HC Deb 27 June 1961 vol 643 cc407-16

Motion made, and Question proposed, That this House do now adjourn.—[Mr. Peel.]

2.12 a.m.

Mr. William Ainsley (Durham, North-West)

I apologise for seeking to detain the House for a little longer at this late hour—or perhaps I should say at this early hour of the next day—but I feel it a privilege to refer to a complaint of my constituents, the Weardale Rural District Council, the Rev. Charles Smith, vicar of the parish in Upper Wear-dale, on behalf of his parishioners and now, as the change comes home to so many of my constituents, the many letters of protest that I am receiving.

It will be recalled that on 12th June I asked the Minister if he is aware of the proposal of the local executive council for a change in Upper Wear-dale, County Durham, from doctors' practice to group practice, the additional mileage in travel involved by this proposal ֵ and so on, and the Parliamentary Secretary to the Ministry replied: The executive council has not reached a decision on the doctors' proposals to alter their places and times of attendance."—[OFFICIAL REPORT, 12th June, 1961; Vol. 642, c. 2.] That was not a proper Answer to my Question, for it was already a fait accompli;the doctors' practice had been made into an enlarged joint practice.

I have served as a member of the executive council in Durham for a number of years and am familiar with the administrative council and its committee work. I have with me the full file of correspondence from the clerk to the local authority, which goes back to 3rd March of this year. Weardale is a large rural area, stretching from the lower reaches of the villages through the hamlets consisting of isolated private residences of retired people to those of people with small fixed incomes, and farms on the hillsides, to the open moorland.

Contrary to expectations, the recent census showed an increase of 7.6 per cent. in the population of this rural district. I have taken part in negotiations with the local authority and the North East Industrial Development Association on the production of a brochure to popularise Weardale as a tourist area. It already attracts a large number of visitors, pony trekking and hiking over the moors. The narrow country road winds its way alongside the lovely, peaceful river to its beginnings, and along to the upper heights and reaches of the Pennine Range. A caravan site in Upper Weardale, already approved by the county planning authority and the local authority has, at times, a population of about 300. The county education committee has recently opened a large house as a youth hostel, housing lively and adventurous young people. There are guest houses and the old-type inns which give accommodation.

Thus, the local pattern is continually changing. The railway passenger service has closed and the bus operators are experiencing greater difficulty in maintaining a reasonable service owing to the high cost. The needs of the area for medical services are as great as ever. My home is 1,000 feet above sea level, and when the roads have been blocked with snow I have often put on Wellington boots and walked to the railway station and there changed to shoes in order to travel to the House of Commons. It is nothing uncommon to find roads blocked in winter, and it is a nightmare to the county roadmen to keep the highway clear in the upper reaches towards the Pennines.

I have received a letter from Dr. Robert Fletcher, now in retirement, who practised in Upper Weardale from 1923 to 1960. He describes the hazards he endured to reach his patients, sometimes on pony and later on skis. In Upper Weardale there have always been two and sometimes three doctors, and he tells me that this goes back to the Crimean War.

I have also passed on to the Parliamentary Secretary photographs which I have received from people in Upper Wear- dale. She will see from these that last winter—one of the mildest in living memory—there was still snow in Upper Weardale. I ask my friends on the executive council in Durham to think again about a decision taken in Durham City with little or no knowledge of the conditions in Upper Weardale. Hence my appeal to the Minister. It is laid down in the National Health Service terms of service for doctors: … except upon conditions which appear to the Council, or on appeal to the Minister, to be such as to enable his obligations under these terms of service and in particular his obligation to visit his patients, to be adequately carried out. I cannot recall meeting one of the doctors personally, and what I say is on principle and on the evidence I have rather than against a person. I can only theorise as a result of the correspondence that I have received. Doctors D. and E. Thompson, husband and wife, with Dr. Liddell held a joint practice at Stanhope. Unfortunately the husband, Dr. D. Thompson, was ill and in hospital for several weeks. Dr. A. H. Smith is in practice in Upper Weardale and at one time he thought of approaching the executive council to ask that his wife should come into partnership with him. That was last September. But circumstances brought these doctors together and they agreed among themselves to an extended joint practice all to operate from Stanhope. That led to my Question regarding the additional mileage and travel involved and the cost to the rural area.

We are not against joint practice where conditions are suitable, but circumstances vary between town and country and no set formula can be applied. If Dr. Smith wishes to move to the joint practice in Stanhope, I have no objection. But why should he take all his patients with him? If a vicar moves to an adjoining parish he does not take all his parishioners with him. The present joint practice has been enlarged without the consent of the patients and against their wishes. I ask the Minister or the executive council to say that there should be a practice in Upper Weardale and to advertise it as vacant and to stop the "poaching" from the new and enlarged joint practice.

This new partnership became effective as from 1st April, and this is confirmed in a letter which I received on 5th May. It was written by the executive council to the Rev. Charles Smith. On 23rd March the dispensing committee saw Doctors Thompson and Smith, but there also was present Mr. W. S. Smith, a chemist and optician, from St. John's Chapel. The committee was surprised to learn that some changes in the pharmaceutical services in the area were also contemplated and likely to take effect in the near future.

