CLAUSE 5.—(Application to Scotland, &c.) (Hansard, 3 July 1932)

§ Major MACKENZIE WOOD
I beg to move, in Sub-section (1), to leave out the words two shillings and ninepence shall be substituted for two shillings and fourpence halfpenny. This Amendment, in conjunction with the next one on the Paper—to leave out the words "and twopence halfpenny shall be substituted for three halfpence"—raises a matter of very great importance indeed, both to Scotland and to Wales. I have already tried to get the right hon. Gentleman to see the importance of this and the disastrous effect which it may have on National Health Insurance, but he apparently is not impressed, and I do not desire to go into it as fully as I did before, but I think the House ought to realise what it is doing if it is going to pass this particular Clause, and if it consents to pass the Clause, it ought to do so with its eyes open. The whole basis, as I take it, of National Health Insurance was that all insured persons were to be insured at a flat rate, wherever they were, and that the benefits which were to be conferred by the scheme should be given to each at the same price. That, I thought was a fundamental principle of the whole scheme of National Health Insurance. If this Bill be passed with this Clause in it, that particular principle will have gone entirely. This particular Clause proposes to charge more for medical benefit— and it deals only with medical benefit— to insured persons in Scotland and also in Wales. Scotland is going to pay 2s. 11½d., if you take the increased cost of administration for medical benefit, whereas England is going to pay 2s. 6d., taking the cost of the medical benefit and the administration together, and Wales 3s, 1d. This is a very important change in the whole system of National Health Insurance, and I feel quite certain that if it be adopted it is going to lead to other things which will make it difficult to work the National Health Insurance, and may indeed strike at the whole system itself.
Take the case of international societies. There are many approved societies in the country which draw their members from all the three countries. In future, every 103 society which draws its members from Scotland, England and Wales is going to have its members paying for medical benefit at three different rates, and that in itself is going to create a great deal of additional work for the societies, but that is not all. We know perfectly well that insured persons are a floating and moving population. They are continually going from county to county, and from country to country. If this Clause be passed in its present form, we may have one particular insured person paying three different rates for his medical benefit in one month. If he crosses the Border from Scotland to England, he will at once come under a new rate of medical benefit; if he goes to Wales, he will come under another; and if he goes back to Scotland it will change again. You will have insured persons chopping and changing continually all the year round. This means additional book-keeping, and it opens a vista which might frighten any secretary of an approved society.

Sir F. BANBURY
Does it mean that additional Scotsmen will come to England?

§ Major WOOD
I do not think it will have the slightest effect on the number of Scotsmen who will come to England, so that the right hon. Baronet need have no fear. I suggest to the Minister of Health that this is a very great difficulty which has not been considered, so far as I can see, and certainly it was not mentioned by anyone in the Committee upstairs. I hope he will give special attention to this very difficult question of administration. It has been represented that this Amendment is directed at doctors, and directed with the object of reducing their remuneration. I have no wish to reduce the remuneration which may be paid to doctors. I do not know whether the present remuneration is too much or too little, but I think we are entitled to some statistics from the right hon. Gentleman as to what they get, and what they do for it, before we consent to a change. I said before that I thought there was a good deal of money which, until the arrangement was made a short time ago, was unallocated, and I feel quite certain the right hon. Gentleman could make any adaptations which he thought necessary, so as to give doctors who are in special positions more 104 remuneration for their work than they get at the present time. I want the right hon. Gentleman also to tell us whether he proposes that this differentiation between Scotland, Wales and England is to be a permanent part of National Health Insurance, or is only to last until the present agreement with doctors expires at the end of next year? I think he said a moment ago that this Bill was a temporary Bill. I do not know if that is in the Bill, or if there is anything to show in the Bill that it is temporary. As far as I know, there is nothing to show that, and if the right hon. Gentleman really means that this is only to apply for a certain limited time, why should he not put that in the Bill, so that the matter may come up before this House at the end of the temporary period to which he referred? It was stated in Committee upstairs that the Government had been making a special grant to Scotland, in respect of the fact that the rural districts there—

Sir A. MOND
Will my hon. and gallant Friend look at Sub-section (5) of Clause 1? (5) This Section shall come into operation on the first day of April, nineteen hundred and twenty-two, and Sub-section (1) of this Section shall continue in force until the thirty-first day of December, nineteen hundred and twenty-three.

