Schedule.—(MINOR AMENDMENTS OF THE ACTS OF 1946 AND 1947.)

HC Deb 19 October 1949 vol 468 cc648-86

Colonel Stoddart-Scott

I beg to move, in page 22, line 9, at the end, to insert: In subsection (2) of section five (which provides for accommodation for private patients), leave out the words 'serving whether in an honorary or paid capacity on the staff of a hospital providing hospital and specialist services to make arrangements for the treatment of his private patients either at that hospital or at any other such hospital,' and insert 'to make arrangements for the treatment of his private patients at any hospital providing hospital and specialist services.' The Amendment will not add any cost to the hospital services and will, in fact, if accepted, reduce the cost of these services. At present anyone entering a pay bed of a hospital—by "pay bed" I mean a Section 5 bed, not an amenity bed—must be cared for by either one of the honorary staff or one of the residential staff of the hospital. It is not possible for a general practitioner who has been treating a patient, or even an outside specialist, to continue looking after that patient should he obtain admission to one of these pay beds. As the Minister said, there are advantages, both in investigation and diagnosing and in providing treatment, which can be provided by hospitals but not by nursing homes.

The Act prevents a patient from being looked after by his own doctor and receiving the appropriate treatment or investigation. I cannot believe this to be an advantage to the National Health Service. It should be advantageous for general practitioners to care for and treat their cases even after admission to hospital. It is, in fact, a degrading aspect of their work that they should be prevented from treating their own cases in hospital. If they are able to do so, it should be possible for them to provide this treatment.

The fact that patients who go into pay beds cannot be looked after by their own doctors throws an extra burden on the specialist and residential staffs of the hospitals. The hospitals have borne, probably, the greatest burden of the National Health Service, but this would be relieved to some extent by permitting general practitioners who are not members of the hospital staffs to care for their patients whilst those patients are occupying pay beds.

I shall not suggest to the House all the different types of cases in pay beds which could be treated by general practitioners, but I will mention just one—the maternity case. Some parts of the country have no maternity hospitals with pay beds; there may not, in fact, even be a maternity hospital. The only pay beds available are in the small general hospitals. Quite often a practitioner wishes to treat his own patient, probably for the first confinement or for a subsequent confinement following a very difficult one. The patient who goes into one of these pay beds, however, must be looked after by either the general surgeon or physician or the resident doctor of the hospital who, in many cases, knows much less about maternity than the general practitioner.

The Amendment would improve the National Health Service by enabling these patients to be cared for in hospital by their own medical practitioners. Such a course would ensure greater use of the pay beds and would make a financial contribution to the hospital service. In addition, it would retain what the Minister has always said he wished to retain: a free choice of doctor by the patient.

Sir H. Lucas-Tooth

I beg to second the Amendment.

The Minister's apparent policy is to discourage private nursing homes, and there is agreement between us on either side of the House in that policy. Such a policy, however, could be used for the purpose of killing off private practice altogether. I do not suggest that the right hon. Gentleman has that intention, but that process could happen in two ways. If there were no private nursing homes, and if the only hospitals where patients could be treated were public hospitals within the service, we could, by eventually eliminating private pay beds, make it impossible for doctors to provide private hospital service. That aspect was discussed on an earlier Amendment and I do not propose to say more about it now.

Private practice is also likely to be killed by denying access to private practitioners to public hospitals. By "private practitioners" I do not mean doctors completely outside the Service, but those treating private patients. Obviously, if doctors cannot treat their own private patients in any hospital or nursing home, we are half-way towards completely killing private practice. The right hon. Gentleman has declared that it is not his policy to kill private practice but it is clear, I am sorry to say, that that is not the view of some of those behind him. Let the Minister and those of us on this side who are agreed on the undesirability of killing private practice accept the Amendment.

8.0 p.m.

There is a real feeling in the medical profession that they are being divorced from access to hospitals. I am not saying that that feeling is fully justified, but I can assure the right hon. Gentleman that in speaking to doctors whom I meet casually as friends, at work and in my constituency, I find a large number who hold no strong political views expressing the view that they are being cut off from the kind of access to hospitals which they enjoyed in the past. In this Amendment we seek to put that right.

It is most urgent that doctors should not be given that impression, or that, if it is the intention to kill private practice, it should be stated so that we know where we are. If it is the desire that doctors should continue to have a right to practice privately and to take fees from patients, we must give them a full and proper opportunity to do so. Unless we give them the opportunity provided in this Amendment, we shall be depriving them of a measure of freedom, which will interfere with their general efficiency.

Sir Henry Morris-Jones (Denbigh)

I hope the right hon. Gentleman will be able to accept this Amendment in favour of which quite plausible arguments have been adduced. When the main Measure was going through Committee upstairs, the right hon. Gentleman held very forcibly that there should be a strong line of demarcation between the general practitioner and the specialist. His intention was to divide the sheep from the lambs, as it were, into completely different categories. Since then the right hon. Gentleman, to his credit, because he has a very buoyant mind, has modified his views in regard to that aspect of the Act. That has been exemplified by a recent circular distributed by his Department to the hospitals urging that more facilities should be given for general practitioners, particularly in cottage hospitals and smaller provincial hospitals, to practise in those hospitals.

This, I take it, refers particularly to that minute section of the population, according to the right hon. Gentleman only 5 per cent. of private patients still available to National Health Insurance practitioners. It would be rather a pity if any facilities which can be afforded should be denied them in maintaining what was the intention of the right hon. Gentleman from the beginning and what he assured the medical practitioners of this country was his intention, that the rights of private practice should still be available and that they should have an opportunity to carry on in that respect within the framework of the Act. I hope he will see his way to accept the Amendment, which is a reasonable one in present conditions.

Mr. Messer (Tottenham, South)

That which has been said in support of the Amendment is not apparent in the wording of the Amendment. There is an immense amount of value in what has been said and at some time we shall have to give serious consideration to it. I think it would be generally accepted that if this Service is to be a success, we have to be assured not merely of an efficient hospital service, but of an efficient general practitioner service also. I have noticed rather a tendency to exalt the specialist, and I am not so sure that specialisation to the extent to which it appears to be developing in the medical profession is actually a good thing. It might be a good thing if specialisation had a very good general background, and to that extent one must realise that a high standard of domiciliary service is, I will not say of the greatest, but of immense importance.

No barrier should be placed in the way of improving the standard of the general practitioner. If that means access to the hospital beds, it should be organised in a way that will provide the general practitioner with that contact with hospital work without adversely affecting other aspects of the Service, but, as I read the Amendment, it appears that it would enable something in the nature of an injustice to be done. It would enable a patient to be admitted to hospital by jumping the queue. There are long waiting lists, and once a general practitioner with access to a hospital could get his patient admission more speedily than another general practitioner, another patient would be disadvantaged by having to wait his turn in the queue. I am not unsympathetic towards the reasons advanced for this Amendment, but I could not support the words of the Amendment. I think the matter should be dealt with in a more scientific way than this rather loose, indiscriminate, haphazard and unorganised way.

I was interested to hear the hon. Member for South Hendon (Sir H. Lucas-Tooth). I do not know what hospitals there are in his neighbourhood to which general practitioners have access. If there is value in a general practitioner having access to hospitals, it should be arranged that all general practitioners have the same opportunity, but that is not by any means the case. One may travel through the whole of Central London and find there is no cottage hospital or general practitioner hospital; they do not exist. That does not mean to say that the opportunity which might be given to a general practitioner should not be given, but it should be done in a rather different way from the way proposed in this Amendment, which I think is brimful of difficulties in implementation.

Mr. Bevan

I am in fairly general agreement with what has been said by my hon. Friend the Member for South Tottenham (Mr. Messer). I believe there has been a tendency to dig too wide a gulf between the general practitioner on the one side and the specialist on the other. If the gulf is to be narrowed, it is not necessary to do it by legislation; that can be done by agreement between the members of the medical profession. As my hon. Friend said, we could not admit the right of a general practitioner with private patients to have access to hospitals where his colleagues would be denied that right. That would be entirely wrong. Access of general practitioners to hospitals generally is an entirely different matter and a matter for discussion administratively, and not by Statute.

I think we are rather confusing the general practitioner with the specialist. What is really envisaged by the Amendment is that a specialist not in the public service at all would be able to treat his private patient in a hospital. That is really what is behind this proposal and that I consider to be wholly wrong. If a specialist does not want to be in the Health Service and therefore has not attached himself to a hospital, I do not think that he is entitled to use the Health Service. Indeed, I do not believe he would be much good for long if he were not attached to a hospital. It has been common form on both sides of the House this evening that a specialist must have access to the hospital and ought to live in the climate of the hospital as much as possible in order to do his work properly. That is the reason why there has been this argument against certain nursing homes. If, therefore, a specialist is not in the Health Service and is not attached to a hospital, it does not seem to me that he will be a person of permanent value in his particular calling, and he ought not to have the facilities of the National Health Service.

As I said in Committee, I am afraid I am unable to accept this Amendment. I wish further to point out, reverting to the general practitioner, that if the general practitioner is to follow his patient into the hospital where the patient has been entrusted to the specialist we may have, unless we are very careful indeed, a very considerable quarrel as to the claims of both of them to have charge of the treatment of the patient, and between the quarrels of two members of the profession the patient might succumb.

Viscount Hinchingbrooke

They do not quarrel outside. Why should they quarrel in the hospital?

