HC Deb 29 April 1953 vol 514 cc2283-307

10.12 p.m.

Mr. A. Blenkinsop (Newcastle-upon-Tyne, East)

I beg to move, That an humble Address be presented to Her Majesty praying that the National Health Service (Pay-Bed Accommodation in Hospitals, etc.) Regulations, 1953 (S.I., 1953, No. 420), dated 12th March, 1953, a copy of which was laid before this House on 13th March, be annulled. It appears to us that there has been a change of policy on the part of the Government in relation to hospitals and pay-beds in hospitals, a change of policy which we deeply oppose. It is extremely difficult for anyone to make any sense of the very complex Regulations against which we pray. One might have hoped that the Government, who often complained about the form of wording of regulations made in the past, would have done their best to improve the intelligibility of this document, but they have not done so.

Nevertheless, it is clear that the broad effect of the Regulations is, first of all, to confirm the recent increases in charges for amenity beds, provision for which was made in a regulation last year. Secondly, the Regulations reduce pay-bed charges by sums which will vary from one part of the country to another, and, indeed, from one hospital to another, according to the very complex calculations which have to be made; and I sympathise with all those on hospital staffs who have had the job of trying to calculate the new charges which apply to pay-beds under the Regulations. As far as I can find out, the general effect of the Regulations will be that a reduction of something between 5 per cent. and 10 per cent. will be effected in the charges for pay beds. Thirdly, the Regulations provide for an increase in the maximum fees which can be charged by specialists giving treatment in pay-beds to their private patients.

Some may say, "What is wrong with those three changes?" First of all, I think my hon. Friends have been alive to the fact that private pay-beds have always been an anomaly in a Health Service which has tried to ensure a single standard of service for everyone, irrespective of whether they have money with which to pay for special facilities. As we all know, there have always been complaints—I am sure hon. Members opposite must know this as well as we do—from those who have been told that they have to wait three or six months, or even longer, for an operation or for treatment, whereas those who have been able to afford to pay for a pay bed have been able to get treatment straight away.

Even where there may be good reasons for this it has, nevertheless, always been felt—and understandably felt—as a very real grievance by vast numbers of people, many more than perhaps have been affected by the problem themselves. We agree that it was necessary, in the initial stages when this provision was made and the National Health Service was introduced to ensure that specialists should be broadly spread throughout the hospitals in the service and initially provision of pay beds was certainly necessary.

These Regulations are designed to ensure that there shall be an increased use of pay-beds—otherwise they mean nothing. It means that it is desired that there shall be an increase in the use of pay-beds and, therefore, there will be an increase in the sense of injustice among those who find themselves pushed further back in the queue for free treatment.

Secondly, these Regulations undoubtedly add to the specially favoured position of the part-time specialist in hospitals as against the full-time specialist. I do not think there can be any question about that. The Regulations are designed to ensure that he shall have more beds at his disposal and provides for additional maximum fees. Therefore, he wins all along the line. Yet I should have thought there was general agreement that it is the part-time specialist whose service needs to be examined with some care in the Health Service.

If there is room for cutting down expenditure it may well be that it is in this field. I think there is a great deal of agreement that it is the full-time specialist, who on the whole, gives the most economical service in the Health Service. There is not much doubt that the part-time specialist, with the addition of his private fees and a great deal of sessional fees and special rates for travelling allowances, and so on, can build up a very large income. There has always been a great deal of anxiety about this position, but these Regulations make the position worse, not better.

No doubt I shall be told that the Regulations are designed to reduce the cost of pay-beds, that they are too costly, that it is to ensure that they are fully used as we know they are not being fully used at present and that if they are more fully used hospitals will get more money—and we all want that. That is all very well, but why are these unused pay-beds not being used, as we intended they should be, for patients receiving free treatment? It is perfectly clear from the evidence we have—I am sure the Minister has much more that will no doubt bring out the same factors—that very large numbers of these pay-beds are being sterilised for the use of specialists and are not being made available for ordinary National Health Service patients.

I gather that in one area, in Stoke, for example, 55 per cent.—more than half—of the pay-beds of that management committee are unoccupied. The figures I have had from the area I know best in my own district on Tyneside suggest a comparable figure. Therefore, our argument is that we should face up to the fact that pay-beds are not being fully used.

The Regulations are really an excuse for the Minister to avoid finding the extra funds that the hospital needs to provide a full and adequate service. In fact, for a small and doubtful financial benefit the Minister is encouraging the extension of a two-level service, a service of one quality for those who can afford to pay more and a service at the lower standard for those who cannot afford to pay so much. That is why we urge that the Regulations shall be annulled and we hope that hon. Members on both sides will support us.

10.22 p.m.

Mr. Frederick Messer (Tottenham)

I beg to second the Motion.

I regret very much that it has been necessary to move this Prayer. My hon. Friend, in his brief speech, could not explain the very difficult words used and although I do not intend to take very long I propose to bore the House by reading one paragraph. I ask anyone who has not had the benefit of advice from a lawyer to tell me just what that paragraph means. It is paragraph 6, on page 2 of the Regulations: Where the standard daily charge is determined under paragraph (1) of the last preceding regulation: — (a) If an in-patient occupying pay-bed accommodation makes arrangements under sub-section (2) of section five of the Act for treatment as a private patient by a consultant or senior hospital medical or dental officer, there shall be added to the standard daily charge an amount representing the estimated average daily cost per in-patient in such accommodation of remunerating the medical and dental officers (other than consultants and senior hospital medical and dental officers) employed by the Regional Hospital Board or Board of Governors exclusively for the treatment of patients accommodated in the pay-bed accommodation of the hospital and of paying the due proportion of the remuneration of medical and dental officers (inclusive of consultants and senior hospital medical and dental officers who are whole time officers but exclusive of other consultants, senior hospital medical and dental officers) employed for part of their time, not being, in the opinion of the Board or Committee, an insignificant part, for the treatment of patients accommodated in the pay-bed accommodation. I defy any layman to tell me just what that means.

When an important change is being made, the House ought to have an explanation. We shall be discussing this from the standpoint of what we believe it to mean; but surely, when dealing with important work such as is concerned with the National Health Service, the House ought to be in a position to know what it is doing. I contend that it is not in a position tonight to know what it is doing; I can only surmise what is to happen.

