§ Order for Second Reading read.
§ The MINISTER of HEALTH (Mr. Chamberlain)
I beg to move, "That the Bill be now read a Second time."
Sixteen years ago, under the ægis of the right hon. Gentleman the Member for Carnarvon Boroughs (Mr. Lloyd George) this country embarked upon a new and extraordinarily interesting enterprise for the purpose of providing medical benefits and advice for all classes of the population who might be in need of them. The scheme adopted was one of national insurance based upon a sort of triple partnership. The contributions from the workers were supplemented by other contributions from the employers, and from the State, with the result that it was found possible to offer benefits quite out of proportion to the sums that were being contributed by the beneficiaries. An experiment of that kind contained, of course, many new features. In particular, there was a provision by which the workers, through the approved societies, were largely given control of their own affairs, a form of democracy which, I believe, does not commend itself to many Members of the party opposite. But, on the whole, after a review of the operation of the scheme during those 16 years, it may be said, I think with confidence, that the principles upon which it was founded have proved to be sound.
There have, of course, been many changes in the details. In fact, I believe hardly a year has passed without some amending Act. That is natural. Those changes arose partly from the lessons of experience, but in large measure they were due to the special circumstances induced by the War, and by post-War conditions, and, I think, we cannot for a moment expect that, even now, we have reached finality. This National Health Insurance Scheme is a tremendous undertaking. Under it, there are to-day some 16,000,000 people insured in this country, each of them paying a weekly contribution which individually amounts only to a few pence, but when added together these contributions form a tremendous 1816 aggregate of about £25,000,000 a year. The societies and branches of approved societies which receive those sums, themselves number about 7,000, and they distribute benefits in small sums, mostly not exceeding £1 in amount, up to a total of about £30,000,000 a year. In a scheme of that size, with the tremendous numbers of people involved in it, and with the complicated machinery which is necessary to ensure its operation, it cannot be wondered at if, from time to time, it is found still capable of improvement and if all the time there are constant demands for the simplification of its machinery.
This Bill is a further attempt at simplification of machinery, although it does also contain some improvements of substance. It is founded principally upon recommendations of a Royal Commission which was appointed in 1924, and which, after a year and a-half of laborious work, holding a great number of sittings and examining nearly 200 witnesses, reported in 1926, and I am sure the House will share my deep regret that the Chairman of that Commission, the late Lord Lawrence of Kingsgate, should have passed away just before it was possible for us to put into effective operation the recommendations to which he devoted so much ability and so much industry.
I observe on the Order Paper an Amendment for the rejection of the Bill, but I must say that, upon examining its terms, it seemed to me to be rather a tribute to the skill and the thought which had been expended on the construction of the Bill, for I observe that the hon. Member opposite has found nothing in the Bill to condemn or even to criticise, but has sought to found his Amendment for its rejection, not upon what it contains but upon what it omits. No doubt he is aware that the Bill itself has been approved by the Consultative Council, and that the approved societies generally would be grievously disappointed if the Bill did not pass to the Statute Book, but with that delightful lack of logic, which endears the hon. Gentleman to the House, he proposes to deprive the approved societies of the provisions for which they are asking, in order to emphasise his opinion that they ought to have something for which, in fact, they have not asked. Perhaps he will give us an explanation.
1817 In the meantime, I will pass to some exposition of what the Bill contains. I must frankly admit that I do not see my way to make my exposition entertaining as well as instructive. The mere contemplation of the table "Arrangement of Clauses," with its monotonous repetition of "Amendment of" this and that "Section of principal Act" is enough to induce a feeling of somnolence, especially at this time of the day, and if I were to attempt to explain to the House in detail the meaning and scope of every one of these Clauses, I should certainly completely exhaust its patience. I propose, therefore, merely to confine myself to one or two of the more important provisions of the Bill, and if, in the course of the Debate afterwards, there are various points raised with which I have not dealt, my right hon. Friend will be able to reply later on, arid I am quite certain that he will answer any question with satisfaction to the House.
There is no doubt in my mind that the most interesting Clause, and that which will be most generally approved in the Bill, is the one that comes first, which deals with the case of the man who is unemployed because he is genuinely unable to find work for which he is capable. Now there are two questions which arise about a man in regard to health insurance if he is unemployed. Of course, he cannot pay contributions. If he cannot pay contributions, he must fall into arrears, and the first question is, what penalty or loss, if any, should be exacted from him on account of those arrears? The second question is, how long, and under what conditions, should such a man be continued in insurance after he has ceased to be employed and, therefore, to make statutory contributions? The Royal Commission gave very careful and exhaustive attention to the question of arrears. They point out that, as matters stand at present, a man who has fallen into arrears by reason of unemployment, no matter what the cause of that unemployment may be, is not deprived of medical benefit, but he is mulcted in his cash benefits. His sickness benefit or disablement benefit is diminished by an amount which is proportioned according to the scale for the number of weeks which he is in arrears, and he can only escape from that position by paying the penalty which is provided under the regulations.
1818 It seems, on the face of it, undesirable that for a circumstance which, it is agreed, is not the fault of the man, because the hypothesis is that he is unable to obtain work, he should be deprived of his cash benefits, and the Royal Commission were undoubtedly impressed with that consideration, and also with the illogicality of a position which makes so remarkable a difference between two systems of national insurance. The very circumstance which entitles a man to benefit under the National Unemployment Insurance inflicts a penalty upon him in respect of National Health Insurance, and, accordingly, the Royal Commission recommended that some further provision should be made which would protect from all loss and all penalty a man who had fallen into arrears with his contributions to National Health Insurance on account of his certified unemployment.
Let us consider the other question of prolongation of insurance. Perhaps all Members of the House are not familiar with the fact that, under the Act of 1918, a man who has ceased to be employed, again from whatever cause, is given a free year of insurance with full benefits. At the end of that free year he ceases to be insured, but, in spite of his having ceased to be insured, he is entitled to a further period of medical benefit which averages about nine months. Altogether, therefore, he is retained in insurance for a period of one year and nine months. But while that Measure was brought in to meet the conditions of the year 1918, and while it might have been sufficient to meet all ordinary cases of unemployment about that time, later on, in 1920, when the great period of trade depression set in, it was recognised that this was not long enough, that, as a matter of fact, many men had been genuinely unable to obtain employment for periods longer than a year and nine months, even for periods extending over several years, and, accordingly, an amending Act was passed in 1921 known as the Prolongation of Insurance Act, under which a man who had been regularly unemployed after the expiration of his free year of insurance, was maintained in insurance continuously as long as he did not enter a non-insurable occupation.
That Act was merely a temporary Act. It was drawn, in the first place, to last 1819 for a year, but at the end of the year conditions had not materially changed and, as a matter of fact, it has been continued in the Expiring Laws Continuance Bill each year, and is at the present time still in operation. But it has been viewed with increasing dissatisfaction by those who are administering health insurance. For one thing, the test being not whether a man is genuinely seeking employment, but whether or not he enters a non-insurable occupation, a number of people have been retained in insurance who really ought not to have been, who were not genuinely, I believe, seeking work, but were voluntarily abstaining from employment. I am not suggesting there was anything wrong in their doing so, but it was their choice, and it was not intended that such people should be retained in insurance. More than that, it was seriously complicated, and gave rise to a great many difficulties, because of inconsistencies between the Contributory Pensions Act and the Health Insurance Act.
I think I may say that the time has come when the Prolongation of Insurance Act should finally be put an end to, and some better scheme substituted for it. It will be found that in the Third Schedule of the present Bill we are repealing that Act, and we are substituting for it a completely new scheme which is to be found in the first Clause of the Bill. Under the first Clause, we are providing, in accordance with the recommendation of the Royal Commission, that all the penalties for arrears of contributions incurred because a man is genuinely unable to find employment shall be abolished. That means a loss to the approved societies which is estimated at about £680,000, and it was recognised when we were considering the provisions of this Bill that it would be too much to expect that the approved societies should find the whole of that £680,000. We, therefore, searched about to find a source from which we could make some substantial help towards it. We found that source, and one on which we have already drawn for the purpose of allowing approved societies to give free credits to those of their members who are more than 26 weeks in arrears, namely, the stamp sales account. Now the stamp sales account is made up from the sums 1820 received from the sale of stamps for which there has not been, and is not likely to be, any claim made on the part of any approved society or any deposit contributor.
Another of the present arrangements is that after there has been withdrawn from that account what is necessary to provide the free benefits to which I have just alluded, nine-tenths of the remainder goes to the Exchequer. In Clause 18, we have provided that that nine-tenths which now goes to the Exchequer shall be made available to the approved societies for the purpose of meeting this new extra charge upon them, due to the abolition of the penalty for arrears. We estimate that from this source there will be available some £500,000 a year—a sum which will be subject to reduction as the figures of unemployment go down—to compensate the approved societies for the sums which they will lose. When one remembers that every year the approved societies have to send out about 2,500,000 arrear notices and that they have to calculate in each case the amount of the benefit due to the beneficiary in accordance with the number of weeks he is in arrear, it will be seen at once what a tremendous amount of work is swept away by the abolition of the penalty for arrears, and what a vast simplification this will make in the machinery of administration. It may clearly be stated that in this Clause we have the largest concession to the insured workers and the biggest simplification of machinery that has been introduced into the national health insurance scheme since its inception.
Let me summarize that part of Clause 1 which refers to the prolongation of insurance. We are extending the period during which a person after ceasing to be employed can have free insurance with full benefits from one year to one year and nine months, on the average. If, before the expiration of that one year and nine months, the insured person returns to work, he will return to his full rights in maintenance of insurance and full benefit. If, on the other hand, at the end of that time he can show that during the whole of that period he has been available for work but has not been able to obtain it—we have made special arrangements for the Employment Exchanges to get the requisite certificates 1821 —he is given another year during which he will be maintained in insurance and entitled to all benefits, subject to the condition that his cash benefits may be reduced to an amount which is not to be less than half the standard amount. It will be seen that under the new arrangements any genuinely unemployed person is retained in insurance after having ceased to pay any contributions whatever for a period of time which will be between two-and-a-half and three years. I think that is a very liberal and very generous provision, and one which will, in fact, meet all the ordinary cases of unemployment which are likely to arise.
There is one class of case which has been brought to our notice by the trade union approved societies which is not, perhaps, fully covered even by this provision, and that is the case of the man who has been employed and insured for long periods of years in his life, who has paid a great many contributions and who, having arrived at the age of 60, finds it difficult to get employment, on account of his age. We have taken that case into consideration, and it will be found that in the Clause it iĊ provided that, where a man has been previously continuously insured for a period of 10 years and after reaching the age of 60 falls out of employment, he will be kept in insurance year after year, provided that in each year he can show that during the preceding year he was available for but unable to obtain work. I would point out to hon. Members the particular significance of this extra concession. The trade unions were afraid that a man might reach the age of, say, 62, and then get definitely out of employment and be unable to get back again and, consequently, be unable to fulfil the statutory conditions necessary to enable him to get his old age pension. We can say with confidence that any man who has been in regular employment for a substantial period cannot lose his old age pension by reason of any difficulty in finding employment after he reaches the age of 60.
I come now to the question of additional benefits, and particularly dental and ophthalmic benefits. This is a very important matter. There has been a tremendous development in these additional treatment benefits since the scheme of National Health Insurance started. In some respects one might say that it is 1822 the most important development that has taken place. Its importance lies particularly in this respect, that these treatments are largely preventive as well as curative in character, and that the large sums of money amounting to about £4,000,000 a year which are now being spent by the approved societies upon dental and ophthalmic benefits may be expected in due course to bring their reward to the approved societies by the improvement of the general health which they are calculated to produce. It is a striking fact that, while the administration of medical benefit was carefully safeguarded in the original Act, and while conditions were laid down in the body of the Act for that administration and the Minister was given power to make regulations still further to elaborate those provisions, nothing of the kind is to be found in the original Act in regard to additional treatment benefits. That cannot be wondered at, because those benefits had not then reached their present importance; but I put it to the House that, now that they have arrived at the present pitch of development, it is very necessary that some similar care should be taken in regard to dental, ophthalmic, and other additional treatment benefits to see that the money is properly expended and to the best advantage of the insured people.
In Clause 14 (3) the Minister is given power to make Regulations governing the administration of any additional treatment benefit and the general arrangement of services under which the treatment is to be provided. It is widely recognised in National Health Insurance circles that something of the kind is required. Take dental benefit, for instance. The Consultative Council, recognising how necessary it was that the approved societies should be able to command an adequate dental service at a reasonable price, recommended the establishment of a joint committee to deal with this matter, and accordingly a committee composed equally of representatives of the dental profession and of the approved societies, and known as the Dental Benefit Joint Committee, has been set up to regulate the conditions between the societies and the profession and to ensure the proper working of the service. On the whole, I think the joint committee is to be congratulated 1823 on having worked with a considerable amount of success, but there has been this difficulty, that it was not a statutory body, that it had to work by persuasion and could not work by authority. In fact, there has been a considerable amount of prejudice and some failure in some places to get the best service possible, on account of this lack of authority on the part of the Dental Benefit Joint Committee. One of the things which I desire to do is to make Regulations under the Clause to which I am referring which will enable me to give that authority to this joint committee, to insure that any decision that it comes to shall be made binding and effective upon all the approved societies coming into the scheme.
§ Mr. CHAMBERLAIN
Yes. We hope to get a similar committee set up to deal with ophthalmic additional treatment benefit. There is another matter upon which it is necessary that I should have power to make Regulations, and that is in regard to what is known as dental clinics. I fancy that those two words may be familiar to more than one hon. Member. Something appears to have aroused a certain amount of confusion in connection with this subject. Judging from my own correspondence, I am convinced that many members of the dental profession have altogether exaggerated what is in contemplation. I want to say at once that there is no intention of doing anything more at present than embarking upon an experiment or two in order that we may thoroughly explore the advantages or disadvantages of the system of dental clinics. The argument in favour of the clinic is that where you get a dense population, and you can rely upon a steady flow of patients, you can get in a clinic a standard of equipment and of specialisation among the staff which it would be unreasonable to expect from a single practising private dentist.
I suppose the argument against the clinic is that it is going to drive out the private practitioner and set up a monopoly. The matter has been discussed by the Dental Benefit Joint Com- 1824 mittee, and they did not come to any conclusion except this, that they thought it very desirable that an experiment should be made, so that we may see whether the advantages outweigh the disadvantages, or vice versa. If this Bill passes through Parliament, it is my intention to make Regulations for the setting up of such experimental clinics, one or two perhaps in London. I want to repeat what I have already said, that in no circumstances can I contemplate abolishing the free choice of dentists. No one must be compelled to go to a clinic if he would rather go to a private practitioner. I would add that certainly it will be a condition of the acceptance even of an experimental clinic that there should be adequate representation of the profession upon its management.
Are we to understand that the consent of the local dental profession will first of all be obtained before the clinic is established?
§ Mr. CHAMBERLAIN
No, I do not think that I can give any assurance to that extent, certainly not at this stage. That is my answer. But I do not anticipate that we shall have any difficulty in selecting the most suitable place for an experiment of this kind, where we shall not arouse any violent feeling of hostility on the part of private practitioners in the neighbourhood.
§ Mr. SKELTON
Is it the case that the Regulations to which my right hon. Friend has referred, which will be made with regard to additional benefits, are really on all fours with the Regulations that the Ministry has made with regard to other parts of the Act already, and like them will not need to be laid before Parliament?
§ Mr. CHAMBERLAIN
This Bill is specified as a Bill to be construed as one with the principal Act. Under the principal Act all Regulations must be laid on the Table of the House, and there is the usual power given to put in a Prayer against any particular Regulation, and that, if carried by the House, renders the Regulations null and void; so that the Regulations under this Clause fall under the same procedure as do those under the original Act, and therefore are fully safeguarded as far as hon. Members 1825 are concerned. The next point on which I wish to say a word is the new provision dealing with deposit contributors. When the scheme was originally set up the provision for deposit contributors was that those insured persons who either could not or would not join any approved society, might become deposit contributors, but in that capacity all that they were entitled to, in respect of benefits, was the equivalent of their own contributions plus the contributions from the State. I think it was recognised at the time that that was not a satisfactory position in regard to that class of persons who are unable to join an approved society on account of their own condition of ill-health. Obviously there are various classes of persons who do not join an approved society, but that particular class really had no choice, because the societies would not take them. As far as they were concerned, therefore, the original proposal was a temporary one, limited to a period of 18 months, in the course of which it was hoped that a more satisfactory scheme would be evolved. It was for 18 months. Sixteen years have elapsed, and it is only now that a new scheme has been devised which will, I hope, deal in a satisfactory way with this particular class of persons.
Under our scheme, which is to be found in Clause 10, these people who, on account of their bad health, cannot get into an approved society, are going to be formed into a new section of deposit contributors, which is to be called the Insurance Section, and they are to be entitled not only to the equivalent of their own contributions plus the State contributions, but they will be entitled to all normal statutory benefits given under the original Act. That, of course, means that special precautions have to be taken to insure the solvency of the scheme, because admittedly all those who are in this section will be had lives, and therefore we have to supplement the contributions of the deposit contributors themselves by various provisions, which hon. Members will find set out in Clause 10 and further explained in the Financial Memorandum. On a valuation it turns out that there is a deficiency, and we have taken power to come on the central fund in order to make good that deficiency. Meantime, for the other classes of deposit contributors, the deposit contributors' fund still remains, and it will continue to be the 1826 policy of my Department, as it has been in the past, to do all it possibly can to encourage deposit contributors in that section to join approved societies, because it is only in that way that they can get the full benefits of the scheme.
§ Mr. LLOYD GEORGE
Would the right hon. Gentleman give the number of deposit contributors at the present moment?
§ Mr. CHAMBERLAIN
I am afraid that I do not carry that figure in my mind, but I will ask my right hon. Friend the Parliamentary Secretary to give the right hon. Gentleman the information. There is only one other Clause on which I want to say anything. The hon. Member for Westhoughton (Mr. Rhys Davies), in his Amendment for the rejection of the Bill, expresses the view that the Bill ought to have given a wider extension to the scheme of National Health Insurance and ought to have brought in a larger number of interests. Provided that the hon. Member does not get his way in inducing the House to reject the Bill, we shall, I hope, be able, partly at any rate, to meet his wishes under Clause 17. We cannot see any way by which we can bring into the National Health Insurance scheme those persons who do not stand to any other person in the relation of employed to employer, but the definition in the Schedule to the original Act of the meaning of "employment" does exclude certain classes of workers who are really employed, but who are cut out under the technical objection that they are not under a contract of service. Those are people whom we hope to bring in. They include timber fellers, hay cutters, stone breakers, building sub-contractors, piece-masters or sub-contractors in various trades, hedgers, ditchers, thatchers, drainers, market porters, slaughtermen, and also the share fishermen, in whom I know that some of my hon. Friends are particularly interested.
It is no doubt true that all these classes of persons are more than ever anxious to come into the scheme, now that they see what tremendous benefits may be obtained under the Contributory Pensions Act, which is linked up with the National Health Insurance scheme. But I hope that that is not the only consideration in 1827 their minds, and that they also realise the great advantages to themselves which they can obtain by subscribing even to National Health Insurance, if there were no Contributory Pensions Act at all. At any rate in future, if this Bill becomes law, those people will at last be brought into its ambit, and they will enjoy the benefits from which hitherto they have necessarily been excluded. I do not propose to deal with any of the other Clauses of the Bill.
§ Mr. CHAMBERLAIN
I think I had better leave that to my right hon. Friend the Parliamentary Secretary, who will have an opportunity of replying later. The Royal Commission, when they were considering what improvements should be made in the scheme of National Health Insurance, conceived that their recommendations ought to be limited by the consideration that no further burden should at this time be laid upon industry by increasing the contributions of the workers or of their employers, and that no further burden should be laid upon the back of the taxpayer by increasing the provision made in the Exchequer Grant. Whatever may be the views of hon. Members opposite about those limitations, I hope the House will consider that the Royal Commission was justified, and that the House will give the Bill a Second Reading. Subject to these limits, I want to say that if Amendments are put forward, when the Bill goes to a Standing Committee, from whatever quarter they come, if they are put forward with the object of improving the Bill they will receive the most careful and sympathetic consideration of His Majesty's Government.
§ Mr. RHYS DAVIES
I beg to move, to leave out from the word "That," to the end of the Question, and to add instead thereof the wordsthis House, whilst prepared to welcome improvements in National Health Insurance, cannot assent to the Second Reading of a Bill which fails to recognise, in the light of modern conditions, the necessity for making the scheme more national in character by establishing the right of entry to many persons now excluded, neglects to make better benefits possible by restoring the State contributions of which the National 1828 Health Insurance Fund has been deprived, and fails in many respects to carry out the recommendations of the Royal Commission.This Bill is brought forward on the presumption that it is the result of the recommendations of the Royal Commission on National Health Insurance. The right hon. Gentleman must know that a statement of that kind is a travesty, as I shall endeavour to show. Out of the 122 separate recommendations, made by the majority of the Royal Commission, this Bill contains only 32. In fact, the Bill is neither more nor less than an office measure; purely an administrative Bill. The big questions affecting the health of the 16,000,000 insured people of this country are left entirely untouched. The Minister has been confined by financial restrictions, which he ought to have fought against. Behind the whole of the finances of this scheme is the hand of the Chancellor of the Exchequer. The right hon. Gentleman knows that he is restricted by what the Chancellor of the Exchequer has already done in this connection. I would like to direct attention to the Memorandum attached to the Bill. The explanation of the Measure in relation to the consultative councils is hardly a fair one. I was a member of a consultative council at the time; so I can speak with a little knowledge. This is what the Memorandum says, on page 1, paragraph 4:The various proposals embodied in the Bill have been discussed with the Approved Societies Consultative Councils of the Ministry of Health and the Scottish Board of Health, and have received the general concurrence of those bodies.But those bodies were, never asked a word about the finance of the scheme. When the Minister of Health agreed with the Chancellor of the Exchequer to the reduction of the State grant in the Economy Act, the consultative council was never asked a single word about it. All that the right hon. Gentleman has done in connection with the consultative council is to bring forward certain limited proposals and ask them to endorse them or otherwise; but he has never put the whole of the proposals before them. He has never asked them to endorse anything that would affect the extension of the finances of the scheme. The Consultative Council have only been asked to do certain things; they have always been limited and restricted 1829 according to the financial policy of the Government. What this Memorandum says is true, but it is only in a very small part true. It is not the whole truth, anyhow.
The few remarks I want to make this afternoon will be divided into two parts. The Minister of Health, in his kindly reference to my illogical mind, was probably right; but if I had had his education, probably I could achieve as much as he has done. I want to deal firstly with what the Bill purports to achieve; and the right hon. Gentleman has given us, I think, a very good explanation of the main purposes of the Bill. His right hon. Friend who is following this evening is regarded as an expert on national health insurance, and he will probably be able to reply to the questions which I am about to put to him. I agree in the main with what the right hon. Gentleman has said with regard to Clause 1, affecting the arrears problem. That, undoubtedly, will put the whole of the arrears question on a proper footing. It will be a great advantage to the approved societies, and some advantage to the insured members who are unemployed, because they will all know now exactly Where they stand. But I would refer to the statement made by the right hon. Gentleman that an insured person who cannot find work after he reaches 60 years of age, and who had been insured, say, for 10 years at some previous period, will be safe for his old age pension at 65. That does not meet the whole of the case; and I want to argue that this scheme should meet the whole of such cases. After all, we have to remember that this scheme must be based ultimately on actuarial considerations, but I would refer to the case of the man, say, at 55 years of age. Supposing he falls out of employment at 55, as unfortunately thousands do, and remains unemployed until he is 65, then, I understand, he will be, even under this Bill, outside the scheme for old age pensions. Therefore, while what Clause 1 does is a very good proposal so far as the office side of the business is concerned, and meets many of the difficulties with which we are confronted, it does not meet the cases I mentioned; and there will still be thousands of people outside the old age pensions scheme owing to unemployment.
1830 I agree, too, with another Clause embodied in the Bill, and that is the proposal to deal with benefits accruing in respect of insured persons when they are in hospital. I think that is important. But I am not quite satisfied, and the right hon. Gentleman in replying will be able to tell us what is meant by Clause 3, dealing with what I think may be termed medical charities, particularly in South Wales. I understand that some of these medical charities are doing excellent work, and I hope I may be pardoned for a little suspicion that the medical fraternity are influencing the Minister of Health unduly in this respect.
