§ Motion made, and Question proposed, That this House do now adjourn.—[Mr. I. Fraser.]
§ 11.17 p.m
§ Mr. Harold Davies (Leek)
I still think that the subject I wish to raise, namely, the field work of the family doctor, is worthy of the consideration of this House at this late hour, because the whole of the medical profession undoubtedly is deterred by the general upheaval which now seems to be taking place in general practice. During our debate, on 19th December, both the Parliamentary Secretary, to whom I am grateful for staying so long this evening to answer me, and his Minister made many constructive points on the Annis Gillie Report called "The Field Work of the Family Doctor". I hope this evening to give the Minister more time than I shall take in this half hour debate and that he will, therefore, tell us of the extra thinking and constructive points of view which he and his Minister may have now taken on this Report. The hon. Gentleman said on 19th December:It is not surprising that Professor Almont Lindsay, an American social historian who made an eight-year study of the Service, has described it as one of the notable achievements of the twentieth century, 'magnificent in scope and almost breathtaking in its implications'."—[OFFICIAL REPORT, 19th December, 1963; Vol. 686, c. 1482.]That is quite true, and I think that both sides of the House, despite some of the 1231 bitter debates of the past, now agree that the National Health Service has come to stay, and that it is the duty of whichever party is in power, in Government, to make a success of this. We must ask, however, what is the basis of the service pyramid? The basis of the pyramid is the family doctor, or general practitioner.
I must also point out, as was pointed out by my hon. Friend the Member for St. Pancras, North (Mr. K. Robinson), that while in the Health Service the capital expenditure is up four and a half times on that in 1955, capital expenditure on roads is up nine times, capital expenditure on the Post Office is up two and a half times, capital expenditure on the electricity boards is up seven times. Consequently, I think we are justified on this side of the House in saying that we believe that there is a health investment lag.
Recently Reports have been made that are relevant to the National Health Service. Over the years since the Service was introduced we have called upon experts in all fields of medicine to make reports to the House of Commons. There have been the Annis Gillie Report, the Report on perinatal mortality and the Nuffield Provincial Hospital Trust Report on food in hospitals. On both sides of the House we say that it is good and that these and many other reports show the Parliamentary awareness of the need for vigilance in matters affecting the health of the nation.
Each report deals with service to the patient. But the Annis Gillie Report, the most recent report, deals especially with the work of the family doctor or the general practitioner. Dr. Annis Gillie, the chairman, the five members of the Standing Medical Advisory Committee and the additional co-opted members deserve Parliament's thanks and appreciation, and I hope it will be recorded that the House appreciates the magnificent work done in the report.
That is particularly so for me because I represent a rural constituency in North Staffordshire, and a consultant at quite famous hospitals there—the North Staffordshire Royal Infirmary and the City General Hospital; I will not name 1232 him because that would be invidious—was on the Committee and gave it the benefit of his experience and knowledge.
The terms of reference of the Committee were:To advise on the field of work which it would be reasonable to expect the family doctor to undertake in the foreseeable future, having regard to the probable developments during the next 10 to 15 years both in general practice itself, including its organisation, and in the supporting facilities provided by the hospital and specialist and the local authority services.The Committee met 21 times since November, 1961, and produced its report.
We might logically begin, with the Report, with the definition of a general practitioner given in it in paragraph 6:General practice is the application of the science of medicine to the art of healing in all its aspects, and its involves the whole range of illness in mankind.So our general practitioner is expected to be an expert in the application of the science of medicine to the art of healing in all its aspects, and it involves the whole range of illness in mankind. Thus, it stands out clearly that in his years of training, despite the fact that he may have taken up general practice, the general practitioner is no less important to the pyramid of the Health Service than the cleverest and most expert consultant in any hospital in the land. I think that at the beginning we should make that clear as it is made clear in the report.
In the second chapter of the report, on page 8, we are told of the present situation. What is it? The report says:Whatever the developments in the scientific and clinical aspects of medicine in the world during the next 10 to 15 years, however great the social and environmental changes in this country, human reactions to birth and death, sickness, disability and ageing change very slowly.There has been an explosive advance in medicine and scientific knowledge during the last 20 years, and the survival of the less fit and the aged has added burdens to the general practitioner. The general practitioner is overworked, his lists are too large, and the number of general practitioners is too few.