As far as Section 5 of the Act is concerned, dealing with the type of private patient who is called upon to pay the full cost, the Regulations will attempt to reduce from that full cost certain services that the patient will not receive. When the paragraph to which I have referred speaks of an insignificant part, for the treatment of patients … what are we to understand by "insignificant part"? The House really ought to be better informed than by merely reading the Regulations. In the Explanatory Note, which comprises one paragraph, we get the words: The object of the changes is to rectify certain anomalies—". what are those anomalies?— and to ensure that irrelevant items are excluded from the calculation. I oppose the Regulations principally because of the opportunity I am afforded of expressing my point of view on what has happened in respect of pay beds. When the Bill was originally introduced in the House, many sup- porters of the Government felt that this was a rather dangerous thing, but we believed that it would be justified as an experiment. We have had five years now of the National Health Service, and I assert that as a consequence of this provision there have been empty beds in hospitals and people waiting to get into beds who have not been able to do so.

I know that that is not entirely the responsibility of any one unit of administration. Indeed, I rather think that what the Regulations will do is to improve the position of the specialists. In my opinion, the specialists have already not done too badly out of the Service. If there was anybody who wanted assistance, it was some of those who got it from the Danckwerts award. When the Act came into force, the general practitioners who had big private practices and small panel practices lost their private patients and were unable to get a big panel. I should think that the specialists were not the people who were in need of any increase.

When I apply myself to these questions, the test that I always first apply is to ask what will be the effect upon the patient. I suggest that this will not have a good effect upon the patient. It will in all probability make it more difficult for patients to get into hospital. An added incentive will be given to the specialist to get his private patients into the beds in the hospital, and he will be given the incentive to exercise his influence to say, "I want that bed," and that bed will remain empty until the patient he wants to put in it gets there.

What financial advantage is there to the Service? What will happen is that there will be a reduction in the amount paid by the patient, but there will be an increase which the specialist can draw. That is not the way in which we should handle a problem of this kind. I promised that I should not take up very much time, though one is tempted to continue. I do not think that that would be fair. If I were to talk for an hour I do not think I should be able to be more convincing than if I were to conclude by saying that when we apply the test of whether or not this benefits the patients the House will vote against these Regulations.

10.30 p.m.

Mr. Somerville Hastings (Barking)

I want to speak about the part of these Regulations which applies to what are known as the Section 5 beds—those beds for which the patient pays the cost of accommodation in addition to the doctor's fee. The result of the Regulations will be to reduce slightly the cost to the patient in most cases. There may be an increased demand for these pay-beds. If there is, that will increase the cost of the National Health Service. Strange as it may seem, in many cases these are the most expensive beds to the nation. That is because, so that there may be all this accommodation available, many of the beds—sometimes almost half—are kept vacant.

I know that this is not what the Minister wants. He wants them used for ordinary patients when they are not occupied by paying patients, but the doctors think otherwise (and they are on the spot. The doctors know that only when they can get a patient into hospital at once, instead of having to wait for three or four months, can they maintain and increase their private practices. I have had some experience of these beds. Before the appointed day I had experience of them for 15 or 20 years as a surgeon. I have also been in one as a patient.

I am a member of the pay-beds subcommittee of one of the four boards into which Greater London is divided—the North-East Metropolitan Regional Hospital Board. On 25th March this subcommittee met. We had before us an account of the use of all the 174 pay-beds, the Section 5 beds, in the region for the six months ended on 31st December, 1952. I have analysed the manner in which they were used, and I find that 37 per cent. only were used for paying patients, the average daily occupation being 65.

What about the beds which were not used? I have analysed these also and find that 59 out of 109 beds were used for ordinary patients. In other words, a little more than a third of the beds were used by paying patients and only about one half of the remainder were used for other patients. I say that there is great misuse of these beds. They are not used for ordinary patients as they should be when they are not wanted by paying patients. I suggest that the better the service provided in the Health Service, the more the beds there are used, and the less the waiting period the more pressure there will be by the doctors to keep empty the pay-beds so as to maintain the position that the patient can get into pay-beds quicker than into the ordinary beds.

The Regulations are the most complicated and difficult that I have ever seen. As a hospital administrator—and I am a member of two boards—we find that these beds, in the past, have given a great deal of trouble. I remember that on one board we spent almost the whole of one meeting wrangling with the doctors. They thought we were charging the patients too much. We, as administrators, kept to the terms of the Regulations under which we were working. That happens frequently, and I suggest that these Regulations, with their many doubtful and undetermined points, will increase those difficulties.

The Minister does give us some help. He gives us a list of suggestions for items that should be included in the estimate of cost. It is perfectly right to include "travelling expenses of medical staff and patients." Then he suggests "patients' clothing." I have been an occupant of pay-beds in hospital, and I remember when I went down to the X-Ray department they took off my pyjamas because they had buttons and put on me a nondescript article with tapes. I suppose that was "patients' clothing." When I went to the operating theatre it was in some white socks that reached nearly to my middle. I should include that as "patients' clothing."

Another suggestion deals with "medical records." I cannot conceive any decent hospital where a proper record is not kept for every patient. It would be exceedingly bad for the morale and training of the nurses and the junior doctors if they were not kept. The financial position of patients may change, too. One day they may be able to pay for a pay-bed, and may enter hospital for treatment later and be unable to pay. What a disaster if there is no record. The first thing a surgeon does when he sees a previous operation has taken place, on the abdomen for instance, is to find out what was the nature of the operation.

The Minister of Health (Mr. Iain Macleod)

The hon. Gentleman will agree that the document he is reading from, which is not the Regulations, but the accompanying guidance to hospitals, says that the cost of patients' records is not to be excluded from the charge if the hospital looks after private patients' records.

Mr. Hastings

That is perfectly true and I ought to have mentioned it. My point is that no hospital worth its name will not take records of all its patients.

The last suggestion concerns the almoner's department. I agree that this department is mostly used by non-paying patients, but in some cases it does extra work, such as ordering by telephone ambulances or the car service which may be required by paying patients as well as non-paying patients.

I think that these are disastrous Regulations; and one of the greatest disasters about them is that they have an indefinite character, so that we who have to administer the Minister's hospitals will have to spend—I will not say waste—much of our time wrangling with doctors and others concerned before we determine what the right charge should be for paying patients.