§ Mr. DAVIES
Before we can consent to the abolition of those medical charities, I think we must secure evidence as to whether there is any abuse of the privileges granted them under the original Acts. It will not be sufficient, I feel sure, simply to come to this House and say that those charities are going to be abolished, unless it is proved conclusively that they cannot be worked efficiently into the present scheme. There is another small matter to which I would refer, and that is with regard to benefits wrongly paid. I entirely concur with what is being proposed in that connection; but I would like to ask the right hon. Gentleman one thing in regard to a Clause which he has put into the Bill on the question of maladministration. The position at the moment is this, that if a society does not carry on its administration properly, the Minister can take away the approval of the society. That, of course, is a very strong step to take; and the proposal in this Clause is to the effect that the Minister will be able to reduce the administration allowance as a penalty. That allowance works out, roughly, at the moment at 4s. 6d. per member per annum—actually, 4s 5d., with a few additions here and there. I would like to know, if the Minister is called upon at any time to reduce the administration allowance of a society, what is the destination of the amount so reduced. If you reduce it to 4s. and take away 6d. per member per annum from the society, do I understand that the 6d. is taken away from the society entirely, or is it merely transferred to the benefit fund account of that society? 1831 That, I think, is a point on which the right hon. Gentleman may give us some information.
One important recommendation of the Royal Commission to which I want to refer in passing is only just touched upon in this Bill. I should say that the two most important recommendations of that Royal Commission related to the pooling of surpluses and to the abolition of insurance committees, and this Bill touches neither. That is why I said at the commencement that this Bill, in fact, has only a remote relation to the vast majority of the recommendations of the Royal Commission. With regard to that point, I want to say, though I may return to it later on, that I should like to know what reasons have induced the Minister not to include in this Bill the recommendation of the Royal Commission in regard to the partial pooling of surpluses. I shall be able to show later on the absolute necessity of connecting the several benefits that are paid by the several societies in this country and bringing about equality; but before I do that, might I welcome the proposal with regard to the deposit contributors' fund? I regard that really as an exceptionally good step to take, and a very important one indeed; but I would like to know one thing about it. The right hon. Gentleman is going to set up a separate section for the purposes of the deposit contributors, a sort of an approved society, I presume. Later on, he imposes penalties upon approved societies if they are not carried on to his satisfaction, penalties with regard to maladministration. Supposing the society which the Minister sets up in Whitehall to cover these deposit contributors is not carried on satisfactorily, will the same penalties be inflicted in Whitehall as on other approved societies? I think that is a very proper question to ask. I should like to know, too, whether the Minister has secured actuarial advice to show that it may be possible to do any more for the deposit contributors in this new insurance section than pay the statutory cash benefits; whether there will be any additional benefits at all for them.
The right hon. Gentleman never said a word about Clause 11, and he seems to have avoided it, because the Royal Commission was very emphatic that something more should be done in connection with 1832 maternity benefit and the case of married women in general under the National Health Insurance scheme. This Clause does make the position of married women very much clearer; but it does not touch those issues that were raised by the Royal Commission—the terrible tragedy of maternal mortality in this country, about 3,000 women dying annually in childbirth in this country. When this scheme came into operation at the beginning, one of the ideas behind it was to make it possible to reduce maternal mortality in particular by paying maternity benefit. Really, the right hon. Gentleman does not in this Bill touch that problem in the least. I shall return later on to one or two other points in connection with preventive measures under the National Health Insurance scheme.
The right hon. Gentleman missed too in his speech any reference to the question of surcharging approved society officials, though I take it that his deputy will reply to that point later on. I speak feelingly on this subject. The right hon. Gentleman has come to the conclusion that when an officer of an approved society fails in his duty, he must be put into the same category for surcharge as an officer of a board of guardians or a local authority; but I would warn him that this might act as a boomerang. A society's officer receives a claim for benefit, and he says to himself, "I can now decide at my own discretion as to whether this benefit shall be paid or not," but when later he receives a claim for benefit which may be a doubtful one, and this surcharge is hanging over him, he may decline to meet that claim for fear of being surcharged. I would say to the right hon. Gentleman, therefore, that in Committee upstairs we, on this side, shall probably put in some Amendments to safeguard the position of these officers in this connection.
The right hon. Gentleman, in introducing the Bill, cleared away one or two points in relation to dental and ophthalmic benefits. I take it for granted that clinics of whatever kind under this scheme will be established from the surplus funds of approved societies; that is to say, the Minister, naturally, will not be able, say, to take £10,000 or £15,000 out of the funds of the approved societies and establish experimental clinics himself. I am sure he will not do that; and I think every hon. Member will agree with me when I 1833 say that there is no difference of opinion at all on this point. But whereas dentists, opticians and ophthalmic surgeons are all looking after their own interests—we cannot blame them for that—they must not be allowed to stand in the way of steps being taken to secure a better service for the insured persons of this country, whether by clinic or otherwise. I was very glad to hear that the right hon. Gentleman was very specific on the question of freedom of choice. That is to say, if a clinic is set up in Manchester or elsewhere, an approved society official will inform his members that they ate entitled to go to that clinic; but I take it that the regulations will also provide that he cannot compel his insured members to go to the clinic.
I want to get this point really very clear. Approved society officials have a way with them, just like politicians, and I can see what may happen. In spite of the fact of freedom of choice, the approved society's secretary may, once he has established his clinic, tell his insured members they are invited to go to the clinic at such and such an address; but I want the Minister to safeguard the interests of the insured persons by making it compulsory on the society to include words to the effect that if the insured person fails to go to the clinic, he can still choose his own dentist or optician as the case may be. I do not want any circular to be sent out from the office of an approved society which would indicate to the insured person that he is compelled to go to the clinic.
I return to the question of disposing of surpluses. I am not at all clear with regard to certain words which are imported into this Bill for the first time. They are in relation to the abolition of Section 75. What is meant by the words "the provision of"? The right hon. Gentleman will have had some communications on this subject and he will probably enlighten us. I have no criticism to offer on the Clause relating to penalties, except one. I hope that the Minister, in dealing with penalties by regulation, will see that, whatever penalties he inflicts upon the administrators of approved societies and insured persons, he will inflict similar penalties upon the medical profession, the dentists and the opticians who may transgress the 1834 law. As a matter of fact, cases have been brought before the House, and the Minister knows about them, that some members of the medical profession are issuing medical certificates definitely with a view of increasing their panel practice, and, as far as I know, there is no provision for penalties to deal with cases of that kind in this Bill. I pass now to the point about bankrupt employers, and I welcome that provision. I wish that it had been inserted in the first Bill, because I know of several little tragedies consequent upon the failure to secure benefit, merely because employers had failed to pay contributions and had become bankrupt. I was glad also to hear the right hon. Gentleman state that slaughtermen are to be brought into the Bill along with tree-fellers and a few more people. I do not know whether the canvassers of the Tory party can be brought in; they are perhaps included already.
I am not at all satisfied with the Minister's proposals to deal with the administration of additional benefits. I take it that we must wait for the Regulations before we can decide our attitude on the point; but I want the right hon. Gentleman the Parliamentary Secretary to inform the House whether it is intended under this Bill to give insurance committees ultimately the administration of some benefits which are to-day administered by approved societies. If he proposes to do that, he will find himself in a difficulty with the Consultative Council. He does not always accept the advice of that Council; he likes to consult them, and that is about all he does on occasions. I was a little surprised that the right hon. Gentleman did not refer to the repeal of Section 26. I have here the Report of the National Audit Department for 1926. The right hon. Gentleman has all the support that I can give him in regard to the repeal of this Section. If there has been any abuse at all in connection with the administration of National Health Insurance, I am convinced that it has occurred under Section 26. What has been done, has been done probably strictly within the wording of the Section; but it has not been done very honourably. Consequently, I support to the full the repeal of that Section; and if any approved society wants to do anything by way of clinical work, or 1835 granting money towards charities or hospitals, it ought to do it clean and above board; and I can speak for every Member on this side when I say that anything that the Minister proposes to do to keep this scheme clean in its administration will have our support.
I have touched up to now only with what the Bill proposes to do. I hope that I may be pardoned in dealing for a few moments with what the Bill fails to do. The right hon. Gentleman was rather critical of our Amendment. He knows full well that it touches the only important points, in the whole of the administration of this scheme. He referred to the Royal Commission, and paid a proper tribute to its members, and I agree with what he said. But the Royal Commission said something with regard to the finances of the scheme on which he has not touched. They said that the finances of the scheme should not be altered except in very minor details. What do we get in this Bill? This Bill perpetuates the reduction of the State grants; and the right hon. Gentleman does not say a word about that. He knows full well that he is circumscribed and limited financially; and he cannot carry out the main proposals of the Royal Commission, which ought to be included in this Bill, because he is afraid of his master, the Chancellor of the Exchequer. The result of the operations of the Economy Act and their relations to this Bill was the subject on which I asked a question of the right hon. Gentleman the other day, and I want to show the House what effect the Economy Act has had upon the finances of this scheme. The Economy Act operated as from the 1st January, 1926. In 1925, the total sum available for investments by the societies was £8,000,000. That, of course, was a sum set aside for the payment and increase of additional benefits later on. In 1926, the first year of the operation of the Economy Act, the sum was £1,500,000. In 1927, it was £200,000. That is to say, that part of the effect of the operation of that Act has been to reduce the amount available for investment by the societies from £8,000,000 per annum to about £200,000; and I shall be surprised to find that the societies have much, if anything at all, to invest for 1928. I say, 1836 therefore, that the right hon. Gentleman has not touched the kernel of this problem. He leaves out of count entirely the operation of that Act upon the scheme. Let me put it the other way. Were it not for the amount received by way of interest upon investments last year, the scheme would have shown a deficiency of about £3,000,000. The right hon. Gentleman is not treating the House fairly by not referring to the operations of the Economy Act upon the scheme.
I said a moment or two ago that there was nothing in the Bill to extend the benefits in connection with maternity cases. Let us see what the Royal Commission says about it. When it suited the right hon. Gentleman he quoted the Royal Commission. I will quote it, too, when it suits my purpose, by way of retaliation, or, in the language of Birmingham, by reciprocity. The Royal Commission recommended that the scope of maternity benefits should be extended to cover medical and midwifery services in addition to cash benefits. It will be interesting to learn from the right hon. Gentleman why that provision has not been included in this Bill. The Commission further recommended the extension of the scope of medical benefit in respect of dependants of insured persons in receipt of sickness or disablement benefit, to improved provisions at the time of pregnancy and childbirth, the provision of dental benefit as a normal benefit; and, above all, they recommended that the insured population in this country should be entitled to specialist services as well as ordinary medical practitioner services.
§ The PARLIAMENTARY SECRETARY to the MINISTRY of HEALTH (Sir Kingsley Wood)
Does the hon. Gentleman say that that has anything to do with the Economy Act?
§ Mr. DAVIES
I say that were it not for the fact that the State grant has been reduced, the majority of societies would have been able to pay for specialist services. Does the right hon. Gentleman challenge that?
§ Sir K. WOOD
I say that the fact that there has been no provision made in this Bill for specialist services has nothing to do with the Economy Act, and it is not affected by it in any way whatever.
§ Mr. DAVIES
The right hon. Gentleman has challenged my statement that it is not included because of the operation of that Act; and it will be interesting to know why it is not included. If it were so easy to do it, it would have been included in this Bill; and I repeat that the operations of the Economy Act have nearly torpedoed the finances of National Health Insurance. The right hon. Gentleman knows that full well, but he feels that he must stand by the Chancellor of the Exchequer, who rejoices now over a surplus of £4,000,000 on his Budget. He knows, however, that that £4,000,000, in part, has been taken from this scheme. This is called a national scheme, and the Royal Commission referred to that fact, too. It is becoming less national as the years go by. Let me give the right hon. Gentleman his own figures. I do not know whether he took any notice of them when he replied to me yesterday. This scheme was once an international scheme, covering England, Scotland, Ireland and Wales. All its objects are still international so far as Northern Ireland, Scotland, England and Wales are concerned; but there is a growing disparity as between the cash value per member in the four countries. At the first valuation at the end of 1918, taking the value of a member in England as 100 per cent., the value in Scotland was 108 per cent. They are a more healthy and more robust people, and, on occasion, more intelligent. In Wales, however, the percentage was 92 per cent. That shows that the value per member in Wales was less than either in England or Scotland.
§ Mr. DAVIES
You do not measure health always by intelligence. At the end of the second valuation, the percentage figures were, England 102, Scotland 101, Wales 68. I want to bring those figures to the notice of the right hon. Gentleman, because the scheme is yearly becoming less national. I will give further figures if necessary to prove what I am saying. Nearly every society today has its own additional benefit scheme; and any member will come across a case like this. Take an ordinary household of five persons. The father can be in one 1838 society, and the three sons in separate societies. The father's benefits will differ from those of the three sons, and the benefits in respect of the sons will differ from each other and from that of the father, because each society is valued separately. With a growing disparity between the benefits paid by different approved societies, I should have thought the right hon. Gentleman would have gladly accepted the recommendation of the Royal Commission to pool part of the surpluses. This is not a party question in the least; but it really is unfair that we should have in this country 16,000,000 insured persons, all men and women paying the same amount of weekly contribution, and thousands, if not millions, drawing different amounts in benefit. The way to get over the difficulty would be by pooling the surpluses in part; but the Minister does nothing in this Bill to deal with that problem.
I have only one or two other comments to make. One is in relation to the recommendation of the Royal Commission that insurance committees should be abolished. I would like the right hon. Gentleman to tell us why that recommendation was not acted upon in this Bill. I was once a member of an insurance committee; and although I do not want to speak disparagingly of all insurance committees I must confess that my experience led me to believe that the work was really too small to warrant having a separate authority to do it. The work ought to be transferred either to local authorities or to approved societies jointly. I know full well that vested interests are established if these things are allowed to grow; but we ought to have some explanation as to why these committees are not to be abolished. When the right hon. Member for Carnarvon Boroughs (Mr. Lloyd George) brought in the first Insurance Bill he never contemplated establishing any insurance committees at all. It was the threat of the medical profession to strike which compelled him to set up those committees in the first place. The medical profession have now got over their antagonism to the National Health Insurance scheme. They are glad to be in it, because they are doing well out of it. I said last year, and I may as well repeat it now that before the National Health Insurance scheme came into operation most of the doctors were riding about on pedal bicycles, whereas to-day 1839 they are in motor cars, and sometimes in Rolls Royce cars, too. I do not challenge that position, because I would pay a good medical man a good salary for his services; but I think the time has gone by when there is any need to retain insurance committees as separate institutions, especially in view of the fact that the Royal Commission recommended their abolition.
All I have to say in conclusion is that this Bill is a very small contribution to the problem of national health insurance. It does not assist in the solution of the health problems of this country. What about cancer and rheumatism? Nothing is done in this Bill to deal with those diseases. All this Bill will do is to provide a few more typists and typewriters in the offices of approved societies. If I dare use the simile, it is just like buying a toothbrush and calling it a surgery; it is just like buying a bed and calling it an infirmary. This is a very small Measure. I object to the policy of this Government, indicated all along the line, to throw upon the funds of these social insurance schemes all the liabilities arising from industry, the Government relieving themselves of the necessity for any subsidy ultimately. That is what they have done with unemployment insurance, and what they are trying to do partly in this Bill—throw the responsibility of the unemployed insured persons on to the funds of approved societies. When we compare the recommendations of the majority and the minority of the Royal Commission with what is included in this Bill I say we are justified up to the hilt in moving this, Amendment and taking it to a Division.
§ Mr. WHITELEY
I beg to second the Amendment.
The right hon. Gentleman referred to the fact that the principle of national health insurance was that of giving approved societies democratic control, and he complained that we on this side did not seem fully to agree with that principle. He himself is preventing democratic control by societies in regard to the payment of additional benefits by introducing Regulations which will be so framed that those benefits are administered according to his own ideas. Therefore, if he accuses us of not believing in full in the democratic principle he must 1840 agree that apparently he; himself is not fully in sympathy with it. While we do not in the main complain about what this Bill provides, we are concerned because the Bill does not put into operation the important recommendations of the Royal Commission as to the provision of additional benefits and the methods of raising the necessary finance.
The right hon. Gentleman says that in our Amendment we are asking for something for which the approved societies do not ask. That may be so as regards some societies, but at any rate the association of trade union approved societies are asking for it. I wish to say a few words with regard to the position of societies which have been looking forward to the recommendations of the Royal Commission being put into operation in order to deal adequately with the problems facing health insurance. It has often been said that national health insurance has developed into a sort of network of societies for the disbursement of cash benefits. Societies themselves have made tremendous progress in improving the health of the community by providing additional benefits, principally designed to maintain health; all the additional benefits provided by societies which are fortunate enough to be able to give them have the tendency, in the main, to secure the better health of their members.
In the original Act it was intended that there should be a greater concentration on the health side of the work than on the cash benefit side. It contained a provision which gave power to societies, and even to individuals, to call the attention of the National Health Commissioners, who were operating at that time, to housing conditions and sanitation in areas which were found to have a high rate of sickness. If they could prove that bad housing conditions, bad sanitation and the general environment in which their members lived were conducive to a high rate of sickness, they had the power to put into operation certain machinery to improve things. Unfortunately, there was not sufficient concentration on that side. I myself appeared before the National Health Insurance Commission. I had spent months in securing information about things which tend to increase sickness liability in particular areas, and I put 1841 that information before the Commission in the hope of helping them to help us. All that information is on record, but nothing has been done to overcome the difficulties. I think the right hon. Gentleman himself must feel concerned about the tremendous increase in sickness benefit during the last three or four years. Under-feeding, slums, unemployment and under-employment, and, I think I might also say, the lack of sunshine in the last two or three years, have all had a very serious effect on the health of our people. The fact that we have not had the same amount of sunshine in the last two or three years has had some effect on the health of Members of this House. It is impossible to expect a healthier population unless definite steps are taken by Act of Parliament to assist in securing healthier conditions, and I have always regretted that there was not greater concentration on the purpose of the original Act in that respect.
During the recent Debate on the Ministry of Health Estimates there was a good deal of talk about the tremendous amount of sickness in the country to-day, and a good deal was said about the care which approved societies are now taking with regard to claims which come before them. I think that is a fact. My own experience of the administration of these societies is that to-day it is nearly as perfect as one could expect it to be under a big scheme of this kind. But I would like to call attention to this point. You may have one society which during the course of the year—as has happened—has received contributions amounting to £16,847 from its members and has had to pay benefits amounting to £75,975. The House of Commons ought not to concentrate all its attention on the societies which have the best lives. It is unfortunate that there should be societies in the singular position of the one to which I have referred, but they ought to get some consideration. Side by side with that society there may be another whose members are not engaged in the same arduous occupations. Its members can probably get back to work earlier than the members of the other society, because it would be injurious to the health of the latter if they were to attempt to resume their particular occupations. In such a society the contributions are 1842 greater than the benefits. The one society will never be able to pay additional benefits, and the other society will always be able to pay them, and to increase them, probably, and yet the auditor, who is auditing the accounts of the two societies, will probably admit that the society which is penalised by such heavy sickness is probably just as well managed as the other, and perhaps better.
If the right hon. Gentleman looks at Clause 4 (8), he will see there that it is admitted that the existing system is really a failure. It deals with the restrictions on transfers. Of course, as we know, there are to-day societies that would never be able to pay additional benefits, and whose members are anxious to receive the best possible benefits for themselves and their dependants, and naturally they look round for the best society which is paying the largest additional benefits. One is astonished at the large number of societies that will never have the opportunity of paying additional benefits, and the loyalty of their members is simply wonderful. Those people who remove to other areas are compelled to transfer on account of the distance and will not be able to receive the benefits, because the Minister, recognising that a great influx of transfers may affect the financial position of a society, has made provision for that in the Bill, and he has power to bring in a Regulation to prevent that influx of transfers. This means that the scheme as approved is a failure from a national point of view or else such a provision as is contained in Clause 14 (8) would not be inserted.
I think the Royal Commission felt that the payment of additional benefits has been so successful and has been so much appreciated by the insured members of those societies that can afford to pay them that it was in the interests of the nation to make recommendations along the line of paying these additional benefits, or creating facilities by which they could be paid by all approved societies. Of course, they saw the impossibility of the continuance of the scheme which has such inequalities in regard to benefits as those which exist to-day. It is argued that if you create a system whereby the approved societies 1843 will receive additional benefits rather at the expense of the general body of insured members throughout the country that might tend to lax administration. The Royal Commission have answered that point, and they have pointed out that the establishment of a central fund in order to deal with or assist societies which have been in deficiency in the past has not tended to create lax administration but has tended rather to tighten up the administration. As a matter of personal experience, I know many societies in that position, and their administration has increased in efficiency from year to year. I think that one of the reasons why the Royal Commission made the recommendation which enabled societies to give their members some little addition to their benefit was the fact that they are called upon to pay an unequal contribution.
In their Report the Commission give elaborate details of the scheme which they believe ought to be put into operation for the purpose of giving the additional benefits which they think are essential. They deal with special medical benefit for women during the period of child-birth and pregnancy, and with dental treatment. They deal with those matters, because they are services which conduce to a more healthy population than we find existing at the present time. Of course, all these things cannot be properly accomplished without some assistance. We have to recognise how some of the approved societies have been affected by the application of the Act. Some reference has been made to the Report of the Actuarial Committee and the working of the Economy Act. There is no doubt that at some future time when the societies find themselves in difficulties another review must take place. I think the time has come when such a review ought to take place with a view to repealing what was done by the Economy Act in order that societies might have the opportunity of dealing more generously with their members. I know societies which have prided themselves on the fact that for a course of years they have always had a wonderful balance on their administrative account. I have since seen deficiencies growing greater and greater every year, and it is no use saying that the Economy Act has not had a big 1844 influence on the finances of approved societies. There is no doubt as years go on that that Act will have a greater influence.
When you come to deal with the great problem of health insurance, and when you call it a national health insurance scheme, you ought to deal with it from a national point of view, and insured persons ought not to be penalised because they have hit upon a society which unfortunately has not been able to create a situation under which additional benefits can be paid. Of course, we shall put forward our suggestions with regard to improvement when we come to deal with the actual Clauses of the Bill. I think it is important that the House should realise that insured persons in this country ought to be treated with something like equality from a health point of view, and the sooner we get back to what was in the minds of the people who brought this scheme into operation at the start the better it will be. The original idea of the scheme was to develop it into a real national health scheme. We seem to be getting gradually away from that ideal, and it is our purpose by bringing forward Amendments to try and get the Government to focus their mind on the importance of getting back to the original intention of the scheme instead of dealing with it in a piecemeal way, which is of no use to the insured population of this country.
§ Mr. OAKLEY
I rise to support the Second Reading of this Bill which deals with a very important subject vitally affecting the workers of the nation. This Measure is in somewhat striking contrast to the Bill recently introduced into this House dealing with unemployment insurance, which the right hon. and learned Gentleman the Member for Spen Valley (Sir J. Simon) described as "a Chinese puzzle." I support this Bill for two reasons. Firstly, as an administrator of health insurance; and secondly as a representative of insured persons. As an administrator, I support this Measure because it is one for simplification; and, as a representative of insured persons, I support it from their point of view, because it is a measure of justice. The National Conference of Friendly Societies, of which I have had the honour of being a member for the last 10 years, has expressed its appreciation of this 1845 Measure. While supporting the Bill, I wish to offer a few constructive criticisms for the consideration of the Minister of Health. In Clause 1, I welcome the proposals for meeting the position of persons genuinely unemployed. I also welcome the abolition of the Prolongation of the Insurance Act which has imposed unfair liabilities on approved societies for a number of years.
I would like to draw attention to one or two items. Take proof of unemployment which occurs from two separate aspects. In Clause 1 (3), the Bill extends the period of free insurance and in Sub-section (5) it deals with the excusing of arrears. In the case of the extension of the period of free insurance, it is necessary to prove within a prescribed time that the insured person is "available for but unable to obtain employment." While it states that the insured person must prove, "within the prescribed time," I do not see what is the "method of proof" or to whom proof must be given. To me, it appears there is no provision for this to be laid down by Regulation. In the same Clause, in Subsection (5), it states that that proof of unemployment is to be subject to regulations whīch will, I hope, give the metħod of proof and the party to whom proof is to be given. In this instance, proof of unemployment under these Clauses is not uniform. I suggest that in the case of extension of the period of free insurance it should be laid down what is the method of proof, and to whom proof should be given as in the case of the excusing of arrears; and further in respect of both instances there should be some statutory provision either in the Act or by Regulation applicable to all approved societies.
Considerable difficulty in the past has been experienced owing to the laxity of proof of a person being "available for but unable to obtain employment." Different degrees of proof have operated in different approved societies, and I hope something tangible and definite will be arrived at under this Bill. Clause 1, (3) and (6) deals with the extension of the period of free insurance by sickness. The object is undoubtedly not to put a person out of insurance while ill. I am doubtful whether that object has been attained. Sub-section (6) of this Clause extends the period of free insurance beyond a date arrived at "under any of 1846 the foregoing provisions." Consequently, two dates emanate: (1) under any of the foregoing provisions, and (2) under Subsection (6). While the object is obtained in not terminating the insurance of a person who is ill at a date under previous Clauses, it is possible for insurance to be terminated when a person is ill at the amended date arrived at under Subsection (6). I think this point will require special consideration.
