HC Deb 19 October 1949 vol 468 cc567-99
Mr. Howard

I beg to move, in page 22, line 4, at the end, to insert: In subsection (1) of section five (which provides for accommodation for private patients) after the words 'the whole cost,' the words 'or such proportion of the cost as may be determined,' shall be inserted. It will be within the recollection of the right hon. Gentleman that when the Lord Advocate moved the Second Reading of this Bill he explained that there were three main purposes for it. The first was to deal with partnerships, the second with promises which have to be implemented, and the third— to make certain minor administrative changes which experience has shown are desirable for the smooth working of the machine. The Bill is essentially a minor Measure which embodies no change of principle or policy. It makes no fundamental alterations."—[OFFICIAL REPORT, 24th May, 1949; Vol. 465, c. 1066.] This is an Amendment in the spirit of the third purpose as laid down by the Lord Advocate. It seeks to introduce a measure of flexibility into a section of the existing Act which is somewhat rigid, and which experience has shown is creating and has created difficulties of interpretation and administration and anomalies which tend to a feeling of injustice or unfairness on the part of some of the people affected. It has been at least a partial failure in achieving the object the House had in mind when it inserted the provision.

The Section in question is Section 5 of the principal Act, which gives power to the Minister to permit the continued use of accommodation which was at the time in existence and had been specially provided for fee-paying patients to be treated by their own doctors. It was accommodation already provided, and the provision was to enable this accommodation still to be used in hospitals which had now become public hospitals.

It is important that the Committee should appreciate quite clearly the difference between Section 5 and Section 4. Section 4 makes it possible to provide small wards or special rooms for cases requiring special medical treatment, or for those prepared to pay a little extra for additional comfort and amenities. By Section 4 a patient is required to pay only that portion of the cost attributable to the extra amenities he is considered to be getting and he does not have the right of attendance by his own doctor; he has to be attended by the doctor who is provided as part of the service. By Section 5 the patient is required to pay the whole cost and does not get the benefit of having his contributions to the National Health Service credited to him, although he does have the privilege of being attended by a doctor of his own choice. It is important that we should bear that clearly in mind.

4.0 p.m.

It is not necessary for me to argue in favour of the principle embodied in Section 5 because the Minister himself commended it to the House when dealing with the Bill on Second Reading. He made it clear that he appreciated that there were a number of people who had doubts as to the theoretical wisdom of making this provision at all. But he also made it clear that there were at least three practical reasons why it was desirable that this provision should be made. Perhaps I may quote from what the Minister said on the Second Reading of the 1946 Act: We are driven inevitably to this fact, that unless we permit some fee-paying in the public hospitals there will be a rash of nursing homes all over the country. If people wish to pay for additional amenities, for something to which they attach value, like privacy in a single ward, we ought to aim at providing such facilities for everyone who wants them."—[OFFICIAL REPORT, 30th April, 1946; Vol. 422, c. 57.] I entirely agree, but it is because that purpose is not being wholly met that I have moved this Amendment. The Minister gave two other reasons why it was important that this principle should be adopted. The first was that there were certain disadvantages in guiding patients towards nursing homes. There are good nursing homes, but there are quite a number which are not so good, and there is no doubt whatever that there can be few, if any, nursing homes where there will be available to the patient the same facilities as will be available in a good general or special hospital.

The second reason which the Minister put forward, and about which there can be no dispute, was that there would be economy on the demands of the services of the specialists concerned in that if it were possible for them to treat private patients in the public service hospital where they were doing their other work, they would be able to devote more of their time to public service work. In paraphrasing the Minister's remarks I hope I have not done them any injustice. When, in 1946, Parliament provided that the whole cost of these beds should be met by the persons using them, it may have seemed a perfectly proper provision but, unfortunately, as all who are connected with hospital services know, since 1946 costs have rocketed. I need not go into the reasons why they have rocketed, but in a large measure they are due to other provisions in the National Health Service Act.

Although costs have rocketed, however, the incomes of people who might have been able to avail themselves of these services have not rocketed. I should not like to say what would be the right word to describe what has happened to their incomes, but there is clear evidence—I do not put it higher; it is not wholly conclusive—that some of the facilities are not in fact available owing to the cost to the people who desire to use them.

The operative instrument for putting into effect this Section of the Act was a statutory instrument which was issued by the Minister in 1948, No. 1490, I think it was. It had to be put forward coterminously with the coming into force of the Act on the appointed day, and as a result it was only laid on the Table on 1st July and came into operation on 5th July. It was quite impossible for Parliament to enter into any proper discussion of that instrument. I am not denying that before it was drafted there were many consultations and that the Ministry took advice, but its exact effects could not have been known to Parliament at the time. Broadly speaking, that statutory instrument dealt with the very difficult question of determining what items should be included and what should be excluded in arriving at costs.

By a very masterly use of words—and I hope this is not an unfair description of it—it laid down that there should be standard daily charges which could be calculated in one of two ways: the first was that where there was data available for calculating those charges that data should be used; and the second was that where no such data was available the cost should be calculated on the cost of the ordinary public bed, to which had to be added an arbitrary and fixed percentage to arrive at the assumed cost of the private bed.

I have not heard of any great difficulties arising in hospitals where the full data was in existence. There have been some complaints, but they have been comparatively few, and it may well be that in some cases the actual charges being made are on the low side. But in other cases, where there is no appropriate data and the assumed yardstick has to be used, there have been great difficulties and the results have shown that there will be very considerable overcharges. The reason why this yardstick must be unsatisfactory is because of the vast variety of hospitals and the enormous difference in the nature of the services they provide.

May I give two examples of the sort of anomalies which must arise? It will be quite clear that if there is a hospital where buildings are widely dispersed, or where they are rather old and are perhaps not in accordance with modern ideas, there is at least the likelihood that the costs of running that hospital will be greater than they will be in a more recently planned modern hospital. It is also clear that the actual value of the accommodation in the new and modernly planned hospital should be, and usually is, much better than that in an old hospital. But the costs will be greater in the old hospital, and the unfortunate patient will have to pay more for less good accommodation. That will apply whether there is existing data available for making calculations or not.

The second example I want to put will only apply in the latter case. I could take the Minister to a hospital not 100 miles away from here where he could see it actually in being. On one side of the building, which is apportioned to the use of private patients, there is a busy thoroughfare with a tramway junction. Even those members of the Committee who have been in the habit of trying to sleep over a tramway junction will know exactly how difficult that is. The other side of the building, apart from war damage which has not yet been cleared up, looks over a quiet, peaceful, green garden. It is obvious that the value to the occupants of the two rooms, one on a noisy road and the other overlooking a quiet garden, will be quite different; yet the cost of running those two rooms will be exactly the same. Under this statutory instrument, the hospital concerned will be bound to make the same charge for these two quite different types of accommodation.

The result of this is that some of the hospitals are feeling that they have to collect charges which they really do not feel justified in asking, and some of the payments which the patients are being asked to make bear very little relation to the real value of the facilities which those patients are getting. The main criticism is in part obvious. The intentions of Parliament are not being entirely fulfilled, and this Amendment will enable the Minister to do what he cannot do now. The supplemental point is that it is contended that overcharges are arising because these patients are, in fact, being required to pay twice over for some of the services which they are obtaining. This arises because, although they are patients in public service hospitals, they receive no credit whatever for the contributions which they themselves make towards the provision of the public service.

May I put it in this way? I am quite prepared to buy a 2½d. stamp at the Post Office counter, although I would rather have a penny one, in order that at some future time I may post a letter. If, having written my letter, I took it to the post and found that before I actually put it into the letter box I had to pay another 2½d., I would feel that I was being done. That is exactly the feeling which these patients have, and which in a large measure is justified. I do not believe that anyone should be given special favours or amenities without being required to pay for them, but I believe that when assessing the amount that should be paid regard should be paid to and credit given for whatever payment has already been made.

4.15 p.m.

The effect of this Amendment strengthens and fortifies the Minister in implementing the declared objects of Parliament, objects which he himself commended to the House when he was piloting the Bill through. This Amendment will not compel him to do anything to which so far as I know he personally objects, but it will enable him to do what at present he is prevented from doing by the actual wording of the Act.

Finally, it will improve the whole services which are available to the public by meeting that portion of the public demand which is not being wholly met today, and by encouraging a portion of the public to make payment to the public hospital services where they will get the best medical treatment, instead of diverting them to other forms of hospital or nursing homes where they may get treatment which is not as good. It will also be of benefit perhaps in the most important way of all, in economising the demands on the time and energy of some of our consultants and specialists, for whose skill there is a demand today, which is far greater than it is in their personal power to supply. I commend this Amendment to the House and I hope the Minister will accept it.