10.41 p.m.

Mr. Aneurin Bevan (Ebbw Vale)

I think that I should be expressing the point of view of hon. Members in all quarters of the House if I say that we are not anxious to have a protracted debate on these Regulations but rather to have a fairly early Division so as to enable hon. Members to get to their homes at a reasonable hour. But that is not to say that we do not attach the greatest importance to this Prayer; the reason we do not seek a long debate is that the position is clear; the issue is narrow. However, as the Minister was not responsible for the Act in the first instance, perhaps I might deal briefly with how the provisions of this scheme arose.

When I had discussions with the Royal Colleges of Surgeons, Physicians, and Obstetricians, their representatives put it to me that it was extremely undesirable that a specialist should not have private patients in hospitals; for otherwise, there would be a direct encouragement to go to nursing homes and it was then represented by the best representatives of the profession that a specialist could do his best work at the hospital; that nursing homes were not desirable institutions to encourage. With that view, having some knowledge of them, I heartily agreed; although I would say that there are many specialists who seem to have a predilection towards advising patients to get into nursing homes.

It has never seemed to me that whatever was to be said for the private profit-making motive it was a good thing for patients who went to the nursing home, because the nursing home had an interest in keeping down the cost, which was often to the detriment of the patient. So, whatever hon. Members opposite may think of profit motives as incentives, they are not desirable in so far as they keep nurses away from the bed of the patient in the nursing home. There is instance after instance where well-to-do people, acting under the advice of specialists, have allowed themselves to be maltreated in nursing homes, and I was willing to accept the view of the Royal Colleges that nursing homes were not institutions to be encouraged; and I agreed that the tools of the specialist's craft are to be found in the general hospital.

The full range of instruments and facilities are all there. Therefore, specialists should be at the hospital, where these facilities are available, and their patients should be there, too. I was told that if one wished to keep the specialists at the hospital, one must allow them to have their private patients there. I was extremely reluctant to agree, because I saw in it a very grave breach of the general scheme. I saw in it a great danger—and I am bound to speak on this matter quite frankly.

The medical profession is not entirely exempt from commercialism, and here I think I am speaking on behalf of the whole population, no matter to which political party they belong. It is a very great mistake to believe that there is on this matter a party division, because if hon. Members opposite had been able to read the correspondence which I have seen from ardent Conservatives, who complained bitterly of the treatment they had had at the hands of specialists who had thus exploited them, they would realise that here we are speaking on behalf of the whole population.

What happens is this. Once we give the specialist the opportunity of having private patients in the hospitals, he has a commercial vested interest in increasing the number of private patients, which is exactly what happens. In fact, the very reason why the right hon. Gentleman brings forward his Regulations is itself conclusive evidence that hospital administration is being brought far too much under the influence of the commercialism of the specialist, because the very fact that there are empty beds is itself evidence of maladministration by the authorities. They ought not to be empty.

There is really no justification, under proper administration, for a waiting list at a hospital and empty beds in that hospital. I think there is no hon. Member in any part of the House who would defend that situation, but the empty beds are kept there in order that specialists may be able to offer their patients who can afford to pay a bed at once. I do not want to use superlatives, but, of course, it can become, in some respects, a very evil racket indeed.

An hon. Member told me this afternoon that a few months ago he fell ill, and that his doctor said he thought he had appendicitis and called in a specialist. The specialist conferred with his doctor, and agreed that he had acute appendicitis and that the appendix ought to be removed. The wife of the hon. Member, anxious about his welfare, immediately agreed that he should be taken to a nursing home, because the specialist assured her that the last vacant bed in the hospital nearby had gone, and so the hon. Member went into the nursing home. Eventually, he had the operation, for which he paid 52 guineas, and—[Laughter.] I do not know what there is to grin at in this, because I should have thought there is nothing worse than to play upon the anxieties of relatives in these circumstances merely to get a fat fee. I should have thought it was very bad indeed. Altogether, this simple operation cost the hon. Member 100 guineas. That is shocking, when, at the same time, we have evidence that there are empty beds.

It was never intended by me that pay-bed blocks should be a physical part of the hospital. What was always intended was that there should be pay-beds, but that the pay-bed block should always be available to free patients if other patients were not there. In other words, it was never intended that there should be in the hospital a division between one part of the hospital and another—one part where there were private patients and another part where there were public patients.

It was always intended that the hospital should be a homogeneity and that public patients should have access to all the beds of the hospital if there were any beds available. Therefore, we have here a situation which I consider a reproach to the scheme. Indeed, I am bound to say, speaking after some experience and with a full sense of responsibility, that there are members of the medical profession who have not proved themselves worthy of the responsibility with which they were entrusted.

Sir Ian Orr-Ewing (Weston-super-Mare)

They have not got the opportunity.

Mr. Bevan

There is no single piece of social machinery in Great Britain where the profession handling it has more self-government than in the National Health Service. The hon. Member does not really know what he is talking about, because throughout this Service there are on the governing bodies of the teaching hospitals, on regional hospital boards and on hospital management committees, doctors appointed by the Minister. What many of them have done is to use the influence they possess, which is very considerable in hospitals, to deny beds to patients in order to make them available for their private patients.

As my hon. Friend the Parliamentary Secretary pointed out—[HON. MEMBERS: "He is not the Parliamentary Secretary."] It was a lapsus linguae on my part, which shows how undesirable it is to change sides in the House. The fact is, as my hon. Friend pointed out, that this has caused a great deal of anxiety in the medical profession. In the "Daily Telegraph" of Thursday, 26th March, there was a long article, written by a consulting physician, in which he pointed out that the extra facilities granted to the part-time specialist—because that is the person to whom we are referring—is causing a great deal of heart-burning among the full-time specialists upon which, as a general rule, the hospital service mainly depends.

These Regulations, instead of narrowing the gulf between the status of the part-time specialist and the full-time specialist rather widens it. The part-time specialist has very considerable Income Tax reliefs that the full-time specialist has not got, and, therefore, it was always my view—and I submit this view to hon. Members not in any party spirit at all—that this was a feature of the Health Service that ought to be kept to a minimum by administrative action with a view to its eventual elimination.

