HC Deb 09 February 1949 vol 461 cc490-500

Motion made, and Question proposed, "That this House do now adjourn."—[Mr. Snow.]

10.0 p.m.

Mr. Martin Lindsay (Solihull)

I should like to begin by congratulating the hon. Gentleman on his new appointment as Parliamentary Secretary to the Ministry of Health in which office. I trust, he will be very happy, but in which—and this is more important—I hope he will be able to play his part in ameliorating the conditions of the very large number of people whose lives are concerned by the administration of his Department. If he is sensible enough to take the advice I propose to give to him tonight, he will have the opportunity of making a good start.

I wish to raise the very important question of the large number of people in my constituency—over 3,000 of them—who have been arbitrarily instructed by the executive council of the National Health Service in Birmingham to leave the doctors of their choice, whose patients, in many cases, they have been for a very large number of years, and in whom, of course, they have great confidence. But it does not only concern my own constituents because this has been happening all over the great city of Birmingham and, I do not doubt, in other parts of the country, so that an infinitely larger number of people are concerned.

One can well understand that on the appointed day last year there was a certain amount of confusion and that a number of doctors found themselves taking on very many more patients than they could hope to compete with. I know, in particular, of the case of a Dr. Washington in my own constituency, a medical practitioner who has built up a very fine reputation as a skilful and painstaking physician. This doctor found in due course, when things had been sorted out, and he had time to count the number of forms, that over 3,000 patients above and beyond the figure of 4,000 laid down as the maximum number with which a single handed doctor can competently deal, had registered with him.

Obviously, under such circumstances, the local executive council have no alternative but to ask a number of registered patients to leave their doctor and find another. I do not question that, but what I do most seriously question is the method of selection of those patients who are to be removed, and it is in this respect that I seek the assurances of the Minister tonight. Obviously, the only fair method is to remove the more recent additions to the doctor's list, people who had registered for the first time with the doctor at the appointed date, and who, of course, could not have any great grievance because many of them, no doubt, have not yet been ill and have not had to seek medical assistance. Therefore they cannot feel very hurt at being removed from the list of a doctor who has not yet treated them.

But surely there can be no doubt at all that the one thing which the executive council should not have done was to give arbitrary instructions to leave the doctor to people who had been his patients for a very long time—in one case, as long as 16 years—and in whom, of course, they have the greatest confidence. This is what one of those patients had written to me: Dr. Washington has attended me regularly for the last 11 years, has always done his best for me and now after a lifetime of pain he has at last found the right treatment, with definite improvement. Here is another letter: My wife and I have been patients of Dr. Washington for 16 years. I have a complaint of the chest that is incurable and as he knows all the details I do not wish to have to go to another doctor. Of course he does not, and it is monstrous that he should be so instructed by this executive council. Here is another letter: Naturally, my wife and I chose the doctor who had attended the family during our 13 years residence in Sheldon. This doctor has held our respect, admiration and confidence for the whole of that time. His patients were his friends, every individual one. Why should we have to go to another doctor when we have no such desire? Here is another extract, and these are all typical of the letters I have received: Are we to be treated like dumb animals and handed over to any vet that is available. My doctor has been all that a doctor could be to a family for more than 15 years, having paid particular attention to the health of my wife which is very indifferent after several operations. Now without any apparent consideration we are informed to get another doctor. I think it is difficult to find words to express one's shame and disgust at the monstrous way in which these people have been treated. Not only is it monstrous but it is a direct breach of faith because Ministers, in asking this House to pass the National Health Act, made repeated promises that this Measure would not interfere with the personal relationship which has always grown up between doctors and their patients.

I have quoted the grievances of my own constituents who have been forced to leave the doctor of their choice. In the case of this particular doctor, Dr. Washington, over 3,000 patients have been forced to move. Letters have reached me from different parts of Birmingham showing that similar instructions have been given to other people in the city. Let me quote the case of another doctor, Dr. Lambie, 560, Stratford Road. He has been informed that he has 500 patients in excess of this figure of 4,000 which has been laid down and that he must get rid of them, unless he obtains an assistant, by 4th March. This doctor has taken every possible step which is open to a doctor in seeking an assistant, but he cannot find one as yet because, of course, he is quite unable to offer accommodation to a married assistant and his family. Before 5th July this doctor had exactly the same number of patients as he has now and his practice is working no less smoothly since 5th July than it was before 5th July. It is absolutely fantastic to suggest that he cannot conduct his practice as well since a certain date merely because that date was laid down in an Act of Parliament.

I suggest that this figure of 4,000 should not be a statutory maximum but rather should be a guide as to approximately the number of patients which a single-handed doctor can treat. If a doctor is treating more than he can look after competently, patients have their remedy in their hands. If they consider they are not getting satisfactory service, under the Act they can, of course, leave the doctor of their choice and go to someone else. The doctor therefore has every incentive to keep up his list by looking after his patients properly. As I say, the matter will adjust itself if he does not. It is quite ridiculous to think that every doctor works the same as every other. Some doctors are quicker than others; some are more active than others; some have practices topographically more compact, and can move from one end of a practice to the other more quickly than doctors whose practices are more dispersed, and have to spend less time in travelling than others.