Mr. Quintin Hogg (Oxford)

I am a little perturbed by the speech we have just heard. The Minister has talked with his usual vigour about what should or what should not be permitted to specialists and indeed to general practitioners in the circumstances of the scheme. As I see it, the approach to this question ought to be somewhat different. A hospital, particularly a public hospital under the scheme, is not either a weapon for the Minister to coerce specialists or general practitioners into the scheme or a privilege for the use of specialists or practitioners. It is a convenience for the public, and it is in particular a service to the patient. It seems to me that, throughout the speech to which we have listened, the Minister has utterly failed to realise that matter of fundamental importance.

We are not talking about the rights of specialists or general practitioners; we are not talking about the weapons which must be used to secure the proper administration of the scheme: we are talking about people who are suffering, and the question which we ought to consider is whether those suffering people are better treated inside the public hospital or whether they should have to stay, an unprivileged class, in their own homes. That is the point which the Minister will not face.

Assuming that he agrees with me that if a person is suffering and that if the treatment of that person is better effected in a public hospital that person ought to be allowed to go there, then the right hon. Gentleman must face this further dilemma: either he is to deny that suffering person the right within reason to select his own medical attendant or adviser, or he is not. If he is, then it seems to me that he is breaking one of the fundamental areas of agreement in the scheme, something which has not hitherto been in dispute between the parties. If, on the other hand, he is to allow a suffering person who I understand we agree should be allowed to go to a hospital if treatment is better effected there, to select his own medical attendant, then he has presented no case whatever against the Amendment.

8.15 p.m.

Mr. Bevan

I am trying to understand the hon. Member. Is he saying that a patient ought to have the right to be treated in a general hospital, whether it be a teaching hospital or not, by the doctor of his choice, that doctor being his general practitioner?

Mr. Hogg

I was making no general observation of that kind. I was seeking to analyse the principle upon which the Minister was opposing this Amendment.

Mr. Bevan

The hon. Member must be fair. He must not make such charges without substantiating them. He said that the National Health Service should not be used as an instrument to confer or deny this privilege on this or that section of the medical profession. I quite agree with him. He says that it is always the patient one should consider. Does he suggest that the patient should have the right to be treated in any hospital by the general practitioner of his choice, whether that practitioner be attached to the hospital or not?

Mr. Hogg

The right hon. Gentleman is trying to force upon me an extreme conclusion which is not justified by the terms of the Amendment. I was seeking to support the terms of the Amendment, which are far more narrow than the conclusion the right hon. Gentleman was trying to force upon me. Obviously, when we are dealing with a scheme which is limited in its means and necessarily, even now, partly experimental in its character, we cannot carry out the full intentions of our ultimate objectives. I would say that the limitation which ought to be placed upon the right of the private patient in a hospital to be treated by the medical attendant of his choice ought to be a limitation defined by purely medical considerations, and not by political considerations. I include in "political considerations" exactly the kind of argument which the right hon. Gentleman was using, namely, the sort of argument that one does not want to encourage specialists who do not belong to hospitals. That is trying to discipline the medical profession by exploiting the suffering of the patient, and that is what I gathered from his argument. His attempt to cross-examine me has not in the least removed my disquiet.

Mr. Bevan

With permission, and not wishing to be paternal, I would say that the hon. Member ought to understand his subject before talking upon it. He ought not to come into the House and deliver a philippic so full of rotund ignorance as the one which he has just delivered. Would he say that a patient in the public part of the hospital ought to be allowed to decide whether his general practitioner should treat him?

Mr. Hogg

I think that that is exactly the question that I answered before. I answered it by saying that the limitations on the patient's choice should be determined by medical and not by political considerations.

Mr. Bevan

That is exactly what happens. It has been decided that, except in certain cases of cottage hospitals in different parts of the country, when a patient enters a hospital he is entrusted to the specialist services of the hospital. If a statutory right is given to a general practitioner to enter that hospital and treat a patient, there will immediately be administrative troubles of the greatest possible kind. [Laughter.] The hon. Member laughs, but there are hon. Members behind him who have experience of hospital administration. I am certain that they will tell him that a lot of nonsense is now being talked over there about this matter.

What is desirable is that eventually there should be a closer identification, whether the patients be private or public, between the general practitioners and the work that goes on in hospitals—a far greater identification, and a narrowing, as I said, of the gulf. That is not involved in this Amendment. That ought to be done by progressive professional agreement so as to have co-operation between the specialist and the general practitioner without the claims of one upsetting the status of the other. That is not involved in this Amendment. It goes much further than that, as a matter of act it attempts to confer upon private patients what is not enjoyed by public patients in a public hospital.

Mr. Hogg

I suppose—

The Deputy-Chairman (Mr. Bowles)

rose—

Mr. Hogg

On a point of Order—

The Deputy-Chairman

I am on my feet. I was about to point out that the hon. Member cannot speak a second time.

Mr. Hogg

I was about to raise that point. I understood that the second and third speeches of the right hon. Gentleman were interventions to what I was about to say before I resumed my seat. As one—

The Deputy-Chairman

I must say that it did not occur to me that that was so. It did not appear to be so. If the hon. Gentleman can assure me he had not finished his speech before the Minister spoke, I will permit him to continue.

Mr. Hogg

I certainly object—

The Deputy-Chairman

Will the hon. Gentleman say "Yes" or "No" whether he sat down in order to give way to the Minister, or whether he had finished his speech?

Mr. Hogg

I certainly object to the right hon. Gentleman speaking a second and third time—

The Deputy-Chairman

The hon. Gentleman does not even know the Rules of Order. He will not even answer my question. The Minister is not bound, no more is the hon. and gallant Gentleman who moved the Amendment, by the Rules that he must not make a second speech.

Mr. Hogg

With great respect, the Chair has many rights, but they do not include the cross-examination of hon. Members.

The Deputy-Chairman

The hon. Gentleman must be careful. The Amendment proposed—

Mr. Manningham-Buller (Daventry)

On a point of Order. Cannot we have the position put clearly? I understood that the right hon. Gentleman was interrupting my hon. Friend. If the right hon. Gentleman was making a second and a third speech, ought not he to have the leave of the House?

The Deputy-Chairman

He need not ask the leave of the House. If the hon. and learned Member will look at the Standing Orders he will see that the right hon. Gentleman does not require the leave of the House to make a second, third or fourth speech.

Mr. Bevan

I am bound to say, further to that point of Order, that in asking permission, which I was not obliged to do, I did more than has been done by any right hon. Gentleman the whole evening.

Question put, "That those words be there inserted in the Bill."

The House divided: Ayes, 103: Noes, 253.

