§ Motion made, and Question proposed, That this House do now adjourn.—[Colonel J. H. Harrison.]
§ 12.12 a.m.
§ Mr Denis Howell (Birmingham, All Saints)
I wish to raise various questions relating to the consultancy service operated by the Ministry of Health throughout the country. There are certain trends, about which I have spoken previously, which I and some of my hon. Friends find rather alarming. We did not get a very satisfactory reply from the Parliamentary Secretary in a previous debate, which was rather short, but I hope to do better on this occasion.
Some of us feel that the trend in the consultancy service and in the Health 992 Service ought to be questioned. We are proud of the Health Service and of the great medical and nursing work that is carried out, particularly in the hospitals, but we must not allow our justifiable pride in these things to blind us to one or two undesirable trends and one or two questions which have to be posed.
One of the things concerning me is the change-over from whole-time consultancy to maximum part-time consultancy. The effect is that consultants who have been working the whole of their time for a specific hospital go over to working for nine-elevenths of their time for that hospital and reserve the right to work for themselves in the other two-elevenths of their week. In other words, it opens the door wider for opportunities of obtaining Health Service treatment by privilege.
One would think that the number of whole-time specialist consultants would be expanding, but figures which I have obtained from the Minister over the last few months show that at 30th June, 1955, there were 3,166 whole-time consultants and at 30th September, 1957, the number had increased by only 26. Although we know that probably more consultants have been appointed, the reason why the net gain is only 26 is that we must have lost considerably on the change over to maximum part-time service. Hospital regional boards and hospital management committees are encouraging the change over at a rapid rate, and I find it rather regrettable because there is very little opportunity for part-time consultants to supervise those concerned. It is rather difficult to suggest that a consultant at a hospital should be supervised in his work, but there was a committee, the Bradbeer Committee, which considered this important question and which recommended the appointment of a medical administration.
There are complaints from time to time about some of these part-time consultants, their laxity in ward rounds and in carrying out their out-patient visits; there are also complaints that domiciliary visits are abused. Therefore, one feels obliged to ask, if the Minister is encouraging this service, what safeguard has the Minister in relation to the part-time consultant service? One reason why this change-over from the whole-time service is encouraged is 993 that it is felt right to give consultants the opportunity of earning private fees. As I have said to the hospital management committee on which I serve, where it has been suggested that this change over should be introduced, this would appear to be introducing a salary increase by the back door. It may well be that consultants ought to have more money; I am not discussing that tonight, but it is interesting to note that the salary of a top whole-time consultant is £3,385 per annum, added to which he can earn £840 for domiciliary consultations; also he can get further increases in the form merit awards, which I will deal with later.
The Birmingham Regional Hospital Board obtained an opinion from an eminent counsel to the effect that when a whole-time consultant's position is changed and it is desired to have a maximum part-time consultancy, that constitutes fresh terms and conditions of service. I am sorry to say that regional hospital boards have been pressed by the Ministry into disregarding that legal opinion. The result is that the more of these full-time specialists in the Health Service who become maximum part-time, the more pay beds are required in the Service, because if they are able in part of the time which is available to them to do private work and to see private patients, naturally, having charged a fee, they want to bring their private patients into hospital to receive priority treatment.
This is a trend which I find disturbing because it means that people are not treated under the Health Service on the basis of their need of treatment but that they can buy priority in medical care and attention, using not only the consultant's time hut the service provided in the hospital.
I have no figures relating to the increased number of pay beds, but I suspect—and this is confirmed by many of my colleagues—that it is on the increase. Many people have complained, as I have done to the hospital management committee on which I serve. Recently the West Bromwich Executive Council stated that a child going on the normal waiting list for a tonsil operation had to wait a considerable time, whereas if a parent were prepared to pay a handsome fee the child could be taken into hospital almost overnight and operated on. I 994 know that people who want to enter some of our teaching hospitals in Birmingham have to join the end of a long queue, but that if they are prepared to pay 20 guineas a week they can get in almost the next day and have treatment. We all agree that the medical profession as a whole has a high ethical standard, but nobody can justify that situation on ethical grounds.
I have had passed to me by my hon. Friend the Member for Birmingham, Perry Barr (Mr. C. Howell) a most glaring example of this sort of thing, which I should like to put on record. I am not going to give the names, but the whole thing is available to the Minister if he wants to inquire into it, as I hope he will. I mention it because I think it is typical and indicative of what is going on.