On page 33 of the Annis Gillie Report we find that the distribution, recruitment and prospects of the family doctor 1233 are indeed not bright. In paragraph 120 the Report says:The average number of applications for each advertised practice vacancy has decreased from 43 in 1956 to 17 in 1962. In the last three years particularly the number of applicants for vacancies north of the River Trent and west of the Severn has diminished markedly. In 1962 the average number was 11in the North of England and 5½ in Wales compared with 24 in the South of England. It is now difficult in many districts to fill a vacancy by the appointment of a doctor with the desirable experience, and it is unfortunate that these are the very areas where social and housing conditions demand the highest standard.So the front line warrior in the battle against illness and disease, the general practitioner, is not getting from society the recognition he deserves. The Minister, in other words, said this in the debate on 19th December. He agrees that the general practitioner should be free from financial worry. He agrees that facilities should be available to him in order that he should practise medicine.
We do not want the general practitioner to be an office boy or a filler up of forms. The Minister said:I want to say that it is of the utmost importance that hospitals should provide the family doctor with access for his patients to diagnostic facilities, especially in pathology and radiology.He then added:Our aim must be to ensure that, as need dictates, the doctor can call to his aid the supporting services—the home nurses, home helps, meals-on-wheels, health visitors…"—[OFFICIAL REPORT. 19th December, 1963; Vol. 686. c. 1492.]Doctors want to practise good medicine and the Minister said that his task was to help them to do just that. Some of us in rural areas believe that the doctor is limited today because of the fact that he has not the facilities and is being neglected.
During the health debate hon. Members on both sides of the House hinted at the family doctor's difficulties in rural areas. In North Staffordshire we have magnificent hospitals. In Stoke-on-Trent we have the North Staffordshire Royal Infirmary and the City General Hospital, but they are some 30 or 40 miles from the rural areas. With the mechanisation of farming the country doctor must be prepared for emergencies. We had an example the other day, given by the hon. Member for 1234 Chippenham (Mr. Awdry), where a horse bit off the ear of a man working on a farm. I hope that the horses in the Leek division are more polite.
The doctor who attended that man had to do the job at half-past one in the morning, and he estimated that taking into consideration the time and the trouble incurred in getting to the area his financial reward was about 2s. 9d. In order that something may be done, I hope that the Minister will study the medical practitioners' pamphlet entitled Our Blueprint for the Future, because on page 3 of that pamphlet they say:The new system of rural practices payments has resulted in widespread reductions in income among rural practitioners. There should be a national reassessment of the Scheme, with a view to a fairer and more realistic evaluation of the difficulties faced by the G.Ps. in rural areas.On page 4, the M.P.U. repeatedly criticised the present method of repayment of practice expenses. In my opinion, particularly in the rural areas and villages, where health centres and group practices are out, provision for premises should be considered as a right. I have discussed this with some rural doctors in my constituency. I do not want to reveal his name, but one told me that as a result of the new system of rural practice payments he is £300 a year worse off.
I wonder whether the Minister realises that some of us are worried about the huge regions. The West Midlands region servos about 4,845,000 people. Leek, Biddulph and other places, with their small hospitals, seem to be the frozen north. I was glad to hear the Minister say that he might reconsider the hospital plan. I hope some of these small hospitals will be available to general practitioners, in towns and villages for maternity beds.
The Minister said that he had no power and did not want to compel doctors to accept an appointments system but that he would try to do some of the things recommended in the Annis Gillie Report. Other things the doctors must do themselves. I believe that consultants and specialists must yield to the family doctor and acknowledge that he is a trained specialist. I cannot do better than quote Professor Brotherston:Far from general practice being out of date I see it more important than ever in the 1235 Health Service. Because of the complexity of modern medicine, the personal doctor is even more important.He added something which I hope the public will bear in mind, because the G.P. is a specialist:General practice is not a repository for doctors who have not got ability to become specialists. It is a different way of practising medicine.I hope that the G.P. will be regarded as a specialist, because the psychosomatic effect of the good bedside manner of the old family doctor is often better than all the drugs many a specialist gives the patient.
§ 11.33 p.m.
§ The Joint Parliamentary Secretary to the Ministry of Health (Mr. Bernard Braine)
I am grateful for this opportunity to discuss the work of the family doctor. The subject is of great importance, and I am only sorry that I have not more time to talk about the many things we are doing in the Health Service, in general, and for the family doctor, in particular.
The hon. Member for Leek (Mr. Harold Davies) ranged rather widely, and much as I would like to I cannot follow him, in the few minutes I have, over allthe ground he covered. He began by quoting a number of percentages, designed, I suppose, to show that we are not investing as much as we should in health. Although I do not accept that, I do not see how the Health Service is to be judged in terms of comparative arithmetic.