I now come to the very important development in National Health Insurance contained in Sub-section (2) of Clause 2, which deals with accumulated benefits. I welcome the suggestion there made that the accumulated benefits should be limited to £50. Instances have occurred in my experience, and must have occurred also to others engaged in the work of administering National Health Insurance, where, in the case of persons in asylums or mental hospitals, it has been impossible to trace any relatives during the whole of the time that they were in the hospital, and yet, on the death of the insured person, it frequently occurs that many relatives turn up and claim the accumulated benefits. While I personally should have preferred any balance in excess of £50 to remain in the benefit fund of the individual society for the benefit of insured persons, I think it is a step in the right direction to have brought this £50 limit into existence for the first time. Sub-section (1) of Clause 6 deals with the withdrawal of approval in certain national areas. I hope that the Minister can give a guarantee that, before the Joint Committee withdraw approval in these instances, due consideration will be given to the voluntary section interests of approved societies to which those members are attached. In deciding this matter, also, I hope that the Minister will take as the test, not the existing number of members in a particular district, but the intention of the society concerned to recruit further members in the future.
Clause 7 deals with the amendment of the rules of approved societies. While I am quite in accord with the general principles of this Clause, I look upon the Clause with mixed feelings. Undoubtedly, there are instances where official action should be taken to amend the rules of certain societies. These chiefly concern the procedure for appeals made by insured 1847 persons against the withholding of benefit. Conclusive evidence was given before the Royal Commission that insured persons were required to go before an unreasonable number of tribunals if benefits were disallowed, before reaching the Minister of Health. In this respect, if the only intention of the Bill is to remove this injustice to insured persons, I welcome the Clause; but, on the other hand, I should oppose it if it were the intention to interfere with the domestic policy of approved societies, as that would be taking away the individuality which was given to approved societies at the inception of National Health Insurance in 1911.
Clause 8 is another very important Clause, and I quite appreciate the desire of the Minister for the power which it gives in regard to penalties for mal-administration. At present, the only penalty which can be inflicted upon approved societies for mal-administration is the withdrawal of approval. It is quite easy to conceive cases where mal-administration does not justify the drastic action of withdrawal of approval, and yet does justify official action, and I quite agree with this. What I regret is that the Minister has confined his action in this direction to approved societies, and in regard to this I agree somewhat with what was said by the hon. Member for Westhoughton (Mr. Rhys Davies) in moving the Amendment. If the mal-administration of affairs entrusted to approved societies is punishable by either withdrawal of approval or reduction of administration allowance, I am of opinion that similar methods should be applied in respect of other bodies undertaking another branch of National Health Insurance—I mean the medical profession. They come very prominently into the picture by reason of the fact that the funds of approved societies are largely in the hands of the medical profession, as the certificates issued by them are prima facie evidence that the insured person is entitled to benefit. Consequently, any laxity on the part of the medical profession in regard to medical certification means that insured persons may be receiving benefits to which they are not entitled, and that, I consider, should be regarded as a punishable offence against the person responsible for payment. As the law stands to-day, gross 1848 mal-administration on the part of approved societies is punishable by withdrawal of approval. Similar mal-administration on the part of the medical profession is punishable by removal from the panel. This Bill introduces a minor punishment for mal-administration in the case of approved societies, and it seems to me to be a pity that a similar minor punishment has not been introduced for the medical profession—by which I mean the withholding of part of the remuneration—in order to make both parties similarly responsible for the administration of National Health Insurance. Perhaps the Minister will look into this point during the Committee stage of the Bill.
I know that considerable criticism will be levelled at this Bill on account of the power given to the Minister to make Regulations. This power cuts both ways. For example, societies wishing to amend schemes of additional benefits would be prevented from doing so unless the Minister had the necessary power to approve of the Amendment without coming to Parliament with an amending Bill. The Minister himself has given an assurance to-day that all Regulations so issued will be laid on the Table of the House, in accordance with the provision in the original Act. In a scheme of this magnitude, to come to the House to legislate in respect of administrative details only would take up far too much of the time of the House, and would, I am sure, leave very little time for what many private Members delight in, namely the bringing in of fresh legislation. I feel that I must say a word on the Amendment which has been moved. One of its features is the reference to "neglect to make better benefits possible," and, apparently, by inference, it attributes the present state of affairs to the reduction in the contribution made by the State. It is, however, rather striking that the funds of approved societies only suffered in any appreciable degree as a result of the general strike in 1926, and I am of opinion that, if right hon. and hon. Members opposite had used their influence to prevent a general strike, it would not have been necessary for that part of their Amendment to appear on the Order Paper to-day.
I have ventured to put these views and criticisms with the intention of supporting the Bill, because it is a Bill of vast 1849 national importance. I use the word "national" because it is important, not only so far as this country is concerned, but in view of the Sickness Insurance Convention passed at Geneva in May last. The proposals of the British Government will undoubtedly be carefully scrutinised by many Continental Governments. I happened to be in Geneva myself during the discussion in connection with the Sickness Insurance Convention, and heard many speeches delivered by the British representative who was charged with this matter. Throughout the whole of the discussions it was apparent that the British scheme held the field, and I am convinced that it was entirely due to the efficiency and tact displayed by the British representative that a Convention of any sort was passed, and that the Convention passed was based almost entirely on the British scheme. To that representative I think considerable tribute should be paid. For this reason, I regard the present Bill as important, not only from the national point of view, but also from the international aspect, using the word "international" in a different sense from that in which it is sometimes used by hon. Members opposite. While I congratulate those who are responsible for the introduction of the Bill, especially in regard to the Memorandum which accompanies the Bill, I feel sure that the Minister will give consideration to the points that I have raised. I assure him that any criticisms that I have made have been made with the intention of improving the Bill, and I support the Second Reading.
§ Mr. HARNEY
This Bill, in my submission, contains some parts that are excellent and some that are bad. I quite agree with the Minister that, in an insurance scheme so novel and so tentative as this, we have to accept the fact that it could only reach perfection by a series of patchwork operations. It has been amended many times already, and now we have this last amendment. I do not, therefore, complain because it has not been made a complete and watertight structure at the moment, but, while the Minister was engaged upon it, I think he was called upon to give consideration to a few large matters which he has entirely ignored. Let us see, in the first place, what are the good features of the Bill. The first is the abolition of the arrears and penalty Clause. The House 1850 understands that many contributors were unable to keep up, in the appropriate year, the number of contributions which would entitle them to their benefits, and a period of grace was given in the Act of 1924, during which they could make up the shortage. That proved a great hardship, and it is now gone.
There is another good point. The Act of 1918, on account of the bad state of things then prevailing, gave a free year to everyone following the cessation of contributions. Everyone who passed out of insurance had a free year during which he had all the benefits of an insured person and contributed nothing. Curiously, however, the free year was confined to what are called cash benefits during sickness or disablement, and about nine months ran on during which the same person was entitled to medical benefits. That was a curious distinction, which I, for one, was never able to explain. It proved very irritating in practice, and I am glad to say that by this Bill that distinction is abolished, and all insurance contributors can run on a free wheel now for a year and nine months. The third good feature is in regard to deposit contributors. As the Minister pointed out, the original scheme had to provide for a class of persons who either did not avail themselves of their rights or who were in such bad health that no approved society would take them in. They became deposit contributors, and the only benefit that they could draw was such as was furnished by the accumulation of their own contributions, together with what was added by the Government, which, of course, was but a very small amount. As the Minister quite rightly mentioned, it was hoped at the time that a period of 18 months would remedy that condition of affairs, but he now, after 16 years, comes forward with a remedy. At any rate, it is better late than never. The remedy which he puts forward is one of which I think we shall all approve. He says that these bad lives are to be gathered together into a particular sort of approved society called the insurance section, but, since their contributions would be few, as their lives would be short, it would never be solvent on an actuarial basis, but it is to be made solvent by draining into it all the balances left over from the contributions of persons who 1851 emigrate or die. All the unused balances are to be put into that fund, and also all the interest on the deposits, and if then there is not sufficient to pay this section the full benefits, the deficiency is to be made up by drawing upon the central fund. That is all to the good. The last good feature is the introduction of the new classes under Clause 17.
Having said this, I have said everything that I can honestly find in favour of this Bill, and I now turn to the parts of it which I think are deserving of criticism. I will take them, not in their order of importance, but in the order in which they appear in the Bill. The first is this: On account of the abnormal unemployment, the free year to which I have referred, allowed to all insured contributors, was extended by the Prolongation of Insurance Act as regards unemployed persons for as long as they should remain unemployed. That, it is true, was a temporary Measure, but it has been continued under the Expiring Laws (Continuance) Act for six years, and the effect of it is that the unemployed regard themselves as having a statutory right, as they have, by reason of this continuance to draw their full health benefit without paying any contribution during the whole time they are unemployed. Now the Minister and the White Paper for which he is responsible naively put it, "We are taking away nothing at all from these people, but we are giving them a great boon." The White Paper puts it, I think truly, but certainly not in the way I should call very frank. It says:Therefore a genuinely unemployed person is to be given a continuous period averaging, not as before one year and nine months, but now, with the full year, 2¾ years before the insurance can be terminated.It goes on to say that during that additional year he will get only half benefits. I hope the House appreciates this. At the moment an unemployed person, by virtue of an Act which has been continued for six years, as long as he is unemployed is entitled, without paying any contributions, to full cash benefits, and how it can be called a boon to him to say that henceforth he will not have his full cash benefits during all the time he is unemployed but will only have them 1852 for a year, and will only get one year's advantage over a person who is not unemployed, and he will only get half benefit, I cannot comprehend. The Minister did not point that out, and it is right that the House should appreciate it.
There is another thing that was put in the form of a boon. The right hon. Gentleman said there was a very hard case. The poor old people who had been contributing to this system for a long time might get out of employment, and might drop out of insurance altogether, and then they would not have the benefit of the old age pension. Again, I must point out that he has taken from them something which they have to this Đay. To this hour, if an old man of 60 is out of employment he is entitled to draw his health benefits every year until he is 65, when he comes within the pension and insurance scheme. What this does is to say, "As benefit you can draw it up to 65 without contributing if you prove, first, that you have contrībuted for 10 years before you were 60 and, secondly, the amount you draw will not be all benefits, as you draw now, but only the medical benefit." The right hon. Gentleman knows I do not mean it in any offensive way, but it is not right for a Minister introducing a Measure of this kind, especially when it is very complex and is not well understood by Members of the House or the country, to put forward a view of it that, without being untruthful, is entirely misleading. There was a sympathetic ring in the applause while the right hon. Gentleman was speaking. Hon. Members thought that here was a Bill giving something to the unemployed that they had not got before, making special consideration for the unemployed old men of 60, and when we analyse it we find it is taking away a great deal of what they have at present.
I want to come to my third criticism, which is the weightiest of the lot. The Minister here has taken to himself an amount of autocratic power which is contrary to the whole original scheme. Where approved societies and insurance committees have a discretion, which they have exercised without any complaint, they are now deprived of that discretion and everything is to be in the hands of the Minister, who can do exactly what he likes by means of regulations. It is 1853 a small matter to say there is nothing in the point made by an hon. Gentleman on the back benches that those regulations are not, by the terms of the Bill, to be laid on the Table of the House, because this Bill is subject to the original Act and all regulations made under it are to be laid on the Table of the House. I agree with that petty answer. Of course they have to be laid on the Table of the House, but that does not mean very much. Clause 3 says:Save as provided by Regulations under this Sub-section, the Insurance Committee shall not after such date as may be prescribed be entitled to allow any person to make his own arrangements for receiving medical treatment and attendance by way of participating in any collective arrangements.I see that in a few cases advantage has been taken of the Act to allow persons to receive special forms of medical attendance. Now, because of these few cases, that power, which was confided originally in insurance committees, is to be taken away from them and is to be transferred to the Ministry. I think that is uncalled for at the moment. Clause 7 empowers the Minister, where he is of opinion that the rules of an approved society do not properly provide for the administration of the affairs of the society, to make rules if he thinks fit, and if they do not accept his alteration of their rules according to his sweet will he can alter the rule in that form and it becomes by law the rule as he made it and not as they made it.
The last one upon which I have to dwell a little is Clause 14, which is really the most controversial in the whole Bill. It deals with surpluses. Sub-section (3) says:Regulations may be made with respect to the administration of schemes under this Section and of any additional benefit.Let me try to make the position as I see it clear, as it now exists and as this Bill will alter it. Additional benefits are payable out of surpluses. A great number of those who have not studied the scheme infer, from the fact that large surpluses have arisen in some approved societies, that the contributions must have been too high. That evidently was the opinion of the Chancellor of the Exchequer when he laid his politically robbing hands on the fund. It is true he did not steal what was in the Treasury but he diverted the stream flowing into the Treasury. The Government, according to the original 1854 scheme, was to make a certain contribution and that contribution, by the Economy Act, was cut down to the tune of nearly £4,000,000 a year. The structure of the scheme was that persons might enter at all ages and in all states of health. It must, therefore, follow that in some societies surpluses must arise if the less favoured societies were actuarially sound, and their contributions were sufficient. That was contemplated in the original Act and, as time went on, it was known actuarially and scientifically, and known in Parliament, that surpluses were a necessary growth. When they grew a bit what was to be done? What was only adumbrated in the Act of 1911 was crystallised in the Act of 1924 into 19 or 20 types of additional benefit to which these surpluses were to be appropriated. They were, if possible, more useful than the standard benefits, because they were to be of a preventive character, and of course what the Chancellor of the Exchequer did under his Economy Act was deliberately to deprive these people of that preventive treatment which otherwise they would have received by taking, not his, but the money that was to be put into a pool when they were asked to add their money to it.
It was directly contrary to pledges that had been given time after time by Governments. The Act of 1924, when it was setting out these types of additional benefits, made provision as to how they were to be administered. It said where they were cash benefits they were to be administered by the approved societies. Where they were direct medical benefits they were to be administered, as standard medical benefits are, by the local insurance committees. But the surpluses are not at the moment sufficiently strong to enable full additional benefits to be given of the type that the societies might choose, and therefore how they will be administered for the time being will be entirely by the approved societies, who will make cash payments towards dental treatment, ophthalmic treatment and otherwise. That is how it is at present. But as soon as the surpluses grow stronger, and indeed had it not been for the raid they would have been strong enough now perhaps—they would have been approaching very much nearer being strong enough—
§ Mr. HARNEY
I have said so. I may have a cup of water. I may have a tube leading into the cup. Is it correct to say you take nothing out of that cup if you do not put a scoop in and take it out when what you really do is to plug the tube? Had that stream not been diminished by the Chancellor of the Exchequer's action under the Economy Act, it is possible that many of the approved societies would now be able to give full additional benefits, and if they were able to do so, these benefits ought to have been administered by the insurance committee.
I want to pass from that to ask the right hon. Gentleman this question. The Report recommended that the Insurance Commissioners should go. The Government have not accepted that, and I am with them in that. Do they intend now, when they say that the administration of these additional benefits shall be withdrawn from both the approved societies and the Insurance Commissioners, and placed into the hands of the Minister, that when the time becomes ripe for the local insurance committees to administer medical benefit out of these surpluses, the insurance committees are to be kept in the position in which they were originally put, namely, of being the proper persons to deal with that medical benefit? There are some points that might be cleared up in Committee. The hon. Member for Westhoughton (Mr. R. Davies) did not seem to be enamoured of the insurance committees. I do not propose to know as much about them as he does, but, as far as I am able to learn, I think they are very useful bodies. I think it would be a great pity indeed if we did away with them. One of the objections I have to the new proposal is that it will enable the Government to withdraw from these committees so much of what is needed for their activities, that when the additional benefits come to be distributed, they will have been starved into such a state that they will not be worthy of recognition. I do not want that to occur, and I hope that the Minister in his reply will give the 1856 assurance that was given in the White Paper:If, however, any of the forms of treatment at present covered by additional benefits should at any future time be made generally available to all insured persons as statutory benefits their administration would be transferred to the insurance committees on lines similar to those at present governing the administration of medical benefit.I hope that we shall have an assurance to that effect. Having made these criticisms, it is right that I should state what attitude I am going to take with reference to the Amendment. I have said that the Bill has some good points. I have endeavoured to point out some that are not good, but the gravamen of the Amendment is that no suggestion has been made by the Government to bring back their contribution to what it was originally. When the insurance scheme was arranged, a careful calculation was made by experts, and the Government's contribution was decided upon. The Bill was carried in this country because of the Government's contribution—the 9d. for 4d., or whatever it was. This was one of the strongest things that helped it through. The Economy Act has cut down that contribution, and it really is equivalent, in my submission, to depriving persons of the benefits they have bargained to get. When employés paid their contribution into the fund, they did so on the basis of the other parties paying their agreed proportions. A fund has been built up out of that. The continuance of that state of things has now been defeated in order that the Government might make a few paltry pounds to enable the Chancellor of the Exchequer to deal with his difficulties. There is much in the Bill, as I say, that is acceptable; there is much more that can be amended in Committee, and simply for that reason I will vote for the Amendment as a protest against the action of the Government.
§ Lieut.-Colonel FREMANTLE
I do not want to take up the time of the House for very long, but there are certain points which, naturally, concern very closely the medical and dental professions, and I shall be glad if I may have the opportunity of voicing one or two of the feelings on these points. In the first place, and in general, I am bound to say that the professions will take a different line from that of the hon. and 1857 learned Gentleman the Member for South Shields (Mr. Harney). He began by saying that he blessed the Bill in certain parts, and that in other parts he found it was bad. I say that the medical profession generally will bless the Bill in certain parts strongly, and that in other parts they will find it good in less degree. On the whole, there is no definite provision in the Bill to which serious objection can be taken by those who are concerned in the working of this wonderful and beneficial scheme of insurance. I would like to call attention to the fact that the dental profession are naturally very much concerned, but they will be partly reassured by the statement that has been made by the Minister to-day. I hope that, possibly, my right hon. Friend the Parliamentary Secretary to the Ministry of Health, who will be replying later, may be able to give the further assurances that are required.
I may speak perhaps with greater conviction for the dentists inasmuch that it it a friendly profession for which I have no direct responsibility, but I have this from the body representing the dental profession. There are three points which they hoped to see definitely established in the statement to-day. The first one is, that the insured person should have the same freedom of choice of his dentist as he enjoys with regard to his medical adviser. I think we have had a very definite categorical statement that will be satisfactory to the dental profession. The second point is, that the acceptance of any agreement as to fees and conditions of service arrived at after free negotiation by representatives of approved societies, on the one hand, and of the dentists on the other, shall be binding on all approved societies alike. The difficulty is that we meet with collective bargaining everywhere. Unless the results of collective bargaining are made to hold with all parties concerned, especially with those who are less inclined or less able to carry out a bargain, the main object of collective bargaining falls to the ground. One hopes that there will be an assurance given on that point. The third point is that there shall be no lay interference with the professional discretion of the dentist in the treatment of his patient. I think that all those who are concerned with the administration of these Acts know what is implied in that 1858 proposal. Always the criticism by the professional men of the approved societies is, that instead of simply confining themselves to administration the approved societies interfere with the actual professional treatment which only a professional man is really able to control or to criticise.
§ Lieut.-Colonel FREMANTLE
I mean that the difficulty of any lay control of professional persons is, that in these matters they do interfere with the actual professional side. It is for that reason you have your supervising officers. The doctors are naturally very sensitive. I think that is really the only reason that sometimes there is friction between the professional men and the approved societies. It is for that reason that one could not accept the suggestion made by the mover of the Amendment that the insurance committees should be done away with, and their duties given to the approved societies. That raises the old original criticism that was levelled against the Insurance Bill. It is obvious that approved societies could not properly administer these medical matters. The insurance committees were formed in order that we might get a better idea of the benefits to be administered. It is quite true also that the Royal Commission suggested that the duties of the insurance committees should be distributed to the appropriate local authority. Obviously, it must be a matter of some concern to all of us that that proposal of the Royal Commission has not yet been acceded to. That proposal was not, as the hon. Gentleman the Member for Westhoughton said, to refer these duties to the approved societies. It was to break up these duties and distribute them to the appropriate local authorities. I suppose the reason is quite clear.
The whole question of local government is now the subject of discussion by a Royal Commission, and we must wait for the result of that before we can see how the local authorities are going to be so arranged that they can properly have these duties placed upon them. I hope that we may be able to look forward before very long to having the result of that Royal Commission brought before 1859 the public and before this House, and that it will then be put into action, and not simply pigeon-holed. When we get the whole subject of local government cleared up and put on an ordinary and a systematic basis, we hope to have this question of the future of insurance committees decided. I am quite sure that the functions of the insurance committees ought to be blendeĐ with those of the health authorities generally. One of the main criticisms of the insurance system is that whereas it was largely introduced by the right hon. Gentleman the Member for Carnarvon Boroughs (Mr. Lloyd George) as a Measure for the prevention of sickness, it has failed in the prevention of sickness to a very large extent. I do not say entirely, but to a very large extent the amount of sickness amongst insured persons remains very much the same, although I believe the kind of treatment applied has curtailed each case of sickness to a considerable extent. The system certainly gives relief, but for prevention it is of very little advantage.
We may remember that one of the objects put forward in connection with the original Bill was definitely to link up the question of prevention and the question of sickness by making a special provision by which, when any particular area was found to be suffering from a very excessive amount of sickness in any one respect, steps could be taken at once to turn the whole services of the Insurance Act on to that particular area. That has been found to be impracticable. Why? Because the Measure was introduced originally independent of the existing health organisations. This is a danger that we constantly have in this House. We seize upon a new idea, we introduce a new Bill, we introduce a new scheme of organisation, with a new set of committees or even of actual authorities, and a new set of officials all the way through, and we add to our burdens while diminishing certain others. We have to use the actual machinery we have, and to improve it. I think local authorities may be used as the central authority for administering medical benefit under this Act.
There is one special form of benefit which, I am sorry, is not provided for as an additional benefit, and that is attendance in cases of maternity. The 1860 answer of the Parliamentary Secretary will be that maternity benefit is provided by a money payment to the mother, who is responsible for providing the midwife or having maternity services. The objections to it are fairly obvious. In too many cases the money is required so urgently for other purposes that it is not sufficiently used for the midwifery services which are so necessary. I am glad that a Committee is to be set up to inquire into the training and supply of midwives. When this Committee reports, I have not the least doubt it will show that for a long time the number of midwives in the more scattered parts of the country has been diminishing and the immense difficulty of getting women to go into that important service. We have to record at the present time the loss of 3,000 to 4,000 mothers as the result of child-birth, and we must, therefore, take some action which will increase tħe midwifery services of the country. We shall not be able to get a better service in this respect unless we can make the profession attractive to the type of educated girl who will want to fulfil these duties properly. It really comes down to a pecuniary benefit, and I should like to see some provision introduced into this Bill which would enable a fund to be set aside for the general purpose of improving the remuneration of midwives. I hope that the preventive aspect of insurance may be always kept uppermost and that as we work this system during the course of years we may see in what way we can use this sum of £25,000,000 to £30,000,000 a year, not merely for the treatment of sickness and the relief of trouble, but also for the prevention of preventible sickness and disease.
§ Mr. HAYDAY
I desire to support the Amendment. The Minister of Health has said that this Bill is another instalment in the long process of the development of this branch of the social service of the country and that scarcely a month passes but what some kind of amending Bill is introduced. All that this Bill does is to make uniform certain methods that are at present adopted by some of the approved societies. Quite a number of the proposals in this Bill are already in operation in some approved societies. With regard to the proposed extension of insurance, I feel sure the approved societies will unanimously welcome it, be- 1861 cause it certainly clears up the position and everyone who is administering the Act as well as the insured member will know just where he stands. But in connection with the continuance of membership in case of unemployment there are certain words in this Bill which give rise to some concern on my part. They may not have the significance which I attach to them at the moment. The right hon. Gentleman said something about having made inquiries in another quarter, and the question which occurred to me and upon which I want to be satisfied, is whether the Minister will take his definition of "available for but unable to obtain employment" from the Minister of Labour? Will it be assumed that a man is disqualified from unemployment benefit because he is considered to be available for employment, and will the time during which he is not in receipt of unemployment benefit accumulate against him in his approved society and lead to possible deductions in benefit; or will the Minister frame regulations which will give power to the approved society itself to determine whether the man or woman is genuinely unemployed within the meaning of the Bill?
There is one other criticism. I have to offer in connection with the maximum of £50 which may accumulate to the credit of a person while in an institution. If the person dies or leaves the institution after a long period, a sum of more than £50 may have accumulated to his credit, but under this Bill the maximum sum which will go to the estate of the deceased person, or can accumulate for payment to the person himself or his dependants, is £50. Any surplus over £50 will not return to the society's funds but will go to the Central Fund. We have to bear that in mind, and also the statement of the Minister that as far as Post Office contributors are concerned, they propose to form a kind of approved society at headquarters to bring them under the general benefits of the Bill. They are isolated owing to the conditions which compel them to become Post Office contributors and any deficit which it is necessary to meet in order to secure the minimum benefits to these Post Office contributors will be met from the Central Fund. I wonder to what extent these two things are connected. In the Bill it says that any surplus over £50 accumulating to the credit of a person shall go to the 1862 Central Fund, and, on the other hand, it says that from the Central Fund shall go any money that is necessary to secure to the present Post Office contributors a certain maximum of benefit.
