§ Motion made, and Question proposed, "That this House do now adjourn."—[Mr. Popplewell.]
§ 10.30 p.m.
§ Mr. Edward Heath (Bexley)
The question I wish to raise tonight concerns problems which arise when a doctor's list of patients has to be reduced. There is one such case at the moment in the borough of Bexley, my own division. It affects some 800 patients. The doctor has been told that his list has to be reduced and 800 patients have to find another doctor. I understand that this is happening all over the country where the lists of certain doctors have to be reduced. I appreciate that this is a difficult problem, but I hope that tonight's discussion will lead to the welfare of the patient being given full consideration in the administration of the regulations on this point. I do not believe that at the moment the welfare of the patient is getting that consideration.
May I first go over the general position as I understand it, and if I am not correct, the hon. Gentleman will correct me. I understand that when the National Health Service Regulations came into force in 1948 they fixed the maximum number of patients for a doctor at 4,000; but nothing was done at the time to implement that decision. Lists were allowed to grow above 4,000 and even above the margin of 200 which was allowed over that figure. In many cases that has proved to be a pity, because people were put on such a list and assumed that they were there for good, I think quite naturally. As they were accepted for the doctor's list, they had every reason to believe that they were accepted for as long as they considered necessary. Many doctors inquired at the Ministry if they should limit their lists and were told, "No, they should allow them to increase and they would be weeded out later." Again, I think that was a pity.
Early this year the Ministry of Health, in agreement with the medical profession, decided that the time had come to reduce the doctors' lists to 4,000, with a margin of 200. The position now is that doctors who have an excess of patients can do two things—they can take a partner or assistant; or, they can name the patients who are to be removed from their lists. 1517 If a doctor declines to do these two things—and it is important to note that he has the right to decline—the local county executive council take in hand the job of reducing his list. The executive council have the discretion as to the method they use. Nevertheless, the Ministry has produced a model allocation scheme and the county executive councils are in a large degree, following that scheme.
I come to the particular case in the borough of Bexley. I can mention the name of the doctor concerned, because his name has already appeared on the Order Paper of the House and in the national Press. He is Dr. Green, who has surgeries in both Bexley Heath and Erith. At the moment, he has just over 5,000 patients. As a result of the decision made earlier this year, he has been told that he must lose 800 of them. I understand he does not wish to take an assistant or partner, nor does he wish to name the patients to be taken off his list, because he considers it invidious to do so. Whether or not we agree with the attitude he has taken, I think we must acknowledge that he is within his rights in taking that attitude. He is within the regulations drafted by the Ministry and approved by the House.
As a result of his declining to alter the list himself or to take a partner, the country executive council have had the job of cutting the list. They have used what I would term the geographical method. They have drawn an ellipse round the area which includes both his surgery and branch surgery so that it will take in the maximum of 4,200 patients. After doing that, they have sent a notice to every patient who lives outside the area "You are now struck off Dr. Green's list seven days from today. You are given notice that in seven days you are struck off the list and you must find another doctor by going to the Post Office and there looking at the list of doctors in the borough."
I want to draw the attention of the House to the effects of this method of cutting down the list. It means that patients with a long relationship with that doctor are suddenly told that their relationship is ended, and they have seven days in which to find another doctor. This method means that one constituent of mine, who, with his family, has for 1518 26 years been attended by this doctor is told that in seven days he no longer has him as a family doctor and must find another. Another constituent, with 20 years' relationship, is told the same thing. An old lady of 73, who has had this doctor for 15 years, is told that seven days hence she has not got a doctor, and must find another. That is the effect of the action which the county executive council has taken in cutting down this doctor's list.
During the debates in the National Health Service Act the House was repeatedly told that the Health Service would not interfere with the relationship between doctor and patient. The Minister of Health himself in the debate on the Second Reading of the Bill said:There is nothing at all in the Bill, no power whatever, which confers on the Minister the right to make a regulation which interferes between a doctor and his patient."—[OFFICIAL REPORT, 30th April, 1946; Vol. 422, c. 77.]The Minister said there was no power, yet surely there could be no greater interference in this relationship than for a patient of 26 years' standing to be told that in seven days he has to find another doctor.