Division No. 251.]	AYES	[8.24 p.m
Amory, D. Heathcoat	Haughton, S. G.	Roberts, Emrys (Merioneth)
Baldwin, A. E.	Henderson, John (Catheart)	Roberts, P. G. (Ecclesall)
Barlow, Sir J.	Hinchingbrooke, Viscount	Roberts, W. (Cumberland, N.)
Beamish, Maj. T. V. H.	Hogg, Hon. Q.	Ropner, Col. L.
Bennett, Sir P.	Howard, Hon. A.	Ross, Sir R. D. (Londonderry)
Birch, Nigel	Hudson, Rt. Hon. R. S. (Southport)	Sanderson, Sir F.
Boles, Lt.-Col. D. C. (Wells)	Hulbert, Wing-Cdr N. J.	Savory, Prof. D. L.
Bowen, R.	Hutchison, Lt.-Cm. Clark (E'b'rgh, W.)	Scott, Lord W.
Bower, N.	Hutchison, Col. J. R. (Glasgow, C.)	Shepherd, W. S. (Bucklow)
Boyd-Carpenter, J. A.	Joynson-Hicks, Hon. L. W.	Smiles, Lt.-Col. Sir W.
Brown, W. J. (Rugby)	Law, Rt. Hon. R. K.	Smith, E. P. (Ashford)
Buchan-Hepburn, P. G. T.	Legge-Bourke, Maj. E. A. H.	Snadden, W. M.
Butcher, H. W.	Lipson, D. L.	Spence, H. R.
Carson, E.	Lloyd, Selwyn (Wirral)	Stewart, J. Henderson (Fife, E.)
Clarke, Col. R. S.	Lucas-Tooth, Sir H.	Stoddart-Scott, Col. M.
Conant, Maj. R. J. E.	Macdonald, Sir P. (I. of Wight)	Strauss, Henry (English Universities)
Corbett, Lieut.-Col. U. (Ludlow)	McFarlane, C. S.	Stross, Dr. B.
Crosthwaite-Eyre, Col. O. E.	Mackeson, Brig. H. R.	Studholme, H. G.
Crowder, Capt. John E.	Maclean, F. H. R. (Lancaster)
Darling, Sir W. Y.	Maitland, Comdr. J. W.	Sutcliffe, H.
Digby, S. Wingfield	Manningham-Buller, R. E.	Taylor, Vice-Adm. E. A. (P'dd't'n, S.)
Donner, P. W.	Marlowe, A. A. H.	Thorneycroft, G. E. P. (Monmouth)
Dower, Col. A. V. G. (Penrith)	Marples, A. E.	Turton, R. H.
Drayson, G. B.	Marshall, D. (Bodmin)	Wadsworth, G.
Drewe, C.	Mellor, Sir J.	Wakefield, Sir W. W.
Elliot, Lieut.-Col. Rt. Hon. Walter	Morris, Hopkin (Carmarthen)	Walker-Smith, D.
Erroll, F. J.	Morris-Jones, Sir H.	Wheatley, Colonel M. J. (Dorset, E.)
Fyfe, Rt. Hon. Sir D. P. M.	Mott-Radclyffe, C. E.	White, Sir D. (Fareham)
Gage, C.	Neven-Spence, Sir B.	Williams, C. (Torquay)
Galbraith, T. G. D. (Hillhead)	Nield, B. (Chester)	Williams, Gerald (Tonbridge)
Gates, Maj. E. E.	Noble, Comdr. A. H. P.	Willoughby de Eresby, Lord
Glyn, Sir R.	Noel-Baker, Rt. Hon. P. J. (Derby)	York, C.
Gomme-Duncan, Col. A.	Odey, G. W.
Granville, E. (Eye)	Orr-Ewing, I. L.	TELLERS FOR THE AYES:
Hannon, Sir P. (Moseley)	Peto, Brig. C. H. M.	Commander Agnew and
Harden, J. R. E.	Raikes, H. V.	Lieut.-Colonel Bromley-Davenport.
Harvey, Air-Comdre A. V.	Renton, D.
NOES
Acland, Sir Richard	Greenwood, A. W. J. (Heywood)	Neal, H. (Claycross)
Adams, Richard (Balham)	Grey, C. F.	Nichol, Mrs. M. E. (Bradford, N.)
Allen, A. C. (Bosworth)	Grierson, E.	Oldfield, W. H.
Allen, Scholefield (Crewe)	Griffiths, D. (Rother Valley)	Oliver, G. H.
Alpass, J. H.	Griffiths, Rt. Hon. J. (Llanelly)	Paget, R. T.
Anderson, A. (Motherwell)	Griffiths, W. D. (Moss Side)	Paling, Rt. Hon. Wilfred (Wentworth)
Attewell, H. C.	Guest, Dr. L. Haden	Paling, Will T. (Dewsbury)
Austin, H. Lewis	Guy, W. H.	Palmer, A. M. F.
Awbery, S. S.	Hale, Leslie	Pannell, T. C.
Ayles, W. H.	Hamilton, Lieut.-Col. R.	Pargiter, G. A.
Ayrton Gould, Mrs. B.	Hannan, W. (Maryhill)	Parkin, B. T.
Bacon, Miss A.	Hardy, E. A.	Pearson, A.
Baird, J.	Harrison, J.	Poole, Cecil (Lichfield)
Balfour, A.	Haworth, J.	Popplewell, E.
Barton, C.	Henderson, Rt. Hon. A. (Kingswinford)	Porter, E. (Warrington)
Bechervaise, A. E.	Henderson, Joseph (Ardwick)	Porter, G. (Leeds)
Bevan, Rt. Hon. A. (Ebbw Vale)	Herbison, Miss M.	Price, M. Philips
Bing, G. H. C.	Hewitson, Capt. M.	Pritt, D. N.
Binns, J.	Hobson, C. R.	Proctor, W. T.
Blackburn, A. R.	Holman, P.	Pryde, D. J.
Blenkinsop, A.	Holmes, H. E. (Hemsworth)	Pursey, Comdr. H.
Blyton, W. R.	Horabin, T. L.	Ranger, J.
Boardman, H.	Houghton, Douglas	Rankin, J.
Bottomley, A. G.	Hoy, J.	Reid, T. (Swindon)
Bowden, H. W.	Hubbard, T.	Rhodes, H.
Brook, D. (Halifax)	Hughes, Emrys (S Ayr)	Richards, R.
Brooks, T. J. (Rothwell)	Hutchinson, H. L. (Rusholme)	Ridealgh, Mrs. M.
Broughton, Dr. A. D. D.	Hynd, H. (Hackney, C.)	Robertson, J. J. (Berwick)
Brown, George (Belper)	Hynd, J. B. (Attercliffe)	Robinson, Kenneth (St. Pancras, N.)
Brown, T. J. (Ince)	Isaacs, Rt. Hon. G. A.	Ross, William (Kilmarnock)
Burden, T. W.	Janner, B.	Royle, C.
Burke, W. A.	Jeger, G. (Winchester)	Sargood, R.
Butler, H. W. (Hackney, S.)	Jeger, Dr. S. W. (St. Pancras, S. E.)	Scollan, T.
Callaghan, James	Jenkins, R. H.	Scott-Elliot, W.
Carmichael, James	John, W.	Segal, Dr. S.
Champion, A. J.	Johnston, Douglas	Shackleton, E. A. A.
Chetwynd, G. R.	Jones, D. T. (Hartlepool)	Sharp, Granville
Cluse, W. S.	Keenan W.	Shurmer, P.
Cobb, F. A.	Kenyon, C.	Silverman, J. (Erdington)
Cocks, F. S.	Key, Rt. Hon. C. W.	Simmons, C. J.
Coldrick, W.	Kinghorn, Sqn.-Ldr. E.	Skinnard, F. W.
Collick, P.	Kinley, J.	Smith, C. (Colchester)
Collins, V. J.	Lang, G.	Smith, Ellis (Stoke)
Colman, Mist G. M.	Lavers, S.	Smith, H. N. (Nottingham, S.)
Cook, T. F.	Leo, F. (Hulme)	Smith, S. H. (Hull, S. W.)
Cooper, G.	Lee, Miss J. (Cannock)	Snow, J. W.
Corbet, Mrs. F. K. (Camb'well, N. W.)	Leonard, W.	Sorensen, R. W.
Corlett, Dr. J.	Leslle, J. R.	Soskice, Rt. Hon. Sir Frank
Cove, W. G.	Lewis, A. W. J. (Upton)	Sparks, J. A.
Cullen, Mrs.	Lipton, Lt.-Col. M.	Steele, T.
Daggar, G.	Logan, D. G.	Stubbs, A. E.
Dalton, Rt. Hon. H.	Longden, F.	Swingler, S.
Davies, Edward (Burslem)	Lyne, A. W.	Sylvester, G. O.
Davies, Haydn (St. Pancras, S. W.)	McAdam, W.	Symonds, A. L.
Davies, R. J. (Westhoughton)	McEntee, V. La T.	Taylor, H. B. (Mansfield)
Deer, G.	McGhee, H. G.	Taylor, R. J. (Morpeth)
Delargy, H. J.	McKay, J. (Wallsend)	Thomas, D. E. (Aberdare)
Diamond, J.	Mackay, R. W. G. (Hull, N. W.)	Thomas, Ivor Owen (Wrekin)
Dobbie, W.	Maclean, N. (Govan)	Thomas, John R. (Dover)
Dodds, N. N.	McLeavy, F.	Thorneycroft, Harry (Clayton)
Donovan, T.	MacPherson, Malcolm (Stirling)	Thurtle, Ernest
Driberg, T. E. N.	Macpherson, T. (Romford)	Tiffany, S.
Dye, S.	Mainwaring, W. H.	Timmons, J.
Ede, Rt. Hon. J. C.	Mallalieu, E. L. (Brigg)	Tolley, L.
Edwards, Rt. Hon. Sir C. (Bedweffty)	Mallalieu, J. P. W. (Huddersfield)	Tomlinson, Rt. Hon. G.
Edwards, Rt. Hon. N. (Caerphilly)	Mann, Mrs. J.	Turner-Samuels, M.
Evans, E. (Lowestoft)	Manning, Mrs. L. (Epping)	Ungoed-Thomas, L.
Evans, John (Ogmore)	Marquand, Rt. Hon. H. A.	Usborne, Henry
Evans, S. N. (Wednesbury)	Mathers, Rt. Hon. George	Walkden, E.
Ewart, R.	Medland, H. M.	Wallace, G. D. (Chislehurst)
Fairhurst, F.	Mellish, R. J.	Warbey, W. N.
Farthing, W. J.	Messer, F.	Watkins, T. E.
Fernyhough, E.	Middleton, Mrs. L.	Watson, W. M.
Foot, M. M.	Mikardo, Ian	Webb, M. (Bradford, C.)
Forman, J. C.	Mitchison, G. R.	Wells, P. L. (Faversham)
Fraser, T. (Hamilton)	Moody, A. S.	Wells, W. T. (Walsall)
Gaitskell, Rt. Hon. H. T. N.	Morgan, Dr. H. B.	Wheatley, Rt. Hn. John (Edinb'gh, E.)
Gallacher, W.	Morley, R.	White, H. (Derbyshire, N. E.)
Gibson, C. W.	Morrison, Rt. Hon. H. (Lewisham, E.)	Whiteley, Rt. Hon. W.
Gilzean, A.	Mort, D. L.	Wigg, George
Glanville, J. E. (Consett)	Nally, W.	Willey, O. G. (Cleveland)
Gordon-Walker, P. C.	Naylor, T. E.	Williams, D. J. (Neath)

Williams, J. L. (Kelvingrove)	Wills, Mrs. E. A.	Yates, V. F.
Williams, Rt. Hon. T. (Don Valley)	Woodburn, Rt. Hon. A.
Willis, E.	Woods, G. S.	TELLERS FOR THE NOES:
		Mr. Collindridge and Mr. Wilkins.

8.30 p.m.