The Health Service is good—second to none—and it is a pity that the hon. Member was not here last night for a debate on the desirability of negotiating reciprocal social service agreements with other countries. His hon. Friend the Member for St. Pancras, North (Mr. K. Robinson) said:The difficulty is that almost no country offers its own citizens anything like the benefits we offer our citizens under the National Health Service."—[OFFICIAL REPORT, 21st January, 1964; Vol. 687, c. 1045.]I consider that we should be judged on how we have tackled the problems of providing a modern and comprehensive service freely available to all, not on the record of other countries and other services. My right hon. Friend and I 1236 dealt with that aspect of the matter in the debate on 19th December, and all I will say now is that in terms of real achievement, that is, in terms of the health of the nation, the record is good. Of course, there is always room for improvement. As I said in that debate, there is no finality in the war against ill health. As tonight we are discussing the family doctor, I will try to show in what ways we have given help and secured improvement in that respect.
There is one point on which I am in full agreement with the hon. Member. The key figure in the provision of medical care is and will remain the family doctor. He is the individual's first line of defence against ill health. In fact, more than 90 per cent. of all illness is treated under his direction. The hon. Member has rightly quoted my right hon. Friend saying that the family doctor who plays this key rôlewants to practise good medicine, and it is our task to help him to do so. I think that it can be fairly claimed that this is what we have been doing. Certainly we are anxious to improve general practice for the benefit of the patient and doctor alike, and I will endeavour to show what is being done.
The hon. Member mentioned doctors' remuneration. I shall not follow him in this, because this is a matter in the first instance for the independent review body set up on the recommendation of the Royal Commission. But there is one aspect of the way in which the doctor is paid to which I should like to refer. It is the very important question of there imbursement of practice expenses. Briefly, the whole of the expenses now incurred by family doctors is reimbursed to them through the National Health Service, but the method of doing so recently came under review. I can best explain by giving an example.
It has become apparent that with his own staff, such as his receptionist or secretary—the family doctor may be discouraged by the present system from making those improvements he would like to make. This may seem obvious now, but it has certainly not been so before. As recently as 1960, the Royal Commission reported that it was common ground that reimbursement of practice expenses through a flat rate capitation fee was the most acceptable 1237 method of payment. The Royal Commission recommended to that effect, and I am not aware that either the profession or hon. Members opposite had any reason to disagree at the time.
We learn from experience, however, and a new view has recently developed. It was in his context that my right hon. Friend referred to the oddities of the present system. I can assure the hon. Member that having expressed this view we lost no time in taking the initiative in approaching the profession, and we hope to agree with it a system under which at any rate some practice expenses can be reimbursed directly to individual doctors in order to encourage higher standards of family doctoring.
The hon. Member said something about rural areas. He represents a rural area, and I can understand his feeling, but I fear that he is not informed about the latest developments. In any case, I do not accept that special incentives to recruitment are especially needed in the rural areas. On the contrary, problems of this kind arise mainly in certain industrial areas, but I am, of course, well aware that over the current system of rural practice payments there have been difficulties. As soon as these difficulties became apparent, we lost no time in getting together with the profession's representatives in order to review the working of the system.
Meanwhile, the hon. Member will be interested to know, arrangements for compensation for those doctors who may have lost by the new scheme have been changed so that there is now compensation for any loss of more than 2 per cent. of gross income as opposed to the previous 5 per cent. I think that this is what the hon. Member was worried about and I will say no more about it for the present. If he has any particular case in mind, I shall be very glad to look into it.
§ Mr. Braine
Of course, but he will see that action in this regard has already been taken.
I now turn to the relationship between the family doctor and the hospital and the community care services, a relationship of the greatest importance. I agree that recent years have seen astonishing 1238 advances in medical science and techniques. There are now many more aids that the family doctor can bring to the service of his patient. He should have access to the diagnostic facilities in the hospitals and be able to call upon the help of the local authority health and welfare services. In fact, family doctors now have direct access to hospital X-ray and pathological departments in most of the major general hospitals. This means that they can use the diagnostic facilities of these departments without themselves having to refer their patients to a consultant. We are making steady progress in this respect.