Mr. Philip Bell (Bolton, East)

I am most anxious to follow the right hon. Gentleman's point. Do I understand that the sterilised beds, about which, I must say, we have heard with some alarm, are primarily due—50 per cent., 70 per cent.—to the dishonesty of doctors or to administration?

Mr. Bevan

I said, quite simply and bluntly, that the specialists use their influence in hospital administration to keep beds idle in private pay-bed blocks in order to have them immediately available for their fee paying patients.

Mr. Bell

That is dishonesty.

Mr. Bevan

I am being quite frank. I think everybody will agree that if a bed is available it ought not to be kept idle if there is a patient on the waiting list.

Mr. Bell

I agree.

Mr. Bevan

Then the hon. Member is agreed. We could spend a great deal of time giving figures. Thirty, 40, 50 or 70 per cent. of the beds in the pay-bed blocks are not occupied at the same time as there are waiting lists at the hospitals. Therefore, the conclusion one reaches is this: either the hospital administration is not doing its job—and one of the reasons for having this debate is to focus attention on the fact they ought to do their job—or the specialist is able to exert undue influence over the administration in order to try to get beds for himself.

There is only one more thing I should like to say. The Regulations are extremely complicated. I looked up the original Regulations made in 1948. I am bound to say that, although I made very many Regulations very hurriedly before 5th July, 1948, I made them in much simpler language than the right hon. Gentleman has been able to discover in his amending Regulations. What he does, as I understand, is to exclude from calculating the cost to the pay-bed block, the general medical services of the hospital so that the private bed patient may have to pay his own medical costs. What the right hon. Gentleman is doing, in other words, is converting the pay-bed block into a nursing home, because he is excluding the pay-bed block from the normal overhead charges of the medical supplies of the hospital.

I consider that to be entirely unfair and, indeed, is formalising and regularising a division in this service which we are so anxious to avoid. The right hon. Gentleman is increasing the operating fees for the specialists. I do not understand why he is doing that. They may say that the cost-of-living is going up. What is the use of putting the cost to the private patient down and then putting up the cost of the operation? All that is doing is transferring money from the patient's pocket to the specialist's pocket and taking it from the State. The only person to benefit is the specialist. Not even the patient benefits.

I said at the beginning that we were anxious that this debate should not be protracted. We have tried to state our case in moderate language. I think I should be expressing the view of everyone in the House, and certainly of anxious people in many parts of the country, when I say that this feature of the Health Service, which we regard as undesirable, ought not to be used to deny to English people access to the hospitals of Great Britain when they need it.

10.57 p.m.

The Minister of Health (Mr. Iain Macleod)

I entirely agree with the right hon. Member for Ebbw Vale (Mr. Bevan) that this is an important matter and that it has been discussed, although fairly briefly, in a very temperate spirit. Perhaps I may, in the time-honoured words, greet the right hon. Gentleman the Member for Ebbw Vale—as this is the first occasion since I became Minister of Health a year ago, in which he has intervened in a health debate—by saying that he has shown considerable knowledge of his subject and that I look forward to hearing him again. [HON. MEMBERS: "Come off it."]

These Regulations do three things. They consolidate the amenity Regulations passed last year. They amend the assessing of charges for Section 5 beds, and they make certain alterations in professional fees. In so doing, they annul the 1948 Regulations made by the right hon. Gentleman.

There are several small points on which I had intended to dwell for a moment, but they were not mentioned from the other side of the House. I do not propose to make them tonight, except to point out, because it has a certain relevance to something I shall say later, that the Schedule attached to these Regulations remains broadly the same as that attached to the 1948 Regulations with the addition of certain new operations and procedures, for example, the development of the fitting of contact lenses.

I want to come straight away to a matter of more substance—the question of arrangements for admissions and undertakings to pay. I want to make my position absolutely clear. I hope it is made clear because some doubt was expressed about it when the hon. Member for Barking (Mr. Hastings) referred to this matter. I have recently sent out, in conjunction with the Regulations, guidance to hospitals. But let us stress again—and there is no dispute in the House about this—that, first of all, if the primary desire of a patient is for privacy and it is a non-serious case he should have his attention drawn to amenity beds if such exist in the hospital. Secondly, if his need for admission is urgent on medical grounds, he has a right to be admitted and there is again no need for the whole charges to be paid.

Thirdly, if he desires a Section 5 bed, it must be made absolutely clear to him, and there must be undertakings given in writing, that he understands in full the implications of what he is doing, because it is here that most of the difficulties arise. At a time of stress it is natural enough for somebody not to bother too much about what he is told or what is on a form put in front of him. But if hon. Members have cases in which the proviso to Section 5 (1) of the 1946 Act is, in their view, not being operated I hope that they will let me know and I will undertake straight away to look into them.

Mr. Bevan

The right hon. Gentleman does not need the information from us. He has it himself, for if there are unoccupied beds in pay blocks during the year, or considerable parts of the year, and there is a waiting list at that hospital that is in itself evidence that the administration is not good.

Mr. Macleod

We will go into that question in a minute. I can quote the right hon. Gentleman against himself on this issue in the proceedings on the National Health Service Bill.

These Regulations supersede the 1948 Regulations, but what is important is that both of them stem, and have to stem, from the 1946 Act. That is the authority for these Regulations and the authority for the right hon. Gentleman's. The important words are these: .… such charges as may be determined in the prescribed manner, being charges designed to cover the whole cost of the accommodation and services provided for the patient at the hospital, …. If they do not do that, not only are these Regulations toad, as has been urged from the other side, but they are ultra vires as well.

My case, of course, is not only that these Regulations do carry out the 1946 Act, but that the right hon. Gentleman's did not. I say, straight away, that I had always thought that it was a remarkable achievement on the part of the Department to bring in in 1948 the mass of Regulations which they had to bring in to get the Health Service going. But no one expected the Health Service to spring fully armed from those Regulations and many of the Regulations have been found inadequate in detail.

That is precisely why the Regulations which we are now considering are very much more complicated—and I concede that point—than were the 1946 Regulations. It is only by making them more complicated that I can achieve not only the fairness to Section 5 patients which I want to achieve but which it is a statutory duty for me to do under the 1946 Act.

