FAMILY DOCTOR SERVICE

HC Deb 27 July 1964 vol 699 cc1009-95

3.33 p.m.

Mr. Kenneth Robinson (St. Pancras, North)

I beg to move to leave out "£219,615,000" and to insert "£219,614,000" instead thereof.

Though, inevitably, reference has been made in a number of health debates to the family doctor service, this is the first time for very many years that we have concentrated a health debate on general practice. I think that the House would agree that at least the debate is timely, for general practice is facing a critical situation in the National Health Service.

Relations between general practitioners and the Government have never been particularly good from the start of the Health Service, a situation for which the present Chairman of the Indepen- dent Television Authority, Lord Hill, bears at least some responsibility. At the outset of the Service, it was expected that before long general practice would be conducted, in the main, through the medium of health centres. In a sense, the arrangements in the National Health Service Act for the organisation of the structure of the traditional form of general practice, that is, the single family doctor or partnership of two or three doctors, were of an interim nature. As the House knows, the expectation that health centres would develop was not realised, apart from a few areas where special considerations applied, such as new towns.

There were two main reasons why health centres never got off the ground. The first was a marked lack of enthusiasm by the medical profession, which, somehow, did not seem to want to function from local authority premises, and the second was the lack of capital provided by central and local government for the building of health centres. Whatever the reasons, there were very few centres.

This presented a new situation, a situation which should have been obvious to the Government many years ago and which demanded action. No action was taken in any way to modify the arrangements for general practice, either then or since. That was the first big mistake. General practitioners, most of whom never felt altogether happy in the National Health Service, began to get disgruntled and to feel neglected and forgotten by the Government, and their morale began to fall noticeably.

There were plenty of warning signs which were ignored by a whole succession of Conservative Ministers of Health. The position was allowed to drift and to go on drifting until about a year ago, when the general practitioners erupted. That is not too strong a word to describe what then happened. I want to make it clear that in my view the troubles of the family doctor are by no means entirely concentrated around the subject of pay. I think that for many of them pay is very much a secondary issue. Nevertheless, the explosion was sparked off by the question of pay. Perhaps I can recall to the House the circumstances which gave rise to this.

It was in March, last year, that all doctors were recommended by the independent Review Body an increase of 14 per cent. It was intended to last for three years and it was accepted by the Government and by the profession. When it came to the point, the general practitioners found that they received not the 14 per cent. which they had, perhaps mistakenly, expected to receive, but only about 6 per cent. The reasons for this are very complicated and are connected with the central pool arrangements, with confusions between net and gross income and with the fact that, in effect, they had already received part of the increase which they had been awarded by the review body. Whatever the explanation, this situation seemed to the general practitioners to be just about the last straw, and a number of things began to happen in quick succession.

First, some G.P.s decided to form their own breakaway association, clearly on the basis that they were not adequately represented by the existing organisation, which they felt, rightly or wrongly, to be dominated by the hospital consultants. Through the medium of my hon. Friend the Member for Stoke-on-Trent, Central (Sir B. Stross), that association presented to the House a petition bearing the signatures of 6,000 family doctors.

Secondly, the general practitioners forced the British Medical Association to go back to the review body and to put forward another pay claim only one year after the previous one, which had been supposed to last for three years. It is interesting that this is the first time—I believe—that a pay claim has been put forward for only one section of the medical profession. Hitherto, the doctors have gone forward as a united profession.

Thirdly, I think that hon. Members who read the medical journals will have noticed that from time to time the correspondence columns became swamped with letters and protests from family doctors, couched often in extremely bitter terms. Lastly, we noticed that whenever doctors seemed to be gathered together in conference they displayed a tendency to pass rather wild resolutions and to close their ears to more responsible counsels, a situation which culmi- nated in the extraordinary performance at Manchester a week ago, and about which I shall say a little more later in my remarks.

If remuneration is not all the trouble, or perhaps even the main trouble, what is it that has brought about this situation of acute malaise in the profession today? In short, it is that the family doctor feels frustrated in his wish to do a better and more significant job, to give a better service to his patients, than present arrangements allow him to do, or the present system makes possible. Certainly, that is the case amongst the younger and more progressive general practitioners, and I believe that it is true of the great majority of them.

What are the family doctors' actual grievances today? I will try to summarise them under four headings which I set out now, not in any particular order of importance. First, the question of remuneration, and particularly the method of payment. Secondly, conditions of work and terms of service. Thirdly, anxiety about their rôle in a comprehensive health service, and, in particular, their relationship with the hospitals. Lastly, their status within the profession and within society, and especially in relation to the hospital consultant. I want to amplify each of those points in turn, and during the course of my remarks I shall say what a Labour Government would do about these things.

The general practitioners' remuneration claim is now being considered by the Review Body, and it would be improper for me to make any comment on that. We shall await with interest its findings. But I believe that the anxieties of the profession are much more concerned with the method, than with the current level of pay, and especially with the very much criticised arrangements for the central pool, which is so complicated that few doctors fully understand its workings, and many have hardly even an inkling of them.

I have had occasion to study the workings of the central pool. Without boasting, may I say that I think that if I had 15 minutes at my disposal I could explain its complexities to the House, but I doubt whether the House would be very much wiser at the end of that quarter of an hour. Suffice it to say that I am sure that it is possible, even without any change in the basic system of capitation fees, to evolve a simpler, more acceptable, and satisfactory method of paying general practitioners than the present pool allows.

I have been asked on many occasions—and so have some of my hon. Friends—to state Labour's attitude towards a salaried service. I should like to make it clear here and now that the Labour Party has no plans to impose a salaried service on general practitioners. But, equally, if the general practitioners themselves decide by a majority that they would prefer the system of a salaried service to the capitation system, we should, naturally, be willing to discuss this with them and try to work out satisfactory arrangements with representatives of the medical profession.

At the outset of the National Health Service the idea of a salaried service was a complete anathema to the doctors—and I think that I am right in saying that there is a provision in the National Health Service Act excluding such a solution—but, from what I have been told, I do not think that the opposition to a salaried service is nearly so strong today. Indeed, I think t hat one local medical committee—I believe that it was in Manchester— passed a resolution only a few weeks ago in favour of a salaried service. If one wanted to make a change, and it was desired by both sides, it would be quite easy to bring it about by amending legislation.

What I think is even less satisfactory than the actual remuneration itself and the method of remunerating is the system for reimbursing practice expenses. This is a matter to which I have drawn attention on many occasions in recent years in speeches in this House and outside. Briefly, what happens is that the doctor gets back from the Government, not the expenses that he actually incurs in running his practice, but an arithmetical proportion based on the number of patients on his list. He gets back a proportion of the total expenses incurred in the aggregate by all general practitioners, and allowed by the Inland Revenue.

That has an anomalous result. It means that a general practitioner who spends more on giving a better service to his patients, on maintaining his surgery and his premises, on employing ancillary staff, a receptionist, running an appointments system, and so on, gets back substantially less than he spends, but if he is one of the other kind, who does not worry about functioning from a shabby surgery in a back street, does not employ help, does not use the appointments system, and so on, he gets back a great deal more than he has spent and makes a handsome profit on the deal. I have on many occasions described this situation as ludicrous, and I do so again this afternoon.

I know that, although his predecessor, shortly before leaving office, said that he could offer no solution to this intractable problem, I think he called it, the right hon. Gentleman has instituted discussions with the profession about the question of practice expenses. I welcome the fact that he has taken this rather belated initiative, but from what I have heard I gather that these discussions got off to a pretty bad start.

The right hon. Gentleman made a proposal to the doctors, which was rejected out of hand by their representatives, and if the proposal was anything like the stories that I have heard about it I think that they were justified in rejecting it. But then the right hon. Gentleman did a rather odd thing. Through the medium of a Written Answer to a planted Question in the House he accused the doctors of circulating a misleading account of the negotiations that had taken place. The doctors were surprised and disgusted at this. They protested to the right hon. Gentleman, and I gather that he was forced to apologise to them, although he did so in somewhat ungracious terms.

The Minister of Health (Mr. Anthony Barber)

Will the hon. Gentleman say where he got the information, first, that I apologised, and secondly, that I did so in ungracious terms?

Mr. Robinson

That information came from those who were involved in the negotiations. Naturally, I was very surprised at this extraordinary statement, given in the Written Answer. If the right hon. Gentleman did not apologise, and if he sticks to saying that a totally misleading account of the negotiations was published, perhaps he will say so now.

Mr. Barber

I was discussing this matter with a small group of people. I gather that the hon. Gentleman has had conversations with them. I explained my position to them, and why I thought that the report which had been given was misleading. We were on the most amicable terms after the meeting.

Mr. Robinson

Does the right hon. Gentleman still say that the account was misleading?

Mr. Barber

I do, and I explained why.

Mr. Robinson

I am glad to have that on the record. I understood that he had changed his view.

Anyhow, he has now put forward some new proposals, and these, we are told, represent a considerable advance on what he put forward in the first place. I very much hope that they will provide a basis for a settlement. I can tell him that if he cannot find a solution, we shall do so after October.

That is all that I want to say on the subject of remuneration. I turn now to the conditions of work. The family doctors complain that they are overworked and cannot give adequate time to their patients. This is certainly true of many of them—perhaps most of them. They are trying to do their job today with nineteenth century tools. It is not possible for the doctor, working on his own, to give the service which his patient is entitled to expect and which is what the best of the doctors would wish to give.

I want to quote what a doctor wrote in the British Medical Journal not long ago. He talked of menial medicine for menials for menial rewards. I would not go so far as that, but the fact that a doctor can use a phrase like this in a public letter is symptomatic of the low state of general practitioner morale at the moment. The solution to the problem lies largely in the development of group practice—doctors in groups of perhaps three or four, up to six or eight, coming together and functioning collectively either from a health centre or a group practice centre.

There are considerable advantages in such a system, both for doctor and for patient. The practice can be carried on from far more pleasant and suitable sur- roundings, which can be properly equipped; it is much easier to employ ancillary help and to run an appointments system for the patients. It is possible to have nurses and health visitors seconded from the local authority services. It makes comparatively simple the working of rota arrangements for weekend duties, night duties, holidays and sickness. I would not say that it copes fully with the locum problem, but it makes it very much less difficult. And it does all this without compromising in any way the concept of a patient's personal doctor.

There has been a steady move towards group practice. I believe that more than a quarter of our doctors now function in group practice. But it has been moving very slowly. That is because there has been insufficient incentive to form group practices, and because formidable financial problems are involved. So far, the only help that the right hon. Gentleman's predecessors have given to group practice has been the interest-free loan scheme, which came originally out of the pool, so that in a sense it was the doctors' own money—although in the last couple of years it has been provided by the Government.

This is on a fairly small scale. I notice from the right hon. Gentleman's annual report that 95 loans were approved last year and only 59 the year before, and that the average amount of each loan was between £5,000 and £6,000. This is quite inadequate for the kind of expansion of group practice that we would like to see. I want to quote two cases with which I have come into personal contact in recent weeks. The first relates to a group of three doctors in a very small group practice who are working from an excellent centre which has been purpose-designed and well equipped, and which cost £17,000. Towards the cost of this the practice received a loan of £9,000, leaving the doctors £8,000 to find out of their own pockets or by borrowing from the bank.

This group is doing well, and it wants an additional partner. But an additional partner will become a part owner of this capital asset, which cost the original three doctors £8,000 plus £9,000 loan. So the new partner is expected to buy himself into the practice. In other words, he is expected to "chip in" about £4,000. Not only does this considerably limit the number of doctors who could apply for such a vacancy; it means that we are once more back into the buying and selling of practices—through the side door. This is a totally unsatisfactory development. These three doctors were giving an excellent service to their patients, but to do so they had to subsidise this practice out of their own pockets to the tune of several hundreds of pounds a year each.

The other case concerns a number of doctors—six in all; two partnerships of two and two working on their own—who wished to form a group in an area west of London. It is not one of the most expensive areas. They searched for suitable premises, and they ultimately found a building which would have done very well, but after conversion it would have cost not less than £42,000. The maximum group practice loan that they could hope to obtain was just about half that figure. They simply could not face the capital liability of more than £20,000 spread between the six, so this admirable scheme, which they all wanted to embark upon, has fallen through.

The Government must accept responsibility for providing premises for group practice. A system of loans must be replaced by one of grants. That is what a Labour Government would be prepared to do. We should also give direct financial assistance towards the employment of ancillary help of the kind that I have described.

We must also, wherever suitable conditions exist and the doctors wish to work from health centres, ensure that health centres are built in those places. At this point I throw out an idea to the House. Why should not executive councils be given the job of planning general practice in the areas over which they have responsibility, in the same kind of way that a regional hospital board plans hospital services? I fully realise that group practice is a less suitable form of general practice in scattered rural areas. Some parallel encouragement and help—perhaps help with premises—will have to be given to those family doctors for whom group practice is not the ideal solution.

Another complaint arises out of the size of doctors' lists—the complaint that they have too many patients to look after. The present maximum is 3,500 per doctor, and the average, which is 2,300 patients per general practitioner, is certainly too large to enable patients to get the service that they are entitled to demand. The development of group practice will certainly contribute towards easing the burden on the individual doctor, but the only long-term solution—as I am sure the right hon. Gentleman realises—is to provide more doctors.

Recruitment into general practice is falling disastrously. I understood, from a Written Answer that I got from the Minister only last week. that the average number of applications for each practice vacancy has dropped in five years from 31 to 13, and of those 13 many will be found to be quite unsuitable. Indeed, recruitment is barely, if at all, keping pace with retirement and death. What will happen in 1968—the year when the National Health Service is 20 years old and in which an abnormally large batch of general practitioners will, for the first time, be able to retire on full superannuation?

We have to have more doctors. There is nothing between us, for the first time, on this matter. I repeat the undertaking that I have given before, that a Labour Government will ensure the setting up of four new medical schools at least, as against the one new school which this Government appear to think sufficient, apart from squeezing a few more students into existing schools. But this is very much of a long-term solution, and we have got to do something in the intervening 10 years.

One of the hopes lies in keeping here in Britain the doctors whom we are currently training, and I hope that the Minister was as disturbed as I was to read the survey by Abel-Smith and Gales, which has shown pretty conclusively that between 350 and 400 doctors emigrate every year, which represents nearly one-quarter of the total qualifying in British medical schools.

I believe that to improve and modernise the conditions of general practice would be one way of encouraging British doctors to practise in our National Health Service. One might also, perhaps, persuade more doctors to postpone their retirement to help us over this hump. That is the only hope that I can see in the short-term.

I now come to the third set of grievances, and that is the general practitioner's rôle in a comprehensive service. The G.P. sees the publicity attaching to the Government's 10-year Hospital Plan. He sees the local authorities' 10-year health and welfare plan. What does he see for general practice? He sees, if he reads the right hon. Gentleman's annual report, just published, this sentence, on page 3: The general practitioner services do not lend themselves to long-term planning on the same basis as the hospital and local authority services … I think that that reveals an attitude which may be an important factor in the G.P.'s frustration today—the sense that he is being neglected, that he is working in isolation, especially from the hospital service which, he feels, is getting a disproportionate amount of attention and resources.

I believe we all want to see the G.P. working in the hospital for part of his time, but there are considerable difficulties in the way of this. The average doctor is far too busy in his own practice, although, here again, group practices would be of some assistance.

Then there is the question of the capacity in which the doctor works in the hospital. Is he to be a clinical assistant attached to a team, or is he to be in charge of his own beds? There is much disagreement about the optimum solution. Somehow, the G.P. ought to feel a part of his local district hospital. It should be the place where he goes for stimulation and refreshment in a professional and intellectual sense. There may be no single solution to this, but I believe that if we can get the G.P. in the hospital it will be of benefit both ways, because it will enable the consultants to understand the general practitioner's rôle and his problems better than many of them do today.

That brings me to the last of the G.P.'s complaints, which is his status within the profession. Too many family doctors see what they think is the exaggerated respect accorded to the hospital consultant. They look at the salary differential between them, the fixed hours of work and the absence of any locum problems of the hospital doctor, and by comparison they feel that they have got a kind of inferior status in the profes- sion and, because of that, in society at large. Somehow, this is a situation which we have got to change. Here action, although it could be encouraged by the Government, must primarily be taken by the profession itself. But since there is little sign of any lead either by the profession or by the Government, perhaps, as a layman, I might throw out an idea or two.

Surely we must in future regard general practice as a specialty, just like surgery, pædiatrics, or general medicine—a specialty which requires, as they do, special post-graduate training, which would include actually working under supervision in general practice for a period. Indeed, I think that it would be of the greatest benefit to medicine as a whole if every doctor could have in the early part of his career some firsthand experience of family doctoring. Then there should be far more extensive arrangements for post-graduate refresher courses, specialist courses in obstetrics, psychological medicine and other subjects.

There is an idea being canvassed at the moment for the setting up of an Institute of General Practice, which would have the job of carrying out research, education and establishing standards. I certainly think that that would be a most desirable development. Possibly it could be in association with the College of General Practitioners, which has made considerable effort in recent years to raise the quality of general practice.

This is the background to those unfortunate debates and ill-considered votes at Manchester a week ago, at a meeting which, we think, must have done great harm to the image of the doctor in the eyes of the patient and the public. The right hon. Gentleman, I believe, spent a couple of days in Manchester and was guest of honour at the British Medical Association's annual dinner. I think that many hon. Members know what excellent hosts the Association's members are. That may be the explanation of the extraordinary statement that the right hon. Gentleman is reported to have made in his speech at that dinner. According to The Times, the Minister said that he would help to protect the family doctor from that minority of time-consuming patients whose lack of consideration places on the doctor a burden out of all proportion to their number. I should like to ask the Minister one or two questions. First, how will he protect the doctor? I hope that he will tell us when he winds up the debate. What further obstacles has he in mind to place in the way of the patient seeing the doctor? No doubt, if he followed his predecessor's example and once again doubled the prescription charge he would keep a lot more patients away from the doctors' surgeries very successfully. Will the right hon. Gentleman tell the House what techniques he adopts in Doncaster to protect himself from the time-consuming constituents that we all know? Does he assume that if a constituent takes up his time, the constituent does not really need his services? Is that the assumption that he makes? What does he think is the main function of his office?