A recent development in which the hon. Member may be interested is the making of arrangements for a free service of syringes to be available to family doctors for use in taking blood specimens for examination in pathological laboratories. Then there is electrocardiography, which is becoming available to doctors with the agreement of the individual consultant. This again is proving a most useful development. As to the direct help which local health authorities can give to the family doctor, a great deal of progress is now being made and we are encouraging it as much as we can. A good example is the attachment of health visitors, either part-time or full time, to individual practices. A great deal depends, of course, on the initiative of the family doctor himself, but if there is anyway in which my Department can help in identifying the points at which he needs the support of these services and in facilitating provision of that support we shall do all we can.
Then there is the doctor's relationship with and the part he could and should play in the hospital service itself. I do not want to repeat what my right hon. Friend said in the debate when he referred to cottage hospitals. That is on the record. We do not want to go back to the days when the small, not very well-equipped cottage hospital, was the centre for treating even major illness. We have gone far beyond that and our aim now is to ensure that the family doctor plays a part in the new general hospitals equipped with the full range of modern diagnostic and treatment, facilities. The number of part-time appointments of family doctors has been 1239 increasing steadily and in the last year for which we have figures it went up by nearly 7 per cent.
In the Birmingham region, which includes the hon. Member's constituency, one family doctor in four does work of this kind. I think we may expect a further increase when hospital staffing has been reorganised as a result of the findings of Sir Robert Platt's working party, which strongly favoured work by family doctors in hospitals. Discussions are now in progress in the profession on the new "medical assistant" grade proposed by the working party which should provide further opportunity for family doctors to take part in hospital work. We find it very encouraging to note that the new generation of doctors entering general practice are particularly keen to maintain their links with hospitals.
The hon. Member touched on the question of recruitment. I do not think I need do more than remind him of what I said to the House on 19th December, namely, that there will be at least one new medical school and that in the meantime the possibilities of further expansion of existing schools will be seriously examined. Of course, there is the difficulty about locums but the increase in the total number of doctors is the most important contribution we can make to the easing of the problem.
We are encouraging the further education of doctors. I can assure the hon. Member that the universities are fully alive to the needs of general practice. A great deal is going on to attract young doctors specifically to general practice and to help those in general practice to receive post-graduate training. We have played our part in this including the provision of financial incentives for trainees. With the agreement of the doctors, £60 is paid from the central pool of remuneration to any family doctor who attends a certain number of refresher courses and this has had the effect of raising the demand for courses of this kind.
I think the hon. Member will agree that the independence of the medical profession is an important thing to preserve and cherish. The doctor works in his 1240 own way with help of his own choosing and makes his own decisions and, I have little doubt, wishes to remain an independent professional man. Of course, in this there is much we can do and are doing to help him. If we are able to reimburse him more directly for the expenditure he incurs we shall have made things easier for him, but let us not go to the length of taking initiative and independence out of his hands altogether. I am glad that this view of the situation is shared by the expert committee on "The Field of Work of the Family Doctor", popularly known as the Gillie Report. My right hon. Friend warmly welcomes that report. It gives a valuaable review of general practice and a great many new ideas and useful pointers to the future. The Gillie Committee throughout had in mind the need for maintaining the independence of the family doctor, and within that framework they have shown us how we can help him to keep in step with the development of modern medicine.
It is true that many of the Gillie Committee's proposals are not directed particularly at the Government but at the medical profession itself and at outside bodies such as the universities. This does not mean that we shall sit back and do nothing. That is why I am particularly glad that the hon. Member raised the question tonight. It would be wrong for any of us to take the family doctor for granted. He needs and deserves encouragement to widen his scope and to enlarge his skills. Medicine is a science, as we all know, but its practice calls for the possession of qualities which no scientific process can provide. I am talking, of course, about human understanding and compassion.
We all respect the family doctor we know in our constituencies for the skill and humanity with which he carries out his tremendous task. Let us be sure that our tributes are not just empty phrases. Government, both central and local, must ensure that the family doctor is not frustrated in playing his proper rôle in the exciting developments now under way in the health service. I suggest that here is an opportunity for all of us as individuals to recognise that the family doctor is a human being, too, that he differs from the rest of us only in that the 1241 burden of troubles and difficulties which he has to bear continuously is almost always greater than our own. For the Government I can say that we are doing and will continue to do all we can by direct action—and the Gillie Report will be our text-book for a long time to come.
§ The Question having been proposed after Ten o'clock and the debate having continued for half-an-hour, Mr. Speaker adjourned the House without Question put, pursuant to the Standing Order.
§ Adjourned at thirteen minutes to Twelve o'clock.