NATIONAL INSURANCE ACT.

HC Deb 14 February 1913 vol 48 cc1431-56

Mr. GODFREY LOCKER-LAMPSON

I desire to ask one or two questions with reference to the speech of the Financial Secretary to the Treasury the day before yesterday as to medical benefits under the Insurance Act. I do not think the Financial Secretary to the Treasury in that speech or the Chancellor of the Exchequer in the least realised the gravity of this question of medical benefit and free choice of doctors. To my mind the Chancellor of the Exchequer is treating the doctors as he would treat one of his own office boys. He has browbeaten them on to the panels, and he has certainly got his way to a great extent by methods which I do not think anybody or any public statemen with a sense of public duty would have used. In his speech to the representatives of the British Medical Association on 31st May, 1911, the Chancellor of the Exchequer said:— I recognise that the first condition of its success (that is the National Insurance Act) is that we should get the whole-hearted, cordial, and unreserved support of the medical profession to carry it out. Can the right hon. Gentleman say that he has got that condition? It is a perfectly well-known fact that owing to the methods which have been used by the Chancellor of the Exchequer throughout a large proportion of the medical profession there is a rankling sense of acute injustice which will fall eventually, I am quite sure, on the shoulders of those very insured persons whom the Chancellor of the Exchequer wishes to benefit. But it is not merely the way in which the Chancellor of the Exchequer has treated the medical profession. He has not only humiliated the medical profession, but I submit he has also grossly deceived the insured persons in respect of medical benefit. The right hon. Gentleman the day before yesterday accused hon. Members on this side of the House of trying to make party capital out of this question of medical benefit. I do not think it is in the least true, but anyhow we have had a great deal of provocation, and surely it is extremely exasperating to remember the promises lavishly made by the Chancellor of the Exchequer when his Bill was in danger of not passing at all, and then to contrast them with the performance after the Bill has passed into law. Medical benefit, as everybody knows, was one of the great popular benefits of the Act, and it was one of the benefits on which the Chancellor of the Exchequer was able to float his Bill in the country. Every insured person, according to the Chancellor of the Exchequer, was to have the doctor of his own choice, the doctor whom he liked, the doctor whom he believed in. I do not think one can too often repeat the actual promise of the Chancellor of the Exchequer at Whitefield's Tabernacle. The hon. Member for Colchester quoted it the other day, and I will not requote it except in the case of two sentences. The Chancellor of the Exchequer said:— Under this Bill lie can have the doctor of his own choice. He is not obliged to go to Dr. A. … pots his confidence in B. … so we say to him, 'go to the doctor you believe in.' … What a fine thing it is to get the doctor you want, and to get somebody else to pay him. That is the Government Insurance Bill. Contrast that for a moment with the answer given to me by the Secretary to the Treasury a few days ago in reply to a question:— No insured person is compelled to select a panel doctor, but— and here is the mockery of the whole thing— payment out of the insurance Fund can only be made for medical attendance under the conditions laid down by this Act and Regulations. It is not only the Chancellor of the Exchequer who promised insured persons free choice of doctors. It was repeated over and over again by his colleagues in the country. It was repeated by the Chief Secretary for Ireland speaking at Bristol on 16th June, 1911. I will not quote it because I do not want to weary the House but only to bring certain important points before, it. The Lord Advocate also promised at Wigan on 1st December, 1911, although I must confess that it ought to have given us reason to pause and made its suspect something was wrong. The Lord Advocate said:— To men and women who were stricken down by sickness, Mr. Lloyd George offered prompt and efficient medical aid at the hands of a doctor chosen by themselves. At Blackburn, on 8th December, he said:— The first thing working folks who were stricken down by sickness required was a good doctor, and Mr. Lloyd George was going to allow them to choose their own doctor. In view of all those promises, special form Medical 21 was issued by the Insurance Commissioners—a form which the insured person was told on his medical ticket he could get if the applied for it. On that form he was told to put his name and address, and the address of his society, and to send it in when filled up. What has happened and is happening every day since that form was published? Insured persons, relying upon the promises of the Chancellor of the Exchequer and other leaders of the Government, and on the notice on their red medical ticket, are sending in applications, and are being put off in two different ways. In some cases they are told that the free choice will not be allowed unless exceptional circumstances are proved.

Mr. BOOTH

Outside the panel.

Mr. G. LOCKER-LAMPSON

I have here three notices to applicants. The right hon. Gentleman can see the docu- ments if he wishes to do so. One notice is from the Middlesex Insurance Committee, another from the Isle of Ely Insurance Committee, and the third from the Sheffield Insurance Committee. In each case the applicant is told that free choice can be allowed only if exceptional circumstances are proved, that each case will have to be judged on its merits, and a proper reason given for the permission to make the free choice. There is not a single word about exceptional circumstances in the speeches of the Chancellor of the Exchequer and other Members of the Government, or on the red medical ticket, or on the form "Medical 21." In many cases exceptional circumstances exist without doubt, and yet the insured person is denied permission to make a free choice of doctor outside the panel. I have a case from Merthyr Tydvil, which I received this morning. Dr. Biddle, a non-panel doctor, writes that a number of insured persons who had been his patients for nearly thirty years, in a medical fund of which he is the medical attendant, have been refused permission to choose him as their own doctor. If a period of thirty years' attendance by the same doctor does not constitute sufficiently "exceptional circumstances," I do not know what does. From what the right hon. Gentleman said the day before yesterday, lie seems to think that the doctors who do not go on the panel are inferior second-rate doctors. As a matter of fact, Dr. Biddle is a very distinguished medical man. He is a member of the Royal College of Surgeons, a licentiate of the Royal College of Physicians, vice-chairman of the local medical committee, although he is not on the panel, surgeon to the General Hospital, medical officer, and public vaccinator.