Does the right hon. Gentleman not agree that the job of the Minister of Health is to ensure that patients get advice and treatment that they need, or even the advice and treatment that they only think they need, or is it the Tory solution just to cut down demand in order to effect economies?—a very simple method, of course. Does not the right hon. Gentleman really appreciate that by that, I think, very injudicious remark, he has given support or, at any rate, will be interpreted as giving support and comfort to those doctors who wish to impose a charge for their services?

Mr. Barber

I will not deal at length now with what the hon. Gentleman has said, but, in the context of what I was saying, what I said had no reference whatever to the imposition of any charge for consultation, which is certainly not the policy of this Government and never has been.

Mr. Robinson

I am delighted to hear that, because I wanted to get the answer to that question. That was the only remark in his speech which was quoted in The Times. I did not say that he said it in that context. I said that he was in danger of being interpreted as coming out in support of this attitude.

I state categorically that a Labour Government would have nothing whatever to do with any such proposition as charging a fee to any patients visiting or being visited by their doctors. I hope that I am right in thinking that the right hon. Gentleman has given an equally categorical assurance on behalf of the Conservative Party.

Mr. Barber

I will give it now if it will save time.

Mr. Robinson

I am delighted to hear that. I refuse to believe that this is what the great mass of general practitioners want either. All the G.P.s to whom I have spoken since that meeting in Manchester have displayed a sense of shame at the whole tenor of the resolutions that were passed there.

A very great Canadian physician and, I believe, a bit of a philosopher, Sir William Osler, once wrote: Medicine arises out of the primal sympathy of man with man, out of the desire to help those in sorrow, need and sickness. That, I am sure, represents, far more accurately than any ill-considered resolutions carried at Manchester last week the attitude of the vast majority of general practitioners to their work.

Anyhow, it is on that assumption, that a Labour Minister of Health would approach this whole problem. Far too many Conservative Ministers have been content to pay lip service to the idea that the family doctor is the cornerstone of the National Health Service, but taking no action to modernise general practice or to improve the lot of the family doctor.

I know what the right hon. Gentleman will say in winding up the debate. He will point, of course, to the Fraser Working Party, which he set up earlier this year, and he will tell us that all these things are being urgently discussed with the profession. What I should like him to tell us is why the Government waited 10 years before setting these negotiations in motion. The need had been there for many years, and it was a pressing need. Now we have this belated action, taken just a few months before the General Election, and that is a fact the significance of which will not be lost upon the doctors. The general practitioners have lost all confidence in the Conservative Party and the great majority of them know that their only hope lies in a change of Government, and when I say that I mean a very large proportion of those who normally support the party opposite.

I want to say this, in conclusion, and I want to say it as unequivocally as I can. I believe that a comprehensive Health Service is unthinkable and impossible if it is not based on the solid foundation of general practice. After all, it is only the family doctor who can see the patient in the round and can treat the whole man against his social and his family background. It is the family doctor who has the responsibility for continuous care. He it is who deals with more than 90 per cent. of the sickness which arises. He is literally the front line of defence. The family doctor can hardly be expected to trust a Government and a party which have so supinely sat for 10 years while general practice has been running steadily down hill, recruitment has been falling off, a sense of isolation growing, and status dwindling, without—at least until the eleventh hour and very near the fifty-ninth minute—attempting even to discuss the problem, let alone to find a solution to it.

The G.P.s are demanding, above all, the tools with which to do a better job for the patients and for the nation, and by now they know that only a Labour Government are likely to provide them.

4.12 p.m.

Dame Edith Pitt (Birmingham, Edgbaston)

I can agree with a great deal of what the hon. Gentleman the Member for St. Paneras, North (Mr. K. Robinson) said in his speech, in what I may call its first three chapters, because I think that he dealt very reasonably and very quietly with some of the issues in the minds of most of us when we think about the family doctor, but some of the points he made about changes which a Socialist Government would contemplate and possibly make in the position of the general practitioner in the National Health Service seemed to me to point more and more to clawing the doctors fully into the State service, and I have no doubt, to quote the hon. Gentleman's own words, that that is a fact the significance of which will not be lost upon the doctors.

I should like to begin what I have to say on this subject with a reference to the Gillie Report on the family doctor, because I think that it is such a valuable and comprehensive document. It gave me pleasure to read it when first it came out, and I reread it yesterday in readiness for this debate. It is written with sympathy and with humanity. One of the things I like most about it is that it offers a model of how to give information without the mystique which so often surrounds documents connected with the medical world.

I liked, too, the humility with which the subject of the need of the service to the patient was approached. Indeed, I would wish to congratulate all those who contributed to this Report and particularly those who wrote it. I liked the words in the introduction referring to personal medicine: our faith in its value. It is an important thing that the general practitioners still have faith in the value of personal medicine and still want it to continue to extend and to succeed.

One should note that some time ago my right hon. Friend said that the National Health Service revolves round the family doctor. That is the answer to some of the points made by the hon. Gentleman the Member for St. Pancras, North. The contribution of the family doctor to the National Health Service—I scarcely have need to remind hon. Members in this House, because I am sure that they all agree—is very much valued by the members of the public who use it. The great majority of them are full of praise for the doctor and the service which he gives. Of course, there are criticisms from time to time, and we have all heard them, about doctors who do not come promptly when summoned, doctors who do not keep promises to come one week later, doctors who do not tell patients enugh about what is wrong with them and their children. But all this is a minor part, and I would repeat that this service is valued by the public.

I would not want to ignore the service which preceded the National Health Service, because although I do not want the pre-1948 days ever to come back again I think it right to say that many good family doctors in those days gave extremely good service, and particularly to families like my own, who never had any money but a large number of children. The doctors varied their charges according to their patients' needs and did not demand them of those who could not afford to pay; if one could not pay one was not charged. I think that these old family doctors deserve thought from us when discussing the present situation.

I turn from that to the National Health Service and the introduction of the comprehensive service with the availability of free medical care to all members of the community as distinct from those of us who were insured persons prior to 1948. This, of course, is the reason why the service has been much more widely called upon; and again, to quote the Gillie Report: the increased load is the central problem in general practice today. This is true, and it remains so, but what the hon. Gentleman the Member for St. Pancras, North omitted to point out was the fact that efforts have been made by the Government to increase the number of general practitioners in the Service to ease the load. I think that it is correct to say that since 1951 an additional 3,500 general practitioners have been recruited to this part of the Service, an increase of 18 per cent. This, too, has been accompanied by a reduction in the under-doctored areas, the areas where there really are far too many patients for the doctors available. Again, I am not making a political point of it, but it is confirmed by the Gillie Report, as hon. Members will see if they like to look at Table V in it.

The question now before us is: what must be done to relieve this increased load to which I have referred? I agree with the hon. Gentleman that the answer, at least in part, is more doctors, but here again, the Government have already taken action. One new medical school is to be established, and there are to be extensions to other medical schools, and I have already referred to the increase in the number of existing doctors.

Another part of the answer is to make better use of these highly skilled members of the community, to make the fullest use of their training, and not dissipate it upon doing work which others can do for them. It is important, too, in this context to remember the needs of the patients. In improving the doctors' lot, and relieving the load, we ought always to have before us the aim of bringing up to the highest standard the quality of medicine in general practice.

I know that there is concern about pay. The hon. Gentleman said that this is a secondary issue, but I think that it is in the minds of most doctors. I appreciate, and think it perfectly natural, that all doctors should desire an increase in their pay—who would not? In fact, they have already had increases, and it is important to put on the record that their remuneration has increased by over 100 per cent. during the period of a Conservative Government.

I know that there is criticism of the pool system and I agree with the hon. Member for St. Pancras, North. But it was the deliberate choice of the doctors that their method of remuneration should be fixed in this way in order that they might avoid becoming salaried servants of the State. The criticism was spelt out well by the hon. Gentleman. I would reduce it to one sentence. The doctors say that the more they do the less they get. I think that this is the doctor's dilemma.

This method of being paid out of a central pool confines all doctors to one level. It does not permit of any career structure such as we have in hospitals. It does not permit of any extra payment for good work. I am sorry that the £500,000, which the Royal Commission suggested should be made available to recognise good work, has never been used. I suppose that the money has gone back to the Treasury. What a pity. It was not used, I understand, because the doctors could not agree on the method of selection, and which of their number should have the extra pay for distinguished extra service. Nevertheless, I do not think it impossible to find a method of recognising meritorious service.

Another point, to which the hon. Member for St. Paneras, North did not refer but which I hear about from doctors, is the feeling which exists regarding the goodwill compensation for their practices which was agreed in 1948. A sum was fixed of which they will get the benefit when they retire, and in the meantime interest is paid on that sum, I cannot remember whether at 2½ per cent. or 2¾ per cent. The older doctors are concerned that an asset which represented £3,000 or £4,000 in 1948 represents much less today, but even though doctors may feel that this asset has diminished in value, surely that is offset by the fact that they participate now in a pension scheme, which was not before available to them, and they are building up pension rights.

The greatest complaint from the doctors is about lack of time, and this point was made by the hon. Member for St. Pancras, North. Doctors have no time for wider interests, which is necessary if they are to give the best service. They have no time for research, in which some may be interested. There is no time to attend refresher courses and to contribute to hospital work, which many doctors would like to do and which would prove useful in their general practice. There is no time for them to serve in other ways, perhaps on medical boards or by doing factory work.

The claims on the time of a doctor are many and one of the most frequent of their complaints is the amount of time they have to spend on writing out certificates. I am not sure whether doctors would like all certificate work to be taken from them, because they charge for the provision of those certificates which are not part of their terms of service. However, the making out of certificates is a time-consuming job.

Another task which has increased enormously since the introduction of the Health Service—and happily so—is the amount of time which doctors give to immunisation. This is a form of insurance, but it still takes time. There is the increased burden of looking after the elderly people in the community, who make heavy demands on the time of the doctors. In some cases early discharge from hospital calls the family doctor into service. What irks doctors most is late messages. To use their own expression to me, this "really niggles". They dislike mesages coming in at all hours when they have a general rule that messages should be delivered before 10 a.m.

That is understandable, but let us also consider the position of the patient. A mother with children who fall ill becomes worried about them and needs reassuring. Often that is the reason why there is a late message asking the doctor to call. It often happens that a child's illness develops and grows worse during the day. None of us would wish there to be any lack of attention in respect of such things.

Doctors dislike having to make unnecessary visits, by that I mean visits in respect of trivial things. Sometimes they are called out to deal with trivial things. One doctor remarked to me that patients treated their doctors as though they were shops. A doctor to whom I spoke yesterday, and who happened to be on Sunday duty, had been called out twice before I spoke to him, once to a woman who had been confined and had discharged herself from hospital. Her husband rang up the doctor and asked him to call to ensure that the wife was all right. Another call was to a family which had returned from holiday the day before. The children were unwell and so a Sunday visit from the doctor was expected. In some cases requests for visits are not very reasonable.

I am glad that at the conference at Manchester, to which reference was made by the hon. Member for St. Pancras, North, doctors said publicly that they would support the retention of prescription charges. Many doctors have thought this privately, but have not said so. This seems to me to be a good thing. Doctors may regard prescription charges as a deterrent, but if a contribution is made by way of a prescription charge—most people can afford 2s. and those who cannot are cared for—more money is available to be devoted to other aspects of the Health Service. What is of prime importance is that under the present system no limit is placed on what a doctor may prescribe for a patient, so I think it right that doctors should support prescription charges.

I was much less happy about the suggestion at the Manchester conference of consultation charges and I was glad of the assurance given this afternoon by my right hon. Friend that such a charge is not being contemplated by the Government. To impose one would be a retrograde step. We should be going back to the conditions which obtained in the days before 1948.

What can be done to help solve the problem created by the demands on the time of the doctors? I agree with the hon. Member for St. Paneras, North that an appointments system would help. I am told by doctor friends who run such systems that the time occupied by patients visiting the surgery can be cut down if people know that they are able to come at a specific time. This system also allows the doctor a longer period to talk to patients. My doctor friends say that the number of visits to patients is cut down, because, apparently, a patient who knows that he can come to the surgery at a specific time will make an effort to go to the surgery instead of calling for the doctor.

Many patients, or their relatives, are in the happy position of owning a car, so it is possible for more visits to be made to the surgery, which saves a lot of time. The existence of cars has a reverse effect for doctors who practise in large towns. One of their complaints is that while, in pre-war days, they could reckon on eight visits an hour, now, because of traffic difficulties, and time lost in finding somewhere to park their car, the number of visits is cut down to five an hour.

Another way in which we could help would be by the introduction of a rota system in which doctors deputise for each other, thus enabling their colleagues to take time off and lead some kind of family and social life, as they are fully entitled to do. It is important that a doctor should keep in touch with the community.

I would agree with the hon. Gentleman on group practice, but I would not go up to as many as six or eight. My view is that about four is the right number if we are to keep the personal service. From what I have seen of group practice, I like it very much, because I think that it enables a better standard of service; it means good accommodation including an examination room and it is appreciated by the patients. The difficult thing in extending group practice is finance, but I would hope that with the help of loans available, and with more ancillary staff, we could see developments in group practice, although I wonder whether it is practicable for rural areas and the single-handed doctor.

I am sure that all these three points are being considered by the Working Party. I wonder whether it might not also consider inducements for certain areas, because although the under-doctored areas are fewer in number, the further North one goes the more difficult it is to find applicants for vacancies, and until we have more qualified doctors in the service I wonder whether it is necessary, for instance, for the Working Party to consider offering some kind of weighting for doctors who will go to the areas in the Midlands and, even more so, in the North.

I make one other point in trying to help the doctors to make the fullest use of their time and service for us, and that is that we ought to see in what ways we can further educate patients. I should like to see much more emphasis on maintaining good health. I sometimes think that we get the wrong angle from television programmes on this question of health. They pander to the morbid interest, the serious accident or serious illness, instead of encouraging people to value the tremendous boon of positive good health. Therefore, I would hope that the television authorities might consider more programmes dealing with health education, with physiology and more family doctor talks.

Mr. Julian Snow (Lichfield and Tamworth)

In British practice, not American.

Dame Edith Pitt

British talks—I take the hon. Gentleman's intervention.

I remember how Lord Hill, when he gave talks on the radio, did much to break down the mystique which I referred to earlier and talked to people about the advantages of good health, and how welcome were those lovely, warm, treacly tones of his. He is still spoken of nostalgically by the people who heard him, and I should like to see something on these lines.

In reflecting on the tripartite arrangements in the National Health Service I come again to the Gillie Report, which says: … many family doctors still fail to appreciate the value of the public health service and the help that it could give them in the work of their practices. This is very important. Over the years, liaison with the local authorities and the general practitioners has, I know, grown and I was very interested to learn that in the City of Oxford, for instance, every health visitor maintained by the local authority is attached to one or more medical practices in that city. That is a good thing in creating liaison and keeping the three parts of the Service knit together.

In the City of Birmingham we have made good progress in seconding health visitors to doctors. We are short of health visitors, but they are attached on a sessional basis of one or two sessions a week. The district nurses in Birmingham are similarly being attached to the doctors' service where the accommodation allows this to be done. I am not even sure whether this is legal. I think that the Act says that the district nurses or home nurses should work in people's homes; but, nevertheless, this is a welcome development, by providing the doctors with extra help and assistance and by the doctors themselves making contact with the local authorities

I know why the health centres did not succeed in early days, when the doctors, as the hon. Member for St. Pancras, North said, had a marked reluctance to take part. It was because they thought that they would lose their independence to the local authority and the local medical officer of health. I think that there is a change coming about that, but the more the services can be integrated and the more each part can help the other the better the quality of the service that the patient receives. I should like to see close liaison between the local authority and the family doctor in the interest of the doctors themselves and their patients.

4.36 p.m.

Mr. W. A. Wilkins (Bristol, South)

There was a point at the beginning of the speech of the hon. Member for Birmingham, Edgbaston (Dame Edith Pitt) when I thought that I should find myself in violent disagreement with her, as on the previous occasion, when we debated hospitals. As she progressed with her speech I found myself probably more in agreement than disagreement. I regret that she rather spoilt what was otherwise a rather appealing case by referring to the speech of my hon. Friend the Member for St. Pancras, North (Mr. K. Robinson) and inferring that by the proposals which the Labour Party would put forward there was the clear intention, as she put it, to "claw" into the National Health Service a State salaried medical service through the G.P.s.

My hon. Friend the Member for St. Pancras, North, said precisely the oppo- site. I can only think that the hon. Lady's mind is so warped or prejudiced against this Service that she was bound to infer that this was the intention of the Labour Party.

It is rather fortunate that we have this opportunity of spending a couple of hours on discussing the family doctor service. We have had many health debates in this House, but, generally speaking, they have neglected the general practitioner and we have concentrated more on the Service as a whole, especially as it relates to the hospital services, and overlooked the fact that the G.P., is really the fundamental basis of the Service.

Those of us who have contacts with the profession will know that they, at least, rightly or wrongly, believe that they have grounds for believing that they are regarded as the forgotten factor in the Service and they have endeavoured by various means to put forward proposals to which they think we in Parliament ought to give due consideration and help to deal with the problems which face them.

I agree very much with the hon. Lady when she referred to refresher courses. It is a fact that where group practices have already begun to operate—I am not talking about group practices necessarily that operate under the aegis of the local authority, that is, on premises that the local authority might have already provided—where doctors have set themselves up in group practices, they have been able to arrange to go back into hospital at intervals for refresher courses. Friends of mine in the profession have told me on a number of occasions how valuable they find it to be able to go back to hospital, even for a short period, to bring themselves up-to-date with modern medical application.

Such opportunities will be considerably improved if we can encourage—I emphasise "encourage"; we do not want to press-gang doctors in the National Health Service—them to form themselves into groups. Then there will be further opportunities for refresher courses, to which the hon. Lady referred. I find a great desire, particularly among younger doctors, which perhaps is an encouraging sign, to go into group practice. It is understandable, and I do not make any criticism of it, that the rather old-fashioned doctor, who has spent his working life in the Health Service, is not so inclined to go into group practice as the younger doctor.

