HC Deb 05 December 1960 vol 631 cc981-1010

Motion made, and Question proposed, That a Supplementary sum, not exceeding £37,665,600, be granted to Her Majesty to defray the charge which will come in course of payment during the year ending on the 31st day of March, 1961, for the provision of national health services for England and Wales and other services connected therewith, including payments to Northern Ireland and the Isle of Man, medical services for pensioners, etc., disabled as a result of war, or of service in the Armed Forces after the 2nd day of September, 1939, certain training arrangements including certain grants in aid, the purchase of appliances, equipment, stores, etc., necessary for the services, and certain expenses in connection with civil defence.

9.11 p.m.

The Parliamentary Secretary to the Ministry of Health (Miss Edith Pitt)

The whole of this Supplementary Estimate relates to increased remuneration. Most of it—£35,978,000 gross—is for payments to doctors and is the result of the implementation of the recommendations of the Royal Commission on Doctors' and Dentists' Remuneration. A sum of £21,399,700 is back payment for the period 1st March, 1957, to 31st March, 1960, and the balance of £14,578,500 is pay for the current year. The opportunity has also been taken in presenting this Supplementary Estimate to ask for money to cover other wage awards already announced.

The Government's acceptance of the Pilkington Report as a whole was announced by the then Minister on 11th April, 1960, provided that the professions did likewise. The Government proposed that the professions should participate in joint working parties to work out proposals in detail for this payment. Two working parties were set up, one to deal with medical and dental staffs in hospital and specialist services, and one to consider the distribution of the increased sums proposed for general medical practitioners. On 28th September the British Medical Association and the Joint Consultants' Committee indicated the medical profession's acceptance of the Government's offer, and the results are contained in this Estimate which I hope the Committee will accept.

Mr. Charles Doughty (Surrey, East)

Can my hon. Friend tell us what were the other wage awards?

Miss Pitt

They are set out in the Estimates and I refer my hon. and learned Friend to page 5, which gives the details. The largest item among the seven is for clerical and ancillary workers.

9.13 p.m.

Dr. Edith Summerskill (Warrington)

I think the Committee will agree that these Estimates were necessary in order to implement the recommendations of the Royal Commission, but there are one or two questions I wish to ask. First, I suppose the Committee could ask whether this large sum is justified. If as a doctor I said that I thought it was, it might be felt that perhaps I was a little biased, but if one recalls the lay Press on the subject, the concensus of opinion was that it was and that the doctors deserve this increase.

While the general practitioners have received their share, how long will the hospital staffs have to wait until they receive theirs? Will all the arrears of salary be paid by January, 1961, including retrospective adjustments for the years 1957, 1958 and 1959? I would remind the Minister of Health that these sums should be regarded as unpaid salary covering four years, and that is a long time for professional men and women to wait. Many of these doctors who are employed in hospitals and clinics are not well off and many of them have heavy family responsibilities. There seems to me to have been inordinate delay in settling this matter.

I have seen a letter addressed to a member of the senior medical staff of a hospital which said that it was unlikely that the Ministry could make these retrospective payments before 31st March at the earliest. The Parliamentary Secretary has already told us that the Royal Commission reported in April. The Ministry then offered the profession what was called a "package deal". Many members of the profession felt rather sore about it. They were told that they had either to accept or reject the offer without amendment.

I read many of the discussions which took place between various organisations within the profession and there was no doubt that in the minds of some of the members there was the feeling that if they accepted the offer without amendment the payments would be made. It is surprising to learn that although the general practitioners have been paid the doctors in the hospitals have been told that the payments cannot be made before 31st March, 1961, at the earliest. I know it can be argued that there have been people who have been on the staff of a hospital for a very short period and they have to be traced—I accept that—but why cannot those who have been in their present posts a number of years and have worked in them during the years in question be paid now? Surely there would be no difficulty about that.

Also, why has not the pay structure involved in this very large sum of money been related to the general health of the service? This was certainly not within the terms of reference of the Royal Commission, but I understand that the Ministry has decided to set aside £1 million to improve general practice. I asked the Minister about this before the debate and I understand that the £1 million is included in these estimates, and so it is in order for me to ask what the Minister proposes to do with the money. I am not suggesting for a moment that he is wrong to do this When any profession or body of workers is paid a very large sum such as this, it would be stupid and short-sighted for the Minister not to say "In these circumstances let us look at the whole Service and see whether we can improve it in some way". There is no reason why the Minister should not do so, and, psychologically, it would certainly be agreed that this is just the moment when the recipients of this money seem receptive to new ideas. The Minister wisely said, "Let us at least have £1 million to improve general practice." That was accepted; but surely this is only tinkering with the problem.

Mr. E. G. Willis (Edinburgh, East)

Where is this stated?

Dr. Summerskill

It is not stated in the Supplementary Estimates. This is known only if one has done one's homework fairly well. I say that to earmark £1 million of this large sum of money to improve general practice is tinkering with the problem. I would remind the Minister that this is probably the last time that such a large sum will be allocated in this way. In future, the Standing Review Body which the Royal Commission advocated should be set up will examine the remuneration of doctors and dentists every three years; this may lead to adjustment of salaries in a very minor way, and structural changes may not be so acceptable when there are only minor salary increases.

This was the psychological moment for the Minister to say that as this large sum of money was being given he wanted the service improved. I do not want to be unkind to the Minister, but has he seen tonight's Evening Standard? It contains a cartoon which suggests that he is coming along with a very big hatchet. It would be cruel to suggest that there is any truth in that. I am sure that he wants to save money, and at the same time to do it in a constructive manner. This was his great opportunity, but unfortunately he has missed it.

