand, should it be confined to London except that it is purely political? We cannot possibly permit it on the scale on which it is demanded, because it would break down the Act. What would happen if we were to allow every insured person who came in to say, "I want my own arrangements?" One advantage of the panel system is that you guarantee medical attendance for every insured person. The question was put to me whether we would allow medical men to go on the panel merely to attend to a certain class of persons—
§ Mr. LLOYD GEORGE
That is a question entirely for the doctors themselves. As long as the panel as a whole guarantees to us an efficient service for everybody there would be no difficulty about that, and that is the advantage of the panel. But what would "own arrangements" mean? It would mean the doctor would pick and choose his patients. You would have the question of picked lives all over again. One doctor would say, "I will have certain people." A doctor getting 8s. 6d. would pick lives and leave the worst lives and the broken lives to the panel doctors. That would be grossly unfair, and it cannot possibly be allowed. There would be no guarantee for effective medical attendance for the bulk of the population. Such a system would allow those who are in bad health, who are broken and very poor, to be attended by a section of the medical profession which may not be of the very best. If you begin to tolerate that, it would break down. That is why so many first-class men have joined the panel in London. We started by saying, "No, we will not allow any doctor to make arrangements for his own patients." If we did we would have no panel, and the result would be the old state of things, and we should be an agency, or messenger boys, for conducting 311 money from the House of Commons to the pockets of the doctors without the slightest control with regard to the expenditure of the money, and without any sort of correction as to whether the service was efficient or not. That is not what the House of Commons intended. Under the panel system you have real effective control. You can see that the doctor who is on the panel does render the services he has contracted with the insurance to give, and if he does not do that you can call him to account. A good many doctors would like to get away from that, but are we to pay the same money to the doctor who is prepared to carry out the regulations of the State, who is prepared to subject himself to State supervision, who enters into a contract with which the State can enforce, and a doctor who can do as he pleases and has only got his own patients to control him?
§ 5.0 P.M.
§ Mr. LLOYD GEORGE
We can do a little more than we have done in the past in that respect. You can see that his name is not retained on the panel, and that is a very powerful sanction to carrying out medical benefit in this county. With regard to the doctors who have come on, we were assured that there would be no medical attendance on 14th January, or that if we had medical attendance it would be purely a sort of refuge for the profession. The British Medical Association issued a statement of what they regarded as a successful panel system. They said you must get 8,000 doctors at the very least to join your panels in order to work the Act. We have got 15,000! With regard to the quality of the doctors practically throughout Great Britain almost all the doctors who have been engaged in industrial work are on the panels today. London may be a possible exception, but I do not deal with that. If you take all the great cities of this country—Glasgow, Liverpool, Manchester, Bradford, Newcastle, Birmingham, and Sheffield—the vast majority of the doctors who have been engaged in industrial practice are now on the list, and it is very remarkable that, although they have been working for three or four weeks under difficulties which would naturally come at the beginning, the number of complaints we have had up to the present are infinitesimal in the 312 whole of those districts. We cannot guarantee the quality of any doctor. There are good and bad doctors, and some in between; but that is the case in every profession, but you cannot guarantee them. Money does not always buy a good doctor. All we can say is that the medical profession such as it is—some of them first class, competent, and skilled men—we have got them on the list. We have got others, but, at any rate, they have been chosen by insured persons. If there are doctors on the list not competent the insured persons need not choose them, and if they choose them it is because they have faith in them, and I think faith very often makes up for works. So much for the number on the list. In London we have about 1,200 doctors, one in 1,100 of the insured population. There are many districts in the East End where the population is under-doctored, and in those districts I have no doubt that in the course of the next few months doctors will drift into those areas. They are beginning to do so. There is a great deal of hard work, but it is due very largely to the fact that in the past these poor people have not been attended at all. Half, if not two-thirds, of the population of this district have never received medical attendance at all, except what they have got as out-patients of the hospitals. For the first time they can call in their own doctor. That undoubtedly increases the work of the doctors. There is also another class of work which I have no doubt has increased the burden of the doctors at the beginning, and that is the filling up of the medical benefit cards. It does not take very long, it is true, but still if a doctor has 500 patients on his list it does take some time to fill in his name and address on each, and very often he has to fill in the name and address of his patient as well.
§ Mr. LLOYD GEORGE
I agree; and the trouble is three-fold to people who are not in the habit of doing this sort of thing. But that is a burden which is passing away. They have only to do it once, and there is an end of it. In future they will only have to fill these cards in respect of new patients.
§ Mr. LLOYD GEORGE
No, the hon. Gentleman is entirely wrong. They have only got to fill the cards and send them 313 in the first time. They have to send the names of those who accept them as doctors once to the insurance committee. Therefore, all this trouble which has taken place during the first fortnight, and of which most unfair advantage has been taken by some of the Press and by one or two hon. Gentlemen who have seen in it an opportunity of putting questions to try and create the impression that all the trouble in this world is due to the Insurance Act, is passing away, and in the course of the next week or two there will be very much less. I should like to say one word about the keeping of books and papers by the medical profession. I think it is possible to simplify some of the documents they have to fill up, and we are looking into the matter. It is one of the things where experience, of course, will teach us how to work the Act. I was interested to hear what the hon. Member for Sevenoaks (Mr. Forster) said about this. He said: "You cannot tell in advance what amendments you want to the Insurance Act. It is only experience which will show you." He quoted a letter which I wrote, I think to a Liberal candidate, and in which I said it was impossible to tell what amendments would be necessary. I have always admitted amendments would undoubtedly be necessary, and said that experience, and experience alone, would teach us what Amendments would be required. This is one of the Amendments in the Regulations which I think will have to be made. I think there will have to be some simplification of some of these documents. I should like to say something in regard to a question about which I have had representations made to me, particularly from Scotland. It concerns what is called the "tuberculosis sixpence." The doctors earn 6s. 6d, or 7s. according to whether they simply get the medical grant or whether sixpence is added out of the tuberculosis grant. Complaints have been made about that, notably from Scotland. They do not want to see their sixpences go.
They complain that the money is not paid out of this grant, but out of the sanatorium grant of 1s. 3d. I think it is rather important that I should say something about that. There are three claims upon the sanatoria grant of 1s. 3d. The first is the dispensary treatment, the second the domiciliary treatment, the third the sanatorium benefit or institutional treatment. The suggestion is that 314 the whole of this domiciliary treatment should be provided out of this sum, and that we should not take it out of the 1s. 3d. It is true that up to the present most of the work that has been done in respect of the sanatorium benefit has been dispensary and not institutional, the dispensary being the clearing house and having also provided tuberculin and observation beds. It is part of the work of the dispensary to decide whether patients shall be passed on to an institution or shall receive treatment in their own homes. I am now concerned with that part dealt with in this Vote, where the doctor is called upon to deal with a patient in his own home. We are criticised from both sides. The doctors say you are not paying enough, and the Scotch county councils say you are paying too much. I think I ought to explain to the House, first, why the proportion is so large. The number of insured persons who come up for treatment must of course at first be necessarily small. You are only dealing with persons who were employed in July last year and who have developed consumption since then. They may have had the germs in them, but they only developed after they had paid their contributions, and filled up their cards, being employed persons. Well, the numbers have increased from week to week and month by month.