One of the reasons why they are critical of the present Health Service is that they are more or less alienated from general hospital work. It has been said to me time and again that they would like to be able to follow their patients into hospital and have some sort of connection with their cases while they are undergoing surgical and other treatment there. I want the Minister to have second thoughts about the proposals foreshadowed in the Hospital Plan for abolishing, or allowing to go into disuse, some of the older hospitals. Of the hospitals built between 1800 and 1900 quite a number are comparatively modern, but are included in proposals for abolition. I appeal to the Minister to review this programme.

There are possibly a number of uses which could be found for these buildings. There may be some question of staffing them, but this is the kind of proposal which is put to me by young doctors now in practice. They say that these old hospitals could be retained and are much needed in the maternity service. Then doctors could follow cases into hospital. Provided the nursing services were available, the institution could be used and could perform an extremely valuable service in this way.

The original intention of the general practitioner service was to function from health centres. I offer the Minister an invitation to visit my city. Within the last two months a noble Lord, known to many of us as a doctor, came to Bristol and opened a new health centre. It has incorporated a group practice for general practitioners. I should like the Minister to see this building, because it is about the ideal for general practice.

Mr. Barber

The hon. Member is kind enough to invite me to come to the city. I gladly accept for after the General Election.

Mr. Wilkins

I invite the right hon. Gentleman to come and have a cup of tea with me, because I live only about 400 yards from this group practice and I know something about it.

I have no doubt that the Minister has heard of this health centre, which was recently opened on the east side of the City of Bristol. The facilities are absolutely superb. They are the kind of facilities one hears about and for which the general practitioner is asking. He says, "This is the kind of place I want in which to do my job".

I often have a conversation with my own general practitioner. When we discuss health matters he frequently expresses the opinion that the value of his work and of other doctors in his group would be enormously increased if they had the services of a health visitor, or if they were able to engage a trained nurse to assist them. He says that this would be a means whereby the general practitioners could ensure follow-up of patients without necessarily having to visit them themselves. That seems to be a valuable suggestion. My doctor has said that it is of great assistance in the practice to have help on the clerical side, because this is a practice which initiated an appointments system from 1st January this year. Some of the patients were very apprehensive when the doctors in the group said that they would go over to an appointments system, but the system works well.

Probably by a slip, the hon. Lady forgot to point out that one of the principal reasons for the introduction of appointments systems was for avoidance of cross-infection in the surgery. One used to go into a surgery when suffering from arthritis and would sit among a number of people who were coughing and sneezing because there was an influenza epidemic. Probably after a few days one returned to the surgery, not only with arthritis but with influenza as well.

It has been suggested to me that if further help could be available, especially to group practices, doctors would be able to do what now they find through lack of time is impossible—to make research into the incidence of sickness among their patients and to see the general trend of illness in districts in which they work. From one part of the country to another there are great variations in the incidence of bronchitis, for example. My doctor has expressed the view that it would be extremely valuable if a study could be made of the incidence of illness among the 6,000 patients who are on his group register.

This is only a very short debate and other hon. Members want to contribute speeches, so I shall not delay the House for more than a few moments longer. I add my plea to that of my hon. Friend the Member for St. Pancras, North for, at least, a review of the basis of remuneration for doctors. I agree with him that this is not the principal concern, but it is a very powerful secondary concern. There is much comment and even complaint about the way the pool system operates, especially in regard to mileage payments in rural areas. I suggest that it is time, perhaps by means of a Ministry committee, or a commission, to try to find a satisfactory basis on which general practitioners may be remunerated. There are odd people in every profession, but, generally, doctors are a most devoted body of people who try very hard to carry out their professional duties to the best of their ability because they believe it a duty to give good service to their patients.

We must try, by negotiation, to find a solution which is acceptable to both sides. In saying this, I want to make it clear that I by no means agree with all the proposals that are being put forward. Indeed, I do not believe that every doctor agrees with all the proposals, some of which are outrageous. I hope, however, that an acceptable and workable basis will be worked out by negotiation so that a proper system of' renumeration can be found.

This basis must, as I say, be acceptable to both sides and it must ensure that the Service goes on without interruption. I do not take too much notice of the threats that are sometimes made about the withdrawal of labour, and, despite some resolutions that are passed at meetings of doctors, I do not believe that the general body of G.P.s would wish to take such action. This does not mean that we should take advantage of their loyalty.

I hope that the Minister will assure us today that he will take the necessary action to try to reach an agreement with the profession on this difficult and intransigent problem.

4.52 p.m.

Miss Joan Vickers (Plymouth, Devonport)

I agree with the hon. Member for Bristol, South (Mr. Wilkins) that there are a great many odd people in all professions, even in this House. I congratulate him on the establishment in Bristol of the health centre to which he referred, which I gather is a great success. He will appreciate that he has a larger population than some districts and that it might be easier for that sort of system to work in his area than in some others. I was also glad that he referred to the older hospitals, because I intend to comment on this issue, particularly the cottage hospitals and the question of a salaried service or capitation service and its developments after a number of years of service.

We have in Britain the best general practitioner service in the world. There is nothing to touch it. The doctors in the service are the most selfless human beings in the whole of the Welfare State. A G.P. in single practice must work 365 days a year. Only if he has a partner is he able to take some holidays by the spreading of duties. If not, he must pay a locum if he is to have any time off at all. I am sure my right hon. Friend recognises the vital part which the G.P. plays in the National Health Service. The fact that he has spent so much time reconsidering the structure, pay and emoluments and other aspects of the Service indicates his great interest in it.

The hon. Member for St. Pancras, North (Mr. K. Robinson) opened the debate in his usual charming manner; so much so that I am tempted to say that in view of his excellent bedside manner he is in the wrong profession. He touched on four main points, and I wish to begin by referring to a fascinating book entitled "Family Ill-Health". Written by Robert Keller, it gives details of an investigation which he carried out into general practice. He comes to the conclusion that there is no real abuse in the Health Service and he concludes—and this was mentioned by my hon. Friend the Member for Birmingham, Edgbaston (Dame Edith Pitt)—that television plays an important part in bringing people to the surgery.

He finds that ill-health in a family creates ill-health; that if one member of a family is in continual bad health that places a strain on the whole family and results in further ill-health. He states that in many circumstances the G.P. needs more time to deal with his patients.

It is suggested in the Gillie Report that no G.P. should have more than 2,000 patients. This recommendation is made because of the rising population; the extension of time necessary to attend to the increased number of children under five years of age and the members of the older generation. Added to this is the fact that, thanks to the G.P., we have a longer expectation of life; for men now till 69 years and women till 74 years. In fact mortality and maternal mortality is an all time record, thanks to the G.P.

A great many old people live alone, particularly with the increased facilities being provided by way of one-bedroomed flats and small bungalows. These in themselves necessitate more visitations by G.P.s. Many mothers are now having babies at home, and in difficult confinements the local G.P. must be present the whole time. And since there are more old people, the G.P. must, if possible, be present when, regrettably, someone dies. Bearing all these things in mind, and remembering how invaluable the G.P. is to the National Health Service, I thank my right hon. Friend for the interest he has shown in the G.P. and trust that that interest will continue to be shown.

A great deal has been said about health centres and the question of group practice. It is interesting to note that both the United States and Russia have tried to urge that patients be treated by what are known as minor specialists working in poly clinics and hospitals. It is equally interesting to note that both of those countries are returning to the G.P. service. I am certain that we shall not go far wrong if we continue to encourage our G.P.s to continue to work our G.P. service, particularly since in other countries experiments in other spheres have not been as successful as at first might have been thought. The Porritt Report stated in paragraph 171 in regard to a general practitioner: … A doctor in direct touch with patients, who accepts continuing responsibility for providing or arranging their general medical care which includes the prevention and treatment of any illness or injury affecting the mind or any part of the body. There are 5 million accidents a year, and 40 per cent. take place in the home. We are beginning to realise that part of the G.P.'s work is prevention. This probably means him being called out more often than at present—and this is one reason why G.P.s should have fewer patients.

Wastage is one of the great difficulties involved in the Service. A great number of doctors do their training and do not go into practice. With the increasing population there can be no doubt that the number of doctors will for a long time not keep pace with the rising population. Apart from the natural increase in population, as the hon. Member for St. Pancras, North pointed out, conditions in the Service are not attractive enough to secure more doctors.

I believe that the time has come when students taking their medical degrees and undergoing their training at the expense of the State, along with receiving grants, should perform some form of practice for the State. I am thinking, among others, of women who qualify and then get married—after having at the State's expense been trained as a doctor. I suggest that they should refund part of the money they have received and so allow others to be trained. I would exempt from this the individual who goes into the medical service of one of the developing countries because the expenditure on training for that man or woman would be equally justifiable. I say this because far too many doctors who receive their training at the expense of the State finally leave to join industry. In such circumstances they should in some way repay the State, at least to some extent, which paid for their original training.

Mr. Denis Howell (Birmingham, Small Heath)

I would draw the hon. Lady's attention to the fact that her hon. Friend the Member for Edgbaston suggested that the obligation is entirely to the State and, therefore, that they should pay up if they do not serve the State.

Miss Vickers

We are used to having arguments in this House—that is largely what it is for—and I do not mind whether it comes from that side or from behind me.

The average practice has 2,285 patients, but distribution is very uneven as so many places are considered more pleasant to live in. I should very much like to see a salaried service, which was referred to by the hon. Member for St. Paneras, North. I have mentioned this subject in a previous debate, I have read through some of the evidence that has been given, and I realise that the majority of doctors are not in favour of a salaried service.

I think that a salaried service would be a great asset. Doctors would know exactly what they were to receive. I presume that they would receive payment during holidays, and when they were sick they could claim on expenses account. They would also have graduated promotion, and they would have pensions. The capitation system that we have tried for a considerable time has not been particularly successful, and a salaried system would provide far more chance of mobility for individual doctors themselves. Furthermore, it would provide a chance for the older doctors to continue work in the less difficult areas—perhaps the rural areas—when the work in the urban areas became too much for them to tackle.

Doctors might start on a fixed minimum salary, rising to a maximum after, say, ten years. There should be allowances for specialising in any particular subject—

Mr. Percy Browne (Torrington)

Would this proposal mean that a doctor would need to have a minimum number of patients before getting a salary at a certain level? How would the salary scale work with regard to the number of patients, which is one of the incentives today?

Miss Vickers

The average number of patients today is 2,285, and I think the salary could be fixed on the basis of a minimum of 2,000 patients.

In partnerships, we might have one partner specialising in midwifery, another in the mentally disturbed and another in the aged. One of the extra burdens put on the general practitioner results from the fact that the hospitals that were once called mental hospitals are now discharging patients much sooner, and those people need continuous supervision to keep them from returning to hospital again. In any case, the capitation system has not been particularly successful in attracting doctors, and I should like to hear my right hon. Friend's views on a salaried service.

If we are to retain the capitation system, the general practitioner's expenses, such as the cost of necessary equipment, should be refunded on production of an accountant's certificate. After all, consultants get all their equipment in hospital free of charge, and it is only logical that the general practitioner should be treated in the same way. Further, if we are to keep this system, we should have higher capitation fees when the doctor has been in the service for, perhaps, ten years or more. I cannot see why the State cannot issue equipment to the local practitioner through the local hospital committee.

In sparsely-occupied areas, general practitioners with small practices might work from time to time in the local hospitals for a fee, and local hospital committees might consider the idea of estimating for this type of contingency. This is particularly necessary in country districts. All general practitioners need more practitioner beds. I understand that a general practitioner now has less than one bed per head, and that includes both maternity and private pay beds.

General practitioners should also have more direct access to X-ray and pathological services, particularly in the country districts. I am thinking here of work relating to cervical smears and X-rays after a barium meal. A general practitioner can easily do a cervical smear if he has the right to deal with it himself in the pathological laboratory. The administration of an X-ray after a barium meal is of great importance, but in the Plymouth Hospital, for example, it is not now possible for a patient known to me to get X-ray treatment until November. That is a long time to wait for such a very important type of medical treatment.

If the general practitioner could have access to the hospitals, it would be of great benefit. Further, when my right hon. Friend is considering the building of new hospitals under the Hospital Plan, will he consider providing beds in what might be called general practitioners' annexes? It would be a very great advantage for them to have a number of beds in special annexes in new hospitals.

The G.P. has too much clerical work to do, and I have wondered whether it might not be possible to reduce the number of sickness certificates that are now needed. Could not the general practitioner give one of these certificates when a man goes sick and give him another when he is fit. Is seems quite unnecessary to issue a sickness certificate every week for two or three months. It adds greatly to the doctor's clerical work, and I hope that my right hon. Friend will consider this suggestion.

Again, where two, three or more doctors are working together, my right hon. Friend might consider attaching a nurse and a health visitor to that type of practice instead of to an area, so as to provide closer liaison between the public health team and the doctor. This would also probably encourage group practice.

What can my right hon. Friend offer doctors in the way of help with rent, wages, rates, running expenses and the cost of equipment? Only too often, the only ancillary help the doctor has is his wife—the general practitioner must by now be the only individual in the whole of our society who has no private life.

I entirely agree with the hon. Member for Bristol, South on the subject of refresher courses. With the quick changes going on in medical knowledge, these are absolutely essential. I am quite certain that a doctor having this opportunity to take time off and learn more would be able to save many patients' having to go to hospital. If the individual patient knew that the general practitioner had gone on a refresher course in midwifery or any other section of the profession—and I understand that there are now more than thirty different sections—I do not think that the patient would consider so necessary the hospital treatment so many of them now demand. Patients would not ask for hospital treatment if they had more confidence that sufficient time could be given by a general practitioner to examination such as can be given by a consultant.

Patients are now discharged so much more quickly from hospital than previously that it is necessary for a general practitioner to visit them more often. Many diseases which used to be considered fatal can now be dealt with by home treatment, and this places extra responsibility on the home doctor. It is far less expensive for patients to be treated in their homes than in hospital, and we all know that hospitals are overcrowded.

This debate, therefore, is extremely important, because we are considering how we can help the general practitioner to give more time to the individual patient, whether in preventive medicine, the treatment of mental illness, or after-treatment following a stay in hospital, so as to reduce the strain on hospital accommodation. The hospital service is dependent upon the actions of the general practitioner who is the greatest figure in the whole of the National Health Service.

I did not vote originally for prescription charges, and I realise that the Opposition now say that they will abolish them. I also realise that at its meeting in Manchester recently the B.M.A. was against the abolition of prescription charges. I understand the reasons. The Association fears that there might be a great demand for such things as tranquillisers if charges were abolished, but if charges are to continue there should be some consideration for that section of the population who cannot afford to pay.

On previous occasions an hon. Friend and myself have asked my right hon. Friend the Minister of Health to urge on the British Medical Association that doctors should use distinctively coloured prescription forms so that those who cannot afford to pay need not pay the chemist on presentation of the form and later have to have the money refunded, as is the case now. If the Opposition intend to abolish the prescription charges there will be no need for this suggestion, but in view of the fact that doctors have come out so strongly in opposition I believe that hon. and right hon. Members opposite will find great difficulty if they try to abolish the charge.

Mr. K. Robinson

I suggest that the hon. Lady might be a little fairer to the British Medical Association. The Association has been opposing prescription charges strongly for ten years and has been in favour of them so far for seven days.

Miss Vickers

I understand that the Association is becoming nervous that right hon. Members opposite may come to power. The doctors knew that it was quite all right for them to oppose prescription charges while a Conservative Government were in office. The Association now realises that its worst fears may be coming to fruition and it is trying to make its position clear. I want to make my view clear that if charges are to be maintained there should be some agreement to help those who are most in need.

I am certain that general practitioners appreciate the tremendous interest which my right hon. Friend has taken in them and their work and the number of efforts which have been made by the Government to arrive at a fair solution to the problem which worries most of us, that of ensuring that every one in the country receives adequate attention at home from the general practitioner who, I repeat, is the most valuable figure in the Health Service and to whom we should pay a tremendous tribute.

5.14 p.m.

Mr. Emlyn Hooson (Montgomery)

I agree with a great deal of what the hon. Lady the Member for Plymouth, Devonport (Miss Vickers) said, although I did not agree with her when she advocated a State salaried service. I think that we would all agree that we are discussing a vocational profession. We sometimes tend to forget that though doctors vary in standard, in dedication and in ability, just as do members of other professions, most doctors initially became doctors because they wanted to heal the sick.

A large part of the fear felt by the general practitioner is that his status, his standing as a healer, is being devalued. Much of the fear of a State salaried service springs from the fact that doctors feel that they might become mere ciphers, mere people to sort out those who need aspirins, those who should be sent to hospital, or those who need a certificate. This is one of the problems which any Minister of Health, of whatever political colour, must face. It is the problem of restoring the confidence of general practitioners in their status in the profession and in the community as a whole.

Most doctors realise that by vocation, training and experience they are capable of giving greater service to the community than they are called upon to give. It is true that they are extended physically, but many of them are not extended mentally in their service to the community. They could be extended, and want to be extended, far more than they are.

The most valuable service in medicine largely is that of the general practitioner. He has elected to give his individual service in a given area to patients in their own environment. He has made as much of an election as has the consultant. The specialist has elected to specialise in a given field. He specialises in a certain disease or certain class of patients, such as in geriatrics. He is concerned with a disease or a class far more than is the general practitioner who is concerned with giving individual service to each of his patients. As our knowledge of medicine increases and research enlarges the sphere of medical knowledge and the specialist is required to know more and more about less and less, so in a different kind of way the general practitioner is required to know more and more about more and more.

I am sure that we would all agree that we would make a great mistake if we allowed the general practitioner to feel, or continue to feel, that his status has been truly devalued. It is important to remember that the service which the general practitioner is able to render in treating people in his surgery or in their homes is much cheaper to the community than is the hospital service. We tend to forget that whereas we spend large sums of money on hospitals the service which the family doctor gives is cheaper and more efficacious in many cases than that which can be rendered by a hospital.