Mr. Bevan

The hon. Member for St. George's, Westminster (Mr. Howard) has moved this Amendment in moderate terms, and has argued it with considerable cogency. Nevertheless, my hon. Friends and I on this side of the Committee are still unconvinced of the necessity or the justice of doing what he has suggested. In the first place, there is no evidence that the existing situation is resulting in an increase in the demand upon private nursing homes. It has been said that that is the case, but there is no evidence that it is so. I confess at once that if it were the case that a very substantial number of patients were being diverted from the great general hospitals to the private nursing homes, it would be a tendency that it would be desirable to check, for it would be conflicting with the principles that he read out from the Second Reading speech which I made to the House. However, until that condition is proved, it does not seem to me at this stage that any case has been made out for accepting the Amendment.

On the contrary, it might give rise to resentment in other quarters. Hon. Members will remember that when the National Health Services scheme was being shaped, a great many of my hon. Friends on this side of the Committee took exception to benefits to different classes of patients in the public service hospitals. They always felt there was a danger that if there were some patients who were paying patients as against those who were free, there would be a tendency to discrimination inside the service itself and create a two tier system of treatment. Whilst admitting that there might be some danger of that, I myself nevertheless believed that by administrative action we could prevent not only discrimination but a sense of discrimination, and I still believe that is true. It is of course a fact that there is a hangover from the past and that certain habits of mind will take some time to eliminate. Nevertheless, I believe the tendencies are all in a healthy direction and that before very many years are over there will not be any sense of discrimination or unfairness in the hospital administration.

The hon. Member is surely at fault when he says that injustice is being done. The persons who are taking advantage of Section 5 are doing so by their own election. He says that it is unfair that they should be charged twice, but it is not we who are the cause of that but they themselves. They make their contribution through the taxes to the National Health Service and then they elect to go outside the service. They are provided with a public service but they go outside the free service. It is only by physical association that it can be said to be outside the public service. It is outside the free public health service. I know this has been argued again and again. It cannot be said that injustice has been done to people in those circumstances, because the free Health Service is available to them. If they like to go outside the free service that is a matter of their own choice.

Mr. Sparks (Acton)

Would my right hon. Friend have regard to the fact that there is great delay in some hospitals in the patients securing immediate treatment, and that therefore some patients elect to be treated privately because they can get into hospital much more quickly in that way?

Mr. Bevan

The answer is that that always was the case, even more so than today. In any case, I should be very unhappy to learn that anybody had been able to pay his way into hospital ahead of another patient who could not afford to do the same.

Mr. Harrison (Nottingham, East)

It is done regularly.

Mr. Bevan

I am unhappy to hear about it. If my hon. Friends would give me particulars I should like to know more about it. It is understood that patients are admitted to hospital primarily on grounds of medical urgency. Cases might arise, I admit, of two patients in the same degree of medical urgency, one able to go into the private, paid-bed block, because a bed would be there, and the other unable to do so. I admit that that might happen, but what my hon. Friends have said is no argument for accepting the Amendment. It merely means that we must go ahead and provide additional hospital accommodation. When it is available these anomalies will disappear.

On the point whether an injustice is being done to the private patient, it seems to me that an injustice would be done to the Health Service as a whole if we charged a private patient less than it costs to maintain him. Why should the public service subsidise the person who has elected to be a private patient? If it can be made out in principle that there should be a subsidy at all, what should be the proportion of subsidy? If I admitted that there should be any subsidy at all from the public to private patients, no matter how small that subsidy, it would then be argued that I had conceded the principle itself. Then, if by some unhappy chance an Administration of a different political character took our places here, the charge to the private patient might be reduced still further on the ground that we had already admitted that the private patient ought not to pay the full charge. Surely the fair principle is that if a person has elected to go into the private, pay-bed block, he should pay the full charge.

Where the individual concerned is anxious to obtain privacy as an additional amenity, he may be able to do so. As the hon. Member opposite knows, such amenity beds are being increased. All over the country it is becoming easier for persons to purchase privacy. It always seemed to me to be reasonable, until we can provide perfect conditions for everybody, that persons who want privacy in hospital should be able to obtain it. They get the rest of the service free, but they pay for the additional amenity of privacy.

Mr. Howard

Would the right hon. Gentleman agree that in those cases they are not likely to have the benefit of the doctor of their choice?

Mr. Bevan

I said that they are paying only for the amenity in such a case. The hospital staffs are available to them. I think it will be discovered before very long by most people that when they pay for the separate specialist of their choice they are having exactly the same one as they would have had in the free ward, and that therefore they are paying for something which they are not in fact enjoying.

I hope that hon. Gentlemen opposite will realise that their Amendment would have the effect of increasing the cost of the National Health Service. I am continually being criticised about the cost of the service, but almost every time an Amendment is moved from the other side it is a proposal to increase that cost. Hon. Members opposite cannot have it both ways. The present practice is one of the ways in which administrative cost is kept down.

Mr. Linstead

I should like to put two considerations to the Minister which have not so far arisen in the speeches made to the Committee on this point. I agree with him that it is as well that we should try to keep the discussion of this subject on the basis of the Health Service rather than on a political basis. I think also we can say that there has been no misuse of the provisions of Section 5 in regard to paying for accommodation in hospital. Taking the hospital service as a whole, I am certain that medical priority determines whether beds are given to any particular patient or not. It is only when that principle has been satisfied that the paying patient can have any advantage.

The two points that I would put to the Minister are these. One of the principles of the service has been the free choice of the doctor by the patient. On the whole, that principle operates fairly in the general practitioner service. Once every six months, I think it is, a dissatisfied patient has the opportunity to change his doctor. Free choice of doctor does not operate in relation to hospital specialist services, except under a very heavy penalty. The only way to get a specialist of our choice in hospital is by becoming a Section 5 patient and paying the full cost of the bed into which we go.

Mr. Harrison

And the specialist's fee.

Mr. Linstead

Yes; on top of that you pay the specialist's fee.

Dr. Haden Guest (Islington, North)

Is the hon. Member suggesting that free choice of specialist existed before the Health Service came into operation? It was most uncommon for a patient to know anything about the specialist, except in a very small proportion of cases.

Mr. Linstead

I would go a very long way with the hon. Gentleman, but would add that the free choice of specialist was in that the general practitioner made his recommendation to the patient by saying, "You ought to see so-and-so." In the majority of cases the patient accepted that advice. That situation has completely disappeared now. When the patient goes into hospital he has either to accept the specialist who goes with the bed or to take the specialist chosen by himself or recommended by his general practitioner, in which case the only way is by paying the full cost. The principle of free choice of doctor is being greatly violated by the conditions tied to certain Section 5 beds, but they are laid down in the Act.

4.30 p.m.

The second point I wish to put to the Minister is much more pertinent to the Amendment. In the country there are something like 500 hospital management committees, and there are probably 1,500 or 2,000 individual hospitals to which Section 5 may apply. Each of those hospitals has to make its own calculation and arrive at its own weekly figure for Section 5 charges. It is not even that each hospital management committee can fix a figure for these beds. We have something like 1,500 possible variations in the weekly charge according to the upkeep costs of each institution. I saw figures the other day showing weekly charges varying from £8 to £12, and I was told today of charges which are considerably higher than £12 a week for the beds. It does not seem to be satisfactory that in a national scheme patients coming into Section 5 beds should have to pay fees varying from £8 to £15 or £16 a week—

Mr. Howard

Even £20 a week.

Mr. Linstead

—my hon Friend says £20 a week—according to the chance of the overhead costs of the hospital which they enter.

If we are to keep the Section 5 principle the least that can be done is for the Minister to fix a standard charge for all hospitals and not to leave it to the luck of the administration—whether it is a new hospital or an old one—as to whether the charges are high or low. I am rather surprised that the Minister is not prepared to accept the powers in the Amendment which would enable him to equalise charges which at present vary by 100 per cent. I hope he will give this matter further consideration if only on the basis that we ought not to present people in the National Health Service with charges varying from £8 to £20 for identical accommodation.

Mr. Baird (Wolverhampton, East)

It seems to me that the Minister is a little complacent about the danger of discrimination under the present arrangement. Under Section 4 we have the right to set up amenity beds and the patients will pay a small sum for a certain amount of privacy. Under Section 5 we have the pay beds, and in this case the patient pays 10, 12 or 14 guineas a week for the service and at the same time has to pay the specialist's private fees. That is all right, but it seems to me that if the Opposition are complaining about high charges for pay beds, the solution is not to reduce the cost of pay beds and make them more popular, but to develop amenity beds faster than is being done at present.

I have a very close relative who had to go into hospital in the London area last week. There was not a single amenity bed in the hospital although there were a large number of private pay beds. I believe that this is common all over the London area. The patient wanted privacy. The only way she could get it was by paying 10 guineas a week for a private bed plus 50 guineas specialist's fees. There are not enough amenity beds. Would it not be a solution to the problem to reduce the number of pay beds and hand them over for use as amenity beds? I believe that to be the right approach, and I hope the Minister will look into this. I want to point out that this does not happen in my division. In the Wolverhampton Royal Hospital we have no private pay beds, and I should like that to be the case in the London area.