The general practitioners were quite happy to allow the Minister to have this £1 million, and he might tell us tonight what ideas he has on the subject. No doubt my hon. Friends can suggest some things to him. I suggest that at this stage he uses it, first, on refresher courses. It is impossible for older men and women in the profession to keep up to date with the tremendous progress which is being made, not only in drugs, but in all kinds of therapeutic processes and diagnostic methods. Refresher courses are important.

If the right hon. Gentleman is making these changes in general practice, he must remember to reduce the maximum size of the list. Why has he not the courage to go further? Time after time he has said, if we are to believe the Press, that he wants to reduce the hospital population. He is quite right in wanting to do that. I cannot believe that there is any truth in the story that he is considering charging sick people for their food while in hospital in order to reduce the hospital population. He knows that that has been alleged, but I cannot accept it. He can reduce the hospital population very effectively if he places more emphasis on the domiciliary service. He has decided to take £1 million out of this sum, which will be agreed to tonight. We shall not divide on this.

Mr. Willis

I am trying to find out under which subhead the Minister has deducted the £1 million, because it is very mysterious to us.

Dr. Summerskill

I am told by the Minister that it is Subhead F, but it is not very clear.

Mr. William Ross (Kilmarnock)

I have been looking at Subhead F, which is the only subhead it can come under, but the information given for the £19 million is: Additional provision required for payments under arrangements made with medical practitioners. I presume that the arrangements are already made and that we should have heard about this from the Parliamentary Secretary.

Dr. Summerskill

I know these things only because I do my homework very carefully and read the British Medical Journal every week. It was reported in full in the medical journals. If I was not a member of the medical profession I should not have known.

Mr. Ross

From what my right hon. Friend said I was under the impression that no arrangement had been made and that the Minister did not know how he intended to spend the money. We are being asked to agree to £19 million, but we have been given no explanation of the £1 million and the Minister evidently has not made up his mind about what he intends to do with it.

Dr. Summerskill

The Minister will not be able to give details when he winds up, but he obviously has something in mind. I have taken the opportunity to plant a few seeds which I hope will germinate and finally bear fruit next year when the appropriate Committee reports. The fact is that £1 million has been taken for the purpose of improving general practice and that comes out of the general medical services. The revised estimate is £11 million, and from that the additional sum required is £2 million. One million pounds will be taken out of that.

If the Minister thought fit to ask for £1 million for the purpose of improving the general medical services, why did he not think fit to ask for a little more to improve other parts of the service?

As I have said, he should have placed more emphasis on the domiciliary service. He should have seized this opportunity to make consultants' domiciliary visits free, so that the consultants' basic salary could be increased. If there is any question whether I am in order, I would point out that the consultants' basic salary could be increased by reducing their merit awards. I suggest that the C class should be abolished. If the Minister will consider this and will also increase the basic pay I am sure that he will be able to persuade the younger consultants coming along that this is the right approach. In every country where a new medical service has been introduced it is always the older consultants who are the most conservative. When they retire or die the younger ones coming along are more adaptable.

If, then, they have this basic salary and they can see domiciliary cases free, which means that the general practitioners can easily have a second opinion, the Minister will find that his hospital population will be reduced. I believe his predecessor agreed with me that it is utterly stupid to pay £25 or £26 per week for a hospital bed when that expense could have been avoided if the patient had had a second opinion, which now costs the State about four guineas.

I would remind the Minister that the consultant sees the first eight domiciliary cases free, and after that he is permitted to see 200 for a certain payment. But 200 is the limit, and there is no doubt that there is some hesitation on the part of general practitioners, when considering whether they can call in the consultant when his services are free. When the 200 limit has been reached, on the other hand, the general practitioner says, "I cannot see the consultant I want to see because he has reached his limit." If the basic salary were raised and the consultants' services were free in respect of domiciliary cases it would help to solve the problem of our overfull hospitals.

Evidence has been forthcoming that it is more economic to provide whole-time consultants, and I cannot see why conditions of service have been loaded in favour of part-time consultants. If the Minister knows his Pilkington he will recall that Pilkington argued this very congently, and pointed out that the part-time consultant had certain concessions in respect of Income Tax and mileage. We are now voting a sum of money which will be given to various professional people working in the National Health Service, and we have a right to ask why the part-time consultant is still more favoured than the whole-time consultant.

I now turn to the general medical services. The Minister will recall that the Royal Commission recommended that a special fund of £500,000 should be provided especially to recognise distinguished general practice by additional remuneration. Although, as in the case of the first £1 million, it is not mentioned, I take it that this £500,000 is included in the Estimates. It must be, because it was recommended that that sum should be applied in accordance with a scheme to be agreed between the profession and the Government and that Until a scheme is agreed, the money should revert to the Treasury. Any part of the fund which is not expended should similarly revert. A sum cannot revert to the Treasury unless it is in the hands of the Minister, so may I ask, is this £500,000 included here?

The Minister of Health (Mr. J. Enoch Powell)

I do not think that any part of the £500,000 is included here, because it is not anticipated that the agreement on which the payment out of it will be based can be effected during the present financial year.

Dr. Summerskill

Would not this £500,000 be in the general medical services? After all, it is earmarked for the general medical services as merit awards to general practitioners.

Mr. Powell

Yes, but if as in the passage of the Pilkington Report, which the hon. Lady quoted, it is in the meantime in the hands of the Treasury, then the sums required are not asked for in Parliament.

Dr. Summerskill

The Minister does not seem to be certain. I am only emphasising the word "revert". A thing cannot revert to the Treasury from the Minister unless the Minister already has it. Therefore I base my case on the wording which says that until the scheme is agreed the money should revert. I am not sure that the Minister is right, unless it has been confirmed—has it been confirmed? I see that a little note is being passed on the Government Front Bench. When I was in office those little notes which were handed to me proved very useful in telling me whether I was right or wrong. May I take it that the Minister was right?