I have other cases from Huddersfield by telegram this morning. Dr. Knaggs, also a non-panel doctor, in his telegram, says that J. J. Brook, of Tunnicliffe Hill, has been a patient for twenty years, and has been refused permission to select him as his own doctor. Two ladies named Girling, of 38, Stanley Street, Lindley, who have been his patients for twenty years, have also been refused permission to choose him as their doctor. Surely twenty years' attendance by the same doctor constitutes sufficiently "exceptional circumstances." Here is a stronger case. Dr. Knaggs says that Miss Beaumont, of 37, Banfield Road, Mold Green, has been refused permission to choose him as her doctor, although she is now ill and he is actually in attendance upon her. Surely a present state of illness and actual attendance by a doctor constitute sufficiently "exceptional circumstances." All these persons have been refused permission by the insurance committee without any explanation whatsoever. Dr. Knaggs also is a distinguished medical man. He is a member of the Royal College of Surgeons, a licentiate of the Royal College of Physicians, and a specialist on eyes and ears at the Huddersfield Infirmary; he has been in practise since 1885, and has written several important medical treatises. In the second class of case—and the Huddersfield cases come under this head—applicants are not even given the opportunity of proving exceptional circumstances. They are refused even a form to fill in, and are dismissed without any explanation at all. I have here a printed circular sent round by the Huddersfield Insurance Committee to applicants for permission to make a free choice of doctor:— Sir or Madam,—I hereby give notice that the Huddersfield Insurance Committee has declined to allow you to make your own arrangements for obtaining medical attendance and treatment. Your medical ticket is returned herewith. I find that absolutely no inquiries have been made as to the condition or exceptional circumstances of applicants. The refusal is made point blank, without any explanation or inquiry. I have another circular sent round by the Bradford Insurance Committee. It is dated 14th January, even before the benefits began to flowin:— Dear Sir or Madam,—In reply to your communication the Committee have considered the question of allowing insured persons to make their own arrangements for medical benefit, and have decided it is not expedient to allow such a course to be pursued. In these circumstances … yon can either make choice of a doctor from the panel or obtain your treatment— And, they might have added, pay for it out of your own pocket— through the Bradford Friendly Societies Association. I received information last night that the Wiltshire Insurance Committee is doing exactly the same thing. I cannot believe that these insurance committees are doing this merely on their own initiative. There is such a curious correspondence in the action of these committees that some intimation must have been given to them by the right hon. Gentleman or by the Insurance Commissioners from headquarters in London. The speech which the right hon. Gentleman delivered the day before yes- terday strengthens that belief, because it directly encouraged the insurance committee to refuse permission for free choice of doctor. Whosesoever fault primarily it is, it is certain that insured persons have been grossly deceived by the Chancellor of the Exchequer in reference to the free choice of doctor. The bait was held out to them; it was paraded on many platforms in the country, and many a man who would have done his utmost to resist the Act coming into operation at all held his hand on the strength of that promise. As I have shown, the insured persons, in spite of the promise, cannot get permission to choose their own doctor, unless they can prove exceptional circumstances. They are bluntly refused permission, and no inquiries are made at all into their conditions and circumstances. It is no use saying that there is free choice of the doctors on the panel! What is the use of that if the doctor people believe in and like and want is not on the panel? The Government, I say, is in honour bound to see that the pledge of the Chancellor of the Exchequer is properly carried out. If the right hon. Gentleman cannot carry out his pledge then the taxpayers of this country ought not to have to pay for the medical benefit promised to the insured persons. It is not merely a question of medical benefit in the ordinary sense of the word. Insurance committees are now actually writing and telling people that they cannot receive the certificates for sick pay unless they get it from the doctor on the panel, and the insurance committees are doing that absolutely without any authority at, all. I would like to ask the right hon. Gentleman whether that, too, is being done with connivance and instigation from headquarters in London?

The FINANCIAL SECRETARY to the TREASURY (Mr. Masterman)

Will the hon. Gentleman give me an example?

Mr. G. LOCKER-LAMPSON

I am going to give you an example. Again, I say, that the Secretary to the Treasury deliberately went out of his way the day before yesterday to encourage the insurance committees to take that course. He said:— I cannot recommend without any hesitation members of approved societies all over the country promiscuously to accept the certificates of non-panel doctors. Yet it is perfectly well known that doctors outside the panel are just as distinguished as a body as the doctors on the panel. [An HON. MEMBER: "More."] I come to my instance. I have here a postcard, that I can show to the right hon. Gentleman, written by the clerk to the Leicestershire Insurance Committee to an insured person. He writes on 7th February, a few days ago:— As regards the sickness benefit under State insurance, you must get a medical certificate from a doctor on the panel. Dr. Cullen— that is to say, the doctor who has been sent down to work in the district because they cannot get doctors on the panel— will now practice in your village from to-day, and you should see him at once. For the present his rooms will he, care or Mr. Squires. I have another letter here showing that the Isle of Ely committee is doing exactly the same thing. What right have insurance committees to do this thing? They have absolutely no right at all. As the right hon. Gentleman knows perfectly well they have nothing whatever to do with the certificates for sick pay. It is sheer intimidation, and I say that that is a matter of public interest, and it should be stopped. Finally, I say that the whole action of the Chancellor of the Exchequer in respect of medical benefit has been signalised by a mixture of tyranny and cunning. He has stifled discussion in the House of Commons. He has brow-beaten the medical profession. He has hood-winked the friendly societies. Last, but not least, he has deceived the insured persons. Before we vote upon this Bill we ought to have some security from the right hon. Gentleman that that medical benefit that we are asked to pay for is really going to be given to the insured persons.