It follows that I have to exclude, if I can, irrelevant items from the calculation. It was on this point that the hon. Member for Barking made some observations. But I should like to be absolutely clear on one point in answer to the hon. Mem- ber for Newcastle-upon-Tyne, East (Mr. Blenkinsop). The object of the Regulations is not to reduce the charge to private patients. It may well be that it will have that result, but that is a different point. The object of these Regulations is to carry out fairly the 1946 Act—[Laughter]—certainly it is. There are two methods of costing and there was some confusion among hon. Members opposite about them; one where the separate block can be costed, and secondly, when we have to estimate. It is in the second case that the difficulties arise, because there is virtually no problem in these Regulations if separate costing can be achieved.

The kernel of what I want to say to the House is that the 1948 Regulations themselves laid down that the standard daily charge, plus an average daily cost per in-patient representing medical care plus various percentages was to be the amount charged. It has been found that that Regulation was trebly unfair, and these are the anomalies referred to in the Explanatory Note. The percentages now are to be added to a sum which excludes the cost of paying medical staff instead of, as under the 1946 Regulations, to a charge which included it, and. therefore, there was an increase in the 1948 Regulations which was unfair to the private patient.

Secondly, they have been shown to be unfair, because certain services were included which have little or no reference to the private block. Thirdly, they have been found to be unfair because the percentages have been found to be too high. Some calculation had to be made by the right hon. Gentleman in 1948 and I am told that the basis for these figures, in the light of experience in the emergency medical service and elsewhere was that they represented the additional cost of the private bed over a public bed.

When these pay-bed Regulations were being revised, and the revision was asked for as early as the first part of 1949, the financial officers of the hospital authorities said that in their view, and in the light of experience, these percentages were too high; but the lower figure has not been altered because, of course, the more beds there are in private accommodation the more it approximates to a ward. Therefore, in the view of those who advise me the right percentages would be the ones indicated in the new Regulations for the second part of the costing.

The hon. Member for Tottenham (Mr. Messer) read out Regulation 6 (1, a) and I agree that it is couched in horrifying terms. The hon. Member said that no layman could understand it. I do not know whether he will understand my explanation, but I will try in a sentence or two to tell him what the words mean. In that Regulation we are talking about the pay-blocks separately costed and we have fixed a standard daily charge which relates only to accommodation. We therefore have to add something for the appropriate amount of medical care.

It is calculated that we do not add anything for the specialist part of the service, because the patient, by employing his own specialist, takes care of that; but it is right that the private patient should pay an appropriate amount for the time of the house officers and others who give their time in the private block, unless the amount is triflng. On the point which the hon. Member also raised about an insignificant amount, I have said in the notice I have given to the hospitals that I take that to be one hour a week. I do not know if that explanation from a layman is clear, but at least it is clearer than the Regulations I am laying before the House.

I turn to the question of new fees. These have been unaltered since 1948 and, as I said, the profession suggested very early in the scheme in 1949, that alterations should be made. The right hon. Member did not agree that the detailed schedules should be abandoned and I do not dissent from that at all. But he did say that they should be examined to see if any amendments were desirable. That was in 1949. What has happened since is that that examination has taken place, that we have consulted—I have consulted and my predecessors have consulted—our various consultant officers in the specialities. They have consulted the appropriate people in the professions and the new figures before the House represent fairly general agreement in this field.

I will take one example. In Regulation 11 boards and committees may, exceptionally, allow an increase from 75 guineas to 125 guineas. Let me take the example (c) in which, if the patient requires an operation on the heart or the excision of a tumour of the brain, or various operations of that sort, that becomes a reason for increasing the fees from 75 to 125 guineas. What has happened is that in these fields of surgery new techniques have been developed both of diagnosis and of treatment which require the attention of a whole team of specialists in these most complicated operations.

It therefore follows that in these sort of operations, if we did not have this sort of extension, we would find that the more complicated an operation is the more difficult it is to achieve; the more consultants needed to carry it out the less the fee would be that they would obtain. It seems perfectly clear to me that in those exceptional circumstances—and it must be only at the discretion of the boards and committees—a considerable increase is justified.

The right hon. Member said it was a strange thing that at the same time that we were putting forward measures which will here and there probably reduce the charges where there is not separate costing, we were increasing the fees. The answer is, of course, that hospital charges reflect actual costs, whereas medical fees have been subject to rigid ceilings and have not been altered since 1948, in spite of the fact that medical technique has developed enormously since then.

I will give one or two figures to the House. The number of Section 5 beds at the latest count, in February this year, was 6,113 or 1.2 per cent. of all staffed beds. The number of Section 4 beds was 1.3 per cent. It follows, therefore, that 97.5 per cent. of all beds in the Service are absolutely free and indeed a high proportion, as has been said, of the beds that are nominally pay-beds are in fact occupied by people under the proviso to Section 5. Those figures compared with the end of 1950 show that there has been in 1951 and 1952 a decrease of 4.5 per cent. in the Section 5 beds and an increase of 13 per cent. in the Section 4 beds, while the Section 3 beds—the free staffed beds—have increased by no fewer than 18,156, or 4.1 per cent. In view of those figures no one can conceivably say that the present Government have taken advantage, or will take advantage, of Section 5 of the Act to multiply the number of pay-beds beyond what was conceived in the original Act.

The last point I want to put before the House is this: it has been said that this is a new policy, and in some respects one in favour of the specialists. I am bound to say that the best witnesses to call into the box on that are the specialists themselves. [HON. MEMBERS: "Oh."] Certainly, and in the "British Medical Journal" of 28th March their joint committee comments on these Regulations and my attitude towards them. I regret to say that there is no word of approval for me throughout their comments.

My part in these Regulations has been confined to this. The specialists came to me and they said, "We should like to abandon the detailed schedule." I said, "No, I cannot agree." So did the right hon. Gentleman before me. They said that they did not want a detailed price ceiling but a few general ceilings, and the specialists would adjust their amounts to the paying capacity of the patients. [HON. MEMBERS: "Oh."] I am sure that every hon. Member has personal knowledge of how generous the medical profession can be in that sort of service. I said, "Whatever might happen in the future, the time is not ripe for that."

The third point they made was that they would like a reduction straight away in the case of pay-beds. I said, "That cannot be done without new legislation, and I see no prospect of that at all." These three points were the only ones on which I interfered in these Regulations, which have been prepared by the consultative officers of my Department. I took precisely the same line in this matter but, frankly, for different reasons as the right hon. Gentleman took a year or two before.