Viscount Hinchingbrooke (Dorset, Southern)

I do not know what this is if it is not an extension of the amenity bed principle. The Minister says that it is right to develop amenity beds and right that a small charge should be made for them, but that when it comes to the provision of extra services on top of that, amenity bed patients are in some degree private patients, and he turns his back on the whole thing and says that the whole cost, including what is provided by the National Health Service, should be borne by the private patient. The Minister was not consistent in his argument. At first he inveighed against the whole principle of private practice in the hospital and then he turned to Section 4 which admits half the principle already. I should have thought that the Amendment only sought to extend the amenity bed principle and to provide that where specialists are brought in and extra services are given, there should still be subtracted that part of the cost provided by the general hospital service.

The Minister welcomed privacy and said that it must be provided and a little addition must be paid by the patient. What follows privacy? Why should there not be special accommodation, such as slightly more comfortable beds? There can be no objection to that. Why does the Minister stop at privacy? Why does he not accept the principle that there should be a sector of private payment to apply to the whole range of the services right up to the private ward and the consultant and specialist? We ask for that and nothing more. The Minister has destroyed the principle by admitting what is already in Section 4.

Mr. Harrison

The Committee will be aware that in many cases it is easy for people who have money at their disposal to buy their way out of the queue and obtain preferential admission to special beds or blocks in various institutions. Would it not give the case away completely if we agreed to the Amendment? There are complaints in many parts of the country about the ever-growing cost of the private beds in the pay bed blocks. There are complaints in my city that probably in the near future the cost will be £20 a week, a figure which it is almost impossible for many of the present occupants of the beds to pay. Those complaints are followed by the suggestion that the Minister should arrange, as the Amendment suggests, to subsidise this section of hospital work. It was with considerable gratification that I heard the Minister say categorically that he is not prepared in any circumstances to subsidise this hospital accommodation. The pressure of the demand for these pay beds has shown no reduction, and even if the pressure declined I suggest that that accommodation should be transferred for ordinary hospital purposes, thus extending the accommodation for people who certainly cannot afford to pay the sums which will shortly be asked of them for this accommodation.

Sir Hugh Lucas-Tooth (Hendon, South)

I merely wish to answer one point made by the Minister, that this proposal would increase the cost of the service. On the face of it that would appear to be so, but I believe that in practice it would have exactly the opposite effect, for this reason. A large number of people are anxious to be treated as private patients when they become sick and, when they enter hospital, would prefer to make a reasonable payment for their beds and to pay a reasonable fee for their specialist or consultant. Many, however, are people of moderate means who could not find a large sum, so when it is a question of finding the amount required to pay a specialist's fee, and on top of that they have to pay 20 guineas a week for perhaps four or five weeks, they cannot face it. All they can do is to go into the hospital completely free, without making any contribution whatever, instead of paying some reasonable amount, perhaps five guineas or 10 guineas a week for accommodation and services while in the hospital.

If the right hon. Gentleman would look into the question, I am certain he would find that he could expand the area in which hospitals could admit paying patients, and that the net result to the service would be to derive a larger financial benefit than the service would suffer by reason of any immediate reduction.

Dr. Segal (Preston)

I think it would be fair comment on this Amendment to say that it is inopportune. Although a case could be argued for it, and some of us on this side of the Committee might feel a good deal of sympathy with it, yet when the resources of the Minister are limited, as we all know they are, they should be concentrated where the need is greatest. For the moment we should not introduce into the framework of the Bill these little ancillary frills which are not as desperately urgent as the main work that lies ahead. Perhaps in a few years time this Amendment may be worthy of fuller consideration but, in the meantime, it is the duty of the Minister to concentrate all his efforts where the need is greatest.

Mr. Sparks

It is important that we should not do anything this afternoon which would tend to encourage an increasing demand for private beds, treated by private specialists in hospitals to the detriment of the general Health Service patient who desires to have treatment. In London particularly there is a serious shortage of accommodation in most of our hospitals for the Health Service patient who cannot afford to pay for an amenity bed and a specialist's fee. Consequently there is a fairly long waiting list in some areas, people are having difficulty in getting in as Health Service patients, and too often it is the practice to persuade such persons to sign a document agreeing to be private patients of the specialist.

A case recently brought to my notice involved a lady who, unable to get into her local hospital as a Health Service patient because of the long waiting list, was persuaded by a private doctor to become a private patient of the specialist. Because she was in pain she elected to do this. She was taken into hospital and after treatment her husband was presented with a bill, which he cannot afford to pay, for 50 guineas, together with the full charge of the pay bed.

There is another way of helping patients apart from reducing the maintenance charge for the use of pay beds in hospitals. If hon. Gentlemen opposite could persuade the specialists to reduce their fees a little to poor people, that would help considerably in overcoming the difficulty which they themselves have adumbrated this afternoon, whereas this Amendment would tend to encourage the increasing demands upon hospital accommodation for private patients to the detriment of poorer people who cannot afford the specialist service.

4.45 p.m.

Mr. Kenneth Lindsay (Combined English Universities)

I want to ask a question, Mr. Bowles, if I may be allowed to do so at this point. My experience is exactly the same as that of the hon. Members for East Wolverhampton (Mr. Baird) and for Acton (Mr. Sparks). I speak with feeling because it concerns a near relative of mine in the City of London. Is it not wrong that a person, who when in great pain agreed to pay three guineas a day for a private bed in a hospital, should not be notified that the specialist service is to be paid for, and should receive a bill for £25 two weeks later? In the case I have in mind, the individual concerned wrote to the general practitioner three times to ask what was the origin of it and why he was not notified before, and he did not even receive a reply. The bill has to be paid, but it seems to me to be an abuse of the present situation.

I am not speaking necessarily for this Amendment but I am saying that the situation in London at present is being abused—

The Deputy-Chairman (Mr. Bowles)

I am sorry to interrupt the hon. Member who is not speaking to this Amendment. It does not refer to specialists or doctors, but to accommodation.

Mr. Lindsay

Indeed I am speaking about the service, which includes specialist service. That is half the point of the Amendment, Mr. Bowles.

The Deputy-Chairman

With respect, I doubt very much whether it does. I think it comes later, when the Bill will be considered on Report stage.

Mr. Henry Strauss (Combined English Universities)

The point made by the hon. Member for Acton (Mr. Sparks) is met completely by the proviso to Section 5 (1) of the 1946 Act. The risk to which he drew attention really is an impossibility if the Minister carries out the express words of the Act. I am not questioning for one moment that the hon. Member thought he had a point which was perfectly germane to the Amendment, but really it does not tell one way or the other as regards the Amendment before the Committee. Having said what I thought needed pointing out, I do not wish to intervene further in a matter which has been dealt with by those who have far greater knowledge of the working of the hospitals than I have.

Mr. Bevan

May I interrupt the proceedings for a moment in order to give a piece of information? I asked for an investigation to be made—not an exhaustive one because that would have occupied too much time and clerical work, but a spot investigation of the number of free patients in pay bed blocks in order to check to what extent free patients were not admitted on medical grounds entirely to these blocks. My information is that at least 40 per cent. of the pay bed blocks are occupied by free patients, which is itself a tribute to the way in which the administration is carrying out the terms of the Act.

Mr. Harrison

On a point of information, would my right hon. Friend say what he means by a free bed patient? Does he mean that the patient pays for the bed only?

Mr. Bevan

I was referring to Section 5 beds—that is to say, where in ordinary circumstances, if a bed is occupied by a fee-paying patient, both the bed and the specialist fees are paid.

May I be permitted to reply to the question of the hon. Member for the Combined English Universities (Mr. K. Lindsay), because it was a point of some substance? I sent out some time ago an instruction that the patient was to be informed by the general practitioner or the specialist, or both, whether in fact he was to be treated under the National Health Service or as a fee-paying patient. That is to say, the patient ought not to be unaware of his position and subsequently be confronted with bills. It is the obligation of the doctor, to inform, or to ask, the patient whether he or she wishes to be treated as a free patient or as a fee-paying patient. I should be grateful for examples of where this procedure is not being followed, for it is obviously a monstrous hardship on a patient who has been assuming throughout that he or she was being treated inside the free service to be faced with heavy bills.

Mr. Sparks

Is it in order for any medical practitioner or specialist to promise that a person can get into hospital for treatment sooner and quicker by becoming a private patient?

Mr. Bevan

It is not proper to do so. It is the duty of the hospital authorities to admit patients on medical grounds and, where medical grounds are satisfied, to admit patients into the free bed block. The figures I have given show that in most cases this has been carried out. I hope that where it is not being carried out, this Debate will be read by the hospital authorities concerned, because it is an abuse of the service not to follow this procedure.