I should like to ask whether it is the intention of the Minister to survey the conditions of present Post Office contributors and advise the good lives to go to established approved societies, and leave those, who by reason of physical defects or other circumstances, could not be accepted by an approved society, in a special branch under the Ministry's own supervision? If that is intended, it appears to me to be very valuable indeed. It is unfortunate that those who, by reason of circumstances over which they have no control, cannot be accepted by any approved society and are compelled to depend solely upon their own resources as Post Office contributors should be left in this position under a national scheme, and if any special treatment could be provided for them it would be of much benefit. There is one other suggestion I should like to make, and it reinforces the statements already made by several hon. Members, that is with regard to the pooling of surpluses. The society of which I happened to be president has somewhere in the neighbourhood of 100,000 approved members, drawn from the general labouring classes, who by reason of their casual employment and the arduousness of the work they are called upon to do, as well as their low wages and conditions of employment, place them in a position in which they are not among the very best of lives.
You cannot select the good lives and separate them from the bad when you are dealing with a trade union approved society. You embrace the whole members of a trade union. But with careful management we have a surplus, and we can give these additional benefits. There are societies of men and women engaged in dangerous occupations, and as they all make a uniform contribution it is not a question of sound management as to whether you have a surplus, but a question of the nature of the lives covered by the membership. You can have the most efficient management possible and still have a high sickness rate. You have no control over that at all, and no action which the management can take can have any effect. On the other hand, you 1863 have approved societies with selected lives. They may have good management or mediocre management, but the fact that the lives are chosen means that a surplus can accrue to a larger extent than in other societies which may have an equally good management. With the development of the society insurance system, it is time that we had a pooling of surpluses—I say that the greater bulk of it should be pooled—in order that whatever additional benefits are now possible they should be at the disposal of every insured person.
In that connection the Bill might make provision for family medical benefits. There is no mention of any such proposal in the Bill, but I think we are fast approaching the time when we must take this matter into account. The Minister himself has pointed out that we are continually introducing amending Bills in order to keep pace with the times and to endeavour to get uniformity in the administration of health insurance. This question of family medical benefits has become a very important one for many reasons. At present if the head of a family is ill, the amount which he receives in sickness benefit is not sufficient to give him the kind of nourishment necessary to help his recovery. If, in addition to that drawback, there are family worries and anxieties, then there are bound to be reactions on the man's capacity, and the whole family is affected, either by diminished income, by additional worry or by other circumstances. Something ought to be done to ameliorate that position. This is not a new point. The hon. Member for the Wrekin Division (Mr. Oakley) paid a tribute to the representatives of the Government, or of the Ministry of Health, who attended at Geneva last year. I happened to be one of the advisers on the workmen's side in that connection, and I find that the International Labour Office sent out a questionnaire, as the result of our discussions in 1925 on this very point. The various countries submitted replies from which a Convention was framed last year. The report states:To the question whether the provision of medical benefit for insured persons' dependants should be made obligatory or discretionary on the sickness insurance institutions many of the Governments replied in favour of the first alternative.1864 The British Government replied in these terms:The British Government it is true, considers that no rule should be laid down in the draft Convention, because if practically the whole of the workers of the country are included in the sickness insurance system, they, with their dependants, would comprise so high a percentage of the whole community that a general medical and pharmaceutical service, financed by the State or local public funds, might be preferable to and more economical than a medical service associated with the insurance system.There our own Government's representatives took up the position that, in the interests of the nation, seeing that our national health insurance scheme could not deal adequately with the position, it might be necessary for the Government by law to make special provision out of national funds, or for local health authorities to make provision out of local funds for family medical benefits. Then I find this statement:Of the great number of Governments in favour of family medical benefits, Austria, Belgium, Czechoslovakia, Esthonia, Luxembourg, Norway, Poland, Roumania and Spain considered that family medical benefits should be made a regular statutory benefit under the draft Convention.The conclusion was:In view of the replies, and the position of legislation it would seem that the principle of family medical benefits should be taken into account, and that it might, at least, be provided that national laws ought to authorise insurance institutions in good financial position to furnish such benefits to the assured's dependants.Surely at this stage, when we are endeavouring to achieve a complete and comprehensive system, by the sequence of Measures passing through this House on the subject, it is time that we looked into this matter of family medical benefits. It is one of primary importance. I do not know whether or not, if all the surpluses accruing to the approved societies were pooled, they would provide a sum sufficient to give medical benefit to the dependants of insured persons. There is one point in connection with administration, to which I would call attention. It may be a matter which can be dealt with more properly in Committee. Approved societies send a large number of those who are on sickness benefit to the regional medical officers for examination. That is done in the interests of the benefit fund of the approved society, but the payment of the 1865 expenses incurred comes from the administrative fund of the approved society. In an approved society like my own, which is purely industrial in character, and where our administrative charges have to be kept low in order to meet the allowances that accrue by reason of membership, I find that in two weeks £140 was spent in postage alone. That is the National Union of General and Municipal Workers. That sum was spent from the administrative side which was already very small, and, I think, slightly in deficit, in order to protect the sickness fund and to see that it was only called upon to pay in those cases found by the regional medical officer to be genuinely entitled to benefit. The Minister ought to permit such payments as that to come from the benefit fund itself, because they are made in order to safeguard the benefit fund. If these payments are to flow continually from the administrative account, then the administration is likely to be affected and you will not get that efficient supervision which is desirable.
The purpose of all our social and insurance services is surely to safeguard the health of the nation. Health is the first consideration, but we make provision in other directions such as unemployment insurance, which provides for payments during periods of enforced idleness. Again that is in the interests of health. That is done for the benefit of the person who is suffering from the disease of unemployment, just as we give medical benefit to those who suffer from other diseases or ailments. But on the unemployment side you give an allowance for dependants to the man who is out of work. On the health side there is no such provision at all. There is just that one payment, at the minimum or above the minimum, according to the surplus at the disposal of the society. The person who is ill requires greater attention and more nourishment at that time, and yet, under these twin systems of social insurance, the person who requires more attention because of his disability being the result of sickness gets less attention than the person suffering from unemployment. What a conglomerate state our social services are in under these various Measures. We have school clinics to detect early possibilities of physical or mental deformation, to test the eyesight, the teeth and 1866 the general physical prospects of the child. Then we have the old age pension at 70 years of age and the old age pension at 65 years of age creating numerous anomalies. Then we have provision for widows and orphans, provision for sickness, provision for unemployment—all trying to give a national service in the interests of the nation and its people. But every new piece of legislation in connection with our social services cuts across an existing piece of social legislation. At the moment, the man who gets the old age pension at the age of 65 is cut off sick pay and in case of sickness he gets less than the man of 64. Then you have the case of the widow whose need pension is brought into account, and the case of the woman who reaches the age of 65 before her husband reaches that age. Because it is the man who carries the qualification she cannot benefit until her husband is 65. We have other anomalies in connection with the granting of pensions at the age of 70.
§ Mr. HAYDAY
That is what I am leading to, and what I feel about the matter is that instead of having school clinics—which are inefficient because of lack of financial resources—starting with the child, and going on into all these medical and social services that I have described, let us have an adequate and proper system; let there be one all-inclusive scheme amalgamating all the present social services and putting them under one separate Department. I know it will be said that this means an additional number of civil servants. I answer that it is worth while, if it is going to give an efficient service and save overlapping. I am certain it would save cost. I am certain there is waste because the present system is departmentalised to such an extent. If it were brought under one Department we could see that no hardships were imposed on any person, and, at the same time, that there were no double entries or cases of double benefit accruing owing to the services being kept separate and apart. The country will become tired of piecemeal legislation—of having, this week, a Bill amending the national health insurance, and next week a Bill amending unemployment insurance, and the week 1867 after a Bill amending the contributory pensions scheme. The people of the country cannot disentangle these various Measures and every new amending Bill seems to take some benefit away from them and replace it by one of lesser value. If we have one all-inclusive scheme we would be able to administer these services more effectively, and we will be spared the trouble of having to criticise piecemeal legislation introduced in the form in which this Bill is presented to-day.
§ 7.0 p.m.
§ Major GLYN
I rise to support this Bill for three reasons. In the first place, it is an Insurance Bill, and its first object is to put back on an economic level the general insurance scheme of the country, and it does that in a way that is very fair and reasonable, if persons through no fault of their own find themselves unemployed. Another reason why I support the Bill is that it is going to simplify enormously the administration of National Health Insurance, and the third reason the Bill should be supported is that it takes definite steps to see that those societies, very few in numbers, who do not administer their business properly, shall in future come under the eye of the Minister and proper steps can be taken to see there is no abuse of the benefits of the members. Clauses 7 and 8 should receive the wholehearted support of this House, because no matter to what party one belongs, or what society, we all unite in this, that the administration of insurance benefit must be carried out cleanly, honestly and wholeheartedly. Therefore, as Chairman of the Federation of Rural Friendly Societies, which extends from the North of Scotland to the South of England, and which has had the benefit of consultation with the officials of the Ministry of Health, I can say we believe that with the exception of minor points, which we hope can be disposed of in Committee, this Bill does deserve the support of everybody inside and outside the House.
A good deal has been said by the Mover and Seconder of the Amendment in regard to matters that do not appear on the face of the Amendment at all, and we are brought again to the point of dealing with surplus funds. We were 1868 the pioneers of the friendly society movement, and the great trade unions also carried out a friendly society movement in their early days. There is little difference between the way one and the other is administered, but when the industrial development took place in this country, the difficulties of administration were greater in the industrial centres than in the rural areas. We all know that in the rural areas an enormous amount of self-sacrificing work is done by persons who are interested and keen on the friendly society movement, and we believe it is utterly wrong and absolutely unfair that, no matter how great the industrial society membership, that they should urge the taking away from the rural societies of their hard-earned surplus. There is one matter on which all rural societies are agreed, and I know they have the support of many industrial Members on the opposite benches. Life in the rural districts to-day from the health point of view requires even more attention than life in the great cities. In the great cities you can walk from one hospital to another and get expert treatment, but in the country districts the Rural Society movement should devote themselves by additional benefits to provide not only dental clinics on motor vans, but to adapt themselves to modern conditions and bring to the rural districts some of the benefits the town dweller takes almost for granted. That is one of the reasons that make us believe in the Rural Society having the retention of their own funds and what they have accumulated.
The Minister of Health is seeing fit to carry out some of the recommendations of the Royal Commission and we believe he has acted wisely. We believe further that we shall be able to prove with these additional benefits it was a very wise thing not to have taken away these funds. In the rural districts to-day, housing conditions are in some places worse than in the great towns. In some places you cannot get fresh milk, for it goes to feed the town dweller. All these things contribute to the importance of people of every section, class and type working together through the medium of these friendly societies to improve the conditions of life of the people in the country and make life in the country more attractive, because in any health system 1869 we want to bring the people from the town to the country, and if you cannot provide any health service you may not be able to make that attraction sufficiently strong.
We support this Bill, but there is one point to which I must draw attention, and that is the habit of carrying out legislation by regulation. It is extremely unpopular among Members on both sides of the House, and I think it is unpopular in the country. It certainly is rather confusing for persons charged with the administration of these important Acts, but I do recognise one fact, that you have changing conditions and, therefore, you must leave some discretion to the Minister without coming to this House. The scheme must be sufficiently elastic and sufficiently adaptable to meet unusual conditions as and when they arise. When the Bill was introduced in 1910 by the right hon. Gentleman the Member for Carnarvon Boroughs (Mr. Lloyd George), the vote given was one of the few votes worth giving in the Coalition days. Under that Bill there were all sorts of regulations. I believe that 48 matters were left to be dealt with by regulation, whereas in this Bill it is cut down almost by one half. That is a step in the right direction, and as these Regulations are to be laid on the Table of the House, I believe the Minister will have the thanks of everybody concerned if he will give us an assurance that these Regulations before being laid on the Table will be gone into with the Consultative Committee, because I really think the work of the Consultative Committee in connection with the Ministry has been exceedingly useful and helpful.
Speaking on behalf of the Federation of Rural Friendly Societies, we have always received the utmost help, assistance and courtesy from all those officials of the Ministry in charge of these duties. I hope we may feel that the co-operation we have had with them has been of some assistance to the Ministry itself. Finally, I believe we are on the edge now of great developments in the friendly society movement, provided they allow individuality still to hold sway. I do not like to try to cast everybody in a common mould. I prefer to help the individual in his efforts, and let each part of the country adapt itself to local con- 1870 ditions that the people of the district know best. I am quite convinced that if you can encourage more people to take an interest in the friendly society movement, it will go forward still further and foster the work done by them. Then, indeed, we shall have greater health in the rural districts of this country and greater happiness in the homes of the people. We will be able to feel that one vote cast in this House will have some practical result to the rising generation.
§ Mr. MELLER
I wish to join in what, I think, is the almost unanimous chorus of approval of this Bill. The Minister, I believe, can pride himself on being in a happy position to-night, because he has gone through many difficult tasks, and has had the introduction of Measures connected with the health insurance that have called forth a great deal of dissension. But to-night he is in the happy position of knowing that, as far as this Bill is concerned, there is practically no criticism. The only criticism made has been in respect of Measures already upon the Statute Book. One of the points the Minister made quite early in his speech this afternoon was that this was a Bill which was a simplification of machinery. Those who have had some experience of the approved societies know that if there is one thing they long for more than another it is simplification, and in connection with the arrears system we have had greater difficulties tħan any other part of the work of the National Health Insurance.
Not only in the matter of simplification will Clause 1 make the work easier. The process of arrears will be more easily understood by the people. It is a fact that the provisions of Clause 1 give to those people who find themselves in the unfortunate position of not having a sufficient number of contributions due to unemployment tħe knowledge that over a long period they may carry on with the hope that if illness comes benefit will be continued. The hon. Member for South Shields (Mr. Harney) gave a wrong impression to the House, at least to those minds disposed to receive wrong impressions. Under the existing scheme, what is known as prolongation of insurance enables a man to continue in insurance only, but no 1871 right to receive sickness benefit. Under Clause 1 the insured person wīll, first of all, have his free year, then a period of nine months, and then, if as a result of unemployment the contributions are not paid, sickness and disablement benefit will still be available at lower rates.
There is another concession which I believe to be of inestimable benefit. That is the provision made in respect of those persons who arrive at the age of 60 and find unemployment before them and no further opportunity of employment. Under the existing system they have nothing but a dark outlook. Under the new Act people at the age of 60 will know that an old age pension has become a permanent right, and that there need be no hesitation and no fear in their minds as to the future. The hon. and gallant Member for Abingdon (Major Glyn) referred to the question of Regulations. If there be any justification for Regulations, it does apply in the case of health insurance. It would be impossible, to my mind, to carry on health insurance, having regard to all the changes that take place in connection with the administration, without Regulations. There have, unfortunately, been disastrous periods of unemployment and other occasions that make a large demand on the contributions. Imagine what would be the position of those people if they had to wait month after month until the opportunity presented itself of bringing a Bill before the House, passing it through a Committee and generally meeting the criticism and opposition which naturally arise in an assembly of this kind. There is a protection in these Regulations. The Minister submits them to the Consultative Committee. I had the opportunity of serving for six years upon the Consultative Committee and I know what work they do, and what sort of people form that body. It was not my experience during my term of office that the members of the Consultative Committee were supine people who were prepared to submit readily to any of the Orders and Regulations brought before them.
There is a second protection in the Regulations, namely, that the Order has 1872 to be laid on the Table of this House. There may be some people who do not know the procedure of laying an Order upon the Table of the House, who may say: "What protection is there in that? People do not know of the Order and do not know of its existence. They do not go through the Order Papers and follow all the things that, they imagine, are being done by Government Departments in a surreptitious manner." Orders laid on the Table of the House by a Minister have been challenged. There have been Debates in this House upon Orders laid on the Table, and in one ease which I can recall, which occurred two years ago, an Order was withdrawn as the result of a discussion which took place here.
Reference has been made to the effect of the Amendment of Section 26 of the original Act. One hon. Member said that there had been an abuse of Section 26. Hon. Members may not have it clearly in mind that Section 26 enables the approved societies to make grants to charitable institutions to meet special cases of emergency, that is, cases where their members may require some special treatment from the hospital, and which they could not obtain except some contribution was made to the funds of the hospital. That was a right and proper provision; but what has been the actual administration of this Section by some of the societies? Some societies have used it as a means of anticipating the additional benefits which ought only to be declared at the end of the quinquennium, as the result of the valuation. The Minister does not seek to take away from the approved societies the opportunity of making contributions, but he says, quite rightly, that if they realise that it is desirable to provide contributions to charitable institutions for the benefit of their members, then they ought to declare it in their list of additional benefits. Those societies which are not in the fortunate position of having a surplus can make application to the Minister, and permission will be given in satisfactory cases. Under the new arrangement any further abuse of Section 26 of the Consolidating Act will be avoided, and the Act will be carried out in the spirit in which it was intended, and in the way in which the insured people of this country desire that it should be carried out.
1873 With respect to the question of setting up clinics, hon. Members have received batches of protests morning after morning. I have wondered how in the world so much interest has been stirred up on the part of insured people that they should sign all these batches of forms, and send them along to Members of Parliament. I wonder whether they realise what the Insurance Acts contain, and what are their rights and privileges. My view is that the insured person is loth to complain, if all goes on well. If a dividend is being paid regularly, shareholders seldom turn up at the annual meeting of a company, but it is when the dividend is lacking or something else goes wrong that they begin to take some interest in the proceedings. It seems to me that the protests which we have received have been gathered in by men, very diligent men, who have gone round the country pouring into the ears of the insured people wonderful tales of what will be the effect upon dental benefit if we allow the Clause regarding the clinics to go in. I am strongly in favour of free choice for the insured person. One-half the benefit to be derived from treatment by a doctor, a dentist or an optician depends upon the patient having full faith in the man who administers the particular service. It would be an unfortunate thing if clinics under the present system of additional benefit were to be set up so as to exclude from the insured person the right of free choice.
Take the question of dental clinics, as an example of the setting up of clinics. It would be a futile thing on the part of the Government or of anybody else to start a dental clinic in a district which did not provide for a reasonable number of persons to attend. Such clinics can only be successful in large industrial areas or closely congested districts. You would be bound to have a free choice of service in the rural districts and in scattered areas. I cannot imagine that any Minister would be so bold as to say that persons who live in towns shall not be given free choice but that if you go to live outside a town, you will have free choice, because you cannot help yourselves. I hope that the Minister will be prepared to accept an Amendment, making it quite clear that free choice, whether it be of a dentist, or of an optician, is the inherent right of every insured person. Until we arrive at the 1874 stage when dental treatment is given as a statutory benefit, there should be no interference with the inherent right of the insured person to have a free choice of dentist.
There is another question which seems to affect some societies which may be called international societies. It may be within the recollection of the House that in the north of Ireland medical benefit is not given. All that you obtain under the system which obtains in the north of Ireland and in the Free State is a medical certificate of incapacity. Medical certifiers are appointed. The insured person comes along and complains of a particular malady and a certificate is given; but there is no attempt at treatment, and the result is a very unsatisfactory state of affairs in regard to sickness treatment in the north and south of Ireland. Clause 6 provides that where a society is an international one it may bring into the general valuation that part of the society which lies outside the district where the parent society is situated. In regard to Northern Ireland it is suggested by some societies that they ought to have the right to exclude members in Northern Ireland from participation in the general valuation, until Northern Ireland brings in a system of medical benefit. The view they put forward is that the Clause is unfair to the English and Scottish societies which have members in Northern Ireland. I hope the Minister of Health will consider that. The proposal in Clause 6 is that where an application is made, first of all, with the consent of the Committee of Management, the Minister may consider it, having satisfied himself that it is in accordance with the wishes of the members in the country who desire to be treated in a particular way. I hope he will take the converse position and realise that after a given notice those societies lying outside who are under an insurance scheme which is not up to the same standard that we have in this country ought not to have the advantage of being valued with the main body but must stand upon their own particular experience. The speech of the hon. Member for Westhoughton (Mr. Rhys Davies) reminded me of the words of Goldsmith that thosewho came to curse, remain'd to pray.I could not help feeling that when the hon. Member had delivered his feelings 1875 upon the question of this Bill, and had given forth his view that the Minister had not provided the money which the hon. Member says was taken away by the Economy Act, he was doing all this with his tongue in his cheek. The hon. Member said that the Minister had only brought within the compass of this Bill some 32 recommendations of the Royal Commission, out of 127. I do not think the hon. Member can have read the Report recently. The portion of the Report to which he refers is headed: "Recommendations and Conclusions." I have hurriedly glanced through them and have refreshed my memory in regard to the Report, and I find that the hon. Member could more correctly have described the recommendations as 127 clauses.
I find that the first 40 are not recommendations which require legislative sanction at all. They are, first of all, statements of fact. They speak of the Insurance Act and of its beneficent work and what has been done by the various bodies. Other things that are mentioned in the other clauses can be put into operation merely by the Department or by suggestions to the approved societies. There are not 127 recommendations. The main complaint which the hon. Member could make in regard to the Bill was that the Minister had only selected a few recommendations. When we come to consider some of the other recommendations, the House is bound to be influenced by the strength of the support which was given to them. If hon. Members will look at the Report of the Royal Commission they will find that many of the things to which the hon. Member referred were recommendations of the minority and not of the majority. After all, in these days we have to be ruled largely by majorities, although we may appreciate some of the things which the minority have put forward.
The hon. Member referred to the fact that there was no reference in the Bill to the abolition of insurance committees. Does he not know that the overwhelming opinion expressed by the people concerned was against the abolition of insurance committees? It has been said that the insurance committees have lost much of their virtue, and that they had become mere recording machines; buŧ it 1876 is a fact that in those districts where the insurance committees have lived up to their responsibilities and carried out their duties as required by the Statute, they have become very helpful and very desirable bodies. In the district of Manchester and in a district well known to the Minister of Health, Birmingham, and in other districts throughout the country, you will find insurance committees doing real and valuable work. It is in those districts where the men and women have failed to realise their duties and responsibilities that we might very well dispense with the cost of the upkeep of the insurance committees. There is one further point with which I should like to deal, and that is the amount available for investment. The hon. Member for Westhoughton said that looking back prior to the introduction of the Economy Bill there was £8,000,000 a year available for investment, and that now there is only something in the neighbourhood of £1,000,000.
§ Mr. MELLER
I thought he said £1,000,000; perhaps it was £200,000. He says that the £8,000,000 has dwindled to £200,000. Let us take his assumption as being right, that the result of the Economy Act has been to rob the insurance scheme of £2,750,000 a year. How does he account for the difference between £2,750,000 and £8,000,000, minus £200,000? He has failed to recognise that the additional benefits to-day, which amount to something like £8,000,000 a year, are being paid out of income instead of the accumulated funds. If the investments had been sold instead of paying out of income there would have been more money for investment. As it is the investments have not been disturbed, a very important thing. The position of the insurance scheme is one of absolute solvency and stability. I am confident that in spite of the difficulties which we have experienced during the past two or three years, in spite of the high rates of sickness, in spite of all the things which are alleged against this Government in regard to the Economy Act, it will be found at the next valuation in 1930 and 1931 that the National Health Insurance is one of the soundest schemes known in the history of this country.
§ Mr. PILCHER
In so far as this Bill relates to a vast technical subject I do not propose to say anything upon it; but I do want to make a reference to one Clause—Clause 17—which makes a definite effort to enlarge the boundaries of National Health Insurance as we have known it hitherto. Hitherto National Health Insurance has been confined exclusively to the relationship of employer and employed. It has always seemed to me that sooner or later we should find it necessary to go outside that boundary, and in this Bill the first step is made in that direction. The first class of persons who are not definitely employed and who are brought in by the Bill is a class engaged on contracts of manual labour for some purposes of business or traĐe. The list enumerated by the Minister included a good many persons with whom many of us, particularly those representing agricultural constituencies, have a great deal of sympathy—hedgers, ditchers and a good many others. Personally I would have liked very much to have seen the boundaries thrown out a little wider still, so as to include, for instance, the seamstress, the mason working on his own account, the small shopkeeper, and people of that class. When the seamstress sips a cup of tea or the mason drinks his glass of beer, each of them through taxation pays some part of the contribution to National Health Insurance the benefits of which only those people classed as technically "employed" can now enjoy. It is my hope that sooner or later we shall be able to extend some of these advantages to people who need the support and assistance of this principle quite as much as do employed persons.
