HC Deb 22 July 1946 vol 425 cc1773-82

The Minister may allow any general medical practitioner to make arrangements for the examination and treatment of his patients whether they he private patients or patients in respect of whom he has undertaken to provide personal medical services under this Act at any hospital within the region of the Regional Hospital Board for the area in which he is practising in which accommodation is set aside for such examination and treatment by general medical practitioners either free of charge or on payment in part or in full of such charges as may be prescribed.—[Mr. J. S. C. Reid.]

Brought up, and read the First time.

Mr. J. S. C. Reid

I beg to move, "That the Clause be read a Second time."

The principle which has been enunciated on a number of occasions by the Minister is that any person is entitled to take any part of the comprehensive medical service while rejecting other parts. For example, he can take the free ambulance service, even if he takes no other part of the comprehensive service, and, accordingly, he can take the free State hospital service, even if he does not take the services of a medical practitioner who is in the scheme. That is admitted, but, when we come to work it out, we come to a curious anomaly, which this new Clause is designed to obviate.

The position is that, if one goes to the State hospital, one can go in one or other of three ways. One can go to the free hospital service; one can go to the small ward or part of a hospital in which one pays a part, but not the whole, of the cost of one's reception; or one can go to the pay block, where one pays the whole cost of one's reception. In either case, one ought to have a free choice of doctor and specialist, if one wants them. I think that the specialist position is, subject to one matter to which it would not be relevant to refer here, reasonably well met, because the Bill does make provision for specialists having beds in pay blocks so that patients can employ any specialist outside the scheme while taking the hospital service. That is very proper, and, indeed, it was admitted that the Bill would not work on any other basis, but, when we come to the doctor, it is rather different. The Minister has admitted that it is proper for the doctor always to be allowed to go in and follow the patient into the hospital, and I think that is common ground in all parts of the House.

Accordingly, if the doctor is in the State medical service, then he is entitled to go into the hospital and see his patient, or, if it is an ailment which does not require specialist treatment but which can be treated by the doctor himself, he is entitled to treat his patient in the State medical hospital, although, no doubt, there would be the staff there which could treat it if the doctor did not come in. When we have a doctor who is part-time in the State service and part-time taking paying patients outside the State service, the Minister has, I understand, very properly agreed that that doctor can follow not only the patient who does not pay into the hospital but also his paying patient on the same basis. If we have a doctor who has some paying patients and some who do not pay, the position of the patients concerned, in regard to the attendance of that doctor in hospital, is identical, and, if that is so, it is, in our view, quite right.

But now we come to a doctor who is not in the State service at all. The Minister has sometimes attempted to say, without any real ground, as I think, that we on this side have not put the interests of the patients first, but here is a case where we are putting the interests of the patient first, and, indeed, exclusively. What is the difference between a paying patient who employs a doctor who is part-time in the State service and a paying patient who employs a doctor not in the State service at all? From the patient's point of view—and it is that on which I concentrate—there is no difference at all. In either case, that patient is employing a doctor outside the State service. It is quite irrelevant, from the point of view of the patient's relationship with his doctor, but it so happens that, in the one case, that doctor will have some patients under the scheme, and, in another case, completely the same so far as the patient is concerned, the doctor will have no patients under the hospital scheme.

We say that the relationship between the paying patient and the doctor in these cases should be identical, and that the paying patient should have some right to the services of his doctor, whom he pays, in hospital, irrespective of whether the doctor has some other nonpaying patients or not. That is the basis of this new Clause. We say that the Minister may allow any general medical practitioner to treat his patients in hospital, that is to say, not only the doctor in the State service; I think he is reasonably well covered apart from this new Clause, but the new Clause makes it clearer so far as he is concerned.

We were told that, in future, there would be certain hospitals, or certain parts of hospitals, where treatment would be given by general practitioners for ailments which do not require the services of a specialist. That seems to me to be a good arrangement and it is common ground that, where a patient suffers from one of those ailments and his doctor is working under the scheme, he will follow the patient into hospital, if the patient so desires, and will give the treatment there. Everybody will agree that it is highly desirable that a patient should not be first under one doctor, then under another and, finally, revert to the first for his convalescence. That sort of thing is apt to lead to difficulties. The patient should complete his treatment under the one doctor.