Mr. Richard Law (Kensington, South)

The right hon. Gentleman, if he will allow me to say so, has this afternoon been very concilatory—I might even say, unusually concilatory. If the force of his arguments equalled the gentleness of his manner, we should not have to ask the Committee to divide on the Amendment, but I cannot see that in either his opening speech or the explanation he has just given there is anything which really justifies him in rejecting the Amendment. I should like to examine some of the arguments which he has given to the Committee. He said that there was no evidence of any increase in the demand for private nursing homes. Of course, he is a far better judge than we are of what the evidence is. He said also that if there were evidence, then, of course, he would have to reconsider the position and possibly accept proposals of this kind. Whether or not evidence exists at this moment, it is surely quite clear that if the existing tendencies continue and if prices continue to rise, the private patient will be effectively driven out of the National Health Service hospitals—the public hospitals—and that these nursing homes are bound to come into being. That seems to me to be inevitable.

One point which the Minister made seems to me to be, not disingenuous, but very one-sided. He said that, after all, even if the choice which private patients in Section 5 beds had to make was a hard one, the choice was free. Of course, that is perfectly true. Patients know when they go into private beds of this kind that they will be called upon to pay twice. In a sense, as the right hon. Gentleman said, the choice which faces somebody going into a Section 5 bed is a free choice. He knows that if he goes into that private bed he will be asked to pay double: he will be asked to pay as a taxpayer and as a subscriber to the social security scheme—

Mr. Bevan

He does that.

Mr. Law

—and he will be asked to pay the whole charge of the private bill That, in a sense, is a free choice, but the framework of that choice is not free. It would be equally a free choice if one were to say to somebody, "You can either have nothing or you can have bread and water." The choices that the right hon. Gentleman poses are unfair choices compared with the choice posed to the ordinary citizen who does not go into a Section 5 bed. If it is the case, as, I think, the right hon. Gentleman will admit, that the patient is in a sense paying twice over, both as a citizen and as a private patient, the argument of the right hon. Gentleman would be equally sound if the patient were paying four or ten times over.

Mr. Bevan

Or if he goes to a nursing home.

Mr. Law

Or if he goes to a nursing home. In fact, the Minister is presenting the private patient with a choice whit is hard by comparison to the choice presented to the public patient.

Mr. Bevan

That happens right throughout the service. A person can go to a dentist and either pay for his treatment or have it under the free service; or he can go to an ophthalmic optician and either pay for his spectacles or have them free. He can do that throughout the whole service. It is the individual consumer of the service who decides into which category he is to place himself.

Mr. Law

The individual consumer of the service may be obliged to go into hospital, but the choice with which the Minister presents him is, surely, not a fair one, because he could have presented him with the other choice—the same choice, for example, as is presented to the people who use the amenity beds of Section 4. The right hon. Gentleman said that it would be wrong to charge the private patient less than the cost of the service. I will not suggest to him that that is begging the question, because everybody who goes into hospital is charged less than the service costs—that is the purpose of the National Health Service; people who are unfortunate enough to become ill and need hospital attention get it as a right and without paying the whole charges.

All we are asking under the Amendment is not that the private patient should be specially treated, but that he should be treated in exactly the same way as the public patient. We are not asking that he should get his private accommodation for nothing; all we are asking is that whatever hypothetical allowance might be made for the public patient, whatever his costs might be, that amount might be deducted from the sum which is chargeable to the private patient. We are not asking that the private patient should have special privileges. We are asking that he should have exactly the same privileges as the public patient.

The last point made by the right hon. Gentleman on the increase in the cost of the National Health Service was a very neat and fairly obvious debating point, but I think it was disposed of by my hon. Friend the Member for South Hendon (Sir H. Lucas-Tooth). The fact remains that if through increasing costs the private patient is driven out of the private ward, the contribution which he would make to the National Health Service will disappear, and, therefore, the cost of the National Health Service will go up, and not down. I should have thought that there were strong arguments, on grounds of both national and administrative economy, for accepting the Amendment, for I am sure that in the long run the charge on the taxpayer would diminish and not increase, as the right hon. Gentleman seemed to imagine.

Several Hon. Members


The Deputy-Chairman

I think that the Committee might come to a decision.

Dr. Morgan (Rochdale)

I am surprised at the arguments used by the other side of the Committee, because the plea which is made is that the National Health Service should become a private service for private individuals with a discrimination in favour of the wealthy. As one who has just had experience of both the National Health Service and private beds in a teaching hospital and one in an exempted hospital, I think that the whole of the argument used here today is in favour of discrimination for the wealthy patient.

The Act is working well, and the first thing the Minister has to see is that any discrimination should be on medical grounds; secondly, that any further discrimination should be on amenity grounds, from the point of view of the patient having solitude and so on, and thirdly, that if a patient has additional amenities and chooses a specialist, for which he has to pay he should also have to pay for his bed. We should have no further extension of the paying beds system by which certain patients can get additional benefits. This subject is controversial and has been fought out in the medical profession. The professional men have decided in favour of the Act as it stands. I know them and am in close touch with the profession, and I know how the profession is feeling on this matter. The Opposition should think twice before they press for a system of this kind, which is so contrary to the whole Act.

Question put, "That those words be there inserted."

The Committee divided: Ayes; 139; Noes, 256.