In November there were about 5,000 cases which applied for sanatorium treatment. Of those, about half were dispensary cases and cases treated by doctors in their own homes, and about half went to sanatoria. The figures received last week show that 5,000 have been sent to institutions. The number has increased to that extent. Remember that the doctor has not merely to examine the case before he sends it from the dispensary to the sanatorium, but it is his duty when on the panel to look after the patient when he returns from the sanatorium and to keep an eye upon him and see how he is getting on. Therefore I would point out to the Scottish county councils that this 6d., although a liberal grant, does cover a good deal of work which is not on the face of it apparent. I have no doubt that as time goes on there will be more and more of those poor people sent on to institutions. You cannot build sanatoria in a day. The Act only came into operation in July. You cannot build sanatoria all over the country in a few months, and I think it would be a great mistake to attempt to do so. You must proceed tentatively and experimentally, even with regard to the treatment of 315 consumption. Some of the authorities still maintain that it is very much better to use tuberculin. The late Leader of the Opposition (Mr. Balfour) in a speech on the subject, urged us not to put all our eggs into one basket, and not to go in wholly for institutional treatment. That was supported by the right hon. Gentleman the Member for East Worcestershire (Mr. Austen Chamberlain), who was very strong about tuberculin. I hope all these things will be tried. That is what we are doing. We are trying to send patients through the dispensaries from their own homes, and to treat them in increasing numbers in institutions. At the end of January we had 5,000 in these institutions. I only wanted to say that in order to make clear to the House why we are distributing the 1s. 3d. in that way.
I think I have dealt with most of the questions which have been raised in the course of the Debate. I would only say in conclusion that most of the benefits under the Act came into operation on 15th January. In Germany they made up their minds not to bring the benefits into operation for a couple of years. There was something to be said for that. The Government decided in favour of making a start as soon as they could. Even in Germany, after two years' preparation, the machine did not work perfectly. You cannot expect that with any new machine. If we had waited for two years there is a good deal of suffering we should not have alleviated, a good many lives we should not have saved, lives which would have been lost if we had waited for two years. There is a good deal of experience we have gained which would not have been placed at our disposal if we had waited for two years. Everything that has happened has justified the determination of the Government to make a start at the earliest possible moment. We decided to bring the Act into operation in July. What happened? It worked with wonderful precision. Fourteen millions of people were insured, and are regularly paying their contributions. I do not believe that anyone looking ahead, not even the most sanguine person, could have expected that these cards would have been stamped with such regularity and returned week after week and month after month. You have 14,000,000 people registered for health insurance. On the 15th January other benefits came into operation. Three weeks before the Act came into operation 316 this is what was said by one paper on the subject:—It is now practically assured that, except in a few scattered districts, the medical benefits cannot come into force by 15th January.[HON. MEMBERS: "What paper?" and other HON. MEMBERS.: "The 'Daily Mail.'"] Here is another:—There are no doctors to work the Act, and very few sanatoria.We have 5,000 poor people in sanatoria at the present time, not one-fifth of whom would have been receiving treatment if it had not been for this Act. There are 15,000 doctors working the Act. It was obvious that there would be difficulties, obstacles, mistakes, but it is very unfair to attribute everything that occurs to the Insurance Act. If a man dies, this is the argument used, "Here is a poor fellow who has paid six months' insurance contributions. Notwithstanding that, there he is, dead!" That is the sort of thing. I do not say that every man will get the best medical attendance. Who does, rich or poor? All I say is that in spite of obstacles which ought never to have been put in its way, in spite of the appeal to prejudice, in spite of an organised appeal to prevent, the medical profession from rendering service to 14,000,000 workmen we have to-day got sick pay for men who would otherwise have been face to face with starvation, for themselves and their children, and we have doctors provided for men who never could have afforded it or who, if they could have called a doctor in, would have been faced at the end of their illness with bankruptcy. I am glad the Government determined in spite of every opposition to go on.
§ Mr. LUNDON
I do not intend to go into the question of finance which will be ably dealt with by the older and more experienced of my colleagues, but I happen to be the president of a powerful labour society in the South of Ireland. At the passage of the National Insurance Act it formed an approved society and I am its first chairman. It has its members scattered through all portions of Munster, through Kildare, King's County, and Queen's County, and I should be wanting in my duty if I did not protest in the strongest manner against the proposal put forward here by the hon. Member (Mr. William O'Brien). He seems now to be struck with the idea that medical benefits are going to ruin the National Insurance Act in Ireland, but what was his attitude with regard to medical benefits during the 317 passage of the Bill? On the Report stage, in proposing an Amendment to have Ireland excluded altogether, he described the medical benefits as the very life and soul of the Bill. He said one of his chief objections to it was that medical benefits were not to be extended to Ireland, and went on to say:—The party behind me would deprive Ireland entirely of the medical benefits, which are the very breath and life of the First Part of the Bill.We are trying to put life into the Insurance Bill against the wishes of the hon. Member, and I trust nothing will induce the right hon. Gentleman, who has done so much to lift the unfortunate workers, not only in Great Britain, but in Ireland, from the position in which they were, to allow this money to be devoted to any other purpose. The hon. Member for Cork and the hon. Member for North-East Cork have very different views on the application of medical benefit to Ireland. In a speech delivered in North-East Cork by the Member for the Division on 15th July, 1911, he said that the Irish Parliamentary party and their Leader were going to force medical benefit upon Ireland, and thus saddle another burden on the ratepayers of the country. Immediately an Amendment, was handed in to have Ireland excluded altogether so far as medical benefit was concerned, he turned a somersault, and described our action as nothing but a betrayal of the interests of Irish workers. He quoted a telegram from a trades body in the city of Cork, and also resolutions and telegrams from various other bodies on the subject. I ask whether he thinks he has a mandate from those bodies to deny to workers in Ireland medical benefit under the Act? The attitude of the hon. Member for the city of Cork and his colleagues during the whole of the discussion of the National Insurance Bill was not only one of hostility to the measure, but hostility to the Irish party who supported it. Now the hon. Member comes forward and says this money ought to be devoted to the housing of the working classes, the feeding of children during school hours, the distribution of free milk to workers in the country, and last, but not least, the buying up of some of the pawnshops in Ireland. Why does the hon. Member think about the housing of the working classes and those other matters now? It is because he hopes to continue the campaign of vituperation and calumny against the Irish party when he goes back to Ireland. It is not the first time the hon. 318 Member has tried to make use of Irish workmen by holding out hopes to them. I have here a resolution passed by the Cork District Committee of the Cork County and City Land and Labour Association on the 4th of this month. It runs as follows:—That we protest on behalf of 2,000 working men in the city of Cork in the strongest manner against the action of Mr. Wm. O'Brien and those associated with him in their efforts to make the housing question a political catch-cry, and that we believe his