That applies equally in the interest of the patient whether the relationship between the patient and the doctor is a fee paying one or not. We want to make the position perfectly clear as, otherwise, if there is a fee paying patient who is a wealthy man and who wishes to be attended in hospital but does not happen to suffer from an ailment where the services of a specialist are essential, he will employ a specialist unnecessarily in order to obtain the attention of his own doctor who can, of course, come in with the specialist. That is provided for. If a patient goes into a paid block where a specialist has private beds, then, as I understand it, that specialist can allow the doctor who is working under him to come in if he wishes. That is not denied, and it means that a patient will employ a specialist unnecessarily in order to get what he wants. But, if a patient is not wealthy, he will be put to a great deal of trouble and expense in order to come under the wing of a specialist. There is a later Amendment which gives the privilege of these beds set aside in paid blocks not only to specialists, who are provided for in the Bill, but also to medical practitioners on the staff of a hospital. But that does not meet our point because there will not be many practitioners, other than specialists, on the staff of a hospital. Therefore, that Amendment goes only a very short way to meet our point, although it does, logic- ally, lead up to it. I shall be interested to hear any distinction which the Parliamentary Secretary may be able to draw.

The point on which there is the most obvious illogicality, as matters stand at present, is the one to which I referred a moment ago, namely, that the fee paying patient gets different treatment according to whether his doctor has some free patients or not. That is wholly illogical, and I challenge the Parliamentary Secretary to show any reasonable justification for such fee paying patients being treated differently just because one of their doctors has some free patients.

Dr. Morgan

One doctor is under contract and the other is not.

Mr. Reid

That is not the point. I would ask the hon. Member to try to follow my argument. I am looking at the matter from the point of view of the patient, as we have been told to do by the Minister. I could understand the Minister saying that if any patient is stupid enough to pay a fee he is not going to get the benefit of the scheme. But he has not said that, and we are glad that he has not. But, having said that the service can be taken piecemeal and that a patient need not take all the service, then, I say, the fee paying patient has the right to get into hospital. He also has the right to get into hospital under the best possible conditions, namely, that he is followed there by his own doctor. It is admitted by the Minister that that is the best possible condition. That being so, I challenge the Parliamentary Secretary to say why this unfortunate patient should be treated in this way and should not have the best available advice merely because of the difference in the position of the doctors.

8.15 p.m.

Dr. Morgan

The right hon. and learned Gentleman is not making his point very clearly. A doctor is under contract with a patient who is on his list and is not entitled, in his general practice, to charge such a patient. What is apparently intended under this new Clause is that if the patient wants to go into hospital, his general practitioner, who could not charge him when he was an ordinary patient outside, could charge him a fee the moment he gets him into hospital.

Mr. Reid

I had hopes that the hon. Member for Rochdale (Dr. Morgan) and other hon. Members who were present during the Committee stage of this Bill would understand without my going into the most complete detail. However, as there seems to be some misunderstanding, I will make it as clear as I can. I am not talking about the patient who is on a doctor's list, because this does not really affect him directly. At the moment, I am talking about.——

Dr. Morgan

The proposed new Clause says: …for the examination and treatment of his patients whether they be private patients or patients in respect of whom he has undertaken to provide personal medical services under this Act…

Mr. Reid

I thought I had made it clear at the beginning of my remarks that we had worded the proposed new Clause in that general form because we thought it made the position of the patient on the list clearer, and not because it made any essential difference to his position. As a matter of fact, I do not think that it does. It merely makes it clearer. Where it does make a difference is in regard to the fee paying patient. We all agree, I believe, that, if a patient goes on to a doctor's list, that doctor cannot charge him, whether he treats him in or out of hospital. I am dealing with the patient who chooses to employ his own doctor on a fee paying basis.

I have tried to point out that the Minister has not said that such a patient is to be excluded altogether from the scheme. That patient is entitled to get into hospital free if he wishes, but his own doctor is not allowed to follow him into hospital. It is that restriction with which I quarrel. The Minister has landed himself into the illogical position where, if the doctor on whose list I am not and to whom, therefore, I pay a fee, happens to have a list, he can follow me into hospital and charge me a fee, but, if he does not happen to have a list, he cannot. Because I am paying, he cannot walk into the hospital and look after me. The matter is wholly irrelevant, and I would ask the Parliamentary Secretary to justify such a position. I can see no justification for it at all. It means that a fee paying patient will get better treatment because the doctor attending him on a fee paying basis happens to have, somewhere else, a list of other patients. It may have relevance from the doctor's point of view, but it has none from the patient's. We are adjured to look at this from the patient's point of view, and it is because that is so that I am asking the Parliamentary Secretary to accept this proposed new Clause and thus remove a glaring and unjust anomaly from the Bill.