§ Major WOOD
I am obliged to the right hon. Gentleman. That disposes of that particular point, but it does not dispose of the other point, as to whether the right hon. Gentleman means to get back to a flat rate for all countries as soon as possible at the end of the present agreement? I hope that we shall get some definite statement on that point. The right hon. Gentleman knows the case that I tried to make out on this point, and I do not want to elaborate it more than is necessary, but I do ask the House to face the fact that this is going to introduce a great change in National Health Insurance —a change which was never contemplated, and which, if adopted, would extend, because there is no reason why, if you differentiate between. Scotland and England, you should not differentiate between Yorkshire and Lancashire, or the North of England and the South of England, or between one particular occupation and another. All sorts of possibilities arise immediately you have taken the first false step away from the scheme of the 105 Bill, which was to give medical benefit at a flat rate all over the country. I hope, therefore, the House will realise the importance of the change, and will see that, before it is assented to, it is thoroughly discussed.

§ Sir G. COLLINS
I beg to second the Amendment.

Sir A. MOND
I do not want to renew the, discussion we had in Committee at any length, but I would like to point out again that this is one of the first fruits of the Scottish Home Rule movement. When the Act of 1918 was passed, Scotland, as well as Wales, insisted on having separate benefit funds, and this is part of the national movement of Scotland and Wales. It is a separate fund out of which these payments are made which necessitates the action we are now taking. The medical payment to doctors for Scotland and Wales has always been more than in England, for the simple reason that the population in those countries is more scattered and sparse, and doctors have to travel more miles to visit their patients. There are greater mileage rates in Scotland and Wales than in England.

§ Major WOOD
Has the right hon. Gentleman any figures?

Sir A. MOND
This differentiation is made from established figures. There has never been a fiat rate in the sense that the hon. and gallant Member has stated. The State has borne the difference between the rates in England, Scotland and Wales. That grant comes to an end. You are faced, therefore, with the following alternative—either that poorer people in the sparsely populated districts in the Highlands or in Wales shall have no medical treatment, or much less adequate medical treatment than they receive today, or you can reduce the mileage rates to those paid in England, because you cannot pool them, as you can only indent on the Scottish fund for the Scottish medical benefit, and only on the Welsh fund for the Welsh medical benefit. For once you cannot indent on the English fund for any of the additional expenditure. The idea, no doubt, that Scotland cannot indent on the English fund is a novelty, but, under the Act of 1918, they insisted on having a separate benefit fund. You must, therefore, either have the medical profession in Scotland brought under an arrangement by which 106 they will receive less money, or the patients receive less benefit. I observe from a letter I have here that panel doctors in Scotland are becoming a little anxious, and my hon. and gallant Friend has added to their anxiety. It is a letter which was addressed to the Secretary of State for the Colonies on the 29th June, as follows: DEAR SIB,—It has come to the notice of this Committee that an Amendment by Major Mackenzie Wood has been made to the Bill at present before Parliament providing for payment of the extra cost of medical benefit out of approved societies' funds. The effect of this Amendment is to reduce the extra sum to be paid in respect of Scotland to the same sum as is to be paid in England. This Committee urge you to use your influence and vote to defeat this Amendment on the grounds that the larger amount in Scotland is due to the mileage grant and the Necessitous Districts Grant, which, owing to the sparsity of population, amounts to a larger sum per head of the insured than it does in the case of England.

§ Major WOOD
Is that not due to the fact that the Treasury undertook to pay a sum to these doctors for mileage rates, and is now threatening to withdraw it?

Sir A. MOND
It has not threatened to withdraw it; it has withdrawn it.

§ Major WOOD
Was it not an undertaking given to the doctors?

Sir A. MOND
After all, the hon. and gallant Member does not mean to say that the Treasury is to go on paying this sum for medical benefit for Scotland?

§ Major WOOD
No; I do not say that.

Sir A. MOND
Or that they should go on paying the difference?

§ Major WOOD
I only want the Treasury to go on paying it for the period during which they promised to pay it.

Sir A. MOND
The hon. and gallant Member raises one bogey, which, I think, I had better lay. He draw a picture of an insured person, apparently living in a caravan, and residing in England, Scotland and Wales alternately, and having to pay a different contribution. The hon. and gallant Gentleman must surely be aware that nothing of the kind will be the case. It will make no difference to 107 the insured person's contribution whatsoever. It will merely make a difference to the way in which the fund of the approved society is being kept. I am afraid I cannot lift the hon. and gallant Member from the horns of the dilemma on which he has been impaled by the national enthusiasm of his countrymen when a separate benefit fund was made part of the scheme.