Mr. DAWES

I want to put a couple of questions in the interests of what I believe we all have at heart—at least the insurance committees of the county of London—peace. I want to question the Secretary to the Treasury on points that are particularly agitating the doctors of London. The first question is: May a doctor—and this request seems reasonable—be put on a panel for a limited number of patients, when, in view of his private practice, he is unable to deal with an unlimited number, or any very large number of insured persons? Doctors may feel that they can deal adequately with a limited, but not with an unlimited, number. Secondly, is there going. to be what I may call a clinical inspection on behalf of the Insurance Commissioners as between the doctors and the patients? That is a point upon which there is great doubt. I believe the Chancellor of the Exchequer, in a memorandum has expressed an opinion on that point. If the right hon. Gentleman the Financial Secretary to the Treasury will be good enough to make these points clear it may help to provide less acrimonious discussion, and more harmony amongst the doctors.

Mr. BRIDGEMAN

I wish to question the right hon. Gentleman opposite, and I may betray a good deal of ignorance of the National Insurance Act, though that ignorance is shared by a large number of hon. Members in this House, and nearly everybody outside. The point I want cleared up is this: The exact position of persons over sixty-five in respect of medical benefit. As I understand it, a man that was over sixty-five at the date of the passing of the Act and belonging to a friendly society, cannot become an insured person, though his employer has to pay his contribution of 3d., and the State has to pay its 2d. Section 15, Sub-section (2), paragraph (e) of the Act says:—

"(e) The provision of medical attendance and treatment on the same terms as to remuneration as those arranged with respect to insured persons, to members of any friendly society which, or a separate section of which, becomes a society, who were such approved members at the date of the passing of this Act, and who are not entitled to medical benefit under this part of the Act—by reason either that they are of the age of sixty-five or upwards at the date of the commencement of the Act. …"

That seems to me to make it obligatory upon the Insurance Commissioners to see that such methods are adopted that the people who are over sixty-five, and for whom their employers and the State pay, shall receive medical benefit in exactly the same way as other people insured under the Act. It now appears that they are being told—I have had complaints from several quarters—that they are not going to get this medical benefit. What I want to ask is: Who has the right to deprive. them of it? Is it done by the Section of the Act which allows the Commissioners to alter the Act in any way they like? Is it, done by the Committee through a misunderstanding? Is it some fault of the societies These people over sixty-five are deserving of consideration almost more than anybody else. They are probably not able to work so hard or earn so much as they used to do. Yet they are not old enough to get their old age pensions. Now they are told they are not to get medical benefit, although they have been subscribing to their societies and clubs for forty or fifty years, have paid much money into the funds, and looked forward to benefit. What happens, I want to know, to the threepence that the employer pays and the twopence the State pays? How is it going to be used for their benefit? Are they still entitled to sanatorium benefit? And are they entitled to maternity benefit? It is not likely people over sixty-five will require sanatorium benefit, and they will hardly consider it worth while paying into their societies in order to get maternity benefit. What is to happen to the money, and how is it to be used for the benefit of those people. Many of those people have got into a state of confusion and very likely have not complied technically with seine of the regulations. I have seen quite different views taken by two different secretaries of friendly societies. I think it would be very hard on these old men if having through a misapprehension discontinued to make their payments they are to be deprived of all benefits for which they have been subscribing. I think their case a particularly hard one, and as far as I can elicit the Government do not seem to have dealt with it in a satisfactory way.

Sir JOHN JARDINE

There is one question I should like to put to the right hon. Gentleman in the interest of the medical profession in the border county I have the honour to represent, and which also affects other counties on the borders of England and Scotland. My county is one of steep hills and distances are long. There are about 200 houses that are ten miles away from any doctor. The doctors there are anxious to know what arrangements are made for giving them rather preferential treatment as regards mileage. On certain occasions in the middle of the night they have to charter an additional motor to get away to the house of some shepherd among the hills or to some farm far away. In those counties the doctors would be glad to know what the arrangements sanctioned are for giving them a fair return for the money they may have to disburse in going these long distances to look after these most industrious people who deserve the best possible consideration.

Sir HENRY CRAIK

There is one constant action with regard to the medical profession and the treatment of the medical profession which has characterised the action of the Chancellor of the Exchequer and has been imitated by the right hon. Gentleman the Secretary to the Treasury, and that has been an alternation between cajolery and bullying. In the course of the earlier discussions on the Bill the Chancellor of the Exchequer repeatedly referred to some of my hon. Friends and myself who represent the medical profession as having been fair in our applications, as having dealt fairly in the various negotiations that were carried on, and as having put forward in a spirit of compromise the rights and considerations in favour of the medical profession. Now an entirely different tone has been assumed. All that we have been urging now we are told is done solely with the object of destroying the Bill. That is a libel upon the medical profession and upon those who represent the medical profession in this House. I could refer to repeated statements of the Chancellor of the Exchequer absolutely in the teeth of those he now makes. We are all accustomed to the banter of the right hon. Gentleman. I myself, as much as anyone else. I treat his criticisms no more seriously than the banter of anyone who uses banter instead of argument. The other night he singled me out as one who put the claims of the profession forward as being guilty of gross inconsistency. Why? Because I had urged, on the one hand, that it. was better medical relief should be in the hands of public Boards rather than friendly societies, and because, on the other hand, I had on behalf of the medical profession objected in principle to contract practice as being degrading to the medical profession and dangerous and harmful for the insured persons. What inconsistency was there between the two?