Division No. 249.] AYES [3.35 p.m.
Adams, Richard (Balham) Davies, R. J. (Westhoughton) Jeger, G. (Winchester)
Albu, A. H. Deer, G. Jenkins, R. H.
Allen, A. C. (Bosworth) Dobbie, W. John, W.
Allen, Scholefield (Crewe) Dodds, N. N. Johnston, Douglas
Alpass, J. H. Driberg, T. E. N. Jones, Rt. Hon. A. C. (Shipley)
Anderson, A. (Motherwell) Dugdale, J. (W. Bromwich) Jones, D. T. (Hartlepool)
Attewell, H. C. Dye, S. Keenan, W.
Attlee, Rt. Hon. C. R. Ede, Rt. Hon. J. C. Kenyon, C.
Austin, H. Lewis Edwards, Rt. Hon. Sir C. (Bedwellty) Kinghorn, Sqn.-Ldr. E.
Awbery, S. S. Evans, Albert (Islington, W.) Kinley, J.
Ayles, W. H. Evans, E. (Lowestoft) Kirby, B. V.
Ayrton Gould, Mrs. B. Evans, John (Ogmore) Kirkwood, Rt. Hon. D.
Bacon, Miss A. Evans, S. N. (Wednesbury) Lang, G.
Baird, J. Ewart, R. Lavers, S.
Balfour, A. Fairhurst, F. Lawson, Rt. Hon. J. J.
Barstow, P. G. Farthing, W. J. Lee, F. (Hulme)
Barton, C. Fernyhough, E. Lee, Miss J. (Cannock)
Battley, J. R. Fletcher, E. G. M. (Islington, E.) Leonard, W.
Bechervaise, A. E. Forman, J. C. Lewis, A. W. J. (Upton)
Bellenger, Rt. Hon. F. J. Fraser, T. (Hamilton) Lipson, D. L.
Benson, G. Freeman, Peter (Newport) Lipton, Lt.-Col. M.
Berry, H. Gallacher, W. Logan, D. G.
Beswick, F. Ganley, Mrs. C. S. Longden, F.
Bevan, Rt. Hon. A. (Ebbw Vale) Gibson, C. W. Lyne, A. W.
Bing, G. H. C. Gilzean, A. McAdam, W.
Binns, J. Glanville, J. E. (Consett) McEntee, V. La T.
Blackburn, A. R. Gooch, E. G. McGhee, H. G.
Blenkinsop, A. Goodrich, H. E. Mack, J. D.
Blyton, W. R. Greenwood, Rt. Hon. A. (Wakefield) McKay, J. (Wallsend)
Bowen, R. Greenwood, A. W. J. (Heywood) Maclean, N. (Govan)
Bramall, E. A. Grey, C. F. McLeavy, F.
Brook, D. (Halifax) Grierson, E. MacPherson, Malcolm (Stirling)
Brooks, T. J. (Rothwell) Griffiths, D. (Rother Valley) Macpherson, T. (Romford)
Broughton, Dr. A. D. D. Griffiths, W. D. (Moss Side) Mainwaring, W. H.
Brown, T. J. (Ince) Gruffydd, Prof. W. J. Mallalieu, J. P. W. (Huddersfield)
Bruce, Maj. D. W. T. Guest, Dr. L. Haden Mann, Mrs. J.
Burke, W. A. Gunter, R. J. Manning, Mrs. L. (Epping)
Carmichael, James Haire, John E. (Wycombe) Mathers, Rt. Hon. George
Chamberlain, R. A. Hale, Leslie Medland, H. M.
Champion, A. J. Hall, Rt. Hon. Glenvil Mellish, R. J.
Chater, D. Hamilton, Lieut.-Col. R. Messer, F.
Chetwynd, G. R. Hardy, E. A. Mitchison, G. R.
Cluse, W. S. Harrison, J. Monslow, W.
Cobb, F. A. Hastings, Dr. Somerville. Moody, A. S.
Cocks, F. S. Herbison, Miss M. Morgan, Dr. H. B.
Collindridge, F. Hobson, C. R. Morley, R.
Colman, Miss G. M. Holman, P. Morris, Hopkin (Carmarthen)
Cook, T. F. Holmes, H. E. (Hemsworth) Morrison, Rt. Hon. H. (Lewisham, E.)
Cooper, G. Horabin, T. L. Mort, D. L.
Corlett, Dr. J. Houghton, Douglas Moyle, A.
Cove, W. G. Hoy, J. Nally, W.
Crawley, A. Hubbard, T. Neal, H. (Claycross)
Cullen, Mrs. Hudson, J. H. (Ealing, W.) Nichol, Mrs. M. E. (Bradford, N.)
Daggar, G. Hughes, Emrys (S Ayr) Nicholls, H. R. (Stratford)
Daines, P. Hughes, H. D. (W'lverh'pton, W) Noel-Baker, Capt. F. E. (Brentford)
Davies, Edward (Burslem) Hynd, H. (Hackney, C.) Oldfield, W. H.
Davies, Ernest (Enfield) Hynd, J. B. (Attercliffe) Oliver, G. H.
Davies, Harold (Leek) Irving, W. J. (Tottenham, N.) Paling, Rt. Hon. Wilfred (Wentworth)
Davies, Haydn (St. Pancras, S. W.) Janner, B. Paling, Will T. (Dewsbury)
Pannell, T. C. Royle, C. Tolley, L.
Pargiter, G. A. Scollan, T. Usborne, Henry
Parker, J. Segal, Dr. S. Vernon, Maj. W. F.
Paton, Mrs. F. (Rushcliffe) Sharp, Granville Viant, S. P.
Paton, J. (Norwich) Shurmer, P. Wallace, G. D. (Chislehurst)
Pearson, A. Silverman, J. (Erdington) Wallace, H. W. (Walthamstow, E.)
Peart, T. F. Silverman, S. S. (Nelson) Warbey, W. N.
Piratin, P. Skeffington-Lodge, T. C. Watkins, T. E.
Poole, Cecil (Lichfield) Skinnard, F. W. Watson, W. M.
Popplewell, E. Smith, C. (Colchester) Webb, M. (Bradford, C.)
Porter, E. (Warrington) Smith, H. N. (Nottingham, S.) Wells, P. L. (Faversham)
Porter, G. (Leeds) Snow, J. W. Wheatley, Rt. Hn. John (Edinb'gh, E.)
Pritt, D. N. Soskice, Rt. Hon. Sir Frank White, H. (Derbyshire, N. E.)
Proctor, W. T. Sparks, J. A. Whiteley, Rt. Hon. W.
Pryde, D. J. Stewart, Michael (Fulham, E.) Wilkins, W. A.
Pursey, Comdr. H. Stokes, R. R. Willey, O. G. (Cleveland)
Randall, H. E. Strachey, Rt. Hon. J. Williams, D. J. (Neath)
Ranger, J. Stubbs, A. E. Williams, J. L. (Kelvingrove)
Rankin, J. Summerskill, Rt. Hon. Edith Williams, W. R. (Heston)
Rees-Williams, D. R. Swingler S. Wills, Mrs. E. A.
Reeves, J. Sylvester, G. O. Woodburn, Rt. Hon. A.
Reid, T. (Swindon) Taylor, H. B. (Mansfield) Woods, G. S.
Richards, R. Taylor, R. J. (Morpeth) Wyatt, W.
Ridealgh, Mrs. M. Taylor, Dr. S. (Barnet) Yates, V. F.
Robens, A. Thomas, D. E. (Aberdare) Younger, Hon. Kenneth
Roberts, W. (Cumberland, N.) Thurtle, Ernest
Robertson, J. J. (Berwick) Tiffany, S. TELLERS FOR THE AYES:
Robinson, Kenneth (St. Pancras, N.) Timmons, J. Mr. Joseph Henderson and
Mr. Bowden.
Agnew, Cmdr. P. G. Harris, F. W. (Croydon, N.) O'Neill, Rt. Hon. Sir H.
Baldwin, A. E. Harris, H. Wilson (Cambridge Univ.) Peto, Brig. C. H. M.
Barlow, Sir J. Harvey, Air-Comdre, A. V. Ponsonby, Col. C. E.
Baxter, A. B. Head, Brig. A. H. Poole, O. B. S. (Oswestry)
Beamish, Maj. T. V. H. Henderson, John (Cathcart) Price-White, D.
Bennett, Sir P. Hinchingbrooke, Viscount Prior-Palmer, Brig. O.
Birch, Nigel Hogg, Hon. Q. Raikes, H. V.
Bossom, A. C. Hollis, M. C. Reed, Sir S. (Aylesbury)
Bower, N. Holmes, Sir J. Stanley (Harwich) Roberts, P. G. (Ecclesall)
Boyd-Carpenter, J. A. Howard, Hon. A. Robertson, Sir D. (Streatham)
Bromley-Davenport, Lt.-Col. W. Hurd, A. Robinson, Roland (Blackpool, S.)
Buchan-Hepburn, P. G. T. Hutchison, Lt.-Cm. Clark (E'b'rgh, W.) Ropner, Col. L.
Butcher, H. W. Hutchison, Col. J. R. (Glasgow, C.) Ross, Sir R. D. (Londonderry)
Carson, E. Jarvis, Sir J. Sanderson, Sir F.
Channon, H. Jeffreys, General Sir G. Savory, Prof. D. L.
Clifton-Brown, Lt.-Col. G. Joynson-Hicks, Hon. L. W. Scott, Lord W.
Conant, Maj. R. J. E. Keeling, E. H. Shephard, S. (Newark)
Corbett, Lieut.-Col. U. (Ludlow) Lambert, Hon. G. Shepherd, W. S. (Bucklow)
Crookshank, Capt. Rt. Hon. H. F. C. Lancaster, Col. C. G. Smithers, Sir W.
Crosthwaite-Eyre, Col. O. E. Langford-Holt, J. Snadden, W. M.
Crowder, Capt. John E. Law, Rt. Hon. R. K. Spearman, A. C. M.
Darling, Sir W. Y. Legge-Bourke, Maj. E. A. H. Stewart, J. Henderson (Fife, E.)
De la Bère, R. Lennox-Boyd, A. T. Stoddart-Scott, Col. M.
Digby, S. Wingfield Lewis, T. (Southampton) Strauss, Henry (English Universities)
Donner, P. W. Linstead, H. N. Studholme, H. G.
Dower, Col. A. V. G. (Penrith) Lloyd, Maj. Guy (Renfrew, E.) Sutcliffe, H.
Drayson, G. B. Lloyd, Selwyn (Wirral) Taylor, Vice-Adm. E. A. (P'dd't'n, S.)
Drewe, C. Lucas, Major Sir J. Teeling, William
Dugdale, Maj. Sir T. (Richmond) Lucas-Tooth, Sir H. Thomas, Ivor (Keighley)
Duthie, W. S. Macdonald, Sir P. (I. of Wight) Thorneycroft, G. E. P. (Monmouth)
Eccles, D. M. McFarlane, C. S. Thornton-Kemsley, C. N.
Eden, Rt. Hon. A. Maclean, F. H. R. (Lancaster) Turton, R. H.
Elliot, Lieut.-Col. Rt. Hon. Walter Macpherson, N. (Dumfries) Tweedsmuir, Lady
Erroll, F. J. Maitland, Comdr. J. W. Wakefield Sir W. W.
Fleming, Sqn.-Ldr. E. L. Manningham-Buller, R. E. Ward, Hon. G. R.
Fraser, Sir I. (Lonsdale) Marlowe, A. A. H. Webbe, Sir H. (Abbey)
Fyfe, Rt. Hon. Sir D. P. M. Marsden, Capt. A. White, Sir D. (Fareham)
Galbraith, T. G. D. (Hillhead) Marshall, D. (Bodmin) Williams, C. (Torquay)
Gates, Maj. E. E. Molson, A. H. E. York, C.
George, Maj. Rt. Hn. G. Lloyd (P'ke) Moore, Lt.-Col. Sir T. Young, Sir A. S. L. (Partick)
Glyn, Sir R. Morris-Jones, Sir H.
Gomme-Duncan, Col. A. Noble, Comdr. A. H. P. TELLERS FOR THE NOES:
Harden, J. R. E. Odey, G. W. Brigadier Mackeson and
Colonel Wheatley.

Question put, and agreed to.