One can only come to the conclusion that these professional people have had private consultations and prepared their plans which are now being put into effect, and that at every step they have ignored the wishes of their patients and the public representatives of the people in Upper Weardale. With the practice in Upper Weardale there were three surgeries—at Westgate, St. John's Chapel and Wearhead. The doctors have been uncompromising all along in their negotiations with the council. They have insisted on one surgery and their arguments are based on economy. The executive council has agreed to two surgeries at St. John's Chapel and Wear-head, the position is to be reviewed at the end of six months. For the six summer months the doctors are to keep records of attendances. The doctors are almost to become the judges and jury in their own cause. Even now I have evidence of patients being told that instead of going to Wearhead they are to go to St. John's and that will be the way that the doctors will count patients attending their surgeries. That is the trend of events. I put it to the Minister that this is far from satisfactory, and I think the executive council will find it so later.

This leads to the third problem. Mr. W. S. Smith, chemist and optician, referring to the recent amalgamation resultting in the loss of service, has from 1st June moved into a similar business in Stanhope where the enlarged joint practice is. That leaves the pharmaceutical service arrangements for Upper Wear-dale entirely in the hands of the doctors. Everything appears to me to be cut and dried. Dr. Mrs. E. Thompson wrote to the clerk of the local authority, when asked for a meeting on 3rd March: At the moment there are many domestic issues and points to be discussed, particularly with regard to the pharmaceutical service … No useful purpose would be served at this juncture. This enlarged general practice, now takes in the whole of Weardale rural district and operates from Stanhope over 16 miles of winding narrow country roads at very high altitudes. The parish of St. John's has a population of 850 under these windswept moors facing all the rigours of the North-East. There is lovely peaceful sunshine in summer, but the conditions can be death dealing in the depth of winter. Many of these people are living in retirement on small fixed incomes. They are quiet and reticent, but they are now burning with indignation. I ask that justice should be done for these people in Upper Weardale. The people are entitled to know what the extra remuneration of these doctors is to be for rural mileage and the dispensing of their own prescriptions. On financial grounds and because this is a medical service, I ask the Minister even at this late stage to intervene on the lines I have indicated.

2.28 a.m.

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

It is the responsibility of the executive council to settle arrangements for general medical services locally in accordance with the provisions of the National Health Act and Regulations and in the light of local conditions with which they are familiar. The hon. Member for Durham, North-West (Mr. Ainsley) has said that he was at one time a member of Durham Executive Council which is the executive council responsible for the services in Weardale. He will not need me to remind him of the advantages of leaving the detailed provision of these services to those who are in a position to know the needs and circumstances of the local population. He will know that the executive council comprises not only members of the professions, including the rural members, but also lay members nominated by the local health authority and by the Minister. It is the duty of the executive council to look at the services from the patients' point of view and to keep in touch with local opinion on matters affecting the medical services.

In the present circumstances, the Durham Executive Council agreed to receive a deputation from Weardale Rural District Council and there was a meeting on 20th April at which the concern of the rural district council about the proposed changes and arrangements for medical services in Weardale were fully discussed. Subsequently, there was a meeting between the rural district council and the members concerned although no mutually satisfactory solution emerged However, I think that it is clear that the executive council has been taking pains to go thoroughly into the matter and will continue to do so.

The proposals as they came before the executive council in February fell into three parts; first, a proposed partnership agreement between Dr. Smith who had been practising single-handed in Upper Weardale since April, 1960. and three doctors whose centre of practice is Stanhope, but who also have several hundreds of patients in Upper Weardale; secondly, a proposal of the doctors, as a partnership, to alter their surgery arrangements and, in particular, to close the small surgery at Dr. Smith's residence in Westgate and to discontinue the surgery held by Dr. Smith, on four afternoons and one morning a week, at Wearhead, a total of three hours. This would have left the surgery at St. John's Chapel at which it was proposed to hold a surgery on six mornings and four afternoons each week, as Dr. Smith had formerly done, but to increase the hours from six to ten. In addition, it was proposed to hold there two ante-natal sessions a month. Thirdly, there was a proposal that all the partners should ultimately live at Stanhope.

On the first point—and this is the main point that the hon. Gentleman raised, the one that he feels was unanswered in his earlier Parliamentary Question—doctors may enter into partnership agreements without the consent of the Executive Council. For the purpose of general medical services provided under the National Health Service, doctors in partnership are treated differently from single-handed doctors in several respects. They may have a larger number of patients on any one individual list, though not more on the average than a single-handed doctor, and the payment arrangements are somewhat different. But provided that the partnership satisfies the definition in the Regulations, it has to be recognised as such by the executive council.

The doctors in this case agreed that their new partnership should begin on 1st April, 1961. The partnership was one within the definition and there was no action for the executive council to take on this agreement, and it is, of course, not a matter on which the Minister could intervene in any way. Unlike the partnership agreement, however, changes in places and times of attendance do require the consent of the executive council, and the executive council has not yet taken a decision on the doctors' proposals to close the Wearhead surgery. As the hon. Gentleman has already said, the executive council has required the doctors to maintain surgeries at both Wearhead and St. John's Chapel as at present with the same hours of attendance. It has requested the doctors to keep a note of the daily attendances at both these surgeries, and we understand that this is being done. The executive council will review the position at the end of six months—that is, in December.