It must be remembered, also, that no consultant service can function as efficiently without the help of the general practitioner. Consultants have told me that among the most valuable help that they receive is a full and proper report from the general practitioner. The consultant sees the patient for the first time and knows nothing about the family background or the patient's idiosyncrasies and he is sometimes puzzled that the patient does not recover as he should do. This is where the general practitioner's report is of great value to the consultant.

We ask ourselves today whether the community is receiving the value which it should receive from the general practitioner. I think that the answer is "No". By and large, most doctors are overworked and they are over-fatigued with routine and unnecessary work. Very often they complain, as they did at Manchester, that so much of their time is taken up by the apparently unnecessary patient; the patient who simply wants reassurance or, perhaps, wants to have a chat with his doctor.

I suppose that all of us, as Members of Parliament, know of constituents who come to us and, perhaps, at times create unnecessary trouble in this way, whereas the constituent with real problems is very hesitant to consult us. A doctor constantly faces this kind of thing. The more overworked he is, the more plagued he is with routine matters, the less does he feel able to deal with that kind of patient. One of the basic problems in our medical service today is that the doctor is working far too long hours and has to give too much time to routine work which could be done by others.

Many general practitioners are prevented from realising their full value to the community by the surroundings in which they work. There is not sufficient incentive for a doctor to improve his surroundings, to have an attractive surgery, and so on; and the family doctor is very often working in isolation from his fellows. This is not good, and there is no material inducement to him to give the even better service to the community.

Moreover, because the doctor is overworked he tends to send more and more people to hospital if he can—this is especially true in urban as opposed to rural areas—many people are in hospital unnecessarily. They could be better dealt with at home, with the assistance of the general practitioner, the health visitor, the district nurse, and so on, but they are sent to hospital, and this makes the hospital service overcrowded and needlessly expensive.

I come now to a few ways in which the service could be greatly improved. We are all concerned at the fairly low rate of recruitment to the profession today. The 10 per cent. cut has been restored, but many more doctors are needed here, and many more must be induced to stay here. As has already been pointed out, recently reported research discloses that about a quarter of those who qualified in British medical schools during the past 10 years have emigrated to one country or another. It is not enough, therefore, to train more doctors or to induce more people to enter the profession. The conditions of medical service in this country must be made sufficiently attractive to persuade doctors to stay here once they are trained.

Here I completely disagree with the hon. Lady the Member for Devonport when she suggests that the State can demand that medical students who are trained as doctors shall stay here and render part of their service to the State. It is up to us to create the kind of country and the kind of service which induces them to stay here. There is no obligation as such on them to stay.

What could be done—and this has been advocated from both sides of the House today—would be to set up many more medical schools, particularly in those areas which are under-doctored. It is well known that doctors, having graduated, tend very often to set up practice in the areas in which they qualify. It can be shown statistically, I think, that most of them set up practice fairly near to the hospital centres in which they qualified. The under-doctored areas of the country could do with some medical schools of their own.

More students could be accommodated in the present medical schools. To take Wales, the country about which I know most, we have there one medical school only, the National School of Medicine, at Cardiff. But we have many very good hospitals and many very fine consultants in our hospitals in North Wales and West Wales. Part of the clinical work of students in Wales could be done in those hospitals so that the input and output of the medical school itself could be greatly increased, the clinical side of the National School of Medicine, at Cardiff, being, as it were, extended in this way. I am sure that something similar could be repeated elsewhere in the country, thus immediately increasing the number of people entering medical schools now even without any increase in the number of schools.

From my own experience, I know of many young men who want to get into medical school and who find it extremely difficult to do so today, although they are convinced that their vocation in life is to qualify as doctors and help to heal the sick. Once we have more doctors qualifying, it will be necessary also to improve conditions here to persuade them to stay. Much has been made of the advantages of group practice, and I do not doubt that group practices are very important and much more attractive to many young practitioners. I can see the advantage of group practice to doctors more readily than I can see the general advantage to patients. I believe that much of the best service in medicine is given by the family doctor working alone. Nevertheless, the conditions in which such a doctor works are extremely unattractive to young men entering the profession today.

One way to improve matters would be to change the free-interest loan system for group practices improvements so that grants are given much as grants are given in agriculture, for instance, for the improvement of buildings and facilities. There is a very good case for giving grants to doctors to improve their surgeries and the facilities afforded to patients at their surgeries. If the Minister decided to limit himself even to the interest-free loan as at present, this system ought to be extended beyond group practices to individual practitioners so that they, too, could be entitled to the same facilities.

There must be far greater encouragement to doctors to improve their premises and conditions of work. I know very little of medical practice personally, save that I come into contact with it very often in my work in the courts, but in my family there are a number of doctors, in private practice, in the hospital Service, or teaching in university. I know that they constantly argue that there is no real incentive—except the feeling of vocation of a doctor—to improve his premises and make them attractive to patients. Indeed, the less one spends, the more one earns because of the way expenses are paid.

I know of a group practice in which three young doctors have spent a good deal of money, their own money and the Minister's by way of interest-free loan, making a very attractive surgery, with accommodation for a dispenser-receptionist—this is a rural practice—and offering appointments to every patient. Nevertheless, the doctors are out of pocket in doing this sort of thing. Per- haps, in the course of time, they may get more patients, but it remains true that the doctor in the little back room in a back street is very often able to earn more money because of the way expenses are paid. There should be more encouragement particularly to young doctors to improve their premises and amenities.

I make again now the suggestion which I made in our last debate on medical services—it has been repeated today in a rather different form by other speakers—that we should in future develop our service so that the general practitioner becomes, virtually, the leader of a welfare team. Much of the work that a doctor performs could be equally well done by a nurse. Much of the work he does could be supplemented by the work of health visitors. It is very important that such people as nurses, health visitors and even welfare officers should be attached to practices.

This has been done already on an experimental basis. In the practice which I mentioned, a health visitor has been attached for some time now. We must regard the general practitioner as the keystone of our National Health Service edifice, looking upon him as the leader of a qualified team, as someone no longer working in isolation but as a qualified man free to devote more and more of his time to his own work. We must ensure that he is able to give the real benefit of his training and experience to patients who need it, relieving him of a great deal of the paperwork that he has to do, providing him with secretarial assistance, and so on.

That is the way in which we would improve the Health Service. This is far more important than arguments about how the general practitioner is to be paid. I regard him as being underpaid. The differentials between the general practitioner and the consultant are far too great. The general practitioner deserves far greater remuneration than he gets. Nevertheless, I am sure that even in his eyes the question of money is secondary to his status in society and the function that he is to perform. I do not think that we will ever encourage the right kind of people to come into general practice if the general practitioner feels that he has been reduced to the status of a cipher or of a sorting office.

My final plea to the Minister is that it is essential to bear in mind that medical practice in rural areas is considerably different from medical practice in urban areas. Whenever I listen to debates in the House of Commons on medical services, I, as coming from an entirely rural area, realise how different are the problems in large towns compared with the problems in the sparsely populated areas such as I represent.

In areas such as mine—and, fortunately, we are well favoured by our doctors—it is important to maintain the doctor's connection with the hospital service. The general practitioner hospital is extremely important in the rural areas. I beg the Minister to take care not to shut the rural hospitals simply on, as it were, a headage basis and to bear in mind the importance of the hopsital as a centre where local practitioners meet and get together. The hospital plays an important rôle in a rural community. It is necessary, above all, not to approach the problems of the National Health Service in the rural areas with an urban mind. What applies to the towns very often does not, or should not, apply to the country.

5.33 p.m.

Mr. Dudley Smith (Brentford and Chiswick)

The hon. and learned Member for Montgomery (Mr. Hooson) has, as always, made a good case with persuasiveness and moderation, and in large measure I do not disagree with him. The hon. and learned Member even managed to bring in agriculture. I used to think that doctors were rather like farmers and that whatever was done for them they still complained and were always in conflict with the needs and ideals of politicians.

I changed my mind earlier this year, however, when as the father of a young family I made great inroads into the time of a group practice when my children had measles, german measles, chickenpox and mumps in quick succession. As a result of my contact, I had a better appreciation of some of the difficulties which face even the group practice.

I was interested to hear the remarks of the hon. Member for St. Pancras, North (Mr. K. Robinson). It seemed to me that his speech was a recapitulation of his article yesterday in the Sunday Mirror, the newspaper which always mirrors the Socialist case so faithfully, up hill and down dale. I found it rather depressing. I should have expected the hon. Member to come up with some even better ideas to try to improve the Health Service if he aspires to become Minister of Health in the unlikely event of our having a Labour Government in the autumn.

Even so, I agree with the hon. Member that whatever the rate of hospital building, however many nurses we recruit, the doctors undoubtedly form the cornerstone of the National Health Service and that we must have more and efficient doctors if that Health Service is to function satisfactorily. There is undoubtedly dissatisfaction among the majority of the family doctors, and it is becoming more widespread. I do not think that the public appreciate just how much the doctors are troubled about their conditions of work.

That dissatisfaction is not, however, as has been suggested by the Opposition, the fault of a Conservative Government. It is because of a general disenchantment which they are experiencing over the National Health Service. Indeed, far from what the hon. Member for St. Pancras, North said, I believe that if a Labour Government were to win the next General Election the doctors would be even more disenchanted with the National Health Service after a period of time.

The personal element in medicine is of paramount importance. I agree with my hon. Friend the Member for Birmingham, Edgbaston (Dame Edith Pitt) that although some of the proposals put forward by the Opposition possess a lot of merit, they tend towards tighter State control of medicine and of individual practising doctors.

Mr. Denis Howell

Rubbish.

Mr. Smith

The hon. Member will have an opportunity later to make his point. That is a personal view, and I believe it to be the case.

The Health Service is 16 years old and the majority of doctors working in it feel that it is getting out of date and needs major revision. I agree with that view, and I hope very much that the next Conservative Administration will make the necessary reforms.

We must, however, ask ourselves what is the basic problem of family doctors bearing in mind that there are 23,000 of them. The family doctor certainly needs more money, as we have heard from speaker after speaker in this debate, and I imagine that he will get it soon as a result of the current negotiations. In many cases, the family doctor is underpaid, particularly when judged by the degree of responsibility which he holds in the community. His expenses have mounted and his duties have increased with the larger numbers of patients. His allowances and expenses are unrealistic. This is one point on which I agree with the hon. Member for St. Pancras, North that an overhaul is necessary. The present system is thoroughly incompetent and out of date, and I hope that something can be done in this direction.

Money is not, however, the main cause of the trouble and of the dissatisfaction. Many family doctors feel increasingly that they are the poor relation of the medical service, the poor relation of specialists and of surgons, some of whom are among the top-salary earners in the community. Family doctors see themselves more and more as the writers of prescriptions and the issuers of absentee certificates. When there is any doubt, they usually refer the case automatically to the local hospital.

For many doctors, the art of doctoring seemed to go out of the window the day they left the hospital service or the day they entered a large practice with too many patients. They become the prisoners of surgery routine and they are the captives largely of their own telephone. The surgery routine is something of a frustrating charade. The doctor with a large practice nowadays finds himself faced with a waiting room which is crammed with patients except, ironically enough, on a Saturday morning, when many people are not seeking time off from work. If the family doctor is to get out on his rounds, he must get through his waiting room of patients quickly. He must rely on his sixth sense to be able to spot the person who has turned up with what is fundamentally a basic serious illness as distinct from the person who merely eats too much or who "swings the lead" and wants a few days off from work.

In fairness to patients, it must be said that they complain that they have hardly time to explain their symptoms during a consultation before the next patient is called in. Despite this, and despite the fact that there is a certain amount of malingering and hypochondria among patients, there is a danger that after a time the doctor will find himself getting more and more out of date in trying to keep up with too large a number of patients. In addition, it must be borne in mind that, despite the malingering, according to a recent report one person in ten in the community suffers from some form of basic serious illness and, unless he gets treatment, will become much worse or may die.

The doctors themselves are partly responsible—I do not say this is too critical a vein—for the way things have gone because of their own indecision and because of their imperfect organisation and the representations which they make concerning the Health Service. I think, also, that some of the patients are to blame for what is happening. The National Health Service has made doctors more freely available to the community than ever before. This is right, as I am sure, both sides of the House agree. But the doctors' service has not grown to cope with the increased commitments and many doctors feel, quite rightly, that the service is being abused by the general public. Selfish people will often call in a doctor when they could easily have made the trip to his surgery and have explained their symptoms to him in the consulting room. One doctor told me recently that he estimates that five out of every ten visits that he makes to patients are unnecessary because these people could easily have gone to the surgery and have taken the burden off his shoulders.

The doctor more than anybody else knows that we are becoming something of a nation of hypochondriacs. We think more about our health than we used to do, and perhaps this is because of the stress and strain of modern living. It may be partly due to the concentration by television, on medical matters, as my hon. Friend the Member for Edgbaston said. Some people today arrive at the consulting room with a self-diagnosis of what is wrong with them. Perhaps there is a morbid tendency aroused in people through the concentration on medicine on the television screen.

I am not surprised at the B.M.A. vote last week on the question of charges. This is mainly because they fear that the abuse of the service is growing and needs checking. I do not believe that they seriously consider that a charge should be imposed, or that a Conservative Government would impose, a charge on patients. I see that in his article yesterday the hon. Member for St. Pancras, North said that he did not think that the B.M.A. vote was a fair reflection of the view of the majority of doctors in this country. I believe that it is the view and that they hold it because they feel that the service is coming into great abuse.

Mr. K. Robinson

What evidence has the hon. Member that the abuse of the service is growing? I have been able to discover none whatever.

Mr. Smith

Like the hon. Member, I am not a qualified medical practitioner, but I am told by people who are that time and again people come to them quite unnecessarily, that their waiting rooms are unnecessarily crowded, that on the whole there is a tremendous amount of abuse in prescriptions and that this abuse will certainly grow if we abolish prescription charges. I believe that if we get rid of prescription charges there will be a gross wastage of drugs and that this will be a severe cost to the State.

There are a number of conclusions which one can draw from this discussion. The doctor's biggest problem is not money, although money comes into it; his biggest problem is the heavy and increasing amount of work which he is required to do and the extra time which he needs in which to keep up to date. In fact, he can ill afford the time and seldom gets an opportunity to do so. A tremendous number of technical journals reach the doctor and are thrown straight into the wastepaper basket because he has no time to read them.

Some family doctors are using out-of-date drugs because they are not sufficiently up to date to know the new drugs which have been introduced and which are more effective. It is more important than ever that family doctors should keep abreast of developments because of the rapid advance in techniques being made over the whole field of medicine.

What are the answers to the doctor's problems? Some have been suggested today. The hon. Member for St. Pancras, North suggested that the only way to cure the trouble is to have a Labour Government. I will not be equally political and say that the only way to cure it is to continue to have a Conservative Government. The doctors must help us to put their own house in order, and we need a new streamlining of the National Health Service. First, we need more doctors; we are all agreed about that. I am glad that steps are being taken to stimulate the recruitment of doctors.

We also need doctors with shorter patient lists, and we want doctors to have fewer patients without suffering any cut in their remuneration. We need more group practices, not only because it is easier and better for the family practitioner to get time off and arrange his holidays but because from the medical point of view there is extremely good value in group practices, with the possibility of on-the-spot second opinions for the patient whose illness raises a query and the possibility of internal consultation. A group practice also gives the patient the chance of having a different doctor if he thinks that his own doctor is not very good. When he telephones for his doctor he may well find that one of the other partners visits him.

We must have diagnostic clinics which can take over some of the work of the hospitals in discovering what is wrong with patients whose illness is not straightforward. These diagnostic clinics could be run by general practitioners, and group practices can play a part here. In due course, when there are sufficient doctors, I should like to see regular medical overhauls for every member of the community. Every person on a doctor's list should have a complete check-up every year or so under that group practice. This would be a definite step forward in helping preventive medicine, and I hope to see it introduced later.

Parliament must soon make up its mind what sort of medical service it wants during the remaining years of the 20th century. This country has always been in the forefront in the practice of medicine. As we approach the twentieth year of the National Health Service, we need a new approach, not only from the point of view of the doctor but from the point of view of the patient.

5.46 p.m.

Mr. Denis Howell (Birmingham, Small Heath)

It has been a long time since a young Member of the House has regaled us with what I can describe, I hope not offensively, as such a senile view of politics and medicine as we have heard from the hon. Member for Brentford and Chiswick (Mr. Dudley Smith). For him to castigate my hon. Friend the Member for St. Pancras, North (Mr. K. Robinson) with failing in an article in the Sunday Mirror to produce any new ideas, when he himself had produced almost every cliché ever written in any newspaper in the last 20 years and at the end of it had offered no new ideas at all, seems deplorable.

I deplore what he said, and what the hon. Lady the Member for Birmingham, Edgbaston (Dame Edith Pitt) said, about prescription charges. Generally, there has been a very constructive line of thought throughout the debate, but the hon. Lady has one great distinction—she was in office when the Government doubled the prescription charges. She currently supports the line of thought which she then pursued at the Ministry of Health.

I cannot understand this dichotomy in the thinking of Conservative Members. If it is wrong to charge patients when they visit their doctor, it must be equally wrong to charge them for the medicines which are prescribed on a visit to the doctor. The hon. Member for Brentford and Chiswick argued that one of the great failures of the National Health Service was to impose a tax on the sick, which is what prescription charges are—

Mr. A. R. Wise (Rugby)

Who invented them?

Mr. Howell

Prescription charges were first imposed by a Conservative Government. [HON. MEMBERS: "NO."] Hon. Members have become so obsessed with their own propaganda that they do not know that they were the people to impose prescription charges.

Dame Edith Pitt

rose—

Mr. Howell

I will give way to the hon. Lady when I have finished this historical account of prescription charges.

The beginning was in the Korean War. During that war the international and national economy were disturbed to such an extent that our late and esteemed colleague Mr. Hugh Gaitskell—who specifically said at the time that it was for this purpose only—said that it was necessary to mobilise the whole economy of the nation to fight the offensive of Communism and the disturbing effect which this had on our balance of payments. For that purpose alone, as he said at the time, he introduced a Bill which would enable certain charges to be imposed. But a Tory Government imposed them. Neither Mr. Hugh Gaitskell nor any other Minister ever imposed a single prescription charge. I am quite willing, having given this history, to have a confrontation with the hon. Lady.