Sir H. Lucas-Tooth

I beg to move, in page 22, line 9, at the end to insert: Subsection (2) of section fourteen (which provides for conditions of service and appointment of medical or dental officers employed on the staff of hospitals providing hospital and specialists services), shall have effect as if the following sub-paragraphs were added:— '(e) for the establishment of a Central Professional Committee and for the hearing by such committee of appeals from officers engaged in the provision of hospital and specialist services who are dissatisfied with any decision under this subsection of any regional hospital board or board of governors relating to their status; (f) for the determination by the Minister after consideration of the recommendations of the Central Professional Committee of any such appeal as may be made under the provisions of the last foregoing subparagraph.' Section 14 of the Act of 1946 provides for the conditions of service of hospital officers, including specialists. Before the Act came into operation, specialists fell roughly into three main groups. There was the most junior group, the house officer. Then there was a middle group, the registrar. Of course, other names were attached to that group at different places but the registrar is perhaps the best name to use when describing that group. The third group comprised the fully qualified specialists.

The remuneration of specialists for the purposes of the Act was a matter considered by the Spens Committee. That Committee reported about the time of the introduction of the Act. It recommended that the specialists should be divided into two main groups the junior of which was to be the registrar group, with a smaller group of fully qualified specialists—the specialist group. The Minister, in his wisdom, has seen fit to divide specialists into three main gradings. He has introduced a third grading—the senior hospital medical officer. Roughly speaking, the gradings are paid on the following basis: the registrar gets from £600 to £1,300 a year; the S.H.M.O. gets from £1,400 to £1,750 a year; and the fully qualified specialist gets from £1,700 to £2,750 a year, plus a very substantial bonus in a limited class of case.

I do not quarrel with the division of specialists into three grades, and I am not in any way objecting to that. What I am concerned with is the question of the actual grading of individuals. Under the regulations which the Minister has made, specialists have to be placed in their appropriate grades by the regional hospital board, or the board of governors in the case of a teaching hospital, for the hospitals to which they are attached, and that is done through the advice of a reviewing committee. If the specialist is dissatisfied with the grade in which he is placed, his only appeal is to the board whose reviewing committee has in fact appointed him, so that the appeal is only back to the same board which has in fact made the original grading. Grading is a matter of vital importance to the specialists concerned, as it not only affects their status and the dignity which they possess among their medical brethren, but it makes an immense difference to their pay. Nowadays, there is no honorary work, so that, whereas in the old days it may not have been a matter of vital importance what he was called, today his career must depend on the grade in which he is placed.

The criticism of the scheme is that a very considerable number of specialists have a sense of grievance in a way that is perhaps inevitable. I am not saying that the grading was badly carried out or that there are a great number of mistakes. I am saying that a great number of those who were graded feel that they have not been properly judged in this matter, and the purpose of our Amendment is to try to do away with that sense of injustice.

One of the reasons why there is a special sense of injustice in this connection is that the grading has been done by the local board of the hospital to which the specialist is attached. Of course, in a sense, a regional board is not a very local body, but the total number of specialists in the country as a whole is not very great, and there is a distinct sense on the part of a number of individuals that they have not been altogether fairly judged by the particular board which had the task of judging their qualities.

The purpose of this Amendment is to give a right of appeal to those who have a grievance. What we suggest is that the Minister should constitute a central appeal committee whose only function would be to deal with the question of status. The House should understand that we are not here concerned with a general discussion of conditions of service. We are not suggesting that the rates of remuneration are too high or too low, or suggesting any machinery for discussing those rates. What we are suggesting is some machinery by which the individual may feel that his own particular status has been fairly assessed, having regard to what has been laid down by the Minister. The central appeal committee would be better than the board for the particular hospital, because it will not be local, and the individual concerned will feel that he has a right of appeal away from people, some of whom may be his own competitors. Again, a central board would have the advantage that it would act as a co-ordinating body in this connection. There is the danger that if we leave this assessment to a number of separate boards they will pursue a slightly different policy which might, in time, diverge a good deal, however careful an eye the right hon. Gentleman keeps on it. With a central body there is no risk of that.

Thirdly, our Amendment provides that the appeal is not to be finally disposed of by this central board; the appeal is to be subject to the Minister's own final approval. He will be able to give the board general directions—as no doubt he has always done in this type of case—and he will have the ultimate responsibility—as he must have—for the policy of the central board as regards the numbers to be put in any particular class, and so on. Therefore, he cannot say that we are here seeking to snatch some financial advantage for those for whom we are pleading in this House. That is not the position at all. All that we are concerned with is to see that these men, who are absolutely vital to the Health Service, start off their careers under the new dispensation with a sense that they have been fairly treated by a fully independent body, and that they have all been assessed throughout the country by the same standard.

Viscount Hinchingbrooke

I beg to second the Amendment.

I daresay that by now the right hon. Gentleman the Minister is conscious of a very great tide of complaints coming in from consultants and specialists under the National Health Service which all relate to this rather harsh treatment which they have received at the hands of regional hospital boards in having their status downgraded as the result of the Minister's variation of the terms of the Spens Report. I have had a very large number of cases brought to my attention from the Provinces, all of them concerning Fellows of the Royal College of Surgeons, men in general surgery, in anaesthetics, in obstetrics, ear, nose and throat specialists, and so on. They have sent in a remarkable series of supporting testimonials from their teachers in earlier days and from their colleagues in the war period, men from other parts of the country who know them well and who, of course, have had nothing to do with the grading. Had they been on the hospital boards, these men would undoubtedly have maintained the grading to which the persons to whom I am referring feel themselves to be entitled.

As my hon. Friend the Member for South Hendon (Sir H. Lucas-Tooth) has said, the complaints relate to loss of status, to loss of emoluments, and, I would add, to growing family and personal anxieties about being able in these days to maintain the kind of life which they had built up over a period of 20 or 30 years before the war. In the first place, the complaint is of the original assessment by men who, if I may quote what was said to me in a deputation by the specialists, "are superior persons in the medical fraternity who gravitated to the Metropolis, men who are cut off by many years now from the knowledge of what kind of work is being done in the provinces." If I may actually quote from one communication I have received, it defines the selecting team of assessors on the central hospital board as men who suffer from the belief that London, in general, and Harley Street, in particular, harbour all but the incompetent nonentities of the specialist branches of medicine. 8.45 p.m.

The trouble is that the initial assessments having been downgraded, the appeal lies through the same body of men. As I understand it, the complaints that have been coming in are not uniform from all parts of the country, which is clearly an indication that the treatment which the subject has received by the regional hospital boards varies considerably. Some regional hospital boards have perhaps initially graded altogether too high, and intend to downgrade in the interests of economy, later sifting up as time goes on. Other regional hospital boards—I instance the South-Western Metropolitan Regional Hospital Board in particular—seem to have downgraded almost everyone but are allowing certain cases to go through on appeal. I maintain that it is very unsatisfactory that these boards should differ so substantially in their methods. That must make for variations in status as between the different members of the profession.

Dr. Guest

The noble Lord would help the discussion if he informed the House whether he knows that this grading of specialists is done inside the medical profession. I understand that the noble Lord realises that. I should like to know whether he proposes that there should be an appeal from the body inside the medical profession which does this grading work, with the full approval of the medical profession in general, to the Minister.

Viscount Hinchingbrooke

No. I do not think the hon. Gentleman can have listened to the speech of my hon. Friend the Member for South Hendon. We all know that the grading is done by members of the medical profession. What we on this side of the House say is that the appeal should be instituted by the man who is downgraded and should lie to a different body altogether.

Dr. Guest

To the Minister?

Viscount Hinchingbrooke

No. Perhaps the hon. Gentleman, who I thought was a specialist in this subject, would be good enough to read the Amendment to which I am speaking.

Dr. Guest

I am trying with great difficulty to follow the noble Lord's obscure speech.

Viscount Hinchingbrooke

We get on better outside than we do in the Chamber.

Dr. Morgan

I am sorry to hear that.

Viscount Hinchingbrooke

The analogy of the Army has occurred to me, and I hope it is not a false one. In the Army, officers who feel aggrieved at their standing have recourse to the Military Secretary's Department. That is one channel of appeal which is quite different from the general chain of command in the Army. I hope the right hon. Gentleman is listening, because what I am saying might indicate certain lines which it might be proper to take. A more interesting channel of appeal is that which is taken on technical lines in the Army. For example, the Commander of the Royal Engineers and his field company commanders are responsible to the divisional general for operations and for discipline. But on all other matters, including appointments, replacements and appeals against unreasonable tasks or orders, the channel is via the Chief Engineer through headquarters upwards to the War Office. The right hon. Gentleman has rushed in with a national medical service formed upon military lines, but he has not yet devised the network of safeguards against falling morale which the Services have been obliged to develop over the course of many years.

No one blames the right hon. Gentleman for having invented a system which is too hierarchical, too rigid and does not allow for complaints to be sifted upwards through alternative channels. The right hon. Gentleman is not a genius. Nobody expected him to devise a perfect system straightaway. But let him have a look at the system in the Services which gives those with a grievance a chance of redress through channels altogether different from the chain of original appointment and command. I think he will find a useful precedent there. Some new machinery is imperative if this quality of the Service is not to deteriorate through the disillusionment and cynicism which is undoubtedly growing in the profession and especially amongst the professional consultants and specialists who have been downgraded. We are not wedded to the actual form we have laid down and if, as he was good enough to do on an earlier Amendment, the right hon. Gentleman would indicate that some appropriate machinery would be introduced in another place, I am sure that would satisfy us.