This is the situation which I advised the hon. Gentleman was the position when I replied to his Parliamentary Question, but I will undertake to convey to the Executive Council the points mentioned by the hon. Member relating to the question of keeping both these surgeries open. As there is a right of appeal by the doctor to the Minister if the executive council refuses consent to a doctor's request to change the places, days or hours of his attendance, it would not be proper to discuss in the House the merits of the case which might in due course, following a decision of the executive council, come before the Minister on appeal.

The question of where the doctor chooses to live is bound up with his obligation's to his patients, in particular the obligation to visit them in their homes when necessary. When a doctor is admitted to the medical list of an executive council to provide general medical services he has to undertake to visit patients within a stated district or dis- tricts. It is primarily the doctor's responsibility to ensure that he is in a position to carry out this obligation—the obligation to which the hon. Gentleman referred. It is an obligation which must be viewed reasonably. Clearly, a doctor cannot attend to two emergencies at once. The same degree of cover cannot be provided in a rural area of scattered population as can be provided in a large town. In particular, it rests primarily with the doctor to choose to live at a place from which he can reasonably expect to carry out his obligations.

A doctor may not carry on practice elsewhere than at his place of residence except upon conditions which appear to the council, or, on appeal, to the Minister, to be such as to enable his obligations under these terms of service, and, in particular, his obligation to visit his patients, to be adequately carried out.

In the present case, Dr. Smith wishes to live in Stanhope because, so I understand, his present property has to be sold. Incidentally, he is a tenant there. The executive council was correctly advised that there is no power under the regulations by which it could name the doctors' place of residence. At that time, although the executive council had no power to ban the move, it did not conclude that it would raise no objection to the proposal until after it had considered all that had been said by the representatives of the rural district council and others about the possible disadvantages.

Dr. Smith was present at the meetings at which the difficulties of transport and bad weather were discussed. He was, apparently, satisfied that he could overcome those difficulties and carry out his obligations. It would be open to the executive council to consider, when the move takes place and arrangements are tested in practice, whether to impose conditions under the provisions of the terms of service I have already mentioned. These conditions could cover not only telephone communications but also such matters as having adequate transport available or making special arrangements in severe weather. It would not be proper to suggest that such conditions would in fact be required or what they might be. This is a matter for the executive council to consider, if necessary, in due course, and, as there is a right of appeal, it would be wrong for me to go into the details.

The hon. Gentleman referred to the extra mileage which would be involved. Rural doctors have special payments from a fixed mileage fund to cover their journeys. If a doctor or a partnership qualifies for more payment from this mileage fund, under the special arrangements made, there is no extra burden on the Exchequer because the fund is of a fixed size and the only effect is that the amount available to other doctors in rural areas will be that much less. I appreciate that the hon. Gentleman's point really relates to how much more goes into the pocket of the doctor.

The hon. Gentleman asked me about the possibility of declaring another practice and getting an additional doctor in Upper Weardale. The position is that an executive council cannot declare an existing practice vacant except where it is rendered vacant by the death of a practitioner or by his ceasing to be on the medical lists of the executive council; nor can a council make a block transfer of patients from an existing doctor to a new practice.

A doctor may be admitted to the medical list to "put up his plate", that is, to commence a new practice and to try to attract patients of doctors already in the area. Any such application must be considered by the Medical Practices Committee, which has power to refuse an application on the ground that the number of medical practitioners undertaking to provide general medical services in the area is already adequate. To assist in obtaining a better distribution of doctors throughout the country, the Medical Practices Committee classifies as "restricted" those areas in which, in its opinion, an application to go on the medical list should be refused.

These classifications are based on information obtained from executive councils.

The area of Weardale Rural District Council is classified as restricted. The average number of patients on the doctors' list there is 1,511, and that is lower than average for rural areas and lower than the average in rural areas classified as restricted. It is, therefore, unlikely that at the present time any doctor would seek to put up his plate in this area or if he did apply that his application would be allowed by the Medical Practices Committee. As, again, there is a right of appeal to the Minister by a doctor whose application is refused, I am afraid that I would not want to express views on the merits of an application in this instance.

Finally, the hon. Gentleman referred to a point which is really separate though related, and that is the pharmaceutical service. On 31st May the pharmacy at St. John's Chapel, one of the two serving Upper Weardale, was closed through lack of business. The executive council arranged for any patients who had difficulty in obtaining medicines or who lived at least a mile from the nearest chemist to obtain medicines from his doctor and 800 in all obtain medicines from one or another of the surgeries in Weardale or St. John's Chapel. About forty chose to remain as at present and to acquire medicines from the chemist in Stanhope. The executive council is satisfied that these dispensing arrangements in the existing pharmacy at Stanhope will provide reasonable service for the area but the dispensing arrangements will be one of the factors taken into account when the executive council reconsiders the matter in six months' time.

Question put and agreed to.

Adjourned accordingly at nineteen minutes to Three o'clock a.m.