Mr. ADAMSON
The right hon. Gentleman, in his reply to my hon. and gallant Friend the Member for Central Aberdeen (Major M. Wood), has told us that this is one of the first fruits of the Scottish Home Rule movement. If that be so, it has taken a considerable time to come into operation, because the National Health Insurance Act has been in operation for a number of years, just as the demand for Scottish Home Rule has been in existence for a considerable number of years. But when this National Health Insurance scheme was put on the Statute Book, there was no demand then for any distinction being made between the insured person or the approved society in Scotland as compared with England. An insured person in both cases paid the same contribution, and the approved society was subjected to the same charge. It is perfectly true, as the right hon. Gentleman stated, that the cost of medical service has always been higher in Scotland than in England, but the difference was met by the Treasury. That was in keeping with the many statements that were made by the Prime Minister and by others when we were discussing this National Health Insurance scheme in 1911. All sorts of glowing pictures were painted as to the benefits to come to the insured person through the medium of this National Health Insurance scheme, and, among other things, it was pointed out that the insured person would get the advantages of the scheme on equal conditions from one end of the United Kingdom to the other. So that in making this change it simply amounts to another breach of faith on the part of the Government, because, undoubtedly, since the beginning of the National Health Insurance Act, the insured person and the approved society in all parts of the United Kingdom have been on an equal footing. I am glad, as the right hon. Gentleman 108 has said, that this is a temporary Measure, but that is all the more reason why the Minister of Health should have maintained the status quo ante. If this is only going on for another year or eighteen months, he ought to have been the more anxious to allow the matter to remain as it was, because if the whole question of medical benefit is to be discussed next year, what he is doing by the arrangement he is making under this Bill is that he is tying the hands of the approved societies and insured persons in Scotland when they come to discuss the question of medical benefits.
My hon. and gallant Friend (Major Wood), in moving his Amendment, pointed out that whether or not the question of the amount of money that was to be paid was involved, undoubtedly the amount of money to be paid to the doctors is involved. By making the arrangement he is making now the Minister of Health is simply putting it into the mouths of the medical profession to be able to say to the approved societies in Scotland: "You have already been consenting parties to the distinction being drawn between the approved societies in Scotland and the approved societies in England." By this proposed change the Minister of Health is touching vital principles in our scheme of National Insurance. Was there ever any intention at the inception of this scheme to make any distinction between contributions paid by insured persons and the conditions under which the approved societies were to work in one part of the country compared with the other? It was recognised at that time when we discussed the scheme of National Insurance that there was the difficulty as to mileage in Scotland and Wales as compared with England. That was recognised as a national responsibility, and should be made one. Consequently I hope the Minister of Health will give favourable consideration to the Amendment of my hon. and gallant Friend, for this is not a question of Scottish contributors or Scottish approved societies wanting to dip into the funds of the approved societies in England. Nobody knows that better than the Minister of Health. What he is seeking to accomplish in this matter is to lift from the shoulders of the Treasury that little extra that they have taken upon themselves in order to equalise the difficulties and to 109 put it on to the shoulders of the contributor or approved society in Scotland. I think that is a dishonourable transaction on the part of the Government. They are seeking to evade responsibility in that way.

Mr. HOGGE
As a Scottish Member I have been trying to find out whether Scotland is being done an injury by this Clause. It is a great pity that there is no representative of any Scottish constituency either in charge of the Bill or directing the criticism, because to that extent we would be both desirous of getting the best possible out of the Government. But there are one or two things I am not quite clear about, and about which I should like to be clear about before I am prepared to vote. The hon. Member for Central Aberdeen (Major M. Wood) put a question to the Minister of Health who said that the existing arrangement would go on for the period for which it was promised. I would ask the Minister of Health—as I am not clear —whether there is any printed evidence that there was a contract? Is it or is it not a fact that there was a definite contract made between the Minister of Health and all the doctors in England, Wales, and Scotland in regard to amongst other things this question of mileage, and that that contract has not yet expired? Can my right hon. Friend say straightaway whether that was so or not, because that is a point of information that I should like the Committee to know.

Sir A. MOND
The present contract was made for two years.

Mr. HOGGE
And has not expired?

Sir A. MOND
Not till next year.

Mr. HOGGE
Then that alters the situation to what we have been told, because if that contract was made and there still is another year to run then what this Bill is doing—it may be right or wrong— I am not discussing the morality of it— is that it is tearing up that contract.