efforts to drag a red-herring across the track by appealing for. funds meant for the sick and disabled to be applied for housing purposes are calculated to embarrass the Irish party in the supreme and unparalleled crisis through which our country is passing, and are in direct contradiction to Mr. O'Brien's own statements with reference to the inclusion of the Medical Benefit Clause in its. application to the National Health Insurance Act.It would be seen from that resolution that he has not commanded approval of his action from his own supporters in the city of Cork. The hon. Member has done everything in his power to prevent the Act from working. I have the figures of the persons insured in the county and city of Cork. They number 30,200, which shows that the Act is working well despite the opposition of the hon. Member. And of these 30,000 insured persons only 7,800; are members of the two societies which were supposed to favour the hon. Member. I am not one bit surprised at the action of the hon. Member in putting forward this plea for the housing of the working classes, because so far as influence among Nationalists is concerned he is a spent force, and he hopes now by taking up this question to be able to raise a labour party by which he can gain back sonic of the power and influence which he used to have. I trust that the right hon. Gentleman wilt turn a deaf ear to this appeal as far as the £50,000 is concerned. My opinion as to, medical benefits, which I did not hesitate to offer at the beginning of the discussion on the National Insurance Act, is that some system should be devised whereby the Poor Law system and the medical benefits may be put into one so as to relieve the Irish ratepayers of the burden which they have to bear at, present. I may be attacked for these views, but I have been connected with the labour movement since. my childhood, and the hon. Member who thought it well to send his men into my Constituency to oppose me should remember that I was returned by a majority of 2,600. Instead of having any fear of coming forward I think it my duty to tell the men who have been associated with me, and who would give me their heart's blood if I desired that, they are going to be deceived by the antics of the hon. Member for Cork. On behalf 319 of the Irish Members, I thank the Chancellor of the Exchequer for the great work he has done in alleviating distress, as much in Ireland as in Great Britain. I trust that he will long continue his good work, and that when we have an Irish Parliament to manage our own affairs we shall look back and offer a hearty prayer of thanks for the good work of one whose name is a household word, not only in this country, but throughout Ireland.
Mr. CATHCART WASON
I am sure that hon. Members on this side of the House will heartily agree with the concluding words of my hon. Friend. We hope that the Chancellor of the Exchequer will live long to enjoy the esteem and respect of the community in this country. I speak more especially as one who has been from the outset a consistent supporter of the National Insurance Act through all its stages, but I may point out that there are very serious difficulties to contend with in the highlands and islands of Scotland. In the two counties which I have the honour to represent there are many islands with a considerable number of inhabitants which are totally unprovided with medical benefit. In Shetland we have the following islands: Burra Isles, 889; Fan Isle, 139; Whalsay, 1,040; Skerries, 144; Papa Stour, 212; Fonta, 175. In Orkney we have Burra, 628; Eday, 529; Hoy Greensay, 393; North Ronaldshay, 436; Rousay Egelshay and Veira, 710. In all those places the position we had to face was that there was no medical service whatever, and to reconcile our duty to our constituents with our strong feeling of friendship for the Act, and the great benefits which we were satisfied it would bring to many in this country, was a difficult matter. I had the honour to bring this subject before the attention of the Chancellor of the Exchequer, just before the Bill went through its final stages, and he promised there and then that the matter should receive his careful attention. I was very loyally and ably supported by my hon. Friend and colleague in pointing out the difficulties under which the population laboured in those parts of the country. As I stated, the right hon. Gentleman promised us his careful and sympathetic consideration. The result of his promise was that a Committee was appointed, under the chairmanship of my hon. Friend the Member for Inverness, to deal especially with this subject. They 320 went, perhaps, a little beyond their reference, but they issued a very exhaustive Report upon the whole position of the Highlands and Islands. I am only going to deal with that part which treats of medical service. My right hon. Friend assured me, in a reply he gave the other day, that the Government had made a Grant of the sum of £10,000 in respect of medical services and mileage in those particular districts.
§ Mr. MASTERMAN
I did not say that a Grant had been made. I said that there was now in the Supplementary Estimates provision for the sum of £10,000 for the service of insured persons.
Mr. CATHCART WASON
That will mean for medical service and mileage, for what the Government propose to do immediately has the force of law; at any rate, we are satisfied with what is to be done. I wish to express my gratitude, and that of the whole of my Constituents to the Chancellor of the Exchequer, and the Secretary to the Treasury, for the manner in which they have taken this matter up and brought it to a successful conclusion. We would have done the best we could to work the Act, even without. the special Grant, for I have no hesitation in saying that it is one of the most beneficent measures that has ever been passed for this country.
§ Mr. T. M. HEALY
May I ask when the Closure is to be applied? We were told by the Government it was to be Six o'clock.
§ The CHAIRMAN
The matter does not rest with the Government at all, and I am not aware that the Government have made any arrangement of the kind. It has never been mentioned to me.
May I claim the indulgence of the Committee on this the first time I have had the honour to address any remarks to the House? I do so now, mainly because in Midlothian there is a large country in which at the present moment only three-fourths of the insured persons are getting the medical benefits for which they believe they have paid by their compulsory contributions. I desire to place the situation before the Committee in some detail, because I believe there are many similar situations in various parts of the country; and there are one or two questions of principle which I should like to raise and which are involved in this situation. We certainly are entitled, I think, before voting this extra Grant, to make certain that there will 321 be reasonable probability that it will provide a thorough efficient medical benefit for all compulsorily insured persons. The parish of Stow in Midlothian consists of 1,600 people. Of those a thousand or thereabouts are in the main parish and the others are scattered about on various farms and small holdings. There is only one resident doctor there. Be is not in his first youth and does not feel inclined to undertake the new conditions under the Insurance Act. There is a panel doctor at Galashiels which is eight miles distant, and also at Gorebridge. There are 400 insured persons in the parish of Stow and of those the panel doctors have accepted 100 who were old patients of theirs. As to the remaining 300, the panel doctors at Gorebridge and Galashiels declare they cannot accept them, as they have undertaken as much work as they can give efficient attendance to. The position is complicated by the fact that there is no chemist in the parish of Stow, as there would not be sufficient business to make a living. The nearest panel chemist is at Galashiels, which is eight miles distant, and the return fare by railway is 1s. 1d. The local secretary of the approved society, to which a large number of those 300 disappointed contributors belong, on 7th January last, addressed letters both to the Scottish Insurance Commissioners and the county insurance Committee asking what steps were to be taken in the matter. The insured persons have been trying to get the benefit through their approved society. The secretary of the approved society has only lead the answer that the position of matters in connection with medical benefit is at present under the consideration of the county committee and of the Scottish Insurance Commissioners. I do not for a moment suggest that there is any blame attached to those bodies. I quite see that there are enormous difficulties and obstacles to be surmounted before proper medical benefit can be given.