The Secretary to the Treasury only a night or two ago accused all of us who brought forward questions as to the working of the Act as being actuated by the worst of motives, namely, party motives. That is a libel by the right hon. Gentleman upon his fellow Members. He knows perfectly well that I have repeatedly brought before him, privately, questions urged in all sincerity by those persons who are interested in the insured persons, and who speak in their interest. In some cases I put questions on behalf of the medical profession. These have been honestly put by me as anxious as the right hon. Gentleman that this Act should work in a way that would be to the advantage of the public, but who have a right to look for some consideration for their own profession. Is it fair for the right hon. Gentleman in his position as a Member of the Government to accuse hon. Members in this House who place questions before him as to the working of the Act of being actuated by the worst of motives, and being anxious solely to promote the interests of their own party. That is a libel which will react upon the right hon. Gentleman sooner or later. The questions I have put have been raised by persons practising in the East End of London or various provincial towns where the members of my Constituency are scattered in all directions all over England. The Chancellor of the Exchequer began by deceiving insured persons and doctors by holding out false and elusive hopes that there would be a free choice of doctors. No one spoke more eloquently upon the free choice of doctors and how there ought to be the fullest confidence between doctor and patient than the right hon. Gentleman. He deluded both the medical profession and the insured persons, and having done that he proceeded when the medical profession had been isolated, after having calmed the fears of the insured persons, to bully them into accepting his terms.

There is no such thing as the free choice of doctors under this Act. Not only is free choice denied and arrangements for your own medical treatment are impossible, but a worse feature than that has been brought in, because it now appears that if you do not go to the doctor assigned to you, you run the danger of being cheated of all the advantages under the Act for which you have paid. I know from my own experience and from the facts laid before us that many insurance committees are refusing to consider even the assignment of the ordinary sickness benefit and other benefits to those who are not able to produce a certificate from a medical man on the panel. This is coercion of the worst sort which will react upon the administration of the Act, and until it is amended so that the free choice of doctors delusively held out to insured persons, and by that means spread through the great body of the medical profession, until you give that free choice and the other benefits under the Act to those who have certificates assigned by non-panel doctors, the Act will be nothing but a failure in many respects. You have not engaged in the administration of the Insurance Act the full energy and enthusiasm of the most enthusiastic profession in the whole community, namely, the medical profession, because they are working under a sense of oppression, and they feel that they have been partly deluded and partly cajoled, and their complaint will not be answered merely by the banter of the Chancellor of the Exchequer or by speeches such as have been made by the Financial Secretary to the Treasury, imputing to all who find fault with the administration of the Act the basest motives.

1.0 P.M.

Mr. CASSEL

I rise to make a personal explanation. I have said all I wish to say on this subject on the Second Reading of this Bill. The right hon. Gentleman seemed to think I was ungracious in my withdrawal of a charge which he supposed I made against him. I did not intend to be ungracious, and, if I had thought that I was, I should have risen at the time in Debate, and I would have done more graciously what it is thought I failed to do. The charge which the right hon. Gentleman thought I made against him was that of having improperly seen the records which are returned under the Insurance Act for the purpose of dealing with them in this House. That charge really was put upon me without my having made it, and if I said anything which conveyed that impression I express regret for it, and withdraw it in absolutely unqualified terms. I hope the right hon. Gentleman will think I have succeeded in doing this graciously on this occasion. So far as this question of secrecy is concerned, I raised it because I thought it was of great import ante that the records should be kept in such a way that it would be absolutely impossible to identify the persons or see what persons were suffering from particular diseases. Those records might have to be produced in Court, and I understand now that there is going to be a change in the method by which those records are to be kept. I understand that no numbers are to be used, and I am glad that such a method will be adopted as will make it absolutely impossible to identify the record, and I am sure that will set at rest the minds of a good many people.

Mr. SHERWELL

Reference has been made this morning to two or three cases of the failure to extend medical benefit to certain insured persons in Huddersfield. I wish to say that the delay which has arisen has been due to the failure of the Insurance Commissioners to issue the proposed Form 21, under which it would be open to insured persons to apply to the Insurance Commission for exemption. One of the cases mentioned I have some knowledge of, and it is a case where the insured person has stated her determination to receive no benefit from a medical man on the panel, and she has also stated that, assuming her own medical attendant were to apply to be placed on the panel, she would not accept the benefits of the Act in that form. I understand that, as a private patient, arrangements may be made that at the end of the year she can receive the amount which is due to her for medical benefit. I hope the right hon. Gentleman will see that the Insurance Commissioners authorise the local insurance committees to deal with exceptional cases on their merits so as to reduce friction to the minimum.

Mr. CHARLES BATHURST

Before the Financial Secretary replies, I should like, on behalf of the County Councils' Association and on behalf of the Gloucestershire Insurance Committee, to draw his attention to the financial difficulties of county insurance committees in regard to this question. Under Memorandum 134, which was issued by the Commissioners in December, 1912, and was followed by a circular letter to the authorities on the 31st January, the Commissioners will only allow payment of expenses which are actually incurred before the 13th January, and are actually paid before the 15th February this year. The county authorities are being allowed a sum of £4 5s. for every thousand population in order to meet the expenses in connection with sanatorium benefit. The county of Gloucester has the handling of some £1,400 as a result of this arrangement, and any balance that is not expended by to-morrow has to be handed back to the Insurance Commissioners.