Sir A. MOND
Not that contract. This Bill does not affect the contract made with the doctors. This Bill transfers the payment from the Treasury of a certain part of the medical benefit to the societies.

Mr. HOGGE
Then clearly the contract made between the Minister of 110 Health and the Treasury guarantees the payments, and substitutes for the Treasury the approved societies.

Sir A. MOND
Yes.

Mr. HOGGE
At last the common-sense man, the ordinary man in the street, who does not sit on that Front Bench opposite, knows that this is tearing up a contract made by the Minister and the medical men of England, Wales and Scotland!

Sir A. MOND
Really I do not want to interrupt the hon. Gentleman, but I cannot allow him to put forward a statement of that kind. This contract regarding the remuneration of the doctors is not affected by this Bill, and refers to England, Scotland and Wales. It is not the approved societies who actually pay the doctors, but my Department through the Paymaster-General.

Mr. HOGGE
If the Paymaster-General, who pays my salary, and that of every Member of the House, said that in future the salary was going to be paid by somebody else, if I did not know who that somebody was—

Sir A. MOND
It is not anybody else who is paying the doctors. The money is paid by the approved societies to the Government, and by the Government to the doctors.

Mr. HOGGE
If my right hon. Friend, representing the Treasury, makes an agreement for the Treasury with the medical men, and then puts it on to the backs of the approved societies, that is altering the payment under the contract which existed before the introduction of this Bill.

Sir A. MOND
indicated dissent.

Mr. HOGGE
I only wanted to get it right. Shall I try again? We want to get at the bottom of this. First of all there was between the Minister of Health and the doctors an arrangement made which runs to the end of 1922. There was paid out money according to the scale of costs in the approved societies which are going to be put under this Bill, so that the doctors are now placed under the approved societies instead of being guaranteed by the Treasury.

Sir A. MOND
Not at all. What I would point out is that payment is made 111 by the Government and not by the approved societies, and the Government is responsible for the money.

Mr. HOGGE
In some respects the speech of the right hon. Gentleman has not made things clearer to us. His complaint is that Scotland wants to get something to which she is not entitled, because she had the management of her own national schemes. I do not make that criticism. I am quite prepared to carry on in Scotland any scheme which operates in Scotland; that we in Scotland shall have a scheme to operate nationally. I do not for a moment begrudge any extra cost that may fall upon us on that ground. The injury to Scotland is surely quite obvious. Up to December, 1923, the doctors operating under the approved societies are to receive from the Treasury what they now receive from the approved societies, although the man who is insured in Scotland has contributed more to the medical benefit than he did before. As a matter of fact when you are making a bargain with Scotland you have to remember that presumably the Government contribute of the whole benefits two-ninths towards those insured under the Insurance Act, but the difference in Scotland in the health of the people who are insured is a great saving to the Government, and therefore when Scotland claims some benefit a fact of that sort should be put on the other side when you say that Scotland is chafing against that which she ought to pay. What is going to happen after this Clause has passed? Take the date on which this Bill comes to an end, namely, the 31st December, 1922. After that date the doctors in Scotland will be receiving more remuneration than their confreres in England, and then you will have the whole medical profession in England coming to the approved society for increased remuneration.
There again you will be throwing the cost on the Insurance Fund. I should very much like to know if the Minister of Health can say what will happen when this particular arrangement runs out in December, 1923. Further, I want to know how far the scheme of the Highlands and Islands Medical Service is still operating. That service was specially introduced because of the enormous geographical difficulties which obtain in the West of Scotland and the Highlands of Scotland. 112 Everybody who knows the geographical situation of that portion of Scotland knows the difficulty of any doctor covering his work even when there is only one patient demanding his attention. I do not know how far that service operates in relieving that difficulty in the Highlands and Islands, or whether, under this Bill, there will be any diminution of the benefits that obtain there now. Those are points on which I think we should have some more information.

§ Mr. R. DAVIES
On the point at issue, I rather agree with the Minister of Health that when the Insurance Act gave Home Rule to Wales and Scotland, those countries had to decide upon the agreements to be made with their own doctors. The point I wish a reply upon is that the Minister still makes the agreements with the doctors both in Scotland, Wales and England in spite of the fact that the Department is taking money from approved societies' funds in order to pay the doctors. The approved societies are very agitated on this subject, and I would like a promise that in future, before the right hon. Gentleman enters into any arrangement with the doctors, the approved societies will be consulted.