But in regard to the second class, not strictly employed people, who are brought into the system, I want to direct attention to the matter in some detail. Some weeks ago I sent to the right hon. Gentleman a letter on the subject, and I want to say something now about the part share fishermen, and some of the difficulties and technicalities of the subject. The method by which these men are brought into this insurance system is by imputing the quality of an employer to some one of the part owners of a small fishing vessel. I am afraid that that is rather a crude method to apply to a branch of work the economics of which are as subtle and delicate probably as 1878 any system of trade economics in the country. An imputing of the character of an employer to some one member of the crew of a part-owned vessel necessarily involves, I am afraid, the exclusion of some one member of every crew from the benefits of health insurance; someone will be treated as employer, and he must, therefore, come outside the benefits, and, in addition, he must have conferred upon him many of the disadvantages and responsibilities which this system entails for the real employer.
In the part of the country which I represent we get a great variety of systems of ownership among these share fishermen. There is one class of boat which is in effect owned by one fisherman, and then he may have a crew of three or four who share in the ultimate share-out when the quantity of the catch is decided. That is a fairly simple relationship. Some criticisms apart it will come into the scheme fairly easily. But you may have a part-owned vessel in which, for instance, one man may own the ship itself and different members of the crew may subscribe their share of tackle or gear. They are, in effect, part owners of the whole machinery, but the man who owns the little boat will be treated as the employer, and he will have all the responsibility and none of the benefits, while the tackle owner will come in as an employed person. There is another variety, a rather rarer variety, in which every man owns his own boat but does not take it out every day or every week. He wants a crew of one besides himself, and one day a week he goes out with the owner of another boat as crew, and the following week acts as crew to the owner of that other boat, and so they alternate week by week. That statement gives some idea of the difficulties of applying this system to fishermen along the particular piece of coast of which I am speaking.
May I make a suggestion? Would it not be better, before we apply this new system to these fishermen, for a number of the technical staff at the Ministry of Agriculture and Fisheries to go down to the ports and ascertain under what system of employment these men live? Probably the information all exists—in fact I am sure it does exist—at the Ministry, for there seems to be nothing that the experts across the road do not 1879 know about our little fishing towns and those who live and work in them. But I would like to impress on the Minister, before it is too late, the danger of rather plunging into this delicate economic system without first considering all the reactions it is likely to have in these fishing ports. I would remind my right hon. Friend that already the fishing industry, particularly in these remoter parts of the country, is the prey of most extraordinarily harassing conditions. There is the keen competition from foreign fish, about which we have heard so much yesterday. Something like 16 or 17 per cent. of the whole fish consumption of the country is now foreign fish. You have the growing competition of the great towns, such as Plymouth and Exeter, as compared with the social conditions which these little fishing ports can offer. I could name two or three ports which have become almost destitute of young men who are willing to follow their fathers' trade. The boys are being drained away from the villages. They are an immense loss to the country from the point of view of physique and ultimately of national defence.
We do not want to introduce a fresh subject of difficulty or discontent in these little ports. If we can do so, we want to make quite certain that the population remains there, that these splendid boys follow in the footsteps of their splendid fathers. But if this acute grievance is created, so far from keeping our lads in the fishing ports we may provide an additional attraction—there are already the cinemas and higher wages—to those which are to be found in the towns. We do not want to increase these incentives to migration. Rather do we want to give these people the benefit of pensions for themselves and their wives in their old age, and, before that time comes, the protection which this Bill will offer them in the near future. I commend to the Minister's attention the extreme delicacy of this economic system, and I would suggest to him the necessity of very careful inquiry.
§ Mr. MORGAN JONES
I rise in order to call attention to two quite limited points. Both of them relate to constituents of mine who have special difficulties, which I have been requested 1880 to place before the Minister before we give this Bill a Second Reading. The first is, from my point of view, already adequately answered, but I would like to ask from the Minister a special assurance so as to remove my constituents' apprehensions on the point that they have raised with me. The point is in regard to Clause 4. That Clause deals with the question of subscriptions to charitable institutions. It has already received a considerable measure of commendation, not only from the Ministerial side of the House, but also from my hon. Friend the Member for Westhoughton (Mr. Rhys Davies). The apprehensions of my constituents about this Clause are probably unjustified, but I would like to put the point to the Minister in the way in which they have put it to me. I will read a portion of their letter to me, which raises the matter specifically. They say:As you are undoubtedly aware, the risk of sickness amongst miners is greatly in excess of that of other industries, particularly in South Wales. Consequently the abolition of Section 26 of the 1924 Act as it now stands will take away from South Wales miners' approved societies the only means they have of granting special benefits to their members.It may very well be that the Minister can allay their apprehensions on that point. Anyhow, I submit the point to him, and I hope that we may be able to get an assurance before the Debate ends. The other point is one which I do not anticipate that any Member representing any part of the country other than South Wales will raise to-night. I speak of bodies which are not exactly approved societies but which in the realm of insurance are referred to as institutions. They are peculiar to the South Wales coalfield. I made some inquiries, and I could not discover that there are any exact parallels to them in any other part of the country. They are old and well-established institutions in South Wales. At the top end of my constituency one such institution exists which is over 80 years old. It may be assumed, therefore, that these institutions have their roots very deep in the history of the locality where they operate. There are about 14 of them in South Wales approved under Section 24, Sub-sections 3 and 4, of the 1924 Act. These institutions are known in South Wales as miners' medical aid societies. There is a considerable 1881 measure of apprehension among them as to what precisely the right hon. Gentleman seeks to do through the medium of Clause 3 of the Bill. They ask me to request some enlightenment as to the repercussion of this Clause upon these medical aid societies.
These societies have existed a very long time. I believe they had some difficulty in securing that their position should be properly and fully recognised when the 1911 Act was passed. They had an interview with my right hon. Friend the Member for Carnarvon Boroughs (Mr. Lloyd George), who was then Chancellor of the Exchequer, and they secured his approval for their formal recognition. Since then—it is now, of course, 17 years ago—these societies have operated over fairly large areas and have served on the whole a fairly substantial section of the industrial population of South Wales. I believe I am right in saying that they actually have something round about 40,000 members, and if you put the dependants in as well, I think it would be well beyond 100,000 people all told for whom medical services of various kinds are being provided through the medium of these organisations. But they have had a very difficult and somewhat stormy career on account of causes over which they have had perhaps little control, though these causes would not, I suppose, have been entirely unanticipated on their part.
Opposition to them has come from two sources, and I am glad that my hon. Friend the Member for Royton (Dr. Davies) is in his place, because he will be able to speak for one section of the opposition, at any rate. They have had opposition from the British Medical Association and also, as they claim, from the insurance committees. Perhaps I ought to explain how these medical aid societies are operating. They operate very largely along co-operative lines. They make arrangements with the various colliery companies that the various workmen who are prepared to join the societies will allow the colliery company to deduct for them, at the colliery pay office, a poundage, say, of 3d. or 4d. in the £,which sum of money would be transferred into the coffers of these medical aid societies. In addition to that fund, they will also have at their disposal the capitation grant which is allowed for 1882 private panel practitioners. Having secured their fund, they then proceed to provide the benefits under their scheme—and here comes the bone of contention with my hon. Friend's organisation—and in order to provide benefits they themselves proceed to engage doctors at a certain salary.
The objection, therefore, comes, I believe, generally from the British Medical Association—and indeed there have been pretty severe and sustained fights on the issue—that this is a larger measure of lay control even than is found under the insurance committees, to which the hon. and gallant Member for St. Albans (Lieut.-Colonel Fremantle) has already referred. It is, therefore, this question of lay control to which objection is taken, plus this allegation, which is important from the standpoint of the argument that I wish to put to the right hon. Gentleman, that this lay control is not only unacceptable as a principle, but that, as a matter of fact, it leads, so it is alleged, to inefficiency as well. These medical aid societies have been operating, I repeat, for some 17 years, and if anyone is sufficiently inquisitive or sufficiently interested in the matter to consult the evidence given by their representatives before the Insurance Commission, he will find that in presenting their case for these societies they challenged the most minute inquiry, not only as to the way in which the medical aid societies were actually controlled, but also into the various benefits secured by the medium of these societies. They feel that the Clause to which I have directed the right hon. Gentleman's attention gives him the power—and I ask him specifically whether he intends to use the power—to terminate the existence of these medical aid societies. The hon. Member for Royton shakes his head, but let me see. The words are:Save as provided by Regulations under this Sub-section, the insurance committee shall not after such date as may be prescribed be entitled to allow any person … to make his own arrangements for receiving medical treatment and attendance by way of participating in any collective arrangements made by or through any system or institution.It seems to me that those words are certainly capable of the interpretation that I have suggested. Whether the right hon. Gentleman intends them to have 1883 that interpretation is another matter, and it is on that matter that I should like to have an assurance from him.
§ Mr. JONES
Supposing we take the date of 1st July. Then it would mean that the insurance committee shall not after 1st July be entitled to allow any person to make his own arrangements; that is to say, these people who are already in the medical aid societies will still require to make their arrangements after 1st July.
§ Mr. JONES
Well, I should like to have that from the Minister himself. Does it mean that this Clause has a retrospective effect? I admit that the interpretation suggested by the hon. Member for Royton is one possible interpretation, but I submit that mine is equally possible, and the issue that I want to raise is as to which is the correct one from the standpoint of the Ministry of Health. We entertain these apprehensions because the next Sub-section reads:Provided that where before the sixth day of March, 1928, any person has been allowed to make his own arrangements … the system or institution by or through which such arrangements were made"—That is the retrospective part—may, within such period as may be prescribed, apply to the insurance committee and the Minister for approval under this Sub-section.Therefore, it appears to me that I am entitled to make the deduction that, supposing the Clause has the retrospective inference for these medical aid societies, they have an appeal to the insurance committee and to the Minister. These people have a strong feeling—and I will indicate why in a moment—that to have to appeal to the insurance committee is in fact, as things are now, and as they have been for the last few years, very largely a situation where they are appealing to people who are definitely opposed to them. I do not want to develop an attack upon the attitude of doctors generally in this matter, but I am entitled, in defence of my constituents, 1884 to submit a case in support of that contention. They draw a contrast between the treatment meted out to these medical aid societies and the treatment meted out to private panel practitioners, and the contrast is one which induces them to believe that the scales are heavily weighted against these medical aid societies, largely because they are subject to the ban of the British Medical Association.
There are some three or four grounds upon which they draw this contrast. First, if you take the ground for refusing a medical practitioner the right to enter upon panel practice in any area, the only ground upon which you can refuse it is that he has been, at some previous time, removed from the medical list, but when it comes to a medical aid society, which for this purpose is acting very largely as a medical practitioner—at least, so they contend—the moment they appeal to an insurance committee, they find their application for the right to conduct a panel practice, through the medium of their engaged practitioners, vigorously opposed by these very insurance committees to whom this Clause bids them appeal in future.
There is another contrast that they make. When the Regulations as to medical benefit were designed, they were designed solely in the interests of the insured person, with a view to securing to such insured person adequate medical treatment. Now there is no stipulation requiring from the medical practitioner who is on the panel any statement of how he spends the capitation grant, but when it comes to a medical aid society, the insurance committees insist on the most meticulous details as to how the capitation grant is spent, and not only that, but they insist that there should be an audit, not only of the State accounts, for which there should properly be an audit, but also of the voluntary accounts, over which the insurance committees have no control whatsoever. There is no objection at all on the part of these medical aid societies to an audit of their accounts, but they object to any outside authority demanding the right to inquire into the allocation of funds over which they have no sort of legal control whatsoever, and it is to the violent contrast in the treatment of the 1885 two respective forces, as you may call them, that they object so very much. These medical aid societies have had their funds audited by a chartered accountant for years and years. Never yet has there been any sort of charge against these 14 societies in regard to any failure to conduct their business in a proper manner. I am speaking of the 14 societies in South Wales.
There is a third point; it is a small one, perhaps, but it indicates unfair and unjust treatment as between one and the other. The rules for the medical practitioners are printed and distributed at the expense of the insurance committees, but they are not printed at the expense of the insurance committees for the societies. They have to issue a printed set of rules at their own expense, and the result has been that they have doubled, in some cases, their expenditure on printing. The fourth is a more substantial point, because it brings me up against the second part of Clause 3. On the insurance committees there are at least four representatives of the panel practitioners; there is not a single representative of medical aid societies. In one case in Monmouthshire they used to have one, but I believe through considerations of economy they had to reduce the numbers on the insurance committee, and the medical aid societies' representative was the very one to be turned off that committee. What, after all, is the insurance committee? It appoints the medical services sub-committee, and that sub-committee is the very body to which complaints must be sent by any person who has a complaint to make, either against the medical practitioner or the medical aid society. Anyone can see, therefore, that, when complaints come to this sub-committee, on which doctors are represented, the medical aid societies feel that charges are heard against them with no one on the committee to put up a case for their side. They object, and I think rightly, to the suggestion that their destiny should be placed in the hands of people who, naturally perhaps, but certainly in fact, do entertain very strong antipathy to every semblance of lay control.
Having said that, I want to add one last point in this indictment against the unjust contrast between medical practitioners and the medical aid societies. At 1886 the end of every year there are certain unpaid grants, and the curious thing is that, when the distribution takes place, it is made only among the private panel practitioners, and the medical aid societies do not participate in any way. It may be argued, and I think rightly, that the law does not allow medical aid societies to participate in that way, but that does not do away with the sense of injustice which they entertain, because, from their point of view, they provide medical services by, it is true, engaging medical service, but they provide it indirectly, while the medical practitioner does it directly. The medical aid societies have been labouring, and will continue to labour, under a sense of disability, which in their judgment is unfair, and they ask that they shall be put upon a par—or I will put it the other way, that their future existence shall not be prejudiced by the terms of the Clause of this Bill which, I have submitted, is capable of a reading both in the sense that my hon. Friend above the Gangway has read it, and in the way in whicħ I have read it. I have tried to plead the cause of these people, and I want to say one last word on their behalf.
I have before me a long list of the very remarkable services which these medical aid societies provide for their members, and no one can challenge or controvert my statement that these societies now provide, and have for years provided, for their members, benefits far beyond those which the private panel practitioner provides. It is not necessary for me to inquire how they are able to do it. Anyone interested in the matter may find it in the evidence submitted to the Insurance Commission. All I need say is, that I hope that I am wrong in my interpretation of this thing; I hope that my constituents are wrong in their interpretation of it; but if I am right, I assure the right hon. Gentleman that the possibility of withdrawing from these medical aid societies, at this late hour, the formal recognition of the Ministry of Health, would be a very severe blow. They cater for 100,000 souls; they perform a very necessary service to the working miners in my area, and I beg the right hon. Gentleman to give me a firm assurance that it is not his desire, when this Clause becomes law, to interfere in any way with the efficient work that these societies perform from day to day.
§ Sir HERBERT NIELD
I will not, after the long and important speeches that have been made to-night by Members who have practical acquaintance of the work of the insurance committees, attempt to test the patience of the House by further referring to it, except to say that, assured as I was a few days ago by an answer to a question put by me, and by an answer given to an hon. Member for Lancashire, I am satisfied as to the questions that have been disturbing the minds of insured persons with regard to dental treatment. Then again, in regard to Regulations, I join with other hon. Members who spoke on that subject, and I trust that the Ministry will do their utmost to confine these Regulations to those cases where they are absolutely necessary. My object in rising is to take the opportunity of asking the Minister, between now and the Committee stage, sympathetically to consider the position of the officers of insurance committees who are shut out from superannuation, and are unable to get any relief, when so many of their fellows engaged in local government service have been amply provided for. The Bill which was passed in this House in 1922 was confined to local government servants, and the words "local authority" were defined as meaning certain bodies like county councils and municipal and borough councils, and other authorities within the meaning of the Local Loans Act, 1875. That shuts out any authority that does not directly or indirectly levy a rate. Therefore, the officers of insurance committees, who are performing excellent duty, are permanently shut out unless the Minister will take this opportunity of allowing in Committee a Clause to be added which will give them the benefit of superannuation. That is the point to which I sincerely hope the Minister will give his attention, and when the Amendment is put up I trust that he will sympathetically consider it with a view to adding it to the Statute.
§ Dr. DRUMMOND SHIELS
We are, I think, all agreed on this side of the House that this Bill, as far as it goes, is desirable, but that it does not go to anything like the extent we think is called for in any amendment of the National Health Insurance Act. The provision in regard to unemployed contributors is wise as well as humane, and the enlargement of the scope of the Act by the addition 1888 of two new classes of persons is on right lines, as helping to make the Act more comprehensive and more a really national scheme. Most of the other items deal with the simplification and modification of machinery. Altogether, we feel that, as a response to the recommendations of the Royal Commission, the Bill is seriously inadequate. We are quite aware that the right hon. Gentleman and his Department are not primarily to blame for this. We find here, as we find in connection with so many other matters, the hand of the Treasury, which prevents from being done so much that this House feels ought to be done. We agree that economy in these days is necessary, and that the Treasury must exercise restraint in many directions, but the health of the people is one direction in which any so called economy is misplaced and where true national economy is to provide adequately for health and prevention of disease. The first suggestion of the Royal Commission was in regard to specialist benefit. The Commission said:While it has been inevitable hitherto that medical benefit should be confined to a general practitioner service, this limitation has detracted from the value of the benefit, and its removal is urgently desirable.Then, in the order of desirable extended benefits recommended, the specialist service is given first place; next comes allowances to dependants, and then provision of additional maternity benefit. This question of specialist benefit is of very great importance. I was rather surprised to hear the Parliamentary Secretary interject, while the hon. Member for Westhoughton (Mr. Rhys Davies) was speaking, to the effect that the provision of specialist benefit had not been affected by the Economy Act. I look forward to his reply to the Debate to hear how that is the case. As the hon. Member for Westhoughton pointed out, if the lowering of the State grant has not prevented the provision of specialist benefit, why is it that we have not got it, and that there is no early prospect of it? What is the present position in regard to specialist benefit for an insured person requiring a consultation or operative treatment? It is exactly the same as that of an uninsured person. Unless it is an urgent case, which would be admitted to the voluntary hospital immediately, he comes on the hospital's waiting list, and has to take his turn, 1889 with the consequence, as happens in so many cases, that treatment is delayed beyond the time when it would be of the greatest advantage. The recent Commission on Hospitals in Scotland stated that there was a waiting-list of no fewer than 5,000 in the case of the four big Scottish hospitals, and that at least 3,000 more beds would be necessary to provide adequate hospital accommodation in Scotland.
Surely a condition of affairs which leaves the insured person dependent on that source for specialist benefit is obviously unsatisfactory. Ordinary ailments can be dealt with by the general or panel practitioner. The more serious cases may require operative treatment, the very latest laboratory appliances, X-ray or light treatment, and other aids from which, at present the insured person is shut out. There are many class distinctions in this world; many of them are unimportant, and some are contemptible; but there ought to be no class distinction in the provision of medical and surgical skill. The finest medical and surgical aid ought to be assured to the very poorest of our population, and Yet here we have a scheme which purports to be a national scheme for the provision of medical service for the insured persons who contribute to it, and surely the Royal Commission were right in pointing out that so long as specialist treatment is withheld the system is unsatisfactory and does not meet the needs and the rights of its members.
This question is obviously linked up with the hospital question, which this Bill does not tackle at all. As I have said, the voluntary hospitals are in a difficult position, having long waiting lists and being short of funds. They have repeatedly made requests for allocations from the Insurance Fund proportionate to the number of patients they treat, but all we have here is a permissive Clause which will enable societies to make contributions to hospitals. Before the Economy Bill was presented to this House certain approved societies did make contributions to hospitals, but since that Act has come in it has been difficult or impossible for them to do so. Now they are to be permited to give donations to count as medical benefit; but that will not meet 1890 the case. Either an allocation of money per head, or some other financial arrangement between the Insurance Fund and the voluntary hospitals, will be necessary. It is desirable for two reasons; in the first place in order that the insured persons should not, as now, get specialist treatment as a charity; and, secondly, in order that the voluntary hospitals, or even, as we expect may be the case soon, municipal hospitals, shall be assisted in the difficult task of finding the necessary funds for their work.
Maternity benefit has been spoken of, and I was very glad to hear the hon. and gallant Member for St. Albans (Lieut.-Colonel Fremantle) emphasise so strongly the need for nursing and medical service as well as financial assistance. Her Majesty the Queen ħas lately called attention to this subject, and it is a matter of some concern that for a hundred years we have made no improvement in the figures of maternal mortality. In England and Scotland we have from four to seven deaths per 1,000 births, and in many of the industrial and poorer districts the mortality rate is up to 11 and 12 per 1,000 births. That is a very unsatisfactory state of affairs, and, as the hon. and gallant Member for St. Albans pointed out, the provision of efficient nurses and midwives is one of the best ways of meeting the situation. I commend his suggestion that through the national health insurance organisation means should be found for training and supplying more midwives than are at present available. There are few subjects on which Members of this House would more willingly co-operate than in making it more safe for the mothers of our country to discharge the great task whicħ they undertake for the nation.
Similar considerations apply to the question of dependants' benefit. The wives and children of insured persons ought to be within the scope of the scheme, otherwise it is not a comprehensive and truly national one. The present scheme is not adequate in the matter of sickness benefit. When a man or a woman is sick, more money, not less, is needed. It is a remarkable state of affairs that as soon as an insured person falls ill and requires additional comforts, involving additional expense, his 1891 income goes down. We all understand why that is so, but it is a curious arrangement of society which allows it to happen. If we look at the remarkable extension of national health insurance since Germany made the first start in 1886, we shall see that it has spread to nearly all other countries, even to the new European countries which have arisen since the War. They have a different method of benefit from ours; they have a sliding scale, according to the amount of earnings of the insured person while in employment; and, while there is something to be said for the flat rate system, I think it will be found, on investigation of the rates in those other countries, that almost all of them have a higher rate of sickness benefit than we have.
I was glad that the Minister of Health relieved the minds of many of us to a large extent by his statement about dental treatment. It is desirable that the Dental Joint Committee should be made a statutory body. Reference has been made to the anxiety of the dental profession in regard to clinics. One hon. Member suggested that this was a form of trade unionism, but, even if that were so, I do not think my hon. Friend should make any criticism in that connection. It will also be agreed that it is in the interests of insured people themselves and of the general public that we should have men and women of good professional status and with the corresponding sense of responsibility, both in the dental and medical professions. The anxiety of the dental profession that the purely professional side should not be interfered with is quite reasonable and in the public interest. Personally I should not approve of clinics being run by approved societies.
I was, therefore, glad to hear the Minister of Health say that members of the dental profession would be represented on the management body of the clinics. It is also very important from the public point of view, as well as from the point of view of the dentists, that there should be a free choice for patients, and I am glad that privilege has been preserved. Some hon. Members said that extended benefits are not all expenditure and that is a very important 1892 point to emphasise. If we take dental benefit, for example, there is no doubt that if it were made an ordinary form of treatment and full dental benefit were given to all insured persons, the health of the members would be very considerably improved. There are many diseases caused by bad teeth. A great many of the rheumatic diseases about which we hear so much in industrial life, and which produce a very heavy sickness rate with important economic implications, are really a form of chronic infection due to bad teeth. Therefore, the expenditure on dental benefit is, in the long run, a very economical expenditure.
The same applies to a lesser extent to efficient treatment of the eyes. The supplying of proper glasses to people who suffer from eye-strain is very important. I think it is well to emphasise the fact that, although the Royal Commission has recommended these additional benefits, and public opinion approves of them, it is impossible to supply them without a restoration of the State grant which was given before the Economy Bill was passed into law. I urge very strongly that the Minister of Health should put up a stronger fight with the Treasury so as to ensure that economy is not practised on the health of the people. If this Bill cannot be sufficiently amended, I hope we shall soon have another Measure bringing in some of the more important provisions which the Royal Commission thought necessary. We must look forward to a time when the National Health Insurance service will be a real comprehensive medical service, developed, as some hon. Members have rightly suggested, not so much on curative lines as upon preventive lines. Many of us look forward to the time when the normal task of an insurance medical practitioner will not be so much that of curing people as that of examining them periodically, so that the earliest signs of disease may be detected. That comprehensive service cannot be carried out until the extended benefits, now so much needed, are given. I think it is necessary to emphasise that this cannot be brought about unless more money is brought into the scheme, and this can only be done by a restoration of the proportion of the State grant which we had before the Economy Bill was passed into law.
§ Sir HENRY CAUTLEY
The provisions of this Bill on the whole are very admirable, but I wish to put, before the Minister of Health one suggestion which I think would very much improve the machinery of the Bill. As I understand these proposals, by giving increased benefits to a larger number of people it does further use up the funds of the National Health Insurance scheme, and further depletes the reserve fund. I have had some connection with the administration of small societies since the passing of the first Insurance Act in 1910, and I view with great apprehension the steady increase of the amount paid out in sickness benefit all over the country. Unless some steps are taken to check this expenditure, I am afraid that the whole scheme, sooner or later, will be jeopardised. I know it has been suggested that this increase can be traced to unemployment which has existed so extensively during the last few years. That may account for some of it, but it does not account for it altogether, because it happens that in the rural societies where there has been no unemployment the same symptoms exist. Probably it may be true that the increase of sickness benefit is greater in the large industrial centres which have been hardly hit by unemployment.