Mr. Powell

Perhaps the right hon. Lady can wait until I come to it.

Dr. Summerskill

I suspect then that I was right.

If this £500,000 for merit awards is included, may I for a moment present an hypothetical case? May we ask whether a scheme has been agreed and what qualifications or qualities a general practitioner should possess to entitle him to a share in this £500,000? The Minister will agree, if he has read the various debates in the medical journals, that medical practitioners are concerned with the approach to merit awards. They would like to have defined precisely what qualities a general practitioner has to possess to entitle him to a merit award. I find it difficult to understand why the Minister is more concerned to encourage extremes of earning than to find ways of improving general practice both in the interests of the patients and the doctors.

May we know more about the distribution of this money regarding matters mentioned by the Royal Commission which said: While we entirely approve of the efforts that have been made, and sensibly made, to encourage the formation of partnerships, we feel that the financial incentive at present provided is somewhat excessive. … The single-handed practitioner is at a financial disadvantage to an extent which we consider unjustifiable. The Commission further stated: The gap between the rural and urban earnings should be somewhat reduced. Has the Minister any plans for that? Greater weight ought to be given to items other than capitation … The pool balance should be distributed more promptly and budgeted more narrowly. Finally, I wish to ask—I think this important—what has been done regarding informing the general practitioners who have already received their remuneration, and implementing this simple recommendation of the Royal Commission, that more should be done to render the pool system intelligible to those whose living depends on it? The pool system is a most complicated approach to payment. Most doctors who are utterly exhausted at the end of the week pick up their British Medical Journal and sometimes see the system described there and how the pool functions. But when these sums of money are sent to doctors it should be explained precisely how the pool, which determines how much they shall get, actually works.

I remind the Minister of Professor Jewkes' minority report. It was astonishing that this Royal Commission sat for three years and there was only one dissentient, Professor Jewkes. He expressed the view that this increase in remuneration would not attract a sufficient number of medical students. As this is essential to the efficient working of the Service, may we know if the increase represented in the Supplementary Estimate would achieve this purpose? Although the Ministry has accepted the recommendations of the Royal Commission with regard to remuneration—and we all welcome that—it has utterly failed to seize the opportunity to remove many of the anomalies of the Service and to make changes in structure which would have benefited both doctors and patients.

9.36 p.m.

Dr. Donald Johnson (Carlisle)

I am happy to support these Supplementary Estimates, but none the less I follow the right hon. Lady the Member for Warrington (Dr. Summerskill) to a general extent in what she said about a missed opportunity in connection with the increases in pay of general practitioners as recommended by the Pilkington Report. I think it a great pity that we in the House of Commons should not have debated the Pilkington Report before the money was granted rather than afterwards.

No one grudges this payment to general practitioners, least of all one like myself who has spent many years in general practice, but I feel that an opportunity has been missed, an opportunity even wider than that mentioned by the right hon. Lady. She confined her remarks to the question of £1 million, but my view is that an opportunity has been missed of considering the whole method of payment of general practitioners and whether we are in fact using the best method available in the payment by capitation fee.

I am not by any means coining an original remark when I say that, under the present method of payment and the present conditions of working, there are definite built-in disincentives to efficient medical practice. The fact that those disincentives are resisted to the extent they are is a tribute to the devotion of the doctors in practice today. We have to realise that in this method of payment by capitation fee the doctor has only one incentive from a financial point of view—namely, to get the maximum number of patients, and that is really all. He gets no more if he attends them all every day and no less if he sends them all to hospital whether as out-patients or in-patients. He is penalised financially automatically if he spends money on his surgery or employs extra secretarial or nursing assistance. That all comes off his salary. The incentive for more work and better work is a negative one.

This question could well have been considered by the Royal Commission. I seem to remember that I suggested that in a Question to the Prime Minister at the time when the Commission was appointed. The Commission turned aside from that, I think deliberately, and a great opportunity has been missed which, for the reasons the right hon. Lady stated, may not recur for a number of years owing to the revised method of fixing remuneration.

The hon. Lady also referred to the question of the £1 million, a question which is hanging in the air. From my reading of the medical Press, merit awards have proved so unpopular that the idea has now been dropped altogether, but we still have this sum of money as an incentive to efficient general practice, and it will be interesting to hear what my right hon. Friend has to say about it.

I admit that the Royal Commission was bound by its terms of reference, but I am not at all certain that it did not neglect the main problem and I am not optimistic about this sum of money being enough for the purpose. It can merely tinker with the problem. However, I shall be interested to hear my right hon. Friend's views, and to hear how he proposes to deal with the present problem, which he has inherited.

Those of us who are interested in the Health Service had a genuine grouse in the last Session of Parliament, because in the whole Session we had only three hours in which to debate the Service. I hope that my right hon. Friend will be able to prevail upon our right hon. Friend the Leader of the House to provide more time on the Floor of the House so that we can impart our ideas and generally keep in touch with developments in the Service.

I want finally to deal with the hospital Estimates and to ask whether my right hon. Friend can pay attention to the question of unnecessary and redundant outpatient attendances which, as those of us with experience in these matters know, is closely connected with the general practitioner service. We talk about developing domiciliary services, but it is the general practitioners who are essentially our agents for providing efficient domiciliary services, and not the local authorities or extensions of the hospital service. Both out-patient and inpatient hospital treatment are largely dependent on how the general practitioner works.

Finally, at Question Time last week I asked to what extent my right hon. Friend thought that capital expenditure on hospitals could be met by an increasing stimulus to voluntary contributions. I am sure that we must increasingly depend on voluntary contributions for helping to meet the cost of hospital extensions, departments and even new hospitals.