I understand that we are to have a vote on these Regulations. We are not going to vote on the merits of the case, because such arguments as the Opposition have marshalled have gone like froth. We are voting for the very good Parliamentary reason which we all understand, that everybody has been brought here to vote and we are jolly well going to. It is most important that the right hon. Gentleman the Member for South Shields (Mr. Ede) should catch his train to Epsom.

Mr. Ede (South Shields)

I have made other arrangements in case I could not.

Mr. Macleod

Very well; I am finishing in a moment.

The only reason for the vote is because these Regulations are not the 1948 Regulations. That has offended the right hon. Gentleman the Member for Ebbw Vale. [HON. MEMBERS: "Oh."] Certainly, it has. Indeed, he takes such a proprietorial attitude towards the Health Service that he thought tonight that he was Minister of Health. He knows perfectly well that if we divide tonight—if we do divide; I suppose we will—it is because these Regulations will strictly carry out the 1946 Act in a fairer manner than it was possible to do—and I make no party point out of it—under Regulations that had to be guesses at the beginning of the scheme. It is on that point that we are to vote tonight, and I must say quite frankly to the right hon. Gentleman that tonight he has, as he has done before, been tilting at windmills.

Mr. Blenkinsop

Could the right hon. Gentleman say what proposals he

intends to bring forward to deal with the empty beds, which is a matter of anxiety to hon. Members on both sides of the House? We are anxious to know what proposals he has in mind to ensure that these empty beds are used for ordinary patients in the hospitals.

Mr. Macleod

I cannot go very far on that tonight without being out of order. As a matter of fact, I have called for a special report on the question of the occupancy of these beds.

Mr. John Baird (Wolverhampton, North-East)

What, another report?

Mr. Macleod

There was no report before.

Mr. Bevan

That is not correct.

Mr. Macleod

As soon as I have the details—and they are almost complete—I shall be happy to discuss the matter when it is in order.

Question put.

The House divided: Ayes, 233; Noes, 261.