Division No. 250.] AYES 4.59 p.m.
Agnew, Cmdr. P. G. Harden, J. R. E. Peto, Brig. C. H. M.
Amory, D. Heathcoat Harris, F. W. (Croydon, N.) Pickthorn, K.
Baldwin, A. E. Harvey, Air-Comdre A. V. Ponsonby, Col. C. E.
Barlow, Sir J. Head, Brig. A. H. Poole, O. B. S. (Oswestry)
Baxter, A. B. Henderson, John (Cathcart) Price-White, D.
Beamish, Maj. T. V. H. Hinchingbrooke, Viscount Raikes, H. V.
Bennett, Sir P. Hollis, M. C. Reed, Sir S. (Aylesbury)
Birch, Nigel Holmes, Sir J. Stanley (Harwich) Roberts, P. G. (Ecclesall)
Bowen, R. Howard, Hon. A. Roberts, W. (Cumberland, N.)
Bower, N. Hudson, Rt. Hon. R. S. (Southport) Robertson, Sir D. (Streatham)
Boyd-Carpenter, J. A. Hutchison, Lt.-Cm. Clark (E'b'rgh, W) Robinson, Roland (Blackpool, S.)
Bracken, Rt. Hon. Brendan Jarvis, Sir J. Ropner, Col. L.
Bromley-Davenport, Lt.-Col. W. Jeffreys, General Sir G. Ross, Sir R. D. (Londonderry)
Buchan-Hepburn, P. G. T. Jennings, R. Sanderson, Sir F.
Butcher, H. W. Joynson-Hicks, Hon. L. W. Savory, Prof. D. L.
Butler, Rt. Hn. R. A. (S'ffr'n W'ld'n) Keeling, E. H. Scott, Lord W.
Carson, E. Lancaster, Col. C. G. Shephard, S. (Newark)
Channon, H. Law, Rt. Hon. R. K. Shepherd, W. S. (Bucklow)
Clarke, Col. R. S. Legge-Bourke, Maj. E. A. H. Smiles, Lt.-Col Sir W.
Cl fton-Brown, Lt.-Col. G. Lennox-Boyd, A. T. Smith, E. P. (Ashford)
Corbett, Lieut.-Col. U. (Ludlow) Linstead, H. N. Smithers, Sir W.
Crookshank, Capt. Rt. Hon. H. F. C. Lipson, D. L. Snadden, W. M.
Crosthwaite-Eyre, Col. O. E. Lloyd, Maj. Guy (Renfrew, E.)
Crowder, Capt. John E. Lloyd, Selwyn (Wirral) Spearman, A. C. M.
Darling, Sir W. Y. Low, A. R. W. Spence, H. R.
De la Bère, R. Lucas-Tooth, Sir H. Stewart, J. Henderson (Fife, E.)
Digby, S. Wingfield Lyttelton, Rt. Hon. O. Stoddart-Scott, Col. M.
Donner, P. W. Macdonald, Sir P. (I. of Wight) Strauss, Henry (English Universities)
Dower, Col. A. V. G. (Penrith) McFarlane, C. S. Stuart, Rt. Hon. J. (Moray)
Drayson, G. B. Mackeson, Brig. H. R. Sutcliffe, H.
Drewe, C. McKie, J. H. (Galloway) Taylor, Vice-Adm. E. A. (P'dd't'n, S.)
Dugdale, Maj. Sir T. (Richmond) Maclean, F. H. R. (Lancaster) Thomas, Ivor (Keighley)
Duncan, Rt. Hn. Sir A. (City of Lond.) Macpherson, N. (Dumfries) Thorneycroft, G. E. P. (Monmouth)
Eccles, D. M. Maitland, Comdr J. W. Thornton-Kemsley, C. N.
Eden, Rt. Hon. A. Manningham-Buller, R. E. Turton, R. H.
Elliot, Lieut.-Col. Rt. Hon. Walter Marshall, D. (Bodmin) Wadsworth, G.
Erroll, F. J. Mellor, Sir J. Wakefield, Sir W. W.
Fleming, Sqn.-Ldr. E. L. Molson, A. H. L. Webbe, Sir H. (Abbey)
Fox, Sir G. Morris, Hopkin (Carmarthen) Wheatley, Colonel M. J. (Dorset, E.)
Fraser, Sir I. (Lonsdale) Morris-Jones, Sir H. White, Sir D. (Fareham)
Fyfe, Rt. Hon. Sir D. P. M. Mott-Radclyffe, C. E. Williams, C. (Torquay)
Galbraith, T. G. D. (Hillhead) Nicholson, G. Williams, Gerald (Tonbridge)
Gates, Maj. E. E. Nield, B. (Chester) Willoughby de Eresby, Lord
Glyn, Sir R. Noble, Comdr. A. H. P. Winterton, Rt. Hon. Earl
Gomme-Duncan, Col. A. Odey, G. W. Young, Sir A. S. L. (Partick)
Grimston, R. V. O'Neill, Rt. Hon. Sir H.
Hannon, Sir P. (Moseley) Orr-Ewing, I. L. TELLERS FOR THE AYES:
Mr. Studholme and Major Conant.
Albu, A. H. Brown, T. J. (Ince) Dodds, N. N.
Allen, A. C. (Bosworth) Bruce, Maj. D. W. T. Donovan, T.
Allen Scholefield (Crewe) Burden, T. W. Driberg, T. E. N.
Alpass, J. H. Burke, W. A. Dye, S.
Anderson, A. (Motherwell) Butler, H. W. (Hackney, S.) Ede, Rt. Hon. J. C.
Attewell, H. C. Carmichael, James Edwards, Rt. Hon. Sir C. (Bedwellty)
Austin, H. Lewis Champion, A. J. Edwards, Rt. Hon. N. (Caerphilly)
Awbery, S. S. Chater, D. Evans, Albert (Islington, W.)
Ayles, W. H. Chetwynd, G. R. Evans, E. (Lowestoft)
Ayrton Gould, Mrs. P. Cluse, W. S. Evans, John (Ogmore)
Bacon, Miss A. Cobb, F. A. Evans, S. N. (Wednesbury)
Baird, J. Cocks, F. S. Ewart, R.
Balfour, A. Collindridge, F. Fairhurst, F.
Barnes, Rt. Hon. A. J. Colman, Miss G. M. Farthing, W. J.
Barton, C. Cook, T. F. Fernyhoush, E.
Battley, J. R. Cooper, G. Forman, S. C.
Bechervaise, A. E. Corlett, Dr. J. Fraser, T. (Hamilton)
Benson, G. Cove, W. G. Freeman, Peter (Newport)
Bevan, Rt. Hon. A. (Ebbw Vale) Crawley, A. Gallacher, W.
Bing, G. H. C. Cullen, Mrs. Ganley, Mrs. C. S.
Binns, J. Daggar, G. Gibson, C. W.
Blackburn, A. R. Daines, P. Gilzean, A.
Blenkinsop, A. Davies, Edward (Burslem) Glanville, J. E. (Consett)
Blyton, W. R. Davies, Harold (Leek) Gooch, E. G.
Boardman, H. Davies, Haydn (St Pancras, S. W.) Goodrich, H. E.
Bowden, H. W. Davies, R. J. (Westhoughton) Greenwood, Rt. Hon. A. (Wakefield)
Braddock, T. (Mitcham) Deer, G. Greenwood, A. W. J. (Heywood)
Brook, D. (Halifax) Delargy, H. J. Grey, C. F.
Brooks, T. J. (Rothwell) Diamond, J. Grierson, E.
Broughton, Dr. A. D. D. Dobbie, W. Griffiths, D. (Rother Valley)
Griffiths, Rt. Hon. J. (Llanelly) Mallalieu, J. P. W. (Huddersfield) Sharp, Granville
Griffiths, W. D. (Moss Side) Mann, Mrs. J. Shurmer, P.
Guest, Dr. L. Haden Manning, Mrs. L. (Epping) Silverman, J. (Erdington)
Gunter, R. J. Mathers, Rt. Hon. George Silverman, S. S. (Nelson)
Hairs, John E. (Wycombe) Medland, H. M. Simmons, C. J.
Hamilton, Lieut.-Col. R. Mellish, R. J. Skeffington-Lodge, T. C.
Hannan, W. (Maryhill) Messer, F. Skinnard, F. W.
Hardy, E. A. Mitchison, G. R. Smith, H. N. (Nottingham, S.)
Harrison, J. Monslow, W. Smith, S. H. (Hull, S. W.)
Hastings, Dr. Somerville. Moody, A. S. Snow, J. W.
Henderson, Joseph (Ardwick) Morgan, Dr. H. B. Sorensen, R. W.
Herbison, Miss M. Morley, R. Sparks, J. A.
Hobson, C. R. Mort, D. L. Stewart, Michael (Fulham, E.)
Holman, P. Moyle, A. Stubbs, A. E.
Holmes, H. E. (Hemsworth) Nally, W. Summerskill, Rt. Hon. Edith
Houghton, Douglas Naylor, T. E. Sylvester, G. O.
Hoy, J. Neal, H. (Claycross) Symonds, A. L.
Hubbard, T. Nicholls, H. R. (Stratford) Taylor, H. B. (Mansfield)
Hudson, J. H. (Ealing, W.) O'Brien, T. Taylor, R. J. (Morpeth)
Hughes, Emrys (S Ayr) Oldfield, W. H. Taylor, Dr. S. (Barnet)
Hughes, H. D. (W'lverh'pton, W.) Oliver, G. H. Thomas, D. E. (Aberdare)
Hynd, H. (Hackney, C.) Orbach, M. Thomas, John R. (Dover)
Hynd, J. B. (Attercliffe) Paling, Will T. (Dewsbury) Thurtle, Ernest
Irving, W. J. (Tottenham, N.) Pannell, T. C. Tiffany, S.
Janner, B. Pargiter, G. A. Timmons, J.
Jeger, Dr. S. W. (St. Pancras, S. E.) Parker, J. Tolley, L.
Jenkins, R. H. Paton, Mrs. F. (Rusholiffe) Turner-Samuels, M.
John, W. Paton, J. (Norwich) Ungoed-Thomas, L.
Jones, D. T. (Hartlepool) Peart, T. F. Vernon, Maj. W. F.
Keenan, W. Piratin, P. Viant, S. P.
Kenyon, C. Platts-Mills, J. F. F. Wallace, G. D. (Chislehurst)
Key, Rt. Hon. C. W. Poole, Cecil (Lichfield) Wallace, H. W. (Walthamstow, E.)
Kinghorn, Sqn.-Ldr. E. Popplewell, E. Warbey, W. N.
Kinley, J. Porter, E. (Warrington) Watkins, T. E.
Kirby, B. V. Porter, G. (Leeds) Watson, W. M.
Kirkwood, Rt. Hon. D. Price, M. Philips Webb, M. (Bradford, C.)
Lang, G. Pritt, D. N. Wells, P. L. (Faversham)
Lavers, S. Proctor, W. T. Wheatley, Rt. Hn. John (Edinb'gh, E.)
Lee, F. (Hulme) Pryde, D. J. White, H. (Derbyshire, N. E.)
Lee, Miss J. (Cannock) Pursey, Comdr. H. Whiteley, Rt. Hon. W.
Leonard, W. Randall, H. E. Wilkins, W. A.
Lewis, A. W. J. (Upton) Ranger, J. Willey, O. G. (Cleveland)
Logan, D. G. Rankin, J. Williams, D. J. (Neath)
Longdon, F. Reeves, J. Williams, J. L. (Kelvingrove)
Lyne, A. W. Reid, T. (Swindon) Williams, W. R. (Heston)
McAdam, W. Rhodes, H. Willis, E.
McEntee, V. La T. Richards, R. Wills, Mrs. E. A.
McGhee, H. G. Ridealgh, Mrs. M. Woodburn, Rt. Hon. A.
Mack, J. D. Robertson, J. J. (Berwick) Woods, G. S.
McKay, J. (Wallsend) Robinson, Kenneth (St. Pancras, N.) Wyatt, W.
Mackay, R. W. G. (Hull, N. W.) Ross, William (Kilmarnock) Yates, V. F.
Maclean, N. (Govan) Royle, C. Zilliacus, K.
McLeavy, F. Sargood, R.
MacPherson, Malcolm (Stirling) Scollan, T. TELLERS FOR THE NOES:
Macpherson, T. (Romford) Scott-Elliot, W. Mr. Pearson and
Mainwaring, W. H. Segal, Dr. S. Mr. Richard Adams.
Mallalieu, E. L. (Brigg) Shackleton, E. A. A.
Mr. Bevan