With these few general remarks, I have much pleasure in supporting the Estimates.

9.44 p.m.

Mr. Donald Wade (Huddersfield, West)

Out of the sum of £37,665,000, one item is for £16,384,000 for regional hospital boards, and on page 5 of the Supplementary Estimate we are told that that additional provision is required for increased remuneration. I take it that that does not cover any remuneration for those engaged in administration.

In page 5, there is item E—Administration, £383,000, and I should like to know whether Item B.1 in the same page—£16,384,000—is inclusive or exclusive of administration. In page 5, again, we have an item of General Medical Services, amounting to £19,030,000, which is approximately half the total of £37 million. Will the Minister confirm that the amount going to the general medical practitioners is approximately half of the total sum that we are being asked to vote?

9.45 p.m.

Mr. Laurence Pavitt (Willesden, West)

I welcome this Supplementary Estimate, as it closes a chapter over which the medical profession has been at loggerheads for about five years, and I think that we may now look forward to greater co-operation between the Ministry and the profession. Nevertheless, I agree with the hon. Member for Carlisle (Dr. D. Johnson) when he says that the Minister has missed a great opportunity. The National Health Service has been in existence for about twelve years, and the Pilkington Report provided the chance not only to submit this Estimate but to make improvements that would have helped the nation, and not just the profession.

Looking at this Estimate, which all arises from the Pilkington Report, I again protest, as I have done week after week, at the way in which the Government have treated the House. The Royal Commission sat for three years, and there has been a considerable amount of discussion about it. It has been discussed in another place, but this is the only opportunity that we in this place get to discuss the very far-reaching matters that will arise. I do not think that even the two Reports mentioned by the hon. Lady have been presented to the House, or are available in a form which can be readily understood by hon. Members unless they refer to the British Medical Journal or other medical periodicals.

The hon. Lady said that the B.M.A. had agreed, but surely it is the General Medical Services Committee that has the responsibility for negotiating on behalf of the General practitioners, and that Committee consists of quite a number of people who do not necessarily belong to the B.M.A.; indeed, other bodies are specifically included.

I welcome the comment of my right hon. Friend the Member for Warrington (Dr. Summerskill), on the way in which this Estimate relates to the central pool. One has to try to relate it to the way in which the sum of £16,384,000 will be divided among all the general practitioners. Not only hon. Members but doctors generally do not really know just how it will work out in practice. The Government treat hon. Members with profound contempt when, in such an important matter as this, they just make ad hoc decisions without taking into consultation hon. Members who have a right to discuss these things, and whose comments might help to relate such an Estimate as this more clearly to the job in hand.

It will be seen that in England we are to provide about £16 million for the regional boards and £3.7 million for the teaching hospitals, yet, as the Minister told me in answer to a Question, he is well aware that the regional hospitals undertake about 90 per cent. of the hospital care, and that only 10 per cent. is covered by the teaching hospitals. Yet we see that the ratio of salaries in the Supplementary Estimate is something like four to one instead of ten to one. Apparently, this does not apply to Wales. Whether it is that the Welsh are more egalitarian in their approach, I do not know, but I see that the proportion in Wales is about the same as the volume of medical care: regional hospital boards, £1 million; teaching hospitals, £107,000.

Cannot the Minister take the opportunity, when preparing Estimates of this kind, to establish some concrete policy in regard to the relationship between the salaries and pay being given to consultants, specialists, registrars and so on in the teaching hospitals as compared with the amount available in the regional hospitals? Surely, the time has come when there should be the same kind of service in the one as in the other. By financial considerations of this kind it could be possible to effect a better balance.

My right hon. Friend has already mentioned the £500,000 proposed for the merit awards, an idea which, as the hon. Member for Carlisle has said, has been frowned upon by most of the correspondents in most of the medical journals. How can the Minister or anyone else judge merit between one doctor and another, whether one is giving good service and another is not? If I understand the reports correctly, this is a matter for further discussion jointly between the Minister and the profession. I hope that, if this £500,000 is to be presented in a future Estimate to the House, at least we may be taken into the Minister's confidence so that we may know just what is meant by that amount and know what kind of provision is intended, not just being faced with an Estimate at the last moment. I hope that we shall be given an opportunity to discuss it first.

I see that we have within the Estimates the amount for general practitioners who are principals, but there seems to be no safeguard at all for assistants who were employed during the period for which the back-pay operates. No doubt, the Minister will tell me that the assistants employed by a general practitioner are purely a matter of private arrangement. Nevertheless, there is no one but the Minister who can safeguard their interests. I know that there have been exhortations that general practitioners will play the game, find out which assistants they employed two years ago, and give them their share, but in the Pilkington Report quite a lot was made of the relevance of the fairness of pay for assistants, having regard to the original Spens Report. I hope that the Minister will not, arising out of these Estimates, just pass this blanket overall Estimate in consultation with the Working Party to the profession but will take steps to ensure that assistants have their due share. He has evailable the statistics he wants. The executive councils have a record of assistants who were employed, because one cannot employ an assistant without the permission of the executive council. Through that medium, justice surely could be done.

I notice from the various reports—which, again, this House is not in a position to discuss—that the £16 million and the other items in connection with Wales and Scotland are to be distributed by increasing the loading.

Mr. Willis

Scotland is not in this.

Mr. Pavitt

I beg the Committee's pardon. I should refer only to England and Wales. I think it is a very good thing that the loading should be increased. It encourages the middle-list man. Although I am not allowed to discuss Scotland on this Estimate, I must point out that there are discrepancies in this country in the size of lists. This opportunity could have been taken not only to increase the loading by 200 at different levels in partnerships and single handed practitioners but an effort could have been made to achieve a more general balance in the size of lists, especially since in parts of the country the average is as low as 1,600 whereas the national average is about 2,300.