I should like to know, first of all, would the Government support the county insurance committee or the Insurance Commissioners if they decide to compel the panel doctors to accept insured persons when those panel doctors say themselves they cannot give more patients efficient medical attendance? It seems to me that there is a large question of principle involved in allotting the residue. Who is to decide of how much work each individual doctor is capable? How far is any 322 one justified in compelling a man to work more hours than he wishes? I mean from the point of view of the interests of the patient. Another alternative open to the insurance committee is that of the whole-time doctor. Even with these Supplementary Estimates, a whole-time doctor for 300 insured persons might be rather expensive. The Chancellor of the Exchequer has stated that the Insurance Act is at present in an experimental stage. I do not dispute that eventually medical benefit may be provided for all insured persons. In the meantime there is a question to which I should like an answer. If any of these 300 insured persons, who have tried, not to make their own arrangements, not to claim a free choice of doctors, bat simply to get medical benefit in some way, fall ill, call in a doctor, and make their own terms for individual visits and treatment, can they recover the doctor's bill in full from the Insurance Commissioners? I, personally, am inclined to think that they can, under the proviso of Section 15 (2). But my Constituents would like a more authoritative opinion than mine, and I hope the Secretary to the Treasury will answer the question. It was only last August that every spare wall in Midlothian was decorated with a most attractive poster, issued by the Liberal Insurance Committee, setting forth the popular benefits of the people's Insurance Act. Those benefits included "free doctor and free medicine for life." The Chancellor of the Exchequer also stated, when he introduced the Bill, that every insured person would be entitled to command the services of a competent doctor. No doubt the case I have laid before the Committee will eventually be satisfactorily adjusted, but the case shows that at any rate in one case with which I am well acquainted these promises have not yet been fulfilled in their entirety. The Supplementary Estimates we are now asked to vote are an increase of 40 per cent. on the original estimated cost to the nation of the administration of health insurance. The insured persons in their capacity of taxpayers are now to pay 40 per cent. more than they were led to believe they would have to pay when they made their first contributions. The medical benefit machine was only started by the promise of this extra money. Most of the doctors throughout the country have only contracted to try to work the Act for three months. Should we not now vote only 323 that portion of the money required to work medical benefit up to the 15th April? Should not this House retain the power to reopen and debate the whole question when we can see more clearly whether there is any reasonable probability of every insured person getting permanent and efficient medical benefit under the Act? I believe it has been stated that the money must be voted in order to give the doctors confidence. I should like to suggest that the doctors undertook their three months' contract in full confidence that this House would vote the additional money. I do not believe the doctors would for one moment imagine that this House would refuse to continue this Grant if the doctors on their part arc willing to perform their contracts. I should like to ask the Secretary to the Treasury if he would be good enough to answer a question I have already put to him, namely, "If A B, insured, can show a good healthy life, and is in all other respects a desirable patient, but cannot get medical benefits and cannot get a doctor to accept him, if he becomes ill and calls in a doctor can he send the bill in to the Insurance Commissioners, and will it be paid?"
§ Mr. MALLABY-DEELEY
I have sat in this House in absolute silence during these Debates and heard the views of others without even venturing to raise my own voice. Whether that will be attributed as a vice or a virtue in me I do not know, but it may perhaps be said I am the one Member of the House who by my silence has contributed to the progress of the discussions. I would maintain my attitude of masterly inactivity even now but for one or two remarks made by the Chancellor in his speech, and also because of another incident near my own Constituency to which he referred. The Chancellor, in his speech, made the following remarks. He said:—The panel gives efficient service for everybody. …. That is the reason of the panel. You can see that the doctor on the panel renders the services he has contracted to give. …. If he does not you can call him to account.In another part of his speech the Chancellor said the number of complaints were infinitestimal. I wish to make reference now to that part of the Chancellor's speech. I put a question to the Chancellor of the Exchequer yesterday, and it was answered by the Secretary to the Treasury. It was:—Whether the Chancellor of the Exchequer's attention has been called to the present condition of Stan- 324 more, in Middlesex, where no insured person is able to, obtain medical treatment, as neither of the local doctors is on the panel, nor can any member of a friendly society obtain medical treatment because the doctors ceased at the end of last year to be club doctors; and will he state what steps he proposes to take to remedy this state of affairs?The reply I received was:—Mr. Masterman: I am informed by the insurance committee Ow there has been no case at Stanmore in which an insured person requiring treatment has been unable to obtain such treatment from a doctor on the panel. I am also informed that the insurance committee consulted their committee of panel doctors, and that committee stated that in their opinion the difficulty referred to would be adequately met by the doctors in the neighbourhood undertaking the responsibility for the medical attendance and treatment of insured persons living in Stanmore.The information I asked for was whether the attention of the right hon. Gentleman had been called to the fact that no insured person in Stanmore had been able to obtain medical treatment from a doctor on the panel. The reply is as I have stated. I wish to give the right hon. Gentleman a specific instance, the case of an insured person who has not been attended by any doctor on the panel, first of all because there is no doctor on the panel in Stanmore; and, secondly, because the doctors who are supposed to attend the cases in Stanmore are several miles away. In this particular instance the insured person was little more than a boy, and he lived at Edgware. He was taken ill on Thursday and applied by telephone to the panel doctor at Edgware. He was informed by the doctor that he was unable to attend then, but that he would come on the Saturday. On the Saturday a message was sent to say he could not come, and the insured person got Poor Law relief on the Saturday. It was not until the following Monday evening that a telegram arrived from the insurance committee in reference to the case. I do think that this is a case that requires a little more elucidation than has been given to me by the. answer of the Secretary to the Treasury. I frankly acquit the right hon. Gentleman of what I may venture to say is a misleading reply. He is not, I am aware, able to, investigate all these cases himself, and he gives the replies that reach him from an official source. But I can assure him that those who know the case, those who are. fully acquainted with it, as I am, will receive his reply with consternation and. amazement and with a considerable. amount of depression. Because if this rather depressing reply is given in a case were the facts are so well known, what may follow in cases not so well known? I 325 only speak to do my duty to my Constituents so far as lies in my power, and I hope the right hon. Gentleman will give a little attention to what I think is a very unfortunate case under the Act, and so make complaints more infinitesimal.
§ 6.0 P. M.