Mr. Messer

I am certain that no hon. Member would object to the principle of giving a right of appeal to anybody who has a grievance, and I do not want to deal with that aspect of the Amendment. I feel it is necessary, however, for someone to make some reference to the way in which the Amendment has been handled. For those who are not engaged in this work the impression would have been created from the speeches which we have heard that the regional hospital board of about 30 members solemnly sits down and assesses whether or not people shall be specialists. That is not so. No regional board does it; no regional board could do it. The regional board, with a majority of laymen on it, which attempted to do such a thing would find itself in difficulties very quickly.

What does happen? When reference is made to downgrading, could we have some instance of anyone who has been downgraded? The truth is that there were members of the medical profession who regarded themselves as specialists, but is there any hon. Member who could tell me what were the special qualifications one had to have to become a specialist before this Act came into force? What examination was passed? What test was applied? Is there any answer?

Dr. Morgan

Yes; plenty.

Mr. Messer

The answer is that anybody who cared to follow a special branch of medicine became a specialist. Now what happens is this: the regional board chooses from the medical committees certain members who do not make any assessment by themselves but who, indeed, are joined by members of the faculty which is concerned—obstetrician, piedatrician, physician, surgeon, orthopaedist, gynaecologist and all the rest of it—and that particular faculty is represented on a committee. Can anybody say that the regional board is responsible for downgrading specialists when, in point of fact, there never was a grade of specialist which was a grade attained by any examination or training? I agree that there are a large number of those who consider themselves specialists but who have not been accepted as specialists; but to say they have been downgraded is quite an exaggeration. To put a thing like this in a Statute is to go to the extreme.

There are two evils which we should guard against in legislation: one is the Act which leaves too much to regulation and the other is the Act which goes into too great detail. If we go into too great detail we shall want an amending Bill every six months. What we want are general principles within which the Service can be properly administered. The Minister has himself taken steps to see that this work is not done by people not qualified to do it. The medical profession are responsible for this grading, and I think that that should be understood. I rose to speak only because I feel that a disservice is being done to the Service by the criticism made of the regional hospital boards, who have a very difficult job to do. The regional boards have done, and are doing, this job, and it is made more difficult by the type of speech we have heard today. The medical profession have this matter in their own hands.

Mr. Bevan

I do hope that we shall be able to get on a little faster. I hope the next time I introduce a Bill to the House it will be opposed on Second Reading, because, perhaps, it will proceed quicker than one which is unopposed. I say that in passing because we have been a long time on this. I am astonished that the Opposition should have picked on this one. Why do they assume all the time that, because they receive a large number of letters, there is a grievance, and that it is necessarily good politics to play it? That is exactly what they are doing all the time. If a body of opinion in the medical profession is aggrieved by anything, they make themselves the mouthpiece of the grievance.

This Amendment is about the most maladroit one I have ever seen on the Notice Paper—this Amendment which purports to be devoted to the grading of specialists and yet deals with the appointment of persons by regional hospital boards. Section 14 deals with the appointment of persons who have already been qualified. It has nothing at all to do with their status. It is the machinery for the appointment of persons on the staffs of regional boards, whereas the Amendment directs itself to the grading which has been taking place recently of persons in the specialist classes. I do not make much complaint about that because the Opposition have not the facilities of Parliamentary draftsmen; and I do not make any heavy weather about it at all, because if a principle which is intended to be conveyed is approved, it is up to the Government to cast it into proper language.

The reason I call attention to it is not to score a debating point, but because it has led to confusion of nomenclature. People have talked about the regional hospital boards. Because they make the appointments on the staffs of specialists, it has led to the assumption that the regional hospital boards actually make the classification of specialists. That is what, as my hon. Friend has already pointed out, they do not do. Also the noble Lord in his statement talked about downgrading. There has been no such downgrading. There never has been grading before. When the hon. Member for South Hendon (Sir H. Lucas-Tooth) talks about three grades, I must say there was never any such thing. The fact is that a very large number of general practitioners who are members of the Royal Colleges—a very large number—would not dare to describe themselves as specialists.

The difficulty is that we have not got an academic qualification that corresponds in the medical profession to any hierarchical arrangement. That is the difficulty. If, according to the hierarchical conception, the general practitioner is placed down at the bottom, I do not agree with it at all. I do not agree with the hierarchical conception. We insist, and have all the time insisted, that the first-class general practitioner is the cream of his profession. Therefore, we ought not to slip into the language of saying that any person has been downgraded or upgraded in relation to whether he is further from or nearer to the status of a general practitioner. That would immediately poison the whole atmosphere. We have not got a way of climbing up, if I may use the term, to a higher position and to higher emoluments merely by virtue of passing a particular examination.

9.0 p.m.

Therefore, in so far as we are to pay different scales of remuneration for people presumed to have different qualifications, we had to have a classification so that the salary that was to be paid should alight on the proper person, and so that when a general practitioner sent his patient to a specialist he was really sending his patient to a specialist and not to some person masquerading as a specialist, or some person claiming to be a specialist who was not a specialist. Therefore, the term "specialist" is not necessarily an academic qualification by itself, but implies a person possessing an academic qualification who has made a particular branch of medicine his speciality. Therefore, it is a question of his behaviour and not of his objective qualification; of his behaviour in such a fashion and his performing in such a fashion as to justify himself as being classified as a specialist.

That was the task which I had to perform. To whom was it entrusted? It was entrusted, on the advice of the medical profession, to a purely professional body. No layman can make a classification himself. That is one of the first defects in the Amendment. It really suggests that after the doctors have been classified by their fellows they should appeal to a Minister. I would refuse to accept the responsibility when people interrupt the noble Lord, he must not be so tart with them and ask them to read the Amendment. He seconded the Amendment, and therefore the assumption is that he had familiarised himself with it. It says: For the determination by the Minister"—

Mr. Henry Strauss

Look at subparagraph (e).

Mr. Bevan

Sub-paragraphs (e) and (f) state: for the establishment of a Central Professional Committee and for the hearing by such committee of appeals from officers engaged in the provision of hospital and specialist services who are dissatisfied with any decision under this subsection of any regional hospital board or board of governors relating to their status; (f) for the determination by the Minister after consideration of the recommendations of the Central Professional Committee of any such appeal as may be made under the provisions of the last foregoing sub-paragraph. If I interpret that correctly, it would mean, first of all, that a person would be subjected to examination by the local medical professional committee, and that, having a grievance against that committee, he would appeal to the Central Professional Committee, and, having a grievance against that Committee, would then appeal to the Minister.

Lieut.-Colonel Elliot

indicated dissent.

Mr. Bevan

I should be happy to be made clear on this point. My legal advisers told me there could be no other interpretation of these words and that the Minister would be, in the last analysis, the last court of appeal for the determination of the professional status of a member of the medical profession. I would not dream of doing that. First of all, a lay Minister would be an improper person to whom to appeal. He would not have access to any more professional information than has already been exhausted in determining the status—

Sir H. Lucas-Tooth

Has the right hon. Gentleman any objection to leaving the final decision to the Central Professional Committee?

Mr. Bevan

I will come to that in a moment. I think the hon. Gentleman will admit that the interpolation of the Minister is a mistake. In fact, the medical profession would be horrified if they thought that His Majesty's Opposition were now asking that a lay Minister, or any Minister, should be allowed to classify specialists in the medical profession.

I will now come to the Central Professional Committee. Everybody, in Great Britain in particular, is always predisposed to the person who wants to make an appeal. Appeal to a higher court against the decision of the lower court until a man has actually reached the supreme court is one of the cardinal principles of British jurisprudence. But here we are not dealing with jurisprudence; we are not dealing with a person's rights under the law. We are here dealing with what I have already described as the proper classification of a person in the practice of his profession in the absence of any objective data, and in order to do that we called into existence a local professional committee, containing all the specialities about which classification is to be made.

Dr. Morgan

One was left out.

Mr. Bevan

Which one?

Dr. Morgan

Industrial medicine.

Mr. Bevan

Let us keep our eye on the ball for the moment.

Dr. Morgan

Do not let us cock our eye at it.

Mr. Bevan

Do not let us wander into alien fields at this moment. Let us keep where we are. We will digest that one when we come to it.

This local committee was, therefore, appointed. I want hon. Members to realise that what we are trying to do is to classify a person, not only in respect of his academic qualifications, which are ascertainable, but also in respect of his behaviour, so that the more local it is—that is the whole point—the more knowledge, the more particular and the more exact. I grant it may also be more prejudiced; there is always that danger. But also remember that, as people are being classified on the grounds of their craftsmanship, the more particular, immediate and precise the knowledge, the more just the conclusion is likely to be, other things being taken for granted. Therefore, it was a local committee that did the classification.

This thing is being done for the first time in the history of medicine, so that we are at the moment denied any precedents and guidance. Therefore, as the first review was bound to be empirical, we decided that a further review should take place. "Review" is the right word; it is not an appeal. If a person wished to have his case reviewed it could be referred to a committee of two people from outside that region, so that they could bring a fresh mind to bear upon what had happened. Now, that has taken place, or is in process of taking place, and it would be a disaster of the worst kind if we churned it all up again after all this has been done.

Hon. Members must bear in mind that, whilst they might satisfy, or hope to satisfy, the small number of persons who would wish to make an appeal, they would dissatisfy a very large number of those who have been established. Hon. Members must not think that they will have praises bestowed upon them. On the contrary. All those people who are now fitting themselves into their positions will feel insecure. [HON. MEMBERS: "Why?"] Because if there is an appeal by the individual to a higher body there must be an appeal against a lower body by the higher body.