The scheme for the administration of sickness benefit rests entirely with the doctors and the only control we have is the appointment of a medical referee. For my part, I do not think the system could be improved in that respect. I think the sole judge of when an insured person requires medical service, and when he should receive his certificate to get medical benefit must be the doctor, subject to the procedure relating to the medical referee. My suggestion to the Minister, and it is a small one, is that, if the doctor is entrusted with this responsible work, his position ought to be made as far as possible such that his interest does not conflict with his duty. At the present moment, as I understand it, any insured person can, on a mere whim, because it would annoy his panel doctor, at once say, "I will change my panel doctor and go to someone else." That system, I am perfectly certain—I hear it in all directions, and I have seen it—is working in this way.
1894 I make no charge, either against insured persons or against panel doctors, but, if an insured person is feeling ill, and he thinks that his doctor does not consider him ill enough—if the doctor says, "You are not bad enough to stop work; you are not bad enough to have sick pay"—then, in a fit of annoyance, he says, "I will go to a neighbouring doctor and go on his panel, because he is easier." Look at the position of a certifying doctor in such a case. He has as his private patients, perhaps, the man's wife and his family, and, if he loses that particular patient, he loses the whole family. The same thing happens when the doctor has to certify the patient as being off benefit. Again, in a fit of annoyance, he says that he will change his doctor. My suggestion is that no one should be entitled to change his doctor without giving, say, three or four weeks' notice. In such cases as those to which I have referred, I have not the least doubt that the fit of irritation will have worn off in a day or two, the person will have gone back to work feeling better, the whole thing will have blown over, and he will no longer have any desire to change his doctor. My recollection is that, when the Acts were first commenced, no one could change his doctor without the permission of the Insurance Committee, and he had to show good cause for wishing to make the change. As I am not aware of the reason why that was altered, I should be glad to be informed of it. It has been suggested to me that, in addition to notice, reasons should also be required, but I do not approve of that, because I think it would encroach on the free right of choice of doctor, in which I am a very great believer. I think, also, that it would mean the setting up of some sort of tribunal to investigate the reasons. I firmly believe, however, that, if some specific period of notice had to be given, there would be a very marked difference in the sickness benefit paid out.
Why do I say that? In the few societies with which I am directly connected, we have found that in many cases where we have had to appoint a medical referee the patients have never gone to the medical referee at all, but have at once gone back to work, and in many other cases the referee has upset the certificate that has been given. I was told the other day, tħough I cannot 1895 vouch for it, that in an instance in the neighbourhood of Bristol, where a referee was appointed to examine some 3,000 cases, roughly speaking only 1,000 came before the referee. The mere fact of this appointment sent many of these people back to work, and there the matter ended, while in many of the other cases the medical referee discharged the certificates that had been given and said that the patients were fit to work. In only one-third of the cases, roughly speaking, was the decision of the existing doctor maintained.
I would ask the Parliamentary Secretary to say, when he replies on this point, whether the facts and information that he has in his own office do not bear out the case that I am making for this small alteration. I feel perfectly convinced that in the Ministry of Health they know that every word I am saying is correct, and I should like to ask whether the Minister could not see his way to put into the Bill this administrative reform, which is really only common sense, merely putting the arbiter into the position in which every arbiter is always put—otherwise his arbitration would be void and would be upset—that is to say, in such a position that his duty cannot possibly be in conflict with his interest. The doctor has to decide a very difficult point, and there is no machinery that I can see except leaving it to the doctor. I say that the Ministry of Health ought to help him, and we ought to help him, by putting him in this position. Do not let it be thought that I am suggesting any scheme that would involve hardship to insured persons. It is not a case of hardship. I want them to have the fullest possible medical assistance, and to have their sick pay for the period when they ought not to be at work; but I equally want the position of the Insurance Fund for the whole body of insured persons to be protected, because every penny that is saved on the sick pay given to a person who ought not really to have it is going to increase the benefits for the others who really deserve it. It is only a question of right and equity, and not of hardship, and it is in order to secure equity among all insured persons that I make this proposal.
§ Mr. MORRIS
One or two hon. Members have already spoken of their dislike of legislation by Regulation, and also of legislation by reference. I would commend to the Minister of Health some words of the Home Secretary on the occasion of the Second Reading of the Franchise Bill last Thursday, when he expressed his opinion about legislation by reference in these words:The House knows my own objection, very often mentioned before, to legislation by reference. I thought it would be a crying shame in a Bill of this kind once more to adopt that old foolish system."—[OFFICIAL REPORT, 29th March, 1928; col. 1362, Vol. 215.]That system has been adopted in this Bill. The Minister, in introducing the Bill, said that there were 16,000,000 insured persons. Those 16,000,000 insured persons have a right to know what their position is, and what the law is as it applies to them, but no one reading this Bill can hope to know what the position of the law is unless he goes through a whole library of Statutes. It is time that the law with regard to National Health Insurance was codified, so that, instead of going through a whole library of books to find out what the law is, one could turn to a single handy volume and find the exact position. As matters stand, that is practically impossible. It has been said, with regard to legislation by Regulation, that there are two safeguards. There is the safeguard, in the first place, that the Regulations will be placed on the Table of this House. One hon. and learned Gentleman said there was ample opportunity for anyone to raise the matter, and he cited an instance that occurred two years ago where a Regulation that was tabled on the House was defeated after discussion. It may be that that in itself is an ample safeguard, but there was an additional reason given by the Minister in justification of legislation by Regulation, and that was that the consultative councils would be consulted before the Regulation was drawn up and tabled in the House. Paragraph 4 of the Memorandum accompanying the Bill states that the various proposals embodied in it have been discussed with the Approved Societies Consultative Councils of the Ministry of Health and the Scottish Board of Health. Before the Bill was drafted was the Consultative Council for Wales, for instance, consulted with regard to its provisions?
§ Sir K. WOOD
Regulations made under the powers given by the Bill will have to be laid before Parliament, and there is nothing improper in the Minister having prior consultations with the Consultative Council. The position, however, is rather different in the case of Bills to be presented to Parliament.
§ Mr. MORRIS
I am asking whether the provisions of the Bill were discussed with the Welsh Consultative Council? If they were, the right hon. Gentleman would have found that there are some provisions to which that council objects. There is, for instance, the repeal in the third Schedule of Sub-section (5) of Section 75. That Section provides that additional benefits shall be administered by the society or branch of which the persons entitled to benefit are members, except where the benefits are in the nature of medical benefit, they shall be administered by the insurance committee. There is one other objection to the Bill. It is an encroachment on the powers of insurance committees and approved societies, and the Welsh Consultative Council views with some degree of alarm the encroachment upon the powers of insurance committees.
The paragraph in the Memorandum dealing with Clause 14, says thatif any of the forms of treatment at present covered by additional benefits should at any future time be made generally available to all insured persons as statutory benefits, their administration would be transferred to the insurance committees on lines similar to those at present governing the administration of medical benefit.It may be the right hon. Gentleman's intention that the position will remain practically the same as it was under the Act of 1924. It might very well be said, in defence of this Memorandum, that he contemplates not only giving the insurance committee the same powers they had under the Act of 1924 but of extending their powers beyond the provisions of Sub-section (5) of Section 75 and that he justifies the repeal upon that basis. If that be so all we have at the moment is a pious expression of opinion by the Minister in the Memorandum, and that is hardly satisfactory. If it be intended that the powers of insurance committees shall be extended beyond those of the Act of 1924, the only proper solution is that that further extension of powers should be embodied in the Bill and be 1898 given statutory form. The right hon. Gentleman is not always going to be in office. Other Governments may not feel themselves bound by the undertaking that he has given. The fact that he has expressed his opinion in this Memorandum will not weigh with them. The Welsh insurance committees are asking that this provision should be embodied in the Bill.
That is not the only case. In Clause after Clause there is encroachment by the central power upon the work of the approved societies and the insurance committees. The hon. and learned Member for South Shields (Mr. Harney) has called attention to some of these Clauses and there is one provision to which I desire to call attention in Clause 7, which providesWhere the Minister is of opinion that the rules of an approved society do not properly provide for the administration of the affairs of the society under this Act, or that any of the rules is likely to prejudice unfairly any member of the society.He may under certain circumstances call upon the societies to revise the rules and amend them in the manner he suggests. A proviso to the Clause provides for the case where a dispute arises between the Minister and the society, and on the application of the approved society the Minister shall appoint an independent body, in accordance with Regulations under the Act, to investigate and report on the state of affairs of the society. In that case, where the Minister has appointed a committee, on the application of the approved society, to deal with a dispute arising between himself and the society, one would imagine that both the Minister and the approved society would be bound by the decision, but that is not the case.The Minister, in making the Order, shall have regard to the report of the investigating bodyHe has already made up his mind with regard to the approved society and gives his decision before the dispute arises, and, notwithstanding the fact that he has appointed an independent committee and the case has been fully heard, and notwithstanding that the independent committee may give a decision in favour of the approved society, the Minister can override its decision, which is a very unjust proceeding. That may be a point that can be amended in Committee. What I am asking at the moment 1899 is that the Consultative Council in Wales shall be set up before the Regulations are drawn up and shall be consulted in the same way as the other Consultative Committees and that the power of the insurance committees shall be safeguarded.
§ Dr. DAVIES
I should like to join in the congratulations from all sides of the House on the extreme lucidity of the right hon. Gentleman's explanation of the Bill. We expect great things from the Minister of Health, and, fortunately, he never disappoints us in the introduction of a complicated and difficult Bill, but presents it in such a manner as to meet with the hearty approval of all sides of the House. So well did he do his duty, that the hon. Member for Westhoughton (Mr. Rhys Davies) was at once placed in a difficulty. One could see his admiration for the feat of the Minister in his countenance, and he was wondering how in the world he was to move an Amendment in opposition to such a splendid piece of work. He proceeded to attack the finance. If there is one thing the party above the Gangway have not the slightest interest in, it is how to provide the money. All they are concerned with is the spending of it, especially if it is somebody else's money. The only way they can attack the Bill is by making some obscure reference to a past raid on the insurance fund and pointing out that my right hon. Friend must be very subservient to the Chancellor of the Exchequer. If that be true, it increases very considerably my admiration for the Chancellor of the Exchequer, if he has sufficient power to overawe or to guide the Minister of Health, because I may say that among the medical profession in this country the Minister of Health is not by any means regarded as a soft man. In fact, they find him rather difficult to deal with, and, perhaps, sometimes a little autocratic. The hon. Gentleman the Member for Westhoughton is a very busy man and occupies a very important position in his party, and perhaps he has forgotten some of the facts concerning the Economy Bill. As it happens, I have in my possession a few notes about that Bill. Perhaps he will forgive me if I refresh his memory on some of these points, which I am sure 1900 he will be very pleased to hear. He may remember that there were accrued surpluses of £65,000,000 which were not touched in any shape or form by the Economy Bill. The Government Actuary, in reporting on this matter, said:The proposals in the Bill will not necessitate any reduction whatever in any of the additional benefits to be provided by societies as a result of the recent valuation which will run on for the next five years.
§ Dr. DAVIES
We must also remember that at the second valuation there was nearly £20,000,000 extra carried forward, and between that time and 1926 another £20,000,000 accumulated. The societies were earning over £2,000,000 extra per annum from the increased rates of interest. The average number of contributions had increased from 43 to 47 per annum per member, and the State had paid out over and above its statutary obligations a sum of £24,000,000. The hon. Gentleman had forgotten all these things, had he not?
§ Dr. DAVIES
Well, if he had not forgotten them surely he is not justified in coming to this House and making accusations against the Chancellor of the Exchequer and against our side of the House that we raided the fund, robbed the insured and diverted all this money. You are receiving to-day more than was promised in the original Act of 1911. [An HON. MEMBER: "No!"] Oh, yes, undoubtedly. But the point is, that hon. Members, instead of having a certain amount of money which was expected under the Insurance Act, find that the money has increased so tremendously owing to the higher rates of interest we were paying for money during the War that it has made them greedy and avaricious. There is all this money, and, no doubt, hon. Members above the Gangway say, "Let us get as much as we can; the more we get the better." They never to pause to think where that money comes from. Who pays that money? The taxpayers and the non-insured members of the population, and the Government are simply acting in a perfectly honest, careful and legitimate manner in 1901 order to see that the insured people get fair treatment, and more than fair treatment, and at the same time safeguard the money of the people who are not insured. I hope that hon. Gentlemen above the Gangway will at the end of this Debate say, "This is not such a bad Government after all. They have been exceedingly generous. They have found the money which is more than we could do, and in fact more than we are interested in doing, as all we want to do is to spend it."
The hon. Gentleman went further and made an accusation by stating that one of the great failures in the Bill is the failure in regard to Specialist services. One of the recommendations of the Royal Commission in regard to Specialist services is not included in this Bill. How did the Royal Commission recommend that it should be paid for? By the partial pooling of the societies' surpluses which they said could be done without entrenching in the slightest degree on the margin of the contribution. Who objected to the pooling of the surpluses? Not the Government, I am sure. Will my hon. Friends deny that that was turned down by the Consultative Council? Why blame the Government? The Government would be perfectly willing to grant these benefits if the society would pool the surpluses. They would not agree; therefore, do not blame the Government. The hon. Gentleman in referring to the diminished investment income from £8,000,000 to £200,000 unfortunately had not the benefit of hearing the hon. Member for Mitcham (Mr. Meller) who referred to that very effectively indeed, and if I may, without offence, I would advise him to read that speech in the OFFICIAL REPORT.
The hon. Gentleman the Member for Caerphilly (Mr. Morgan Jones) brought up a subject which I was very glad to hear brought up, because I intended to raise it myself. It was with reference to what he called the Medical Aid Societies in the colliery districts of South Wales and which we used to call "clubs." Whatever name they may be called, they are really clubs. Though I hold no brief for the British Medical Association, I imagine that the objection they have and have had for a long time is, that this puts medical men under lay control. This 1902 was manifested in the original opposition to the scheme, and for some years now, I believe, they have taken certain steps to advise medical men not to apply for these appointments. What happens? The medical man becomes the servant of a lay committee who have the power to dismiss him.
§ Dr. DAVIES
When you apply the Insurance Act to these medical aid societies you are in a different position straight away, because the essential thing under the Insurance Act is that the patient must have freedom of choice of doctor, and he has not that choice in the clubs. You appoint one, two, or three or more doctors to act in connection with your club.
§ Dr. DAVIES
I beg the hon. Gentleman's pardon. I will say that the medical aid society appoints one, two, three or four doctors, as the case may be, and every member of that society is expected to go to one of those doctors, and therefore they have not freedom of choice. The essential point of national insurance is that a patient has freedom of choice and freedom of change. I think that is one of the great objections to the present system, but I would like to say, that from all that I have heard I believe the standard of medical treatment which these medical aid societies have been able to give has been very high. Although these societies have perhaps not met with the approval of some members of the profession, the medical men who have served these societies have been of a high standard professionally, capable men, and the members of the medical aid societies have probably received equally as good treatment as any other people in the land. Personally, if I interpret the Clause rightly, I believe that the existing medical aid societies will not be interfered with, but I hope that no new societies will be allowed to be formed.
The Bill is a very useful one and has been deservedly welcomed in all parts of the House. It does not go far enough 1903 according to some hon. Members above the Gangway, but nothing would go far enough to suit Members of the Labour party. We on the Conservative side believe in the old saying, "Cut your coat according to your cloth," and when we are cutting somebody else's cloth we are more particular still. The Clause dealing with the continuance of insurance and arrears will meet a difficulty which has been felt very keenly by many people, and the repeal of Section 26 will be welcomed by all. Then there is the Clause dealing with deposit contributors. These poor people were in a very bad condition. They were charged so much per week and the only benefit they could get was the amount they had paid in. The Bill treats them very generously. Then tħe Clause with regard to married women is also generous. I do not agree with all that has been said on the question of maternity mortality. It is a difficult thing. It is not entirely due to a lack of midwives, as some of my medical colleagues would suggest.
There are a number of midwives in the country who will not undertake ordinary midwifery. They want to become nurses at welfare centres and object to doing the rough and tumble of going out every night in the week. That is one of the great difficulties. But the greatest difficulty of all is not the lack of Medical attendance or sufficient nursing attendance, it is the conditions under which confinement takes place, that is the danger at the present time. If you go into some of the houses you have the confinement taking place in the living room, and there may be two or three more children in the house. The following day they live and eat there, and sometimes do the washing there, and in those circumstances it is extremely difficult to keep the confinement case healthy. A great move towards improving this condition of affairs would be to move these patients into a home where they could be attended by their own doctor and their own nurse. The Clause dealing with additional benefit is a most important one. We have heard about the power of the Minister to issue regulations, but in the matter of additional benefit it is essential that he should have control. It is important that approved societies should only spend money they 1904 have and not mortgage future money. By having the control of the Minister we can be quite certain that no approved society will be allowed to spend money in excess of their income, which will make for the security of the fund.
The question of dental clinics is also important, and if these joint dental boards are to be set up, I think the dentists should be represented. It is suggested that in the case of experimental dental clinics which are to be formed, the approval of the dentists in the district is not essential. There is a certain amount of danger in that. You may have one or two of the superior dentists in the district who will not touch this insurance work because the fees are not enough, but they may go on to the dental board and give the benefit of their advice. The men who are doing the actual work may, in that case, be overlooked and there may be a difficulty in running the experimental dental clinic if the dentists of the district are not in cordial agreement. I ask the Minister to bear that point in mind. As long as you extend freedom of choice of dentist to the patient it is equally essential that you should get the goodwill of the dentists if you are to make the scheme a success.
As to the question of ophthalmic benefit, that is different, and I noticed that the Minister skated over this question very delicately indeed. He referred to ophthalmic benefit but not to ophthalmic clinics. The important point is that in this case the patient should not have freedom of choice; and for this reason. You have ophthalmic surgeons and you have below them a certain class of optical practitioner, with a certain amount of training, and below them again the people who sell spectacles by the gross, where you can help yourself until you find a pair which suits you. If you are going to give your patient absolute freedom of choice, they can go into a sixpenny shop or any other place they feel inclined. The essential thing in ophthalmic benefit is that the person should receive efficient and satisfactory advice, and the scheme which the British Medical Association has suggested, to supply a sufficient number of trained doctors who will work at fees suitable for approved societies, is the best way to deal with this subject; ophthalmic 1905 clinics run by qualified ophthalmolists who will give the best attendance and attention at the lowest economical price. I hope the Minister will not allow freedom of choice.
Before closing I should like to draw my right hon. Friend's attention to one or two omissions in the Bill. There is the question of pregnancy. The Parliamentary Secretary knows that occasionally women are sent home from their work six weeks or two months before confinement and are told that they must not come back to work for a month or six weeks after the child is born. That woman gets no unemployment benefit because she is turned out partly for health reasons. She gets no sickness benefit, and these women, at a time when they want all the money they can get, obtain no benefit. There is a certain amount of suffering as a consequence. You may say that pregnancy is a natural function, that it is not sickness or disability and, therefore, should not be paid. But it is the easiest thing in the world to get over the difficulty by simply obtaining a certificate and getting the sickness benefit from the approved society. It would cost about £3,000,000 a year. If any medical man simply said that Mrs. So-and-so is suffering from Albuminuria, and most of them do, she would draw benefit two months before and six weeks afterwards, and the approved societies could not refuse it. It is much better that something should be put in the Bill so that some benefit should be given to these women at a time when they need it.
§ Mr. RHYS DAVIES
Is the hon. Member aware that approved societies are not compelled to accept any medical certificates?
§ Dr. DAVIES
I admit that, and on occasions they have refused to accept one or two of mine. To show how exceedingly foolish the approved societies are, I remember that they would not accept any certificate giving debility as the cause of illness. I quickly got out of that difficulty by calling it asthenia, which is the Greek word meaning debility; and they paid every time. They would never pay for "headache." Very often you do not know what is going to happen in the case of headache. It may mean typhoid fever or influenza. You put down "headache" and they refuse to pay, it is not a disease. I put down Cephalalgia which 1906 means headache, and they paid every time. It simply shows that approved societies do not always know what they are doing. It is very easy for any doctor to get over the approved society if he feels inclined to do so.
I may give another instance to show how ridiculous is this medical certification. I once attended a man who had an ordinary "common cold," and I simply put on the certificate "suffering from a cold." The approved society, refused it and said there was no such thing. They declined to pay. I asked the patient if he was in a hurry for the money and when he said he was not I sent the case to the county office at Preston. It was given deep consideration there and they were doubtful if there was such a thing as a cold, and so the case was sent up to the Commissioners in London. They held a board on the matter and went into it very seriously, and ultimately came to this conclusion. "We think there is such a thing as a cold but, for goodness sake, if you can call it anything else, do so.'' Is not that situation ridiculous? The approved society paid. It shows how medical certification can be made a farce. Another omission from the Bill is in regard to the question of secrecy concerning venereal disease. The Minister knows that a guarantee or promise was made to panel practitioners that any information received in connection with the treatment of venereal disease was to be held secret and inviolable. That guarantee or promise, was made also to insured people; but now a Judge in the High Court has decided that a panel practitioner can be compelled to disclose such information. The Minister ought to recognise this difficulty, and something ought to be put into this Bill to meet it.
It is a misnomer to call this a National Health Insurance Bill. It is simply a national sickness insurance Bill. All that so-called national health insurance has done, has been to enable people to seek medical advice sooner than they otherwise would, but what has been the result? It has probably lengthened the lives of people who are already more or less damaged; and it means that the longer they live the greater is going to be your expenditure under the Insurance Act. These people are living longer and that may have something to do with the increase in your drug bills, and your 1907 certifications, because the longer people live, unless they are in perfect health, the more medical attention they require. I would ask the Minister to remember that there is a preventive side as well as a curative side to this question, and, personally, I have doubts as to whether the most economic way of getting rid of your surpluses is by establishing dental and ophthalmic benefits. At the ages when those benefits apply people, as a rule, are capable of full work, and can afford to pay the dentist and the eye surgeon. More good would be done if instead of pushing your surpluses forward, you pushed them backward, and did something to establish clinics for rheumatism, where you could get at the children and the young people after school age when rheumatism is so dangerous, give sunshine treatment, and, by other means, help to establish a firm foundation of health at an early age, so that when they do enter into industrial life they will be fitted for it in every way.
§ Mr. JOHN
I wish to deal particularly with the Clause of this Bill which contains a principle referred to just now eulogistically by the hon. Member for Royton (Dr. Davies). That is Clause 3, which deals with the administration of medical benefit. The hon. Member mentioned that he was very proud of the fact that the Chancellor of the Exchequer had so much authority over the present Minister of Health, but, that as far as the profession to which the hon. Member belongs is concerned, they had not impressed the Minister in any shape or form. If we read Clause 3, however, we can conceive that the hands are the hands of the Ministry of Health, but the voice is the voice of the British Medical Association. Clause 3 is going to abolish medical institutions. I have been connected with medical institutions for the last 16 or 17 years, and I never heard the name of "clubs" attached to any one of them. Probably there are some institutions peculiar to South Wales, but when the original Act was passed, provision was made for the medical institutions then in existence to be approved, and also for the approval of other institutions subsequent to the passing of the Act. It was not intended that the original Act should he a pre- 1908 ventive or deterrent factor in connection with the approval of medical institutions. This Clause, however, is going to refuse the right of further existence to these medical institutions.
One cannot understand this refusal of further approval. No complaints have been brought against these institutions and they are subject to approval every year by the insurance committees. I contend that the operation of this Clause will militate against the best interests of the members of these medical institutions and their families. Not only so, but the Clause will be detrimental to the real object of providing the best medical service and treatment for insured persons. One of the intentions of the National Health Insurance Act is to extend the scope of medical service, and give benefit to a greater extent than has been possible in the past. One of the definitions in the Regulations with regard to medical service is as follows:That the treatment which the practitioner is required to give to his patients, comprises all proper and necessary medical services other than those involved in the application of special skill and experience of a degree or kind which general practitioners as a class are reasonably not expected to possess.If I understand that Regulation correctly, the real intention is to confine the panel patients to one doctor only, and to rationalise the work of the medical practitioner in the same way as is done by the fixing of the capitation figure. Although there is a free choice of doctors, once a man has chosen his doctor then he is entitled to the services of that one man and that man alone. The medical institutions are really getting down to the fundamentals and the objectives of the National Health Insurance Act itself on the lines of attempting to co-ordinate the whole of the medical services. The benefits not only include what is contained in the Regulations I have read out, but the other benefits of the medical institutions. I am a member of a medical institution called the Mid-Rhondda Medical Aid Society, and in addition to medical benefits contained in the Regulations, such as proper aid and Điagnosis of the complaint or disease, there are the use of the pathologists and second opinions with respect to expert specialist advice. The hon. Member for Royton has been arguing for the right 1909 to increased benefits in the direction of pooling a certain proportion of funds for the payment of experts or specialists. That is not necessary with the medical institutions. The medical institutions at the present time provide expert and specialist advice and special treatment. They also provide all the laboratory facilities, and dental and ophthalmic treatment and benefits. There is no need at all for the members of the medical scheme to discuss the question of dental or ophthalmic treatment, because all that is provided through the medium of the medical institutions.