Here is a case of a man injured in December, 1957, and who is living in the Derby district. He periodically lost time from work. Eventually his doctor and his employer wrote to the medical superintendent of the hospital asking when the man could go for treatment. The following is the reply which the man's doctor eventually received from the consultant:I am in receipt of your letter asking for preference for this patient with regard to his admission for operation. While it is, of course, quite reasonable for you to write in this vein I have also had a letter from the manager of the firm which is I think quite improper. From the medical point of view Mr.… has a condition which is by no means an emergency and indeed has been provided with conservative treatment to case the waiting period so that I consider there is no reason whatever why he should be advanced on the National Health Service list. He was put on this list at the beginning of July so it is likely that his admission will be before Christmas.In other words, the man has to wait seven months to get into hospital. The consultant goes on to say:Since the matter is so urgent from an economical point of view I would have thought he should consider having the job done privately and he is in the happy position that, assuming he has a wife to look after him at home and that you would be prepared to look after him from time to time during the immediate post-operative period, he has a condition on which I would be prepared to operate privately as an out-patient under local anaesthetic, in which case he would incur only my operating fee of twenty guineas. I might point out that the N.H.S. out-patient operating waiting list would involve a wait of some 12 to 18 months and the operation would be carried out by a junior so that he is already as well off a= he can be under the Health Service. It is possible that his firm would help him with his expenses.995 This raises some other important questions. Quite clearly the consultant is saying that the man has to wait at least seven months for treatment, but that if he is paid 20 guineas he will treat the man at once. Secondly, and I think more important, what the specialist is saying is that not only will he do the operation for 20 guineas, but also that if he is not paid the money he will not do the operation at all. When the man eventually goes into hospital he will receive inferior treatment under the Health Service and will not have the services of the consultant. I find that even more remarkable than the fact that the consultant is asking for 20 guineas.
That sort of letter illustrates the trend which some of us in the House find rather disturbing after twelve years of the Health Service, and we are even more disturbed that this trend should appear to be encouraged by the Ministry. This change-over from the whole-time service to the maximum part-time service is a problem. There is no set-up in the Health Service to supervise when these part-time consultants come to the hospital. They are paid traveling allowances. There is no way of checking whether they are abusing the position or not.
Fortunately, the overwhelming majority of consultants maintain a very high standard in their public duties and do not abuse it. Those responsible for the spending of public money have to be very careful to see that it is well spent.
Finally, I want to refer to the question of merit awards, which I also find rather disturbing. This is a system under which an almost secret committee goes round the countryside seeing the regional boards and consulting the consultative services committee and looking at the work of various consultants region by region and deciding to give them extra payment over and above their salaries.
There are three rates of pay which the committee can give—£2,500, £1,500 or £500 a year. I understand that 279, which is 4 per cent. of the number of consultants, get the higher rate; 698, which is 10 per cent., get the middle rate, and the lower amount is received by 1,397, which is 20 per cent. of the total number of consultants. Therefore, 34 per cent. of 996 consultants are awarded considerable sums of increased pay.
The point is that nobody is ever told about this. It is causing considerable disturbance among consultants who do not know whom among their colleagues receive the increase, and it is causing concern among the regional boards. Once the committee responsible for making special merit awards makes this extra payment, it does not have to sit again and the payment goes on to the end of time. To award a specialist doctor, no matter how good he may be, £2,500 a year is a very big step to take, and to do it without consulting his employers, the regional board, is another disturbing action. Even more disturbing is that the board, not having been consulted about it, has to find the money out of its own finances.
This also causes suspicion among colleagues and does away with a certain amount of fair play in that fellow-doctors do not know whether the award has been justified or not and there is no provision for appeal by a consultant who feels aggrieved. He cannot appeal because he does not know that the award has been made to a colleague. It is an important principle that those employed in any public service should not be paid in this secret manner. Payment to civil servants, Members of Parliament and all who receive salaries from the public should be open and above board, and its award should be the responsibility of a reputable body which could be questioned about it. Alternatively, such salaries should be nationally negotiated through national negotiating machinery. That certainly does not apply to these merit awards.
These trends away from the National Health Service as we set it up are very undesirable. They are putting an absolute premium on ability to pay for specialist attention rather than on treatment justified on merit. That is the only conclusion to be drawn from the increasing number of pay-beds and the increasing concern of the Minister to get consultants to become maximum part-time consultants instead of full-time consultants. I hope that the Minister can give us rather more adequate reasons for these practices than he has given on previous occasions.
§ 12.28 p.m.