The Minister might enlighten us also upon the way in which part of the money given to general practitioners is to be devoted to the increase of the obstetric fee. If I understand the Working Party Report correctly, the fee is to go up from 7 guineas to 12 guineas for obstetrics. Is not this part of the pattern of the piecemeal approach of the Minister to the whole subject of the National Health Service? We had the Cranbrook Report which dealt with obstetrics, which still has to be discussed by the House and still has to be implemented. We now have a little more for the general practitioners, who if they are on the obstetrics list will get an increase to 12 guineas, while the ones not on the obstetrics will get an increase to 7 guineas for their own patients.

I feel sure that if biological arrangements were different and men had to have the babies instead of women, this opportunity would have been taken to have a wholesale reorganisation of the obstetric services. Apart from the fact that we are fiddling about from 7 guineas to 12, there is a complete lack of co-ordination going right through in dealing with childbirth. The local authorities and the local health authorities are responsible for ante-natal clinical arrangements, while the general practitioners may have responsibility for the actual confinement, and if something goes wrong the flying squad from the hospital is called in. I hope to hear something from the Minister about this co-ordination. All we have is the opportunity to discuss the supplementary estimate, which is not included here, but is part of the total sum in raising the general practitioner's fees from 7 to 12 guineas.

I join with my right hon. Friend in welcoming the fact that the doctors have agreed to put aside £1 million of the money to which they are entitled in order to improve general practice. Although it may sound a large sum, it represents only 3d. in the £ of the gross amount received by general practitioners, and I think this is a step in the right direction. I should welcome from the Minister some idea as to how he will use this and what he is going to do with this £1 million in order to improve general practice.

I think the crying need is that patients should not have to wait so long in such dreary and uncomfortable waiting rooms. Will he therefore devote part of this £1 million to encouraging general practitioners to have comfortable well designed waiting rooms? Will he put part of this sum to encourage them to have appointment arrangements, so that patients need not lose a morning's or an afternoon's work each time they visit a general practitioner?

Will the Minister devote part of this sum to developing within his Ministry, in the same way as hospitals can have advice, some advice on the best way of building doctors surgeries in the most efficient and most economical way? Will he advise the doctors on the best way to organise their surgeries and how best to design them, so that they can be pleasant, and make sure that people do not sit crowded and huddled together, with a certain amount of anxiety not knowing whether the next call will be for them or not, coughing, spluttering and sneezing together? There is a whole field in which this £1 million can be usefully applied, and I hope that we shall have an opportunity of hearing the present Minister of Health more often than we heard his predecessor.

I should be only too pleased to put further questions to the Prime Minister, as I did last year, suggesting that he should include the Minister of Health in the Cabinet. The Government should stop treating the Minister of Health as being in a lowly position. These Estimates are part of the typical attitude which we have had—the Minister presents us with Estimates, and this is the only opportunity we have to discuss the whole range of the Health Service. I hope he will not be cheeseparing. I read with great interest the document which he prepared with his right hon. Friend the Colonial Secretary in 1952. Eight years have passed since then, and I hope that as a result of the experience gained, he will not approach these Estimates or any other future estimates with any idea that at all costs we have got to snip a little bit off the cost to the taxpayer at the expense of the care of the sick.

In welcoming these Estimates, I suggest that they can do good not only for the health of the nation, and for co-operation between the Ministry and the general practitioner, but so far as the economy of the nation is concerned, it is important that our workers, executives and the people who are producing the wealth of the country should remain healthy. I remind him that we lost 262 million days' production in 1958 from ill health, and this gets no headlines. We lost 3.7 million days from strikes, and we see something about strikes in the newspapers every day. Therefore, it seems to me that these Estimates and health policy they serve can be used not only for the benefit of the health of the people but for the benefit of the national economy, and the general well-being of the community. I welcome the Estimates on those grounds.

9.59 p.m.

Mr. Charles Doughty (Surrey, East)

The Minister has come here over the past years in more than one capacity. In his previous capacities the thought of handing out nearly £43 million would have caused one of those heart attacks with which specialists are only too pleased to deal. Tonight he can come here and ask for £43 million—

It being Ten o'clock, The CHAIRMAN left the Chair to report Progress and ask leave to sit again.

Committee report Progress.

Proceedings on the Committees of Supply and Ways and Means exempted, at this day's Sitting, from the provisions of Standing Order No. 1 (Sittings of the House.—[Mr. Powell.]

Supply again considered in Committee.

Mr. Doughty

Despite that slight delay, the Minister is still asking for £43 million. The cause for which he has asked for it is a very worthy one. I am in complete agreement with the right hon. Lady the Member for Warrington (Dr. Summerskill), who rightly declared her interest, and other hon. Members who said that the doctors are a well-deserving body of people. They are a very hardworking body and, on the whole, very knowledgeable. We are all grateful for what they have done in the past and, no doubt, they will continue to do it in the future. I do not begrudge them a penny of this money, but it must have hurt the Minister a lot to ask for an additional £43 million. He should have looked round to see whether every penny of that sum should be handed over to the regional hospital boards and the teaching hospitals and whether it could not have been found from other sources.

Let me say at once that I am not suggesting for a moment that any of these nebulous charges should be put upon the public or that any additional charge should be made on the National Health Service. That is not what I have come to say.

Mr. Willis

It would be out of order if the hon. and learned Gentleman did.

Mr. Doughty

The cartoon in the Evening Standard to which reference has been made was both inaccurate and misleading. I do not believe that the Minister will in any way slash the National Health Service. But that is no reason why it should not be conducted with the same efficiency and greater economy. Like, I believe, hon. Members on both sides, I do not want to cut down the National Health Service in any way. But because large sums of money are spent on an article it does not necessarily mean that it is the best. It is possible often, with efficiency, to obtain the same article for less money.