In this case, remember, we are not talking about courts. I wish the hon. Member for Oxford (Mr. Hogg) would not scribble so assiduously, because his legal precedents will have no relevance at all to this matter. I hope he will not drag a whole shoal of juridical red herrings across this trail. We are here dealing with practical problems and not academic jurisprudence. If it is possible for the local committee to have made a mistake against which the aggrieved person could appeal, it could also have made a mistake in appointing the other people. In other words, the whole of its findings are exposed to doubt, because if it can be wrong in the ones it refuses to classify, it may be wrong in the ones which it does. Furthermore, this central committee would not be a committee of superior status to the local committee. It would consist of exactly the same type of people, possessed of less knowledge about the individuals concerned than the local committee against which appeal is made.

Viscount Hinchingbrooke

Not always so very local.

Mr. Bevan

I could not gather from the noble Lord's speech whether he was against or for a central committee. He referred to remoteness, whereas his hon. Friend referred to local prejudice. I am not clear whether the mover and seconder were moving this for the same reason. It does not matter, and it happens quite frequently.

I now there have been hard feelings about this because we are dealing here with people's professional status, with their pride, and the position they occupy in the minds of their fellow craftsmen. Therefore, it is inevitable, having passed through this sieve, that a lot of individuals should have feelings about it. Unhappily that is the case, but the person who has failed to pass an examination has not usually an appeal against those who examined him—he has a grievance, but no appeal, and a sense of grievance is not necessarily entitlement to appeal. Therefore, I should not in this case, if I were the Opposition, throw this apple of discord into the arena just now. It will do no good to anyone, but will merely undo the good work done and be resented by the profession, because they will think that politicians have been having a holiday at their expense.

Mr. Hogg

I was not proposing to enter into any judicial precedents. The object of my notes was to render some sort of protest against the habit of the Minister using words on the precedent of Humpty-Dumpty, making them mean what he wants them to mean—talking about appeals from higher courts back to lower courts. There is nothing particularly commonsense about nonsense, and nonsense is what the right hon. Gentleman was talking in a very great part of his speech. The broad, simple answer to the point he was making was this. His argument appeared to be that because a person turned down was given an appeal, we must necessarily give the classifying body an appeal, or someone else an appeal, when an appointment was made. There is nothing about that in the Amendment. The Amendment provides solely for appeals by persons who are aggrieved.

Until he went off into that fog of verbiage, the Minister was making a rather sensible and valuable speech. In the first place, I was grateful to him for pointing out the drafting defect of this Amendment, that in fact the Amendment is apparently put in the wrong place because local hospital boards were concerned with appointments and not with classification. But no one answered that objection better than the Minister himself, by pointing out the difficulties private Members find in drafting Amendments to complicated systems of legislation; so I do not think we need take up any more time about that.

The real question is a point of principle raised by the Amendment. I was very much impressed by what the Minister said in relation to his own position in the Amendment. I thought that to be a very good point. I thought he was well entitled to say that the classification of specialists was not a matter for which political responsibility ought to be taken by a lay Minister. So far I am rather with him. But, there again, I still did not think he was dealing with the real substance of the Amendment. The interesting question which underlies the Amendment is the administrative machinery which ought to exist for the classification of specialists. It is true, as the Minister says, that there is not—and I rather think there could not be invented—a formal academic qualification which constitutes a specialist. I think it would be very undesirable to try to invent one even if one could be invented, because all kinds of things may be specialised in for which no formal academic qualification exists or is desirable.

9.15 p.m.

Having assumed that, it becomes an extremely important practical question of how we are to exclude from the circle of specialists those who have no qualification to call themselves such. No doubt all kinds of professions attach to themselves a small minority of people of that kind. The Minister is right in having entrusted the question of classification to a local body. He is correct in saying that the local body can judge practice as well as theoretical qualification and prima facie ought to be given responsibility, but what the Minister has failed to understand is that it is absolutely vital to have a single standard throughout the country for this purpose and that that cannot be obtained by the operations of a local man acting alone.

Mr. Bevan

It is the absence of an objective test that makes impossible the presence of uniformity. It is the professional status of the individual himself in the conduct of his work which constitutes his entitlement to status. Uniformity is, therefore, absolutely impossible.

Mr. Hogg

I quite agree, and that is why I am somewhat surprised that, starting from exactly the same premise, we should arrive at opposite destinations on matters which have nothing to do with our party difficulties.

Having started from the premise that an objective standard is impossible, and having agreed with the right hon. Gentleman that responsibility must lie, in the first place, with the local committee, I think the conclusion which follows is that a central professional body ought to supervise the work of the local committees. I do not think it is impossible to deal with these matters on appeal; I do not agree that what is being introduced is a juridical or legal concept. I can see no reason to suppose that the Central Professional Committee which it is suggested should be inaugurated would be other than a co-ordinating body of practical men, deciding cases on practical principles and evolving a code of practice from case to case which would give the desired uniformity so far as it could be given. I do not believe that in the long run it is desirable to have a series—I, am not sure that I recollect how many—of local committees all over the country, each independent of the other and unco-ordinated even by political responsibility.

I accept the Ministers word that his new proposal, which is that there should be a review, with two added persons from outside, by the same body which gave the original decision, is acceptable to those concerned. I cannot say what those concerned might think about that, but for my part I am not altogether persuaded that it is an administrative acceptability. I have no doubt that the Minister will consider a more uniform system, but he has not altogether persuaded me that it is not desirable for a purely professional body to overlook the work of the local committees provided, of course, that it confines its attention to appeals from individual cases and thus devolves a sort of case law and not a kind of hierarchical administration with the imposition, with authority, of general principles.

Dr. Morgan

I am very sorry to have to speak now, because the House has been treated to two oratorical displays neither of which I can scarcely hope to equal, but I am speaking because I feel rather deeply on this subject. I have always been in favour of professional reform. I have always been in favour of some recognised scheme by which specialists and the different grades in the profession can be recognised. I have pleaded for this for years, both inside and outside the profession. The public is disinterested in the reform of the profession. People do not care a hoot who calls himself a specialist. I have great sympathy with the Minister, who tonight has been most conciliatory on this most difficult of all problems—the grading of specialists and the recognition of men who are really specialists. This is not a thing for political controversy or, indeed, for professional controversy, but something which requires good will and judgment in order to work out an equitable scheme to meet different conditions in different parts of the country.

While I have considerable sympathy with the Amendment which has been moved, I do not agree with the whole of it. I suggest that we should sit down some time and consider this matter of the reform of the profession from this point of view. Let us take this particular Amendment. All that is being asked here is that there should be a Central Professional Committee, which would consider cases on appeal and make recommendations to the Minister, who would have the final say in the matter. The Minister, who is always very brave, has become scared at that. He says, "No, this is a professional matter"; but he would be acting on the recommendations of a proper, constitutional professional committee, and I do not see why he should shirk doing the same thing as he does nearly every day.

Whatever the Minister, the Government or the House of Commons may think, there is in the profession and among the most competent specialists in the country a great deal of professional dissatisfaction at the way things have gone so far. I know that the hon. Member for South Tottenham (Mr. Messer) has remarked that there was no grading previously. He knows very little about the profession if he thinks or says that. There may have been no recognised grading, but there was plenty of professional grading within the profession, and many a man who failed to get his F.R.C.S. examination, in which there was a certain element of choice as well as learning, did not fail altogether because of lack of learning.

I remember that on the day when I failed in my first primary of the F.R.C.S. examination, one of the examiners pulled me aside and told me, "You did not fail because you did not know the subject, but because you are too keen on Socialist policy." It may be changed now, because Labour has got respectable, but there is a considerable amount of dissatisfaction amongst most highly efficient specialists on the question of grading and the recognition of specialists. I urge the Minister to take some steps in regard to questions within the profession which are binding on the public, because I believe that it is the public who should be the masters of the various professions in this country.

I could say a lot on this subject, but I do not wish to go on too long tonight. I only wish to say that I have considerable sympathy with the underlying basis of the whole idea. Specialists have come to me and I have seen specialists of standing and competence—whom I would trust with my own body or the bodies of those dearest to me—who are almost emotionally affected by the fact that they are not graded efficiently as compared with some nincompoop in the provinces.

We may say what we like; we may agree or disagree with grading; but the fact is that we have now a good service in the country and hope for better things in the future. We ask the Minister to look at this problem from the point of view of seeing whether something can be done to meet this great difficulty in the profession; to see whether some body, professional or mixed, can be brought into being to clean up the profession and solve the problem in a way pleasing to those most competent within the profession.

Lieut.-Colonel Elliot

I have every sympathy with the Minister in his contention that the Debate has now continued for a long time and therefore I will make him an offer. Let us take the Third Reading without Debate. After all, the essence of this Bill is the bits and pieces. It is a survey piece by piece of a field, and I do not think there is any necessity for a review afterwards of the whole field.

Mr. Bevan

May I say that so far as I am concerned I was hoping to take the Third Reading formally. Of course, we are always in the hands of hon. Members in all parts of the House, and if hon. Members wish to speak, I assume that Mr. Speaker must see them.

Lieut.-Colonel Elliot

It could not be permitted for any of us even in the mildest degree to suggest—whatever other courts of appeal were existing anywhere else—that there was any court of appeal in this House but Mr. Speaker. I would merely say that I think, so far as my hon. and right hon. Friends are concerned, that they would be willing to take the Third Reading formally. But we are not at all sorry that the Debate has continued on several of these points for some length, and indeed on this point which is a very important one.