I beg to move, in page 22, line 9, at the end, to insert: At the end of paragraph (a) of subsection (1) of Section twenty-one (which requires facilities at health centres to be available for the provision of general medical services), there shall be inserted the words 'and, on such terms and conditions as may be determined by the Minister, for the provision by medical practitioners of such other personal medical services (if any) as may be so determined in the case of a particular health centre.' The purpose of this Amendment is to enable general practitioners to treat private patients in health centres. This proposition has given rise to considerable controversy, and at one time I set my face against it. The reason I did so was because at that time it was uncertain what proportion of the population would actually register with practitioners. Now, however, the number of persons outside the scheme is so infinitesimal that no danger can arise to the structure of the Service as a whole by allowing general practitioners to take their private patients into the health centres when they are available.

It would not have been unreasonable that if a general practitioner had a substantial proportion of private patients he should treat them in his own private surgery and go to the health centre to treat his public patients. Also, there was always a doubt in my mind whether, if there was a large number of private patients and a large number of public patients at the health centre, there might not be the danger of discrimination which we have already discussed in connection with the hospital service as a whole.

In view of the fact that the number of people outside the Health Service is very small, it would be unreasonable, where a health centre is available, to expect the general practitioner to maintain a private surgery at which to treat his private patients. However, we shall make it quite clear by regulation, when the health centres are available, that there shall be no two doors in the health centre—one through which shall go the private patient and another through which shall go the public patient—because that would create the very atmosphere which we are anxious to avoid. If a person wishes, for some strange reason which I am afraid I cannot distinguish, to attend a private practitioner in a health centre, that private patient must take his proper place along with the general public in seeking the services of his doctor.

5.15 p.m.

As I say, we shall, when the time comes, frame regulations so as to prevent a discrimination which I am sure everyone on both sides of the Committee would be anxious to avoid. We shall, of course, also be making provision that a doctor shall have a substantial number of patients in the public scheme before he can avail himself of private facilities at a health centre. If a doctor had a very large number of private patients and a very small number on his list it would be unreasonable for him to be able to use the services of a health centre for his private patients. In the meantime we have had the help and advice of the Central Health Services Council. After having examined the whole matter, they recommend that it should be possible for a general practitioner to treat private patients in a health centre.

Viscount Hinchingbrooke

The right hon. Gentleman is currently reported to be taking some fairly realistic decisions about the main issues of our time. I am rather surprised that he should come from that atmosphere into this Committee and construct castles in the air. There are no health centres, as he knows full well. There might be, if the labour to build them had not been fully employed 40 hours a week elsewhere; there might be if it had been possible for the raw materials to build them to be acquired either at home or abroad—and we know that there are no incentives to acquire them operating in our economy.

There are no health centres. The Minister's speech was largely irrelevant, although one might well say that this is an additional service which, when the time comes in three or four or five years' time, when this country is in a condition to build these elaborate and costly structures, might fit in with the other subsections in the Section of the Act which detail the content and purpose of these health centres. The main fact of the matter is that this is an irrelevant little Amendment—

Mr. Bevan

On a point of Order. The noble Lord has not yet said a single word about the Amendment. This is not really an argument whether there may be health centres or not or whether there are health centres or not. It is merely an Amendment to make it possible for general practitioners to treat private patients in health centres which do exist.

Viscount Hinchingbrooke

I was saying that the health centres do not exist. There may be just one experimental health centre which was started years before the Minister had anything to do with the health service. In the last four years, during which he has had full opportunity to build them if he had used his building resources aright, he has not been able to build them. This Amendment is therefore quite irrelevant.

The Deputy-Chairman

The noble Lord must not say that the Amendment is irrelevant. He can speak either for it or against it, but it has been selected by the Chair and it is relevant to this stage of the Bill.

Mr. Orr-Ewing (Weston-super-Mare)

I would ask the Minister to go a little further on one point which he raised, when he implied that there would be some sort of filter through which the doctor would have to pass if he wished to treat his private patients in a health centre amongst other patients on the doctor's list. He also implied that it would not be possible within the terms of the Amendment, or rather I should say, he did not propose that it should be possible, according to the words in his Amendment, for a doctor with a large proportion of private patients to be able to treat them in a health centre and that it would only be possible if the doctor had a high proportion of patients on his list. If the right hon. Gentleman did not mean that, will he explain what he said?

Mr. Bevan

I was being perfectly frank with the Committee. If they will look at the words, they will see: … there shall be inserted the words 'and, on such terms and conditions as may be determined by the Minister.…' I did not want to leave the Committee unaware of what I had in my mind in putting in those words. What I really had in mind was that it ought not to be possible for a general practitioner who would nominally enter the Health Service by having a small list then to do most of his practice, which would be private practice, in the health centre. That would be an abuse of the privilege. I also said originally that there should be an intermingling of both public and private patients in order to prevent unsavoury discrimination.

Mr. Orr-Ewing

The second point with which the Minister has dealt is perfectly clear. It is the first point on which I wish he would enlarge if he can. He is fixing in his own mind some sort of proportion between the private patients of a general practitioner and the listed patients. Can he give us any indication of what sort of proportion he is aiming at? I do not want to be meticulous in this matter. Supposing 50 per cent. were private and the other 50 per cent. were listed patients, would that enable him to make use of the health centre? I want some indication. I do not know whether the Minister is able to carry that further.

Mr. Bevan

The answer is that it is really a matter for the House to discuss when the regulations are made. The regulations will be laid before the House. I am merely saying that the reason I am taking the power in the Amendment to make regulations is because I have such a matter in my mind. The proportions will be contained in the regulations, and the House will be in possession of them.