Division No. 163.] AYES [11.20 p.m.
Adams, Richard de Freitas, Geoffrey Holman, P.
Albu, A. H. Deer, G. Holmes, Horace (Hemsworth)
Allen, Arthur (Bosworlh) Delargy, H. J. Houghton, Douglas
Allen, Soholefield (Crewe) Dodds, N. N. Hudson, James (Ealing, N.)
Awbery, S. S. Donnelly, D. L. Hughes, Cledwyn (Anglesey)
Bacon, Mist Alice Dugdale, Rt. Hon. John (W. Bromwich) Hughes, Emrys (S. Ayrshire)
Baird, J. Ede, Rt. Hon. J. C. Hughes, Hector (Aberdeen, N.)
Barnes, Rt. Hon. A. J. Edelman, M. Hynd, H. (Accrington)
Bartley, P. Edwards, John (Brighouse) Hynd, J. B. (Attercliffe)
Bence, C. R. Edwards, Rt. Hon. Ness (Caerphilly) Irvine, A. J. (Edge Hill)
Benn, Hon. Wedgwood Edwards, W. J. (Stepney) Isaacs, Rt. Hon. G. A.
Benson, G. Evans, Albert (Islington, S. W.) Janner, B.
Beswick, F. Evans, Edward (Lowestoft) Jay, Rt. Hon. D. P. T.
Bevan, Rt. Hon. A. (Ebbw Vale) Fernyhough, E. Jeger, George (Goole)
Bing, G. H. C. Fienburgh, W. Jeger, Dr. Santo (St. Pancras, S.)
Blackburn, F. Finch, H. J. Johnson, James (Rugby)
Blenkinsop, A. Fletcher, Eric (Islington, E.) Johnston, Douglas (Paisley)
Blyton, W. R. Follick, M. Jones, David (Hartlepool)
Boardman, H. Foot, M. M. Jones, Jack (Rotherham)
Bottomley, Rt. Hon. A. G. Forman, J. C. Jones, T. W. (Merioneth)
Bowles, F. G. Fraser, Thomas (Hamilton) Keenan, W.
Braddock, Mrs. Elizabeth Freeman, Peter (Newport) Kenyon, C.
Brockway, A. F. Gaitskell, Rt. Hon. H. T. N King, Dr. H. M.
Brook, Dryden (Halifax) Gibson, C. W. Lee, Frederick (Newton)
Broughton, Dr. A. D. D. Glanville, James Lee, Miss Jennie (Cannock)
Brown, Thomas (Ince) Gooch, E. G. Lever, Harold (Cheetham)
Burke, W. A. Gordon Walker, Rt. Hon. P. C. Lever, Leslie (Ardwick)
Burton, Miss F. E. Greenwood, Anthony (Rossendale) Lewis, Arthur
Butler, Herbert (Hackney, S.) Grenfell, Rt. Hon. D. R. Lipton, Lt.-Col. M.
Callaghan, L. J. Griffiths, David (Rother Valley) Logan, D. G.
Carmichael, J. Griffiths, Rt. Hon. James (Llanelly) MacColl, J. E.
Castle, Mrs. B. A. Griffiths, William (Exchange) McGhee, H. G.
Champion, A. J. Hale, Leslie McGovern, J.
Chapman, W. D. Hall, Rt. Hon. Glenvil (Colne Valley) McInnes, J.
Chetwynd, G. R Hamilton, W. W. McLeavy, F.
Clunie, J. Hannan, W. MacMillan, M. K. (Western Isles)
Coldrick, W. Hargreaves, A. MacPherson, Malcolm (Stirling)
Collick, P. H. Harrison, J. (Nottingham, E.) Mallalieu, E. L. (Brigg)
Craddock, George (Bradford, S.) Hastings, S. Mallalieu, J. P. W. (Huddersfield, E.)
Cullen, Mrs. A. Hayman, F. H. Mann, Mrs. Jean
Dalton, Rt. Hon. H. Healey, Denis (Leeds, S. E.) Manuel, A. C.
Davies, Ernest (Enfield, E.) Henderson, Rt. Hon. A. (Rowley Regis) Marquand, Rt. Hon. H. A.
Davies, Harold (Leek) Herbison, Miss M. Mason, Roy
Davies, Stephen (Merthyr) Hewitson, Capt. M. Mayhew, C. P.
Mellish, R. J Reid, Thomas (Swindon) Timmons, J.
Messer, F. Reid William (Camlachie) Tomney, F.
Mikardo, Ian Rhodes, H. Turner-Samuels, M.
Mitchison, G. R. Roberts, Albert (Normanton) Ungoed-Thomas, Sir Lynn
Monslow W. Roberts, Goronwy (Caernarvon) Usborne, H. C.
Moody, A. S. Robinson, Kenneth (St. Pancras, N) Viant, S. P.
Morris, Percy (Swansea, W.) Rogers, George (Kensington, N.) Wallace, H. W.
Mort, D. L. Ross, William Weitzman, D.
Moyle, A. Royle, C. Wells, Percy (Faversham)
Mulley, F. W. Shackleton, E. A. A. Wells, William (Walsall)
Murray, J. D. Shawcross, Rt. Hon. Sir Hartley West, D. G.
Neal, Harold (Bolsover) Short, E. W. Wheatley, Rt. Hon. John
Noel-Baker, Rt. Hon. P. J. Silverman, Julius (Erdington) Wheeldon, W. E.
Oldfield, W. H. Silverman, Sydney (Nelson) White, Mrs. Eirene (E. Flint)
Oliver G. H. Simmons, C. J. (Brierley Hill) White, Henry (Derbyshire, N.E.)
Orbach, M. Skeffington, A. M. Whiteley, Rt. Hon. W.
Oswald, T. Slater, Mrs. H. (Stoke-on-Trent) Wigg, George
Padley, W. E. Smith, Norman (Nottingham, S.) Wilcock, Group Capt. C. A. B.
Paget, R. T. Snow, J. W. Willey, F. T.
Paling, Rt. Hon. W. (Dearne Valley) Sorensen, R. W. Williams, David (Neath)
Palmer, A. M. F. Sparks, J. A. Williams, Rev. Llywelyn (Abertillery)
Pannell, Charles Stewart, Michael (Fulhum, E.) Williams, Ronald (Wigan)
Parker, J Strachey, Rt. Hon. J. Williams, W. R. (Droylsden)
Pearson, A. Strauss, Rt. Hon. George (Vauxhall) Williams, W. T. (Hammersmith, S.)
Peart, T. F. Stross, Dr. Barnett Wilson, Rt. Hon. Harold (Huyton)
Plummer, Sir Leslie Summerskill, Rt. Hon. E. Winterbottom, Ian (Nottingham, C.)
Popplewell, E. Swingler, S. T. Winterbottom, Richard (Brightside)
Porter, G. Sylvester, G. O. Woodburn, Rt. Hon. A.
Price, Joseph T. (Westhoughton) Taylor, Bernard (Mansfield) Wyatt, W. L.
Price, Philips (Gloucestershire, W.) Taylor, John (West Lothian) Yates, V. F.
Proctor, W. T. Thomas, David (Aberdare) Younger, Rt. Hon. K
Pryde, D. J. Thomas, George (Cardiff)
Pursey, Cmdr. H Thomas, Iorwerth (Rhondda, W.) TELLERS FOR THE AYES:
Rankin, John Thomas, Ivor Owen (Wrekin) Mr. Bowden and Mr. Wilkins
Reeves, J. Thomson, George (Dundee, E.)
NOES
Aitken, W. T. Clyde, Rt. Hon. J. L. Halt, John (Wycombe)
Allan, R. A. (Paddington, S.) Cole, Norman Harden, J. R. E.
Alport, C. J. M. Colegate, W. A. Harris, Frederic (Croydon, N.)
Amery, Julian (Preston, N.) Conant, Maj. R. J. E. Harris, Reader (Helton)
Amory, Heathcoat (Tiverton) Cooper, Sqn. Ldr. Albert Harrison, Col. J. H. (Eye)
Anstruther-Gray, Major W. J. Craddock, Beresford (Spelthorne) Harvey, Air Cdre. A. V. (Macclesfield)
Arbuthnot, John Cranborne, Viscount Harvey, Ian (Harrow, E.)
Ashton, H. (Chelmsford) Crookshank, Capt. Rt. Hon. H. F. C. Hay, John