§ The Parliamentary Secretary to the Ministry of Health (Mr. Richard Thompson)
I shall answer the hon. Member for All Saints (Mr. D. Howell) as quickly and as fully as I can because tie has raised a number of matters of considerable public importance. As he knows, the remuneration of consultants, with that of other medical and dental staff, is under consideration by a Royal Commission. Further, a Working Party has been set up jointly by my Ministry and the medical profession to consider the whole structure of hospital medical staffing. It follows, inevitably, that many of the problems raised by the hon. Member will no doubt be dealt with in its Report. I do not want to shelter behind that fact, but the hon. Member must realise that we expect to receive a good deal of guidance from that quarter.
On the question of the transfer from whole-time to part-time appointments in the consultant service, when the establishment of these services was first under discussion the point was made that some consultants, while prepared to devote most of their time to hospital work and to give it priority on all occasions, preferred a maximum part-time to a whole-time contract. This preference was given statutory recognition in 1949—when the hon. Member's right hon. Friends were responsible for the Government—when Section 12 of the National Health Service (Amendment) Act ensured that regulations should not contain any requirement that all specialists employed in the hospital and specialists services would be whole-time officers.
Ever since 1948 it has been the view of successive Ministers of Health that, subject to the needs of the hospital service, which always come first, employing boards should weigh the circumstances and preferences of the consultants concerned. For several years it has been normal practice when a new appointment is made, unless the board considers that the need of the hospital service demands a whole-time appointment, for competition to be thrown open to all applicants willing to give substantially the whole of their time to the post, be it a whole-time or maximum part-time contract.
Similarly, the preferences of consultants who wish to transfer from whole-time to maximum part-time service 998 should be taken into consideration, again subject to the over-riding question of the needs of the service. All the individual decisions in cases of this kind are decisions of the regional board. The board is the employer and it is locally responsible for the provision of consultant and specialist services. It normally takes into account the views of the hospital management committees responsible for running the hospitals concerned, but as the principal responsibility is that of the board and as the board is the employer, it must also have the last word.
I can assure the hon. Member that applications for transfer from whole-time to part-time service are not automatically granted and that the statistics available to me certainly do not imply large-scale transfers. He has quoted the figures which I gave to him in reply to Parliamentary Questions and I will not go over them again, but he made the point that the rise in the number of whole-time consultants between the end of 1955 and 1957 was very small. The figure he quoted was twenty-six. The number of consultants and senior hospital medical and dental officers employed whole time has nevertheless continued to increase, although I agree that the increase has not been very great and that part-timers have increased much more in proportion than have whole-timers. Many of these, however, are not people who have transferred from whole-time service but are new men who have been appointed into the service on a part-time basis.
We must remember that the Guillebaud Committee in 1956 considered that there was a valid case for the retention of part-time consultant appointments in addition to whole-time appointments but that the financial arrangements should not be such as to induce a consultant to seek a part-time rather than a whole-time appointment. This is the point which the hon. Member was trying to make. That is also my right hon. and learned Friend's view, and evidence on the differences in the bases of payment to whole-time and part-time consultants has been given to the Royal Commission on Doctors' and Dentists' Remuneration. We must await any observations which the Commission will make on the subject in its Report.
May I say a word about supervision? The hon. Member suggested that there is 999 no control, or at any rate inadequate control, over what consultants do, how many sessions they work and how much time they devote to each session. This is not so. A consultant's duties are set out in his contract with the board whose responsibility it is to assess the time required to perform them. My right hon. and learned Friend more than once has drawn the attention of the boards to the importance of regular reviews of these assessments of time.
I turn to the thorny question of private practice. The question of transfer from whole-time to part-time employment is closely connected with a consultant's right to undertake private practice, to which the hon. Member referred. When the National Health Service was first established it was generally agreed that facilities for private practice should continue to be provided. That is the origin of Section 5 of the National Health Service Act, under which the Minister may set aside accommodation for private patients provided that he is satisfied that it is reasonable to do so. The numbers of pay beds set aside in this way have not varied greatly in recent years. The hon. Member's suspicion was that they were steadily increasing.
I am glad to give him figures which, I hope, will set his mind at rest. In 1949, the number of staffed beds allocated for private patients was 6,647 in England and Wales and 729 in the Birmingham region, including the Birmingham teaching hospitals. I obtained these figures in view of the obvious reason for the hon. Member's interest in the matter. In 1953, the figures were 5,793 and 611, respectively, and in 1958, 5,645 and, again, 611, respectively. In the same period, the numbers of staffed beds provided without charge increased by 6,000. I hope, therefore, that the hon. Member will realise that there has not been a progressive rise in the number of pay beds. In fact, the number has gone down and the number of non-paying beds has gone up.