The right hon. Lady, in talking about reducing the hospital population, said that we could save, I think, £25 or £26 a week. I say with respect to her that her figures are wrong. This is where we should have made an economy. The figure for maintaining hospital patients in some London hospitals, at any rate—here I include the medical services—is approximately £80 a week. I do not think that that figure is fully known.

The Temporary Chairman (Mr. John Diamond)

The hon. and learned Member is going into considerable detail about a matter which does not appear to be strictly relevant to this Supplementary Estimate.

Mr. Doughty

I thought that someone might say that, Mr. Diamond, and therefore I had it carefully in mind. The question is: from where are we to get the money? Do we vote it out of the Treasury or find it from some other source? On an Admiralty Vote, if we wish to build new ships the question which must be considered is, what should be done with the old ones? We are asked to spend £349,628,000 for the regional hospital boards because, we are told, a further sum is rightly required for doctors.

The Temporary Chairman

If I may help the hon. and learned Gentleman, the question concerned is the expenditure of the additional sum of £16 million odd.

Mr. Doughty

The original sum was £330 million odd. Should this Committee vote it or should the Minister be told to effect economies which will save the whole or, at any rate, part of that sum? That is the point that I want to bring before the Committee tonight.

The Temporary Chairman

I am aware that the hon. and learned Member is anxious to bring that point before the Committee tonight. Unfortunately, it would not be in order so to do. I am trying to indicate to the hon. and learned Member what is in order and I am sure that he will now come closely to the Estimate for the supplementary amounts.

Mr. Doughty

Of course, I accept your Ruling at once, Mr. Diamond. I am saying that the House of Commons should not be asked to vote the whole of this sum, because the sums could have been found by the regional hospital boards from other sources. With the greatest respect, Mr. Diamond, that is in order.

The Temporary Chairman

I am grateful for the respect, but it is not in order. We are concerned, not with where the money is coming from, but with where it is going.

Mr. Doughty

It is going to the doctors. The question is whether, when it goes to the doctors, they ought not, perhaps, to contribute some of it to the hospitals, because they are so expensive to run. If one looks at the cost of the hospitals—

The Temporary Chairman

The hon. and learned Member must realise that we are not responsible for what the doctors do with this sum when it reaches their hands. I hope that he will now come to the point of the Supplementary Estimate.

Mr. Doughty

I am entirely in favour of the Supplementary Estimate, Mr. Diamond. This Committee, however, must look closely at the sums which it votes. Although the money goes to the regional hospital boards for a certain purpose, we have to ask ourselves whether those boards require that sum. If a person has to spend more money and, therefore, asks for that sum, one naturally says to him, "Can you not economise in another way?" That, I respectfully suggest, is a question that we can properly ask ourselves in this Committee.

The Temporary Chairman

The hon. and learned Gentleman is very clear to me. I am sorry that I am failing to be equally clear to him. I hope that I do not have to go to any further stage to make it clear to him that what he is endeavouring to say in relating his remarks to alternative sources from which the money could come, or might have come, is definitely out of order.

Mr. Doughty

Naturally, I accept your Ruling at once, Mr. Diamond.

Mr. Willis

The hon. and learned Member has had a good bash.

Mr. Doughty

I hope that my views are before the Committee. I do not wish to say that the doctors are not entitled to this sum. On the contrary, they are fully entitled to it. On a future occasion, however, perhaps I may deal more fully with the hospital costs, because they are a matter which I have very much in mind.

Mr. W. R. Rees-Davies (Isle of Thanet)

On a point of order. Surely, Mr. Diamond, if on this matter one seeks to argue, for example, as I would, that one could provide by way of maintenance charges on a hospital, by way of private patients, the sum of money which the House of Commons could allocate under the £16 million to the doctors, it must be in order to say, "I agree that £16 million should be paid to the doctors and I agree that in the knowledge that I can recover that figure for the Treasury, because I will make a maintenance charge, say, for the full provision in hospitals." My hon. and learned Friend is merely seeking to say, "I agree in principle with the payment of a sum of money to these doctors, but I believe that there are other ways in which adequate provision could be made for that sum."

Is it not right, when debating the adequate provision of a sum of money, to be able to say at one and the same time, "I believe that that sum of money should be paid. I want to vote in support of it, but I want to argue the contention that the Minister should look at the argument which I am addressing to the Committee that whilst we will vote for this, we invite him to look to see whether he cannot make adequate provision out of certain measures in the Health Service." Surely, in those circumstances, my hon. and learned Friend would be in order to seek to advise the Committee that the scope should be broadened and the Minister's view broadened to take account of these factors.

The Temporary Chairman

No. The hon. and learned Member would not be in order in praying appropriations in aid, which is exactly the argument that is being put forward. The hon. and learned Member will find it referred to on page 735 of Erskine May if he would like to withdraw from the Chamber and consider the matter a little further.

Mr. Doughty

I do not propose to withdraw from the Chamber until I have made quite clear that at some future stage I shall raise this point, when I shall, perhaps, be in order. Perhaps I could put it in another way. There are several ways in which I could put it, but I should only come back to the same point. The Minister knows very well what I have in mind. I shall raise this point again on every possible occasion, and I give him the sound advice that he had better have a look at it.

10.10 p.m.

The Minister of Health (Mr. Enoch Powell)

The whole Committee has welcomed the acceptance by the Government of the Pilkington recommendations, which, of course, is the fact which underlies the Supplementary Estimate which is before the Committee. I would associate myself wholeheartedly with that, for I believe that the acceptance of that Report cart, without exaggeration, be said to mark the opening of a new era in the relations between the medical profession, the National Health Service, the Health Ministries and, indeed, this House.