Then, again, in addition to the service in respect of curative treatment, professional nurses are provided by the medical institutions. The hon. Member for Royton was speaking of the advisability of the Minister considering the question of light treatment. Here, again, the medical institution provides not only electrict treatment, but light treatment and massage. Everything necessary for the patient from the curative point of view is provided by the medical institution. I want to say that there is not another panel doctor either in South Wales or in any other part of the country that is providing this treatment and services on the same scale or anything like that which is provided by the medical institution. The hon. Member said he would like to see these schemes abolished, or, if not abolished, at least that no provision should be made for the extension of the principle of the medical institution. He admitted that tħe institutions did provide medical service equal to either the panel or individual panel patient. I do not know what his organisation will say to him with respect to statements of that kind, because before the Commission the British Medical Association asserted that the service and the standard of quality of the service given under the medical institutions was in no way inferior to that provided by the ordinary panel doctors. In evidence against that the Secretary of the Welsh Insurance Committee did say that possibly in some circumstances that might be so, but that it was to be entirely attributed to the ban placed upon the medical profession by the British Medical Association. Is the assertion true that the quality of the medical provision is not lower than that of the ordinary panel service and that 1910 that is entirely due to the ban and restrictions placed on the medical profession by the associations? Let us see whether that is correct. Take the mid-Rhondda, or any other Medical Aid Society. I am prepared to give chapter and verse. Out of six or seven doctors in the mid-Rhondda Medical Aid Society every one of them is more than above the average standard of the qualification of the panel practitioner. Therefore, the service which is being rendered both in dealing with disease and from the curative point of view is on a much higher standard.
The hon. Member for Royton said there was not a free choice. That, again, is speaking without any definite knowledge. Every member of a medical institution has a free choice of doctors. Every six months he may contract out of the scheme and go to the individual practitioner. He cannot change the ordinary practitioner every day, but neither can he go to the medical institution at the end of the six months period. Therefore, as far as free choice is concerned, he has equally free choice in regard to the medical institution as he has in regard to the individual practitioner. Then, it is said, a serious objection is that the layman controls the provision, which again is not true. The Committee does not interfere with the medical provision or with its work or with tħe organisation from the medical point of view of the scheme. If there is anything wrong, the doctor appeals to the chief medical man of the scheme who is the deciding factor with regard to the dismissal of a medical man, or as to the merits or demerits of the case that is being brought before him.
My intention in bringing the qualification of the medical institution before the House was to make an appeal to the Minister not to dissolve these medical institutions as he intends under Clause 3. Supposing they are dissolved. In the Mid-Rhondda Medical Aid Society there are at the present time 2,000 members unemployed. Does anybody believe that medical practitioners are coming into that area to replace the medical men of our own scheme and that they are going to take on these 2,000 unemployeĐ for medical services? Those unemployed will be without any medical attendance at all. They have been unemployed for the last three years. The scheme now provides 1911 for medical attendance both for themselves and their families. If there is anything wrong with the medical institutions of this kind, what is to account for the tremendous success of those institutions? Take the case of the one to which I am referring which was approved in 1913 with 840 members and which at the present time has got over 5,000 members. That success and that growth are sufficient to demonstrate that these medical institutions are beneficial to the workers. It may be argued by the Minister that the medical institutions which are commonly called 24 (3) are going to be transferred to 24 (4). In the event of their being transferred I should like the Minister to consider, in Committee, the question of amending tħe conditions of the medical institution under 24 (4) and at least to put them on a par with the conditions applicable to the panel practitioners at the present time.
Take the relative conditions of the medical practitioners and the conditions applicable to medical institutions. It may be argued that it is desirable to abolish these medical institutions. One cannot understand the British Medical Association, because even at the present time these institutions are under a distinct disadvantage as compared with the medical practitioner both as regards supervision from the Insurance Committees and also with respect to the amount of money that is being paid to the individual practitioner and to the medical institutions themselves. I will not weary the House by discussing the various disadvantages which can be brought up in Committee, but I would like to impress upon the Parliamentary Secretary the advisability of transferring the medical institutions which are known as 24 (4) to 24 (3) and that he should consider the point that the medical institutions of 24 (4) should have the same advantages as the medical practitioner.
I should like to emphasise the point that in regard to the provisions embodied in this Bill Wales has not been consulted. When the Act was originally passed, Wales was made a distinct entity from England for National Health and administrative purposes. A Ministry of Health was set up for Wales, with a secretary, officers and offices. Why has 1912 not the representative body from Wales been consulted upon this question? There are over 1,000,000 insured persons in Wales, and as National Health Insurance touches the conditions of the people of Wales very closely, surely they ought to have been consulted with respect to proposals of this Bill in the same way as England and Scotland. It is not the first time that the Minister of Health has disregarded the insurance committees of Wales or the Consultative Committee of Wales. That is a very frequent occurrence on the part of the Ministry of Health. With regard to the evidence to be furnished in regard to the Pharmaceutical Distributive Committee, the Association of Welsh Insurance Committees made an application to the Minister of Health for representation upon the Committee, and notwithstanding the fact that the Minister of Health invited nominations from the English Association of Insurance Committees, he refused the Welsh Association the right to have representation upon the Committee. When Amendments were proposed with regard to medical benefits, and the Association of Welsh Insurance Committees approached the Ministry of Health with regard to certain suggestions upon those Amendments, they were politely told that those Amendments had been agreed upon by the English Association of Insurance Committees. Surely Wales has an equal right with the English and the Scottish people to have been consulted with respect to a Bill of this kind. which has as direct a bearing upon the lives of the Welsh people as upon the English and the Scottish people. I protest against the entire policy of the Minister of Health in ignoring the Welsh Association of Insurance Committees and in doing that, ignoring Wales as a nation.
§ Mr. WOMERSLEY
With respect to Clause 17, the hon. Member for Penrhyn and Falmouth (Mr. Pilcher) spoke of what I consider to be a great concession to the share fishermen as a doubtful quantity. I want to make it clear, speaking on behalf of a large number of share fishermen, that we do welcome this Clause. Ever since I became a Member of this House I have been agitating on behalf of these men that they should be included in the Insurance Act. It is true that, at their own re- 1913 quest, the fishermen of Cornwall were excluded from the benefits of the Insurance Acts in former years, but I was in that part of the country a few weeks ago and, in conversation with fishermen and in addressing meetings of fishermen, I found that the Cornish fishermen were anxious to come into the scheme as laid down in the new Bill, and that they welcomed it on behalf of the share fishermen.
I should like to put a question to the Minister of Health in regard to the skippers of steam trawlers. The ordinary members of the crew and the mates of steam trawlers are already insured, and will be insured under this new Bill, but the skippers have never been allowed to become insured persons. A man graduates from a deck hand to a mate and then he becomes a skipper. During the time he is a deck hand and a mate, he pays insurance and his employer is paying insurance on his behalf. When he becomes a skipper, he ceases to be an insured person, owing to the fact that he is deemed not to be a man employed in manual labour—from my experience, he does perform a good deal of manual labour—and that his earnings may be £250 a year. That is a somewhat anomalous position, because it very often happens that the skipper, owing to certain conditions, has to become a mate or a deck hand and he then goes back to insurance; but as soon as he resumes his position as skipper he is once more excluded from insurance. On looking through a Departmental Memorandum which has been issued, I discovered a fact of which I was ignorant before, that it is possible for a skipper to remain on as a voluntary contributor. I would like the Minister to make it quite clear that the information which I have garnered from the Memorandum is not incorrect, and I would like a statement from him so that the men may know their position and may be reassured.
There is another matter of importance, and that is the provision in Clause 14 (7) with regard to the setting up of clinics, dental and otherwise. It may be argued that because the Minister will have to lay this particular Order on the Table of the House and that it is open to hon. Members to raise objections, that no one need worry about it or need have any fear. We are told by the Minister 1914 that he is not going to take away the right of free choice from the insured person. The fear in regard to the clinic is not so much the fear of the dentist or the optician but of the insured person as well. I, in common with many other hon. Members, have had hundreds of forms sent to me protesting against this particular Sub-section. Some hon. Members have had so many of these forms that they have had a printed reply to send to their correspondents. I have in my possession one printed reply which has been sent by one hon. Member in hundreds of cases. This correspondence has not been engineered simply by the dentists, who have talked to their patients.
I have made inquiries in my own constituency during the last two week-ends, and I find that there is a great objection on the part of insured persons to clinic treatment because they regard it very much in the same way as institutional treatment. It was put to me in this way: "We might as well go up to the Poor Law institution to be treated as to go to a clinic." We are told that the clinics are only in the way of experiments, but they seem to me to be more like the thin edge of the wedge of a sort of nationalised medical service as regards dental, optical and, possibly, medical matters. I hope that if Amendments are put forward, as I have no doubt they will be, the Minister will consider them, so that we can strengthen the position and reassure the people who are afraid of the clinic idea. If we can do that, it will be well received by the insured people.
§ Mr. A. GREENWOOD
Nearly all the speakers who have spoken in support of the Government have regarded it as strange that we should have found any objection to the Bill. I wish to say that we have no objection to the Bill as such. There may be points here and there which are open to criticism and which may be put right in Committee, but, regarding it as a general administrative Measure, so far as I personally am concerned, I regard it as a great step forward. The objection which we take to the Bill is that at this stage, and having regard to all the knowledge that we have on this question, the Bill does not meet what is undoubtedly the national need. It may be true that, as a result of the 1915 Bill, the existing system, within the limits laid down, will be improved, and I am prepared to accept it; but the case which we have tried to make to-day, and the reason for our Amendment to the Motion for the Second Reading, is that the system is not broad enough and large enough, and that whilst we ought, as far as we can, to improve it in places, there are larger things than that to be considered. The Minister, in moving the Second Reading, was skating on thin ice. He spent the whole of his time in carefully avoiding any reference to the real questions of public health and National Health Insurance. His time was taken up with explaining in detail the provisions of the Bill, while ignoring the larger questions which are becoming so insistent as to demand treatment.
Up to the present the right hon. Gentleman's contribution in this Parliament to the development of the health insurance system has been the Economy Act, in which, in collusion with the Chancellor of the Exchequer, he reduced the State's contribution and, as my hon. Friends have suggested, did much to shipwreck the whole insurance scheme. It is quite clear that the diminution of the resources whch go to the Insurance Fund, whether they are from workers or from employers, or from the State, is a diminution of resources for national health purposes. The right hon. Gentleman in his speech quite rigħtly said that additional benefits are perhaps the most important side of health insurance. I believe that they are essential to a good scheme of insurance. But the ultimate effect of the right hon. Gentleman's last attempt to interfere in health insurance by reducing the State contribution, has been to restrict the possibilities for developing those additional benefits which he regards as being so important a feature of this scheme.
The chief question to which I wish to draw the attention of the House is the importance of regarding the health services from the broad national point of view. As a result of the misguided efforts of the right hon. Gentleman the Member for Carnarvon Borougħs (Mr. Lloyd George) in introducing his original insurance scheme, we have two rival public health services side by side. 1916 We have the health services administered by local authorities and the health services administered largely by approved societies, both of them being administered centrally by the Minister of Health. I submit that the largest single problem that confronts the Ministry of Health to-day is the proper co-ordination of these two health services. The Minister had an opportunity in this Bill of facing that tremendously large and important problem. It was pointed out earlier to-day that the original Insurance Act did contemplate preventive measures and did realise that the prevention of disease is infinitely more important than mere treatment. But, broadly speaking, the whole of that side of health insurance has broken down, and to-day, speaking quite generally, the health insurance system is dealing with the wreckage arising out of the social conditions of our time; it is dealing with the cure and the treatment of people who are very largely suffering from diseases that are known to be preventible.
The Minister's mind ought to have been turned to the tremendous question of how to develop the health service to the maximum on its preventive side, in order to diminish the drain on health insurance funds in the treatment of diseases which might well have been prevented. The evidence is overwhelming. The Annual Reportsof the Chief Medical Officer in the Ministry of Health and the Annual Reports of some distinguished man who is Chief Medical Officer of the Board of Education, refer year after year with almost monotonous reiteration to the enormous amount of preventible disease which ultimately is found battening on the Health Insurance Fund. Each year we have in the Report on the state of public health a summary of the actual financial state of the health insurance scheme. This is the kind of paragraph which appears every year in the Report: There is a Table showing sickness and invalidity, sickness benefit anĐ disablement benefit for men and women, and the financial cost, and underneath the Table is this paragraph:These figures indicate that in England and Wales there was lost to the nation in the year, among the insured population only and excluding the losses due to sickness for which sickness and disablement benefit is not payable, a total of 25,000,000 weeks' work, 480,770 years, or the equivalent of 1917 12 months' work of nearly half a million persons. Moreover, it must be remembered that it is not only the working equivalent of nearly half a million persons that is involved, but also the labour and expense entailed in their care.We hear also from Sir George Newman's reports that that enormous loss to the nation in working time, in physical vitality and in money, is very largely due to diseases which are known to be avoidable. There is a very striking passage in the report on the Health of the School Child, dealing with the incidence of rheumatism amongst children. It is pointed out how important and how serious is this problem of rheumatism amongst the child population. The Report goes on to say:It causes sooner or later probably something like 80 per cent. of the deaths from heart disease under 20 years of age, and not less than 40 per cent. of the total cardiac mortality, itself the principal cause of death at all ages in England in 1926.I submit that the Health Insurance Fund is bearing this enormous strain of heart disease of one kind and another very largely arising out of conditions in childhood that could be remedied. One could go on with other cases of a similar kind, and it is, I suggest, the wildest extravagance for us to concentrate on the mere improvement of health insurance administration when the major problem that lies before the Minister of Health is to get rid of that drain upon the scheme by dealing with the prevention of the disease and by bringing his two rival, overlapping health services into one great popular health service. To take another side of the question, the right hon. Gentleman spoke as though this Bill embodied the recommendations of the Royal Commission on Health Insurance. I am not myself satisfied that the Report of that Commission represents the last word in wisdom. It seems to me that over the sittings of that Commission there brooded the frowning figure of the Chancellor of the Exchequer, and that Commission showed an extraordinary timidity in facing the real problems of public health. But notwithstanding its unwillingness to recommend any proposals which might involve further financial expenditure, the Royal Commission did make this recommendation:That it is desirable that, as soon as funds are available, the scope of maternity benefit should be expanded to cover medical and midwifery services in addition to a cash payment; that the service element should 1918 then be administered by the local Health Authorities and be co-ordinated with the other local medical services; and that a cash element should be retained and be administered in connexion with the other cash benefits.I am well aware that, with the timidity which characterises the Royal Commission's Report from beginning to end, the words "as soon as funds are available" are inserted, but the Minister of Health knows, and his Chief Medical Officer knows, that this question of maternity benefit is one of the greatest needs of our day.
There has been a certain amount of public interest recently in the problem of maternal mortality. Four years ago there was published a Report by a very distinguished medical offices of the Ministry of Health, Dame Janet Campbell, dealing with the problem of maternal mortality and drawing attention to this important, urgent, pressing problem, a problem which shows no signs of being solved, and in the opening introduction to that Report, by the Chief Medical Officer, we read what the fact was four years ago:The problem with which we are faced is this. There are not less than, say, 700,000 mothers in England and Wales giving birth to children per annum. Of this number, approximately 3,000 per annum have died during the last 10 years in the fulfilment of this maternal function. That is a serious and largely an avoidable loss of life at the time of its highest capacity and in its most fruitful effort.10.0 p.m.
This year there has been a second Report published dealing with the same problem and the fact that for every 250 births in this country there is the death of a mother, which makes maternity by far the most dangerous occupation there is in this country to-day. We know that the occupation of mining is a dangerous occupation, but there are three times as many deaths in childbirth as there are in the mines, and a smaller number of mothers per year than there are miners engaged in the mining industry. As Sir George Newman has repeatedly pointed out, it is not merely that there is this gap left in 3,000 homes, with all that that, means, but for every mother who loses her life, there are a large number of others who are permanently injured, with disastrous consequences to future children who may be born and to the health and happiness of the home. I do not believe there is any more serious national problem to-day 1919 than the standing disgrace of 3,000 deaths of mothers in childbirth, and I should have thought the right hon. Gentleman, if he had not been prepared to accept all the recommendations of the Royal Commission, would at least have made it in his way to see that funds were available for dealing with this great problem, because it is perfectly clear from the reports of everybody who has examined this question, that there must be some form of ante-natal care, proper care for the mother in childbirth, proper care for the mother and infant after childbirth; and that, it is suggested, can only be effectively carried out by utilising the resources both of national health insurance, on the one hand, and of the local health services on the other. This Bill leaves out what I believe to be one of the most important next steps that ought to be taken in the extension of our national health insurance service.
The Minister of Health, referring to the Amendment on the Paper, said he had extended the scope of health insurance. He had gone from tree fellers, through slaughtermen, to share fishermen, and I am all in favour of that. I am not saying that it is not a good thing to bring in the tree fellers and the share fishermen and the other relatively small groups of people who hitherto have been excluded from the health insurance scheme, but really, if there is to be a decent national standard of health, the health insurance scheme ought to be extended far beyond the small groups who are being included now. I think the case is overwhelming in favour of bringing in, in one way or another, all the mothers. I think this mere payment of a cash maternity benefit, while it is a recognition of the claim of this Amendment, is quite insufficient at the present time. Not only so, but there are large numbers of people to-day with incomes over £250 a year who are excluded who really ought to be included within the national health insurance scheme, and however inadequate widows' pensions and old age pensions may be, the exclusion of people from health insurance does mean their exclusion from the benefits for widows, orphans, and old age.
The health insurance scheme, important as it was, was never as important as it is to-day, since there was attached to it 1920 additional provision for widows and orphans and old age pensioners over 65, and it is clear, therefore, that if there is to be common justice done to a very large number of people, there should be steps taken to bring them within the scope of this Bill. By the extension of the scheme we mean, not merely dealing with the hard cases of relatively small groups of people, like the share fishermen, who should have been in long ago, but the larger group of people who were left out on account of their income limit. By the extension of insurance, we mean also making more generally available for all insured workers those additional benefits which are absolutely essential, and which make the health insurance scheme worth while. It is difficult to justify the fact that a number of people are paying the same contributions and not getting similar benefits. That is because of the complications that arose when the right hon. Gentleman the Member for Carnarvon Boroughs invented the approved societies. It is clear from all medical testimony that these additional benefits, dental treatment particularly, eye treatment, and hospital treatment, are really necessary if the mere expenditure on health insurance is to be made worth while. That means, in some way or another, giving for equal contributions something approximating similar benefit. The right hon. Gentleman has not done that in his Bill. It may be true that many approved societies would dislike the partial pooling of surplus funds, but there is no doubt about the recommendation of the Royal Commission on that question, and something along those lines is clearly essential if justice is to be done to the contributors under the Act.
§ Mr. BLUNDELL
May I ask the hon. Gentleman if that is part of the official policy of the Labour party?
§ Mr. GREENWOOD
That does not happen to be a health insurance policy. I thought my hon. Friend the Member for Westhoughton (Mr. Rhys Davies) made it clear that it was essential, from our point of view, to do something in the direction of pooling surpluses in order to give similar benefits for similar contributions. Our great case against this Measure is that it is primarily a machinery Bill when it ought to have gone much outside the mere improvement of administration. The argument, I assume, is the argument for economy. The Chancellor of the Exchequer, I understand, is now a happy man, for he has a surplus of £4,000,000. No one knows where that £4,000,000 will go. I would like to give it to the Minister of Health to be used either in the development of health insurance or in the development of the public health services, in which the nation could find no better means of investing the money. It is important, notwithstanding the cries of economy, that first things should come first. Report after Report has been issued dwelling on the appalling conditions prevailing among large sections of the community. The operation of the health insurance scheme itself has brought to light the need of further steps forward. The work of the public health services have shown an improvement of preventive work in the sphere of public health, and instead of dealing with this matter merely as an office departmental matter, improving the internal administration of the Department and of approved societies, the right hon. Gentleman should have dealt with the problem that faces the country to-day. This Bill will do very little indeed to grapple with the big problem of public health. It will not touch the major problem that confronts us to-day.
Good as it is as an administrative Measure, it really misses what is the need of the times, and it is because of the defects of the Bill from the point of view of health policy that this Motion was put down on the Paper to-day. I am certain that the Minister himself, and all Members of the House, must feel that no question of economy ought to be allowed to stand in the way of development of public health in this country. Our claim is that the Minister in this Bill had a magnificent opportunity of carrying a stage further the social 1922 machinery that has been established, of bringing it into closer relation with the public health services, and of doing something to set in the forefront of the minds, of the people the enormous importance of health. Instead of that, attention has been directed to economy on the one hand, and machinery on the other. I regard it as unfortunate that that should have been so. If the Bill had extended, instead of stabilising the present position with regard to health insurance, it would have met with a warmer reception on this side of the House. We can only regard this Bill with lukewarm feelings. We are glad to have such improvements in administration which it gives, but we deplore the fact that the Minister has missed a great opportunity.
§ Sir K. WOOD
The House will have to decide whether it will give this Bill a Second Reading or not. As I understand it from the hon. Member who moved the Amendment this afternoon, and—though not with such emphasis—from the hon. Gentleman who has just spoken, the Labour party, and certain members of the Liberal party, propose to vote against the Bill, and, if possible, prevent it having a Second Reading. The hon. Gentleman who has just spoken has described the Bill as of a very secondrate nature, and practically a Bill relating to machinery. I am afraid he has given very little attention to the actual terms of the Bill, because, not only does it extend and simplify the national insurance system, but it gives additional benefits to additional classes of workers who have repeatedly asked to be included in the national scheme. It will also give most valuable advantages to unemployed people, and remove penalties and restrictive conditions which have hitherto applied to them. The Measure—and this I commend to the House—is particularly designed to keep unemployed workers in insurance, and thus in benefit, and it will also give, in a most generous and valuable way, advantages to people who have hitherto been debarred from obtaining full insurance on the ground of ill-health.
I want at once to tell the House that I can say, without fear of contradiction, that this Measure has received the general approval of the societies up and down the country, and of their leaders 1923 and officials. In fact, the hon. Gentleman himself, who is closely associated with the approved societies, before apparently he made up his mind to vote against this Bill to-night, made a statement in one of the newspapers that this Bill would particularly make the task of the administration of the aproved societies very much easier. All the leaders of the approved societies up and down this country desire that this Bill should have a safe and speedy passage to the Statute Book. In my judgment, it is only in keeping with the general attitude of the Labour party towards social legislation in this House during the last three years that they should seek the rejection of this Bill.
The Labour party are asking us to reject a Bill which has practically the unanimous support of the approved societies of the country. It has also received the general approval of the Consultative Council, which is composed of representatives of all approved societies, trade unions included. They are asking the House, by rejecting this Measure, to deprive insured persons of many valuable benefits, and the societies of many opportunities to carry on their work more effectively and more efficiently. The hon. Member who has just spoken has great visions—I admire them, and desire to share them with him—of the future of health insurance in this country; yet he desires to prevent the passing of a Measure—small if you like, you may say it does not go far enough—which, in the opinion of all who give it impartial consideration, is at any rate a step in the right direction. With all respect I venture to suggest to the hon. Gentleman and the party opposite that that is a dog-in-the-manger attitude; and with such advice and leadership it is not surprising that after 17 years of national insurance the President of the National Association of Trade Union Approved Societies should have summed up their achievements in connection with national health insurance in the following terms:Ninety per cent. of the 15,000,000 insured workers, at least 3,000,000 of whom are trade unionists, look to organisations other than those belonging to the trade unions of the country for advice and assistance when they are most in need of it.I have a good deal of sympathy with the general secretary of this association of trade union organisations who, on the same occasion, said: 1924Nine-tenths of the trade union executive committees consider health insurance a nuisance. If the trade union executive committees were half as much alive to the value of research to improve the standard of health as quibbling over industrial matters they would get a good bit further than they did.In my opinion, this Amendment of the Labour party's is neither candid nor courageous. Why do the Labour party really desire this Bill to be rejected or, if that is not possible, for its benefits to be minimised, its reforms hindered and the general insurance scheme decried? This Bill does something else besides simplifying insurance administration and conferring further benefits upon insured people. It strengthens the national scheme as a great contributory insurance Measure in which the State, employers, and workmen all pay their appropriate share, and consequently it firmly maintains the approved societies' system, and thereby rejects the scheme for the nationalisation of insurance which is a real anĐ avowed object of the Socialist party. The true attitude of the Labour party towards national insurance will not be found in the terms of the Amendment on the Paper, but in the Minority Report of the Royal Commission and in the resolutions of the National Association of Trade Union Approved Societies. What do they ask for? They have asked in the first place that the approved societies should be abolished; secondly, they want the whole of the national insurance, in which they include death benefits, to be administered by a central department; and, thirdly, they want a non-contributory scheme. After the hon. Member for Westhoughton (Mr. Rhys Davies) had read the Minority Report of the Royal Commission, he said:The Report recommended the abolition of Approved Societies and other matters. The Minority Report is much more able and courageous. It deals with fundamentals. It attacks the Approved Society system, and in this connection it is in line with the whole of the National Association of Trade Union Approved Societies.If we really did try to find out what the Socialist party wanted we should find that it was not the things referred to in the Amendment, but a nationalisation of the whole system. They want approved societies to be abolished and the whole of the expenditure to come from the State. The principal criticisms 1925 which have been made during the Debate to-day are that my right hon. Friend the Minister of Health has failed to carry out the recommendations of the Royal Commission so far as the Majority Report is concerned. The hon. Member who moved the Amendment said:There are 122 recommendations and only six or seven of them have been carried out.