I ask the Minister to look again at this fixed limit on the number of patients, which is part of the scheme, and to consider whether the exact maximum number should not be left to the doctor concerned, the figure of 4,000 being merely a guide. Above all, I beg him to instruct the executive councils to the effect that if the number of patients on a doctor's list is very much too large, even so in no circumstances are the patients who have been a long time attended by that doctor to be arbitrarily removed from the list, but rather the more recent additions. I press the Minister to give us an assurance tonight that this will be done, because only in this way can the Government keep faith with the people, and keep their pledge that the unique relationship between doctors and their patients will not be interfered with by the National Health Service.

10.12 p.m.

Sir Peter Bennett (Birmingham, Edgbaston)

I should like to support my hon. Friend the Member for Solihull (Mr. M. Lindsay). I represent a constituency on the other side of Birmingham, and I have had complaints similar to the ones to which he has referred. The original duplicated letter was not a very good example of duplication. It has caused intense resentment. It is almost a sort of circular that has been sent out, and there is a feeling that people are being regimented, treated in an off-hand way, after, as my hon. Friend has said, assurances had been given that the old relationship between doctors and patients would not be broken down.

People who have had long associations with their doctors are now told that they must find other doctors, because their former doctors have more than the prescribed number of patients. It is not the doctors who have sent out the letter. It has been sent by some outside authority. People object to being treated in the mass. They like to be treated individualistically. In my own organisation, when we have to circularise our people, we spend a lot of time and take a lot of trouble in trying to persuade them that they are not being circularised, but being treated individually, that they are not being treated in the mass. It is particularly important to treat people individually in such a personal matter as that of selection of one's doctor. What has been done here is causing great irritation and considerable resentment.

I have been asked to find out how this selection is being operated, who is settling who shall remain on the lists and who shall not. This suggestion has been made to me: "It is a bit hard that doctors should be allowed to choose the good ones, that they should be allowed to get rid of those with whom they have to go to some trouble. Human nature being what it is, the doctors will take all the young and healthy ones who do not want much attention and unload from their panels, when they are overfull, the old ones who require a lot of attention." That sort of thing has been said to me. I do not for a moment suppose that is the method by which this is done, but it is not altogether surprising that people should say that sort of thing when they are parted from the doctors who have attended them a long time and yet find new patients going on their doctors' lists. Discontent is growing about it. I hope that the Parliamentary Secretary, whom I would congratulate upon his appointment, as my hon. Friend also congratulated him, will be able to tell us how this happened, and how it is happening, and give us some hope that the old, valued clients of a doctor may be allowed to remain with their doctor, and that some other method will be found of spreading the work of those doctors whose lists are overloaded.

10.16 p.m.

The Parliamentary Secretary to the Ministry of Health (Mr. Blenkinsop)

May I first of all thank both hon. Members who raised this matter tonight for their kind references to myself? May I also thank them for the manner in which they have raised it, because I am sure that it is one about which we are all anxious there should be no misunderstanding. I am grateful, too, to the hon. Member for Solihull (Mr. M. Lindsay) who has stressed the fact that he agrees that there should be some agreed limitation to the total number of patients that a doctor should keep on his list.

Of course, it is very far from our intentions or the intention of the executive councils that there should be any arbitrary decisions. I think that I shall be able to convince the hon. Member that in fact no arbitrary decisions have been taken in these cases to which he has referred. Perhaps I should explain, first of all, that when it was agreed with the medical profession that there should be this general limitation of the total numbers on the lists—this agreed figure of 4,000 on the individual practitioners' lists—it was understood that, at the start of the scheme, there should be a broad latitude, because we were particularly anxious that there should be no splitting up of families, which otherwise would have arisen, had there been any attempt at the start to keep the practitioners' lists down to any precise figures.

Therefore, it was agreed that there should be latitude at the start and that the matter should be reconsidered later. After discussion with the medical profession, a circular was sent out by the Ministry to the executive councils in November of last year, suggesting that this matter should now be looked at, because there were very wide discrepancies between the lists of one practitioner and another. It was, I think, the general view of everyone in the medical profession, as well as of the Ministry, that it would be quite impossible to get the type of service we wanted if some of these grossly overloaded lists were allowed to continue.

The Ministry suggested in that circular that the first action taken should be to try to prevent the addition of new patients to the lists, but it was always understood that the executive councils locally should decide on the action that they were to take in relation to the circumstances in their own areas. In this particular case, before the Birmingham Executive Council were able to consider the matter, the doctor to whom the hon. Member for Solihull has referred—Doctor Washington—had in fact written to them saying that he found the total numbers on his list, which in fact was not 3,000 but over 4,000 above the agreed figure, was far too much for him, and he asked the executive council to help him by trying to reduce his list for him. It was certainly not the case that the executive council were jumping in with arbitrary action. They were obliged to consider—and very rightly—the appeal made to them by the doctor in this case. They had to discuss what would be the basis on which to limit the total number of patients.