It is a little inconsistent, perhaps, in welcoming the acceptance of the Pilkington Report, as the Government accepted it as a whole as it stood, to complain that acceptance has involved the loss of a number of opportunities—a point which was made by my hon. Friend the Member for Carlisle (Dr. D. Johnson) and the hon. Member for Willesden, West (Mr. Pavitt)—because part of the effectiveness of the acceptance of the Pilkington Report is that it was accepted as a whole. There may have been imperfections in it, and there may have been respects in which many hon. Members would have felt that those recommendations should have gone further or even, perhaps, have been somewhat different; but the essence of the Government's act was the acceptance of that Report as it stood as a whole—those were the words—and I believe that one cannot welcome that and at the same time go too far in criticising the result for the lost opportunities which are involved.

The Committee has shown a very kind and flattering desire to hear my hon. Friend and myself on the subject of the National Health Service on several occasions and al greater length. Without wishing to trespass upon the domain of my right hon. Friend the Leader of the House, I am personally glad of that because, of course, as the Committee appreciates, in this debate we are very narrowly bound in by the rules of order, and, in particular, one cannot within the rules of order refer to savings. Perhaps, Mr. Diamond, I might in one sentence respond to what I think is in the mind of my hon. and learned Friend the Member for Surrey, East (Mr. Doughty) by mentioning to him that in the first public speech which I made in my present office I ventured to say that, in my opinion, the National Health Service was intended to be comprehensive, but that did not mean that it was intended to be exclusive. All the same, there are a large number of questions which have been asked and points which have been raised in the course of this debate which I can and will do my best to answer.

The right hon. Lady the Member for Warrington (Dr. Summerskill) asked about the arrears due to doctors in the hospital service. So far as those arrears relate to the period back to 1st January this year, I would expect them all to be paid before the end of this calendar year. I do not take so pessimistic a view as her informants as to the payment of the remainder, that is, the arrears back to 1st March, 1957, which, I hope, will also all have been paid out by the end of this financial year; in faith whereof the full amount of those arrears has been included in this Supplementary Estimate which, of course, refers only to this financial year.

But, I am sure it would also be accepted that fairness is of the essence of the distribution of those arrears. It is a very complicated calculation which the regional hospital boards have to make. I do not think any one of us would wish for the sake of a few weeks, however overdue these payments are, to lay ourselves open to the charge that the distribution was not as scrupulously right and fair as it could be made.

The right hon. Lady and her hon. Friend the Member for Willesden, West devoted a good deal of their remarks to the £1 million, if I may so call it. The right hon. Lady once said that the Ministry had decided to set aside this sum, and she even said I had decided to set aside the sum, and she therefore logically went on to ask what I intended to do with it. But that is not quite the situation. This sum arises out of a recommendation of the Pilkington Committee, that the remuneration of general practitioners which they recommended should be distributed in a manner to be agreed between the Health Departments and the profession, and in the course of the work of the Joint Working Party which was set up to implement that recommendation it was recommended that the sum of £1 million per annum should be reserved so that further consideration can be given to methods of making the best possible general medical service available to the public".

Mr. Willis

Is that £1 million taken simply in England and Wales or does part come from Scotland?

Mr. Powell

The Great Britain figure was used because it was a Great Britain Working Party.

It went on to recommend that a "further Working Party of representatives of the profession and the Health Departments should be appointed to consider this matter."

The rather complicated recommendation that this sum should be set apart for the general purpose of improving general medical services, and secondly, that the manner in which it should be applied should be subject to further study, was welcomed in a very emphatic way by the General Medical Services Committee, and that recommendation, as my hon. Friend said, was accepted by the profession at the end of September.

So it would be an impertinence or worse on my part to indicate in advance of the work of that second working party how I as Minister of Health believe that the £1 million should be applied. That does not mean that the views which have been expressed on both sides of the Committee tonight are not of importance, and I feel sure that they will be given due weight by the working party when it comes to consider this matter.

Mr. Ross

Am I to understand that there is in the Estimate the Committee is being asked to vote £1 million which should be spent or required before 31st March, 1961, and that we are now being told by the Minister that he does not know how this money is to be spent?

Mr. Powell

Perhaps I ought to come clean with the Committee on this point and with the right hon. Lady. The right hon. Lady was good enough earlier today to consult me on this matter, and I then, on the best advice which was available to me, informed her that the whole of the £1 million was included in the additional sums which I am asking in this Estimate. In fact I have later and, I believe, more accurate information, that little or none of that amount is included in this year's Supplementary Estimate.

Dr. Summerskill


Mr. Powell

Could I finish? I was further advised—and I gather, from the fact that we have all been allowed to proceed thus far, that I was advised correctly—that nevertheless, since this the sum here which is being asked for is in consideration of the general medical services, the right hon. Lady would not be out of order in developing her points. I therefore did not seek to avail myself of the narrow fact that little or none of the £1 million is included in this figure. And it has had the adventitious advantage that the Committee has been able to place on record, as I was just saying, its view, which I am sure will not be without effect on the way in which this sum can best be applied for the improvement of the general medical service.

Mr. Pavitt

I am still not quite clear about this. This sum of money for general practitioners includes back-pay to 1957 and is the overall sum due to the central pool. It is really the practioners' money and the Working Party has agreed that instead of distributing it to the general practitioners it is to be put aside. Does this mean that if this sum does not come into the Estimates this year the general practitioners are losing £1 million to which they are entitled this year, or does it mean that the Estimates are £1 million short because the sum has been carried over?

Mr. Powell

The position is exactly the same as with the £500,000 referred to earlier. The money is due. It belongs to the general practitioners, but as it will not, in all probability, be paid within the current financial year, as with the £½ million, it would not be appropriate to ask for it to be voted in the current financial year.