As the Minister has said, there is no political profit to be made out of it one side or the other. I believe that some people will he satisfied and some people will he dissatisfied but I do not think that we shall make anything out of it. I do believe it is the business of the House of Commons to ventilate grievances. The hon. Member for Rochdale (Dr. Morgan) has borne witness, and not merely from a party point of view. He is of the same political opinions as the Minister, and according to his own account has suffered for those opinions even professionally. Therefore we are now discussing an important point. Everyone has pointed out that there was no hierarchy, no fully established hierarchy before. A fully established hierarchy is now being brought into being and this is therefore a new problem.

What is more, it is a problem which will pass, because once the hierarchy has been brought into being for good or ill the steps are established; and now we are attempting to classify a number of persons whose qualifications, as the Minister has truly said, are not academic qualifications, but qualifications of craftsmanship, professional competence, and behaviour. Then we have a very difficult task indeed. I ask the Minister first to consider that point, that a difficult task is there and that difficult task has not, I think, been fully satisfactorily performed up to now.

The next point is this, that we bring forward the suggestion for a central body, a body which at the end of the day advises the Minister who then acts. The Minister says, "You could not have such a thing. Professional men would all be up in arms." He is flanked by two Ministers who are continually receiving appeals and deciding upon them. The Home Secretary is the final court of appeal in this country. The home Secretary has great responsibilities. It may be said, "These are matters of justice, matters of life and death: these are not the sort of matters we are considering."

9.30 p.m.

Let me turn to his left hand side at which is sitting the representative of the Secretary of State for Scotland. Who makes the final appointments for many of the greatest Chairs in Scotland? Who appoints the professor of Greek or the professor of mathematics, the professor of Italian literature or the professor of history? The Secretary of State for Scotland.

Mr. Bevan

He does not determine whether they are to be professors.

Lieut.-Colonel Elliot

He does. If he makes a man a professor, he is a professor.

Mr. Bevan

The analogy is that the regional hospital board would appoint a person to be a senior surgeon at a particular hospital after that person had been classified as a specialist in a speciality, but it would not determine whether that person should be a specialist in that speciality.

Lieut.-Colonel Elliot

The Secretary of State for Scotland can appoint a man, and would appoint him. I have appointed men myself not because they were professors anywhere else but because I thought highly—and was advised by professional men—of their academic qualifications and of their performance. Whether they were professors beforehand or not was of no importance at all.

Mr. Bevan

We do not want to be at cross-purposes. We merely want to be clear here. I want everybody to understand that what the right hon. and gallant Gentleman is now pressing upon the House is that the Secretary of State for Scotland and the Minister of Health in England should accept the responsibility, on the advice of a central body, of determining the professional competence of a specialist. That is what he is asking. The analogy he makes is that the Secretary of State for Scotland sometimes appoints a person to a Chair in one of the universities in Scotland, but the fact is that that person would already have reached academic eminence and would already be fully established with his peers before he would be selected from among his peers to occupy the Chair.

Lieut.-Colonel Elliot

These can only be analogies and to some extent analogies are inevitably misleading. I was pointing out that at the end of the day the responsibility of a layman on high professional advice is admitted in realms quite as important as the realm which we are now discussing. I go no further than that, but that it does exist is true. My hon. Friend the Member for Southern Dorset (Viscount Hinchingbrooke) raised the analogy of the Army. That is also an hierarchical body. Believe me, it has been found necessary there to provide some machinery of appeal. The machinery of grading differs slightly in Scotland. In England the appeal committee is a committee with two more of the speciality concerned added. In Scotland I believe that it is a committee of 14 with one other person added, and it is not necessarily any more satisfactory to those in Scotland than is the English procedure.

I think from all the arguments brought forward tonight that some body which is not the local body, some body where one will not be appealing from a committee to the same committee again with perhaps one or two added members, would be of great advantage if it were only to remove any sense of grievance.

A sense of grievance does exist, and nobody denies it. The Minister asked if we could quote examples, and we have had many examples, but it would not be fair to quote them by chapter and verse. The Minister must take it from us, and, indeed, he can take it from hon. Members on his own side of the House, that many types of people have recently come forward and said they felt a grave sense of uneasiness and dissatisfaction because of an anonymous decision by people whom they could not get at or understand. [Interruption.] The Minister must not pick up small points like that, because I am not using the phrase "get at" in any Stanley-ish sense, but in the sense that a man should not feel that

he is being judged by some one with a coat over his head, or that he should go away thinking that his case has been heard fairly only to find out that the whole thing was quite different.

It is all very well for the Minister to say that some people will always be aggrieved. Of course, they will, but he is dealing with a very important matter here and it is very necessary that he should keep his mind open on the subject. I think he attempts to close it too soon. He says that the whole thing would be churned up. By churning we get butter, and that is better than a jar of sour milk. I am not sure that a certain amount of churning which would get a certain amount of butter would not be better than such unpleasant stuff as sour milk.

I do not think the Minister has dealt fully with this matter, and I must say that unless he can meet us a little further, we shall be compelled to divide the House on this issue. If the Minister cannot meet us, we shall have to register our view that the final word has not yet been said on this matter by carrying the issue into the Division Lobbies.

Question put, "That those words be there inserted in the Bill."

The House divided: Ayes, 97; Noes, 241.