§ Mr. GLYN-JONES
The last speaker has been the first Member of the House who has put forward an alleged case of inability on the part of an insurance committee to provide medical benefit. He has mentioned the case of Stanmore, in the district of the Middlesex Insurance Committee, of which I have the honour to be the chairman. It is a village with a population of about 3,000 and there are two resident doctors. For some reason or other those doctors have ceased to treat their former clubs patients and up to now have refused to enter into any arrangement with the committee to treat those very people at an advanced rate of remuneration. It is more or less an isolated village, and the committee will have no difficulty whatever in getting into the district a medical practitioner able to take charge of the whole of that population. But in the interests of those two doctors in that district whose practices would undoubtedly be affected if any such step as that were taken, the committee consulted the doctors' committee, consisting of those on the panel for the immediate neighbourhood and those doctors said that, at any rate, in the meantime, there was no necessity for the insurance committee to take the drastic step which otherwise would be necessary and they said that they would have no difficulty in providing the necessary assistance. One of them lived within a mile of that village. Here we have a specific case put before us in regard to which the clerk of the Middlesex Insurance Committee on Monday morning this week received the first intimation from a relative of this young man stating that on Saturday medical attendance had been declined, and that he had received a telegram from his doctor stating that he was unable to attend him. That was on Monday. We got into communication with the doctors in the district, and on Monday afternoon that patient was sent a telegram informing him of a doctor who was ready and willing to attend him. Within a few hours of the committee being told about this case they put at the disposal of this patient a fully qualified doctor, and yet that is a case which is 326 brought up here to-day as evidence of the failure of the Insurance Act. The difficulty, such as it is that exists there, is one which is due, rightly or wrongly, to the attitude taken up by the two medical men in that village. The Act has been in force three weeks, but if it is the fixed determination of those doctors not to treat the insured persons in that village the moment we are assured of that we can make other arrangements. It is in their interests, expressed by the practitioners of Middlesex, their own profession, we did not take the step we should otherwise have taken. That is an instance of the kind of criticism we have been hearing from the Opposition. Twenty years ago I was engaged in something like the practices we have heard about in the East End of London. The hon. Member for Colchester (Mr. Worthington-Evans) has said this Insurance Act has taken away from these insured persons their free choice of doctor; they could have got doctors from 3d. to £3 3s. Yes, the choice was limited by the 3d. That is the answer. If they had 3d. they could get a threepenny doctor; that was the only choice open to them. It does not lie in the mouth of the medical profession to say these men are not fitted to be on the panel. If they are not fitted to treat these people as insured persons, they were not fitted to treat them as ordinary patients, and steps should have been taken to have had them removed from the medical register. It was not until they came on the panel we were told they were unfit.
§ Mr. GLYN-JONES
I am not talking about Stanmore at all. There can be no doubt, whatever the leaders of the Opposition may have said, every difficulty has been placed in the way of bringing the medical benefit into operation. The fact that the administration has been unfairly criticised by the Opposition has made it all the more difficult. At the time when the whole profession were being asked to vote whether they should accept service under the Act or not, the "British Medical Journal," their own organ, kept quiet; but the Carmelite Press, one of the 327 leading organs of the Tory party, said that the more preponderating that vote was against acceptance of service the better. I have been asked what the Middlesex Committee mean to do with regard to contracting out. The majority of the applications for contracting out which have reached the committee have come on a form—and it is well the House should note what the Middlesex Committee have been asked to do—headed—Medical benefit and the means of escape.It is signed by twenty or thirty doctors in various parts of the western portion of Middlesex, and it proceeds in this way:—We, the undersigned, have refused to place our names upon the panel of the Insurance Act and desire to state plainly our reason for so doing. The primary reason is that we pledged ourselves not to accept service except in accordance with the declared policy of the British Medical Association. That policy was declared by a huge majority to be one of no service. We consider the medical section of the Act to be unworkable, derogatory to the medical profession, and injurious to public health.That is the application to us to allow contracting out. I challenge any Member of the Opposition or of the medical profession to deny that the conditions under which hundreds and thousands of the poor workers of this country have in the past received their medical treatment has been a disgrace to the profession and a danger to the community. They know it and they admit it, and they have done their best as a profession to stamp out the evil. Through all their organisations, such as the British Medical Association, they have tried to stamp out the 3d. doctor and all that which is implied in the phrase. They have failed, yet here is a scheme which at any rate is going to give a man who is only able to pay 3d. for a doctor an opportunity of going to a doctor who is not a threepenny doctor, a scheme which is going to give him a free choice in that way. If he thinks the doctor he has is not properly treating him he may go to someone else. That will do more to eradicate this evil system than any attempt on the part of the profession. As to the question of contracting out, these doctors organised public meetings in the West Middlesex Division in the interests of insured persons. It is the first time I have ever known the medical profession to spend money in organising public meetings in the interests of insured persons. What does their circular say? They are so anxious to break down the Act that they say:—By thus becoming a private, as opposed to a contract patient, a person will escape from the glaring evil 328 of the old club practice which has been specially incorporated in the new Act and which was a direct inducement to prescribe cheap as opposed to effectual drugs.Twenty years ago I was dispensing for a surgeon where people paid a shilling for a visit three times a week and two bottles of medicine thrown in. I know something" about the old system and about the inducement to prescribe cheap as opposed to effectual drugs. The panel doctor is not looking for the floating sixpence. There is 1s. 6d. to be put into the pool. His income remains wholly unaffected. This panel doctor, this low-down doctor, this man who has lost his honour, and has done something derogatory to his profession, knows that there is 1s. 6d. to be put into the pool to provide drugs and medicines for insured persons, and that there is a possibility even of 2s. Yet we have this circular and this case put before the servant girls of Middlesex. They are told that the panel doctors are going to stint them with cheap drugs for the sake of saving sixpence, and I am entitled to warn them that the inducement to the doctor who is not on the panel will be to save the 2s. instead of the 6d. The past curse of the treatment of the poor people of this country has been that for every bit of medical material the doctor gave to a poor patient the cost came out of his own pocket. It is because this great scheme will in future provide that a doctor for a poor man will be able to write a prescription for the drugs he needs without any consideration of the cost to himself, and because he will be able to treat the poor man as he has treated the rich man, that I welcome this additional Grant.
I worked in Bermondsey, and I have lived in and now represent Stepney. Compare the death-rate of Bermondsey or Stepney with that of Highgate or Hampstead. There are more persons who die in Stepney and Bermondsey. What is the explanation? The man in the street and the social reformer will tell you that Hampstead is a much healthier place to live in than Bermondsey or Stepney, because there are no nasty factories and works, no slums, and people are not crowded out. That means that it is more difficult to keep well in Stepney than it is in Hampstead. In that sense it has a great effect upon the death-rate. But there is a far bigger factor, which is that when my poor Constituents become ill they do not get the same chance of recovery as the people who live in Highgate or Hampstead. I do not wish to say a word 329 which will make it difficult for all the doctors in Middlesex to come upon the panels. We have 500 there now, which means one for every 600 persons. We are told that this Act is a failure. There have been inquests which the Opposition Press have referred to as instances of the Insurance Act killing people. At Enfield a young domestic servant sent for a doctor. She went to a panel doctor. She died about three days after she first saw him, and no death certificate was given. There was an inquest, and the papers used that as an instance of the failure of this medical benefit scheme. Does the "Evening News," as a rule, give a dozen or twenty lines to any ordinary inquest which is held in regard to a person who died because he did not send for the doctor soon enough? When I worked in the East End and in the South-East surgeries it was a weekly occurrence for a poor wretch not to send for a doctor until he was beyond all hope because he had not the money. There were inquests galore, but I never saw anything about them in the "Evening News." But when this medical benefit scheme comes into force and a certain section of the Opposition and a certain section of the medical profession desire to discountenance it, they take the Enfield case.