Mr. MASTERMAN

I have no wish to avoid answering questions, but I do not think questions of sanatoria benefit are relevant to the Third Reading of the Appropriation Bill.

Mr. BATHURST

It is not only sanatorium benefit, but the whole of the expenses of the insurance committees. I do not know to what extent they come under the Appropriation Bill, but I fancy there is a special Grant, at any rate, in connec- tion with the administration which comes within the Supplementary Estimates, and, if that is so, I will confine my remarks to that matter.

Mr. MASTERMAN

Would it not, be better to raise the matter on the Motion for the Adjournment, when I can give a reply on the whole question?

Mr. BATHURST

I will accept the right hon. Gentleman's suggestion.

Mr. W. THORNE

I think the question has been raised once or twice with regard to insured persons having a free choice of doctor. I do not think the blame is altogether upon one side, because it has been brought to my notice that doctors in some cases have absolutely refused to sign any more forms in consequence of having so many people already on their books. Some doctors in the Division I represent have at least 4,000 insured persons on their books, and when people have applied to them to have their cards signed they have refused, and those people have been compelled in some cases to go a mile or a mile and a half before they could obtain a doctor to whom they could apply when sick. I should like to know whether there is any intention of limiting the number of insured persons to each doctor. It is only natural where there is a well-qualified doctor in a district that insured persons should apply to him, and the result is that he gets his books overcrowded, and other doctors get no chance at all. In these cases during surgery hours you can see 200 or 300 people waiting in a file in the road, just the same as if they were going to the Empire or to a theatre. It seems to me there ought to be some limit as to the number of insured persons on the books of any particular doctor. I saw a few days ago a letter in. the "Essex Times" that an insured person who fell sick went to the doctor before eight o'clock at night, and got a prescription, but when he got to the nearest chemist, which happened to be three miles away, the shop was closed. In cases of that kind, where a chemist is so far away, would it not be possible for the doctor to give the medicine? I hope, at any rate, we shall have some assurance that there will be some limit placed upon the doctors as to the number of persons on their books. Unless that is done, doctors in some cases will be overloaded with work, and we-shall be told this Act is killing the doctors, when, as a matter of fact, they will be killing themselves.

Sir G. YOUNGER

I was informed yesterday that a most unfortunate arrangement had been made in Edinburgh with regard to medical attendance. A great many servants in the West End have been placed under the control of a Portobello doctor, some miles away. There is no complaint made about the qualifications of the medical practitioner; he is in every way satisfactory, but it does seem strange that a doctor at the remotest point, in a seaside place, should have had allocated to him a large number of domestic servants in the West. End. It will be extremely difficult for them and equally inconvenient to him. Perhaps the right hon. Gentleman will make inquiry to see if any better arrangement is possible.

Sir J. D. REES

I hope the right hon. Gentleman will be able in his reply to say something about the outworkers.

Sir JOHN BARRAN

I wish to reinforce what my hon. Friend the Member for Roxburgh (Sir J. Jardine) has said with regard to the question of mileage in the county of Roxburgh, and also in the county of Selkirk itself. These, although Lowland counties, have certain areas that are relatively high where the roads are bad, and some of the dwelling-houses a mile or two from any road. I hope the right hon. Gentleman will be able to tell us something about this question of mileage. Representations have been made from those counties to the Insurance Commissioners, and we hope something will be done in order to meet these exceptional circumstances. It seems to me this is an appropriate time—and it certainly would be received with satisfaction—for an announcement to be made that the point is recognised and is to be substantially and fairly met.

Mr. MASTERMAN

Perhaps it will be convenient before the House passes to other subjects that I should deal with the group of questions that has been brought before me in connection with insurance. I may perhaps be allowed to congratulate the House on the tone and temper of this particular Debate, and to express my gratitude at being given an opportunity of dealing with some of the questions that have been raised which excite not only interest inside this House, but also considerable interest outside. With the exception of some carefully prepared adjectives by the hon. Member for Salisbury (Mr. G. Locker-Lampson), who, having had them suppressed a few days ago, has found it necessary to bring them out before the Session ended, I think the whole Debate has dealt with real things, and in order that the general friendly temper of the Debate may be continued to the end perhaps, in response to the hon. Gentleman the Member for Glasgow and Aberdeen Universities (Sir H. Craik), I may be allowed to say that I never meant to associate him with any charge of political controversy in this matter. I have always realised he has had a special position in speaking on this subject as representing probably one of the largest constituencies of medical men. He has spoken foil them and voiced their opinions many times very effectively, and certainly I never remember any intervention of his, either in connection with Questions or Debate, which I would in any way attribute to political motives. I do not want to make any general withdrawal of the statement, but I do want to make a withdrawal, so far as he is concerned, as he seems to think the point was raised against him. With regard to the statement of the hon. Member for Salisbury, that we are refusing, either through subterranean influences in connection with the insurance committees or by direct prohibition, that which was promised to insured persons when the Act was being passed, namely, a free choice of doctor, I am amazed that anyone who has followed the course of the controversy in connection with the medical benefit, a course which has culminated in the free Grant which we are voting to-day of nearly £2,000,000 a year for the medical profession, should accuse us of bullying the medical profession, of being neglectful of the petitions and amendments suggested by the medical profession, of simply squeezing them into reluctant service, and of refusing free choice to the insured person.