The questions I should like to put to the Parliamentary Secretary to the Ministry of Health are these. Is it really necessary suddenly to reduce this doctor's list from 5,000 patients to 4,200? Does he tell the House it is a vital matter? After all, this list has been allowed to grow during the last two years. I will accept that 4,000 or 4,200 patients is an ideal figure: it is the figure at which the Minister is aiming.
§ The Parliamentary Secretary to the Ministry of Health (Mr. Blenkinsop)
If the hon. Gentleman will allow me, we say nothing of the sort. We say it is a maximum, not an average, figure and not necessarily a desirable figure.
§ Mr. Heath
Compared with the lists of doctors before 1948, 5,000 is not a large figure. In addition, there have been no complaints about this doctor. His patients must have received great satisfaction, or they would not be struggling so strongly to remain with him. I also understand that the general turnover of a doctor's list varies between 300 and 600 patients. Why could not the list be closed so that no more patients could be taken, 1519 and let it reduce itself in about a year-and-a-half to about 4,200, thus avoiding hardship to the patients if it must be reduced.
If the Minister insists on reducing it suddenly to keep within the regulations, suggest that the geographical principle is wrong, and that the principle should be that those who joined the list last should be the first to go. I acknowledge that that is an interference, but if it is done it will cause less harm than removing patients of 25 years' standing. I also acknowledge that members of families of long-standing patients should not be struck off. The Parliamentary Secretary may say that he has not got the information necessary for that procedure, or that the executive council has not got it. But no attempt has been made to acquire the information, and I am most anxious in this case, and in any other case that may arise, that an attempt should be made to get it. The doctor can provide the information, and it is also possible for the patients to give that information. An attempt should be made to get it.
The next point I wish to raise is why these patients should be struck off the list with only seven days' notice. In this the local executive council is only following the model allotments scheme drawn up by the Minister and set out in the handbook, which says that patients will only receive seven days' notice. This notice is callous. This area consists largely of working-class people, and they are told to find a doctor in seven days or they will not get one. But a patient wishing to give notice to a doctor has to give three weeks' notice. Why should there be this difference in the terms? I urge the Minister to alter this period, and to make it a longer period—at least three weeks.
If a patient is struck off a doctor's list and told to find a new doctor, is he entitled to go to the nearest doctor and ask to be put on his list? That doctor may reply that his list is full. Has this patient then the right to say that the doctor must strike from his list people living further away, as the patient has already been pushed off another doctor's list? The geographical basis is going to lead to repercussions throughout the area.
My next point is the method of finding a new doctor. A patient wishing to 1520 find a new doctor is told to go to the Post Office. But the lists of many doctors in this area are full. The patient is involved in getting the names of doctors and going to them to see if they can accept him. Is it asking too much to suggest that the executive council for the area, on striking a person off a doctor's list, should send him a list of the doctors whose lists are not already full? That is surely an administrative action which could be followed by the executive council.
My main point, to which I revert, is that in this case administrative convenience has been placed before the welfare of the patient. I am convinced that with a little extra trouble this matter could have been handled better. It is wrong that administrative convenience should be placed before the welfare of the patients. I hope that the Parliamentary Secretary will do what he can to see that this is altered.
§ 10.43 p.m.
§ Mr. Dodds (Dartford)
I am sure that hundreds of my constituents will be deeply grateful to the hon. Member for Bexley (Mr. Heath) for raising this matter. As I have only a few minutes in which to make my contribution to this Debate, I should like to support the example which the hon. Member has mentioned, namely that of Dr. Green, who resides in my constituency and has his practice in both constituencies. It is the opinion of scores of my constituents that the way this difficult matter has been handled is an example of soulless bureaucracy, or at least of a "ham" type of handling. I have a feeling that when the Parliamentary Secretary gets up he will not speak very well of Dr. Green.
§ Mr. Dodds
I am only anticipating that he will say that the doctor was not cooperative. But I have heard testimony from the Labour group leader in the area, who says that Dr. Green has been from the outset most co-operative in the institution of the Health Service, while other practitioners in this area were decidedly the reverse. Their activities have given rise in no small degree to the position in regard to Dr. Green's list. In other words, Dr. Green is an enthusiastic supporter of the Health Scheme. If a patient goes to him while he is having lunch, Dr. Green tells him that if he will wait until he has 1521 finished his meal he will deal with him. He is a highly desirable doctor, and my constituents would like to remain on his list.