What was the Enfield case? A girl sent for a doctor. You cannot go to the "Evening News" and to the public papers if you want the truth about these matters. I have here the doctor's deposition given before the coroner's jury, and he said he went and examined the girl, and found some obscure disease which he was not able to diagnose. He said he would call the day but one after. Meantime the girl got worse and died before he got there. There was a post-mortem examination, and it was found that she was suffering from pneumonia, and that she had died of heart disease. Have any of you known of people who have had pneumonia and the doctor, who was calling three or four times a day, has failed to diagnose it for three or four days? Because the doctor on the first occasion did not diagnose this it is the Insurance Act and it is reported in the Press that the doctor could not properly do it because he was signing cards and because he was doing too much work for the Insurance Act. These records, which some people do not like and which I agree should be simplified, are useful when charges of this sort are made. I have been through the records before coming to the House. This took place on the 22nd of this month. On 330 the 21st of the month the doctor signed eighty-two tickets. On the 22nd, the day of the girl's death, forty-four. On the 18th he made four visits and one attendance, on the 19th no visits and four attendances, on the 20th two visits and eight attendances, on the 21st one visit and three attendances, and on the 22nd, this very day when the "Evening News" said he was much too busy to attend to this poor girl, two visits and six attendances. That seems to me, at any rate, to do away with that case, and I think the Opposition would be well advised in assisting what they know in their heart of hearts is a magnificent scheme. It is not a short-cut to all the difficulties which have existed in the past, but it is a pioneer movement, and instead of throwing difficulties in the way they should join and help. We have had two suggestions made this afternoon, one that a doctor should sign his name on the ticket and the other that people over sixty-five years of age should have medical benefit. I agree, but will the hon. Member (Mr. Worthington-Evans) who made the one suggestion about people over sixty-five and the hon. Gentleman (Sir P. Magnus) who made the other suggestion about signing the tickets guarantee that if the Government make these two changes they, at any rate, will do their best to induce the doctors to attend these old people, and that the putting of the extra addresses on the medical ticket will not mean extra clerical work? The one criticism is that you will not put the doctor's address on the ticket, and the next is that the doctor has too much clerical work. You cannot have it both ways, and it suggests party feeling in your criticism.
§ Mr. T. M. HEALY
I rise for the purpose of asking some questions with reference to this Vote, which, so far as I understand, seems to be a wholly illegal Vote. This is the first time that this Vote has appeared upon the Paper of the House, and it is described as a Supplementary Estimate. A thing must be supplementary to something. Last year there were six Votes in relation to National Insurance. We have now got into a new Class—Class 8—and Vote 1 was the National Health Insurance Committee; Vote 2, was National Health Insurance (England); Vote 3, National Health Insurance (Wales); Vote 4, National Health Insurance Commission; Vote 5, National Health Insurance Commission (Ireland), 331 and Vote 6, Labour Exchanges and Unemployment Insurance. This is a Supplementary Estimate, and I should like to ask which of these six Votes is that supplementary to? If you take every other Estimate ever presented to the House—the Votes for the War Office, Board of Trade, Board of Agriculture, Stationery Office, and other Departments—you have there an Estimate on which you can graft something. Here you have in the Session just past six separate Votes, and then you have an omnibus Vote of £1,750,000, to which it is suggested this is supplementary. I therefore think that on the framework of the Estimate it is unconstitutionally framed, and that the Government will be met with this difficulty next Session: They will have to pour, as it were, into one of these six decanters the money from this reservoir, and they will have to allocate sums to England, Scotland, Ireland, and Wales. The importance of that is, when dealing with Ireland, which of the Irish decanters will you pour it into? I ask that question because form is not only of the essence, but of the rights and privileges of this House. We have no medical benefit in Ireland, and I wish to know under what Section of any Act of Parliament you claim power to vote for Ireland £50,000 for which you can cite no Statute. So far as England is concerned, let me point out the predicament you are in. The extraordinary thing about the Estimate is that it is called a special Grant, but in the Paper the whole Supplementary Estimate is described as an "Estimate of the further sums required to be voted for the service of the year ending 31st March, 1913." Let me first deal with the English position. The Paper states:—Estimate of the amount required in the year ending 31st March, 1913, for Grants in aid of National Health Insurance (United Kingdom), in addition to the sums payable under Section 3 of the National Insurance Act, 1911.Section 3 of the Act is of enormous importance when you are dealing with a tax which is paid partly by the employer, partly by the employé, and partly by the Crown, because if you have a right to put down £1,000,000 for this particular subject, I say that it entirely deranges the two-ninths and the seven-ninths upon which the scheme was based. If you have the right to vote £1,800,000, why not put down £10,000,000? If the right hon. Gentleman has statutory authority for it, he is right, but if he has not, he might as well put down £10,000,000. The money 332 put down in the Estimate must be money which is to be allocated and provided for by reference to the Statute. The Estimate uses the extraordinary phrase "in addition to the sums payable under Section 3." Section 3 is most precise, and it cannot be under that Section. This cannot be part of the two-ninths of the benefits when you are not taking it under Section 3. Then under which of the 115 Sections do you claim authority to vote this money? In an ordinary transaction of a legal character the parties would be obliged each to make discovery, but what the Treasury does is to come to the House of Commons for money and give the House of Commons no information on the Estimates. What information is it to me, as an humble inquirer, to be told that they are asking for this money, in addition to the sums payable under Section 3? Why not tell us under what Section it is asked? We are entitled to know. In almost every other estimate of this nature the Committee is informed by specific reference to the Sections what it is the Government are asking for, and what is the legal authority for the demand. Printing is cheap, and the Government have at their disposal a large and authoritative staff. Why are we not told by what authority you come to Parliament and demand this money? That is my humble suggestion as regards the English branch of the case.