My right hon. Friend the Chancellor of the Exchequer expressed again and again the object of the Bill, which was to try to give to the insured person, in so far as it could be given, the doctor he liked and the doctor he believed in. In order that that might be given to the insured person under the Bill, the whole of the Bill was transformed when it was passing through the House, and, in spite of the strenuous opposition, and the unpopularity accompanying that opposition, of the great organised friendly societies of the country, the old friendly society system, under which all the members of a society deal with one doctor, was swept aside, and a system, contrived by the House and approved by the House by an overwhelming majority, was set up, allowing every doctor who agreed to work under the Act to have his name put on a list, and all the members of the insured classes to have free permission to choose from that list any doctor they wished to attend to them. It is under that system, and for that system approved by a majority of 400 in this House, that we in the administration of the Act have been fighting. If we had abandoned that system in the administration of the Act, we might rightly have been impeached in this House for refusing to carry out a system of which the House had approved. It is to carry out that system that we have asked this House to vote this enormous sum of two extra millions to help to work the system. In order that the system should not be broken up by what was an avowed conspiracy to break it up, we accepted the decision of the insurance committees to very greatly limit and circumscribe what is called contracting out from that system. The hon. Gentleman seems to think that insured persons have a grievance. I must say that in the administration of the National Insurance Act I have heard very little of that grievance from the insured persons themselves, although I have heard a good deal from Members of Parliament, and I have heard a certain amount from the doctors who are trying to destroy the Act. He seemed to think that insured persons have a grievance against the Chancellor of the Exchequer because the Chancellor of the Exchequer cannot compel doctors to work under the Act if they refuse to work under it. That is the whole subject of the charge.

Although the hon. Gentleman comes here with plausible words about contracting out, it is only fair to say of the doctors who have been fighting for the destruction of the Act, especially of the medical benefits portion of it, that they have made no secret of the matter. They do not say, "You have some persons here who wish to get their own doctor, and a few doctors who wish to attend their own patients and who wish to work under the Act under Section 15, Sub-section (3), and it is monstrous that they should not be allowed to do so." The policy of those who captured the British Medical Association, from some of its wisest and most trusted leaders, who resigned from the association that they themselves have built up by years of work, because they knew that policy was a policy of madness and suicide, was not a policy of using the contracting-out Clause in conjunction with the panel system as laid down in Section 15. It was a deliberately avowed policy to break the panel system, accompanied by every form of friendly or unfriendly intimidation and coercion against the doctors who wished to work under the panel system. We had to defend that system and to fight against the attempt that was made to break up that system. They wished to go back from the request they made to Parliament to have a list system. They wished to go back outside of that, not to make contracts under exceptional cases, but to make them on a wholesale scale with the friendly societies, with whom they had refused to make contracts the year before. There is no doubt about the case upon which they fought. When that policy was discussed, those who were opposed to it. raised the question before the British Medical Association and said, "How can you now break up the panel system and destroy the insurance committees and endeavour to start a separate medical system apart from the Act and in conjunction' with friendly societies, when you have already made one of your chief six points a refusal to have anything to do with the friendly societies?" And this is the answer they received from those who wished to carry out that policy: The Committee endorse the reply of the Chairman that the suggestion of dealing with the Friendly Societies was for services outside and not under the Act. Now you have the doctors definitely saying, "We will not take service under the Insurance Act, but we wish for the money which is allocated to service under the Insurance Act. We also wish for the £2,000,000 more which is being allocated in order that the Insurance Act may go smoothly." Any Government, in my opinion, that gave way to a demand of that kind would not be worthy of the confidence of the House. I say to hon. Gentlemen opposite who have been helping resistance to the insurance committees by this organised conspiracy, that they have been working for a system which, if they had been successful, would have caused untold harm and misery to the great bulk of insured persons, because the sole result would be that there would not be provision, as there was under the friendly societies, for certain selected lives, but under these contracting-out terms the whole mass of insured lives would come in whether they were poor or well-off, whether ill or well. So long as the insurance committees in different parts of the country were faced with the same demand for so long, they were undoubtedly right in opposing a similar policy, and no explanation is needed of any secret circular sent to them from the central authority. No secret circular was sent to them from the central authority. These insurance committees knew that really they were fighting for their lives in this matter, and the friendly societies realised that they were fighting for their lives, and one of the immediate results of the appeal to a certain section only of the doctors, backed up by political influences which ought never have been brought to bear to ally themselves with the friendly societies in order to break up the insurance committee, was that a manifesto was issued by the friendly societies themselves, in the public Press, saying that they would not enter into this conspiracy however speciously the net was spread in the sight of the bird. In spite of the desire of these doctors to go back to the friendly societies, and to adopt a very contrary policy to that which had been adopted by this House for medical benefits, a year ago when the Bill was passed, they had sufficient foresight and patriotism to realise that as a matter of fact it was an attempt which, if it succeeded, would have a most disastrous effect upon the medical benefits and upon their members.

Mr. G. LOCKER-LAMPSON

Will the right hon. Gentleman kindly deal with the cases I have mentioned of exceptional circumstances, and tell us also whether he approves of the action of certain insurance committees in regard to certificates for sick pay?