Sir H. Lucas-Tooth

I do not think there will be any difference of opinion about this. It is desirable that, on the whole, both private and public practice should be kept in step with one another. We are all agreed that we must have both forms of practice in a hospital and it is desirable to have both forms in the health centre. The Minister has quite properly suggested that there would have to be certain terms and conditions upon which practitioners might have the advantage of using the health centre for their private patients, but I do not think he said whether this would include financial conditions—

Mr. Bevan

Oh, yes.

Sir H. Lucas-Tooth

In other words, does he intend—

Mr. Bevan

That will be in the next Amendment.

Lieut.-Colonel Elliot

I think the Minister is going our way. We shall, as he says, see when the regulations are laid how far he is going our way. But a step along the right road is a step along the right road, and we welcome it.

Amendment agreed to.

Mr. Bevan

I beg to move, in page 23, line 8 at the end, to insert: In section forty-six (which provides for the use of health centres by practitioners) after the words "general medical services" there shall be inserted the words "or other personal medical services or," after the words "subject to regulations," there shall be inserted the words "and to any determination by the Minister under section twenty-one of this Act," and after the words "the Executive Council may," there shall be inserted the words "subject to any such determination as aforesaid. The purpose of these words is to enable the executive council, when prescribed by the Minister, to make differential charges to general practitioners which will vary with the amount of use they will make of the health centre for their private patients.

It is quite clear that the general practitioner will have to pay a charge to the executive council, in the first place because he will have been relieved of the necessity of maintaining his surgery. That is a matter for future discussion with the representatives of the medical profession, and I am sure that those discussions will take place. At the same time, obviously if in addition a general practitioner is earning money at the health centre by treating private patients, it is also reasonable that he pays an additional fee, as rent, because he also will have been relieved of the necessity of providing a surgery. I do not think any general practitioner will quarrel with this. It is merely to take power to make those varying charges when the time comes.

Lieut.-Colonel Elliot

Again, we welcome the Minister's step. This is a further step along the right road. He is making private practitioners who are treating a large percentage of private patients rather more eligible tenants of the health centre. It may seem to some rather an extreme measure, but we welcome it, and we only wish that the argument had prevailed on him earlier when we were considering the analogous case of the hospital. If health centres are provided, the further use of them by practitioners for private patients is in line with what we have always argued, but, I should have thought, rather against what has been argued by hon. Members on the other side of the Committee. However, with the powerful influence of the Minister behind it, not merely the Minister but Government supporters are moving our way. We are delighted to see that, and we welcome this Amendment.

Amendment agreed to.

Mr. Bevan

I beg to move, in page 23, line 8, at the end, to insert: In paragraph (d) of subsection (2) of section thirty-three (which provides for the issue by medical practitioners providing general medical services of certificates reasonably required under or for the purposes of any enactment) after the word 'of,' there shall be inserted the words 'such certificates as may be prescribed being'. The Committee may be aware that some while ago, I believe it was before the Health Service Act in fact came into operation, my right hon. Friend the Secretary of State for Scotland and myself appointed a Committee to try to weed but the number of certificates which doctors have to provide. It is fairly obvious that a little streamlining can be done in this direction, and that committee, which was known as the Safford Committee, have issued an interim report in advance of its general report in order that some effect may be given to their recommendations.

Mr. Linstead

We all welcome anything that will cut down paper work on the part of medical practitioners, but I ask the Committee to look at this for a moment from the point of view of the patient.

Section 33 of the 1946 Act gives the Minister power to make regulations for certain purposes under paragraphs (a), (b), (c) and (d). The one we are concerned with is (d): for the issue to patients or their personal representatives by medical practitioners providing such services as aforesaid of certificates reasonably required by them under or for the purposes of any enactment. The Minister is taking power to limit the certificates which may be issued. Looking at it from the point of view of the patient, he may require a certificate for the purposes of some enactment, for some statutory purpose. The Minister is proposing to curtail the freedom of the patient to get that certificate, I suppose, free of charge. That is the effect of any limitation imposed by any regulations.

I should like some assurance from the Minister that he has that point in mind; that the effect of powers he is now taking may be to prevent certain patients getting certificates free of charge which they require for the purposes of some statutory enactment. It seems rather a strong thing to do. If it is a certificate for some private purpose that is another matter, but some of these certificates may be for a statutory enactment.

Mr. Bevan

The words of the original statute are very extensive indeed, and in the opinion of the Safford Committee throw the net far too wide. It would include a certificate required by the Minister of Transport in connection with an application for a licence to act as a conductor of a public service vehicle. That seems to me to be rather wide for a free certificate. As the free certificates required will be listed in the regulations I think that probably will be the time when we can raise this matter.

It is necessary to do it one way or another. The Safford Committee have stated that a list of free certificates which can be obtained should be provided and the words of the Statute should not be applied.

5.30 p.m.

Mr. Linstead

I should like to pursue that example. That is presumably the extreme type of case which the Minister would rule out by regulation. Is it not unreasonable that somebody who is making an application—be he the driver or conductor of a vehicle—who is required to produce a certificate of general good health should have to pay for that certificate and should be unable to get it free of charge?

Mr. Bevan

Let us consider that at the time. What we are now considering is not my argument for this or that. We are considering a proposal of the committee set up for the purpose that the free certificates which it should be possible to obtain from a general practitioner should be listed.

Dr. Morgan

Is there any likelihood of the report or the recommendations being published soon?

Mr. Bevan

This is a very complicated matter. I should not like to hurry the committee in its work because it is necessary that when the report is made there should be fairly general acceptance of it. Otherwise, there will be a lot of irritation.

Mr. Charles Williams (Torquay)

I feel sure that the Committee will welcome what the Minister said about the elimination of unnecessary clerical work on the part of the doctors or any other members of the community. However, there is one point upon which I am a little doubtful. These certificates can mean a great deal to individuals. I gather that there is nothing in this Amendment to prevent a person in ill-health from getting a medical certificate for the purpose of obtaining extra milk, but it behoves the House of Commons when we get a Minister like the present one who suddenly starts streamlining, to be sure that he is not one of those people who will indulge in cuts to an excessive extent. When we get this sudden conversion in favour of cuts in a person like the Minister of Health, we ought to be careful and watch him. At the same time, I congratulate him on this very small beginning towards putting this service on a better administrative footing, because all of us realise that the doctors have to do a tremendous amount of clerical work. I congratulate the Minister on the step he has taken today. Now he will be able to say that he is one of those in favour of bigger and far more drastic cuts.

Major Gates (Middleton and Prestwich)

Will the Minister give a simple assurance that if this Amendment is passed it will not tie the hands of the House of Commons on any future occasion should a wish be expressed for a certain class of certificate seekers to be included in this list?

Mr. Bevan

We shall have to await the report of the committee before we know what the recommendations are likely to be and we shall have to consider the regulations in the light of that report. Obviously we shall be guided very substantially—but not bound—by what they recommend. The committee will always be able to make its observations on whether the list is too wide or too narrow.

Major Gates

Yes, but are we binding the hands of the Minister or of the House of Commons by passing this Amendment?

Mr. Bevan

All we are doing at the moment is amending the original statute by inserting the words: such certificates as may be prescribed being.

Mr. Howard

Will it not be necessary to prescribe the certificates immediately this provision comes into operation? The only certificates available will be those which are prescribed, and therefore it will be necessary to have ready the list of prescribed certificates at the exact moment when this Bill comes into operation.

Mr. Bevan

I do not think that it will be necessary at the exact moment.

Mr. Howard

I think so.

Amendment agreed to.

The Lord Advocate (Mr. John Wheatley)

I beg to move, in page 26, line 21, at the end, to insert: At the end of section fifteen (which requires facilities at health centres to be available for inter alia the provision of general medical services) there shall be added the following subsection:— '(6) Any medical practitioner providing general medical services at a health centre, may, with the consent of the Secretary of State, make use of the facilities available at the centre for the provision of such other personal medical services on such terms, in- cluding terms as to the payment of charges by the practitioner, and such conditions as the Secretary of State may determine.' This Amendment gives effect to the principle which was discussed in two earlier Amendments in relation to the English Bill dealing with the right of doctors to use health centres for private purposes. Owing to the different structure of the two Acts we have been able to compartment this into a single Amendment. There is no differentiation in principle between the Amendments.

Lieut.-Colonel Elliot

Of course, we should not seek to debate this matter again. There are several occasions upon which, when a principle has been decided by the Committee, it will obviously apply in our Northern Kingdom as well as south of the Border. Therefore, the Committee having decided upon this in the case of England, we certainly should not wish to make an alteration in the case of Scotland.

Amendment agreed to.

Schedule, as amended, agreed to.

Bill reported with Amendments; as amended (in the Standing Committee and on recommittal), considered.