Dame Edith Pitt

The hon. Member has made the point which I was trying to persuade him to put on the record—that the power to make prescription charges was made by his own party.

Mr. Howell

For what it is worth, I give that away. Hugh Gaitskell, who never did anything without explaining it clearly, specifically said that it was for the purpose of the Korean War. The Korean War ended in the early 'fifties. This coincided with the arrival of a Conservative Government, who, if they had accepted Mr. Hugh Gaitskell's philosophy, should also have accepted his remedy, which was to end the provision when the emergency had passed.

I turn now to the evils of prescription charges. I ask any hon. Member opposite to justify their imposition upon people suffering from Parkinson's disease or on diabetics. I am the chairman of a very large hospital in Birmingham which has a Parkinson's disease clinic. It is a very terrible illness, and, unfortunately, medical science cannot cure it, but it can keep it reasonably under control. Every time one of these sick persons goes to the clinic, it means he has to take away a prescription bearing four, five or six items in order to keep him going.

These are people who must be among the worst off financially in the community, certainly from the health point of view, and because of a Conservative Government they have to meet this charge of 8s., 10s. or 12s. or even 14s. per week or fortnight every time they take a prescription to a chemist's shop. Is there a single Tory Member who will justify that? Not one. Hon. Members opposite know perfectly well that one cannot justify that. Nor can one justify the charge for the diabetic.

While the responsibility is originally that of the Tory Party, it becomes a national responsibility as and when the nation decides to endorse the system. I make a simple and political point which is justified, that anybody who votes Conservative wishes to impose a tax on the sick of the nation. It is a simple proposition, and I believe it is true.

I want to turn now from heady political points. I do not know what is amusing the hon. Member for Rugby (Mr. Wise).

Mr. Robert Cooke (Bristol, West)

Before the hon. Gentleman leaves that point, would he like to know—

Mr. Howell

I was just dealing with the hon. Member for Rugby when the hon. Member for Bristol, West (Mr. Robert Cooke) rose. I cannot deal with two hon. Members at the same time. The hon. Member for Rugby seems to find it amusing that people suffering from Parkinson's disease have these charges imposed upon them.

Mr. Robert Cooke

Perhaps I might read to the hon. Member what Lord Attlee said in October, 1949: We propose to make a charge of not more than 1s. for each prescription under the National Health Service. The purpose is to reduce excessive and, in some cases, unnecessary resort to doctors and chemists, of which there is evidence which has for some time troubled my right hon. Friends the Minister of Health and the Secretary of State for Scotland."—[OFFICIAL REPORT, 24th October, 1949; Vol. 468, c. 1019.] Perhaps the hon. Gentleman will bear that in mind when making his suggestions.

Mr. Howell

This illustrates Tory mentality. Because I told the House what Mr. Hugh Gaitskell said, the hon. Gentleman decided to find out what Lord Attlee had to say about the matter. Whatever Lord Attlee or Mr. Hugh Gaitskell said on the subject, even bearing in mind the quotation just read by the hon. Member about the suggestion of a 1s. prescription charge, the fact is that the Labour Government, under Mr. Attlee, did not impose a 1s. prescription charge or any prescription charge. [Interruption.] It is no good the Joint Parliamentary Secretary saying that we were driven out of office. His hon. Friend has quoted from a speech made in 1949. We did not go out of office until 1951. The Joint Parliamentary Secretary's remark does not square up with what his hon. Friend has quoted.

The Joint Parliamentary Secretary to the Ministry of Health (Mr. Bernard Braine)

The hon. Gentleman is making very heavy weather of this. The principle of making these charges was first introduced and legislated for by a Labour Government, not for the reasons which the hon. Gentleman has given the House but for the reasons which my hon. Friend the Member for Bristol, West (Mr. Robert Cooke) has told the House about. Whether or not those charges were imposed is a matter of history. The present Leader of the Opposition was one of those who resigned from the Labour Government at the time largely because he thought that these moves were unnecessary cuts in the social services, to quote his own words. My feeling is that it is quite unprofitable for the hon. Member to pursue this line of argument.

Mr. Howell

I have no doubt that the hon. Gentleman thinks it is unprofitable for me to pursue this line, but it is a very late conversion, because we have already had three Tory Members talking about it, and they were not stopped by the Joint Parliamentary Secretary. He obviously feels that it is all right for Tories to talk about prescription charges but it is morally indefensible for Socialists to talk about them.

The short point is that 1949, the very time mentioned by the hon. Member for Bristol, West, was the year when the Korean War broke out, and that was what brought this matter to a head. [Interruption.] The hon. Member for Rugby sits there shouting all the time. If he has something to say, will he get up and say it?

Mr. Wise

I was expressing the view that, whatever the hon. Member may say, he cannot know better than the Labour Prime Minister at the time, who announced the exact object of these charges. His very intelligent and brilliant mind is not as brilliant as all that.

Mr. Howell

I apologise to the House. It is clear that I ought not to have sat down and allowed the hon. Member to intervene. My point is that the great argument which took place in the Labour Party and the nation was bound up in an increase in defence expenditure brought about by the Korean War and a very greatly changing international situation. Mr. Hugh Gaitskell said that it was entirely to do with the additional burden imposed on the economy by the Korean situation.

To bring ourselves up to date, the question is: what are the Tories going to do about it? It seems to me that to impose this tax on the sick is a disgrace to a civilised society. One thing which has come out of the debate—I am sure that it will be read outside with interest —is that the next Labour Government will get rid of the charges but that the Conservative Government will go from strength to strength and no doubt impose further burdens on the sick.

I turn to the question of a salaried service. I agree with what the hon. Lady the Member for Plymouth, Devonport (Miss Vickers) said about this. I take issue with the hon. Member for Brentford and Chiswick and the hon. and learned Member for Montgomery (Mr. Hooson), both of whom said that they are firmly opposed to a salaried service. But we have got a salaried service. The fact that we refer to a capitation fee does not matter. The moment one puts a limit on the number of patients that a doctor can have by telling him that he can have 3,500 patients at 20s. 6d. or 35s. 6d., whichever of the two figures one picks, it is a very simple calculation to work out what his income or salary is. More nonsense is talked about a salaried service than anything else in medicine. We have a salaried service, and we ought to make it respectable and acknowledge that it is a salaried service. Then we could move from that point to ensure that it was a decent and adequate salary, and all the other things that we want could flow from that.

I agree, that questions of status and prestige are involved. People have spoken kindly about general practitioners and said that money is not the root of all their discontent, but we know that at the bottom it jolly well is and that all the questions of prestige and status mean nothing compared to remuneration. They need a decent salary, and there is no reason why they should be ashamed about it. After all, to become a doctor a man has to spend about seven years in a university and a hospital. It is a longer training than almost any other person has to undergo, and at the end of the time the doctor is entitled to a decent and adequate salary and to all the aids that we can give him so that his expertise, skill and professionalism can be used to the best advantage of society.

One difficulty, of course, is that they do not want a full-time salaried service. We could get over this by offering a very good salary—the Review Body or some other organisation could look at commensurate salaries in other professions—which would be paid for a notional seven-eighths of their time, thus allowing one-eighth of the time for the doctors to do their police or insurance work which has to be done and which they want to do. This would get round the psychological difficulties—which is all they seem to me to be—about the question of a salaried Service.

I am glad my hon. Friend the Member for St. Pancras, North made the point that there is no question of imposing anything like this on the profession, and I am sorry that the hon. Lady the Member for Edgbaston did not appreciate that. We hope that the doctors will accept our proposal, but it could not be introduced until the profession decided to accept it of its own free will.

What are the reasons for wanting to build up the general practitioner service? We cannot divorce consideration of this from consideration of the load upon the hospital service. Those of us who work in hospitals know that. My hon. Friend the Member for Bristol, South (Mr. Wilkins) said that G.P.s should be able to go into hospitals to follow up their cases. I am not sure what that means. As chairman of a hospital, I cannot quite see what the G.P. could do if he followed a case into hospital because, on entry, a case automatically comes under the charge of a consultant, the registrar and probably a houseman. It is difficult to see how one could change that fundamental pattern.

Mr. Wilkins

I hope that I was not implying that the G.P. should follow every case into hospital. Nevertheless, there are some things of great interest to the G.P. and from which he could profit by seeing certain patients under treatment.

Mr. Howell

I take the point and, speaking again as chairman of a hospital, I can cay that I do not know any hospital or consultant who would not welcome the interest of a G.P. in following a case into hospital. I can only speak with certainty of my own hospital but we would welcome a G.P. coming in to discuss a case.

What we need is a link between the G.P. service and the hospital service whereby we could make available to the G.P. three things—a radiological service, a pathological service and a central sterile syringe and pack service. This would be a boon to G.P.s. In my own hospital we are trying to give a radiological service but it is almost physically impossible to do so. The load on the radiological service is already very heavy. We intend to extend the department but we are not helped by the fact that, in the latest hospital plan, provision which was shown in an earlier plan has now disappeared.

However, we shall do our best to provide a radiological service. If the Minister wants to stop the frustrations of G.P.s he could help the hospitals to provide these three things to general practitioners which I have mentioned. They would be of great help to G.P.s.

I am glad that doctors' wives have been mentioned. Apart from the wives of M.P.s they are the main unpaid public servants in our society. I do not suppose that we shall ever get pay for the wives of M.P.s, particularly as we cannot get proper pay for M.Ps. But in many ways the problems of G.P.s and M.P.s are similar. Everyone recognises that we are doing a good job dirt cheap but no one is willing to come forward and pay what we are worth.

I believe that doctors' expenses should be paid. I understand that the Ministry is being niggardly about what it suggests for ancillary help and is offering about £300. What can one provide for that these days? What a group practice needs is a qualified nurse and a secretary cum receptionist, quite apart from the money provided for the group practice through the National Health Service. One of the reasons for encouraging group practice or health centres is that there are not enough trained nurses to go round under the present system. While it might be possible to provide a nurse for each group practice or health centre it is impossible to provide one nurse per G.P.

I have made careful inquires of my own G.P. I find that there is a real feeling of grievance about documentation. He and his colleagues have done a little research for me and they say that, if there were a simple change in the National Insurance Regulations, they could cut down the number of people coming to their surgeries by 40 to 45 per cent.

It seems that no G.P. can give a certificate under the National Insurance Regulations for more than one week, even though he knows that the man hobbling into his surgery with a broken ankle, for instance, has no possibility of returning to work for weeks to come. If that patient were in hospital care, the hospital could issue a long-term certificate. Why on earth cannot the G.P. be put in the same position? If we get nothing else out of this debate I hope that the Minister will look at this and try to make it possible for G.P.s to issue long-term certificates in cases where it is warranted.

We can surely trust the G.P.s. We know that they are doing wonderful work. They can surely be trusted to say whether a man will be unfit for work for a certain number of weeks ahead. This would be a substantial advantage in their daily practice.

Little else needs to be said about salaries. It is a crazy system that puts a premium on inefficiency. I would only add that, when we employ G.P.s in the hospital service, then what they are paid for this help comes out of the global sum available to the doctors as a whole, and that is ludicrous. If a G.P. gives up what time he has available to help out in the casualty department of a local hospital, that correspondingly reduces the global sum available to the profession as a whole. That is utterly wrong.

We need some variety in medicine. Above all, we need to raise up again the hopes of G.P.s along the lines I have mentioned. The suggestion by my hon. Friend the Member for St. Pancras, North that executive councils should play a more positive part is excellent. That is the correct approach to the problem. Those G.P.s who are fortunate enough to practice in health centres are in effect being subsidised, usually by the local authorities. Certainly they are in Birmingham, where they use the ground floor of a high block of flats. Here again there is an inconsistency which is indefensible.

If a principle is at stake, and it is necessary to have G.P.s in group practices or health centres, then financial assistance must apply to all who are in group practice or in health centres. If we can get their salaries right and their position vis-à-vis the hospital service adjusted, the doctors themselves will have to do some readjustment and rethinking.

It is a matter of regret to me to have to tell the House that it is the experience of some consultants in my hospital that the night service is nothing like as good as it should be. One can understand that, after a very hard day such as we have heard about, doctors do not like being fetched out two or three times in the middle of the night. But that seems to be simply a matter of organisation. Why cannot general practitioners make sure that one of their number goes on comparatively late in the evening and does night work, so that the others can arrive fresh in the morning?

What we are finding more and more—and the Ministry will have to note it—is an unfortunate tendency by a minority of doctors—and I repeat, a minority—who are fetched out at night but who, instead of visiting their patients, send for an ambulance and have them packed off to hospital. We have come across some of these cases and we are trying to chase them, but it is a matter of regret that a general practitioner should send his patients into hospital simply because he himself is in such a state that he cannot carry on with more visits in the night after having had such a long day.

If we play fair with the doctors and get their salaries right—and we all want to do that and there seems to be no reason why it should not be done—and if we give them all the things which we want them to have and set them up in group practices or in health centres, these little difficulties—and I put them no higher than that—about giving an adequate service to the hospitals as well as the patients ought to be remedied.

6.12 p.m.

Dr. Reginald Bennett (Gosport and Fareham)

I am sure that the House has enjoyed the speech of the hon. Member for Birmingham, Small Heath (Mr. Denis Howell) with its forays into party polemics, and, in all seriousness, the constructive contributions which he has made from a position of authority.

I have not been in general practice for many years. As many hon. Members know, I transferred my studies to mental medicine and ended up here. I have been asking some of my friends and former colleagues in general practice about where the shoe pinches and I have been hearing something from them. Inevitably, what I have to retail to the House is secondhand, but it is clearly authentic, straight stuff.

I am glad to have the chance to support my former colleagues and to put some of the points which they make, which, I am bound to say, have been very pertinently found out this afternoon by hon. Members who seem to have got down to the nub of the subject in all sorts of directions. There is a great consensus of opinion throughout the House about what is wrong and what needs doing and almost about how it should be done. All the points which have been made on the subject of how to improve the lot of the general practitioner and his patients require action. They must be met, and met as a matter of urgency.

The first clear comment on the situation is the fact that young doctors are not coming into the service. Recruits are not coming into the profession. There is one universal comment behind all this which does not apply only to doctors by a long chalk. It is that the work requires 24 hours' service, and in these days, when people can earn good money without having to do night emergency work, getting people to volunteer for the arduous professions like medicine, or police work, or other service work of any sort, becomes increasingly difficult. The people who are actually in medicine soon discover that they would much prefer to work in the hospital service, or even overseas and that the lot of the general practitioner in this country is very harsh.

As has frequently been said, there is no doubt about the reality of the annoyances and frustrations with which the general practitioner is faced at every turn. As a consequence of all this, there are too few doctors, especially in the younger-age groups, and there are nothing like enough to fill the vacancies which are now cropping up.

I think that I am right in saying that after the war an inquiry reported that there were too many doctors and that there should be a discouragement against entry into the profession. This was at the time when I was making my first attempt at resettlement after the war, and I was thunderstruck to hear it. Anybody in medicine knew perfectly well that it was complete balderdash. Now, a decade or two later, we are faced with the consequences of that great error of judgment and now we have to do something to increase recruiting into this arduous profession.

A medical friend of mine told me that 18 years ago there were 120 applicants for every job which became vacant, whereas now practices were going begging. He told me that, recently, not in one of the under-doctored areas of which we know so well, but in darkest Chelsea, there was a complete practice which needed someone to run it. Three applicants put in their names and in turn each found that he could not run it. In the end, the practice had to be carved up and redistributed among adjacent practices. That is the situation which we have reached right on our own doorstep, here in the middle of London.

One of my informants has told me about this terrible business about money. I do not mean salary. The case for that is obvious enough and I did not discuss it with my general practitioner colleagues. I am concerned with the money invested in practices. There is an injustice in this connection which has been mentioned but which has not been squarely put and which my right hon. Friend should examine. Interest-free loans are available for the improvement of practices only where there are three or more partners. The wretched single-handed man and the practice with two partners are not entitled to expect finance of this sort. This is most unfair because, as we all know, it is the single-handed man who is up against it in the worst sense.

It seems a little odd that Government funds can be used for improving hospitals and not be available for improving practices while practitioners are by law prevented from owning their practices. A curious issue was raised by an hon. Friend of mine who pointed out that there was an amount which had to be paid by a doctor going into practice because of the money which the existing partners had raised for paying off loans, and so on. We are thus getting into the situation where part of a practice has to be paid for with his own money by someone who wishes to become a partner. This is quite anachronistic, and there is something grossly illogical about the expectation that private money should be spent on what are public practices.

Another handicap for all those in practice, as was recognised this afternoon, is the cost of premises. The price of premises for a practice in London is now prohibitive. When tens or scores of thousands of pounds represent the value of one perfectly ordinary house, it is impossible for any practitioner, or pair or trio of practitioners, to be able to raise the money to house a surgery.

Nor is there any London weighting for practice expenses. One informant told me that he thought that it was a bit hard that he and his colleagues in London should be appraised for expenses of their practice on precisely the same financial basis as a doctor practising in Merthyr Tydvil, or somewhere else where the cost of a practice would be approximately one-tenth as much. We come back to the doctor who is trying to run a single-handed practice. He finds that locum tenens are practically unobtainable, and practically prohibitive if they are obtainable, so that the single hander cannot go on holiday and is breaking the law if he goes sick. This seems to me to be a foolishness which we ought not to continue to counterance.

Another difficulty is that experienced in London and in many big cities. Doctors on their rounds, as they used to be called, cannot park their cars outside the house at which they want to call, and have to drive past and find somewhere else to park. This is absurd. I realise that any concession to doctors might open the door to all sorts of abuses; that people might put medical stickers on their cars and get away with it; but my right hon. Friend the Minister of Transport might well pay attention to this, because he allows people who are invalids to park their vehicles in defiance of the regulations. It might be possible for those who are on their rounds to make use of unloading bays. Unless this is done, the medical practice will suffer and none of us wants that to happen.

The biggest trouble, I think we all agree, of this difficulty about medical practice is that of patients requiring chronic supportive treatment. It is all very well to say that people should be discouraged from going to doctor's surgery, or that it is grossly unfair that they should be discouraged from going there, but one doctor tells me that he can tell the day of the week merely by looking at the faces in his surgery.