What I wish to refer to, on behalf of my constituents, is the manner in which, out of the blue, comes a circular letter telling people who have been Dr. Green's patients for 20 years that they have only seven days in which to change their doctor or their names will be removed from the list, when everyone knows that this sort of thing has been hanging fire since the vesting date. I ask the Parliamentary Secretary tonight to give a sensible reason why there should be this necessity for seven days—why not seven weeks? Why the urgency? It is this sort of handling that is bringing the Health Service into disrepute.
I would reinforce the point made by the hon. Member for Bexley by giving an example of the way in which hardship is caused—[Interruption.] The debate goes on for another 15 minutes, and the Parliamentary Secretary wants about 12 minutes in which to reply; that leaves me three minutes for dealing with this case. Here it is, in a letter which I have received from one of my constituents, and it is similar to the case mentioned by the hon. Member for Bexley:My wife and I, both seventy years of age, have been with Dr. Green for over twenty years, and as well as being our general practitioner, he is our confidant and great personal friend. How can we, as old-age pensioners, change him for the unknown, and afford his private practice? I cannot understand the fairness of legislation which condemns people like myself to hardships which have been caused by faulty and soulless administration.These few lines give, more or less, an example of the type of case which has infuriated people in my area, and I ask the Parliamentary Secretary why on earth the Minister should support a letter of the type to which I have referred; it is a circular letter, and is giving only seven days—"or else!" That is inhuman—[Interruption.] It is no use the Parliamentary Secretary frowning. It says, seven days or removal from the list. The Act is one of the finest which has ever been put on the Statute Book, but this is not just a case of introducing legislation; but an important point of how it is being carried out. Why does not the Kent and Canterbury Executive Council do a job of work in finding out from 1522 the people how long they had been members and avoid some of the handicaps from which these people are suffering?
§ Mr. Blenkinsop
No, if he works it out for himself, the hon. Member will find he objects to the method by which the executive council is choosing the 800. If he wants a better method, does he not suggest that we should, in some way, approach the whole 5,000 patients to see if they are last on the list or not?
§ Mr. Dodds
If my hon. Friend approached many of the patients, they will give their own answer; but why should this be done in a period of seven days? If a little more consideration is given, some of this would be avoided. Here is a notice to a man, "to change in seven days—or else." But the man to whom the notice was sent has been dead for seven years and this Kent and Canterbury Executive Council have dealt with this matter in a most inhuman manner.
§ 10.49 p.m.
§ Mr. Maudling (Barnet)
Very briefly, I support what has been said by hon. Members from both sides. In my division there is a case which is similar to this in every way. Both doctors and patients are satisfied that the intervention of the authorities in these cases has been wholly unwise.
§ 10.50 p.m.
§ The Parliamentary Secretary to the Ministry of Health (Mr. Blenkinsop)
I am glad that this matter has been raised by the hon. Member for Bexley (Mr. Heath) and supported by my hon. Friend the Member for Dartford (Mr. Dodds), because there is a certain amount of misunderstanding. Looking at the wording of the circular sent out by the executive council concerned, I must say I do not think it is perhaps the best which could have been designed. I think that in the other case, with which the hon. Member for Barnet (Mr. Maudling) is concerned, the wording was rather better.
Let me deal with the two main points. One is the principle which, as far as I 1523 can see, is not being very strongly argued against. It is the principle that the maximum list ought to be either 4,000 or whatever the figure may be. That there should be some maximum figure certainly is the desire both of the profession and of the Ministry. It always was the intention of the Ministry that we should insist upon a certain maximum number, beyond which it was agreed that proper service really could not be given. What is more, there could not be openings for the number of new doctors to come into actual practice unless we did insist upon some reasonable maximum figure.
Some I know in the medical profession argue that 4,000 is far too high. If anyone followed the argument of one who was speaking at the annual meeting recently of the Executive Councils' Association for England, they would find it was being strongly argued there that it should not be 4,000 but 3,000. However, I am not going to enter into that general argument. It is accepted that there must be some maximum figure of this kind and indeed, of course, there was a maximum figure in the old days of the insurance scheme although not the same one.