Mr. MASTERMAN

I will deal fully with that afterwards, but with the indulgence of the House I desire at present to deal with those particular points, because this is the last opportunity in this particular Session, and they are most important to the persons outside. The hon. Gentleman said that a free choice of doctors working on a panel system was a sham, a fraud, and a delusion. Why is it a sham, a fraud, and a delusion? Over the great mass of the country practically all the doctors who are engaged in industrial practice are on the panels. Only in London and the district round London is any organised fight still being maintained to break down the medical benefit under the Insurance Act. I do not think that so long as my hon. Friend the Member for Walworth (Mr. Dawes) is chairman of the London Insurance Committee, and my hon. Friend the Member for Stepney (Mr. Glyn-Jones) is at the head of the Middlesex Insurance Committee, that it is likely to result in any large measure of success. Throughout the greater part of the country, and through almost the whole of Scotland, practically every doctor who is engaged in industrial practice is on the panel, and there is the freest possible choice of those doctors among the insured persons. In some counties all the doctors are on the panel. I think I am correct in saying, although I will not pledge myself absolutely, that in some counties every registered doctor has come on the panel, both in England and in Scotland. The average is certainly well over SO per cent.—I should say it is more than 90 per cent. outside London—of the registered doctors who have come on the panel, and who will work the Act, as I believe, with ever-increasing enthusiasm so long as they are left alone.

Then the hon. Gentleman says, supposing there is a general willingness to the work the panel system as designed by the Act, and supposing that the doctor who really wishes to deal with industrial practice is willing to do it under the Act and does not try to do it outside the Act, what about the exceptional cases where doctors, for some special reasons, do not want to work under the Act, and where the insured persons still wish for those doctors. As I said earlier in the week, so I say again to-day, no kind of obstacle will be put by either the Insurance Commissioners or the Government in the way of insurance committees exercising their discretion in any manner they choose in order to allow exceptional cases to be dealt with by an exceptional Clause under the Act. So long as the insurance committee is realising that it is fulfilling the primary duty for which it was created, that is, to give medical benefit to every insured person within the Act, and so long as it is also assured that the giving of permission under special circumstances to certain persons to receive medical benefit under the conditions of Section 15 (3) is not in any way interfering with the general responsibility to give medical benefit to all the persons under the Act, and is given in conjunction with the panel doctors who are serving, then they are very freely welcome, so far as we are concerned, to deal with the exceptional cases under an exceptional Clause. That leads me on to the question raised by the hon. Member for Walworth, namely, whether exceptional cases should not best be dealt with by not so much encouraging who is called contracting out under Section 15 (3), but by allowing doctors who are willing to go on the panel to take only a limited number of patients, doctors, for instance, who may be getting old, and do not want to take a very large practice, or doctors whose main practice is not what is called industrial, but who are willing to take certain cases including some of their old patients who specially wish for them.

My own desire is to see as many members of the medical profession on the panels as possible, because I believe, and here I am quite sure I am expressing the wish of the great majority of the leaders of the medical profession, that nothing could be worse for the medical profession itself than that there should be a divergence between two classes of doctors, those who are called insurance doctors and other doctors. I am quite sure that even those doctors who have been resisting the Insurance Act system so long as they thought there would be a general resistance, will now he well-advised, so long as it is evident that the great majority of doctors are going to work under the Act, to throw in their lot with those doctors, forget the controversy which tore the profession in two, and make again one unity, which will again make the negotiations with the committees as a unity in order that the best system may be devised under the Act and the Regulations, so that all passing difficulties can be considered and met. Our sole desire now is not in any sense to express any triumph for any victory we have obtained, but, so far as possible, to carry out in the letter and the spirit the promise we always made from the beginning, that our whole object would be to work the Insurance Act with the cordial and unreserved support of the medical profession of this country. While agreeing, as I said a few days ago, with the suggestion of the London Insurance Committee, we think it very desirable that where doctors wish for a limited number of patients, if it is possible, in conformity with the general interests of the insured persons, that they should be permitted to go on the panel for that limited number of patients, that that should be subject to two reservations. First, it would be unfair to doctors on the panel who are willing to receive all the patients, that doctors should be allowed to go on the panel and pick out certain special lives, with less than the average rate of sickness, and known to have less than the average rate of sickness, and yet to receive a remuneration, which we believe to be a liberal remuneration, for lives chosen out of the average, good and bad alike. I think it will be necessary for an insurance committee, in giving permission to doctors to have a limited number of patients, to say that either those doctors are to take an average sample of lives, and not selected lives, owing to their being not liable to illness, or else that the doctors who do take selected lives should be willing to take less remuneration for those selected lives, in order that more remuneration might be given to those who take the lives which no doctor wishes to take, owing to a more or less chronic state of illness.

The second condition must be this, that an insurance committee can only give its consent to doctors taking this limited number of lives in conjunction with, and with the free approval of, those doctors who have taken the general risk in that respect. What is the condition at present? I will not take a large area. Let me take, for example, quite a small area. Suppose ten or twelve doctors are taking work in a small county town. Those doctors have undertaken the liability for all the insured persons in that town—a collective liability for which they are receiving all the remuneration which is available for those insured persons. That does not mean that any doctor has definitely to undertake a patient he does not wish to undertake, but it means that the doctors on the panel have to ensure, under a collective responsibility, medical attendance for all persons on the panel. It must be with their agreement and consent that any of these doctors are allowed to say, "No, I will not accept the collective responsibility; I will only accept responsibility for 300, 400, or 500 selected lives." My hon. Friend, who is the chairman of the London Insurance Committee, tells me that he thinks that there will be no difficulty in London, at least, in carrying out such conditions as these, with the approval of the doctors who are on the panel and with an arrangement whereby selected lives shall not be selected on account of their immunity from disease; and it will be possible to give all those who are willing to tome in and work the Act such limited practice as, for example, among domestic servants and others, and by that means we may be able entirely to avoid a system, which would be a disastrous system, of breaking up the medical profession into insurance doctors and other doctors, and also to fully carry out every promise made by the Chancellor of the Exchequer that every patient should have free choice of any doctor, provided that that doctor is willing to work under the National Insurance Act.