These people are undergoing supportive treatment which is not physical. It is psychotherapy. It is often said that 30 per cent. of the patients seen by a general practitioner are in some measure nervous cases, to describe them in the jargon. Here is the difficulty, and I think that we all understand what has happened. There has been a game of pat ball. When the National Health Service started, the old relationship by which the private practitioner was paid 2s. 6d. a time to go on seeing people who needed his spport although there was no real medical content in it ascertainable by laboratory means, broke down. When the Health Service was introduced and these doctors were given their lists and had great demands put on them, there was no place in the scheme of things for the chronic patient needing supportive treatment.

The result was that they were sent to the hospitals because these had the psychiatric services, and many of us know that the psychiatric outpatient clinics regarded these patients as not being within their province so they were sent back. As I say, it was a game of pat ball. This is no good. We all recognise this as a fact, and we must do something about it because these are the people who are breaking the back of the general practitioner.

I suggest to my right hon. Friend that the only way out of this impasse is to provide some sort of therapist. I do not mean the psycho-analytical expert who talks in high-flown jargon. I mean some work-a-day trained male nurse, or dual trained nurse, who might be called a medical auxiliary, to look after the chronic patients who need this supportive treatment. This would provide a substantial easement of the burden on the general practitioner.

I appreciate that the problems are very heavy both for the general practitioner and for my right hon. Friend. There are more people in this country now. There are more harassing things today. There is more paper work. One good idea for cutting it down was brought out by the hon. Member for Small Heath. There are more chronic patients. All this work has to be undertaken for a less satisfying life. I believe that one of the things which, quite properly, is upsetting the general practitioner is that while everybody else's leisure is increasing his is diminishing to vanishing point. He is entitled to less scurvy treatment, and we have a duty to improve his position.

The problems are the number in the profession, money and its distribution, and the provision of supportive services, and I am glad that one other hon. Member has paid tribute to the general practitioner's wife who, as everyone knows, is the only unpaid medical auxiliary both for clerical and for therapeutic work available to a general practitioner.

I urge my right hon. Friend to try to become the general practitioners' champion, and to get down to a solution of these problems.

6.25 p.m.

Mr. Laurence Pavitt (Willesden, West)

It is a pleasure to follow the hon. Member for Gosport and Fareham (Dr. Bennett). His speech was full of knowledge on the subject, and I found very little with which to differ in his analysis of the situation.

I propose to comment on one or two of the matters with which he dealt, and which, I think, need underlining. The cost of premises in London is becoming acute. It is almost impossible for a general practitioner to move, or to extend his premises. The Minister said in answer to a Question that I asked that the executive council is enabled to give some support and aid where there is difficulty, but I shall be grateful if, when the Minister replies, he will tell me what kind of support and financial aid it is empowered to give in London where general practitioners find it almost impossible to obtain premises at less than an impossible rental or purchase price.

The hon. Gentleman made a point about the lack of London weighting, and I suggest that the Minister ought to consider this with regard to the problem of giving justice to doctors working in the Metropolis on the subject of locumtenentes, it is interesting to note, on the question of providing services for night calls and. for week-ends, that out of 2,237 general practitioners under the London Executive Council, 1,305 have sought and been granted deputising arrangements. When we talk about doctors doing full-time work, at least in London more than 50 per cent. of them have deputising arrangements on various schemes. Although I should like to discuss the Emergency Night Call Service and its implications for doctors' pay, time does not permit it.

The only other point on which I wish to follow the hon. Gentleman is the question of the chronics who turn up on Monday mornings, and what one should do about them. I agree with the hon. Gentleman's suggestion for a therapist who is able to take some of the load off the general practitioner's shoulders, but surely it must be accepted as part of a G.P.'s job. He is the family doctor. He recognises those who need support, and he can do more to help than can be done by a straightforward application of clinical medicine It is our task to see whether, instead of a few lectures in psychiatry and an examination of the exotics of the Tavistock Clinic, we can provide the training which will enable him to deal with the ordinary middle-aged person who is under stress and strain.

Prescription charges led to a good deal of discussion in this debate. May I remind the House that we voted against this when the then Minister of Health—at that time it was the right hon. Member for Enfield, West (Mr. Iain Macleod)—introduced it in 1952. We had a Division on the Regulations, and this party voted against it. In addition to the comments which have been made by my hon. Friends, it should be noted that this is not only a tax on the sick, but that it means that the more sick one is the more one pays.

A general practitioner see those over 65 10 times a year. Those under 5 also visit him 10 times a year, but those in the middle age group visit him five times a year. This is therefore not only a tax on the sick, but also a tax on the old and on the young, and I am grateful to my hon. Friend the Member for St. Pancras, North (Mr. K. Robinson) for making it clear that a Labour Government will get rid of the prescription charges.

Mr. Barber

Will the hon. Gentleman tell the House, first, which Government took power to impose prescription charges, and, secondly, which Government introduced charges for spectacles?

Mr. Pavitt

That point has already been made by the hon. Member for Bristol, West (Mr. Robert Cooke). I do not want to go over the old ground again, because I am anxious to get to the new ground. It is true that the legislation was introduced by a Labour Government, but it is equally true that it was firmly stated that this was of a temporary nature in time of emergency, and was for only three years. That period has long since passed.

I should like to have followed the hon. Member for Birmingham, Edgbaston (Dame Edith Pitt), because I enjoyed the period when she was Parliamentary Secretary to the Ministry of Health. I pick up one point she made of dissatisfaction among the older general practitioners on the question of the way in which the amount allocated to them in respect of practice goodwill has declined in the period since it was first allocated. It so happens that I have the figures which the Minister gave me recently. The total amount remaining to be disbursed to general practitioners is £27,316,000. If that were brought up to modern prices the Minister estimates that the figure would be £50 million. There is, therefore, a clear discrepancy between the amount that general practitioners were given and the amount that they would get—and to the older practitioners this must rankle not a little. They feel that they are being rather unjustly treated.

I am pleased to be able to have caught the eye of the Chair, on this my last week in my five-year stretch. The hon. Member for Gosport and Fareham talked about mental health, and put forward some analogies in this respect to the kind of life we lead here. My feeling is that I am at the end of my first five-year sentence here. At the beginning of it I had the honour to be the first Member on this side to make a maiden speech, and in that speech I dealt with the question of general practice. I am, therefore, pleased that I am able to speak today, and to wind up what has often seemed to me a five-year duologue between myself and three successive Ministers of Health on the question of general practice.

One of the important things that has happened now—three Ministers and several reshuffles later—is that at long last the Government are coming round to thinking of doing something about general practice. Today, we have had tribute after tribute from hon. Members on both sides for the general practitioner. The hon. Member for Gosport and Fare-ham is right. There is plenty of talk and plenty of tribute, but very little action. In the near future I hope that we shall be able to follow up some of the ideas that have been floating around for some time. We have had the Porritt Report, the reports of dozens of working parties, and the Fraser Committee is now sitting, but at the end there is still need for action to be taken. That action will be political, and I am sure that a Labour Government will be in a position to take it.

For the last 13 years the family doctor has been at the bottom of the queue. The hon. Member for Edgbaston talks about the Gillie Report. I agree with her that it is a first-class job of work. But this is the first opportunity that we have had in this House to discuss it. We have had the 10-year plan for hospitals; we have had the 10-year plan for local health authorities, but general practitioners are not even considered. They are at the bottom of the scale, last in line. The Government have not even found the time to discuss the Gillie Report or to put forward a Government statement for discussion arising from it.

As for pay, we should get it clearly on the record that the average pay of a general practitioner today is £2,765, or £4,200 gross. He gets only 17s. per patient, and 9s. for each in addition as his part of the expense factor. The House assessed the mood of the general practitioner correctly today when it pointed out that it is not just a question of pay or of expenses, but a question of our having to reassess the whole pattern of things and to see how the general practitioner can best fit into the National Health Service.

Dr. Murray, of the T.U.C., recently likened our National Health Service not to the usual form of economic cake which is cut up into individual sectors, but to a layer cake, with four layers. The top layer consists of a large sector of the population which is quite healthy and has no symptoms. The people in this sector do not worry anybody about anything. It is quite a large sector. Then there is another layer, consisting of people who do have symptoms but who either take care of them themselves or go to chemists and say nothing about it. They do not consult anybody. Those top two layers represent about 50 per cent. of the population.

The third layer consists of people who have symptoms and go to see their general practitioners, who give them prescriptions and then see them again in a few weeks' time if they are not better. The bottom layer is the hospital service, which caters in an institutional way. But the whole of our medical practice is based on only part of this lower tier—a very small sector consisting of the teaching hospitals. The whole of our Health Service practice stems from this little sector of teaching hospitals. Therefore, it is not to be wondered that we have an illness service and not a health service. This is where our preoccupation lies.

We must entirely change this situation. In the past, the doctors themselves decided on their method of remuneration and for a long time the Spens Report was like the law of the Medes and Persians, which could not be altered. At the moment, however, opinion in the medical service is fluid, and it is up to politicians to take advantage of that situation so as to make sure that when we make changes those changes are made in the right direction.

I congratulate my hon. Friend the Member for St. Pancras, North not only in his diagnosis, but on the number of points of treatment that he put forward. I would like to add one. I contend that in general practice today there is a certain amount of schizophrenia. The general practitioner is more or less divided. One part of him wants to be above society—the witch doctor type of person—as was the case in the old days, before the National Health Service, especially at the end of the last century, when the squire, the doctor and the parson were above the ordinary run-of-the mill person and were looked up to not as humans, but as being a little godlike.

General practitioners are human enough to want to be a little god-like, or exceptional, or out of the ordinary. But on the other side, in 1964 they realise the need for them to be part of professional society—to be professionally trained and competent members of the community, who, like barristers or architects, live normal married lives in normal homes, with six weeks' holiday with pay and with a normal expectation of being able to fit into the life of the community. It is because, as a profession, they cannot make up their minds where they want to be, that we get the kind of resolution that was passed last week in Manchester.

I suggest that the Minister can help them in this matter if he gives them the opportunity of deciding which type of doctor they want to be—either a member of the present system, under which they have to find everything themselves, including locums and premises, and where they are entrepreneurs on contract to the Ministry, in which case they may retain a little of their god-like father figure relationship with the community 24 hours a day and 365 days a year, or alternatively, accept the fact that, like judges and hospital consultants, there is no reason why they should not be part of a salaried service.

This will not be easy, but is it not possible for the Minister to give an option so that when a doctor starts in general practice he is offered an alternative. He can decide either to be under the capitation pool system, with all that it involves, or to accept a salary together with conditions of service, in which case arrangements will be made for locums, holidays and coverage for his premises—and certainly complete coverage in respect of the kind of ancillary and auxiliary services that he requires. Possibly a solution of this kind would succeed in bringing about a fresh approach on the part of new doctors.

If we are to be successful in this we must have a complete reorganisation of our approach to general practice, and to our idea of where it should fit into the Health Service. The hon. Member for Gosport and Fareham hit the nail on the head when he said that a doctor cannot do everything for his patients. In this respect, we want not merely more doctors and not merely more time. We must begin to study the question as a group job. I do not mean merely three or four doctors operating together. We must consider the matter from the point of view of the kind of people as a team we can put round the doctor—the possibility of providing for him a receptionist, besides health visitors and nurses.

Beyond that, the doctor needs to know the whole range of social services that exists. He needs to know what family service units are doing and what the Council of Social Services is doing. He must know what help he can get from the Multiple Sclerosis Society. Many agents, both voluntary and statutory, are there to help him in his work.

Too much clap trap has been talked about the doctor being the leader of the Health Service team. The hon. and learned Member for Montgomery (Mr. Hooson) referred to him in those terms. Over the whole of my five-year sentence in this House we have paid lip service to this idea, but what has any Minister done about it? Nothing at all. There has been no discussion of the way in which the general practitioner ties in with the local health authority. There is a complete division between the local health authority service and the general practitioner. The general practitioner who practises obstetrics often finds difficulty in being able to obtain the services of the same midwife time and time again, so that he can have the right kind of teamwork relationship with her.

Let us stop talking in glib phrases about the general practitioner being the leader of the Health Service team. If we mean that, we have to take the necessary action nationally, regionally, and locally, in order to give effect to the concept so that the doctor may be surrounded by the kind of people giving service whom he needs to help him and to give him the necessary status. If we are examining the way in which general practice over the next 10 or 20 years will work out we owe a debt to Dr. Abraham Marcus for his clear article in yesterday's Observer. If we are going into preventive medicine, the general practitioner will see more and more people. There will be an increasing need for screening before the disease occurs, and the obvious person to do that is the family doctor who is close to his patients.

We have the appalling situation that during the year before last it was reported by the Chief Medical Officer of the Ministry of Health that 2,599 women died from cancer of the cervix and this could have been prevented. There are many things which cannot be prevented, but when 3,000 women die, and their deaths could have been prevented it is an appalling situation. We could not provide the 400 cytologists to give the necessary pathological tests to arrest the disease in the early stages.

Obviously, the general practitioner is the person on whom the extra burden will fall. In various other spheres the general practitioner will have to stand in the front line. This is the aspect which we must consider rather than the old "horse and buggy" picture where the general practitioner sits by the patient's bedside all night, and at the dawn a grateful mother says, "Thank you, doctor. You have saved the life of my child". We must realise that we are living in a scientific age in which we have modern scientific and technological aids to put in the hands of the general practitioner. He can use these aids only if we give him the power to do so. For goodness' sake let us stop expecting to use a doctor, who has been trained for seven years, as a filing clerk, or a shorthand typist writing letters and doing social service work, for which he has no time or qualifications.

I suggest that the pattern of medicine, in future, makes nonsense of any idea of putting a financial barrier between the doctor and the patient. This point has been answered already, but I would say to those doctors who were foolish enough to pass that resolution at their Manchester conference that they should consult their colleagues in rural practices who still have to charge for dispensing. As professional people, they loathe the idea of giving advice to a patient and then saying, "That will be 2s., please." The patients feel they are paying the doctor at that rate for his services.

If the right pattern of medicine is to emerge it is not enough for us, as politicians, to ensure that there is the right framework of legislation available and sufficient power and finance behind it. The doctors must put their own house in order. Too few ordinary doctors engage in medico-politics. Those who do are usually those doctors who have large combined lists and three or four partners to assist them, so that they have time to attend meetings. They are not "with it" in relation to what is happening on the "ground floor", or aware of the problems of young doctors entering practice in a modern world.

Perhaps the Minister may help in this respect. It is time that the General Medical Services Committee, which represents the general practitioners under the National Health Service Act, was completely independent from the medico-political organisation. The framework is there. Local medical committees should be made to elect doctors in a democratic fashion. They should put their members on the General Medical Services Committee, for which there is provision in the Act. If this was completely independent from the British Medical Association nothing but good would result. The doctors would feel that instead of being in the hands of a small group of members of their profession—who had managed to get to the top and had time to indulge in medico-politics as a spare-time hobby—there existed a democratic structure, from the local committee to the top organisation, negotiating on their behalf. Thus, the independence of the G.M.S.C. is vital, if doctors are to generate the kind of practice which we all want to see.

The annual conference could still decide policy. At the same time, the Minister should have his own lines of communication. It is an appalling situation that in negotiations, and when the Fraser Committee reports, when the hospital plan is put forward and there is discussion on it, the whole of the information which gets to the general practitioner should come through the British Medical Journal. The report could be biased against the Minister and opportunities for the right hon. Gentleman to put his case could be extremely limited. Therefore, the whole question of communications between the Minister and the G.P. is important, because he is unaware of the kind of decision being taken and the reasons behind it. All too often there is a wide gap between what the general practitioner wants and what the Minister thinks that he wants.

During the next five years we may have to start to choose our priorities in medicine. Priority has been towards the institution. Now we must be clear that in the coming years we must give priority to domiciliary medicine rather than to the institution. I have no hesitation in urging my right hon. and hon. Friends, if as is sometimes the case when there is a limited amount of finance available a choice has to be made between the institution and the domiciliary service, that priority should be given to the general practitioner and the domiciliary service.

We want an investment programme. We have been discussing the problems of ordinary income and expenditure. We must pay far more attention to capital investment. It is no good talking about £750 million invested in hospitals if, at the same time, we have Victorian, outdated and out-moded general practice surgeries where general practitioners have not the tools to do the job, and are unable to give the right kind of buttressing to the institutional services which we already possess.

I agree with hon. Members who have urged the Minister to consider the question of direct grants. I think that the whole question of interest-free loans should be extended—as was said by the hon. Member for Gosport and Fareham—to all forms of practice. This means the executive council must be the instrument for deciding not just the areas and fringes, but must also be able to take the initiative and decide and act on the quality of the service to be rendered. It should judge whether the practice premises conform to the kind of standards which are necessary in modern medicine.

This means that the present method of a group of general practitioners judging the premises of each other, and reporting whether they are good or bad, must be abandoned for something much more effective. The Ministry must seek power to aid good design, which means that the sort of work done by the Ministry's hospital building unit for hospitals must be available for general practice. We must have architects and experts on organisation and method, the kind of thing which the noble Lord, Lard Taylor, put forward some years ago in his book entitled, "Good General Practice". It could be done by the Ministry and advice given to doctors about how best to use their time, energy and service.

I contend that the present system is poised ready for the second stage. The basic necessity for general practice is still the integration of the three sections of the service. This is needed for the whole of the service, but particularly to secure the right kind of practice for the general practitioner. I suggest that the Minister must act boldly to achieve this. At the moment, we have three separate empires and no one is prepared to relinquish an empire without fighting. Therefore, a tough Minister will be needed to get the three sections, plus the occupational health service, integrated into a new administrative form. I believe that it is possible if only we can get the action—we have the knowledge to enable the general practitioner to reach the standard enjoyed by hospital specialists. They are specialists in their sphere. In this way, we should start to move from the present illness service and change the accent to a service for the prevention of illness.

6.50 p.m.