Division No. 252.]	AYES	[9.40 p.m.
Agnew, Cmdr. P. G.	Harden, J. R. E.	Peto, Brig. C. H. M.
Amory, D. Heathcoat	Harvey, Air-Comdre, A. V.	Raikes, H. V.
Baldwin, A. E.	Haughton, S. G.	Renton, D.
Barlow, Sir J.	Henderson, John (Cathcart)	Roberts, Emrys (Merioneth)
Beamish, Maj. T. V. H.	Hinchingbrooke, Viscount	Roberts, P. G. (Ecclesall)
Bennett, Sir P.	Hogg, Hon. Q.	Roberts, W. (Cumberland, N.)
Birch, Nigel	Howard, Hon. A.	Ropner, Col. L.
Boles, Lt.-Col. D. C. (Wells)	Hudson, Rt. Hon. R. S. (Southport)	Ross, Sir R. D. (Londonderry)
Bowen, R.	Hulbert, Wing-Cdr N. J.	Sanderson, Sir F.
Bower, N.	Hutchison, Lt.-Cm. Clark (E'b'rgh, W.)	Scott, Lord W.
Boyd-Carpenter, J. A.	Hutchison, Col. J. R. (Glasgow, C.)	Shepherd, W. S. (Bucklow)
Bromley-Davenport, Lt.-Col. W.	Jeffreys, General Sir G.	Snadden, W. M.
Buchan-Hepburn, P. G. T.	Joynson-Hicks, Hon. L. W.	Spence, H. R.
Butcher, H. W.	Law, Rt. Hon. R. K.	Stewart, J. Henderson (Fife, E.)
Carson, E.	Legge-Bourke, Maj. E. A. H.	Stoddart-Scott, Col. M.
Clarke, Col. R. S.	Lipson, D. L.	Strauss, Henry (English Universities)
Conant, Maj. R. J. E.	Lloyd, Selwyn (Wirral)	Sutcliffe, H.
Corbett, Lieut.-Col. U. (Ludlow)	Lucas, Major Sir J.	Taylor, Vice-Adm. E. A. (P'dd't'n, S.)
Crookshank, Capt. Rt. Hon. H. F. C.	Lucas-Tooth, Sir H.	Teeling, William
Crosthwaite-Eyre, Col. O. E.	Macdonald, Sir P. (I. of Wight)	Turton, R. H.
Crowder, Capt. John E.	McFarlane, C. S.	Wadsworth, G.
Darling, Sir W. Y.	McKie, J. H. (Galloway)	Walker-Smith, D.
Digby, S. Wingfield	Maclean, F. H. R. (Lancaster)	Ward, Hon. G. R.
Dower, Col. A. V. G. (Penrith)	Manningham-Buller, R. E.	Wheatley, Colonel M. J. (Dorset, E.)
Drayson, G. B.	Marlowe, A. A. H.	White, Sir D. (Fareham)
Drewe, C.	Marples, A. E.	Williams, C. (Torquay)
Elliot, Lieut.-Col. Rt. Hon. Walter	Marshall, D. (Bodmin)	Williams, Gerald (Tonbridge)
Fyfe, Rt. Hon. Sir D. P. M.	Mellor, Sir J.	Willoughby de Eresby, Lord
Gage, C.	Morrison, Maj. J. G. (Salisbury)	York, C.
Galbraith, T. G. D. (Hillhead)	Mott-Radclyffe, C. E.
Gates, Maj. E. E.	Neven-Spence, Sir B.	TELLERS FOR THE AYES:
Gomme-Duncan, Col. A.	Nield, B. (Chester)	Mr. Studholme and
Granville, E. (Eye)	Odey, G. W.	Brigadier Mackeson
Hannon, Sir P. (Moseley)	Orr-Ewing, I. L.
NOES
Adams, Richard (Balham)	Guest, Dr. L. Haden	Paget, R. T.
Allen, A. C. (Bosworth)	Gunter, R. J.	Paling, Rt. Hon. Wilfred (Wentworth)
Allen, Scholefield (Crewe)	Guy, W. H.	Paling, Will T. (Dewsbury)
Alpass, J. H.	Haire, John E. (Wycombe)	Palmer, A. M. F.
Attewell, H. C.	Hale, Leslie	Pannell, T. C.
Austin, H. Lewis	Hamilton, Lieut.-Col. R.	Pargiter, G. A.
Awbery, S. S.	Hannan, W. (Maryhill)	Parkin, B. T.
Ayles, W. H.	Hardy, E. A.	Pearson, A.
Ayrton Gould, Mrs. B.	Harrison, J.	Popplewell, E.
Baird, J.	Haworth, J.	Porter, E. (Warrington)
Balfour, A.	Henderson, Rt. Hon. A. (Kingswinford)	Porter, G. (Leeds)
Barton, C.	Henderson, Joseph (Ardwick)	Price, M. Philips
Bachervaise, A. E.	Hewitson, Capt. M.	Proctor, W. T.
Bevan, Rt. Hon. A. (Ebbw Vale)	Hobson, C. R.	Pryde, D. J.
Bing, G. H. C.	Holman, P.	Pursey, Comdr. H.
Binns, J.	Holmes, H. E. (Hemsworth)	Ranger, J.
Blackburn, A. R.	Horabin, T. L.	Rankin, J.
Blenkinsop, A.	Houghton, Douglas	Reid, T. (Swindon)
Blyton, W. R.	Hoy, J.	Rhodes, H.
Boardman, H.	Hubbard, T.	Richards, R.
Bottomley, A. G.	Hughes, Emrys (S. Ayr)	Ridealgh, Mrs. M.
Bowden, H. W.	Hutchinson, H. L. (Rusholme)	Robertson, J. J. (Berwick)
Brook, D. (Halifax)	Hynd, H. (Hackney, C.)	Robinson, Kenneth (St. Pancras, N.)
Brooks, T. J. (Rothwell)	Hynd, J. B. (Attercliffe)	Ross, William (Kilmarnock)
Broughton, Dr. A. D. D.	Isaacs, Rt. Hon. G. A.	Royle, C.
Brown, George (Belper)	Janner, B.	Sargood, R.
Brown, T. J. (Ince)	Jeger, G. (Winchester)	Scollan, T.
Burden, T. W.	Jeger, Dr. S. W. (St. Pancras, S. E.)	Scott-Elliot, W.
Burke, W. A.	John, W.	Segal, Dr. S.
Butler, H. W. (Hackney, S.)	Johnston, Douglas	Shackleton, E. A. A.
Callaghan, James	Jones, D. T. (Hartlepool)	Sharp, Granville
Carmichael, James	Keenan, W.	Shurmer, P.
Champion, A. J.	Kenyon, C.	Silverman, J. (Erdington)
Chetwynd, G. R.	Key, Rt. Hon. C. W.	Simmons, C. J.
Cobb, F. A.	Kinghorn, Sqn.-Ldr. E.	Skinnard, F. W.
Cocks, F. S.	Kinley, J.	Smith, C. (Colchester)
Coldrick, W.	Lang, G.	Smith, Ellis (Stoke)
Collick P.	Lavers, S.	Smith, H. N. (Nottingham, S.)
Collindridge, F.	Lee, F. (Hulme)	Smith, S. H. (Hull, S. W.)
Collins, V. J.	Lee, Miss J. (Cannock)	Sorensen, R. W.
Colman, Miss G. M.	Leonard, W.	Soskice, Rt. Hon. Sir Frank
Cook, T. F.	Leslie, J. R.	Sparks, J. A.
Cooper, G.	Lewis, A. W. J. (Upton)	Steele, T.
Corlett, Dr. J.	Lewis, J. (Bolton)	Swingler, S.
Cove, W. G.	Lewis, T. (Southampton)
Daggar, G.	Lipton, Lt.-Col. M.	Sylvester, G. O.
Davies, Edward (Burslem)	Logan, D. G.	Taylor, H. B. (Mansfield)
Davies, Ernest (Enfield)	Longden, F.	Taylor, R. J. (Morpeth)
Davies, Haydn (St. Pancras, S. W.)	Lyne, A. W.	Thomas, D. E. (Aberdare)
Davies, R. J. (Westhoughton)	McAdam, W.	Thomas, Ivor Owen (Wrekin)
Deer, G.	McEntee, V. La T.	Thomas, John R. (Dover)
Delargy, H. J.	McGhee, H. G.	Thorneycroft, Harry (Clayton)
Diamond, J.	McKay, J. (Wallsend)	Thurtle, Ernest
Dobbie, W.	Maclean, N. (Govan)	Tiffany, S.
Dodds, N. N.	McLeavy, F.	Tolley, L.
Donovan, T.	MacPherson, Malcolm (Stirling)	Tomlinson, Rt. Hon. G.
Driberg, T. E. N.	Macpherson, T. (Romford)	Turner-Samuels, M.
Dye, S.	Mainwaring, W. H.	Ungoed-Thomas, L.
Ede, Rt. Hon. J. C.	Mallalieu, E. L. (Brigg)	Warbey, W. N.
Edwards, Rt. Hon. Sir C. (Bedwellty)	Mallalieu, J. P. W. (Huddersfield)	Watkins, T. E.
Edwards, Rt. Hon. N. (Caerphilly)	Marquand, Rt. Hon. H. A.	Webb, M. (Bradford, C.)
Evans, E. (Lowestoft)	Mathers, Rt. Hon. George	Wells, P. L. (Faversham)
Evans, John (Ogmore)	Medland, H. M.	Wells, W. T. (Walsall)
Evans, S. N. (Wednesbury)	Mellish, R. J.	Wheatley, Rt. Hn. John (Edinb'gh, E.)
Ewart, R.	Messer, F.	White, H. (Derbyshire, N. E.)
Fairhurst, F.	Middleton, Mrs. L.	Whiteley, Rt. Hon. W.
Farthing, W. J.	Mikardo, Ian	Wigg, George
Fernyhough, E.	Mitchison, G. R.	Wilkins, W. A.
Forman, J. C.	Monslow, W.	Willey, O. G. (Cleveland)
Fraser, T. (Hamilton)	Moody, A. S.	Williams, D. J. (Neath)
Freeman, Peter (Newport)	Morgan, Dr. H. B.	Williams, J. L. (Kelvingrove)
Ganley, Mrs. C. S.	Morley, R.	Williams, Rt. Hon. T. (Don Valley)
Gibson, C. W.	Morris, Lt.-Col. H. (Sheffield, C.)	Willis, E.
Gilzean, A.	Morris, P. (Swansea, W.)	Wills, Mrs. E. A.
Glanville, J. E. (Consett)	Mort, D. L.	Woodburn, Rt. Hon. A.
Gooch, E. G.	Moyle, A.	Woods, G. S.
Gordon-Walker, P. C.	Nally, W.	Yates, V. F.
Grey, C. F.	Naylor, T. E.	Younger, Hon. Kenneth
Grierson, E.	Neal, H. (Claycross)
Griffiths, D. (Rother Valley)	Nichol, Mrs. M. E. (Bradford, N.)	TELLERS FOR THE NOES:
Griffiths, Rt. Hon. J. (Llanelly)	Oldfield, W. H.	Mr. Snow and Mr. George Wallace.
Griffiths, W. D. (Moss Side)	Oliver, G. H.

Bill read the Third time, and passed.

Mr. Bevan

I beg to move, in page 22, line 36, at the end to insert: In subsection (1) of section thirty-two (which relates to local representative committees) at the end of paragraph (c) there shall be inserted the words 'or (d) of the ophthalmic opticians and dispensing opticians providing supplementary ophthalmic services in that area,' after 'Local Pharmaceutical Committee' the word 'or' shall be omitted and after the words 'Local Dental Committee' there shall be inserted the words 'or the Local Optical Committee.' This is one of a series of Amendments. The purpose of this Amendment is to give the local optical committee the same statutory position as is now occupied by the local medical committee, pharmaceutical committee and dental committee. There is nothing controversial about this Amendment.

Amendment agreed to.

Further Amendments made: In page 22, line 37, after "of," insert "the said."

Line 37, leave out: (which relates to local representative committees).

Line 41, after the first "Committee," insert: or the Local Optical Committee.

Line 44, after the second "services," insert "general dental services."

Line 45, leave out "general dental," and insert "supplementary ophthalmic."—[Mr. Bevan.]

The Lord Advocate (Mr. John Wheatley)

I beg to move, in page 26, line 41, at the end, to insert: In subsection (1) of section thirty-three (which relates to local representative committees) at the end of paragraph (c) there shall be inserted the words 'or (d) of the ophthalmic opticians and dispensing opticians providing supplementary ophthalmic services in that area.' after "Local Dental Committee," the word "or," shall be omitted, and after the words "Local Pharmaceutical Committee," there shall be inserted the words "or the Local Optical Committee."

This is the corresponding Amendment, dealing with the Scottish position, to the Amendment which has just been moved by my right hon. Friend the Minister of Health.

Amendment agreed to.

Further Amendments made: In page 26, line 42, after "of," insert "the said."

Line 42, leave out: (which relates to local representative committees).

Line 46, after "Committee," insert "or the Local Optical Committee."—[The Lord Advocate.]

The Lord Advocate

I beg to move, in page 27, line 1, after the first "services," to insert "pharmaceutical services."

This is a drafting Amendment consequential on the Amendment which I have just moved.

Amendment agreed to.

Further Amendments made: In page 27, line 1, leave out "pharmaceutical," and insert "supplementary ophthalmic."

Line 12, at end, insert— In paragraph (d) of subsection (2) of section thirty-four (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 Lord Advocate.]