Assheton, Rt. Hon. R. (Blackburn, W.) Crosthwaite-Eyre, Col. O. E. Heald, Sir Lionel
Astor, Hon. J. J. Crouch, R. F. Higgs, J. M. C.
Baldock, Lt.-Cmdr. J. M. Crowder, Sir John (Finchley) Hill, Dr. Charles (Luton)
Baldwin, A. E. Crowder, Petre (Ruislip—Northwood) Hill, Mrs. E. (Wythenshawe)
Banks, Col. C. Darling, Sir William (Edinburgh, S.) Hinchingbrooke, Viscount
Barber, Anthony Davidson, Viscountess Hirst, Geoffrey
Barlow, Sir John Deedes, W. F. Holland-Martin, C. J
Beach, Maj. Hicks Digby, S. Wingfield Hollis, M. C.
Beamish, Maj. Tufton Dodds-Parker, A. D. Holmes, Sir Stanley (Harwich)
Bell, Philip (Bofton, E.) Donaldson, Cmdr. C. E. McA. Holt, A. F.
Bennett, F. M. (Reading, N.) Donner, P, W. Hope, Lord John
Bennett, Dr. Reginald (Gosport) Doughty, C. J. A. Hornsby-Smith, Miss M. P.
Bennett, William (Woodside) Drayson, G. B. Horobin, I. M.
Bevins, J. R. (Toxteth) Drewe, C. Horsbrugh, Rt. Hon. Florence
Birch, Nigel Dugdale, Rt. Hon. Sir T. (Richmond) Howard, Hon. Greville (St. Ives)
Bishop, F. P. Duncan, Capt. J. A. L. Hudson, W. R. A. (Hull, N.)
Black, C. W. Eccles, Rt. Hon. D. M. Hulbert, Wing Cdr. N. J.
Boothby, R. J. G. Elliot, Rt. Hon. W. E. Hurd, A. R.
Bossom, A. C. Erroll, F. J. Hutchinson, Sir Geoffrey (Ilford, N.)
Boyd-Carpenter, J. A. Fell, A. Hutchison, Lt.-Com. Clark (E'b'rgh W.)
Boyle, Sir Edward Finlay, Graeme Hylton-Foster, H. B. H.
Braine, B. R. Fisher, Nigel Jenkins, Robert (Dulwich)
Braithwaite, Sir Albert (Harrow, W.) Fleetwood-Hesketh, R. F. Jennings, R.
Braithwaite, Lt.-Cdr. G. (Bristol, N.W.) Fletcher-Cooke, C. Johnson, Eric (Blackley)
Bromley-Davenport, Lt.-Col. W. H. Ford, Mrs. Patricia Johnson, Howard (Kemptown)
Brooke, Henry (Hampstead) Fort, R. Jones, A. (Hall Green)
Brooman-While, R. C. Foster, John Kaberry, D.
Browne, Jack (Govan) Fraser, Hon. Hugh (Stone) Keeling, Sir Edward
Buchan-Hepburn, Rt. Hon. P. G. T. Galbraith, T. G. O. (Billhead) Kerr, H. W.
Bullard, D. G. Gammans, L. D. Lambert, Hon. G.
Bullus, Wing Commander E. E. Garner-Evans, E. H. Lambton, Viscount
Burden, F. F. A. George, Rt. Hon. Maj. G. Lloyd Law, Rt. Hon. R. K.
Butcher, Sir Herbert Godber, J. B. Legge-Bourke, Maj. E. A. H.
Campbell, Sir David Gomma-Duncan, Col. A. Legh, Hon. Peter (Petersfield)
Carr, Robert Gough, C. F. H. Lindsay, Martin
Cary, Sir Robert Gower, H. R. Linstead, H. N.
Channon, H. Graham, Sir Fergus Llewellyn, D. T.
Churchill, Rt. Hon. Sir Winston Gridley, Sir Arnold Lloyd, Maj. Sir Guy (Renfrew, E.)
Clarke, Col. Ralph (East Grinstead) Grimston, Sir Robert (Westbury) Lloyd, Rt. Hon. Selwyn (Wirral)
Lockwood, Lt.-Col. J. C. Ormsby-Gore, Hen. W. D. Stewart, Henderson (Fife, E.)
Longden, Gilbert Orr, Capt. L. P. S. Stoddart-Scott, Col. M.
Low, A. R. W. Orr-Ewing, Charles Ian (Hendon, N.) Strauss, Henry (Norwich, S.)
Lucas, Sir Jocelyn (Portsmouth, S.) Orr-Ewing, Sir Ian (Weston-super-Mare) Studholme, H. G.
Lucas-Tooth, Sir Hugh Osborne, C. Summers, G. S.
McAdden, S. J. Partridge, E. Sutcliffe, Sir Harold
McCallum, Major D. Peaks, Rt. Hon. O. Taylor, William (Bradford, N.)
McCorquodale, Rt. Hon. M. S. Perkins, W. R. D. Teeling, W.
Macdonald, Sir Peter Pete, Brig. C. H. M. Thomas, Rt. Hon. J. P. L. (Hereford)
Mackeson, Brig. H. R. Peyton, J. W. W. Thomas, Leslie (Canterbury)
McKibbin, A. J. Pickthorn, K. W. M. Thomas, P. J. M. (Conway)
Mackie, J. H. (Galloway) Pilkington, Capt. R. A. Thompson, Kenneth (Walton)
Maclay, Rt. Hon. John Pitman, I. J. Thompson, Lt.-Cdr. R. (Croydon, W.)
Maclean, Fitzroy Powell, J. Enoch Thorneycroft, Rt. Hn. Peter (Monmouth)
Macleod, Rt. Hon. Iain (Enfield, W.) Price, Henry (Lewisham, W.) Thornton-Kemsley, Col. C. N.
MacLeod, John (Ross and Cromarty) Prior-Palmer, Brig. O. L. Tilney, John
Macpherson, Niall (Dumfries) Raikes, Sir Victor Touche, Sir Gordon
Maitland, Comdr. J. F. W. (Horncastle) Rayner, Brig. R. Turner, H. F. L.
Maitland, Patrick (Lanark) Redmayne, M. Tweedsmuir, Lady
Markham, Major S. F. Rees-Davies, W. R. Vane, W. M. F.
Marlowe, A. A. H. Remnant, Hon. P. Vaughan-Morgan, J. K.
Marples, A. E. Renton, D. L. M. Wakefield, Edward (Derbyshire, W.)
Marshall, Douglas (Bodmin) Roberts, Peter (Heeley) Wakefield, Sir Wavell (St. Marylebone)
Maude, Angus Robinson, Roland (Blackpool, S.) Walker-Smith, D. C.
Maudling, R. Rodgers, John (Sevenoaks) Ward, Hon. George (Worcester)
Maydon, Lt-Comdr. S. L. C. Roper, Sir Harold Ward, Miss I. (Tynemouth)
Mellor, Sir John Ropner, Col. Sir Leonard Waterhouse, Capt. Rt. Hon. C.
Molson, A. H. E. Russell, R. S. Watkinson, H. A.
Moore, Lt.-Col. Sir Thomas Ryder, Capt. R. E. D. Webbe, Sir H. (London & Westminster)
Morrison, John (Salisbury) Salter, Rt. Hon. Sir Arthur Wellwood, W.
Mott-Radclyffe, C. E. Scott, R. Donald Williams, Rt. Hon. Charles (Torquay)
Nabarro, G. D. N. Scott-Miller, Cmdr. R. Williams, Gerald (Tonbridge)
Nicholls, Harmar Shepherd, William Williams, Sir Herbert (Croydon, E.)
Nicholson, Godfrey (Farnham) Simon, J. E. S. (Middlesbrough, W.) Williams, R. Dudley (Exeter)
Nicolson, Nigel (Bournemouth, E.) Smithers, Peter (Winchester) Wills, G.
Nield, Basil (Chester) Smithers, Sir Waldron (Orpington) Wilson, Geoffrey (Truro)
Noble, Cmdr. A. H. P. Soames, Capt. C. Wood, Hon. R.
Nugent, G. R. H. Speir, R. M. York, C.
Nutting, Anthony Stanley, Capt. Hon. Richard
Odey, G. W. Stevens, G. P. TELLERS FOR THE NOES:
O'Neill, Phelim (Co. Antrim, N.) Steward, W. A. (Woolwich, W.) Mr. Heath and Mr. Vosper.

Question put, and agreed to.