The Minister of Health (Mr. Anthony Barber)

If I have one regret about this debate, it is that, as the hon. Member for Bristol, South (Mr. Wilkins) said, it is all too short. I am sure that the whole House listened with interest to the points made by the hon. Member for Willesden, West (Mr. Pavitt). In the short time that I have been Minister of Health, he has always shown, not only in this House but in correspondence and in other ways, both assiduity and knowledge in health and welfare matters, and I know that he always speaks with sincerity.

The hon. Member for St. Pancras, North (Mr. K. Robinson) opened the debate with a speech which I shall have to criticise in part, but which, in the main, was a very thoughtful one, dealing really with the philosophy of general practice. Indeed, my hon. Friend the Member for Plymouth, Devonport (Miss Vickers) said that the hon. Gentleman had a very nice bedside manner. I would not know about that, but, at any rate, we all listened with interest to what he had to say.

I suppose it is true to say that since I became Minister of Health I have given more thought to the family doctor service, than to any other branch of the National Health Service. In part, this is due to its importance, but it is also due to the fact that to find solutions to the problems which undoubtedly exist is no easy matter.

The first thing to realise is that many of the problems and causes of discontent stem from the fact that the general practitioner is not an employee of the Minister of Health, but an independent contractor. For example, to deal with one point made by my hon. Friend the Member for Gosport and Fareham (Dr. Bennett), if we have a salaried service, then the Government would presumably provide and pay for both the doctor's practice premises and also for his ancillary staff. Again, the doctor's leave would be regulated, and there would be some control over how much work he could undertake for other employers. There would also be an establishment of doctors for different areas, which would enable them to be recruited where they were most needed. But, like the hon. Member for St. Pancras, North, I have no intention of imposing a salaried service against the wishes of the profession. It certainly has its attractions, but it also has its defects from the point of view of the doctor's independence of action, and we cannot have the one without the other.

There has been a great deal of talk in the course of this debate about the status of the family doctor. This is important because the status of the general practitioner is linked with the well-being of his patients. For the family doctor, status is a means to an end. What he wants can, I think, be put quite succinctly. He wants to practice good medicine, and he needs the pay, the conditions of service, and the status to enable him to do just that. One asks oneself where does the responsibility lie?

There are three parties who between them determine the doctor's status—the Government, the public, and the profession itself, and no one of these can do the whole job. Take the public first. I agree entirety with the hon. Member for St. Pancras, North that no one wants to prevent a person from seeing his doctor when he is ill. Indeed, early treatment is often of the utmost importance. But I make no apology for repeating what I said last week, and what I have said before, that I am frankly appalled at the intolerable attitude of a small minority of patients whose actions and lack of consideration can lead one to suppose only that they have. no conception that the family doctor is a highly-trained man—a man who, day in and day out, has to take decisions of the utmost gravity, and a man whose hours of work and devotion to duty should of themselves invoke particular consideration.

One of the problems that the National Health Service has thrown up, is, that over the years, doctors have been faced with a small minority of time-consuming patients whose lack of consideration places on the doctor a burden out of all proportion to their number. Listening to the hon. Member for St. Pancras, North taking me to task for what I said last week on this topic, it occurred to me, with all due respect to him, that if he does not recognise this undoubted fact then, quite frankly, he would seem to be completely out of touch with reality, because it is something which is well-known to every general practitioner throughout the country.

I am not merely concerned with the hours of work of the general practitioner, or his welfare. I raise this because the result of lack of consideration by the minority that I am talking about is that, all too often, the doctor, when he has finished dealing with these people, has not the time left to deal as he would wish with those patients who really need his advice and the exercise of his professional skill. Much less has he the time and energy that he needs to keep up with the rapid progress of medical science.

I said that the general practitioner needs the pay and the conditions of service to enable him to practice good medicine.

Mr. Denis Howell

What is the right hon. Gentleman going to do about it?

Mr. Barber

I want to talk about that.

Mr. K. Robinson

If the right hon. Gentleman is going to talk on the question of the time-consuming minority, I want to make clear that I do not deny the extent of the problem, although perhaps I do not regard it as so large a problem as he does. I was interested in how he was going to protect the general practitioner from this minority.

Mr. Barber

One way, I think, is by making speeches on occasions like this.

Mr. Robinson

That will not help.

Mr. Barber

The hon. Gentleman says that he does not think that will help. There are other ways, television and others, which naturally I am considering, but whether I shall be successful in bringing this home to the minority of patients concerned, I do not know. I was saying that to pretend that this problem does not exist seems to me to be completely out of touch with reality.

The hon. Member for Willesden, West and the hon. Member for St. Pancras, North referred at some length to the question of remuneration. As the House will remember, both the Government and the profession accepted the increase of about 13 per cent. in the total net public pay of the general practitioner which was recommended by the Royal Commission in 1960. That was an increase which yas to last for a period of about three years, and it was fully implemented by the Government. The Government and the profession also accepted the recommendation that there should be set up an independent review body to advise the Government on the pay of the profession. That was implemented also. I can think of no better way of dealing with the question of remuneration, and I take it, from what has been said today, that the Labour Party would not want to alter that arrangement. Last year, the independent Review Body advised a further increase of 14 per cent. in the total net pay of general practitioners from public sources.

The hon. Member for St. Pancras, North said that the way in which this had worked out was "just about the last straw for the general practitioner", but of course this further increase, I am sure he would agree, is being implemented to the full by the Government in accordance with the recommendation of the independent Review Body.

A short time ago the profession submitted to me a new claim for increased remuneration. This new claim is for an increase of something over 30 per cent., or an average of about £900 a year for each general practitioner, to be back-dated to 1963 and paid in addition to the 14 per cent. recommended by the Review Body. That is how the claim worked out. In accordance with the undertakings given by my predecessor, I have passed the claim to the indepedent Review Body for its advice. While that Body is considering it, I am sure the House will agree it would not be right for me to make any public comment.

The hon. Member, in opening, said that the majority of doctors felt that they were being unfairly treated over pay. In order to avoid any misunderstanding in this pre-election period, I hope that if there is any disagreement at all with the way in which I have dealt with this matter of net remuneration, the hon. Member will say so now. If not, I assume that we can take it that there is no dispute between the Government and the Opposition about the method of dealing with the quantum of general practitioners' remuneration.

Of course, I agree with the hon. Member that the level of pay is not the only aspect of remuneration which is important. From the point of view of providing an incentive to good doctoring the method of payment is almost equally important. I shall mention my proposals in a moment, but in passing I find it very difficult to know where the Labour Party stands on this. I have listened to what has been said in this House and I have also read what has been said by leading members of the Labour Party in another place.

There is a lot of misunderstanding about this question of the method of payment of general practitioners, even by the general practitioners themselves. They do not always realise that in addition to the net pay which is recommended by the independent Review Body, every penny of practice expenses as agreed with the Inland Revenue is reimbursed to the profession out of public funds. Together with the doctor's net remuneration which now averages £2,765 a year, the addition of the reimbursed practice expenses brings his average gross income from public funds to something over £4,200 a year.

The House will know that one feature of the present method of payment which struck me as wrong as soon as I became Minister of Health is that although the total of practice expenses is reimbursed in the profession as a whole, the system of distribution does not take proper account of the differences in expenditure between one practice and another. The result, as the hon. Member pointed out, is that some doctors get reimbursed more than others.

The hon. Member described this method of payment as "ludicrous". I am not sure whether he would have done anything about it against the wishes of the majority of the profession, but we have to keep in mind when criticism of the Government is made on this account that the present system is no accident. Until recently, as my hon. Friend the Member for Birmingham, Edgbaston (Dame Edith Pitt) said, this was the system which the profession itself favoured. The advantage of the present system, which I certainly want to change, is that it permits the payment of all expenses by the taxpayer without any interference at all with the doctor's discretion as an independent practitioner to arrange his practice as he wishes.

The system, therefore, safeguards the taxpayer because the expenditure of the individual doctor directly affects his own pocket. Nevertheless, I thought that we should try to get some change in the system so that, for instance, those who employ the staff they need are not at a disadvantage financially compared with those who do not. So it was that shortly after I was appointed we started these discussions with the profession. That these discussions have taken so long is not the fault of anyone, because we have been trying to evolve a system of direct reimbursement which is appropriate for an employee but we have been trying to do this without prejudicing the position of the general practitioner as an independent contractor.

As to ancillary help—nurses, receptionists, clerical help and so on—the House will be pleased to know that after very full discussions with the British Medical Association I have now put to the Association new proposals which Dr. Cameron, the Chairman of the General Medical Services Committee, has described as being: an advance on anything we have had so far. He added: They give great grounds for optimism that a settlement may soon be reached. I understand that these proposals will be considered by the General Medical Services Committee at a special meeting within the next couple of weeks or so, so the House will not expect me to say any more about them now. I add only that Dr. Cameron and his senior colleagues in the B.M.A. are tough negotiators but I am sure they recognise that my aim, like theirs, is to encourage doctors to employ the staff they need. What I have to do is to reconcile my responsibility to satisfy myself that the taxpayers' money is properly spent with my wish to allow doctors to run their practices as they choose even though the taxpayer foots the bill for the expenditure they incur.

I am also in the course of negotiation with a view to helping the doctor to raise the service the capital he needs. I recognise that setting up in practice in these days raises considerable problems for the young doctor. If the general practitioner were an employee like his colleague in the hospital, the Government would simply provide the premises, but, because he wishes to remain as an independent contractor and it is natural for an independent professional man to want to take decisions about his own premises, we have to try to find some other way of helping him.

Dr. J. Dickson (Greenock)

May I ask a question about the magnitude of that reference? Group practice loans do not amount to very much money compared with other things. Is the right hon. Gentleman thinking of a large scheme of £5 million or £10 million a year capital investment in general practice?

Mr. Barber

I should rather on this, as on any question about ancillary help, not say more because I am in negotiation with the B.M.A. The hon. Member will understand that the British Medical Association at its annual conference last week disclosed no details about this. I am in honour bound not to say more about it this evening. I should have been happy, had it been possible to reach agreement by now, to have made an announcement to the House.

I want to say something about the burden of work which falls on the general practitioner, which has been referred to by my hon. Friend the Member for Edgbaston and a number of other hon. Members in this debate. There are a number of ways in which the family doctor can be helped. First, there is the point I made earlier. The public can help by treating the doctor with the consideration which is due to a highly-trained man who, day in and day out, is having to take decisions of the utmost gravity.

Secondly, if we are successful, as I believe we shall be, in agreeing on some satisfactory way of dealing with expenditure on ancillary help—nurses, receptionists, clerical help and the like—of course, the doctor will have a greater incentive to employ more help. That will cost the taxpayer more, but it will give the doctor more time to exercise those special skills which only he possesses.

I entirely agree with one hon. Member who spoke in the debate that it cannot be right that a highly-trained medical man should spend so much of his time looking after his records, writing letters, or making arrangements with hospitals and the ambulance service or the welfare authorities. The third way in which I believe we can help—this is a point which was referred to by my hon. Friend the Member for Edgbaston—is to ease the burden on some doctors by encouraging more of them to go into what are known as under-doctored areas and fewer to go into the other areas. Already a great deal has been done. In 1951 the under-doctored areas contained one-half of the population. Such areas now contain only one-fifth of the population, although I agree that we must go further.

I am pleased to say that the Medical Practices Committee has recently stiffened its criteria for identifying the better-provided area, where entry of additional doctors is restricted, and has said that it intends to apply the new criteria more strictly. I appreciate that this is not the full answer and I understand that the Working Party will have something to say on this issue, too, but unless we take powers of direction— which, in my view, would not be desirable—what the Government can do will always be limited.

The fourth way to help to relieve the burden of work on doctors raises a matter which was mentioned by my hon. Friend the Member for Gosport and Fareham, and that is whether any amendment is needed in the doctors' terms of service. It is now more than 16 years since the inception of the National Health Service, and I am sure that the Working Party which I set up some months ago is the right way to tackle this aspect. This is, after all, a co-operative effort between the Health Departments and the medical profession. I am sure that it would have been wrong—and this will not be disputed in any quarter of the House—had I, without the sort of consultations now going on in the Working Party, decided in what respects I thought their terms of service should be amended or modified. Although I will not quote the actual terms of reference of the Working Party, I would remind the House that they are extremely wide and cover all the causes of discontent.

The Working Party has been meeting frequently and at the end of this week it will be publishing its first group of papers on matters of concern to the profession—not on fundamental questions which must obviously have longer study but on topics of current interest where something can be done quickly, without prejudice to the wider issues. These papers will be distributed to general practitioners throughout the country and I will make them available in the Library of the House.

Mr. K. Robinson

Has an estimate been made of the probable length of time the Fraser Working Party will take to reach its conclusions?

Mr. Barber

No estimate has been made, first, because this is a co-operative effort and, secondly, because the Working Party is not steering its way towards one solution but is dealing with a whole mass of problems. The Working Party decided that because there were so many problems—some minor and some major—it would be best for it not to wait until the end of the day, when it was able to produce one mammoth report, but to feed out, as it were, commentaries on the points that had been considered and on which it felt able to issue documents.

The fifth way in which the lot of the general practitioner can be eased is by working in partnership. There has been considerable progress here. In 1952, 43 per cent. of general practitioners were working single-handed, with all the obvious difficulties involved. By last year only 27 per cent. of them were single-handed. One particularly valuable form of co-operation is group practice, which was referred to at length by my hon. Friend the Member for Devonport and the hon. Member for St. Pancras, North.

The Cohen Committee recommended that this development should be encouraged by the provision of interest-free loans to group practices for the building or purchase and conversion of practice premises. I am always willing to look at any suggestions to see whether we can improve this in any way, but I do not think that the hon. Member for St. Pancras, North was fair when he said that we were moving extremely slowly in this direction. I am sure that the House will be pleased to know that about 600 such loans have already been approved. What is particularly important, the rate of approval has recently been increasing fast. Applications in 1962 numbered 93. By 1963 they had jumped to 145. They were up by 56 per cent. and approvals were up by 60 per cent. This is bound to happen because there is a time-lag between application and approval.

The sixth way of helping the family doctor is, as my hon. Friend the Member for Plymouth, Devonport said, by providing direct help by the attachment to individual G.P.s of local health authority staffs such as health visitors, midwives and district nurses. We are making considerable progress in this direction. In an otherwise fair speech, the hon. Member for Willesden, West said that there was complete division between general practitioners and local health authorities. This is not so and is not borne out by the facts because, as I say, we are making considerable progress. One of my hon. Friends referred to the position in Oxford. In one county which I know, Hampshire, for instance, 160 family doctors have such workers attached to them and I am told that the results are excellent. I am sure that we must do all we can to encourage this trend.

Mr. Pavitt

I hope that the Minister is aware that this is not a question merely of attaching social workers to general practitioners. This is not the concept of one social worker. This is the concept of team work between the local health authority and the local executive council.

Mr. Barber

If the hon. Gentleman will study the figures he will see that we have gone a long way towards achieving that. This is, in essence, a question of co-operation between local practitioners and local health authorities.

I have mentioned six ways of easing the burden on general practitioners. The seventh, of course, is to increase their numbers. Listening to the Opposition it is apparent that they simply have no idea of what has already been achieved. Let me give some figures. In 1960–61 the intake of British—and I stress that I am ignoring overseas students—medical students was 1,788. The next year 1961–62, it was 1,896. The following year it had risen to 2,047 and last year, the autumn intake had risen to 2,153. That represents an increase of 365, or 20 per cent. in three years. So much for the jibe of the hon. Member for St. Pancras, North about our squeezing a few more students into existing schools. An increase of 20 per cent. in three years is not bad. However, I will come back to that. I recognise that this is not enough, and that is why we are taking steps to increase the number of medical students still further.

While it is clear that there must be a further increase, the actual number will depend on many factors, some of them very difficult to assess for the future. One obvious factor is the number of doctors originating in this country who are leaving permanently—I stress "permanently"—to practise overseas. What we need to know is the net rate of emigration; not simply the number of doctors who are emigrating but more about those who are coming back to this country. It is the net rate of emigration which counts. With the agreement of the B.M.A., I am about to send out a special questionnaire to a sample number of doctors to help us to obtain a realistic estimate. At the same time, we are considering the rate of immigration of doctors from overseas. In a recent article, the hon. Member for St. Pancras, North wrote that the Abel-Smith Report … shows that about a quarter of our newly-qualified doctors emigrate each year. Of course, the Abel-Smith Report shows no such thing. The fact is that very few indeed of our newly-qualified doctors emigrate.

What that Report does show is that between 350 and 400 British-born doctors emigrate each year. But it also shows—which, I think, is very significant in the context of this debate—that the majority of doctors who choose to leave Great Britain are not general practioners; they are doctors who were last employed in hospital work, and many of them apparently felt that they were unable to obtain here a post of sufficient seniority.

Of course, we do not want excessive emigration, but criticism on that score should, as I think the whole House will agree, be in guarded language. After all, this country has always made a contribution to the health of other parts of the world, and when one sees the distressing conditions in some countries where one solitary doctor can effect an improvement seemingly out of all proportion to the efforts of one man, then I, for my part, despite my responsibility to the people of this country, cannot begrudge some contribution to those overseas.

The House will remember that it was announced some time ago that there was to be at least one new medical school, and it will be pleased to know that it has been decided to provide this at the University of Nottingham. It will involve the building of a new teaching hospital with about 1,200 beds, and the medical school will be planned for an annual entry of 100 students. The City Council has generously offered a contribution of £100,000 towards the establishment of the Medical Faculty.

The Labour Party talks glibly about building four new medical schools, but all hon. and right hon. Gentlemen opposite know perfectly well that such a policy cannot possibly relieve the pressure on general practitioners or other doctors for at least 10 years, and very likely longer. The immediate task must surely be to increase still further the intake of medical students in the immediate future, and this we will do.

I have already mentioned that the intake of students normally resident in Great Britain has increased by 20 per cent. during the last three years. The House will be pleased to know—as, I am sure, will the medical profession—that after taking the advice of the University Grants Committee, my right hon. and learned Friend the Secretary of State for Education and Science has agreed that the existing medical schools should be expanded to increase the annual intake of British-based students by about 150 by October, 1966. Some of these additional places will be available this October.