The hon. Member for Solihull has said that, when it comes to the selection of the patients who should be removed from the list, clearly those who came on to the list most recently should be removed first. I am afraid that we cannot accept that, although it may be a convenient way in some cases. The doctor himself was asked what his views were. He felt—and I think there is a great deal of sense behind it—that if he could limit his area of operation to the area outside Birmingham where he had quite a large practice and where there were few other doctors to whom patients might choose to go, he would be doing the right thing. In discussion with the executive council he suggested those he would wish to be removed from his list and the executive council, after discussion, notified the names after they had been agreed with the doctor concerned.

It seems to me a reasonable and perfectly fair thing for the executive council to do. It enabled the doctor to keep his practice going over the 4,000 limit in an area where there were few alternative doctors to whom the patients could go, and he released patients for whom there were a number of alternative doctors with whom they could sign up. That was a reasonable arrangement in the circumstances. The executive council notified this large number, something over 3,000 cases, of the position, and added a note concerning the other doctors in the area whom they could approach and whose lists were well below the maximum figure mentioned.

I think we would all agree that it is most important that we should do our utmost in co-operation with the medical profession to see that the service which is provided is the very best possible. While we are most anxious that there should be no arbitrary decision and that we should keep the confidence of the patients as well as of the doctors in this matter, we must look at the problem as it stands before us and try to find a solution which is fair both to the patient and to the doctor. I feel that in this case we have done precisely that.

The hon. Member has suggested the difficulty of getting medical assistants. It is true that if Dr. Washington, or the other doctor to whom the hon. Member referred, had been able to get assistants, they would have been able to take many more patients on to their lists. It is probably true that it is difficult to get accommodation, particularly, for a married assistant. I do not know what difficulty has been experienced about the single assistants. It might well be possible to get an assistant into the other practice to which the hon. Member referred. If it were possible it would solve that particular difficulty.

Perhaps I ought to add on this matter that many members of the medical profession feel that 4,000 is too high a figure and that it is unfortunately true that there is a wide disparity between one doctor's list and another's. Therefore, it would be impossible to leave the position where one doctor has well over 8,000 on his list, which quite clearly, according to all medical experience, it would be impossible for him to deal with adequately, and for other experienced doctors to have very much smaller lists. It is obviously essential, for the benefit of the patients themselves, that we should in the friendliest and most co-operative way possible try to get some re-distribution between one extreme and the other.

I can assure both hon. Members that there is no desire on our part, or, I am sure, on the part of the executive councils, to take any arbitrary action which will cause difficulty. The executive council in Birmingham issued a statement to the Press explaining the position and trying to explain why they felt they had to take this action. There is no desire, as some people are suggesting, that we shall consider breaking families and taking individuals off the list just because it is a few over the maximum or anything of that kind. That is very far from our attitude and desire.

Mr. M. Lindsay

I am grateful for the hon. Gentleman's patient explanation, but is he prepared to look into those cases where people have actually got orders to leave the doctor and are unwilling to do so because they have been with him for so many years and consider that they have special reasons? Will he instruct the executive council that these people should not be arbitrarily thrown out?

Mr. Blenkinsop

There is no need for any fresh instructions. The executive councils have very reasonable discretion in this matter.

Mr. Lindsay

But they are not using it. Think of the letters I have read tonight.

Mr. Blenkinsop

In any case, the executive council can perfectly well examine individual cases. I suggest that the action they have taken in trying to secure that the area left to the doctor was a reasonable area of operation for him is a very fair one. If the executive council had taken some other basis for operation, we might well have found some patients turned off the list who would not easily find an alternative doctor. Very great care has been taken to avoid that difficulty. I am perfectly willing to say that we are most anxious that any individual cases of special hardship shall be looked at—there is no difficulty about that—but we must try to achieve the broad aim which is, I am sure, the desire of all hon. Members and the medical profession. I am anxious that from this short discussion tonight it shall be well understood in the country that there is no desire for any arbitrary or vigorous action of the kind which has been suggested, but that we are really anxious to secure the very best possible personal service which can be provided under the National Health Scheme.

10.28 p.m.

Mr. Joynson-Hicks (Chichester)

I want to add my word of congratulation to the hon. Gentleman on his translation. In his previous sphere of influence, he and I had certain differences of opinion because I charged him with being sympathetic in appearance but unsympathetic in practice to the cases with which he dealt at the Ministry of Pensions. He accepted my challenge, and I am very happy to have the opportunity of testifying to the fact that he proved that he was right. He did a very great deal of good in that Department in humanising the administration and sympathising with the people with whom he came in contact. I beg him to adopt the same attitude at the Ministry of Health. He said that it is not the Ministry's intention to make arbitrary rules and decisions, but that is the appearance given by the present attitude of the Ministry. I urge the hon. Gentleman to pursue the part he has already adopted and prove to the patients and doctors that he is dealing with them as human personalities, and not as ciphers appearing on a card index.

Question put, and agreed to.

Adjourned accordingly at Half-past Ten o'Clock.