The case for Ireland is, of course, wholly different, because you have provided by Sections 81 that there shall be no medical benefit provided for Ireland except those under Part 2 of the Fourth Schedule. The benefits that are granted as respects this £50,000 are not under the Fourth Schedule, Part 2. Therefore, I want to know what is your authority for coming to Parliament for this £50,000? The importance of the case is this: I understand that the Government are taking up this line which they took up last Session, that under the new method of administration they are entitled to legislate by means of Estimates. Last year, with regard to the salaries of Members of Parliament, they said, "We do not want any Act of Parliament; rain the £400 each into the Appropriation Bill." Similarly, with regard to the Grants to African railways last Session, it was said, "We have Put the Grants in the Appropriation Act, and consequently they are perfectly legal, because Parliament has approved of them. In this case Parliament has said by Statute 333 that medical benefit was not to exist by Statute. You are providing £50,000 by this Vote, and I want to know by what authority. Remember it was for this purpose that you appointed your Committee, which was shot upon the House as from a catapult, two of its Members being connected with organisations which would benefit under this system. Let us see what authority you have for proposing this £50,000. This whole demand must have been the subject of correspondence, and if Canada, Australia, and South Africa are entitled to correspondence, are we not entitled to have the Papers and to know, as regards the rest of the equivalent Grant, on what basis that is to be allocated? We get no such information. If this is the method of modern legislation, no wonder we want Home Rule. Here is the proposal in the Estimates which is suggested as legislation:—The Grant-in-Aid will be paid to a special account in the National Health Insurance Fund. Ireland, and will be applied by the Irish Insurance Commissioners in grants towards the cost of medical certificates of sickness, and other expenses of administration arising owing to the absence of medical benefit in Ireland.Have you a Statute for that? If you have, refer us to it. You have no right, even though you are a Government, to override the Statute. If there is anything in the Insurance Act to authorise that Statute let us know what it is. My hon. Friend the Member for Cork was within his rights when he made a very moderate speech, which I do not think deserved the arraignment by which the hon. Gentleman who made it was, for the first time, introduced to us in the form of a maiden speech. My hon. Friend the Member for Cork was not giving offence to anybody. [HON. MEMBERS "Oh, oh!"] I know some people are very sensitive. Princesses of old lay on fifty eider-down quilts, and if they were scorched on the back next morning they were of the true blood. No doubt some are descended from those princesses. My hon. Friend, in a speech which I thought entirely inoffensive, suggested to the Government, referring to the specially appointed Committee on the subject of dealing with the unallocated funds, that there were other objects which ought to be taken into consideration. I would suggest to the Chancellor of the Exchequer, if you frame a particular instrument in one way, you can only get one result. When you pack a jury you can only get one verdict. If you put certain persons on the Committee who are known to be committed to a particular view of allocation, you can only get 334 one particular form of allocation recommended. The hon. Member for Cork suggested that there are other methods of allocation. It is quite true that we voted against the Insurance Act, not against any Clauses in the Act. I voted against the Act as a whole, and if the Act came up again I would vote against it again and again and again. Those things were not done in a corner. They were done openly on the floor of this House. When the Tory party confined themselves to voting for Amendments, we voted against the Third Reading, and so we would do if the Act came up a second time. But the Act is now law, and the Act being law, I have not said anything to discourage it in its administration.
If the Irish people choose to bear the blisters that are put upon them, or any other blisters that are in the horn of plenty of the hon. Gentlemen behind me, who are now proposing that an additional three-halfpence should be put on the farmers of the country, I have no objection whatever; let them do it, but let it be done openly. For instance, the right hon. Gentleman has put the hon. Gentleman the Member for Monaghan (Mr. Lardner) on the Committee, a very capable and earnest representative. Will he go down to the farmers of Monaghan, to his constituents, not as the head of the Foresters, but as their representative and say, "I am in favour of you having to pay three-halfpence before the question of medical benefit under the Poor Law is adjusted"? We have a very efficient system of medical benefits, but it would be out of order to discuss that question now. All my hon. Friend the Member for Cork did was to ask the Chancellor of the Exchequer, in dealing with the question of the equivalent Grant, not to foreclose the question in his own mind. The right hon. Gentleman himself called this body a Committee, and it has been called a Commission. It, cannot be a Committee of this House, as it consists of gentlemen who are not Members of either House, and unless it is a Departmental Committee, I really do not know what it can be. The right hon. Gentleman has been asked by my hon. Friend to tell us whether in the formation of that Committee he had the intention of bringing in a fresh Act which would have the result of putting an additional blister upon the backs of the farmers of the country. Whatever that Committee reports, if it has that result, the Bill will have a very difficult passage. It certainly will not be an agreed Bill. 335 The Irish party last year declared in favour of the omission of these medical benefits. So far as I know they have not met since to consider the matter—at any rate, there has been no public statement to that effect—and yet the right hon. Gentleman has framed a Commission which can have no other result than that which I have indicated. My hon. Friend made a very moderate suggestion in a very moderate speech, and I think he is entitled to an answer.
§ Mr. LLOYD GEORGE
The Treasury has had varied experiences in dealing with Ireland, but I think this is the first time it has had the experience of having an Irish Member raising a technical objection to a Grant of £50,000. This sum is for the purpose of enabling sanatorium treatment to be given to poor consumptives.
§ Mr. LLOYD GEORGE
I beg the hon. Gentleman's pardon. I will give the facts, because while he was less than usually entertaining he was more than usually inaccurate. There is a very considerable sum of money here due to the fact that, owing to great distances which had to be travelled by doctors in order to attend poor consumptives in some of the wilder districts of Ireland, the sum provided was not adequate. The doctors did not refuse, but they naturally complained. They had to travel very long distances, perhaps fifteen or twenty miles across very wild country, merely to see one poor consumptive, and they said, "We cannot do that for 1s. 2d." Half of this money is for the purpose of paying doctors for visiting these poor consumptives, for reporting upon their cases, and for helping them to get treatment which may save their lives. In that case we want a certificate. You cannot get that without a proper medical examination. There is no medical benefit in Ireland. The money is paid, not for the certificate, but for the medical examination that is preliminary to it. There is sickness benefit in Ireland. The doctors have to examine the patient beforehand, and they want to be paid for it. Money was put down for the purpose, and the hon. and learned Gentleman has used the whole resources of his remarkable ingenuity for the purpose of preventing the House of Commons voting a sum of money to enable the poor consumptives in his own country to be examined for sanatorium treatment. I come to the 336 objection that, not for the first time, has been put forward that this has never been done before—that it is an outrage on constitutional precedent due entirely to the wicked people here, who want to extend these benefits to Ireland. It had never been done before! Well on the very occasion to which he refers he said exactly the same thing! What happened? He challenged precedents. He got one. He got many more precedents than he cared for. My right hon. Friend has a list as long as my arm, and he pelted and buffeted the hon. and learned Gentleman with them, and I think, for the first time, reduced him to a state in which he was left dizzy and speechless. It was the first time, I think, that I have found the hon. and learned Gentleman absolutely speechless. I will do him the credit to say that he is never dismayed by the badness of his case. But this time it was so hopelessly bad that he had not a word to say for himself. It has taken him twelve months to get over it. He has recovered, and here he is at it again. With tremendous truculence he puts forward his case. He has forgotten what took place, and he has relied upon the memory of everyone else being as bad as his own. Luckily it is not! I remember his questions: there was a very long string of them. It is not by any means the first time that this has been done. I hope it is not the last time—when the occasion is used for so excellent a purpose as now.