The House will appreciate the significance of the fact that the figure of 150 is the figure of annual intake. Because any increase in the annual intake results in a progressively greater increase in the actual number of students as the years go by, the result of this decision will be that by October, 1966, there should be some 400 extra British-based medical students in our schools. The necessary additional funds for this expansion will be made available.

This is really a considerable increase but, even so, we are now considering the possibility of further increases in the longer term. These developments will be welcomed, I know, by the medical profession, because they will relieve the burden far more quickly than the construction of new medical schools which, as far as I can see, seems to be the only pancea proposed by the Labour Party for increasing the supply of doctors—

Dr. Dickson Mabon

Is not the Minister aware that it is also the policy of the British Medical Association that there should be four medical schools; and that they should be in the North? And, while most would welcome the statement about existing universities, is it not true that there is a limit to the capacity of existing medical schools, many of which are already overcrowded?

Mr. Barber

All I say is that the only policy put forward by the Labour Party is four new medical schools, which everyone knows perfectly well—the hon. Member for St. Pancras, North admitted it a moment ago—cannot possibly help for at least 10 years. What I propose now, and what my right hon. and learned Friend the Secretary of State for Education and Science is arranging, is something that will help well before the 10 years are up, and it seems that this is the only sensible policy that should be pursued.

The hon. Member for St. Pancras, North said that this debate is a timely one. I hope that I shall not be thought to be ungenerous when I say that, having heard that the Opposition had decided to have this debate within the last fortnight of the Session, it occurred to me that they might conceivably have had in mind some electoral advantage. [Interruption.] What is the position?

First, the Labour Party has suggested no way of improving on the Government's handling of the question of the family doctor's pay. Secondly, the Labour Party have suggested no way of improving on the Government's handling of the question of the family doctor's practice expenses.

Thirdly, as I have just said, the Labour Party has suggested no way of improving for at least 10 years on the Government's handling of the manpower question. Hon. Members opposite have talked, as I said said, about four new medical schools, but they know that this will not help.

Fourthly, while the noble Baroness, Lady Summerskill, wants a salaried service, Lord Taylor, who leads for the Labour Party on health matters in another place, does not want a salaried service. I did not even hear from the hon. Member for St. Pancras, North whether he was in favour of a salaried service or not. What he said was that if he had responsibility, he would certainly not introduce one unless it had the backing of the profession.

Lastly, the one positive—[Interruption.]—and immediate proposal of the Labour Party is to abolish prescription charges, which the B.M.A. decided only last week would be against the interests of the overworked family doctor. The subject of this debate was chosen by hon. Members opposite for party political advantage—[Interruption.] As things have turned out, I can only express to the Opposition my profound gratitude.

Question put, That "£219,615,000" stand part of the Resolution:—

The House divided: Ayes 241, Noes 199.

Division No. 142.]	AYES	[7.28 p.m.
Agnew, Sir Peter	Bishop, Sir Patrick	Clark, Henry (Antrim, N.)
Anderson, D. C.	Black, Sir Cyril	Clark, William (Nottingham, S.)
Arbuthnot, Sir John	Bossom, Hon. Clive	Cleaver, Leonard
Ashton, Sir Hubert	Box, Donald	Cole, Norman
Atkins, Humphrey	Boyd-Carpenter, Rt. Hon. John	Cooke, Robert
Awdry, Daniel (Chippenham)	Braine, Bernard	Cooper, A. E.
Barlow, Sir John	Bromley-Davenport, Lt. -Col. Sir Walter	Cordeaux, Lt.-Col. J. K.
Barter, John	Brown, Alan (Tottenham)	Cordle, John
Batsford, Brian	Browne, Percy (Torrington)	Corfield, F. V.
Beamish, Col. Sir Tufton	Bryan, Paul	Costain, A. P.
Bell, Ronald	Bullard, Denys	Coulson, Michael
Bennett, Dr. Reginald (Gos & Fhm)	Bullus, Wing Commander Eric	Courtney, Cdr. Anthony
Berkeley, Humphry	Campbell, Gordon	Critchley, Julian
Bevins, Rt. Hon. Reginald	Carr, Compton (Barons Court)	Crosthwaite-Eyre, Col. Sir Oliver
Bidgood, John C.	Carr, Rt. Hon. Robert (Mitcham)	Curran, Charles
Biffen, John	Cary, Sir Robert	Currie, G. B. H.
Birch, Rt. Hon. Nigel	Chataway, Christopher	Dalkeith, Earl of
Dance, James	Kerans, Cdr. J. S.	Rawlinson, Rt. Hon. Sir Peter
d'Avigdor-Goldsmid, Sir Henry	Kerby, Capt. Henry	Redmayne, Rt. Hon. Martin
Deedes, Rt. Hon. W. F.	Kerr, Sir Hamilton	Rees, Hugh (Swansea, W.)
Doughty, Charles	Kershaw, Anthony	Renton, Rt. Hon. David
Drayson, G. B.	Kimball, Marcus	Ridsdale, Julian
Duncan, Sir James	Kirk, Peter	Rippon, Rt. Hon. Geoffrey
Eden, Sir John	Kitson, Timothy	Roberts, Sir Peter (Heeley)
Elliott, R. W. (Newc'tle-upon-Tyne, N.)	Langford-Holt, Sir John	Robertson, Sir D.(C'thn's & S'th'ld)
Emery, Peter	Leavey, J. A.	Rodgers, Sir John (Sevenoaks)
Emmet, Hon. Mrs. Evelyn	Lewis, Kenneth (Rutland)	Ropner, Col, Sir Leonard
Farey-Jones, F. W.	Lilley, F. J. P.	Russell, Sir Ronald
Farr, John	Linstead, Sir Hugh	Scott-Hopkins, James
Fell, Anthony	Litchfield, Capt. John	Sharples, Richard
Fisher, Nigel	Lloyd, Rt. Hn. Geoffrey (Sut'nC'd field)	Shaw, M.
Fletcher-Cooke, Charles	Lloyd, Rt. Hon. Selwyn (Wirral)	Shepherd, William
Foster, Sir John	Longbottom, Charles	Skeet, T. H. H.
Fraser, Ian (Plymouth, Sutton)	Longden, Gilbert	Smith, Dudley (Br'ntf'd & Chiswick)
Galbraith, Hon. T. G. D.	Lucas, Sir Jocelyn	Stainton, Keith
Gammans, Lady	Lucas-Tooth, Sir Hugh	Stanley, Hon. Richard
Gibson-Watt, David	MacArthur, Ian	Stevens, Geoffrey
Giles, Rear-Admiral Morgan	McLaren, Martin	Stodart, J. A.
Gilmour, Ian (Norfolk, Central)	Maclean, SirFitzroy (Bute&N. Ayrs)	Storey, Sir Samuel
Glyn, Dr. Alan (Clapham)	Macleod, Rt. Hn. Iain (Enfield, W.)	Studholme, Sir Henry
Glyn, Sir Richard (Dorset, N.)	Macmillan, Maurice (Halifax)	Talbot, John E.
Goodhart, Philip	Maitland, Sir John	Tapsell, Peter
Goodhew, Victor	Markham, Major Sir Frank	Taylor, Sir Charles (Eastbourne)
Gough, Frederick	Marshall, Sir Douglas	Taylor, Edwin (Bolton, E.)
Gower, Raymond	Marten, Neil	Taylor, Frank (M'ch'st'r, Moss Side)
Grant-Ferris, R.	Mathew, Robert (Honiton)	Taylor, Sir William (Bradford, N.)
Green, Alan	Matthews, Gordon (Meriden)	Teeling, Sir William
Gresham Cooke, R.	Maude, Angus (Stratford-on-Avon)	Temple, John M.
Griffiths, Eldon (Bury St. Edmunds)	Maudling, Rt. Hon. Reginald	Thatcher, Mrs. Margaret
Grosvenor, Lard Robert	Mawby, Ray	Thomas, Sir Leslie (Canterbury)
Gurden, Harold	Maxwell-Hyslop, R. J.	Thomas, Rt. Hon. Peter (Conway)
Hall, John (Wycombe)	Maydon, Lt.-Cmdr. S. L. C.	Thompson, Sir Kenneth (Walton)
Hamilton, Michael (Wellingborough)	Mills, Stratton	Thompson, Sir Richard (Croydon, S.)
Harvey, Sir Arthur Vere (Macclesf'd)	Miscampbell, Norman	Thornton-Kemsley, Sir Colin
Harvey, John (Walthamstow, E.)	Montgomery, Fergus	Touche, Rt. Hon. Sir Gordon
Harvie Anderson, Miss	More, Jasper (Ludlow)	Turner, Colin
Hastings, Stephen	Morrison, Charles (Devizes)	Turton, Rt. Hon. R. H.
Heald, Rt. Hon. Sir Lionel	Morrison, John (Salisbury)	van Straubenzee, W, R.
Heath, Rt. Hon. Edward	Mott-Radclyffe, Sir Charles	Vaughan-Morgan, Rt. Hon. Sir John
Henderson, Sir John (Cathcart)	Nugent, Rt. Hon. Sir Richard	Vickers, Miss Joan
Hiley, Joseph	Oakshott, Sir Hendrie	Walder, David
Hill, Mrs. Eveline (Wythenshawe)	Orr, Capt. L. P. S.	Walker, Peter
Hobson, Rt. Hon. Sir John	Orr-Ewing, Sir Ian (Hendon, North)	Walker-Smith, Rt. Hon. Sir Derek
Hocking, Philip N.	Osborn, John (Hallam)	Wall, Patrick
Hogg, Rt. Hon. Quintin	Page, Graham (Crosby)	Ward, Dame Irene
Holland, Philip	Page John (Harrow, West)	Webster, David
Hopkins, Alan	Pannell, Norman (Kirkdale)	Wells, John (Maidstone)
Hornby, R. P.	Partridge, E.	Williams, Sir Rolf Dudley (Exeter)
Hughes Hallett, Vice-Admiral John	Peel, John	Williams, Paul (Sunderland, S.)
Hughes-Young, Michael	Percival, Ian	Wills, Sir Gerald (Bridgwater)
Hulbert, Sir Norman	Peyton, John	Wilson, Geoffrey (Truro)
Hutchison, Michael Clark	Pickthorn, Sir Kenneth	Wise, A. R.
Iremonger, T. L.	Pike, Miss Mervyn	Wolrige-Gordon, Patrick
Irvine, Bryant Godman (Rye)	Pitman, Sir James	Wood, Rt. Hon. Richard
Jackson, John	Pitt, Dame Edith	Woodhouse, Hon. Christopher
Jenkins, Robert (Dulwich)	Powell, Rt. Hon. J. Enoch	Woodnutt, Mark
Jennings, J. C.	Price, David (Eastleigh)	Woollam, John
Johnson, Dr. Donald (Carlisle)	Prior, J. M. L.	Worsley, Marcus
Johnson, Eric (Blackley)	Prior-Palmer, Brig. Sir Otho	Yates, William (The Wrekin)
Jones, Rt. Hon. Aubrey (Hall Green)	Quennell, Miss J. M.
Joseph, Rt. Hon. Sir Keith	Ramsden, Rt. Hon. James	TELLERS FOR THE AYES:
		Mr. Finlay and Mr. J. E. B. Hill
NOES
Abse, Leo	Bottomley, Rt. Hon. A. G.	Crosland, Anthony
Alldritt, W. H.	Bowden, Rt. Hn. H. W.(Leics, S. W.)	Cullen, Mrs. Alice
Allaun, Frank (Salford, E.)	Bowen, Roderic (Cardigan)	Dalyell, Tam
Allen, Scholefield (Crewe)	Bowles, Frank	Darling, George
Awbery, Stan (Bristol, Central)	Boyden, James	Davies, G. Elfed (Rhondda, E.)
Bacon, Miss Alice	Braddock, Mrs. E. M.	Davies, Harold (Leek)
Barnett, Guy	Bradley, Tom	Davies, S. O. (Merthyr)
Baxter, William (Stirlingshire, W.)	Bray, Dr. Jeremy	Deer, George
Beaney, Alan	Brockway, A. Fenner	Delargy, Hugh
Bellenger, Rt. Hon. F. J.	Broughton, Dr. A. D. D.	Dempsey, James
Benn, Anthony Wedgwood	Butler, Herbert (Hackney, C.)	Diamond, John
Bennett, J. (Glasgow, Bridgeton)	Butler, Mrs. Joyce (Wood Green)	Dodds, Norman
Benson, Sir George	Callaghan, James	Doig, Peter
Blackburn, F.	Carmichael, Neil	Donnelly, Desmond
Blyton, William	Castle, Mrs. Barbara	Driberg, Tom
Boardman, H.	Corbet, Mrs. Freda	Duffy, A. E. P. (Colne Valley)
Boston, T. G.	Craddock, George (Bradford, S.)	Ede, Rt. Hon. C.

Edelman, Maurice	Lipton, Marcus	Redhead, E, C.
Edwards, Rt. Hon. Ness (Caerphilly)	Loughlin, Charles	Reynolds, G. W.
Evans, Albert	Lubbock, Eric	Rhodes, H.
Fernyhough, E.	Mabon, Dr. Dickson	Roberts, Albert (Normanton)
Finch, Harold	McBride, N.	Roberts, Goronwy (Caernarvon)
Fletcher, Eric	McCann, J.	Robertson, John (Paisley)
Foley, Maurice	MacColl, James	Robinson, Kenneth (St. Pancras, N.)
Foot, Dingle (Ipswich)	MacDermot, Niall	Rodgers, W. T. (Stockton)
Foot, Michael (Ebbw Vale)	Mclnnes, James	Rogers, C. H. R. (Kensington, N.)
Galpern, Sir Myer	McKay, John (Wallsend)	Ross, William
George, LadyMeganLloyd (Crmrthn)	Mackenzie, Gregor	Royle, Charles (Salford, West)
Ginsburg, David	Mackie, John (Enfield, East)	Shinwell, Rt. Hon. E.
Gordon Walker, Rt. Hon. P. C.	McLeavey, Frank	Short, Edward
Griffiths, David (Rother Valley)	MacPherson, Malcolmn	Silkin, John
Griffiths, Rt. Hon. James (Llanelly)	Mallalieu, E. L. (Brigg)	Silverman, Julius (Aston)
Griffiths, W. (Exchange)	Mallalieu, J. P. W. (Huddersfield, E.)	Skeffington, Arthur
Grimond, Rt. Hon. J	Manuel, Archie	Slater, Mrs. Harriet (Stoke, N.)
Hale, Leslie (Oldham, W.)	Mapp, George	Slater, Joseph (Sedgefield)
Hamilton, William (West Fife)	Marsh, Richard	Small, William
Hannan, William	Mason, Roy	Snow, Julian
Harper, Joseph	Mellish, R. J.	Sorensen, R. W.
Hayman, F. H.	Mendelson, J. J.	Soskice, Rt. Hon. Sir Frank
Healey, Denis	Millan, Bruce	Spriggs, Leslie
Henderson, Rt. Hn. Arthur (Rwly Regis)	Milne, Edward	Steele, Thomas
Hilton, A. V.	Mitchison, G. R.	Stewart, Michael (Fulham)
Holman, Percy	Monslow, Walter	Stonehouse, John
Houghton, Douglas	Morris, Charles (Openshaw)	Stones, William
Howell, Charles A. (Perry Barr)	Morris, John (Aberavon)	Stross, SirBarnett (Stoke-on-Trent, C.)
Howell, Denis (Small Heath)	Mulley, Frederick	Swingler, Stephen
Hughes, Cledwyn (Anglesey)	Noel-Baker, Francis (Swindon)	Taverne, D.
Hughes, Emrys (S. Ayrshire)	Noel-Baker, Rt. Hn. Philip (Derby, S.)	Taylor, Bernard (Mansfield)
Hughes, Hector (Aberdeen, N.)	O'Malley, B. K.	Thomas, Iorwerth (Rhondda, W.)
Hynd, H. (Accrington)	Oswald, Thomas	Thompson Dr. Alan (Dunfermline)
Hynd, John (Attercliffe)	Owen, Will	Tomney, Frank
Irvine, A. J. (Edge Hill)	Padley, W. E.	Wainwright, Edwin
Irving, Sydney (Dartford)	Paget, R. T.	Warbey, William
Janner, Sir Barnett	Pannell, Charles (Leeds, W.)	Watkins, Tudor
Jay, Rt. Hon. Douglas	Pargiter, G. A.	Weitzman, David
Jeger, George	Parker, John	Whitlock, William
Jones, Dan (Burnley)	Pavitt, Laurence	Wilkins, W. A.
Jones, T. W. (Merioneth)	Pearson, Arthur (Pontypridd)	Willey, Frederick
Kelley, Richard	Peart, Frederick	Williams, D. J. (Neath)
Kenyon, Clifford	Pentland, Norman	Williams, LI. (Abertillery)
Key, Rt. Hon. C. W.	Popplewell, Ernest	Williams, W. T. (Warrington)
King, Dr. Horace	Prentice, R. E.	Willis, E. G. (Edinburgh, E.)
Lawson, George	Price, J. T. (Westhoughton)	Wilson, Rt. Hon. Harold (Huyton)
Lee, Frederick (Newton)	Probert, Arthur	Winterbottom, R. E.
Lee, Miss Jennie (Cannock)	Pursey, Cmdr. Harry	Woof, Robert
Lever, L. M. (Ardwick)	Randall, Harry
Lewis, Arthur (West Ham, N.)	Rankin, John	TELLERS FOR THE NOES:
		Mr. Grey and Mr. Ifor Davies.

It being after half-past Seven o'clock, Mr. SPEAKER proceeded, pursuant to Standing Orders, to put forthwith the Question necessary to dispose of the Resolution under consideration.

Question, That this House doth agree with the Committee in the said Resolution, put and agreed to.

Mr. SPEAKER then proceeded to put forthwith the Questions, That this House doth agree with the Committee in the outstanding Resolutions reported in respect of Classes I to XI of the Civil Estimates, the Defence (Central) Estimate, the Defence (Navy) Estimates, the Defence (Army) Estimates, the Defence (Air) Estimates, and of Navy, Army and Air Services [Expenditure].