I come to the second question asked by the hon. Member (Mr. Dawes): Does the right of inspection which rests in the Regulations for the carrying out of medical benefit imply a clinical inspection of persons or a detailed investigation by an inspector, without complaint, of the relationship between doctor and patient?" I think that is the question. As clearly as possible I would assert that that is not the policy of the Insurance Commissioners or the insurance committees. As the Chancellor of the Exchequer explained to the Advisory Committee in the autumn, we have no intention of bringing any inspectors to examine either the method of diagnosis or the treatment of the patient by the doctor on the panel. I wish to make that statement as clearly as it can be made. The only reservation we make is that in case of definite complaint by the insured of the treatment he has received, that complaint is referred to a committee which is established by Regulation. It is a committee on which both the medical profession and insured persons are represented. It is a committee which, under the circumstances, would hear evidence and would report on that definite case. But the idea which some doctors have in their minds, and which they endeavour sedulously to foster in the minds of their brethren, that an inspector is suddenly to descend from the insurance committee upon a so-called panel doctor to investigate his day-book, to ask why he gave medicine in one case and not in another, why he treated one man that way and not in another way, is a thing which is utterly remote from any suggestion under the National Insurance Act, and I hope that particular libel, having been clearly refuted, may no longer be repeated either among the medical profession or among the halfpenny or threepenny newspapers.

I come now to the very important question—I am glad it has been asked—of the hon. Gentleman (Mr. Bridgeman). He asks what is the position of persons over sixty-five. Perhaps I might make an explanation in regard to the various classes of persons over sixty-five. There are, first, the men and women who are employed and were over sixty-five at the commencement of the Act last July. They became insured persons, but they are insured in a separate fund. They are insured persons who can receive 9d. worth of insurance for the 4d. of their contribution. To that 9d. we have now added 2s. 6d. per head for those who select medical benefit, by the Act which is now passing, and they will therefore receive something over 10d. per head of insurance for the 4d. which they have laid down.

Mr. BRIDGEMAN

Are these the people who were over or under sixty-five when the Act was passed?

Mr. MASTERMAN

They were over sixty-five at the time of the commencement of the Act, and if then employed came into insurance on 15th July in the ordinary fashion by their employers contributing on their employers' card. They therefore received, under a system calculated either by the friendly societies or by tables prepared by the Insurance Commissioners, what insurance can be given to them in proportion to 10d. per week for every 4d. that they contribute, and they can receive any benefit within those limits which their approved society may select for them. During all the early part of the year the approved societies only asked for tables for sick pay. They seemed to think that the best thing for these persons over sixty-five was to receive all that 10d. worth of insurance in the form of sick pay, and the Insurance Commissioners consequently issued tables showing how much sick pay could be given on an actuarial calculation for men of that age in proportion to 10d. per week for every 4d. they contributed. Since, however, medical benefit has been given there has been a strong demand, voiced partly in the House and to a certain extent outside, and I have had a large number of letters given me by Members of Parliament on the subject saying that these persons over sixty-five feel very much the fact that they will not receive medical benefit, and that they would prefer that some portion of the 10d. which will be given should be allocated for medical benefit and less consequently for sick pay. As a result of that request we have issued from the Insurance Commission actuarial tables which would enable any society which pleases to give to these persons medical attendance and treatment and a certain amount of sick pay.

Mr. WILLIAM THORNE

Does that mean altering the rules?

Mr. MASTERMAN

I am not sure. In some cases it may in respect of that particular class of persons. In others it will be left open, and it will not mean an alteration of the rules. In respect of any persons of that age for whom medical benefit is chosen the extra 2s. 6d. which we are voting in general for medical benefit will be paid to the society in respect of that person, so that if medical benefit is given there will actually be paid, in respect of that person, somewhat more than if medical benefit is not given and only sick pay is given.

Mr. ALBERT SMITH

I understand that where medical benefit is given the sick pay is reduced to 4s. 6d. in the case of a person over sixty-five years of age at the time of the commencement of the Act, and in employment, and a member of a trade union, can the trade union, out of its trade union fund, pay this medical benefit for the insured person, and, if they give him the money benefit, will he receive also the 2s. 6d. grant, because a case happened where a society had only a few of these members over sixty-five, and the trade union wants to give them the full medical benefit at the same rate? Will the doctor attend them at the same rate as other insured persons, and, if the trade union cannot do that, can they pay the full amount out of the trade union fund?

Mr. MASTERMAN

I think it must depend in part upon the particular rule of the particular union. What the union can do is to make up the sick pay of the person over sixty-five to 6s. a week, and then give the medical benefit out of the National Insurance Fund, and then they will undoubtedly receive the extra 2s. 6d. from this particular fund.

Mr. BECK

They have to pay to their society many years for medical benefit, and they are now losing the medical benefit for which they have paid.

Mr. MASTERMAN

I say nothing as to that. In the second case, the case of persons who were insured in friendly societies before the passing of the Act, there are two cases. They may become insured persons under the Act or they may not. If they are insured in friendly societies which have been doing what the hon. Member for the Oswestry Division (Mr. Bridgeman) says—that is, taking their money for a great time—the societies ought to be able to give them medical benefit from the money now available. Many of them will be able to do it. I have a sort of belief that one of the largest societies has declared that in every case medical benefit will be given although a man is over sixty-five, because there have been accumulated funds for this very purpose, and the reserves are being set free owing to the operation of the National Insurance Act.