§ Mr. LLOYD GEORGE
I am amazed, with the very long experience of the hon. and learned Gentleman, that he should raise so entirely absurd a point. The Statute is the Appropriation Act. Does my hon. and learned Friend suggest that the House of Commons cannot possibly vote money except in accordance with Statute?
§ Mr. T. M. HEALY
If you ask me that question, the Statute has provided that there shall not be medical benefit in Ireland.
§ Mr. LLOYD GEORGE
I know exactly, my hon. and learned Friend says it is toothless! We are here providing it with 337 a set of teeth. The only thing the hon. and learned Gentleman said was that the Act did not provide is a negative. It does not say that Parliament shall not vote money for the doctors of Ireland; that Ireland shall not have a single penny for consumption in Ireland. A Statute of that sort would have been perfectly preposterous—a Statute which does not as a matter of fact provide it. Does the hon. and learned Gentleman mean to say that because an Act of Parliament passed for Ireland does not provide for something not in it, that nothing else shall ever be provided for Ireland?
§ Mr. LLOYD GEORGE
There is no part of the country that stands to lose more than Ireland does by that peculiar and eccentric interpretation of the British Constitution which the hon. and learned Member has presented to the House of Commons. It simply means Parliament is not entitled to say that she will vote £50,000 if she likes towards Ireland. You have got to get the money out of the Consolidated Fund, and of course until the Appropriation Act there is no legal sanction for the payment. My hon. and learned Friend said this is a Supplementary Estimate. If he only looks at it he will see it is not a Supplementary Estimate merely, but is the amount required to the end of the 31st March for the Grant-in-Aid to the National Health Insurance. On the outside of the document, it is true, there are the words "Supplementary Estimate," and it is supplementary in the sense that it is supplementary to the Estimates, but so far as Parliament is concerned this is a new Estimate and that is the form in which it is presented. I am very sorry we should have this unsavoury red-herring drawn across the track. The hon. Member (Mr. O'Brien) put some questions to me which I do not deal with now because it would not be strictly in order to do so, as to whether there are not other methods of applying this sum. He talked a good deal about equivalent Grants. That does not apply to this at all. It is purely a question of half-a-crown per head of insured persons in the United Kingdom. In England that half-crown per head is met by a contribution of three-halfpence by the insured persons. We have appointed a Committee to ascertain whether in Ireland they desire the extension of medical benefits. We shall be perfectly ready to listen to any 338 alternatives, but it would be idle to appoint a Departmental Committee to inquire into these matters if a Minister, before that Committee sat, was to express his view of what ought to be done. We must wait until the evidence is given and the Report handed in, and then we shall be perfectly prepared to face the problem in the light of the evidence submitted. Take the question of housing, to which the hon. Member referred, and he asked for a sum of money to spend in Ireland on the housing of the working classes. There they are paying about half the annual value of the rent. If an equivalent Grant was to apply, England, Scotland, and Wales should have an equivalent Grant for what is devoted to these purposes in Ireland. There is no question to which the hon. Member for Cork should refer less to support his claim than that. The amount here is necessary for sanatorium treatment and to see that consumptives get the best out of the Act and seeing that sick persons get their sick pay. That is why the £50,000 has to be voted, and I hope that explanation will be regarded as satisfactory. I must say, in reply to my hon. Friend (Sir John Dewar), and those who acted with him, that they have done most valuable work and the best bit of work done in my experience. They prepared a very valuable Report, which showed that the condition of things was deplorable. We have not had time, I will not say to digest, but to consider the best method of carrying it into operation, but we feel that an overwhelming case has 7.0 P.M. been made out by my right hon. Friend, to who we all owe a debt of gratitude for what he has done. We have put down a special Grant of £10,000 for the Highlands, which will enable us to do something until we can consider a more permanent scheme for extending medical benefits in the Highlands. The Highlands are a very special case. In other parts of the country the insured persons are one in three, whereas in the Highlands the proportion is one in ten or twelve, and where the need is greatest the fund is the smallest. They have often to travel fifty miles across very Stormy and rough seas in all weathers, and go to islands where there are neither doctors nor nurses, and the poor women are often left without any sort of medical or trained aid in very trying circumstances. These remote parts do a great service to the Empire in the 339 way of producing a very fine race who render us gallant service, and we ought to go out of our way to help them in their trying conditions of sickness. Hon. Members representing the Highlands may rest assured that in regard to this £10,000 we are putting it down as an earnest that we are taking this matter up. May I appeal to the Committee to conclude the Debate, because we have now had a very interesting discussion upon all branches of this subject?
§ Mr. BUTCHER
I will call attention to the question of medical benefit as regards men over sixty-five who are not in employment. The North-Eastern Railway Company have a pension scheme to which both employers and employed contribute, and the men retire at sixty-five with a pension. There are others in the same category in other occupations. There are two classes—(1) those who have attained the age of sixty-five at the commencement of the Act, and (2) those under the age of sixty-five at the commencement of the Act. As regards the former it is obvious that they cannot get insured under the Act, and consequently they cannot get the medical benefits under the State scheme. As regards the medical benefit they get under the friendly societies voluntary scheme the difficulty is that those schemes have been largely upset by the operation of the Act, and the difficulty is now that medical benefits cost more than they did before.
§ The CHAIRMAN
It seems to me, if I catch the point of the hon. Member correctly, that it would require legislation to make the alteration he desires. If the hon. Gentleman can show a way in which it can be done without legislation, it would be in order.
§ Mr. BUTCHER
I suggest the Government should make an extra Grant of 2s. 6d. per head to the friendly societies for the purpose of supplying medical benefit for those men who cannot get it now because it is too expensive. No legislation is necessary.
§ Mr. MASTERMAN
On a point of Order. The hon. Gentleman is now advocating the giving of a Grant quite independent of this Grant for a purpose quite independent of the Insurance Act. Surely that opens the way to an unlimited field of discussion.
§ Mr. BUTCHER
The Government might allocate some of this money to a purpose which I suggest is better than the purpose for which it is to be voted.
§ The CHAIRMAN
Another hon. Member has been called to order for going into alternative proposals. Obviously, there might be no end of such proposals as to other ways of spending the money. All we can do is to criticise the way the Government propose to utilise it.
§ Mr. BUTCHER
Might I not suggest to the Government it would be appropriate to spend some of the money in order to provide with medical benefit men who have not already got it and cannot get it under existing circumstances. I have, however, put my point.
§ Resolution to be reported To-morrow (Saturday): Committee to sit again Tomorrow.