In the hospital management group with which the hon. Member is associated, the number of pay beds has been constant at nineteen until a recent change, when two additional beds were designated for private patients at the Marsden Green 1000 maternity hospital. In view of the development of this hospital, the designation of merely two beds does not seem to me to be excessive.
§ Mr. Thompson
I cannot give way; I have much to cover.
The hon. Member has complained that private patients are buying earlier admission. It is true that it is often easier to obtain a bed quickly as a private patient, but this is by no means an invariable rule. Indeed, in some of the larger teaching hospitals, private patients have to wait longer. It would not, in any case, be true to conclude that the abolition of private practice for hospitals would have any appreciable effect on the waiting list. The numbers of private beds amount to little more than 1 per cent. of the total bed complement and many of them are scattered over a large number of hospitals, perhaps with only two or four of such beds.
These beds are already making a contribution to the free services. There is an express reservation in Section 5 of the Act to the effect that nothing in that Section shall prevent private accommodation from being used for Health Service patients who urgently require it on medical grounds. In the past three years, in the Birmingham region, the average occupancy of pay beds was 270 by paying patients and 130 by National Health Service patients—naturally, free of charge. They have, therefore, been making a considerable contribution.
I have a minute or two in which to say a word on the subject of distinction awards, or merit awards, to which the hon. Member referred. The Spens Committee of 1948 recommended that the upper band of specialist pay should not be determined by length of service. This was with the objective ofproviding sufficient incentives to stimulate effort and encourage initiative; of holding out opportunities of higher reward to all specialists alike in whatever branch of medicine.The Spens Committee suggested that individuals should be selectedfor exceptional reward in respect of outstanding professional ability.It is difficult to see how that outstanding ability can be judged except by a professional body. The hon. Member 1001 was quite right in his description of the three bands in which these awards operate.
The Government of the day accepted those recommendations and the proposals of the Spens Committee were translated almost exactly into the existing 14-member Committee under the chairmanship of Lord Moran, who still holds the post, and awards have been made accordingly since 1948. Every consultant is invited to inform the Committee of his claims and to keep these up to date. Any consultant may, further, appeal to the Committee if he considers that his claims arc insufficiently regarded. By means of annual tours, members of the Committee, and the Chairman in particular, add to the information available.
It is true that the Committee meets privately and its proceedings are confidential, as they must be from the personal nature of the questions with which it deals. The names of award holders are likewise regarded as confidential, because any general publication of names might lead to misunderstandings—for instance, by inducing patients to judge the quality of the treatment they receive by the pay of the consultant in whose charge they are placed.
The Government witness before the present Royal Commission on Doctors and. Dentists Remuneration agreed that the system had some disadvantages. For example, confidential awards obscure the total amount of remuneration; and employing boards, as the hon. Gentleman said, have no final voice in determining the remuneration of some of the consultants they employ. On the other hand, I must make this point. The system has met the main requirements of securing higher remuneration on the basis of individual distinction rather than age or length of service or because of a particular skill. There has been some success in rewarding more than ordinary ability, and the method has met broadly 1002 with general acceptance. Despite the obvious objections, to which the hon. Gentleman has referred, quite fairly, I think, it is the view of my right hon. and learned Friend that no superior alternative has yet been found, and the balance of advantage seems to lie in the continuation of these arrangements. Evidence to this effect, as I said, has been given to the Royal Commission and its report must now be awaited.
Of course, the total sum involved in this is controlled by the Exchequer, but in the actual distribution of it the Minister is advised by an advisory committee, and it is very difficult to see how any appeal body could be set up here because this is a professional matter and. as far as I can see, any appeal would once again have to be to professional people.
In the short space of time at my disposal I have tried to deal with a number of the really very important points which the hon. Member made. I would conclude on the note with which I started, that a good deal of what we have been Talking about today forms a subject which will have to be and is being considered by the Royal Commission which is now sitting.
§ Mr. Thompson
Yes. I am obliged to the hon. Member. I should be obliged to him further if he would let me have full details of that complaint, because if there has been abuse or anything of that kind I should like to know.
§ The Question having been proposed of ten Ten o'clock on Tuesday evening and the debate having continued for half an hour, Mr. SPEAKER adjourned the House without Question put, pursuant to the Standing Order.
§ Adjourned at eighteen minutes to One o'clock.