§ Sir K. WOOD
The hon. Member said that only 32 have been dealt with in this Bill. That is a nice statement to make, because if the House will look at the recommendations numbered from 1 to 122 they will see that the first one that the hon. Member complained of not having been carried out is as follows:The National Health Insurance has established its position as a permanent feature of the social system in this country, and should be continued on its present compulsory and contributory basis subject to the various changes recommended below.I will give No. 10 recommendation as another example. The complaint is that we have not carried out this recommendation, which is as follows:That medical benefit has been a valued and successful element in the scheme of National Health Insurance.Therefore, these matters of which the hon. Gentleman opposite complained are really conclusions to be found in the Majority Report, which in many instances says that the present position is satisfactory. In other instances, the Royal Commission say that various recommendations can be carried out by Regulations, and they say that administrative action can be taken in other cases. In many of the cases action has already been taken by the Minister of Health. Various allegations have been made by the hon. Gentleman opposite, and also by an hon. Gentleman who spoke from a bench below the Gangway, to the effect that on account of the Economy Act, and also, apparently, owing to the threats of the Chancellor of the Exchequer, various reforms had not been undertaken by the Government in connection with this Bill. The first one which the hon. Gentleman chose, after mature reflection, was that the specialist services which had been recommended by the Royal Commission had not been put into this Bill by my right hon. Friend because the Economy Act had robbed the societies of the oppor- 1926 tunity of providing them. I ventured to suggest, while the hon. Gentleman was speaking, that he might think that matter over again. In fact, if the hon. Gentleman will look at page 281 of the Majority Report, he will see it there stated, and I do not think it is dissented from in any portion of the Report, Minority or otherwise, that:The scheme of extended medical benefit could be financed through the funds made available under the scheme of pooling of surpluses referred to in recommendations (40) and (41).In fact, but for the opposition of the approved societies of the country, it would be perfectly possible to put into operation the scheme of specialist services without bringing any additional funds into the National Insurance system at all, and no one has a right to say in this House that the specialist services are not being adopted in connection with National Health Insurance on account of the Economy Act, or of any question of finance, or any matter of that kind at all.
§ Mr. RHYS DAVIES
If the right hon. Gentleman will pardon my interrupting him, may I ask if he means to say that specialist treatment can be provided without money? If that specialist treatment has to be paid for, must it not be paid for from the funds of the approved societies, and is it not a fact that the funds of the approved societies have suffered to the tune of about £3,500,000 per annum as a result of the Economy Act?
§ Sir K. WOOD
He will find there that the Royal Commission went very carefully into this question of specialist services, which many of us would be very glad to see, and that they have stated that, if the approved societies would come to an agreement and pool certain of their funds, that scheme could be put into immediate operation without any further addition whatever, either by way of extra contributions or by way of State assistance. In other words, the reason why the specialist services have not been put into operation is simply and only the consistent and determined attitude which, for reasons which they may consider per- 1927 fectly right and proper, the approved societies have maintained on the matter.
There is another complaint which was made very strongly indeed by the hon. Gentleman, and which I think got a good deal of support from one of his hon. Friends who attended the Insurance Conference at Geneva. He asked, why should not the Government bring in a scheme which would give medical treatment to the dependants of insured persons in this country; and he asked what finer progress could be made in our national insurance system than to bring in a matter of that kind? In the first place, it would mean bringing in altogether, including the people who are already in the scheme, a total of no fewer than 31,000,000 people; and, secondly—and I am sure that this is a matter which must receive some consideration even from hon. Gentlemen opposite—it would cost another £10,000,000 a year to put only that particular part of the scheme into operation. I do not think that many Members in this House Would advocate, at this particular time, desirable as that service would no doubt be, that we should add to the contributions which are compulsorily obtained under this Act.
As the hon. Gentleman himself knows, when this matter was discussed at Geneva, it was decided, in the first place, that to give medical benefit to the whole of the insured people of any country and their dependants as well would not necessarily be part of an insurance scheme at all, and, in fact, it would be better if it were not; and, secondly, that the system which this country has adopted in connection with National Health Insurance—that is to say, to make provision for the breadwinner of the family first—is the right system and the right principle to adopt; and, as the hon. Gentleman knows, almost all the countries represented at that great Conference adopted the principles of the British National Insurance scheme, and, after very considerable criticism and consultation, all agreed that our scheme of National Insurance was pre-eminent in the world.
I have had a good many questions addressed to me during the Debate, and it is quite impossible to attempt to reply to some 40 or 50 questions. A very large number of them are Committee points, 1928 and I do not think it is necessary to say, on behalf of my right hon. Friend, that we will give very careful and sympathetic consideration to any Amendments that seek to improve the Bill. I have already endeavoured to convey our anxiety, if possible, to meet very many of the points that have been put, and we will certainly give very careful consideration to them when we reach the Committee, but there are one or two questions on which I will say a word or two from a wider point of view. My right hon. Friend has already explained the new and important step we are taking with reference to deposit contributors. Under the scheme that the Labour party seek to reject, for the first time in the history of the country a scheme is going to be put forward by which men and women who on grounds of ill-health have hitherto been unable to join approved societies will now be able to get their ordinary statutory benefits. The right hon. Gentleman the Member for Carnarvon Boroughs (Mr. Lloyd George) asked what was the number of deposit contributors to whom this opportunity would be open. The number is something like a quarter of a million, and therefore a very important class of the community well worthy of our help will be assisted.
Another question was whether something still more cannot be done for the deposit contributors, and, instead of giving them only the statutory benefit, whether it will not be possible to give them additional benefits. I am sure every one would desire that if it were possible, but already deposit contributors who are put into this section will, on account of their ill-health and generally bad condition, cost much more, on the average, than the ordinary member of an approved society, and each member in this new section of the deposit contributor class will get far more than the average member of a society with his additional benefits as well. Another advantage of this scheme especially to this class of deposit contributor, who is even in a better condition than the ordinary members of an approved society, is that he will have his benefits guaranteed to him, and there is no question, as in the case of an ordinary approved society, of having to seek other means of obtaining his benefits. There is no intention whatever on the part of my Department—this 1929 question has been put and I have seen letters written about it in the newspapers—to set up a big State society of this kind. What we want to do, in the first place, is to give some real benefit to people who are unable to join an approved society on grounds of ill-health, but, secondly, we are going on with our efforts, which we have been endeavouring to make as powerful as we can during the last few years, to get the ordinary depositors to join approved societies, because we think that it would be a good deal better for them and for the insurance system if they would only join an ordinary society and take the ordinary benefits.
Exception was taken to a provision in the Bill in which for the first time we sought to take power to surcharge persons who administered approved societies where the administration ħad not been conducted on proper lines. If an insurance committee official or anyone concerned with the administration of an insurance committee's work acts improperly and makes payments which are obviously wrong and unlawful, we have the right to surcharge him. We are now asking for the right to surcharge individuals in connection with approved societies for the same purpose and in the same way. I would suggest to the House, that instead of hon. Members complaining of that being done, they ought to support the Government in the step they are taking. I do not think that any system in this country has been so well managed as the approved society system, and there has been very little maladministration. It is a matter of great credit to the very large numbers of members of committees and to officials up and down the country, who number some thousands, and it is a tribute to the very excellent work they have done. Undoubtedly, there are cases where the Government ought to be given further powers. We have had cases such as the following, and I only give it as an illustration. It can be found in one of the papers presented to Parliament. There was a proposed paymentin a society's accounts in respect of subsistence allowances for a period extending from Friday to Tuesday to two representatives visiting three convalescent homes in a seaside town on behalf of the society. The long duration of the visit was explained at audit to have been due to the postponement 1930 of the visit to one home from Friday until Monday owing to the absence of the secretary of that home. The auditor's report, however, pointed out that the town visited was only about an hour's journey from the city in which the society's office was situated, and that subsistence allowance was not reasonably necessary for more than two days. The same report took exception to an excessive charge for subsistence allowance to four representatives attending an annual meeting of an Association of Approved Societies.We have had cases where it has been sought to use the funds of approved societies for presenting gold medals, illuminated addresses and gold plate and matters of that kind. All we desire is simply to have power to check that kind of thing and to be able to prevent it.
Exception was also taken to the additional power which is being provided in this Bill to enable the Minister, if a society does not administer its affairs properly, to deduct a certain sum from its administration allowance. At the present moment the law is that in the case of a society that offends materially in that way the only remedy the Ministry of Health has is to withdraw its certificate of approval. That is a very drastic step, and in a great many cases it is unnecessary and undesirable, and far too big a penalty to be exercised. If this Bill becomes an Act the Minister will have power in certain cases to order that a sum shall be deducted from the administrative allowance of the particular approved society.
§ Mr. HARNEY
I see in tħe White Paper which has been issued these words, "Advantage has been taken of the provision in a few cases." Does he think the existence of a few exceptional cases justifies the alteration of the whole system which is working well?
§ Sir K. WOOD
The hon. and learned Member is making too much of the matter. This is not an alteration of the system. It is simply that in tħese cases where it is not necessary to take the drastic step of withdrawing approval—the case of a society which has taken a certain course, against tħe advice of the Department—a certain amount will be deducted from the administration allowance. And this deduction will go to the benefit of the fund of the society itself, so that the members of the society will obtain the advantage in that way. Many matters have been put to me 1931 during the course of the Debate and I hesitate to answer all of them. Let me take one other matter, and tħen I hope the House will allow me to deal with the other questions which have been raised in the Committee stage of the Bill. Exception has been taken, in spite of the statement of the Minister, to the establishment of dental clinics. There has been a considerable amount of correspondence with hon. Members in relation to this matter.
I want to emphasise what my right hon. Friend has said, that there is no intention whatever of making anything like an extensive provision of dental clinics. It is intended to make an experiment in the case of one or two. I repeat, as I have been invited to do, that no insured person will be compelled to take treatment at a clinic and that freedom of choice in regard to dentists will be retained as a cardinal feature in any scheme. The hon. and gallant Member for St. Albans (Colonel Fremantle) wanted me to give an assurance that the scale of fees which would be adopted by a majority of the approved societies should be made compulsory on the whole of the approved societies in the country.
§ Sir K. WOOD
I am afraid I cannot give that undertaking. After all, the House must remember that these additional benefit funds are not uniformly fixed. They differ very much, and we must allow this matter to be dealt with largely by the societies themselves and the dental profession. I should like to tell the House that the present scale of fees has been adopted by societies representing 95 per cent. of the insured people of the country, and there is good hope, therefore, that this scale of fees will be universally adopted. In conclusion let me say this. Throughout the Debate the criticism of hon. Members opposite has been that in some way or other this scheme of national insurance, in fact, our health services generally, ought to be revised, and that sufficient has not been done in that connection.
On the other hand, there is a good deal to be said for the statements made in this House. and also the statements 1932 which have appeared in the Press from employers and others, to the effect that the cost of national insurance and social services is very heavy indeed. We must remember in dealing with a matter of this kind, and in listening to speeches such as that made by the hon. Member who spoke last, that Great Britain is spending on old age pensions, workmen's compensation, Poor Law relief and health and unemployment insurance, at a rate of 78s. 6d. per head of the population as compared with 13s. in France, 5s. 6d. in Belgium and 3s. in Italy. I do not think any contention is so untrue as that this country is indifferent to the needs of the poorer section of the community, or unwilling, wherever it can, to give them a fair chance in life or to assist them in any way it can. I am giving the reply to statements which have been made on this subject, when I say that if hon. Members will look at a return issued to the House of Commons quite recently, on the expenditure on public health services, in this country, they will find that in one way or another no less than £340,000,000 is being spent in Great Britain alone. When we have such figures as that and when we see such a great advance as is represented by this Bill, I say we have no reason to be ashamed of what we have done or of the efforts we are making in this respect. Those efforts are represented, in some part, by this Bill to which I now ask the House to give a Second Reading.
§ Mr. THURTLE
If it is an unparliamentary expression, I withdraw it, Sir. 1933 Having listened to the most offensive lecture which has just been given to us by the right hon. Gentleman opposite, I feel that I should like to use language as emphatic as that of the Admiral on the "Royal Oak."
§ Question put, "That the words proposed to be left out stand part of the Question."
§ The House divided: Ayes, 206; Noes, 99.1935
|Division No. 69.]||AYES.||[10.54 p.m.|
|Acland-Troyte, Lieut.-Colonel||Griffith, F. Kingsley||Oakley, T.|
|Alnsworth, Lieut.-Col. Charles||Guest, Capt. Rt.Hon. F. E.(Bristol, N.)||O'Connor, T. J. (Bedford, Luton)|
|Albery, Irving James||Guinness, Rt. Hon. Walter E.||Penny, Frederick George|
|Alexander, E. E. (Leyton)||Gunston, Captain D. W.||Percy, Lord Eustace (Hastings)|
|Applln, Colonel R. V. K.||Hamilton, Sir George||Perring, Sir William George|
|Apsley, Lord||Hamilton, Sir R. (Orkney & Shetland)||Peto, Sir Basil E. (Devon, Barnstaple)|
|Ashley, Lt.-Col. Rt. Hon. Wilfrid W.||Hannon, Patrick Joseph Henry||Phillpson, Mabel|
|Baldwin, Rt. Hon. Stanley||Harris, Percy A.||Pilcher, G.|
|Balniel, Lord||Harrison, G. J. C.||Pownall, Sir Assheton|
|Beamish, Rear-Admiral T. P. H.||Harvey, G. (Lambeth, Kennington)||Preston, William|
|Betterton, Henry B.||Harvey, Major S. E. (Devon, Totnes)||Price, Major C. W. M.|
|Bird, E. R. (Yorks, W. R., Skipton)||Haslam, Henry C.||Raine, Sir Walter|
|Bird, Sir R. B. (Wolverhampton, W.)||Headlam, Lieut.-Colonel C. M.||Ramsden, E.|
|Blades, Sir George Rowland||Henderson, Capt. R.R. (Oxf'd, Henley)||Rees, Sir Beddoe|
|Blundell, F. N.||Henderson, Lieut.-Col. Sir Vivian||Reid, D. D. (County Down)|
|Bourne, Captain Robert Croft||Henn, Sir Sydney H.||Remer, J. R.|
|Bowyer, Capt. G. E. W.||Hennessy, Major Sir G. R. J.||Rhys, Hon. C. A. U.|
|Bralthwaite, Major A. N.||Herbert, Dennis (Hertford, Watford)||Rice, Sir Frederick|
|Brass, Captain W.||Hills, Major John Waller||Ropner, Major L.|
|Briant, Frank||Hilton, Cecil||Ruggles-Brise, Lieut.-Colonel E. A.|
|Briscoe, Richard George||Hoare, Lt.-Col. Rt. Hon. Sir S. J. G.||Runciman, Rt. Hon. Walter|
|Brockiebank, C. E. R.||Holbrook, Sir Arthur Richard||Russell, Alexander West (Tynemouth)|
|Brooke, Brigadier-General C. R. I.||Holt, Captain H. P.||Rye, F. G.|
|Broun-Lindsay, Major H.||Hope, Capt. A. O. J. (Warw'k, Nun.)||Samuel, A. M. (Surrey, Farnham)|
|Buchan, John||Hope, Sir Harry (Forfar)||Samuel, Samuel (W'dsworth Putney)|
|Burman, J. B.||Hopkins, J. W. W.||Sanders, Sir Robert A.|
|Butler, Sir Geoffrey||Hopkinson, A. (Lancaster, Mossley)||Sanderson, Sir Frank|
|Campbell, E. T.||Howard-Bury, Colonel C. K.||Sandon, Lord|
|Carver, Major W. H.||Hudson, Capt. A. U. M. (Hackney, N.)||Sassoon, Sir Philip Albert Gustave D.|
|Cassels, J. D.||Hume, Sir G. H.||Savery, S. S.|
|Cautley, Sir Henry S.||Hunter-Weston, Lt.-Gen. Sir Aylmer||Shaw, R. G. (Yorks, W.R., Sowerby)|
|Chamberlain, Rt. Hon. N. (Ladywood)||Hurd, Percy A.||Sheffield, Sir Berkeley|
|Charteris, Brigadier-General J.||Hurst, Gerald B.||Shepperson, E. W.|
|Christle, J. A.||Iliffe, Sir Edward M.||Sinclair, Major Sir A. (Caithness)|
|Cobb, Sir Cyril||Inskip, Sir Thomas Walker H.||Slaney, Major P. Kenyon|
|Cockerill, Brig.-General Sir George||Iveagh, Countess of||Smith, R. W.(Aberd'n & Kine'dine, C.)|
|Conway, Sir W. Martin||Jackson, Sir H. (Wandsworth, Cen'l)||Smith-Carington, Neville W.|
|Couper, J. B.||Jephcott, A. R.||Smithers, Waldron|
|Courtauld, Major J. S.||Kennedy, A. R. (Preston)||Somerville, A. A. (Windsor)|
|Courthope, Colonel Sir G. L.||Kindersley, Major Guy M.||Stanley, Lieut.-Colonel Rt. Hon. G. F.|
|Cowan, D. M. (Scottish Universities)||King, Commodore Henry Douglas||Stanley, Lord (Fyide)|
|Cowan, Sir Wm. Henry (Islington, N.)||Kinloch-Cooke, Sir Clement||Sugden, Sir Wilfrid|
|Craig, Sir Ernest (Chester, Crewe)||Lamb, J. Q.||Thom, Lt.-Col. J. G. (Dumbarton)|
|Crooke, J. Smedley (Derltend)||Locker-Lampson, G. (Wood Green)||Thompson, Luke (Sunderland)|
|Crookshank,Cpt.H.(Lindsey,Gainsbro)||Loder, J. de V.||Thomson, F. C. (Aberdeen, South)|
|Culverwell, C. T. (Bristol, West)||Long, Major Eric||Thomson, Rt. Hon. Sir W. Mitcheil-|
|Cunliffe, Sir Herbert||Looker, Herbert William||Titchfleld, Major the Marquess of|
|Davidson, Major-General Sir J. H.||Lougher, Lewis||Tomlinson, R. P.|
|Davies, Dr. Vernon||Luce, Major-Gen. Sir Richard Harman||Ward, Lt.-Col. A.L.(Kingston-on-Hull)|
|Eden, Captain Anthony||Lumley, L. R.||Warner, Brigadier-General W. W.|
|Edmondson, Major A. J.||Lynn, Sir R. J.||Waterhouse, Captain Charles|
|Edwards, J. Hugh (Accrington)||McLean, Major A.||Watts, Dr. T.|
|Everard, W. Lindsay||Macquisten, F. A.||Wayland, Sir William A.|
|Fairfax, Captain J. G.||MacRobert, Alexander M.||Wells, S. R.|
|Fanshawe, Captain G. D.||Maltland, A. (Kent, Faversham)||Wiggins, William Martin|
|Fermoy, Lord||Malone, Major P. B.||Williams, A. M. (Cornwall, Northern)|
|Fielden, E. B.||Manningham-Buller, Sir Mervyn||Williams, Com. C. (Devon, Torquay)|
|Ford, Sir P. J.||Margesson, Captain D.||Williams, Herbert G. (Reading)|
|Forestler-Walker, Sir L.||Marriott, Sir J. A. R.||Wilson, R. R. (Stafford, Lichfield)|
|Foster, Sir Harry S.||Mason, Colonel Glyn K.||Windsor-Clive, Lieut.-Colonel George|
|Fraser, Captain Ian||Meller, R. J.||Winterton, Rt. Hon. Earl|
|Fremantle, Lieut.-Colonel Francis E.||Merriman, Sir F. Boyd||Womersley, W. J.|
|Ganzonl, Sir John||Mitchell, W. Foot (Saffron Walden)||wood, B. C. (Somerset, Bridgwater)|
|Gilmour, Lt.-Col. Rt. Hon. Sir John||Moore, Sir Newton J.||Wood, Rt. Hon. Sir Kingsley|
|Glyn, Major R. G. C.||Morris, R. H.||Woodcock, Colonel H. C.|
|Goff, Sir Park||Morrison, H. (Wllts, Salisbury)||Yerburgh, Major Robert D. T.|
|Gower, Sir Robert||Nelson, Sir Frank|
|Graham, Fergus (Cumberland, N.)||Neville, Sir Reginald J.||TELLERS FOR THE AYES.—|
|Grant, Sir J. A.||Newman, Sir R. H. S. D. L. (Exeter)||Captain Wallace and Sir Victor|
|Greene, W. P. Crawford||Nield, Rt. Hon. Sir Herbert||Warrender|
|Adamson, Rt. Hon. W. (Fife, West)||Hall, F. (York, W.R., Normanton)||Pethick-Lawrence, F. W.|
|Adamson, W. M. (Staff., Cannock)||Hall, G. H. (Merthyr Tydvil)||Potts, John S.|
|Alexander, A. V. (Sheffield, Hillsbro')||Hardie, George D.||Richardson, R. (Houghton-le-Spring)|
|Baker, J. (Wolverhampton, Bilston)||Harney, E. A.||Riley, Ben|
|Baker, Walter||Hayday, Arthur||Ritson, J.|
|Barnes, A.||Hayes, John Henry||Saklatvala, Shapurji|
|Barr, J.||Henderson, Right Hon. A. (Burnley)||Scrymgeour, E.|
|Batey, Joseph||Hirst, G. H.||Shepherd, Arthur Lewis|
|Beckett, John (Gateshead)||Hudson, J. H. (Huddersfleld)||Shiels, Dr. Drummond|
|Bowerman, Rt. Hon. Charles W.||John, William (Rhondda, West)||Short, Alfred (Wednesbury)|
|Broad, F. A.||Jones, J. J. (West Ham, Silvertown)||Sitch, Charles H.|
|Bromley, J.||Jones, Morgan (Caerphlliy)||Smith, Rennle (Penistone)|
|Brown, James (Ayr and Bute)||Jones, T. I. Mardy (Pontypridd)||Snell, Harry|
|Buchanan, G.||Kelly, W. T.||Stamford, T. W.|
|Buxton, Rt. Hon. Noel||Kennedy, T.||Stephen, Campbell|
|Charleton. H. C.||Kenworthy, Lt.-Com. Hon. Joseph M.||Stewart, J. (St. Rollox)|
|Cluse, W. S.||Kirkwood, D.||Strauss, E. A.|
|Compton, Joseph||Lansbury, George||Sullivan, J.|
|Connolly, M.||Lawrence, Susan||Sutton, J. E.|
|Cove, W. G.||Lawson, John James||Thurtle, Ernest|
|Davies, Rhys John (Westhoughton)||Lee, F.||Townend, A. E.|
|Day, Harry||Lindley, F. W.||Varley, Frank B.|
|Dennlson, H.||Lowth, T.||Viant, S. P.|
|Dunnlco, H.||Lunn, William||Watson, W. M. (Dunfermline)|
|Edwards, C. (Monmouth, Bedwellty)||MacDonald, Rt. Hon. J. R. (Aberavon)||Watts-Morgan, Lt.-Col. D. (Rhondda)|
|Fenby, T. D.||Mackinder, W.||Welsh, J. C.|
|Gillett, George M.||Maclean, Nell (Glasgow, Govan)||Wilkinson, Ellen C.|
|Gosling, Harry||March, S.||Williams, Dr. J. H. (Lianelly)|
|Greenall, T.||Maxton, James||Williams, T. (York, Don Valley)|
|Greenwood, A. (Nelson and Colne)||Montague, Frederick||Wright, W.|
|Grenfeil, D. R. (Glamorgan)||Morrison, R. C. (Tottenham, N.)||Young, Robert (Lancaster, Newton)|
|Griffiths, T. (Monmouth, Pontypool)||Naylor, T. E.|
|Groves, T.||Palln, John Henry||TELLERS FOR THE NOES.—|
|Grundy, T. W.||Paling, W.||Mr. Allen Parkinson and Mr.|
Resolutions agreed to.