Sir A. MOND
On the Second Reading I made a very full statement on this question and also in Committee upstairs. When I made this arrangement with the approved societies, I gave them clearly to understand that they would be consulted in the fullest sense before the Ministry entered into any further arrangement with the medical profession, and I wish now to repeat that statement. Most certainly the approved societies will be taken into consultation.

Mr. PRATT (Parliamentary Under-Secretary of Health, Scotland)
The hon. Member opposite (Mr. Hogge) has made some reference to the Highlands and Islands medical service. That service still applies, and the funds are still available in that statutory area. The extra mileage for which this Bill provides applies more to the necessitous areas outside the districts I have mentioned, and they are districts just as widely separated and sparsely populated. I understood my hon. Friend to say that if the Bill passed during the coming year the Scottish doctors will be receiving pay at a higher rate than the doctors in Eng- 113 land. I can assure my hon. Friend that while the sum paid to medical practitioners in Scotland will, as a matter of fact, be somewhat higher than in England, this extra payment is for the extra mileage.
With regard to the other point raised as to whether individual members of approved societies will be called upon to pay an extra contribution, that is not contemplated under this Bill. The extra sums required for these purposes are taken out of the funds of the approved societies and out of the central fund. I would like to remind the House that the Amendment we are discussing would have the effect of reducing the amount that the Scottish Board of Health could take from the funds to which I have alluded, to 2s. 4½d. per member instead of 2s. 9d. The result of that would be that the Board of Health would have at their disposal just half the sum necessary to meet the extra mileage charges which in Scotland represent something like 9d. per member, while in England it is about 4id. That is why we are asking for an extra 4½d. in Scotland. The Treasury say they are not going to give us this grant, and the Board of Health must find it in some other way. The only method by which we can make that deficiency good is by charging this extra 4id. For these reasons I hope the House will reject this Amendment.

Mr. WALLACE
I hope my hon. and gallant Friend who moved this Amendment will not press it to a Division, in view of the statement which has just been made by the Minister of Health. I should like to ask my right hon. Friend, in view of the fact that this Bill is to be a temporary measure, whether he will not apply his mind, when the larger Measure comes before us, to attempting some uniform system for the three countries. It seems extraordinary to me that this has not been done before. In all these national services we are quite aware of the inequalities, so far as charges are concerned, in the various countries. We are all aware that it costs far more than 1½d. to deliver a letter in the Orkney Islands, although the same charge is made for the postage upon a letter to this House or to an address in Whitehall. I think, however, that there should be, in a national service of this kind, some attempt at uniformity. For 114 these reasons I hope this Amendment will not be pressed to a Division, because if it were passed it would have a most unfair effect upon the medical profession in Scotland, more especially in rural areas. The Minister of Health, in his reply, said that this was one of the first effects of home rule for Scotland. What I suggest is that we should have a few of the advantages of the new system before the disadvantages are visited on us in this particular manner. If it is possible for the right hon. Gentleman to give us an undertaking that he will inquire into the possibility of adopting a more uniform system, I feel sure it will be greatly appreciated in England, Scotland and Wales.

§ Major WOOD
The Minister of Health says that this is one of the first effects of Home Rule for Scotland, but I would remind him that the whole of this difficulty has arisen simply because we have not got Home Rule for Scotland. It was the right hon. Gentleman himself who carried through all these agreements, and he never consulted Scotland at all. I hope the Minister of Health will give me an answer to the question which I have put to him. I do not desire to press this Amendment to a Division, but I think we are entitled to some statement from some-representative of the Government as to what is the policy to be pursued when the present agreements run out. We believe that there is quite enough money being paid for medical benefit in Scotland to provide ample remuneration for the doctors all over the country. It may require a little re-organisation, but that can be done easily. I would like the right hon. Gentleman, or some of his colleagues, to give an undertaking that when this particular agreement has run out an attempt will be made to bring back the different countries to their former level, and place them all in the same position, so that an insured person in Scotland will pay exactly the same as an insured person in England or in any other part of the Kingdom. If the right hon. Gentleman will give that undertaking I shall not press this Amendment to a Division.

Sir A. MOND
I do not know how I can give such an undertaking because the terms of the agreement with the Scottish doctors are made by the Scottish Board of Health. I will undertake to consider 115 the whole matter most carefully when the question comes up for reconsideration, as it must do next year.

§ Major WOOD
After what the right hon. Gentleman has said, I ask leave to withdraw my Amendment?