§ Sir Hugh Lucas-Tooth (Hendon, South) rose——
§ Mr. Blenkinsop
I am sorry but I have not very much time. I want to deal more particularly with the detailed points of how this reduction was carried out and I appreciate that this does cause hardship and a certain amount of ill-feeling amongst the patients concerned. The hon. Member for Bexley suggested that there had been no opportunity for Dr. Green to refuse the addition of further patients to his list, but that is not so in his case. He was asked in point of fact, I understand, to refuse to accept further patients, so that his list would not grow any further. The reason why, in the initial stages of the service, we allowed the lists to grow was to be certain that we did not rule out the families of patients already on the lists. It is obviously highly desirable that the members of one family should be on one doctor's list. Most hon. Members would agree about that, even if the hon. Member for Luton (Dr. Hill) is cogitating on the point at the moment.
1524 Dr. Green, I understand, was, in fact, asked if he would refuse further patients. [An HON. MEMBER: "When?"] I should have to get the information as to the precise date, but it was some time after the initial opportunity had been given to allow the families of patients already on his list to join, which, I think, was a reasonable step. The hon. Member for Dartford suggested that I was going, as it were, to attack this doctor hip and thigh. Not a bit of it. I agree he is well regarded in the district, and so on. I do not intend to make any attack upon him, but it is true that, had he tried to help the executive council, as, in fact, most doctors have tried to help, in carrying out this general decision on limitation, we should have been able to avoid a great deal of the difficulty that has undoubtedly arisen.
For example, if he had been able to offer to let the executive council know those who had come latest on to his list, it might have been desirable——
§ Mr. Blenkinsop
I do not know if he was, but I know he was invited right at the start to co-operate in finding the best way to reduce his list and, surely, that covered the whole point. In other cases that have arisen in precisely the same way, the doctor has in nearly every case suggested ways in which this could be done with the least trouble to patients, and the executive councils have, of course, accepted the suggestions made by the doctors concerned. The doctor mentioned by the hon. Member for Barnet did co-operate to the extent at least of suggesting those names that had come latest on to the list—and that has not been without difficulty, too. That has not necessarily been the most satisfactory way in every case; but what we want to achieve is, obviously, a method that will be the most satisfactory in the particular circumstances.
Not having the assistance of the doctor, the executive council took on what I must say is, on the whole, a reasonable decision—that they would try to rule out those patients who appeared to them to be the farthest away from the doctor's main centre of practice. Any patients who were actually in receipt of treatment at the time should, of course, have notified the 1525 executive council and they would certainly not be withdrawn from the list. The council inserted this in the notice they sent out and I am glad they did put this in. I think there was some misunderstanding among those who complained about the procedure. They did not realise that that was the case, though it was clearly stated in the notice.
My hon. Friend the Member for Dartford has made a good deal of the period of notice. There is no actual requirement in our regulations that specifies seven days and the executive council are allowed some latitude in the period of time they wish to insist upon, and I think it is a point as to whether or not seven days is the right period.
§ Mr. Blenkinsop
I think the seven days' notice refers to the doctor rather than to the patient. I believe that is so. I know in some cases 14 days are given, but I would remind hon. Members what we are discussing. We are saying that after seven days a patient who is not under treatment is excluded from that particular doctor's list. He can still go and get emergency treatment should the need arise before he manages to select another doctor, so this is not quite such a life-and-death question as is suggested. But I think there is something in the 1526 point that the executive council should have regard to the idea that some people have—quite wrongly—that the necessity for action is put like a pistol to their heads. Executive councils would willingly consider that.
Another point that hon. Members raised is, I think, also a matter for consideration. I think on the whole that executive councils should give the patients a list of other doctors in the area—instead of referring them to the list at the local Post Office. Again, this was a matter that was left in the past to the discretion of the executive council. The practice varies from one area to another and on the whole it will be desirable if this method were more generally used. After examining this case I do not feel that the strictures on the executive council are really justified. I think there were one or two points that might well be looked at further, but at the same time I cannot but say that had the doctor in this case offered his assistance rather more as other doctors have done elsewhere where we have had difficulty, this problem would not have arisen.
§ The Question having been proposed after Ten o'Clock and the Debate having continued for half an hour, Mr. DEPUTY-SPEAKER adjourned the House without Question put, pursuant to the Standing Order.
§ Adjourned at Eleven o'Clock.