Dr. Summerskill

I cannot understand this. The right hon. Gentleman says that it is due. The Pilkington Committee recommended it, but the right hon. Gentleman says now it is not included in this financial year. Therefore, it means that the general practitioners must lose £1½ million.

Mr. Powell

It only means that the £1½ million due to them cannot be paid out to them in the course of the current financial year, because the manner in which it is paid out will not by thin have been decided in the manner recommended by the Joint Working Parties. But the profession is not losing anything of the £1 million which is part of the remuneration which the Pilkington Committee awarded to it.

Dr. Summerskill

Will the right hon. Gentleman break the sum down? I have never known a Minister to behave as the right hon. Gentleman has behaved tonight. When he discovered that he had misinformed me, he said to the Committee that he thought he had better come clean. I have never heard such an extraordinary statement. Having told me one thing, the right hon. Gentleman just sat there and allowed me to develop a long argument knowing that the £1 million was not in the Estimate. He is now talking about £1½ million. Has the right hon. Gentleman not realised that the £500,000 for merit award has to be paid every year, but the £1 million presumably is being paid to improve general practice? Or is £1 million going to be used every year?

Mr. Powell

Yes, it is £1 million per annum.

Mr. Ross

We are in a very strange position now. Up to now, all this has been in order, but now that the Minister is coming clean we are all out of order. He says that the £1 million we are talking about is not in the Estimates, so this can hardly be in order. There is £1 million to be spent per year, including this year, for improving general practice. It therefore means that next year the Committee will have the estimate not only for the £1 million but also for this past year. How one can improve future services by paying more for the past retrospectively is beyond me.

Mr. Powell

Only that the Working Party must, in accordance with the agreement with the profession, be allowed to recommend the manner in which the £1 million is to be applied.

A number of hon. Members made the point, of which I took special note, that the House of Commons should have detailed information as to the result of the considerations of the Working Parties. I certainly take that point and would like to consider how, in due course, the result which is arrived at can best be made available.

The right hon. Lady went on to draw an analogy between what is recommended here by the joint Working Party and the hospital service, because the Working Party's recommendation refers only to the general medical service. There I think that we are limited by the actual recommendations of the Pilkington Commission and that it would not have been practicable within the terms of accepting that Report as a whole, as the Government undertook, to make the alterations which the right hon. Lady had in mind in the payment of doctors in the hospital service. She asked whether there was any reference in this Estimate to the domiciliary visiting of consultants and to the loading of conditions in favour of the part-time consultant. There are no increases in this Estimate in regard to domiciliary visits, and since weighting for part-time consultants is reduced in accordance with the recommendations of the Pilkington Commission, a fortiori there is no provision in this Estimate.

As to the £500,000 to which the right hon. Lady referred, that is a quite different subject from the £1 million. She called to the attention of the Committee certain special factors, and read out four which the Pilkington Commission mentioned in paragraph 342. Those relate to the £1 million about which we have been talking. The provisions for the application of the £500,000—the distinguished general practitioner payments—will be found in paragraph 345 onwards of the Pilkington Commission Report. These are a quite separate matter and a quite separate issue.

Dr. Summerskill

When the right hon. Gentleman reads the OFFICIAL REPORT tomorrow he will see that I made all this quite separate. I cannot quite understand how he has become confused between the merit awards and the £1 million, an entirely different matter.

Mr. Powell

Yes, indeed. At any rate, I think that no harm has been done in emphasising that those are two separate considerations.

The right hon. Lady finally asked me whether I believed that the increases of which the reflection is found in the Supplementary Estimate will result in a sufficient increase in recruitment to the medical profession. I should not like to hazard a specific prediction, but I think there can be no doubt that the great improvement in conditions and prospects of the profession which will result from the implementation of the Report must have a beneficial effect upon both the quality and the numbers of the profession.

The hon. Member for Huddersfield, West (Mr. Wade) asked me about Subhead B.1. It covers the administrative increases as well as the increases in pay to doctors under the Pilkington award. Those increases, if I might just mention the subject-matter of them to the Committee, are increases for domestic and ancillary staff, for administrative and clerical staff, for part-time nursing and midwifery staff, for occupational therapists, orthoptists and physio-therapists and, finally, for building labourers and craftsmen and for the works organisation staff. Therefore, those increases in the advances to the regional hospital boards will cover both the professional increases arising out of the Pilkington Report and the awards for other staff which have been made at various times and which it has not been possible until now to put into estimates.

I noted the point made by the hon. Member for Willesden, West about the relative emphasis upon teaching hospitals and regional hospitals. He will appreciate that, in working out the impact in year one of the Pilkington award, one has to take the establishments and the merit awards, and so on, as they stand and gross them up. But that is without prejudice to any developments and changes of relative emphasis which may be foreseen within the Service as a whole.

Although in dealing with this Estimate we are able to look only to the specific increases which they have thrown up under various subheads, I believe I am right in saying that the Committee as a whole welcomes the Pilkington Commission's recommendations and the new opportunity, which I hope will be taken and not lost, which the acceptance of the award gives to all of us who are concerned with the National Health Service.

Question put and agreed to.

Resolved, That a Supplementary sum, not exceeding £37,665,600, be granted to Her Majesty to defray the charge which will come in course of payment during the year ending on the 31st day of Match, 1961, for the provision of national health services for England and Wales and other services connected therewith, including payments to Northern Ireland and the Isle of Man, medical services for pensioners, &c., disabled as a result of war, or of service in the Armed Forces after the 2nd day of September, 1939, certain training arrangements including certain grants in aid, the purchase of appliances, equipment, stores, &c., necessary for the services, and certain expenses in connection with civil defence.