Sir H. Morris-Jones

I am sure that my right hon. and learned Friend the Member for Hillhead (Mr. J. S. C. Reid) has explained this new Clause to the satisfaction of the House, although it is a very difficult Clause to explain. It proposes to give the inalienable right of free choice which has been promised over and over again during the Second Reading and Committee stages. If this Clause is not accepted I cannot see how there will be a free choice of doctor under this scheme. My right hon. and learned Friend has given a particular case. There may be a large number of panel patients who choose another doctor of whose panel they are not members. There must be hundreds of such people, and they will be the private patients. They will be entitled to be treated privately. In Committee the Minister was rather reluctant to accept a proposition that doctors who are outside the scheme should have the right of access to hospitals. I hope the Minister will reconsider that point, because otherwise the scheme will be most restrictive in its effects on a number of practitioners. The Minister's view was that he freely allows everybody to come into the scheme, but that a lot of doctors may remain outside and, therefore, sabotage it. My feeling is that the majority of general practitioners will come into the scheme. I do not think they will strike, although there will be a certain number of practitioners who will wish to be paid by private patients. Some are getting on in years and some are semi-retired. If they are deprived of the right of access into the hospitals as general practitioners, we shall deprive the subject of the right of treatment by the doctor of his choice.

I therefore ask the hon. Gentleman to consider this Clause favourably, because there are a large number of hospitals where there are no specialists available, and the general practitioners in the areas of those hospitals have been accustomed to have access to those hospitals for many years. Surely, just because the Minister is taking over a hospital he does not intend to deprive one or two general practitioners in the area of the right of access to that hospital where they have been treating the patients for a number of years. That would be a serious hardship not only to the doctor but to the sick person, and he will be depriving a large number of chronic cases of the opportunity of getting hospital treatment if this Clause or something similar is not accepted.

Mr. Key

This again is a subject which was debated fully in Committee upstairs. We had in Clause 5, Subsection (2), a provision whereby a specialist who was serving on the staff of one of the hospitals which was provided in the hospital service, could treat his private patients in the hospital on the undertaking that he was inside the national service. The point that was raised in Committee was that there was no reason for restricting that facility to the specialist, but that it might well be extended to the general practitioner who could look after his private patients inside the general practitioner hospital. When that matter was discussed my right hon. Friend undertook to look into it, and as a result there is an Amendment on the Paper which carries out that undertaking. The Amendment is to Clause 5 and extends to the general practitioner the same power as is given to the specialist of attending his private patients in a hospital, on the understanding that in both cases—in the case of the specialist and in the case of the general practitioner —they are in the national service.

In this new Clause we are asked to give that facility to the general practitioner who is not in the national service. What we are asked to say is that he can stand entirely outside the national service but that all the facilities which are provided in the hospital can be made available to him so that he may build up a big private practice outside the national service. That is a thing that we are not prepared to do. So far as his patients are concerned, they can be admitted to the hospital, but if their 'practitioner is not in the national service they must be put under the care of a specialist or a general practitioner who is in the national service.

Mr. Linstead

The Parliamentary Secretary has spoken with a good deal of vehemence in opposition to this new Clause, and possibly in some sections of the House his arguments have sounded convincing. I think those Members who have indicated their approval of what he has said, and possibly the Parliamentary Secretary himself, have overlooked one vital point in Clause 5 which will still remain after it has been amended as the Minister proposes. The Minister proposes to amend Clause 5 in such a way as to allow a general medical practitioner on the staff of a hospital to have his patients in a general practitioner hospital. But the Parliamentary Secretary did not use those words when he was speaking just now. He insisted on talking about a general medical practitioner who was in the service, and I think that it is very important that we should know whether the phrase "in the service" means the same thing as "on the staff of the hospital."

Mr. Key

I can give the hon. Gentleman an answer now. Where the general practitioner is looking after his accredited patients in a general practitioner hospital, he is regarded as being on the staff of the general practitioner hospital in which he looks after his patients under the scheme.

Mr. Linstead

May I pursue that point a little further? This is really an important point and it requires elucidation. Are we to understand from the Parliamentary Secretary that every general practitioner practising within the area served by a general practitioner hospital is, by virtue of practising there, automatically regarded as being on the staff? [HON. MEMBERS: Of course not."] If the answer is "No," it means that there will be a certain number of general practitioners practising under this scheme who will not be able to follow their insured patients into a general practitioner hospital because there will be a certain number who will be in the service but not on the staff of the hospital. I did not understand that from the explanation which the Parliamentary Secretary gave, but apparently that is the view taken on the benches behind him. I repeat my question to the Parliamentary Secretary: Are we to assume that every general practitioner in the service is to be regarded as being on the staff of the general practitioner hospital serving that area?

Mr. Key

Every general practitioner serving in an area will have the opportunity of following his patients into the general practitioner hospital. If he does so he will be regarded as being on the staff of the general practitioner hospital.

Question, "That the Clause be read a Second time," put, and negatived.